Tag Archives: Psychotherapy

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.

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.