Tag Archives: Practicum Training

Unplanned Termination by Therapist

diane suffridge therapistI have been working at an agency job for a year and have been seeing a number of clients for six months or more.  I’m looking for another job, and I’m wondering how much notice I should give at my current job in order to allow enough time for termination with my clients.  

The topic of termination is covered in Chapter 13 of my book, including planned and unplanned endings that are initiated by the client or the therapist.  The situation you describe is one in which you will be initiating the termination process with clients who may or may not have completed their treatment.  It is a good idea to think ahead to the impact your job change will have on your clients so you can do as much advance planning as possible.

I recommend thinking about three tasks to be addressed: reviewing the treatment progress and relationship, anticipating future needs for treatment, and saying goodbye.  These tasks are discussed in more detail in a previous blog.  Another blog discusses the importance of processing your feelings about ending with your clients, preferably before you begin the termination process with them.

Usually it is ideal to allow 4-6 weeks for a termination process with clients you have seen for six months or more and 2-4 weeks for shorter term clients.  If you work in an outpatient setting, always assume that some of your clients will miss one or more sessions during the ending process, making it advisable to have a longer rather than shorter time to end.  When making a job change, however, you may not be able to give your clients more than 2 or 3 weeks notice, depending on the circumstances of your job search and any break you plan between leaving one job and beginning another.  I’ll discuss here how you can handle the three termination tasks mentioned above in this compressed period of time.

The first issue to keep in mind if you are ending treatment of six months or more with 2-3 weeks notice is that the ending will inevitably feel somewhat incomplete.  Since you are initiating the ending, you may feel a degree of guilt which could lead you to minimize the discomfort of the ending for both you and the client.  It will serve both of you to acknowledge that you would like to have more time to say goodbye.  In addition, you will be ending with all of your clients at the same time, which will bring up a lot of emotions for you, while you are also saying goodbye to colleagues and supervisors.  Anticipate the emotional work this will require of you and use your support system to help with your own need for processing the endings of these relationships.

A second issue to consider is that some of your clients will miss their final scheduled session, so begin the termination discussion at the time you let them know you are leaving, even if you plan to meet another one or two times.  Since the clients won’t be expecting this news, you’ll need to give them time to take it in before talking about it.  I recommend beginning the session by telling them that you’re leaving, with a simple statement like “I’d like to start our session today by letting you know that I’ve taken another job and will be leaving here on (date).  I’d like to take some time to talk today about ending our time together, though we’ll also be able to do that in our next (1 or 2) session(s) as well.”  Then wait for the client to respond, and if she/he moves quickly into another issue about her/his life, look for another opportunity later in the session to come back to the termination process.

When the termination process is brief, it is often helpful to give the client a written note with some of your thoughts about the treatment as a supplement to your discussions in person.  Many clients lack the experience of talking directly about the ending of a relationship, and this often leads to avoidance and denial of feelings of loss.  You may not have an opportunity to share everything you would like to say to the client in a session, so writing a note ahead of time gives you a chance to express yourself more fully.  It may also be easier for the client to take in your thoughts at a later time.  If the client misses the session in which you plan to give her/him the written note, you can consider sending it by mail.

One of the three tasks I recommend addressing during termination is the client’s future needs for treatment.  When you are leaving your job, the client’s continued treatment will be dependent on another clinician’s availability at your agency so you will discuss this issue differently based on those circumstances.  The other two tasks—reviewing the treatment and saying goodbye—are solely about your relationship and aren’t dependent on the agency arrangements for the client to continue or end.  Although there may be a lot to say, it is possible to accomplish these two tasks in a relatively short period of time if you prepare for these sessions by thinking about each client individually and what you can say about the nature of your work together and how you feel about ending.  It is often meaningful for the client to hear how you have been affected by the work.

These recommendations will help you in managing an unplanned ending with clients with thoughtfulness.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Coordination of Care

worried therapistI am working with a client who is taking an anti-depressant prescribed by a psychiatrist.  She has begun to show symptoms of euphoria, rapid speech, and decreased need for sleep, which makes me wonder if she should be taking a mood stabilizer.  She has signed a release giving permission for us to share information, so I’m wondering how to approach this issue in a phone call with the psychiatrist.  

This is a good example of a case in which coordination of client care is very important.  You probably see the client more often than the psychiatrist, so it’s understandable that you would see the emergence of these symptoms first.  Communicating with your client’s prescribing psychiatrist will be beneficial to your treatment as well as possibly influencing the psychiatrist’s decisions.  The topic of case management is covered in Chapter 12 of my book.  Case management includes coordination of care and contacts you have with other professionals or family members.  

The first issue that clinicians often face when contacting a psychiatrist is the difficulty of scheduling a time to talk.  If s/he has an assistant, you may be able to schedule a time relatively easily, but if s/he works independently it is likely to be more challenging.  I recommend leaving a message introducing yourself, stating you have a release you’re your mutual client giving permission for you to share information, and giving some times that you’re available.  It is wise to include late afternoon or early evening times if possible, since s/he may return calls at the end of the day.  If you don’t get a return call within two or three days, it’s fine to leave another message.  There may be some back and forth exchange of messages before you’re able to speak in person, so be persistent.  

Before you have the phone conversation, take some time to plan what you want to say and what you want to know.  Separate the information you wish to provide from questions you have for the psychiatrist so you’re clear about your goals for the conversation.  In this case, you want to share your observations about the client’s symptoms and you want to ask about the psychiatrist’s diagnosis and observations.  There may be additional information that is helpful to exchange, but keep in mind the HIPAA requirement to share the minimum necessary information.  Do not share details of the treatment or the client’s history that are not relevant for the psychiatrist’s prescribing decisions.  

Before the call, notice your feelings in anticipation of the conversation.  Some clinicians feel intimidated by psychiatrists, and this can lead to defensiveness or a lack of clarity.   Work to prepare yourself for a collaborative, professional discussion.  Since your primary goal is to let the psychiatrist know about the client’s recent symptoms, you might plan to start the conversation by saying “I have observed some changes in XX’s symptoms lately, and wanted to pass along that information.  She has appeared euphoric and reports a decreased need for sleep.  I’ve also seen some rapid speech that seems to indicate a flight of ideas.  These changes have taken place over the last couple weeks, and I thought I should let you know.”  It is best to refrain from making any suggestions about prescribing, since that is outside your scope of practice and may be off-putting to the psychiatrist.  Stay with an objective report of what you have observed and what the client has reported.  Keep your questions in mind, so you can ask those before the end of your conversation if they don’t come up naturally.  The conversation may end with a plan to talk again in a specified period of time or with a more open ended agreement to check in as needed.  

I recommend that you create a progress note documenting each time you have contact with another professional about your client.  It provides evidence in the record that you have followed the standard of care, and it also gives you a reminder of the details of the conversation which may fade with time.  A paragraph is usually long enough to summarize your conversation and any plan that resulted from it.  

I also recommend that you talk with the client about your conversation with the psychiatrist when you meet for your next session so she feels included in the communication.  A short summary reporting what you shared and what you heard is sufficient, followed by asking if there is anything else she’d like to know about your conversation.

You are now prepared to talk with the psychiatrist in a way that will benefit your client.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Evolution in Therapeutic Issues

I have been seeing a client in therapy for over six months.  He was very depressed when he came in, and his depression has improved though he still scores in the mild range on the Beck Depression Inventory.  I’m not sure what more to do to help him continue his improvement.  It seems like therapy has reached a plateau.

The topic of the therapeutic relationship is covered in Chapter 11 of my book, which reviews different aspects of how therapy evolves over time.  In this case, you report significant improvement followed by a period when the symptoms are remaining stable. I can recommend several things to consider at this point, to help you and the client understand the meaning of this plateau.

I would first suggest that you talk with the client about your perception that his symptoms have reached a plateau.  He may be aware of subtle changes that aren’t reflected in his BDI score, indicating that change is still taking place during this period.  If he does report that the pace of change has slowed, you can ask him how he understands this and engage in a collaborative discussion that may result in some insight into the next phase of therapy.  Two specific areas for discussion would be his feelings about the changes that have occurred since he began therapy and an examination of the function his remaining symptoms may serve in his life.

Discussing your client’s feelings about the changes he has made may identify some ambivalence or some discomfort with what is unfamiliar to him.  Although improvement in depression is desirable and is probably the primary goal you and he have worked toward, there are times when change can feel uncomfortable or even frightening.  If he is handling situations differently, he may need some time to adjust to his new approach or a new way of thinking about himself and others.  It’s possible you don’t need to do anything more; instead this pace may fit your client’s needs.

If your client indicates that he feels stuck or stalled in his progress, I would recommend that you reflect together on the function his symptoms may serve.  In some cases, clients come to recognize that their identity is associated with being depressed or that they are repeating a pattern from their family of origin or that being free of depression may increase the expectations they and others hold for themselves.  These factors are usually outside of awareness, so this examination may unfold over several sessions.  The client’s history and current life circumstances may provide you with some ideas of how depression may serve a purpose.  For example, he may feel closer to a depressed parent or sibling when he is also depressed or he may be avoiding the pursuit of a different job or entering into a new relationship.

It is possible that discussing these issues with your client will result in expanding or shifting the focus of therapy to incorporate your perspective on this plateau of symptoms.  You might begin to talk more about the client’s sense of identity, his childhood experiences, or conflicts in his work or relationship life.  You also might find that the client needs to learn and use different strategies for managing his symptoms in light of the new insight you and he develop together.  This isn’t a matter of you figuring out what to do, but you and the client working together to discover what he needs to continue his healing.

I hope these ideas are helpful in understanding a period of slow change in therapy.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

 

Progress Notes and Psychotherapy Notes

How can I protect the notes I take during supervision and consultation from being seen by a client who requests her record?  I find the notes valuable in planning for sessions and for tracking my own countertransference, but I don’t want clients to be able to see my notes.  

Your question refers to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) which make all health records accessible to clients upon request.  There is an exception, however, that is important to know in creating and maintaining documentation for psychotherapy.  Chapter 10 of my book covers issues related to HIPAA and other issues to consider in clinical documentation.  

HIPAA defines progress notes as part of the treatment record which must be provided to the client and psychotherapy notes as the property of the clinician and kept outside of the treatment record.  I’ll define each of these terms more specifically and describe the practices that make it clear whether you are creating a progress note or a psychotherapy note.

Progress notes are part of the client record and are used to document the service you provided. Generally they include information about the date, time, location, and length of the session; who attended; the client’s mental health status in terms of symptoms and functioning; your interventions and the client’s response; assessment of any risk or danger; progress toward treatment goals; and plan for continued treatment or referrals.  Progress notes are written in objective, professional language and are relatively concise. These notes may be requested by a third party funder to support a billing claim or as part of a periodic audit.  If the client requests her/his record, you are required to provide copies of the progress notes along with other clinical documentation such as assessments and treatment plans.  

Psychotherapy notes, as defined by HIPAA, contain material that is clinically relevant to the clinician but not required to document the service provided.  Examples of material that is appropriate for a psychotherapy note rather than a progress note are impressions or hypotheses, details of the client’s history or therapeutic interactions that are meaningful but not necessary for a progress note, descriptions of your personal countertransference responses, and notes from supervision or consultation.  

Based on these definitions, your notes from supervision and consultation are psychotherapy notes and are not part of the client’s record.  However, you need to use care in how you keep the psychotherapy notes in order to be clear that they are your property and kept for clinical purposes only.  I recommend keeping your psychotherapy notes in a separate folder rather than keeping them in the client’s chart.  This makes it less likely that there will be any misunderstanding or confusion if the client does request the record or gives permission for you to release the record to a third party.  If you work in an agency, you may not receive the request, and another staff member may not be able to distinguish between progress notes and psychotherapy notes if they are kept in the same chart.  If you receive the request yourself, it may be difficult to separate them without the time consuming step of reading each individual note.

There are no requirements for keeping psychotherapy notes for a specified period of time, in contrast to legal and ethical requirements for keeping client records for seven years or more after the end of treatment.  For this reason, you may wish to destroy your psychotherapy notes once they are no longer clinically relevant.  You may also wish to keep the psychotherapy notes free of any identifying information that could fall under the HIPAA definition of Protected Health Information (PHI).  If you use initials only or a number code that is known only to you, it is more clear that the psychotherapy notes are not part of the client record.   

I hope this clarifies the question of what notes must be disclosed to the client and what can be kept for your own use.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Deciding Who is the Client

FullSizeRender (49)I was contacted recently by the mother of a 10-year-old girl who has been showing symptoms of anxiety. The mom said her father died two months ago and the whole family has been affected by his death. She asked if I can see her 10-year-old daughter weekly and also see the family (including mom, dad, and older brother) every few weeks to help them through their period of grieving. I’m not sure how to respond to her request.

This situation illustrates one of the first questions we face in beginning with a new case: “who is my client?” or “what is the unit of treatment?”. You need to define the unit of treatment in order to decide who will participate in therapy sessions and how you define your therapeutic relationship with one or more members of the family. Chapter 9 of my book is devoted to the topic of treatment planning, which includes decisions about the therapeutic frame and structure, the client’s goals for change, and the therapeutic interventions that will facilitate that change.

When a child is involved in the initial request for therapy, your client may be the individual child with the parents participating in collateral sessions or may be the family. Your decision about the unit of treatment will affect how you structure the sessions, in terms of who participates and how frequently, but more importantly it will affect your treatment goals and interventions. Let’s look at how you might make this decision, assuming that you have experience in conducting both individual child and family therapy.

The first step is to recognize that you can take time to reach a decision about how to approach this case. You can respond to mom’s request by telling her that you would be open to seeing both her daughter alone and the family together, but that you would need to learn more about them in order to recommend the best way to work with them. All cases begin with an initial assessment, but the complexity of this situation make it preferable to explicitly begin with several sessions of assessment. This would give you a chance to meet with the family in different combinations, gaining information and making observations about them individually, as a unit, and in different subgroups. I would recommend one or two individual sessions with the daughter, one or two sessions with the parents individually and/or together, one family session, and possibly an individual session with the older brother. At that point, you would be able to determine the best way to proceed.

As I mentioned above, answering the question “who is my client?” primarily refers to how you define your relationship with the family. If you decide that the 10-year-old daughter is your client, your treatment goals and interventions will be focused on her symptoms and you will hold sessions with her parents and possibly the whole family in order to facilitate her progress. If you decide that the family is your client, you will develop treatment goals for the family as a whole and any individual sessions with the daughter or other family members would be in the service of helping the family grieve and reach some resolution of their loss. Your interventions would be oriented toward strengthening and improving the communication patterns and relational dynamics within the family rather than being targeted toward the symptoms or behaviors of any individual in the family.

Answering the question “who is my client” is an important step at the beginning of treatment. It deserves time and attention in order to make sure you will be successful in addressing the presenting symptoms and issues. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Value of Case Formulation

I recently started at a new practicum placement, and the agency assessment form includes a case formulation.  I haven’t done this before, so I’m not sure how to write it and how I can use it in my work with clients.  

A case formulation, also called a clinical or case conceptualization, is a theoretically based explanation for the client’s presenting problems and symptoms.  You use the concepts from your chosen theoretical perspective to describe why this client has developed the particular issues that are the focus of treatment.  The formulation follows your diagnosis and assessment and guides development of your treatment plan.  Chapter 8 of my book is devoted to the topic of case formulation, including an illustration of a case formulation written from three different theoretical perspectives for the same case.

The case formulation model I present in my book includes the following five aspects of the case:

  • Symptoms and presenting problems—Begin with a brief summary of the reason for treatment, both from the client’s initial presentation as well as additional issues that may be emerged from the assessment.
  • Developmental history and recent events relevant to the symptoms—Summarize the life events that are relevant to the client’s symptoms.  These would include traumatic events, losses, and significant psychosocial stressors that occurred in the past as well as recent precipitants that have contributed to the client’s current presentation.
  • Factors that contribute to the symptoms—This is the core of your case formulation, making clinical inferences about the links between your client’s life events and symptoms.  It is best to use one theoretical orientation as the basis of your formulation, in order to have a cohesive guide for your treatment.  Sample statements are “client developed a core belief of that she is unworthy of love and attention” or “the early disruption in client’s family life led him to develop an avoidant attachment to his mother.”
  • Cultural issues—Describe how cultural identities and other cultural factors impact the client’s symptoms and will be relevant in the treatment.
  • Strengths and resources—Review the internal and external factors that will assist in lessening the client’s symptoms and will enhance the client’s progress in therapy.

Regarding the question of how you can use a case formulation in your work, it can enhance your work in several ways.  When you hold and communicate an accurate understanding of the client’s difficulties, you are able to convey a deeper level of empathy than is possible based only on the client’s presenting symptoms themselves.  Your case formulation also guides your choice of treatment goals and interventions, allowing you to target more specifically the underlying source of the client’s problems.  Last, you are able to organize new clinical material more readily when you have a case formulation that structures your knowledge of the client’s present and past experiences.

I hope this model for case formulation enables you to develop clinically useful descriptions of the links between your clients’ symptoms and history.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Working with Separation and Divorce


diane suffridge therapistI was recently contacted by a single mom asking for therapy for her 8-year-old son.  She describes him having problems with anxiety and concentration, especially in the day or two after weekend visits with his dad.  They have had joint custody since their divorce two years ago, but mom says dad is skeptical of therapy so she wants to bring her son in for an initial appointment without talking to dad.  I usually like to meet with both parents at the beginning of child therapy, so I’m reluctant to make an exception in this case.  What should I consider in responding to mom’s request?  

Working with families involved with separation and divorce is complex, and you are wise to be thoughtful about how you approach the beginning of therapy in this case.  Chapter 7 of my book includes more detail about this topic, as well as other specialized areas of assessment.  I’ll review the legal and clinical implications of working with one or both parents in child therapy and discuss some of the factors that influence parents to request therapy for their children following divorce.

First, it’s important to consider the legal issues regarding parental consent for a child’s therapy.  If the parents share joint custody, the consent of only one is required; however, if the other parent objects at any point you will be required to end treatment.  It would be detrimental to the child to end therapy abruptly after a few weeks or months, and that is a risk inherent in beginning therapy without the consent of both parents.  At minimum, I would recommend asking the mother to provide a copy of the custody decree so you have confirmation of her report.

Although you might be legally permitted to begin therapy with only one parent’s consent, there are many clinical reasons to engage both parents in the therapy.  Your practice of meeting with both parents indicates you are aware of the importance of hearing both parents’ perspective on the child, the importance to the child of knowing that you maintain a relationship with both parents as he does, and the benefit to the child of providing consultation to both parents about their influence on him.  Part of the initial phase of any therapeutic relationship is establishing the frame, and making an exception to your usual practice would undermine the clarity of the frame and your role as a professional.

It is often helpful to reflect on some of the factors that may influence this mother to seek therapy for her son.  In addition to concern about his emotional wellbeing, she probably has other motivations, both conscious and unconscious.  She may wish to attribute any difficulty in her son’s emotions and behavior to his father in order to reduce her feelings of guilt and shame; she may be looking for an advocate in a legal proceeding regarding financial support or custody; or she may feel threatened by her son’s relationship with his father.  It is wise to assume that this mother’s request is more complex than it may initially appear and to remember that your role is to serve the child’s needs which overlap with but are not identical to those of his mother.

You may find it helpful to develop a standard way of describing your reasons for involving both parents in therapy, especially after divorce.  An example that would fit this case is “I understand your son’s dad has some reservations about therapy, but I have found it essential to talk with both parents in order to make sure I have the full picture.  I won’t be effective in helping your son if I’m not in touch with both of you.  How could we work that out?”.  It is possible that the mother will decide to look for another clinician, and you may feel pulled by your concern for the son.  However, maintaining a clear therapeutic frame is especially important in cases involving divorce.

Most clinicians find it challenging to work with families of divorce, so consultation with an experienced clinician will be helpful.  You may also find ongoing peer consultation to be a resource for navigating the emotionally charged issues that are part of this work.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Sources of Information for Assessment

I have had two therapy sessions with a 24-year-old woman who was hospitalized six months ago for suicidal ideation. She has been stable since then and wants to use therapy to understand what led to her suicidal thoughts. She has given me permission to talk with her psychiatrist and her parents with whom she lives, and she suggested I contact the hospital to get their report of her stay. I usually like to keep the therapy between me and the client, but in this case I think information from these other sources might help.

I agree that it might be necessary to expand beyond your client’s self report of history and symptoms in order to insure your client’s safety while she explores her past suicidal ideation. This question addresses the decisions inherent in conducting an initial assessment, which is discussed in Chapter 6 of my book. I’ll review whether and how to include information from other mental health providers, family members, and treatment records, after discussing the sources of information that come from your client sessions.

Therapy usually begins with a conversation between you and the client in which she tells you what difficulties are leading her to seek help. The initial phase of establishing a therapeutic alliance overlaps with doing an assessment of the client, so you develop a comprehensive picture of her life and circumstances that will guide your treatment approach. Your therapy sessions provide two sources of information about the client: her self-report and your observations. In the first two sessions, she has probably told you about her current concerns and symptoms, living circumstances, and relevant events from the past including her hospitalization. Whether you have been consciously aware of it or not, you are also observing her and noticing the nonverbal aspects of her presentation that are congruent or incongruent with her verbal presentation. Another aspect of the therapy sessions is the impact of the sessions on your own emotional state.

Client self-report and therapist observations are usually the primary source of assessment information, and sometimes are the only source. In this case, I would suggest expanding the client’s self-report by using one or more assessment measures. The Crpss-Cutting Symptoms Measure, contained in the Assessment section of the DSM- 5, is free and can be downloaded at https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. Your agency may have other measures that are relevant to her presenting issues or you can find assessment tools at http://www.integration.samhsa.gov/clinical-practice/screening-tools. It may be useful to compare the client’s narrative report in session with her self report on an objective assessment measure. Your treatment approach will be different if her scores on objective measures indicate greater risk than she has reported to you in the first two sessions.

In terms of the other sources you mention, consulting with her psychiatrist seems essential so that you can develop a collaborative relationship as treatment providers. As your client explores the sources of her suicidal ideation, her symptoms may temporarily increase and her medication needs may change. The psychiatrist can also share the client’s treatment history and response, which you can compare with your client’s report. Talking with your client’s parents is more complicated and needs further evaluation. I recommend postponing that conversation until you know more about your client’s current relationship with her parents, past events in the family, and general family dynamics. Over time you will begin to make inferences about these issues as you hear more about her perspective on their interactions. I would begin this exploration by asking what she expects her parents would tell you and how she would feel about you hearing that from them.

Last, your client has suggested that you read the hospital record. This may contain useful historical and clinical information, so I would recommend requesting it. Be aware that it may be more difficult to obtain a hospital record than to talk with the psychiatrist, depending on the procedures in place there. The discharge summary is the most useful clinical document, so you can ask for that rather than for the full record which will include notes from each nursing shift during her stay that are less relevant to her current status.

Combining these sources of information will result in a comprehensive assessment, which is especially important in cases with elevated risk. Supplementing the therapy sessions with self-report measures, information from another provider, treatment records, and possibly family members will enable you to be clearer in your treatment approach. Your overall goal will be to respond to the client’s desire to understand her past suicidal ideation while helping her maintain physical and emotional safety.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Discussions of Diagnosis

writing-notebookI work at an agency that requires us to give a diagnosis to each of our clients. I’ve gotten comfortable with this requirement and the diagnoses I give to my clients, but I’m concerned that someone will ask me about their diagnosis. I think the clients will feel upset about knowing that I have diagnosed them, so I dread the possibility of someone asking me about it.

One section of Chapter 5 of my book specifically reviews how to discuss diagnosis with your client, and the case example at the end of that chapter includes an illustration of a therapeutic conversation about diagnosis. I’ll summarize some of the important points here.

Your concern is common among clinicians, who associate diagnosis with the medical model and a lack of subjective understanding and empathy for the client. Agencies whose clients rely on third party funding generally require that all clients receive a diagnosis because of funder requirements. Your clients might not be able to get the treatment they need without third party payment and your documentation of a diagnosis that meets medical necessity guidelines, but it does raise a clinical dilemma.

A place to start with this dilemma is to review your diagnoses and confirm that they are accurate based on the clients’ report of symptoms and your observation of them in session. It sounds like you’ve done this with your clients, but your level of concern may decrease if you go through this review systematically. If any of your diagnoses don’t fit the client’s report or if symptoms have changed during the course of treatment, you can modify the original diagnosis to fit the current symptom picture.

In anticipating a conversation with your client, there are several things to keep in mind. One issue is to think about the meaning of diagnosis at this particular time in treatment. A client who raises a question about diagnosis in the second session probably has different reasons for wanting to discuss it than a client who raises the question after six months. When a client asks about diagnosis, you can explore the meaning by saying something like “I’m happy to talk with you about this, but I’m also curious about what goes into your question.” Starting with reassurance that you will answer the question makes it more likely that the client will be open in sharing her/his motivation. You can then discuss the diagnosis in a way that addresses the client’s concern. For example, if the client expresses worry that she/he is “crazy” you will answer differently than if the client wonders what the number means on the statement she/he received from the insurance provider.

A second issue to consider is the emotional response your client is likely to have to the specific diagnosis you have assigned. Approach this conversation in the same way you approach any topic in the therapy. It is best to say a few sentences initially, then ask the client for her/his reaction and be alert for nonverbal cues that provide additional information. If the client’s diagnosis is something that may be negatively charged for your client, consider prefacing disclosure of the diagnosis by a statement like “You may have some preconceptions about what this particular diagnosis means, so if it’s all right, I’d like to tell you why I have used this diagnosis for you.” Then summarize the aspects of the client’s report of symptoms and your observations that support the diagnosis. You can then ask the client if your summary seems accurate. After you and the client have agreed on the symptoms and issues, you can then say “In the field of psychotherapy, that combination of difficulties is described with the diagnosis of (the name of the disorder)” and pause for the client’s response. If the client is concerned about whether this diagnosis means she/he will be unable to improve or to achieve life goals, you can discuss the treatment approaches that you are using and express realistic optimism that the client’s symptoms can be managed effectively.

Probably the most important way to insure a productive and therapeutic conversation about diagnosis is to continue to reflect on your views of diagnosis and the stigma you may hold about diagnosis in general or about specific disorders. If you develop the skill to speak openly about diagnosis, your clients’ shame, self-judgment and suspicion will be minimized. My personal definition of diagnosis is that it is a standard, professional way of summarizing a broad range of information about the client’s present and past symptoms and experiences. For me, a diagnosis doesn’t reflect a feeling or judgment about the client and it doesn’t imply a prediction about the client’s overall capacity to lead a fulfilling life. Holding the meaning of diagnosis in this way enables me to respond to my clients’ questions with confidence that the conversation will not have a negative impact on our therapeutic relationship.

I hope these suggestions are helpful in having conversations about diagnosis with your therapy clients. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Awareness of Cultural Influences

counselingI am a female therapist working with a young woman in her 20’s. She has an opportunity for a promotion which would involve business travel a couple times a month, and would be a good career move for her. However, she is considering turning down the promotion because she helps her parents care for her grandmother who has many health problems. It’s hard for me to see my client sacrifice her professional success for this family obligation. How can I help her with this decision?

This is an example of the influence of cultural values in psychotherapy. You and your client are both female, but you may be different in other cultural identities such as age, ethnicity, social class, sexual identity, religious affiliation, and immigration status. Our values and our views of relationships are shaped by the combination of cultural factors that make up our identity, and these differences between you and your client lead you to different cultural values. The topic of cultural issues in psychotherapy is covered in Chapter 4 of my book.

It is important for you to recognize that you have formed an opinion about what is best for your client based on your values, but she is letting you know that she views her situation differently. Assuming that she needs to come around to your point of view interferes with the understanding that can develop when you are curious and interested in her perspective. Take time to encourage her to explore and reflect on the values she is expressing by pursuing a career and by caring for her grandmother so she can become more clear about the dilemma she is facing. As you are more open to considering her point of view, you will be able to empathize with her complex feelings and to support her making a decision in line with what is most meaningful to her.

Be aware that your client may be making assumptions about what is and isn’t acceptable to her family, and she may not have discussed her decision openly with her family. Our beliefs about ourselves and relationships are often internalized early in life and may not be fully within her awareness or part of recent family conversations. Once you have helped your client become aware of her values, you and she can examine them together to see the extent to which they inform her decision. It may also be useful for her to talk with others in her cultural community to see whether there is more diversity of opinion than she assumes or than she believes based on her individual experience in her family. Getting consultation, especially from someone who is familiar with your client’s cultural influences, will be helpful in managing your feelings as she arrives at her decision.

In addition to your client’s values, examine the practical issues that may influence her decision to take this promotion. The immigration status of her parents and grandmother, the family’s financial resources, and the presence of other support in the community are all factors that may make it more or less difficult for your client to prioritize her career, if that is what she wishes to do. It may take time for her to disclose some of these details to you, depending on the extent to which she holds cultural values that consider such matters as private, not to be shared outside the family.

This career decision may be the beginning of numerous situations your client will face and need to discuss in therapy. Whatever she decides about this promotion, continuing to talk with her about her cultural values will be helpful in her developmental progress. It is likely that she will face similar choices in the future as she navigates her career and family commitments. If you recognize your values and assumptions as culturally influenced and develop an authentic interest and curiosity in your client’s perspective, the therapy is likely to develop into a deeper and richer relationship. You have an opportunity to provide your client with the experience of empathy, understanding, and respect that will build her confidence in making this and future decisions.

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