Tag Archives: Therapy

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.

 

Sharing Client Information in a Team

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

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

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

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

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

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

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

Evaluation of Client Appropriateness for Treatment

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

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

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

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

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

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

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

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

Cultural Values in Treatment Goals

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

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

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

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

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

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

Impact of Therapist’s Personal History

I have been assigned to see a 12-year-old girl whose father died a year ago, and her mom and teachers report she seems depressed.  My mother died when I was 14, so I have a good idea of what she’s going through and think I’d be a good therapist for her.  My supervisor said she’s concerned that this case could be too close to my own experience, but I think it’s good that I know what’s it’s like to lose a parent. 

This situation illustrates how our personal history informs and affects our work with clients. We have similarities and differences with each client, but the balance between the two is different with each one. When you are working with someone who seems very much like you or with whom you are heavily identified, it is important to rebalance your attention by being aware of the ways in which your experiences diverge. Similarly, when you are struck with how different your life is or has been from your client’s, you need to look for commonality.

In this example, you and your client share the experience of losing a parent in your early adolescence. It is understandable that this common experience takes the foreground of your attention when you think about beginning to work with her. However, there are some important differences that are apparent even in the preliminary information you have: the death of a father compared to the death of a mother and being 12 or 14. Undoubtedly, there are other differences between you and your client in your specific family relationships, cultural background and identities, other developmental events, and personality characteristics. I’ll discuss three strategies to maintain your attention on your client’s needs while minimizing the potential interference of your experience of parental loss.

First, pay careful attention to your tendency to make assumptions in this case. It will be easy to believe that you understand your client’s thoughts and feelings without your usual level of curiosity and information gathering. Err on the side of caution by asking questions or being tentative in your reflections with statements like “are you saying you feel lost?” or “it sounds like you might be angry.” Remember that it is your job to help her on her own journey of grief and loss and that hers will inevitably differ from yours.  She may feel sad in a situation in which you felt angry, or she may feel burdened rather than afraid.

Second, be especially careful when you think about self-disclosure. You will probably think of several examples from your own life and experience that are related to your client’s pain and grief. It may seem as though sharing your experiences will let your client know you understand her and will give her a sense of hope for her own healing. However, self-disclosure always has a risk of diverting the client’s attention from her own experience to yours, especially when she hasn’t asked about your life. In this case, it may be appropriate to share minimal information with your client if she asks. For example, if she asks whether anyone close to you has died, you could say “yes, that did happen when I was a teenager” and you might tell her that your mother died if she asks for any other details. Then I would turn attention back to her experience and how she feels knowing this about you.

Third, a case in which your personal history is similar to your client’s makes supervision extremely important. You may feel that your knowledge of your client’s experience means you don’t need as much guidance from your supervisor as with your other cases. However, as noted above, there is a potential for your clinical judgment to be clouded by this similarity, so discussing this client and her progress in treatment is essential. Your supervisor’s concern suggests that she is aware of this difficulty and will be able to support you in thinking through your emotional responses to the client. You may also find it helpful to talk with your personal therapist about the emotions and memories that arise for you in working with this young woman. You may find that your grief and loss emerge in a new way as you face the issues as a therapist.

I hope you find this helpful in managing the impact of your personal history in your clients’ treatment.

Assessing a Confusing Initial Presentation

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

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

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

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

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

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

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

Client Attendance

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

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

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

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

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

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

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

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

Client Disengagement

Client DisengagementI’ve been working with a client for about six months, and we’ve agreed on a treatment plan. However, he doesn’t seem very engaged in working toward his goals. My supervisor suggested I bring this up with him, so I asked if he has changed his priorities and he said no. How can I help him make progress when he isn’t motivated?

This is a difficult situation, and it sounds like you haven’t yet identified the reason for your client’s lack of engagement with the treatment plan. In addition to a change in priorities, this type of withdrawal could be due to his reluctance or inability to verbalize his preferences or due to pressure from someone in his life about the purpose and outcome of the therapy. Your client told you his priorities haven’t changed, but you still don’t know whether that or another factor may be explain your sense that he isn’t working collaboratively with you. I’ll make a few suggestions of ways you might work with yourself and your client to change the pattern or your interpretation and response to it.

The first step I would recommend is to identify and explore your countertransference response. You say he seems disengaged, which suggests that there is a disruption in your experience of the therapeutic relationship. Give thought to his behavior and your emotional response without making an interpretation of what it means. Also, reflect on whether your client’s behavior has changed over the six months you have worked together. It is possible that there is a mismatch between you and your client in interpersonal pace, rhythm, and emotional expression. If that is the case, the meaning you are assigning to his behavior, i.e., that he isn’t engaged in working on goals, may not be accurate. In addition, if you notice a similarity in your emotional response to this client and to other situations in your personal life, you may need to become more flexible in attuning to your client’s preferred style and not assigning the same interpretation to his behavior as you have made in other relationships. Talk with your supervisor about your countertransference and your observations of your client’s behavior to help you get clearer about why you have come to the conclusion that he isn’t motivated.

After you have checked your countertransference responses, consider bringing up the issue of your client’s engagement as a process comment. Be sure you are feeling open and nonjudgmental when you initiate this discussion. Examples of ways to bring up the issue would be “I’ve noticed that our discussions of your treatment goals haven’t been very fruitful and wonder if you have any thoughts about that” or “I’m wondering how the therapy is feeling for you and whether we’re addressing the things that are most important to you” or “I’d like to check in with you about how we’re working together to make sure I’m helping you in the ways you want and need.”

Last, after you have initiated this process level discussion, respond with curiosity and interest to the client’s comments. It is especially helpful to use reflective listening, empathy, and clarification. Even if your client responds by saying “everything is fine,” you can respond with “so you feel we’re working on the things that are important to you?” to affirm the client’s statement and encourage him to elaborate. If he gives any indication of ambivalence or dissatisfaction, you can follow up on that using reflective exploration which may lead to greater understanding and collaboration between you. If he doesn’t directly express any discontent, you can still express your openness to hearing his negative feelings by making a normalizing statement. An example is “people often find that they have a mixture of feelings about therapy, so if that does happen for you I hope we can talk about it.”

I hope this discussion has been useful to you in understanding client disengagement. Please email me with questions, comments, and suggestions for future blog topics.

The Value of Listening

Grieving womanI’ve seen a client for three months and am at a loss for what to do. Her husband of 35 years died suddenly last year, and our work has focused on her grief and loss. Her feelings are still very intense, and I’m beginning to wonder if I can help her. I’m in my early thirties with both of my parents still living, so I don’t know what she’s going through.

It’s good that your client is getting your help and support at this difficult time. It isn’t necessary to have personal experience with issues like those of your clients in order to be helpful to them. Instead, your grieving client will benefit from your attention and skillful listening as she struggles to live with her intense grief. Listening to your client is a vital part of the therapeutic process and will facilitate her healing.

You may be more accustomed to thinking about and planning for active interventions in your clinical work. Clinical training often emphasizes the use and mastery of techniques, and this may have given you the impression that being a therapist centers on finding something to do that will lead to change in your clients’ lives. You may undervalue the impact of your presence in listening to your clients and sharing their pain without pressure to make it go away. This is especially true for feelings of grief and loss, which many people in our society avoid. Clients who have experienced a recent loss often have been encouraged to “get over it” or advised to “move on” by well-meaning but ill-informed friends and family members.

In this case, your primary task is to give your client as much room and time as she needs to talk about her 35-year marriage, the circumstances of her husband’s death, the feelings she has had during the last year, and how she feels on a day-to-day basis as she copes with this loss. Although you haven’t experienced such a loss, you can and should be open to hearing from her what this loss has been like for her. Your empathy, warmth and acceptance will be the primary therapeutic tools you need. You may find yourself feeling overwhelmed with the intensity of her emotions, since it sounds like she feels overwhelmed with them. It’s not your job to change her feelings, but they will become more manageable over time as she feels your presence and support in sharing them with her. This process will unfold gradually as she recognizes your ability to work on her internal timetable rather than imposing one of your own.

If you work in a setting that places a time limit on treatment, you may need to let go of your wish for a specific outcome and instead focus on her need for you to share this part of her journey, which began before she came to see you and will continue after she ends. She will be grateful for your capacity to sit with her rather than to rush toward an artificial end point.

I hope you found this helpful in understanding the value of listening. Please email me with comments, questions or suggestions for future blog topics.