Tag Archives: Therapist

Illness and Identity

The topic for this blog post comes from my recent and ongoing experience with persistent pain that has been difficult to diagnose and treat.  In addition to living with this condition for almost four months, I have been reflecting on the parallels between my experience and that of many of our clients. 

My pain symptoms had a sudden onset, though I can see some subtle precursors for a few weeks before the onset.  This is often true for our clients, though some report symptoms that are more gradual in onset.  I have consulted with and received varying degrees of help from a number of health professionals including traditional and alternative practitioners, which our clients often do as well.   Ways in which I differ from many of our clients are that I have a high baseline of physical and psychological health, stable health insurance paid by my employer, and sufficient financial resources to pay for services not covered by my insurance.  Without these privileges, our clients face much greater challenges in managing their mental health symptoms, so I thought I would highlight some of the issues that come up with our clients who deal with persistent symptoms of depression, anxiety, PTSD, and other diagnoses.

One important issue related to living with persistent symptoms is one of identity.  This may take the form of resistance to a diagnosis (e.g., “I’m not a depressed person”), anger about the impact of the symptoms (e.g., “I want to be able to go to work without feeling panicked when I drive over the bridge”), and expressions of loss (e.g., “will I ever be able to get a good night’s sleep again?”).  We all develop a sense of who we are in the world and in relation to others, and this identity is disrupted when psychological symptoms make it hard or impossible to do the things that reflect our identity.  The client’s expressions of this disruption of identity may seem like obstacles to treatment, and we may find it difficult to empathize with the client’s distress.  However, acknowledgement of clients’ disruption and disorientation related to identity is likely to be necessary in order for them to engage productively in treatment.  The struggle about identity may continue for a long time, as is the case with a client of mine who has been in treatment for most of her adult life and has been receiving federal disability income for more than 25 years.  We still have conversations at times in which she says “I don’t want to have a mental illness.”  She sometimes expresses a belief that if she only tried harder she would no longer have the symptoms which are frequently debilitating.  I have come to understand this belief as an alternative to accepting an identity which seems intolerable.

A second issue that is likely to be prominent when working with clients whose symptoms interfere significantly with their daily lives is that of self-efficacy.  It is hard to maintain a strong sense of agency when symptoms feel unpredictable or uncontrollable.  It is also hard to balance self-efficacy as expressed by “what can I do to manage or improve my symptoms?” with self-blame as expressed by “what did I do to cause these symptoms or this illness?”  The first question can be helpful while the second is often unhelpful, but they are often confused in the minds of clients and sometimes for therapists as well.  When a client seems resistant to taking proactive steps to improve their condition, it may be useful to explore the question of self-blame or a perception of blame from others including you.  With the client I mentioned above who is very vulnerable to self-blame, I often say explicitly that her illness isn’t something she caused or can control directly while also reminding her of the things she can do and has done that contribute to a lessening of her symptoms.

The last issue that has become very apparent to me is the difficulty of our fragmented health care system.  Finding appropriate health care providers, making decisions about treatment recommendations, and coordinating care from multiple providers are all extremely complex tasks.  It is rare that a client has a provider who is able or willing to look at the whole picture of the client’s care, and for clients whose symptoms are moderate to severe it is rare that any single provider has the full range of expertise needed to treat their illness.  Some clients may have a family member who can assist in navigating the health care system, but this often carries other complications.  Other clients may be capable of this complex task when they are functioning at their best, but not when they are in a depressive episode or experiencing frequent panic attacks or other significant symptoms.  I would encourage all of us to coordinate our care as therapists with that of other providers when possible and to acknowledge, to ourselves and our clients, the inherent difficulty of assembling a treatment team to address all of the aspects of a particular set of mental health symptoms.  We can sometimes find ourselves feeling impatient or frustrated with a client who is struggling to find appropriate care or we may expect a client to comply with the limited options that are available based on their insurance and financial situation, without acknowledging the inadequacy of these options.

I hope my comments are helpful to you when working with clients whose disorders and symptoms require attention to issues of identity, self-efficacy and health care complexity.

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.

Using Supervision

therapyI’ve been meeting with my supervisor for about six months. I find it helpful but wonder if I could be getting more out of it. My supervisor is very experienced and I’m not sure I’m using her expertise to my best advantage.

You are wise to look for ways to maximize the benefit of your supervision. It is generally the most powerful tool for examining and improving your work as a therapist. I’ll address your question in two parts, in terms of the content and the process of supervision.

There are three content areas to cover in supervision. In order of importance or urgency, they are 1) crisis or emergency situations, 2) new clients, and 3) regular review of ongoing therapy with all of your clients.

When one of your clients is in crisis or there is an emergency such as an abuse report or need for hospitalization, you should contact your supervisor between scheduled sessions to discuss crises and emergencies when they arise, then give an update and develop your plan for follow-up in the next supervision hour.

When you begin with a new client, spend time in supervision talking about the client’s clinical presentation and issues of concern or difficulty. You should develop a diagnosis, case formulation, and treatment plan within the first four to six sessions so that your work is focused and effective. Your supervisor’s input is vital in answering your questions, helping you understand the client from a conceptual framework, and suggesting appropriate interventions.

Most of your supervision time can be spent reviewing your ongoing work with clients whose treatment is established and progressing toward the clients’ goals. Talk with your supervisor about the best way to review your ongoing work, since there is a choice to be made between breadth, or giving brief updates about all clients each week, and depth, or spending more time each week on a few clients. Make sure to present each client on a regular basis, including those who you enjoy and are making progress. It is easy to focus supervision time on your challenging clients but there is much to learn in sharing your successes and going into more depth in understanding the clients with whom you feel an easier bond.

Attending to the process of supervision will allow you to get the most benefit. One aspect of process is the quality of your organization and preparation. As you go through the week, reflect on your client sessions and make note of issues that are a priority for your next supervision hour. Examples are differential diagnosis questions, changes in the clients’ symptoms, progress or lack of progress in therapy, questions about treatment approach and interventions, conflict or ruptures in the therapeutic alliance, and strong countertransference. Your supervisor will be able to give you more guidance when you have prepared in advance and lead with the questions that are most pressing.

A second aspect of process in supervision is your degree of openness in the supervisory relationship. Supervision includes mentoring and support as well as evaluation and constructive guidance. Your awareness of the evaluative component of supervision may make you reluctant to bring in difficulties or mistakes, but the greatest learning occurs when you bring in situations that trigger uncertainty, distress, self-doubt and other strong feelings in you.

It is often useful to talk with your supervisor directly about your fears of looking bad, about your own self-criticism, and about what you feel you need from your supervisor. These conversations are good practice for talking directly with clients about emotionally challenging issues, which is part of every therapist’s repertoire. You are also likely to feel more supported by your supervisor when you take the risk to express your vulnerability and your needs.

I hope you follow some of these suggestions and increase the benefit you get from your supervision. Please email me with comments, questions or suggestions for future blog topics.

Self Care for Enhancing Well-being

calmI’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

This blog continues the topic of self care, which I introduced with suggestions about work habits. We’ll look at additional strategies for self care to enhance physical, mental and emotional well being. As I mentioned before, I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. It may seem as though making drastic changes is necessary, but it is easier to start with something small. You are more likely to be successful and less likely to feel discouraged by the enormity of what you are taking on. Remember you can always start again if you slip back into old habits.

We’ll start by looking at physical health and well-being. This is an area that is easy to neglect especially with the pressure of classes and practicum or internship training. However, neglecting your physical health will take a toll on your mental and emotional health as well. Examine how you are caring for your basic needs for nutrition, movement and rest. Small changes in eating, exercise and sleep habits can yield significant benefits. I find that paying attention to my body’s signals results in being more productive since I’m bringing more resources to bear on my work.

Being in graduate school is a time for developing the mind. You are gaining knowledge and putting a lot of attention to your intellectual growth. This may mean that your mind is working at maximum capacity and you may find it hard to shift out of a preoccupation with your thoughts and ideas. Introducing a mindfulness practice may be helpful in balancing your mental energy. Meditation, progressive relaxation, stress reduction, and guided visualization are all readily available in online formats if taking a class isn’t feasible in your schedule. If doing a structured mindfulness practice doesn’t fit for you right now, simply spending time in nature is a great alternative. You can also go to services that provide medical marijuana cards in Clearwater, FL if you want access to medical marijuana to help alleviate stress.

Your emotional equilibrium will continue to be challenged as you progress through your training. Supportive relationships are the most helpful resource for building and restoring your emotional reserves. Personal psychotherapy gives you a chance to talk confidentially about the emotions that are triggered by your clients as well as your academic courses, trainings and supervision. Supportive relationships with peers and mentors in the field can help you share some of the experiences common to clinicians. In addition, strive to maintain and establish supportive personal relationships both individually and in community. It is important to engage in relationships and activities unrelated to the mental health field to provide perspective and balance.

It may seem like a big task to attend to these three areas of your health, but you can choose one activity that serves several functions. For example, following a YouTube yoga instruction will move your body and still your mind. Sharing a healthy meal or going on a hike with a good friend will meet your physical and emotional needs. In addition, any change you make that improves your health in one area will help in other areas because our physical, mental and emotional well-being are interconnected.

I hope you find these suggestions helpful in sustaining and improving your health in all aspects. Please email me with comments, questions or suggestions for future blog topics.

Self Care in Work Habits

Iimg-article-are-you-too-stressed-out’m in my second year of practicum placement and I feel really burned out. What can I do to keep going in this career without constantly feeling depleted by my work with clients?

Your concern is a universal one for clinicians. We tend to enter this field with a predisposition for caregiving others and neglecting ourselves. The emotional demands of doing psychotherapy with highly distressed individuals and families are intense and most of us reach the limits of our previously developed coping strategies during our training. This is a good time to create new routines and habits that will serve you throughout your career.

In this blog, I will suggest some general strategies that will help to build your emotional reserves and detach in a healthy way from the intensity of clinical work. The next blog will address more specific ways to attend to your physical, mental and emotional health. I recommend that you choose one or two small steps to try out first, see if they are helpful, modify them if necessary, then build on those after you have had some success. You will probably find it hard in the beginning to give attention to yourself, as you go against longstanding patterns. Be gentle with your expectations and remember that you can always start again if you slip back into old habits.

It will be easier to sustain your physical and emotional energy if you build in breaks for yourself, both on a daily basis and throughout the training year. Look at your daily routine and schedule one or two breaks if you have a full day at your placement. Use your break to eat a meal or snack, take a walk, read or watch something unrelated to your work, or talk to a colleague. Turning your attention away from your work for a period of 15 minutes to an hour will enable you to be more engaged when you return to it. If you have classes and clinical work in the same day, give yourself some transition time in addition to your commute.

Another aspect of your routine to examine is the structure of your day. It is helpful to alternate more and less demanding tasks throughout the day. Consider taking an hour to work on paperwork or do some research into resources for a particular client to break up your client hours. If you have several particularly complex or challenging clients, schedule them on different days or at different times of the day so you have other work or less challenging clients between them.

Clinicians often have a very hard time taking a vacation from clinical work. Because of our pattern of caregiving, we often feel as though we must be available at all times. We don’t feel comfortable having someone else provide coverage. However, we cannot maintain our own equilibrium if we never take a break to restore ourselves. Throughout the training year, take vacation time as it is permitted at your agency and have a colleague provide coverage for your clients so you can be free of responsibility and preoccupation. It is tempting to check voice mail or email when you’re away from the office but you will benefit more from your time off if you fully detach. Keep in mind that taking a vacation means being away from the office and not having any client contact for at least a week. Taking short periods of a few long weekends will not allow you to truly rebuild your reserves and return feeling restored.

I hope you can use these tips for developing some work habits that counter your feelings of depletion. The next blog will continue on this topic, addressing specific ways to care for your physical, mental and emotional well-being. Please email me with comments, questions or suggestions for future blog topics.

Social Media

new1One of my clients recently mentioned a post I put on my Facebook page and I just received an invitation from her on LinkedIn.  My social media presence is part of my personal life, and I don’t want her or other clients to be part of it.  How do I talk to her about this and ask her to respect my privacy?

The increasing use of social media by therapists highlights one way in which our personal and professional lives intersect.  A starting point for creating more separation between the two is to maintain control over access to your profile and posts by choosing more restrictive privacy settings.  However, this may be in conflict with your professional goals on a site like LinkedIn where your goal is visibility and access for colleagues and other behavioral health professionals to find you.  You’ll need to balance your desire for privacy with your desire to be visible to the professional community in deciding how to restrict access to information about you on Facebook, LinkedIn, Twitter, Google Plus and other social media sites.

Your question suggests that you are thinking about talking with your client about this issue and are aware the conversation may be difficult.  It is preferable to have a standard policy regarding all electronic communication including social media and to talk about this when you begin treatment.  If your agency doesn’t have such a policy, you can talk with your supervisor about the advisability of bringing up the subject in the first session when you talk about other issues related to your client’s privacy and confidentiality.  When this issue comes up after treatment is underway, there is some risk that the client will experience your desire for privacy as a personal rejection; however, being aware of that risk will help you talk with her with sensitivity that minimizes her feelings of rejection and hurt.  Keep in mind that your client may have cultural expectations about personal contact and disclosure that are different from yours and this is important to acknowledge and discuss.

I recommend being straightforward with clients about all issues related to boundaries and limits, whenever they arise.  This includes acknowledging that the boundaries are often based on your needs and preferences.  In this instance, you might say something like “I realize I neglected to talk with you at the beginning of our treatment about my preferences for social media.  I prefer to keep my social media presence limited to personal friends and professional colleagues.  I don’t respond to client invitations or other communication on social media sites, and my privacy settings limit the information clients can see about me.  I’m happy to talk with you about how this feels to you, since my preference may be different than yours.  I also think it’s important that we talk about what you saw about me and what reactions to you had to my profile and post.”  This communicates both a clear boundary and an openness to talk about the impact of your boundary and your inadvertent self-disclosure on the client.

My next blog will address the issue of how the personal and professional intersect in the lives of psychotherapists more generally.  In the meantime, I hope you can use these suggestions in having conversations about social media.  Please email me with comments, questions or suggestions for future blog topics.