Tag Archives: Practicum Training

Sharing Client Information in a Team

Teachers TalkingI am a counselor at a high school, and the teachers often ask me about my clients’ progress. I know they have good intentions, but I’m uncomfortable answering their questions. How much should I share and how do I explain the reason I can’t answer some of their questions?

This is an example of working in a team with other professionals who have different expectations and requirements regarding confidentiality and privacy of information. Your client work is probably covered by the Health Insurance Portability and Accountability Act (HIPAA), which carries more limitations on sharing information than the regulations applicable to educational information. It is likely that the teachers know you can’t share fully with them, but your role in the school supports the students’ academic success so it is important to find ways to communicate productively with teachers. This requires that you create a collaborative working relationship with the teachers and other staff in the high school. I will recommend several steps you can take to establish yourself as part of a professional team.

One step is to have a short response regarding confidentiality requirements that you can use when a teacher asks you for specific information. An example is “you probably know I can’t share any details about the counseling, but I’d like to work together within the constraints I have to follow.” This establishes the limits of confidentiality while also communicating your desire to collaborate. Remember that teachers are often working in difficult circumstances and may be looking for support. When you can express your understanding of their concern for the students and the challenges they face in the classroom, the teachers will see you as an ally even if you can’t answer their questions. Follow your statement about confidentiality with an acknowledgement of their concern and desire for the student to get the help he/she needs.

Often, the next step will be to open a conversation with the teacher about how the student is doing in class. You might say “has anything happened lately that I should know about?” or “I’m interested in your perspective on how things are going.” The teacher’s question to you about the student’s progress may represent a desire to tell you something about the student’s life or a recent incident in the classroom. This information can be valuable background in your understanding of the student. Your client may present very differently in your counseling sessions than in the classroom or with teachers and peers. HIPAA limits the information you can share about treatment, but it doesn’t limit what you can hear from others.

You may also want to schedule a more formal conversation with one or more of your student’s teachers to ask specific questions that will aid in your assessment and treatment planning. It is wise to prepare a list of questions in advance so you can be focused in your discussion with the teacher and insure that you get the information you need. As treatment progresses, check in with the teachers periodically to get updates on the student’s progress in the classroom both academically and behaviorally. This information will enhance your review of treatment goals and help you to shape the direction of treatment.

Last, there may be times when you feel it would be helpful for you to share your impressions of the student with one or more teachers. You might have suggestions that the teacher could implement in the classroom or you might be able to provide an explanation for some of the student’s behavior that is otherwise confusing or creates conflict. If this is the case, you will need to have written permission from the parents and/or your client. Generally, parental consent is required for sharing treatment information for children under 18, but some states allow a minor to consent to treatment which would require that you get the student’s permission to share information. Even if it isn’t required by law, it is clinically sound to talk with the student about what you plan to share with the teachers and the reasons you think it would be helpful.

I hope you find these suggestions helpful in working as part of a team. Please email me with comments, questions, or suggestions for future blog topics.

Evaluation of Client Appropriateness for Treatment

worried therapistA client was recently assigned to me, and when I contacted her to set up an appointment she told me she had been in the hospital a month ago because of suicidal thinking. I’m not sure whether I should take on this client since I’m in a practicum and have only seen clients for a few months. What should I do?

It is a very good idea to ask the question of whether a client is appropriate for treatment with you before you begin with anyone new. This situation poses particular challenges because of the client’s recent suicidal thinking, but it is a good idea to take some time to evaluate that question with all new clients assigned to you. I will outline some factors to consider in the evaluation of your client’s risk.

Since you are in a practicum setting, the first step is to consult with your supervisor. She/he needs to know about your client’s hospitalization to determine whether she/he is comfortable supervising the case and proceeding with an initial appointment. If not, you’ll get suggestions on how to refer her to another resource either within or outside your agency. If you get approval to schedule an initial appointment, ask for your supervisor’s guidance about how to make an evaluation that will guide your decision to proceed with ongoing treatment.

Some of the factors I would consider in evaluating your client’s risk and the appropriateness of outpatient treatment are 1) her history of suicidality and hospitalization, 2) her ability to describe the precipitants and current strategies for managing suicidal thinking, 3) her level of engagement in treatment, and 4) the availability of other resources both within your agency and outside. I will discuss each of these factors briefly.

Your client’s history of suicidality and hospitalizations will assist you in determining whether you can help her to manage her symptoms on an outpatient basis. Her risk is lower if this was her first episode and is greater if she has had prior episodes especially if they occurred within the last year. Another area for evaluation of risk is her ability to describe the suicidal episode with some insight into the contributing factors and how she will manage suicidal thoughts that may recur. You’ll want to know whether she has a safety plan and how she has used it since being discharged from the hospital. Outpatient treatment is likely to be more successful if she has developed some insight into the recent episode and if she has strategies for managing recurring symptoms. Some clients adopt an attitude of distance from their symptoms after a hospitalization and are unwilling to talk about a safety plan, stating things are different and the symptoms aren’t going to recur. Although it may seem reassuring to hear this from a client, it is actually indicates a greater risk of future escalation.

While you are meeting with your client, you can assess her level of engagement in treatment by noticing whether she interacts with you in a collaborative manner and has ideas about her needs and plans for using therapy. If she is more passive or doubtful about the usefulness of therapy, it is less likely that you’ll be able to work with her productively. This is especially true if she is unable or unwilling to access other resources in addition to your individual outpatient treatment. Seeing a psychiatrist for medication management, attending a support or psychoeducational group, engaging in couple or family therapy, and/or receiving assistance with financial and housing needs are often vital to the success of therapy with someone who is recovering from an episode of suicidality.

A final step I recommend in evaluating the appropriateness of this client for your case load is to reflect on your experience with suicidality in your personal life as well as in a professional or volunteer capacity. This case may bring up past memories and difficult feelings if you have personal experience, and this is an area to discuss with your supervisor before and after your initial session. At some point, you will need to face this area of difficulty, but you should do this at a time that you feel as prepared and supported as possible.

I hope you find this helpful in evaluating the appropriateness of a client for treatment. Please email me with comments, questions, or suggestions for future blog topics.

Cultural Values in Treatment Goals

counselingI just completed my first session with a 21-year-old Latina who is a first generation American. She seems to rely too heavily on the opinions of her parents and other older members of her family in making decisions about her career and dating life. She said she wants to feel less anxious, and I think that will only happen if she becomes more independent of her family. How shall I talk with her about this?

Before talking with your client about her goals, I would suggest doing some exploration of your views and how they differ from your client’s. This situation highlights the impact of cultural values on treatment goals, and it is important that we examine our values and assumptions before recommending a treatment approach.

The first step in this situation is to recognize that you have developed an agenda that is different from your client’s. Any time this happens, you need to pause, examine the discrepancy, and work to understand your client’s perspective on what is best for her. In this case, you seem to have made some assumptions about your client’s relationship with her elders that will interfere with the therapeutic alliance. Her alliance with your depends on experiencing your respect and support for her in working toward her priorities. Over the course of time, your client may come to desire greater independence from her elders, but your task at the beginning of treatment is to join with her in working toward reducing her anxiety. Otherwise, she may feel undermined in defining what she needs.

The second issue to recognize is the extent to which values and beliefs about developmental goals and relationships are embedded in a cultural context. Your view that independence from parents and other family members is a desirable goal for young adults is no doubt consistent with the values of your cultural community, but your client comes from a cultural community that values interdependence and respect for elders. Talking with your supervisor and other colleagues about these cultural differences will help you to identify the strengths and benefits of your client’s values rather than assuming that she should come to share yours.

Another more complex issue to consider is the extent to which your response to your client may reflect her own conflict about her family relationships. It is helpful to reflect on your countertransference feelings and to talk about them in supervision. If you usually find it easy to join with your client’s agenda, it is possible that your strong opinion about this client’s need for independence represents your resonance with a part of herself that she is reluctant to articulate. If this seems plausible, you can support your client to recognize and sort through the complicated nature of her feelings toward her parents and other family members. This will work in her best interest if you can express an attitude of curiosity rather than judgment and if you help her identify and honor the mixture of different feelings she holds.

I hope you find this helpful in working with clients whose initial treatment goals are different from yours. Please email me with comments, questions, or suggestions for future blog topics.

Using Therapist Emotions to Understand the Client

new2I have been seeing a 35-year-old woman for about six months at my practicum site. I left the last session feeling at a loss about how to help her. She was sexually abused as a child, and I’m afraid I don’t have enough experience to be an effective therapist for her. How can I decide whether to refer her to a more experienced clinician or get more training myself?

It sounds like you had a strong emotional response to the recent session with this client that brought up questions for you about your effectiveness. Before making a decision to do something different in the treatment, I would suggest reflecting on your emotions as a way to understand the client in a deeper way. Your feelings of inadequacy and self-doubt may reveal something important about the client’s experience in relationships and her view of herself.

The first step I recommend is to take some time to identify your emotional response to the client more completely. In addition to your own reflection, you may find it helpful to talk about this with your supervisor, therapist, and colleagues. When we feel uncomfortable emotions during and after a session, it is tempting to ignore or avoid them and to take action to reduce our discomfort. Instead, take time to go more deeply into your emotions by identifying the thoughts, images, and physical sensations that accompany the emotion. If you have a mindfulness practice, use that practice to engage with your emotional experience without judgment.

After you have a more complete understanding of your emotional response in this recent session, review what you know about your client’s history, developmental trauma and losses including the sexual abuse, and her current relationship patterns. All of these experiences may be relevant to the emotion that has been stimulated in you. Think about the connections you can make between your emotions and the client’s experience. It is likely that your emotions mirror a painful experience from her past and present relationships. Ask yourself when your client has felt inadequate and ineffective with others. She may or may not have been able to talk directly about these feelings, so you may need to make inferences about feelings she has kept outside of her awareness and aren’t accessible verbally. Supervision is helpful in identifying links between your emotions and the client’s.

Last, identify ways you can respond therapeutically to your client in the face of your feelings of inadequacy. It will help to think about capacities she needs to develop or how she could manage her feelings of inadequacy with greater strength and confidence. An example might be for you to say “it may feel daunting to face the impact of your past but I think our work together can result in you developing different ways of handling the triggers when they arise” or “I wonder if you sometimes feel like giving up and it’s hard to believe things can get better.” If your client is directly questioning your capacity to help her, you can acknowledge her worry along with your commitment with a statement like “you may worry whether your difficulties are more than I can handle and I think that’s an important issue for us to talk about together.”

As you respond therapeutically to the client using your understanding of your emotions as a connection to her experience, you will notice changes in her way of relating to you and changes in your emotional response to her. She may begin talking more directly about her feelings of inadequacy, she may deepen her engagement with the therapy and the pain of her abuse, or you may notice that you’re feeling more sadness about the impact of her trauma rather than worry about helping her. All of these changes are indications that you have used your emotions to further the therapeutic process. If your questions about the effectiveness of the therapy continue, talk further with your supervisor about whether a different therapeutic approach or a referral to additional services would be indicated.

I hope you find this helpful in using your emotional responses to understand your clients. Please email me with comments, questions, or suggestions for future blog topics.

Assessing a Confusing Initial Presentation

Diane SuffridgeI just had the first session with a 22-year-old client at my practicum site. She seems depressed, but there is also something different about her than my other depressed clients. I found it hard to connect with her, which is unusual for me, and she couldn’t really tell me anything about her history. She says her childhood was fine, but she doesn’t remember much until she was about 11. How can I figure out what is going on for her?

You have identified several factors in your client’s initial presentation that leave you feeling uncertain about your diagnosis and conceptualization of her difficulties. An important first step in understanding your client is to acknowledge the confusion you feel rather than rushing to a premature conclusion. It may take several sessions to begin to piece together a cohesive picture, but it is preferable to move slowly than to attempt to resolve your questions too quickly. I’ll outline some approaches I would recommend for the next 3-4 sessions to move toward understanding your client more fully.

It seems likely that this client will benefit from your direct expressions of empathy and understanding. This is the basis of all therapeutic relationships, but your experience that it was hard to connect with her suggests that she has more fear and expectation of harm or rejection than many of your other clients. This may be outside of her awareness, so she probably didn’t say anything directly to reflect fear or mistrust. However, pay particular attention to making reflective statements, summarizing what you understand, and validating her decision to seek help for her distress. This will create a therapeutic atmosphere in which she will gradually develop trust and will be more open in talking about herself.

Since you have identified differences between this client’s presentation and others who describe their problems in a similar way, I would also recommend asking clarifying questions in order to avoid making assumptions about the meaning of her statements. For example, when she says she is depressed, you could say “people experience depression differently—how does it affect you?” or “can you tell me more about what is happening with the depression?” Since aspects of her presentation indicate the possibility of early trauma, I would also recommend reviewing the diagnostic criteria for PTSD and dissociative disorders so you are familiar with symptoms that could be interpreted as depression but are actually the result of trauma. A way to begin to identify dissociation would be to ask something like “would you describe yourself as more sad or more numb?”

As your client feels more comfortable with you, she may begin disclosing unusual symptoms and experiences that go beyond depression. This is another reason to familiarize yourself with other diagnoses, including dissociative and psychotic disorders, that could present similarly to depression. You may want to ask direct questions about these symptoms in order to identify an accurate diagnosis, and it is best to do this in a straightforward, normalizing manner. Examples are “Some people find themselves hearing voices when no one is around. Does this ever happen for you?” or “Sometimes people feel detached from their surroundings or themselves, as though they’re looking at themselves from the outside. Have you ever had that experience?”

Last, I recommend continuing to be aware of your observations and emotional responses to this client. Since she seems to hold large parts of her experience outside of awareness, the nonverbal communication between the two of you will be central in your understanding of her. Including this information in your assessment will lead you to a more accurate diagnosis and case formulation. It is also likely that you will continue to have some questions for the next several months, so continue move slowly in reaching conclusions. Identify what things seem clear and what things are uncertain about her presentation, and hold the ongoing ambiguity.

I hope you find this helpful in assessing clients who have a confusing or puzzling presentation. Please email me with comments, questions, or suggestions for future blog topics.

Ending Therapy or Taking a Break

I am doing my practicum placement in a high school, and I plan to return there next year after a summer break. Several of my clients have said they want to see me again in the fall, so I’m wondering how to talk with them about taking a break and returning to therapy.

It is wise to think ahead about how to handle this situation. I would recommend thinking of the therapy as ending when the school year is over with the possibility of resuming when school begins in the fall. There are many factors outside of the control of you and your student clients that make the continuation of your relationship uncertain. For example, they may move, their presenting issues and symptoms may improve or worsen in a way that changes the decision about your work with them, or the school may set different priorities for which students can receive therapy. There are clinical benefits for clients to engage in a thoughtful process of termination, and they will miss those benefits if you assume continuation of therapy and it isn’t possible to do so.

I have previously published some general guidelines related to psychotherapy termination which may be helpful to reference (Psychotherapy Termination and Termination Tasks). There are some additional issues that are present when you may be resuming therapy in a few months. The first is the variation in your feelings of closeness and enjoyment with different clients. Talk with your supervisor about your countertransference feelings related to all of your student clients and your preference for seeing them next year or discontinuing permanently. It is important to examine these preferences and to discuss your plans to return to the placement next year in the same way with all of your clients. If you are more explicit with some clients than others about returning to therapy next year, you are probably expressing your countertransference, unless your statement is based on a clear clinical decision approved by your supervisor. Examining and understanding the countertransference is preferable.

A second issue is the likelihood of changes in the life of your clients over the summer, both logistically and psychologically. The client may feel differently about therapy in a few months, and issues in her life may change in a way that affects her decision. Your desire to focus on the continuation rather than termination of therapy may be a way of avoiding the potential loss of ending your therapeutic relationships and the realistic ambiguity about the coming school year. Maintaining a focus on the ending of the current therapy by reviewing the progress that has been made and acknowledging the importance of your relationship with each other provides more therapeutic benefit to your client.

Third, talk with your supervisor about recommendations you may make to your clients and their parents about ways to reinforce the gains they have made in therapy. Parents and teenagers often view summer as a time for vacation from therapy, especially when therapy has taken place at school. However, your clients may be participating in activities that provide opportunities to practice some of the coping skills they have acquired or to take on new social and emotional challenges.

I hope you find this helpful in managing psychotherapy termination when the circumstances are ambiguous. Please email me with comments, questions, or suggestions for future blog topics.

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.

Resolving Problems in Supervision

img-article-are-you-too-stressed-outI am having problems with my supervisor and am thinking about requesting a new supervisor. She seems impatient and critical of me, so I feel intimidated and that makes it hard for me to take in her feedback. When I tell her how I feel, she says she’s trying her best to help me learn. I don’t know how to make this better so maybe I should change to someone else.

This is a painful situation, since supervision is a crucial part of growing into the therapist role. It’s easy to feel hopeless and think that a change of supervisor is the only alternative. My experience has been that this kind of impasse can often be improved with thoughtful self-reflection and conversation, so I’ll first suggest some ways to examine the possible dynamics of this situation. Then, I’ll outline some recommended steps to approach the conversation that are likely to make it more clear whether your supervisory relationship can improve and contribute to your learning and growth.

My first comment is that engaging in self-reflection and finding ways to shift your feeling of intimidation to one of empowerment will contribute to your ability to handle other difficult clinical situations. You are likely to face interactions with clients, family members, or other professionals that contain some of the same features of this supervisory relationship. Since your supervisor’s job is to support your clinical growth, she is likely to be most responsive to your efforts so it is a good place for you to test out some new relational skills.

To begin your process of self-reflection, I encourage you to shift your attention from your supervisor’s comments to your own response. You mention feeling intimidated, so explore the thoughts, feelings, and images that are present in that sense of being intimidated. You may identify thoughts undermining your self-worth and competence, feelings of shame and inadequacy, and/or images of yourself as a child being chastised by a parent or other authority figure. As you identify your response on a deeper level, remember that these thoughts, feelings, and images are yours and are stimulated by your supervisor but are not the only response you might have. Although your supervisor is an authority figure, you are not a child dependent on a parent’s care and approval but an adult growing into a professional role. When your supervisor gives your feedback on your clinical work, it is not confirmation of incompetence but confirmation that you are in the early phase of learning a set of new skills.

It may be helpful to talk with other supportive people while you engage in this process of self-reflection, especially if your supervisory interactions stimulate unresolved issues from your early life. Talking with your therapist, academic mentors, or past clinical supervisors may be useful. It can be hard to recognize and challenge old patterns when your feelings are strong and painful. It may also be helpful to talk with peers and friends to gain support and encouragement; however, be careful to avoid presenting the situation in a way that will lead them to see the situation as hopeless and affirm your fear that it can’t get better.

After you made progress in understanding your response, challenging some of your underlying beliefs, and grounding yourself in your clinical role, it is time to return your attention to your interaction with your supervisor. Consider the possibility that simply shifting your response from one of intimidation to collaboration will change the dynamic in a positive way. I would suggest initiating a conversation about your supervisory relationship, acknowledging it has been difficult and sharing that you have examined your response and are attempting to shift some of the things that have interfered with your openness to her feedback. State in a positive way what you feel you have received from supervision and what you wish to gain from her expertise.

If supervision continues to be difficult after having a conversation like I describe above, the next step that may be helpful is to talk with the director of training or another clinical supervisor in the agency. Your agency may have a procedure in place for resolving supervision difficulties, which you should follow, but if not seek out someone who has some supervisory and/or administrative responsibility for the training program. A conversation with a third party may give you further insight into the difficulty you are facing and lead to a more fruitful conversation with your supervisor, or it may lead to a decision to schedule a meeting between you, your supervisor, and the third party to discuss the problems and attempt to reach resolution. A decision to change to a different supervisor is rarely necessary if you follow all of these recommended steps.

I hope you are able to use these suggestions in understanding difficulties you face in supervision. Please email me with comments, questions, or suggestions for future blog topics.

Client Attendance

young woman in therapyI’ve been seeing a client for three months, but she has only come to 7 sessions.  Sometimes she calls to cancel, but often she just doesn’t show up. I don’t know whether I should stop seeing her or if there is another way to help her understand the importance of coming in regularly.

This is a common dilemma, especially for clinicians in training or agency settings. It is difficult to make therapeutic progress when clients miss one or more sessions each month, and it is often challenging to engage the client in examining the reasons for irregular attendance. I will describe two approaches to this issue, and you may find either or both of these approaches helpful with this client and similar situations.

The first approach involves having a standard policy regarding attendance, setting a limit on the number of missed appointments or late cancellations. Your agency may have such a policy or you may develop one if you are working in a private practice setting. This policy should be part of your informed consent process, and I recommend that you remind the client about this each time she misses an appointment without notice or with late notice. A common standard is to allow three missed appointments or late cancellations (usually less than 24 hours’ notice) in a four month period before ending treatment. You may decide to make exceptions for illness or unavoidable emergencies, but be sure to discuss this with the client and let her know the reason for making an exception. The purpose of this type of policy is to insure that there is discussion about the issue of attendance and that the client is able to make progress on the issues she wants to address.

The second approach, which can be used instead of or in addition to an attendance policy, is to handle the client’s sporadic attendance as a clinical issue. The basis for this approach is an assumption that the client is repeating a traumatic or maladaptive interpersonal relationship and that you can provide the client with a different experience that will have a therapeutic outcome. I will outline a three step process for making such a clinical decision.

The first step in understanding the meaning of the client’s missed sessions is to reflect on her developmental history, especially regarding attachment and loss, and her descriptions of current relationships with intimate partners. Identify one or two themes that are present in these early and recent relationships. One common theme is an unpredictable attachment figure which leaves the client with feelings of longing and inadequacy. Another is an intrusive or abusive attachment figure leading the client to sacrifice safety to meet her need for connection. Think about the implications of these interpersonal experiences for the client’s view of herself and expectations of others.

The second step is to examine your countertransference and identify the interpersonal experience that the client is repeating with you. Be honest and thorough in reflecting on all of the thoughts, emotions, and images that are present when you wait for your client or when you pick up a message cancelling a few hours before the appointment. Notice any attributions you make about the reasons for the client missing the appointment and about the value of the therapy or your value as the therapist. Think about parallels between your thoughts and emotions and the client’s interpersonal themes. The client may be placing you in the position of the attachment figure or in the more vulnerable position she was in as a child.

Once you have identified the relevant experience and the roles being enacted by you and the client, you are ready to decide on a response that will allow the client to experience this interaction differently. This third and final step usually begins with shifting your countertransference state so that you are in touch with your therapeutic intentions and skills. You can then talk with the client in a different way than is possible when you are in the grip of the client’s enactment. In the best of circumstances, your response allows the client to become more engaged in the therapy whether or not she gains insight into the nature of the repetition. At other times, the client continues her side of the repetition, and you will need to decide whether to introduce limits as discussed above. Even in these situations, however, there is an opportunity for your learning and you can end the therapy, if necessary, knowing that you provided every opportunity for a therapeutic outcome.

I hope you are able to use these suggestions when working with clients whose attendance is irregular. Please email me with comments, questions, or suggestions for future blog topics.

Applying for Internship Training

FullSizeRender (49)I plan to apply for internship training in a few months, and I want to work with children and families. How can I make myself a competitive candidate when my clinical experience so far has been with adults?

Your question highlights a common dilemma that isn’t limited to clinical work; i.e., how does one gain experience when the positions require prior experience? You are wise to plan for this ahead of time, and there are several strategies that will increase the likelihood of you being accepted into a training position that will give you the experience you want. Typically, there are two steps in being accepted for a training position. The first is to be invited for an interview, and the second is to be offered a position. Therefore, it makes sense to think of your strategies in two steps as well.

Your written application will determine the decision of the training agency to invite you for an interview, so let’s look at that step first. You are more likely to be invited for an interview if you submit written materials that follow the format and structure requested by the agency and are professional in appearance and language. Prepare your materials in advance of the deadline so you have time to proofread them. It is preferable to have someone else also look over them for obvious errors. If you submit materials electronically, by email attachment, be sure they are in a commonly used document type (PDF or Word document) without complicated formatting.

Familiarize yourself with the agency, and mention in your cover letter the aspects of the agency that are particularly attractive to you. You can research an agency by looking at their website, talking with other students in your program who have done training there, attending an open house if possible, and asking supervisors and professors what they know. Be careful to not make assumptions, though. I have received applications that incorrectly assumed the agency used a specific modality of treatment or served a particular client population, based only on its name.

Regarding the content of your written application, I would recommend that you both acknowledge your lack of clinical experience with children and families and highlight other relevant experience. For example, you might have done child care, teaching, camp counseling, or volunteer work. In your cover letter, explain how the work you did gave you valuable knowledge about the challenges faced by children and families and how you want to expand that knowledge by working clinically. You would be wise to take on a volunteer commitment now, even if only 5-10 hours per week, that would demonstrate your commitment to improving your skills. Also consider applying to agencies that see individual adult clients as well as children and families, so that your prior experience will be more relevant to the agency population.

If you are successful in step one, you will be invited to interview with one or more staff members. Think about the interview process at your prior placements, and be prepared to answer typical questions about your interest in the agency, your preferred theoretical orientation, your self-assessment of strengths and challenges, and your future career goals. It is also wise to prepare a short case vignette that illustrates a challenging situation that you managed successfully.

Plan your answers to interview questions about your lack of child and family experience carefully. In addition to the suggestions above which apply to an interview as well as a cover letter, consider ways in which your clinical experience with adults will transfer to child and family work. For example, you may have worked with parents and developed empathy for the difficulty of raising children when living with a history of trauma and psychosocial stress, you may have had worked with young adults facing many of the developmental issues of adolescence, or you may become aware of the impact of family relationships in your contact with the family members of adult clients living with serious mental illness. Also highlight the skills you have acquired that will transfer to child and family work such as diagnosis and assessment, case formulation, treatment planning, or the use of trauma or substance abuse treatment models. Be realistic in acknowledging how much you have to learn while describing the knowledge and skill you have attained thus far.

After your interview, solicit feedback from the interviewers if you aren’t accepted into the agency training program. Ask if they have suggestions on how you could improve your presentation or performance in the interview. This might give you valuable information about how to be a more competitive candidate for future positions.

I hope you find these suggestions helpful in applying for internship training. Please email me with comments, questions or suggestions for future blog topics.