Seven Tips for Building Rapport with New Telehealth Clients

Telehealth is a necessity in the face of COVID. Professionals and clients alike are feeling grateful to have this option to provide space for services and support clients with change, uncertainty, and the unknown. If you are like me, you weren’t fully prepared for the shift to telehealth back in March. Perhaps it wasn’t part of your business model as a therapist. Maybe it wasn’t an interest for you as a professional. Nevertheless, as we adapt to continue this meaningful work, let us take a look at some helpful tips for rapport and by-in when engaging new clients through telehealth.

1.     Look at the Camera Frequently. It’s hard not to feel self-conscious being on a screen. Invest in a light ring and elevate your camera so you are looking forward instead of down. Be sure to look at the camera directly when asking questions and when closing the session, as it encourages connection in feeling like you are truly looking at the client instead of looking at an image of you or them.

2.     Explain Loss of Eye Contact. You don’t have look at the camera the whole time. In fact, you need to be able to glance down from time to time to see how the client is presenting when it comes to body language. Be sure to name why your gaze is shifting, such as writing notes or referencing something in their initial paperwork.

3.     Review Documents. Review their initial documents beforehand and reference them in session. Not only does this show you are paying attention, it prevents your client from feeling like they have to repeat themselves.

4.     Obtain Consent for Telehealth. Engage your client in reviewing the telehealth software and protocols to obtain their consent. This includes emphasizing how their information will be protected and what to do when a call is dropped or requires another method due to connectivity issues.

5.     Encourage Questions. When building rapport via a screen, encourage your client to ask questions. This allows them to address any anxiety or worry about the work and permits them to feel like the conversation isn’t one-sided. Summarize goals and next steps for feedback and to demonstrate active listening.

6.     Explore Therapy History. A powerful question in building rapport can be normalizing that therapy is not a one-size-fits-all approach. Encourage your client to open up about what works for them by asking what they liked or disliked about past therapy experiences. Are they brand new to therapy? Ask how you’ll be able to gauge if something you say or do upsets them. This highlights our humanness as providers and encourages new clients to be honest and self-aware about triggers for upset as well as opportunities for therapeutic repair.

7.     Be Transparent. As the intake session comes to a close, summarize what you’ve heard them share, including what they want to work on and scheduling needs. Are they open to weekly therapy? Biweekly? Did you capture their initial goals? Scan and share your intake notes for complete transparency, inviting them to provide corrections or feedback as appropriate.

These tips are by no means an exhaustive list. However, the hope is that they compliment your own experiences as a professional adapting to telehealth. Allow these ideas to support your best work by providing a meaningful first impression. Your clients will be grateful for your attention to detail and your efforts will encourage their active participation in scheduled telehealth sessions going forward.

Action Over Insight: Why You Should Be Asking “What?”

There’s the old saying that, “deeds are more powerful than words.” It means that action is just as important, if not more so than simply talking. Although finding insight and discussing your intentions are valuable, the more critical step is actually taking action. It’s also the hardest as it means committing to a path, course, or direction.

Also, it means taking a risk, with the haunting possibility of failure. Yet, an action also has the greatest chance of success. After all, if you choose to do nothing then there will certainly be no benefit. Therefore, consider the importance of action and why you should be asking “what?”

Understand Action and Empowerment

When you commit to action and focus on the “what” you are empowering yourself. You are the person who is choosing to do something. This is much more strength-based as opposed to letting others do things for you. Or, to allow events to direct you instead of you being the one to take direction. If this is new for you then taking action may be intimidating or even scary. However, it is also thrilling and exciting to be the one committing to action. It’s led to some of the defining moments of our history. For example, it was the simple act of refusing to move from a bus seat that sparked the modern civil rights movement.

Focus on the “What” Versus “What Ifs”

When considering action, it’s easy to get caught up in the “what ifs” rather than the “what.” For example, you may spin your wheels considering all of the possible outcomes of a situation. Although both the positive and negatives outcomes exist, it’s not uncommon to solely focus on the negative ones. In turn, this can quickly lead to inaction. Instead, direct your attention to the “what” and doing the action. Yes, considering the outcome of your decision is important. Yet, if you get too stuck on the “what ifs” then you will never actually do anything.

Know That There Is No Perfect Choice

Another problem that you might have is focusing on the “perfect” decision. If you don’t make the perfect decision, what could happen? The possibilities are endless, no doubt. The reality is that there is no perfect choice. There is simply the choice (or choices) in front of you. Therefore, decide what you can do right now. In short, choose your “what.” Otherwise, you will again be stuck in the zone of crippling indecisiveness.

Find Purpose with Your “What”

You may feel that you don’t have any purpose in life. Thus, you are listless, drifting about in the world. This doesn’t have to relate only to your professional life or job. It could have to do with anything in your life. Are you just waiting for something to happen? Maybe you’re waiting for life to come to find you, fulfilling your goals and dreams. Waiting won’t fill the void that you are looking to fill.

Instead, the fastest way to discover your purpose is to choose your “what.” The reason is that your “what may take you down a path you weren’t expecting, leading to new possibilities that you never even considered. Or, perhaps you discover that you have chosen a dead-end. So what do you do now? Make a new choice and take a different course of action. Both paths are ways to finding your purpose.

Be Willing to Commit

When you choose your “what,” you are committing to something. Despite commitment being a word you may frequently hear, do you truly understand its meaning? Committing to something means a willingness to stick with it, even with the ups and downs. It means being in it for the long haul and being dedicated to the action. It’s easy to be scared away from your “what” because of the commitment. Yet, committing is necessary in order to find success. When you are asking “what,” you are directing yourself toward action. Even if you decide later on down the road that it was the wrong decision, you’re still on a successful journey to your purpose. You can always make another choice. For now, being willing to commit to the “what” and to the direction you take.

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Guest post written by Brenda Bomgardner, LPC, BCC, ACS

After completing a successful 17-year career in Human Resources at a Fortune 500 Company Brenda returned to school to earn her master’s degree in community counseling and a certificate as a board certified coach. She then launched a private practice, Creating Your Beyond, LLC.  Working with adult survivors of childhood sexual abuse and providing entrepreneurial guidance along with career coaching brings her fulfillment and joy. She is described by her peers as an expert on Acceptance and Commitment Therapy (ACT). Her new book, Sweet Spot: Finding Your Private Practice Groove with Principles for ACT, will be released in the summer of 2019. Chocolate is her favorite food group and adventure is her passion pursuit. She loves visitors and invites you pop on over to her website at Creating Your Beyond and take a look around. https://brendabomgardner.com  

The Power of Ritual in Healing

As a long-time bereavement counselor I have had the privilege of working alongside clients whose grieving is both complicated and intense. Even as we together tease out the knots and kinks that make relationships tangled and messy, we also focus on the beauty, the memories, and the pain. Whether it is the individual flow of mourning or grief that is heightened by society’s focus on anniversaries or holidays, using rituals and ceremonies to move through the grief is something I encourage all therapists – and clients – to be open to.

What causes us to tear up over a favorite song or poem that reminds us of our loved one? Our body provides us with a natural healing outlet for our grief when we are confronted with memories that trigger our emotions. Not everyone sheds tears easily or willingly after a loss, but the process of grieving can allow us the opportunity to work through this physical pain.

What can we do to encourage our own healing in way that is both respectful of the death and mindful of our life? Memorials and rituals are excellent ways to personalize the life of the person who has died. While many traditions encourage the sending of flowers or food to the bereaved family immediately after the death, there are other, longer-term gifts, memorials, or rituals that can carry forward the meaningful life that is no longer on this earth. 

In our Western culture, many have found solace in placing a tombstone where they can visit the deceased on a regular basis. We have also begun seeing additional options for creating a living memorial. Purchasing park benches, planting trees, buying a brick at a museum walkway, making donations to a cause that inspired your loved one are all options that are lasting reminders. But beyond the public shows of support, there are smaller daily or weekly things that can help keep the conversation open in your heart. Finding a place or creating a time for “sacred space” is a way of elevating the emptiness to a different level within your consciousness. 

Individualizing the loss

Consider a theme that resonates with you and the person who is gone: nature, sports, travel, music, food. Think about how you remember that person. Create a process or memorial that embodies that idea. Spend some time thinking about what feels authentic and what you feel comfortable with. Begin your journey when you feel ready.

• Perhaps nature is a theme. Collect small rocks from your hikes or nature walks that you keep in a spot in the garden or in a glass jar. Allow yourself the freedom to know your loved one was with you as you enjoyed nature and that you are respecting his or her presence by bringing it home.

• Hobbies can offer us a way to connect. Be mindful of the time you spend allowing your emotions to be present while you garden, bowl, or cook. Make a decision to incorporate your loved one in the process – cook his favorite meal once a month, print her name on your bowling bag or plant their special flowers annually. 

• If you are so inclined, take on an activity that you dedicate to do as an internal connection with your loved one. Take an art class, begin blogging, volunteer to read in an elementary school. Embrace the feeling of doing the activity together in your heart.

• Meditate or spend a portion of time each day in a safe spot for you to grieve and remember. Read a favorite poem, look at photos, or play a special song and let yourself cry or laugh.

What I have found is most effective in soothing the grief is to work with clients to discover what makes them connect with the soul of their loved one. It matters not at all that others don’t “get” it – it can be an inside joke. One woman felt comforted going to the golf course where her father used to play; another donated her husband’s clothes to a shelter where he had volunteered; another family whose young child died collected donations to enhance the playground at his school. And for those whose memories were bitter, I’ve suggested planting herbs or vegetables whose sharp quality can ultimately become something valuable. Making meaning of their life and honoring that which feels good and familiar is the key.

Grief and the (many) holidays

Being in a vulnerable state during the holidays can cause anxiety and depression. While those around you are celebrating and enjoying what they have, you may be feeling the loss of what you no longer have. The rule for observing a holiday is: trust your gut. If you don’t feel able or celebrate with others, don’t – you are allowed to say NO. Change it up. Have Thanksgiving with a neighbor, go away for the week, volunteer at a shelter for Christmas, have another family member host the Easter or Passover dinner.    

While seeing the trappings of public holidays can cause pain, there are other more personal observances that no one may be aware of or choose to remember, and the same principle of ritual can help. Whether you share these moments with others who can support you or you gain strength from the intimacy of privately remembering, know that your journey is unique and unless your activities are taking you out of living, you should feel comfort in your rituals.

• Create a special memorial cup that celebrates your loved one, and use it only on holidays, anniversaries or birthdays. 

• Offer a toast or a blessing or a prayer with those you love.

• Visit the gravesite or a spot sacred to you in the weeks prior to a remembrance date.

• Buy an ornament or decoration that acknowledges the loss and display it .

• Wear an item of clothing or jewelry that brings to mind your loved one; keeping a physical reminder can be comforting.

• Buy or make a card and write loving thoughts on an anniversary; keep it as long as you wish.

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Guest post written by Tia Amdurer, LPC, NCC

Tia Amdurer, LPC, NCC, has her private practice, Heartfelt Healing Counseling, in Lakewood, CO, where works with individuals healing from grief, loss, abuse, low self-esteem and family of origin issues. She is the author of Take My Hand: The Caregiver’s Journey (www.TakeMyHandJourney.com ). www.HeartfeltHealingCounseling.com

6 Reasons Highly Sensitive People (HSPs) Matter to Your Therapy Practice

If you aren’t familiar with the term Highly Sensitive Person (HSP) it refers to about 15-20% of the population who possess a unique sensory processing trait which allows them to pick up more on subtleties in the environment, resulting in deeper processing and often being easily overwhelmed with stimuli. HSPs are often gifted with having a rich inner life, complex imagination, and deep empathy for others.

Most HSPs exist on a spectrum of sensitivity, with about 1 in 5 HSPs who are considered High Sensation Seeking. High Sensation Seeking HSPs often experience life with ‘one foot on the gas, one foot the break’. Since they are often drawn towards stimulating environments, they often don’t appear as your ‘typical’ HSP. However they often need more time to recover from those stimulating experience than non-HSPs.    

As a therapist in private practice, you have plenty on your plate. Networking, continuing education, billing and insurance, not to mention the emotional work of hearing client’s stories of suffering and pain day after day. Given HSPs make up only 15-20% of the population, why should you care about them? And why do they matter to your practice? You might be surprised.  

1) HSPs Are Probably Already Your Clients

If you are thinking to yourself that you don’t have an HSP clients, think again! Remember that fun 80/20 rule? Dr. Elaine Aron (the official HSP guru) believes that, in psychotherapy, HSPs are the 20% of the population that make up 80% of your client base.  

I suspect you have at least one client on your caseload who is highly sensitive (or a high sensation seeking highly sensitive person). They may be aware of their trait and embracing it, aware of their trait and fighting it, or not aware of this trait at all.  

You already take into account many demographic details of your client, such as age, cultural background, gender identity, and trauma history. Why would you ignore your client’s innate temperament in the care you provide? Wouldn’t you want to know a critical detail about your client’s nervous system and adjust your treatment approach and expectations accordingly?

2) They Are Your Most Loyal Clients

When HSPs are receiving supportive therapy, in a setting where they feel valued and cared for, they will become your most loyal and dedicated clients. You may see them make progress fairly quickly. They probably will continue to see you even after the original issue has been treated.

One reason for this phenomenon is that many HSPs learn to view self-care not as a luxury, but as something inherently necessary for them to manage a delicate nervous system in a stimulating world. With their capacity for deep emotional and intellectual processing, therapy is a consistently needed outlet for their busy brain. If the client has the resources to do so, they may see seeking outside support from a therapist as a lifelong investment, not something that only occurs when they are in crisis or their needs are acute, although this may be how they initially come to your practice.

Even after their original issue has been managed, you can expect them to continue to support your business, either by continuing to see you for maintenance sessions, bringing their family and friends to you, or by sending clients your way who are also HSPs.

3) They May Be Your Most “Complex” Clients

When I use the term “complex”, I refer to clients with multiple concerns who appear to stall on progress despite long term or intensive support. They may also be the clients who you see frequently due to complex and challenging issues. They may be the client where you find yourself continually hitting dead ends or that feeling you are ‘missing something’.  

When treating HSPs, one must take into account how HSPs are impacted by differential susceptibility and vantage sensitivity. Simply put, these phenomena mean HSPs may have more long term negative effects than non-HSPs from adverse experiences or environments, but they thrive more than non-HSPs in enriching environments or relationships. Thus, HSPs who experience difficult childhoods are more likely to have anxiety and depression than non-HSPs.  They may even be mistakenly diagnosed with Borderline Personality Disorder.  

The key is not to use the HSP trait as the reason for all your client’s ailments.  It is to understand their susceptibility and take into consideration the delicate interaction between this trait, their environment, and whatever issues they are facing. For example, if your client is a person of color and/or part of the queer or trans community, you must also consider how the compounding impact of racism, oppression, heterosexism or cisnormativity, may impact HSPs vs. non-HSPs.  

When you take high sensitivity into account with your most ‘complex’ clients, you may need to reexamine and reframe your client’s past and current experiences. Stressor that may seem ‘minor’ to you or the client, but can actually have significant impact on an HSP’s psyche and physical health. You may need to support your client in reevaluating their past, lifestyle choices, and experiences with acknowledgement of their HSP trait. From there you may uncover some of the blocks to the client’s recovery and healing.

4) Awareness of a Client’s Sensitivity Can Improve Treatment Outcomes.

If your client is an HSP, you and your client have the potential to become frustrated or dishearten with lack of progress or barriers if you are not taking into account the client’s sensitivity. This may manifest as having the focus of treatment goals is in opposition of their innate temperament. You and your client may be frustrated because therapy goal’s are not taking into account your client’s finely tuned nervous system.  

You will never find a cocktail of medication that will prevent HSPs from processing deeply or being highly sensitive (although some clients report certain medications and supplements can help lessen sensitivity). You will never be able to ‘treat’ an HSP until they are no longer moved by others suffering or deeply empathetic. An HSP will never become ‘cured’ from picking up on subtle stimuli in their surroundings, but they can learn skills to manage overwhelm.

For example, most HSPs who work 40+ hours a week in a stimulating environment don’t have much energy left over at the end of the day. If your HSP client is wanting to be more social in order to meet more friends, but continually finds themselves not leaving the home after work, both of you may feel frustrated of their lack of follow through around social goals. You may see this as resistance, denial, or self-sabotaging behavior. The client may blame themselves for ‘lack of willpower’ or cite social anxiety. However, if you take into account the HSP trait, and the limitations around stimulation during the day, the goal may be to have the client instead look at adjusting their work schedule (i.e. working from home, scheduling more personal days) so that they have the energy to engage in social activity. You can help reframe their social anxiety as actually the anticipatory feeling of getting overwhelmed in certain social setting. Thus, you could encourage your client to attend social meet ups that are in less stimulating environments and help them distinguish between what is social anxiety and what is sensory overwhelm. You both can also reframe what is a realistic expectation around social engagement.   

If you are not able to educate and explore the possibility of your client’s sensitivity, you may continue to set your client up to be unreasonably distressed by something that is an inherent part of them. HSPs are susceptible to mental health disorders that require specific treatment and helping professionals must take into account an HSP’s basic temperament during their treatment process. It is possible for HSPs to learn skills so they do not become highly disregulated or overwhelmed, yet it is unlikely that their will lose their propensity for emotional depth and deep processing of the world.

5) Talking About the HSP Trait May Improve Your Relationship With Your Client

Often HSPs are relieved to understand that their trait is not something pathologically wrong with them. If your client is already aware of their sensitivity, even if they don’t have a name for it, they may be relieved to know their helping professional is open to talking about it.  Opening up the dialogue will invite a deep and meaningful conversation that can allow the client to feel valued and seen. This can result in your client feeling more motivated to engage in treatment and also deepen the healing relationship between you.

Keep in mind, it may be initially difficult for clients to hear about the HSP trait. Most HSPs have been shamed, ridiculed, bullied or even abused for their sensitive temperament. In turn, they will often internalize the devaluing of their sensitive nature, as opposed to seeing it as a strength.  

Be mindful of when to broach the topic. You can describe their sensitivity without naming it or without ever using the term “Highly Sensitive Person”. Consider using terms like: sensory processing sensitivity, finely tuned nervous system, or easily overwhelmed or overstimulated.  As you know, the best approach is to use the client’s own language.  

6) Discussing the HSP Trait Can Improve Your Client’s Relationships With Others

When clients learn they are highly sensitive, it can help them reframe their past experience and present functioning in a compassionate and new way. In my experience, once HSP clients really learn to embrace their trait, they often feel renewed energy and clarity around setting boundaries around their time, energy, and emotional labor. Many of my HSP clients have been able to finally make career decision that were more suitable to their temperaments, as opposed to what was expected from them by their family and culture. Other HSP clients have become able to frame relationship difficulties with their romantic partner as temperament differences (one is an HSP, one is not) as opposed to a fundamental flaw between them. 

Acknowledging the interplay between a client’s sensitivity and their personal relationships does not eradicate all problems, nor does it excuse legitimately harmful or abusive behavior. Yet, it can allow an increased clarity around the client’s true needs and the open the dialogue for your client to have relationships that are about honoring their innate sensitivity, as opposed to allowing it to be devalued. The first step might be exploring with your client how their sensitivity might show up in the therapeutic relationship.  

Moving Forward

If this article resonates with you personality or professionally, you might be wondering how you can continue to learn more about Highly Sensitive People or what your next steps should be.

Your first step is to do some self exploration. Are you a highly sensitive therapist? Are you a high sensation seeking HSP? It will be hard to truly understand the trait in your clients without seeing where you lie on the sensitivity spectrum. You can start with going to Elaine Aron’s website, where she has several self-tests around the HSP trait, including how the HSP trait might appear in children. You might also consider sharing these tests with any loved ones who are also curious about the trait.  

Should you want to incorporate knowledge of HSPs into your therapy practice, the next step is to educate yourself about this trait in the context of a clinical setting. Elaine Aron’s book Psychotherapy and the Highly Sensitive Person is an excellent resource for therapist who would like to start becoming knowledgable around working with HSPs. You may also want to pursue consultation and collaboration with therapists who specialize in working with HSPs.

Whatever path you choose, educating yourself around Highly Sensitive People will undoubtedly benefit your clients and your practice. Hopefully, this exploration will also uncover aspect of yourself and your relationships, bringing increased understanding and clarity to your own life as well.

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Guest post written by Arianna Smith, MA, LPC, EMDR

Arianna Smith, MA, LPC, EMDR is the owner of Quiet Moon Counseling in Littleton, Colorado. She specializes in working with Highly Sensitive People (HSPs) and LGBTQ survivors of trauma. She has a passion for helping HSPs learn to cope with overwhelm, find belonging, and craft their ideal life. She provides affirming therapy to LGBTQ survivors of trauma and abuse as they embark upon their healing journey. Learn more about her practice here. 

Geared towards Growth: Exploring Maslow’s Hierarchy of Needs

Have you had a client come into your office wanting to work on their relationships? What about a client who wants to work on self-worth and self-esteem? These goals are valuable and achievable, and could greatly benefit your client in their functioning and connection in the world.  However, depending on your client’s stressors and current life events, basic needs may need to be attended to first in order to achieve the growth and progress desired within your therapeutic work.

Hierarchy of Needs

Abraham Maslow first introduced the concept of a Hierarchy of Needs in a paper published in 1943. The image found most often in reference to his concept is a pyramid with the bottom representing the building block or foundation for higher functioning. According to Maslow, every human being has needs that must be met and stable prior to advancement to another level of human need. The levels he identified begin with physiological needs, followed by safety needs, love and belonging, esteem, and finally, self-actualization. Below are some examples of needs for each level:

• Physiological: food, water, oxygen, sex, sleep, excretion
• Safety: security of shelter, employment, resources, health, body
• Love & Belonging: family, friends, intimate partners
• Esteem: confidence, self-esteem, respect by others, respect for self
• Self-Actualization: Acceptance, lack of prejudice, enlightenment

Goals for Growth

So how do the levels of need impact your client’s therapeutic work? For many helping professionals, the awareness of the hierarchy manifest through client psychoeducation around basic needs. Perhaps your client wants to work fully on their relationships, but is impacted by the stress of not having a job to pay their bills. Maybe your client wants to strengthen self-esteem, but can’t identify housing in suffering from an eviction this month. The present crises will require therapeutic attention and intervention first prior to a client allotting mental energy to higher levels of functioning.

Within your work, it can be helpful to normalize and educate your clients on basic needs being the foundation for functioning. You may consider describing the imagery as basic needs being the foundation of a house. If the foundation is crumbling, the other parts of the house become low priority or unseen in trying to stabilize the problem due to risks of it all collapsing around them. With this analogy, clients can absorb the importance of a stable foundation of basic needs requiring their attention before other goals can be successfully met.

Accessing Needs

A stable foundation may require other resources outside of your office. As a helping professional, it is in your best interest to be aware of resources to provide additional support to your client. The databases in your state, (Colorado Crisis Services and Colorado 2-1-1 for example) can be helpful in identifying food, shelter, clothing, legal advice and more.  You may also consider coordination with helpful organizations that would warrant a release from your client in order to collaborate.

Assessing needs can also occur from a place of looking at client resistance. One way this may manifest is through your client’s capacity to work on homework or assigned tasks between sessions.  Although some clients don’t like homework out of personal choice, other clients may struggle to articulate the crises that prevent progress on the homework you assigned, including forgetfulness, loss of focus, or stressors demanding their attention instead. This attempt at juggling varying demands could even translate to cancelled sessions in trying to handle the stressors at home or work. By being aware of basic needs, it can help you as the professional to better understand contributing factors that may present like resistance as elements requiring attention to support client progress.

Maintenance and Motivation

With collaboration and stabilization of basic needs come the client’s motivation for maintaining the foundation.  It is the hope that client’s basic needs, once addressed, remain in good standing.  However, with clients experiencing poverty, trauma, or other adversity, the fluctuating circumstances of their life can delay progress on higher functioning goals. Encouraging ongoing boundaries and self-care can support the client in reaching higher goals around self-esteem and relationships. With awareness and effort, a client can harness a healthy sense of control and autonomy in their life. Remaining flexible to the stressors that may occur between sessions, it is important that you and your client continue to be mindful of what takes precedence to allow the deeper, meaningful work you both value to occur at the appropriate time.

Supporting Self-Esteem: Tools to Identify Strengths

“I don’t know what to say. I was raised not to talk about myself. I don’t want to sound cocky.” You are engaging your client in an intake session where you’ve created an intentional, positive shift from an otherwise heavy series of questions about symptoms including details as to why they are seeking therapy. Your new client appears caught off guard by your questions about strengths and they struggle to identify anything that is going well, or things they like about themselves. You make a note to identify a possible goal around self-worth and self-esteem, to be explored with the client upon building more rapport.

So how does one engage a client in exploring their strengths while acknowledging the vulnerability to do so? For many, talking about elements they like about themselves or their resiliency may be difficult when entrenched in negative emotions.  For example, a client experiencing a depressive episode may have a hard time identifying any emotions of hope or former pleasure based on their current negative cognitions around hopelessness and feeling stuck.

Look to the Past

For depression and being entrenched in symptoms, it can be easier for a client to recall the events or strengths of the past than experience the present or predict the future. By engaging a client in exploring what would formerly describe their circumstance, you can encourage the initial stages of cognitive reframing and thus rewiring from negative to positive thought. Some examples of questions to support access to the past can be found below.

• Is there a time you felt confident? Can you tell me more about that?
• When is a time you felt like everything was going well? What made it so?
• Wisdom, Sacrifice, Kindness. Can you share a time you demonstrated each of these strengths?
• What is one thing you are happy or satisfied with in your life?
• What is one thing you like about yourself?

Engaging a client in reflection on these elements can support new awareness and positive feeling through revisiting pleasant memories. By exploring former experiences, the client may be able to identify ways to rediscover those experiences in the present.

Likeable and Lovable

If a client continues to struggle with identifying their strengths, it can be helpful to engage them on the thoughts and statements of others that know them well.  You may find asking them what their mother, sister, friend, partner, or close colleague would say about them if those relationships are healthy. Here are some ways you could explore self-image through the eyes of others:

• What would your mom say is one of your strengths?
• What compliments have you received from others about your efforts at work?
• How would you be described by your best friend?
• What do you think your partner appreciates most about you?
• If you were represented by an actor for a movie, who would that be and why?

By encouraging the client to explore loved one’s statements or compliments as a reflection of their own strengths, it may remove some pressure to identify them on their own while still encouraging positive thought and reflection.

Sort and Seek

A reflection tool that can further encourage exploration of strengths and thus improve self-esteem is a value sort. A value sort instructs clients to review a list of values and narrow down their choices based on order of importance. This can allow clients to explore their values and make connections to how those values are being represented in their life. A favorite tool is the value card sort, currently being used by mental health professionals and some universities. In the value card sort, a stack of values is sorted into levels of importance including minimal, moderate, and most important. Client are instructed to go with their gut and sort quickly, supporting a narrowing of values to the top seven most important to the client. Reflection can then be encouraged by asking the client the following questions:

• How are these seven values represented in your life currently?
• How are these values represented in work, home, and relationships?
• What needs to be changed or improved to maintain these values for you?
• How would enhancing or improving these values in your life help you?

For many, exploring their values and current representation in their life can support a movement towards measurable goals to improve those values, thus improving sense of control, pursuit of happiness, and higher self-esteem.

Mastering Mindfulness: Supporting Positive Coping

“I want to turn off my mind, catch my breath, feel less tension, sleep better.” The techniques of relaxation and mindfulness have been around for centuries, both in definition and in practice in various cultures. For some, the process of mindfulness describes being aware of your surroundings and slowing down your mind to remain in the present moment. For others, it has become a vital coping skill for anxiety or distress to allow grounding, emotion regulation, focus, and a sense of calm in otherwise difficult situations. So how does one present the ideas of grounding, mindfulness, or relaxation to clients in meeting their individual needs?

Explore the History

For many, the concept of feeling relaxed or calm is experienced rarely due to elevated anxiety or trauma triggers in everyday life. Perhaps you start a session with exploring the times they’ve felt more at peace or relaxed. Even if it were years in the past, this exercise can provide helpful insight into situations or context that allow your client small shifts or temporary relief from discomfort or anxiety.  Questions that might help you explore this with your client include:

• Can you remember a time when you felt calm and relaxed? Can you tell me more about it?
• How does it feel in your body to experience calm or relaxation? What sensations do you experience?
• What has helped you before in feeling calm or relaxed? What makes that different now?

Become Body Aware

Exploring the history of times a client has felt calm or relaxed is but one piece of the puzzle. Depending on the client’s background, trauma history, or the impact fight/flight/freeze reactions, their body may have adapted to the increased stress and cortisol levels in interesting ways.  Some clients will express increased anxiety or panic in response to relaxation, as it feels vulnerable or uncomfortable in their current, adapted state of functioning.  For others, a numbness may exist where they cannot feel their body with possible contributing factors including depression, hypoarousal/freeze response, or desire to maintain self-preservation. Lastly, clients may easily drop into intellectual conversation about their symptoms but avoid experiencing any sensation in their body due to anticipated discomfort or negative arousal.

Keeping client limitations and comfort in mind, it can be helpful to encourage clients to gently become more aware of their body through various therapeutic activities. It is suggested to start with neutral areas of the body and move quickly from one area to another to prevent exacerbation of sensation that would prevent progress or cause a client to retreat from noticing their body out of fear or discomfort. By engaging them in the following activities, you can support a client in building body awareness and distress tolerance in ways that feel safe.

• Body scan-start at your feet and notice any sensations as you move gently upward to your calves, thighs, hips, waist, etc.
• Concentrated body scan-have the client identify neutral or safe areas that aren’t associated with negative sensation like hands, knees or feet.  Have them focus on one area in detail, asking questions about temperature, sensation when touched, and encouraging the client to engage in use of textures and varying touch to explore sensation.
• Colored Glasses-our new favorite intervention from Dr. Dan Siegel in his book Mindsight, obtain or create colored lens glasses for clients to explore varying perspective of objects around them, insight into sensation in low-risk ways, and connection to memory that all support the practice of mindfulness.

Use all Five Senses

All of the above exercises support experiential learning in session. Another favorite tool that can support a client who experiences any negative sensation or experiences hyperarousal or flooding during a therapeutic exercise is to move their attention outside of themselves and into the room as a grounding technique. To do this, you can ask the client to become more aware of the chair underneath them or their feet on their floor.  A few of our favorite tools are listed below that can be helpful in engaging a client outside of their own body.

• 5-4-3-2-1: What are five things in the room that are blue? Four things you can touch? Three things you can hear? Two things you can smell? One thing you can taste?
• Four Elements by Elan Shapiro: 1) Earth/Grounding: what do you see/hear/smell, 2) Air: Take measured breaths, inhale for four counts, exhale for four counts, 3) Water: Take a drink of water, use gum/mints or think of your favorite food to generate saliva, which serves as a calming agent to activate the parasympathetic nervous system and relaxation response, 4) Fire/Light: think of a place real or imagined that makes you feel calm or safe. Can you describe it using your five senses?
• 5 Minute Mindfulness: have the client pick an object to focus on, either in their hands or within sight. Gently direct them to notice all qualities of the object including temperature, texture, color, height, etc. for five minutes duration.

Modeling of Mindfulness

In addition to the mindfulness exercises listed above, it can also be helpful to create a coping kit of objects that can be engaging and cater to all five senses for client use within your office. Many therapists utilize objects such as essential oils, lotion, touchstones, magnets, putty, carved wooden objects, fur, water, and sand to engage clients in mindful practice. As your client discovers which objects are effective for them to practice mindfulness, you may encourage them to purchase and utilize these objects outside of session as well.

Regardless of which tools or techniques you elect to use in support of your clients, it can be even more helpful to notice your own body and energy in the room. By becoming aware of your breath, posture, and energy levels, you can support client in feeling safe or supported to do this work. By practicing alongside your clients, you model what it means to feel grounded or mindful, which is beneficial not only to your client seeking relief, but to yourself as the clinician mindfully engaging each client in their meaningful work and progress towards health.

Community Confidentiality: Supporting Collaboration with Consent

“I cannot confirm or deny.” How do you maintain confidentiality for your client? It may seem easy enough when there is a clearly written, signed release or when your client refuses a release, thus declining collaboration at this time. However, what does it look like in the following situations?

• Your client is involved in an open Child Abuse and Neglect case.
• An attorney calls you saying they represent your client and would like copies of your client record for a disability claim.
• An insurance company calls to report the client listed you as a provider and they want to know your diagnosis to award the client a life insurance policy.
• You outreach an organization about who they serve. They respond by wanting to obtain additional information from you on the client you want to refer.
• A referral source wants to know if their client called to set up an intake and begin services with you.
• A community resource shares that your client scheduled an appointment with them for next week.
• A foster parent wants to know why the parent isn’t engaging in services to reunify with their child.
• A CASA volunteer wants to know if the family is working on their fighting in your sessions because they believe it would be helpful.
• The spouse of your client calls asking you how sessions are going.
• Your client acknowledges that their friend is also your client.
• Their probation officer includes you in a group text or email to schedule a meeting on behalf of the client with several parties you don’t know.

These are just a few of what could be dozens of examples of sticky situations when it comes to maintaining your client’s right to privacy. Let us look at possible responses to the above scenarios to determine what could be best. And as always, seek consultation, supervision, or legal advice if you have needs or concerns.

Signed Release

When a third party reaches out to you by email, text, or voicemail, it can be helpful to notify your client and obtain a release in the next scheduled session. Notifying your client of the outreach you received can support trust and transparency in the therapeutic relationship. It can also help facilitate a discussion on the importance of getting a client’s written permission to respond to an inquiry on their behalf, whether it’s an insurance company, secondary referral, family member, or community partner.

Legal Requirements

Perhaps your client is involved in an open Abuse and Neglect case, diversion, or probation. These entities have been assigned to your client as part of a larger treatment plan to address a legal concern. Whether your client is mandated to complete therapy or the third party referred directly to you, there is a different level of confidentiality implied due to the collaboration needed from you to provide progress reports and updates as appropriate around your client’s engagement in services. If you client is resistant to signing a release, helping them identify the specific pieces of information to share—and thus restricting some information in the effort of privacy—can be helpful to the client’s anxiety about personal information that is disclosed to others. When submitting a progress report to DHS or probation for example, providing your client with a copy can also demonstrate a sign of transparency and trust in encouraging them to review it and provide feedback on their level of comfort with the material shared.

Sense of Urgency

The desired scenario is one of those mentioned above, where we have the client complete a signed release of information highlighting exactly what is released and for what purpose. However, there are times that a sense of urgency may arise in getting permission quickly to collaborate with a community partner in a timely fashion. Depending on the frequency of client contact including regularly scheduled appointments, you may need to get email or verbal permission over the phone from your client as a temporary measure in obtaining consent prior to a written release. Standard practice is to have permission in writing so email can feel slightly more comfortable than verbal permission to us as providers. Either way, documenting your client’s permission with intention to get a full release in the immediate future can be helpful in allowing collaboration and sharing of information under a time restriction.

Curbing Curiosity

Collaboration is a helpful component of therapy, within reason, to support and validate client efforts. It may become apparent that there are other parties involved who may want updates on your client’s progress. This could include caseworkers, probation, child advocates, other mental health providers, foster parents and more. Where it can feel confusing is when third parties know you are actively working with the client and make assumptions that you can share information in the spirit of collaboration. For example, the foster parent is wanting to know how the parent, your client, is doing in services in order to encourage their child of the parent’s hard work. The inquiry may feel innocent enough, however the foster parent is not your client, and is therefore not privy to this information without your client’s consent. Something as innocent as attendance or participation in services can be reported back to other parties and could result in information being misconstrued or shared without permission.

Encompassing Electronics

In an effort to not have information shared unintentionally with third parties, being mindful of how your electronic correspondence is recorded can be helpful. Being aware of emails with additional recipients or group text messages requesting scheduling of a team meeting can feel nebulous regarding confidentiality. Documenting your effort to send correspondence only to approved parties identified on a signed release supports your client’s wishes as well as ethics compliance. Providing disclaimers in your electronic signature in email composed on your computer or phone can also support limiting liability if information is sent to the wrong recipient or forwarded to a third party outside of your control.

Limiting Liability

Documenting each of your efforts to maintain confidentiality as a standard of your practice can limit liability. Obtaining regular releases yearly from your client can keep their record up to date. Utilizing encrypted email and electronic health records for client progress notes can restrict situations where their information could be compromised. When it comes to confidentiality in direct interaction with third parties, identifying a statement of “I cannot confirm or deny they are my client” can feel unhelpful, restrictive but necessary in not admitting unapproved information to family, friends, referral sources, or legal representatives without permission. This feels most challenging by phone when even acknowledging your need to obtain a release is admission of your client’s connection to you. For many, having to share that a release has been revoked can feel even more challenging. You may say something like “permissions have been revoked and we suggest you contact the person of interest directly” can provide enough information for them to understand you won’t be interacting with them further and prevents direct identification of your client by name or circumstance.

Communication with community partners is an intricate dance that can feel challenging when caught off guard by emails, texts, or phone calls asking for updates on your client’s work. Demonstrating your ethical capacity in delaying disclosure of information until a release is obtained can indicate your professionalism in the community and willingness to collaborate under the appropriate circumstance. Be sure to follow up with the community partner once a release is signed to further demonstrate your willingness to collaborate together. Lastly, thinking about the possibly scenarios that put privacy at risk and obtaining signed releases upon introduction to the client can streamline this process by simply asking who else is involved in their treatment or care. Having a scripted response ahead of time for situations where a release is not yet completed can support you in making the best decision to support client confidentiality and community engagement with consent.

Clinical Writing: Consistency and Confidentiality

A question heard frequently in private practice is how do we stay on top of paperwork when our passion is engaging the client in doing meaningful work? What if clinical documentation supports them in getting additional resources such as disability or explores reunification with their children? When working with individuals or families involved in the Department of Human Services (DHS), probation, diversion, or other entities evaluating your client, the documentation you keep takes on an additional level of importance in capturing the client’s progress. So how does one balance recording the content of the session consistently while protecting client confidentiality? Balancing requirements for documentation with client privacy is an art form that requires consistency and practice.

Construction of Case Notes

Depending on your preference for hand written, typed, or electronic notes, your content and formatting of those notes could be dictated by private or state assistance insurance panels in order to process claims and receive payment for services rendered. With this in mind, most insurance panels require the following to be identified in each note:

• Full name of client and insurance ID
• Date of service
• Time of Service
• Duration of Service
• CPT Code that indicates individual therapy, family therapy, case management, etc.
• Overview of therapeutic interventions utilized in the session
• Progress towards identified treatment goals
• Current mental health diagnosis
• Client presentation in session
• Next scheduled appointment

By formatting your notes in a similar fashion, you can streamline any documentation needs from secondary parties desiring collaboration. Don’t forget a signed Release of Information from your client to facilitate collaboration!

Consistency in Content

Formatting not only provides the outline of a universal progress note, it can support consistency that will reduce the time spent on notes each week. Many therapists report frustration that their notes are behind schedule due to wanting to dedicate their time and energy to the client work. By utilizing a template for notes, it will become easier and more efficient to complete notes in a timely manner, especially in utilizing clinical language. When struggling with how to write clinical language that captures the professional interventions present in each session, it can be helpful to have some go-to phrases that indicate progress without providing too much detail. Here are some examples of common content and professional language that could be helpful in writing clinical notes:

Confidentiality for Clients

In addition to clinical documentation supporting professional record keeping in line with ethical requirements, another component it can support is client confidentiality. It can feel like a fine line providing adequate written evidence of professional interventions without violating client privacy.

One strategy to ask yourself is, “would my client feel uncomfortable with my notes being seen in court or by others?” If the answer is yes, you may want to re-evaluate how you write your notes to support clear, concise interventions that would not put confidentiality at risk. Below are some documentation tips to consider in supporting client privacy:

• Keep client direct quotes to a minimum.  They are best included when capturing safety concerns. Client reported “I want to die” leading to assessment and safety planning in session.
• Avoid emotion-driven language without evidence such as, client was happy/sad/angry in session.
• Support ownership of statements such as, this writer observed or client reports when documenting statements or content of a session.
• Keep language neutral. It is best to avoid a positive or negative tone in notes to prevent accusations of bias or alignment that would put professionalism in question.

It is recommended you seek consultation or supervision to further explore your documentation needs. Your professional organizations can provide ethical guidelines whereas insurance panel websites offer Providers valuable templates for clinical documentation that meet audit standards. With luck, you will perfect your clinical writing to maximize time in therapeutic interventions while remaining compliant with documentation needs to best serve your clients and your practice.

Avoidance and Attendance: How to Address Each in Therapy

It’s that time of year. The time where certain clients disengage from therapy in response to the season, holidays, or stress, and the time when others need appointments the most in order to support them through trauma, family conflict, isolation, and loneliness. When working for an agency, the crises seemed to intensify during the holidays. First it was the client diagnosed with Bipolar Disorder experiencing depression symptoms due to the winter weather. Then the client with trauma from sexual assault having to see their perpetrator at the family holiday dinner. Or the single client with no access to family experiencing increased suicidal ideation in response to spending the holidays alone. Or the client with high anxiety becoming stressed about money and gifts for their family, losing sleep and snapping at their kids. And finally, the client sober from alcohol for three months having to navigate holiday parties around family and friends where temptation may lead to relapse. Combine these factors with a client’s distress tolerance and they could engage in therapy fully to receive support, or in some cases, disengage in response to their symptoms. As helping professionals, how do we balance the variety of client needs with consistency, empathy, and grace?

Lack of physical attendance

The more easily measured is a change in physical attendance in your scheduled sessions. Perhaps the client starts to cancel sessions when they’ve been consistent in attending each week in the past. How do you explore their needs when you haven’t been able to see them in the office for several weeks now? Depending on how they are engaging you to cancel the appointments, you may offer a couple of ideas in response to their distress:

• Completing a phone call to gauge what is going on in their world and attempting to re-engage them in sessions to support symptom management.
• Offering a phone session rather than a face-to-face to explore and address present stressors if they are unable to attend.
• Identifying a different appointment time that allows physical attendance such as an early morning or later evening if appropriate.
• Redirecting text messages of distress by offering an appointment to discuss and support them.
• Reviewing their attendance contract with them to determine how they’d like to proceed, including possibly placing scheduled appointments on hold and resuming at a later time if appropriate.

Lack of emotional attendance

The hope is that with ongoing rapport, the conversations above can demonstrate healthy communication, accountability, and boundaries with a client experiencing increased distress. Rapport becomes even more important when engaging a client around a lack of emotional attendance or participation in session. Perhaps you begin to notice that the client arrives late every week, jumping into sessions with surface-level details or changing subjects rapidly throughout the scheduled time. Or maybe they remain at head-level in their processing, not dropping down into emotions and deeper meaning in session with you. With healthy rapport, you as their support can gently name the behaviors you are seeing in the room to encourage a healthy conversation about their avoidance. Here are some examples of how you might approach them in a compassionate way:

• In response to their running late: “I’m noticing how rushed it feels lately coming into our sessions and feeling like we have to fit it all in. Can you tell me more about what that’s like for you?”
• In response to staying in their head: “I’m noticing you are very much in your head today when it comes to describing how you feel, can I ask you to pause a moment and share with me what’s happening in your body right now?”
• To encourage reflection: “I feel like you are very far away in this session even though we are sitting across from one another, what does it feel like for you?”
• To encourage feedback: “I’m hearing that you have a lot on your plate right now. What can I do to help you best in this moment?”

Any of these gentle inquiries can lead to a tenderness and connection to emotion as well as an access point for clients to identify and explore their needs. These sessions can prove to be some of the most impactful and fruitful in not only holding space for emotion and modeling what it looks like to communicate needs, but also supporting vulnerability and self-advocacy in the client as to how they can engage their supports.

I hear you

As a therapeutic support, engaging clients from a place of compassion and empathy can be powerful to their experience. Balancing a neutral curiosity with ongoing optimism that, together we can find relief, can be empowering for the client. By starting with gentle reflection and gaining better understanding of their emotional response to stressors in their life, we can then encourage exploration and practice of positive coping. Whether it be concrete tools for coping or holding space for their emotions, we are creating a safety net to address any fear, guilt, or shame they may be harboring around their functioning in these moments of distress. Like any roadmap, with direction and insight, we can address avoidance and attendance from an authentic, supportive place to best help our clients in navigating their world.

“If we can share our story with someone who responds with empathy and understanding, shame can’t survive.” Brene Brown in Daring Greatly: How the Courage to be Vulnerable Transforms the Way We Live, Love, Parent, and Lead.