Tag Archives: Psychotherapy

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.

If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.


Theoretically Based Concepts in Documentation

person-apple-laptop-notebookI’m using a psychodynamic theoretical orientation in my work with clients, and I don’t know how much explanation of these concepts to put in my client’s progress notes and assessment. If anyone else looked at my notes, they might not understand why I chose particular interventions without the theoretical background. However, I learned from my supervisor that documentation should be behavioral rather than psychodynamic.

This is an important issue to consider in creating a client record, since your record may be viewed by other professionals or by your client. The primary interest for others viewing the client’s record is less about the reason for your interventions and more about what you did and how your client responded. When a client or another professional requests a record, it is most often for the purpose of insuring continuity of care or to learn about your client’s presenting problem and progress. You can maximize the value of the record for those purposes when you use language that is easily understood by people who are unfamiliar with psychodynamic or other theories of psychopathology and psychotherapy. It is likely to be distracting rather than helpful to try to explain the theoretical basis for your interventions.

One way to create a record that others can understand and use is to translate theoretically based concepts into terms that are more descriptive and objective. An example is to describe the client as “protecting herself from painful experiences” rather than “using the defense of projection” or to describe your intervention as “assisting the client to develop insight in order to modify his habitual patterns” rather than “interpreting unconscious motivations for self-sabotage.” This approach may be contradictory to assignments in your academic courses, where you are being evaluated on your understanding of and ability to apply theoretical concepts. That is an important skill, and it is a crucial element to an effective treatment plan. However, clinical documentation serves a different purpose and is written for a different audience than academic papers or a clinically oriented theoretical formulation of a case.

Another way to focus your attention in writing clinical documents is to keep the client’s goals uppermost in your mind. This means being aware of the context of your interventions as working to help the client make the changes they want to make. This might lead you to say “declined client’s request to extend the length of the session and supported her ability to self-regulate intense emotions” rather than “set limit on client’s attempt to test boundaries when in a dysregulated state.” Your documentation will convey a more collaborative tone when you focus on the desired outcome of your interventions, which is preferable when the record is viewed by others including the client.

I hope you can use some of these suggestions in writing clinical documentation that is understandable to professionals who have a different theoretical perspective and to nonprofessionals. Please email me with comments, questions, or suggestions for future blog topics.

Nonverbal Cues Related to Culture

nonverbalculturalcluesI recently had a first session with a client who immigrated from India last year. I’m Caucasian and haven’t lived outside the United States. My client didn’t seem as receptive to therapy as most of my other clients, and I assume this has to do with our cultural differences. What can I do to make it easier for her to benefit from therapy?

It is good for you to begin this therapeutic relationship with an awareness that you will need to make some adjustments in your usual therapeutic practices in order for this client to benefit from therapy. When we have significant cultural differences from our clients, it is our clinical responsibility to learn about the implications of these differences for establishing a therapeutic relationship.

The first step I would suggest is to get some education and consultation on your own, with supervisors, professors, and colleagues and by accessing professional publications in print or online. Since there are many cultural groups within India, it will be important to know your client’s geographic, religious, and class identifications. The easiest aspects of this education will be general information about views of health and mental health, symptoms, and treatment. Your client will also be able to tell you about her understanding of these aspects of her culture. Issues and struggles for first generation Indian clients are reflected in movies and books. The movie “Bend It Like Beckham” and the book “Life’s Not All Ha Ha Hee Hee” by Meera Syal are examples.

In general, boundaries within the Indian culture are very different from those in the West. Many generations live together, elders are expected to be cared for, and daughters in law are expected to bear the brunt of the work in traditional homes. Explore your client’s family structure and expectations, including the family members and living arrangement she left in India and whether she lives with family members or has acquaintances in the U.S. Approach these discussions with openness and keep in mind that individuation may not be the goal of therapy for your client. The structure of a family system that fosters both a sense of connection and a sense of individual wellbeing for this client may look different than for your clients who come from traditional Western culture.

The more difficult aspects of your need for education will be learning about the relational expectations of your client’s culture including nonverbal cues (i.e., eye contact and other gestures) and boundaries. It may be helpful to supplement your education about your client’s specific culture by consulting with colleagues and acquaintances who have immigrated from other cultures. They may be able to share their observations about the unspoken practices and expectations of U.S. culture which are outside of your awareness.

Regarding Indian culture specifically, clients are likely to present as cautious, anxious, or even timid with limited eye contact. These nonverbal cues are not a reflection of avoidance or resistance to therapy, but are signs of deference. The client will expect guidance and direct instruction and will feel comfortable knowing that the clinician is the expert. Therapy initially should be somewhat structured and have clear goals.

If your client immigrated in midlife or later, be aware that many older generation Indians are not psychologically educated and as a result present with somatic problems. They may be referred by a physician rather than self-referred. Consider spending time understanding how the somatic issue affects the client’s life and overall sense of wellbeing including how it affects their spiritual practice, diet, and family life.

In addition to education and consultation, your attentiveness to your client in session will give you valuable information. You mention that she didn’t seem as receptive to therapy as other clients, so I recommend giving some thought to what you observed or inferred in her behavior. Notice the nonverbal aspects of her interactions with you, and see if you can match her level of engagement in terms of expressiveness and eye contact. This may increase her comfort by reducing the interactional discrepancies between you. Be attentive to times in the session when she seems more or less comfortable and think about what may have been different in your relational style at those times. Emotions are often communicated through nonverbal gestures as much as or more than our words, so be careful about making interpretations about her emotional state based on your cultural assumptions. Note that the meaning of nonverbal cues is different across cultures; for example, a nod of the head that indicates saying “no” in western culture means “yes” for Indians.

It may also be useful to have some direct discussion with your client about some of the structural aspects of therapy that are unfamiliar to her. Interpersonal boundaries are experienced very differently in different cultures, so the meaning of professional behavior may be different for your client than you intend. Consider telling your client about the meaning of your professional boundaries and the therapeutic frame, acknowledging that these practices may be unfamiliar to her and may even seem odd. Invite your client’s comments and be open to shifting some aspects of your boundaries in minor ways if that will facilitate the development of the therapeutic relationship. For Indian clients, examples of appropriate differences in boundaries are accepting a small gift or a hug offered out of gratitude from the client, joining in the use of humor to bring warmth to the session, and using a double-handed hand shake.

I hope you find these suggestions helpful in understanding the nonverbal aspects of the therapeutic relationship in a cultural context. Please email me with comments, questions, or suggestions for future blog topics.

My colleague, Fenella das Gupta, LMFT, Ph.D. Neuroscience, provided consultation in developing the content of this blog post.  See Fenella’s website at http://www.innermirror.com for more information about her practice.



Steps to Developing a Diagnosis

My agency requires assigning a diagnosis after the first session, and this is very hard to do.  How can I give a diagnosis to my client when I don’t have complete information about them?

This agency requirement is probably related to third party billing and the need to document the medical necessity of the services you are providing to the client. While this requirement ensures that your clients have access to the services they need, it can be frustrating as a clinician to assign a diagnosis when you haven’t had a chance to develop a comprehensive understanding of their symptoms. I will suggest a couple of strategies regarding the notation of the diagnosis itself that may alleviate your concern and then  outline a three-step process for arriving at a diagnosis after the first session or after a more thorough assessment.  My comments are based on using the DSM-5, and may need to be adapted if your agency is using the DSM-IV.

One strategy is to check with your supervisor or the billing manager about the use of diagnoses marked “Provisional” when you have incomplete information.  If this is allowed by the third party, it is a way to acknowledge that your diagnosis is tentative.  Situations in which a “provisional” diagnosis are appropriate are when you know a client meets most of the criteria but haven’t confirmed the full set of criteria required for the diagnosis or when the client reports a diagnosis given by another health care provider that you haven’t verified independently. Also ask about the use of “Other Specified” and “Unspecified” diagnoses when you have determined which category the client’s symptoms fit but don’t know whether they meet the criteria for a specific diagnosis within that category.  These diagnoses are often useful when your information is incomplete, if they are acceptable to the third party.

A second aspect of diagnosis that may alleviate some of your concern is to view diagnosis as an ongoing process rather than a decision that is made once for the duration of the client’s treatment. The diagnosis you assign after the first session may not be the diagnosis that accurately reflects the client’s history and symptoms that emerge as you complete an assessment. This will be most likely if you have used “provisional,” “other specified,” or “unspecified” in your diagnosis, but there are other times when the client’s initial presentation differs from the impression you get after four to six more sessions. I also suggest reviewing the diagnosis every six months or whenever you update the treatment plan. This allows you to update the diagnosis if appropriate, to reflect changes in the client’s symptoms or new historical information you have learned.

I have developed a three-step process to help new clinicians develop a diagnosis, and the worksheet reflecting this process is available for download in an online workbook. I find that new clinicians often have difficulty prioritizing the different pieces of information they have about clients, and this leads to confusion in identifying the most accurate diagnosis. A more detailed description of the diagnostic process is contained in Chapter 5 of my book, available through Amazon or Routledge.

My recommendation is to begin by listing the client’s current symptoms and past symptoms reported as part of the history. This ensures that you consider all of the data that is relevant to the client’s diagnosis rather than prematurely focusing on one aspect of the presentation that may lead to an inaccurate diagnosis or may neglect a secondary diagnosis that is clinically important.

Second, make note of the categories in the DSM-5 that fit your client’s symptoms, being as comprehensive as possible.  In the worksheet, I suggest that you note the categories in which symptoms are present (or are part of the history) and then note whether these symptoms are relevant to the current treatment, i.e., part of the reason for the client seeking treatment. This notation will serve as a reminder to address the relevant symptoms in your treatment goals.  Remember to include the “Other Conditions” category if your client has psychosocial stressors, relationship difficulties, or a history of trauma.

The third step is to look at the specific diagnoses within the categories you have noted to see whether your client’s symptoms meet the criteria for one or more diagnoses. If you noted the “Other Conditions” category, review these codes to determine which situational factors are important to include in your diagnosis. Often, your client’s clinical presentation may be best described by one or more diagnoses and one or more Z codes.  If this is the case, choose the diagnosis that best represents the reason for treatment as the primary diagnosis which will be reported for billing purposes. The other diagnoses will be included in your assessment to provide a comprehensive view of the client’s symptoms, history, and current psychosocial stressors.

I hope you find these comments helpful in working with DSM-5 and diagnosis. Please email me with comments, questions, or suggestions for future blog topics.


Having Difficult Conversations with Colleagues

I’m seeing a heterosexual couple in couples therapy, and a colleague at my agency is seeing the wife individually. Last week my colleague made a critical comment about the husband and questioned how helpful couples therapy could be. She said this in front of several of our peers, and I didn’t respond because I was shocked and hurt. I think I need to say something to her, because her negative view of the couples therapy will undermine the wife’s participation. There is a lot of conflict in the relationship but they have both expressed a commitment to work it out and stay together.

This is my second blog on the topic of having difficult conversations. It may be helpful to read the prior blog about client conversations if you didn’t do so already. This situation with your colleague is an example of difficult conversations that can arise when we share cases or consult with colleagues about our work. Growing into the role of clinician means developing skills to talk with colleagues as well as clients about uncomfortable issues and areas of conflict. You’ve already made an important first step in deciding that you need to talk with your colleague rather than avoiding a challenging interaction. I would agree that having a disagreement between the individual and couples therapists can be harmful to the client, and I would add that it can also be informative to both the individual and the couple therapy.

I would suggest that you engage in personal reflection before you approach your colleague. It is important to identify 1) the nature of the conflict or difficulty you are experiencing with your colleague, 2) assumptions you may be making about the reasons for the conflict, and 3) the desired outcome of a conversation. During this process, it may be helpful to consult with another trusted colleague or your supervisor to sort through your feelings and hear some alternative explanations or outcomes you may not have considered.

When you reflect on the nature of the conflict, identify the content or issues of disagreement as well as the emotions associated with the conflict. In this instance, you mention shock and hurt, but you may notice other emotions that have arisen since then. If you find that the issue and associated emotions are similar to interactions that have been a struggle in your personal life, it may be helpful to take this to your own therapy as well as getting supervision and consultation.

After you feel clear about the conflict itself, reflect on the assumptions you have about why your colleague made this remark. Usually an emotionally charged interaction leads us to develop explanations for our hurt or angry feelings, and these explanations often include criticism and judgment of yourself or the other person. For example, you may wonder whether your colleague doubts your skill as a couples therapist or whether she has a bias in favor of separation for couples in conflict. Consider other explanations as well, possibly with the help of your supervisor, therapist, or colleagues. One possibility is that the wife is describing her view of and feelings about her husband and marriage differently in her individual therapy than in the couples therapy. This would mean that you and your colleague are holding two disparate parts of the wife’s experience that she hasn’t reconciled.

Third, identify the outcome you desire for your conversation. There are a number of possible outcomes when approaching a colleague about a difficult interaction: expressing your point of view, engaging your colleague in understanding your difference of opinion, and sharing your view of possible reasons for your differences in perspectives are a few. Make sure that the outcome you identify is something that is focused on your communication and is collaborative in nature. A desired outcome of changing your colleague’s point of view establishes a more adversarial tone and is likely to lead to a deterioration of your collaboration rather than strengthening it. If you have difficulty identifying your desired outcome, check with your supervisor, therapist, or another trusted colleague who can maintain neutrality.

Once you have moved through these steps in understanding the interaction with your colleague, you are ready to plan a conversation with her. I would recommend letting her know you’d like to talk and planning a specific time and plan for the conversation. You’re more likely to achieve your desired outcome if both of you have set time aside and if your colleague knows what you want to talk about. Make sure you describe the purpose of the conversation in neutral terms by saying something like “I’d like to talk further about our work with X and the questions you raised last week about the couples therapy.” Follow that statement with some suggested times and a private location where you can talk without disturbance. When you come to the designated time and place, you may benefit from having a clear opening statement about your reason for wanting to have the conversation, setting the tone as positive, curious, and collaborative. An example of an opening statement in your situation might be “I was surprised to hear what you said last week about X’s husband and the couple therapy. I’d like to compare our perspectives to see if we can make sure the two therapies are beneficial to her.” The preparation you have done will enable you to listen to your colleague’s point of view, express yours, and work to establish common ground in understanding your client.

I hope you find these suggestions helpful in addressing difficult conversations with colleagues in your clinical work. Please email me with comments, questions, or suggestions for future blog topics.

Having Difficult Conversations with Clients

Mother and daughter having an argumentI have a client who has been 10-15 minutes late to every session since we started meeting three months ago.  My supervisor says I need to talk with her about this, but I’m afraid she might stop therapy if I confront her.  Is it possible to continue seeing her in therapy without talking about why she’s late?

I sometimes say to my supervisees and people I am training that as mental health practitioners we are in the business of having difficult conversations.  Growing into the role of clinician means developing skills to talk about issues and areas of conflict in a way that is different than usual social conversations.  I’ll discuss first some of the steps that can help us in having these conversations, then address the specific situation you describe.

Each of us comes into the clinical role with interpersonal skills that are familiar and comfortable, and these familiar strategies involve avoiding some type of discomfort.  As we work with different kinds of clients, we find that these interpersonal skills are helpful in some of the situations we face but not in others.  We also face situations with supervisors, peers, and colleagues that may challenge our familiar strategies for coping with conflict or distress.  When we can expand our repertoire of skills in managing these difficult conversations, we are capable of being effective in a broader range of clinical challenges.

In working toward greater interpersonal flexibility, it will be helpful to take some time to reflect on the situation and your emotional responses to it.  Supervision and personal therapy are good resources to use in developing greater self-awareness.  Some steps to consider are to identify 1) the specific nature of the conflict or discomfort you feel, 2) the benefits and limitations of your familiar strategy for managing this type of conflict or discomfort, 3) the fears or worries that arise when you consider handling the situation in a different way, and 4) a small step you could take to expand your skills.  Remember that change usually happens in small steps, so think about developing your interpersonal skills incrementally rather than pressuring yourself to do something dramatically different.

Applying these steps to the specific situation you mention, we start with the nature of the conflict.  It seems your supervisor is suggesting something that you perceive as confrontational, but it isn’t clear whether you perceive the client’s lateness to be a problem and why discussing it would become adversarial.  A starting point would be to explore more of your own response to the client being late and the potential meaning it might have.  This would be something to discuss in supervision as well.  It seems that your familiar strategy with managing this type of conflict is to avoid discussing it directly, so the next step would be to consider the positive and negative results of this type of avoidance in other situations in your life.  It may be that this was the most effective way to respond in your personal relationships, but remember that your job as a clinician is to help your client face and resolve the issues that are interfering with her life.  A limitation of relying solely on avoidance of potential conflict is that your client will not have an opportunity to gain insight into a pattern that may contribute to her difficulties outside of therapy.

A third step to consider is the nature of fears and worries you have about responding differently to this situation.  You express a fear that your client will stop therapy if you discuss her lateness.  This seems to reflect an assumption that she will feel judged or criticized by you and that your therapeutic alliance isn’t strong enough for a conversation about something that affects your work together.  Consider approaching the conversation with curiosity rather than judgment.  You can talk about the issue without requiring that she begin coming on time.  A small step you could take toward handling this situation differently would be to say something like “I notice that you usually come a bit later than our scheduled time and I wonder if there is anything about that you’d like to discuss.”  The client may simply say “no” and move on to another topic, but taking this step moves you into an area that has previously been fearful for you.  You can then look at the meaning of your client’s pattern and additional ways you might discuss it with her.

I hope you find these suggestions helpful in addressing difficult conversations with clients and other professionals in your clinical work.  Please email me with comments, questions, or suggestions for future blog topics.

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.