Tag Archives: Therapy

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.

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.

Electronic Communication

therapyOne of the clients at my field placement has been using email to reschedule appointments and let me know about things she wants to talk about in our next session. This has been fine with me since it’s easier for me to read and answer a quick email than a phone message. However, her emails are getting longer and I don’t want to take the time to read and respond to them between sessions. How can I let her know this without causing a rupture in our relationship?

This is a good example of how communication in the therapeutic relationship can move quickly from simple and straightforward to complex and entangled. This can happen with conventional communication in person and by phone, but there are many more possibilities for complexity with electronic communication.

When communicating with clients by email, you need to be aware of security and privacy as well as clinical issues. Regarding security and privacy, email is not considered a secure form of communication under HIPAA, so you need to inform the client of the risk to her privacy for anything she sends you by email. In the future, you can include this discussion early in treatment, but you now have an opportunity to do so in response to the client’s expansion of her email communication with you. I recommend documenting your conversation about email security in a progress note so it is clear you have informed the client of the risk to her privacy and that she is making an informed choice to communicate by email.

There are also clinical issues related to email communication with clients, as you have found. Email is best used only for scheduling appointments. Some clients may also send information to you that is related to their treatment, in order to talk about it in the next session. Examples are a client forwarding an email from a family member or partner with whom she is in conflict, a parent forwarding information from a teacher about your child client, or a client wanting to tell you about something that happened or an insight she had during the week. It is safest to either let the client know you won’t respond directly to emails containing clinical information or to limit your response to these email to a simple acknowledgement and invitation to talk more in person in the next session. I recommend printing email exchanges with the client that contain clinical information and including them in the client’s record. Check with your supervisor about the policy at your field placement site.

At this point, you need to talk with your client about both security and clinical issues related to email. The conversation is likely to be less disruptive to the relationship if you begin by acknowledging your oversight in not talking about this sooner. You should let the client know about the risk to her privacy with email communication and ask if she wants to continue using email despite the risk. You can then move to a discussion of your preferences about the issues discussed by email, preferably by again acknowledging your oversight in not discussing it sooner. A straightforward description of the limits of email would be “I prefer to use email only for scheduling purposes and to save our discussion of other issues for when we meet in person. If there is something you want to let me know about, you can certainly send me that to me by email but I will wait to comment on it until we see each other.” You then can invite the client’s thoughts and reactions, again acknowledging that this is a change on your part if the client expresses confusion or worry about having done something wrong. This will relieve you of the burden of responding between sessions and will redirect the client’s communication to your sessions where you can talk about the issues in depth.

I hope you found this helpful in dealing with electronic communication. Please email me with comments, questions or suggestions for future blog topics.

Termination Tasks

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I have a final session scheduled with someone I’ve seen for 6 months.  What should happen in the session to make the ending go well for the client?

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This blog focuses on the tasks of termination.  If you haven’t read the previous blog on Psychotherapy Termination, you’ll find that helpful before you focus on the logistics.

The main goal of termination is to create an ending that is less traumatic than the client’s prior experiences of separation and loss and that honors the client’s way of managing loss.  The tasks of ending treatment are the same regardless of whether the ending is planned or unplanned and whether it is initiated by you or by the client.  I will discuss one way to organize the ending into three tasks: reviewing the work you have done together, discussing future circumstances when therapy could be helpful, and sharing the experience of saying goodbye.  It can be helpful to share these tasks with the client in preparation for a final session, since most clients have little experience of ending a relationship with thought and acknowledgement of the emotions surrounding the loss.

The first task is to review the therapy, with you and the client sharing your thoughts about what you have worked on together and the changes that have occurred.  When you share your perspective, it is especially meaningful to the client to hear your memories about the early sessions.  An example is “When we began working together, you were really depressed and you had a hard time imagining how you could ever feel better.  Now you seem to be enjoying your job and time with your kids and you have ways to cope with sad feelings when they come up.”  If there are issues that are still problematic or have not been a focus of your work with the client, you can acknowledge those with a statement about how the client might address them on her/his own.

Second, the end of therapy is a time to provide support and education regarding returning to treatment in the future.  People often wait until symptoms are debilitating or until their lives are seriously impaired before seeking help, and a reminder about the steps that led up to the client’s presenting symptoms and condition may help her/him seek treatment more quickly.  Also, you can talk with the client about life transitions or developmental stages that may present a risk or vulnerability.  For example, a woman who was sexually abused at age 8 is likely to experience increased anxiety and reminders of her trauma if she has daughter who reaches the age of 8.  An adolescent who loses a parent will be vulnerable to episodes of depression or other grief-related symptoms when losses and transitions occur throughout adolescence and adulthood.  You can provide encouragement for future treatment by saying “If you find your symptoms returning again, I hope you’ll seek help again.  People often find it helpful to see a therapist when times are stressful or when there are life changes that may bring up some of the issues we’ve worked on here.”

The last task is to share the experience of saying goodbye.  Many clients are avoidant of emotions related to loss, and the depth and extent of this part of your conversation about ending may be limited.  However, at minimum you can make a statement like “I want you to know that I have enjoyed getting to know you and participating in the progress you have made.  I feel some sadness in saying goodbye, and I wish you well.”  This direct expression of your feelings provides the client with a different experience of ending, even if s/he doesn’t share her/his feelings.

I hope you find this structure helpful in organizing your final session.  Please email me with comments, questions or suggestions for future blog topics.

Working With Depression

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I’m worried about one of my clients who was very depressed and overwhelmed in our last session. How should I decide whether to call her before our next session?

This is a common and distressing situation for students in psychotherapy training. You may find yourself preoccupied with worry and uncertainty about your client’s wellbeing, especially if you are personally vulnerable to anxiety. Part of the developmental process in clinical psychology training is expanding your focus from alleviating your own distress to evaluating the impact on your client of different interventions. As behavioral health professionals, our primary responsibility is client welfare so all of our clinical interactions should be centered on that consideration.

Regarding a depressed, overwhelmed client, your first step should be consulting with your supervisor. This is especially important if you are in your first practicum or field placement setting and you should continue to consult with your supervisor throughout your training whenever you are concerned about a client’s safety. These situations bring up intense feelings for clinicians and it is hard to be objective in evaluating the most appropriate response when you are caught in the emotional intensity. Some of us respond to intense emotions by shutting down and minimizing the client’s risk and others of us become agitated and overestimate the risk.

Some of the factors to consider in evaluating your client’s risk, in consultation with your supervisor, are the length of your relationship with the client, whether the client’s emotional state is a change in response to a recent stressor or is more longstanding, how the client has coped or reacted to similar feelings in the past, and what internal strengths and external supports are available to the client. Clients who are new to you, who are reacting to a recent precipitating event, who use self-destructive or impulsive coping strategies, and have few strengths and supports are at greater risk. If you are concerned about suicidality, use a risk assessment tool such as the Suicide Assessment Five-step Evaluation and Triage.

If you and your supervisor agree that the client’s risk is high, you should contact the client to make a further assessment. If the client’s risk is low, you can wait until your next session to do further assessment. If there is a moderate level of risk, your decision will be based on your understanding of the meaning your intervention will have to your client. You may contact the client as a way to communicate your care and concern, but the client may experience your call as intrusive and undermining. You can develop an understanding of your client’s likely interpretation of your interventions based on your knowledge of her/his early experiences with parents and other caregivers and your observations of her/his relational patterns. A client who experienced neglect and has an expectation that others will be absent and uncaring will respond more positively to an unexpected call from you than a client who experienced abuse and intrusion. However, because psychotherapy always has the overriding goal of supporting client autonomy and self-determination, it is safer to refrain from initiating contact with a client unless there is a clear reason to do so.

After consultation and consideration of your client’s welfare, you may determine that contact with the client isn’t appropriate but still feel worried. This is the time to refocus your attention on your own coping strategies and self-care. Learning psychotherapy involves strengthening your ability to manage intense emotions and placing the client’s welfare above your personal needs. It also involves differentiating between your relationships with family and friends and your professional relationships with clients.

I hope this has been helpful to you. Please email me with feedback or suggestions for future blog topics.