Tag Archives: Therapy

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.

Making Referrals to Additional Services

hispanic young woman in therapyI have been seeing a client for a couple months and I think she needs more help than I can provide with individual psychotherapy. I have recommended that she get a psychiatric evaluation, join a DBT group, and sign up for a subsidized housing program. All of these services are available at the agency where I am doing my practicum training, but so far she hasn’t followed up on any of my referrals. How can I encourage her to get the additional help she needs?

Many clients in individual psychotherapy also need and benefit from additional services. Therefore, our work as therapists often involves some case management such as making referrals and collaborating with other professionals. We sometimes think of these case management tasks as outside of our therapeutic role and handle them pragmatically. This blog posting will help you think about making referrals as an integral part of the psychotherapy, which may lead to a better outcome.

I’ll start with some discussion of the reasons for recommending additional services. The combination of services you mention suggests you have multiple purposes for your referrals: clarifying the client’s diagnosis, managing crises or instability, improving living circumstances that contribute to symptoms, and following the recommended practice for specific clinical presentations. It also seems like your client presents with a complex set of emotional and psychosocial issues and you may be feeling overwhelmed. I would suggest first that you take some time to reflect on your countertransference responses to this client, preferably with some consultation from your supervisor and colleagues. This may clarify the support you need in managing this case and help you identify the reasons for your referrals. With a clearer perspective you can develop the most effective method for helping your client.

Once you have become clearer about the purpose of your referrals, approach them in order of priority. You can prioritize the referrals based on the client’s preferences and goals as well as safety concerns. It may be useful to use a harm reduction approach, which is often used with substance use disorders and has application for other situations involving safety. Identify the areas of greatest potential harm to your client and work first to reduce that harm, through your work in therapy as well as through referral to additional services. For example, if your client’s suicidal ideation puts her at serious risk, you would begin by looking for ways to reduce that risk. She might benefit from any of the referrals listed above or from accessing a 24-hour suicide prevention hotline, and the best recommendation would be the one that she is most willing to pursue. The remaining referrals would be deferred until her suicidal risk is reduced.

You express a view that your client needs more help that you can provide. There are some instances in which individual therapy can only be effective in conjunction with other resources. Talk with your supervisor about the client’s risk so s/he can help you decide whether to require the client to use one or more other services as a condition of individual therapy. That is sometimes the best decision to make in a complex, volatile clinical situation.

A final issue to consider is the therapeutic tone and manner of your referral recommendations. Pay particular attention to your countertransference and the possibility that you want to hand off this client to someone else because she feels like too much for you to handle. It is easy for a client to experience a referral as a sign of rejection rather than support. The client is bringing her concerns and difficulties to you and may feel your ambivalence about helping her. She is more likely to experience your support if you discuss your countertransference with your supervisor, then make it clear to the client that you plan to continue working with her. It will also help to describe how you believe the other services will contribute to the therapy rather than being a substitute.

I hope you found this blog helpful in making referrals in a therapeutic manner. Please email me with comments, questions or suggestions for future blog topics.

Managing Silence

LGBT therapyI have a client who has a hard time talking in our therapy sessions. I want him to benefit from therapy so I prepare for the session by having topics for us to talk about. This has been going on for several months now, and I’m beginning to wonder if there’s a different way to handle this situation.

This is a common question for therapists in training. Since the nature of our work is listening and talking, we tend to feel uncomfortable when the back-and-forth flow of our interactions with clients is interrupted by silence. One aspect of professional growth as a therapist, though, is becoming comfortable with therapeutic interactions that are different from social interactions we have with friends, family and co-workers.

When I am working with a client who doesn’t initiate conversation or falls into silence, I usually respond first by simply sitting quietly myself. Often the client will then continue with the previous line of thought or bring up a new issue that we can explore together. In the beginning of therapy, I don’t let the silence continue for more than 20 or 30 seconds especially if the client seems uncomfortable, but that is often enough time for the client to guide the direction of our conversation.

If I do choose to break the silence, I ask an open-ended question rather than bringing up a specific topic. Examples are “is there more you’d like to say about that?” or “what’s on your mind?”. If I notice something in the client’s body language, I might say “it looks like you’re feeling sad about that” or “maybe it’s hard to realize how much pain you’re in.” If you use this type of question or statement, your client will know you’re interested in his inner experience and that he sets the direction of the therapy. Usually he will feel encouraged to continue exploring the thoughts and feelings related to the current issue or to shift to an issue that feels more relevant.

When silence is a recurring part of the therapy and the client doesn’t respond to your open-ended questions or reflective statements, your task becomes one of assessment or conceptualization of the reasons for his behavior. Some possibilities are a lack of familiarity with therapy and self-reflection, social anxiety or skill deficits, and cognitive limitations. Talk with your supervisor about your client’s history, diagnosis and relationship experiences as well as the therapy process and your countertransference responses. This discussion will help you develop an understanding of your client’s experience of the therapy and choose the most therapeutic way to engage him. You may also need support from your supervisor in managing your countertransference with a client who seems passive and disengaged.

When silence is recurring, it is sometimes helpful to provide some education about the therapy process. Clients who are new to therapy may be unsure of what is expected, and clients who have a history of contact with social service systems may have been socialized to take a passive role with professionals. Giving a short description of therapy and your approach and expectations provides guidance in these situations.

Another helpful intervention is to make a process comment or question related to the silence itself. Examples are “what’s it like for you to sit quietly here?” or “it looks like you’re not sure what to say next” or “how would you like me to respond when you’re quiet?”. You may learn that the client has assumptions about your role or your reactions to him that lead to a fruitful discussion between you. For example, the client may express a desire for you to provide an answer to a complicated emotional dilemma or may be worried that you are bored by the circumstances he is describing. In general, process comments and questions serve the purpose of communicating your presence and interest in the client and provide an opportunity to talk directly about obstacles to the client’s engagement.

I hope you found this helpful in managing silence in your therapy sessions. Please email me with comments, questions or suggestions for future blog topics.

 

Therapist Self-Disclosure

portrait-female-therapist-office-her-patient-44629457I was recently assigned a new client who is a gay male in his 40s. He had a recent relationship breakup and is depressed. In his intake interview he requested a gay male therapist and was told the agency would try to honor his request but couldn’t guarantee it. I am a straight female but I am very close to my gay brother, his husband and their two kids. I also have a number of gay friends, both men and women. What should I tell the client to help him feel at ease with me?

The previous blog discussed issues related to cultural competence in this case. This blog will discuss the issue of therapist self-disclosure. Self-disclosure refers to the choices we make about sharing personal information explicitly with clients, in addition to what they may infer or assume about us based on our appearance and style of relating. There are complex clinical questions involved in decisions about self-disclosure so it is important to be cautious and thoughtful.

One area to consider regarding self-disclosure is your client’s need and right to have information relevant to his treatment. You are required by law in California to let clients know your status as a clinician in training working under supervision. It is also good clinical practice to answer clients’ questions about the amount of experience you have, the graduate program you currently attend or from which you graduated, and special training your have received.

Disclosing personal information brings up more complicated issues. The first is the question of the therapist initiating self-disclosure or responding to client questions. I do not recommend disclosing personal information unless the client asks a specific question, unless you have discussed it thoroughly in supervision and your supervisor agrees it would be a therapeutic intervention. The motivation to volunteer personal information often reflects unconscious countertransference rather than an accurate understanding of the impact on the client.

A second issue about personal self-disclosure relates to your preferences and comfort about sharing aspects of your life. You can anticipate questions about your marital status, your sexual identity, racial or ethnic background, whether you are a parent or are in recovery, or if you have a history of childhood trauma from some clients. I recommend talking with your supervisor at the beginning of your practicum placement about the information you are willing to share and how you will respond to questions about aspects of your life that you want to keep private.

A third issue to consider is the extent to which you or the client may be trying to address issues of trust through disclosure of personal information. Clients enter therapy with varying levels of fear and concern about trusting someone with their painful emotions and experiences. They may believe or wish that their fear will be lessened if they know more about the therapist. Therapists also have varying levels of confidence or doubt about their ability to help and may see self-disclosure as a way to boost the client’s trust (for example, by saying “yes, I’m a parent too”). The solution to the client’s fear and the therapist’s self-doubt does not lie in therapist self-disclosure, however. It lies in the therapist being attuned and empathic to the client’s fears, approaching therapy collaboratively, and using supervision to address self-doubt and other countertransference.

Regarding your new client, after you have heard his concerns about seeing a female therapist rather than a gay male, it might be appropriate to tell him about your experience working with gay male and female clients, your experience working with gay and straight individuals who are depressed after a relationship breakup, your support for same-sex relationships and marriage, or the fact that you have relationships with family members and friends who are gay. If he asks directly if you are gay or straight, I would recommend answering truthfully but not being specific about having a gay brother who is married and has kids. Your client’s relationship has just ended and it could be a distraction for him to have this information.

I hope you find this information useful in making decisions about self-disclosure. Please email me with comments, questions or suggestions for future blog topics.

Completing an Assessment

therapyI am working at a new field placement which requires doing an assessment in the first session, which lasts 2 hours. How can I do this before I have established rapport and a therapeutic relationship with the client?

It is challenging to complete an assessment in your first contact with a client; however, there are also advantages to gathering comprehensive information about the client’s history and current circumstances early in the treatment process. I will outline some ways to approach the assessment that will facilitate rapport and relationship building so the session will have a therapeutic outcome as well as meeting your agency requirement.

I would first recommend that you talk with the client about the reasons for the assessment when you schedule the initial appointment. Express your desire to be helpful to the client and state that learning about his current symptoms, life situation and history will make the treatment more effective in working toward his goals. This communicates the message that your purpose and interest is aligned with the client’s, rather than simply meeting a bureaucratic requirement.

Before the assessment session, familiarize yourself with the format of the assessment template or report. You may want to bring a copy of the assessment template into the session or a list of general areas for questioning. If there are specific questionnaires for the client to complete, bring those with you as well. You may find it helpful to role play the introduction of the assessment with your supervisor or a colleague before you meet with your first client. The more comfortable and confident you feel, the more easily you will develop a therapeutic relationship with the client during the assessment session.

When you start the session, remind the client of what you discussed in your scheduling conversation about the assessment contributing to the effectiveness of treatment. Then begin with the client’s primary concern in seeking treatment and ask follow up and clarifying questions covering different areas of the assessment as they emerge from the conversation. It is more facilitating of the therapeutic relationship to engage in a dialogue that is relatively fluid and follows the client’s lead rather than imposing a standard order of questioning. It is also preferable to ask open-ended questions which allow the client to determine the direction and content of what he shares. The client’s answer to “can you tell me what your family life was like as a child?” will tell you more about him than the answer to “did you grow up in a two-parent or single parent household?”

If your agency practice requires you to be directive rather than following the client’s lead, you should acknowledge this at the beginning of the session and explain that this is different from the structure of future therapy sessions. For example, you could say “The assessment format we use here requires me to ask you about things in a fairly structured way, so I’ll be leading the conversation today more than I will in our future sessions. Please let me know if you feel uncomfortable about my approach at any time, or if there is something you want to share with me that isn’t directly related to my questions.”

Remember that you are asking the client about events and experiences that may be painful, may bring up feelings of shame and which the client may want to avoid rather than disclose. Expressing empathy, conveying acceptance rather than judgment and reflecting your understanding of what the client is saying will create a therapeutic atmosphere. For example, if the client describes a childhood history of physical abuse and adult relationships involving domestic violence, you might respond with a statement like “It sounds like your childhood taught you to expect physical violence as part of intimate relationships. It’s not surprising that you found that pattern repeating in your adult relationships.” Although you will not have time to explore the details of the client’s experience in the assessment session, you can respond therapeutically to the material he shares.

When you approach topics that you expect or know will be difficult for the client to discuss, it is helpful to let him know this information is asked of all clients and to ask his permission to inquire about those areas. For example, many clients come into treatment with shame and denial associated with past and current substance use. You can introduce the topic therapeutically by saying “We ask all clients here about their use of substances because we find that to be related to aspects of mental health. Is it all right if I ask you some questions about your past and current use of alcohol and other drugs?”

When you follow these tips, you’ll find the assessment session results in a positive therapeutic relationship as well as information that enhances your understanding of the client. I hope you find these suggestions helpful in completing assessments in the first session. Please email me with comments, questions or suggestions for future blog topics.

Concerns About Diagnosis

new2I just started my first practicum placement and I am supposed to give a diagnosis to each client.  I’m worried that I don’t have enough experience to make a diagnosis and that my diagnosis might create problems for my clients later on, if they or someone else sees their records.  

Your concerns are common among students in practicum training.  It often feels daunting to take on the role of assigning a diagnosis to your client.  You may be uncomfortable with the gravity of this professional responsibility, and you may have questions about the validity of diagnostic labels that don’t include consideration of the client’s strengths and capacities.  Many clinicians are aware of the potential use of diagnosis in pathologizing or stigmatizing individuals who are vulnerable to being treated with discrimination and bias.  I will share several steps you can take to maximize the likelihood that your diagnostic process will be beneficial to the client rather than harmful.

The first step is to be thorough and comprehensive in gathering relevant information and considering alternative diagnoses that fit your client’s symptoms and presenting problem.  If you are required to assign a preliminary diagnosis after the first session, make sure to re-evaluate the diagnosis after you have completed a full assessment.  Be careful of the tendency to jump quickly to a diagnosis that you consider to be non stigmatizing, such as an adjustment disorder, that may not be an accurate reflection of the full clinical picture.  I recommend reading the DSM diagnostic criteria for three to five alternative diagnoses as well as the information about differential diagnosis considerations for these diagnoses.  Once you have reached a conclusion about the client’s diagnosis, review this with your supervisor to insure that your final diagnosis is the most accurate and appropriate for the client’s presentation.  With complex clinical presentations, you may have a primary diagnosis and one or more secondary diagnoses.

A second step to take regarding diagnosis is to include a description of the client’s initial symptoms and presenting issues in the client record, in addition to the diagnosis itself.  Usually you will complete an initial assessment which should contain the client’s report and your observations that support the diagnosis.  Your progress notes should track the client’s thoughts, affective states and behavior related to the diagnosis and any changes to the diagnosis resulting from new information or progress.  This insures that anyone viewing the client’s record at a later date will have a more complete picture of the client’s symptoms and functioning than is conveyed by the diagnosis alone.

A third step to maximize the benefit to the diagnostic process is to discuss the diagnosis with the client.  Clinicians are often reluctant to do this because of the worries mentioned in your question.  However, a collaborative discussion often results in relief and clarity for the client who may feel confusion, self-criticism and shame about her condition.  I generally enter these discussions by summarizing what the client has told me and my observations, then sharing the diagnosis that fits the clinical picture.  An example is ” You’ve told me that you don’t enjoy anything, that your sleep and appetite are disrupted and that you feel really down.  I’ve noticed that you are pretty harsh in judging yourself and your energy seems low.  All of these things are signs of depression, and I believe the diagnosis of major depressive disorder fits what you’re experiencing now.”  I then ask the client what her thoughts and reactions are to hearing this and engage in a discussion of any questions or concerns she  may have.  If there is any indication at that time or later in treatment that the client may want her record to be shared with another party, you can remind her that the diagnosis is part of the record and talk about the implications that may have.

I hope you find these suggestions helpful in making diagnoses with more confidence.  Please email me with comments, questions or suggestions for future blog topics.

Intersection of Personal and Professional Lives

Two women talkingMy current placement is located in the same town where I live. I like having a shorter commute than last year but I’m worried about seeing my clients outside of our session, when I’m on my own personal time. I think I would feel awkward and wouldn’t know what to do.

The intersection of the personal and professional life of a psychotherapist can happen at any time, but it is more likely when we live and work in the same community. It is also more common when the therapist and client are members of the same cultural community and may have shared interests, activities and acquaintances. Even when we maintain boundaries and refrain from disclosing personal information about ourselves, it is impossible to avoid all situations in which clients view aspects of our personal lives. The experience of myself and my colleagues includes seeing a client while shopping with a spouse or children, working out at the gym, going to back-to-school night, and having dinner with friends or family.

It can feel burdensome and intrusive to be faced with these situations, but it is a reality of being a professional, especially when your community is small geographically or culturally. When you see your client outside of a therapy session, you are still the therapist and your interactions should maintain the same level of professionalism. Since our preferences about the degree of separation we maintain are based in part on our cultural identities, the nature of your conversation and the strategy you use will be different based on the cultural expectations and norms for you and your clients. Discussing this with your supervisor is important, to make sure you are keeping appropriate therapeutic boundaries within the cultural or cross-cultural context of the therapy.

Generally, it is best to keep conversations in a social or public situation short and cordial without disclosing more about yourself than is disclosed by the situation. You also need to maintain confidentiality regarding your role as the client’s therapist if others are present during the conversation. This may mean asking your family members to wait for you to introduce and include them in a conversation with someone unknown to them. It is usually best to not include family members in a client conversation and it is a good idea to explain the reasons for this to them in advance, as a general issue regarding your role as a psychotherapist.

At the beginning of treatment, you can sometimes anticipate that you and the client may see each other outside of your therapy sessions. Examples are when your children attend the same school or when you and the client belong to the same religious, political or professional organization. When you recognize this possibility, it is often useful to have a conversation ahead of time with the client after discussing the issue with your supervisor. I recommend not taking initiative in greeting the client in a public setting, unless there are diagnostic or cultural issues you discuss with your supervisor that make another approach more appropriate. I generally begin this conversation with a statement like “I’m aware that we both attend the same meditation center, so it’s possible we will see each there. If that happens, I won’t acknowledge knowing you unless you approach me. I want you to do whatever is most comfortable to you at the time.” I then respond to the client’s questions or comments.

If you see a client unexpectedly, I still recommend following the client’s lead in acknowledging that you know each other. She/he may choose to simply make eye contact, may greet you with a simple hello or may start a conversation. If there are others with the client, do not make any reference to your therapist/ client relationship unless she/he does so. If the client does introduce you as her/his therapist, stay away from any discussion of the therapy itself. It is also possible she/he doesn’t notice you, which has been my experience at times and is another reason to not initiate contact.

I recommend talking with the client in the next session about any interaction you have outside the therapy. It is helpful to ask the client what it was like to see you and what thoughts and feelings came up during or after your interaction. If you saw the client but she/he didn’t acknowledge seeing you, you can preface your comment by saying “I’m not sure if you’re aware that we were both shopping at Safeway on Saturday.” You can include an explanation of your practice of waiting for the client to acknowledge knowing you, if you haven’t already discussed it.

In your discussion of the client’s reactions, be aware of what the client learned about you and how that knowledge may affect your therapeutic relationship. For example, the client may have seen your spouse, partner or children; may have seen you with a glass of wine at a restaurant; or may know what movie you saw or what purchases you made. These interactions may be relieving, distressing or meaningful in different ways depending on the client.

I hope you find these suggestions helpful in handling interactions with clients in a public or social context. Please email me with comments, questions or suggestions for future blog topics.