Avoidance and Attendance: Advocating for yourself

It’s that time of year. The time where you might feel the urge to disengage from therapy in response to the season, holidays, or stress.  The time when you may need an appointment the most in order to support you through trauma, family conflict, isolation, and loneliness. For some, the crises seem to intensify during the holidays. Perhaps you are experiencing depression symptoms due to the winter weather or maybe you are battling loneliness in spending the holidays away from your loved ones. Perhaps you are attempting to navigate the unwanted memories of trauma during your family’s holiday dinner or are experiencing high anxiety because of money stress and holiday shopping. You on your journey to sobriety and anticipate having to navigate holiday parties around family and friends where temptation may lead to relapse. Combine these stressful situations with your ability to cope and you may feel you can engage in therapy fully to receive support, or in some cases, desire to disengage in response to the overwhelming feeling of all that is weighing you down. It can feel like a balancing act to engage your supports when feeling stressed, but rest assured, it can be an empowering experience to engage in through the holiday season in support of your personal and relationship goals.

Avoiding Appointments

The more easily measured type of avoidance when overwhelmed is a change in attendance in your scheduled sessions. Perhaps you find yourself canceling sessions when in the past, you’ve been consistent in attending each week. Or maybe you find yourself cancelling last minute due to feeling like you need to use that time or money for another task? How do you explore your needs when you haven’t been able to justify spending the time or money on your own mental health? Depending on how your therapist structures sessions, you may want to consider advocating for yourself in exploring the following:

• Completing a phone call with your therapist to communicate what is going on in your world and attempt to re-engage in sessions to support managing your stress.

• Engaging in a phone session instead of a face-to-face to explore and address present stressors if you are unable to attend in person.

• Identifying a different appointment time that encourages attendance such as an early morning before work or later evening if appropriate and depending on if your therapist has openings at those times.

• Identifying biweekly or monthly sessions for the holiday season to account for financial constraints and time management.

• Reviewing your attendance contract with your therapist to explore opportunities and restrictions, such as possibly placing scheduled appointments on hold and resuming at a later time if appropriate.

Emotionally checking out

The hope is that with ongoing rapport, the conversations with your therapist above can support you with healthy communication and accountability when experiencing increased distress. Your relationship with your therapist, or rapport, becomes even more important when you find yourself engaged by your therapist around a lack of emotional participation in session. Perhaps you begin to notice that you struggle to arrive on time to your scheduled appointments, jumping into sessions with details unrelated to yourself or changing subjects rapidly throughout the scheduled time. Or maybe you remain surface-level in your processing, not dropping down into emotions and deeper meaning in session because you are avoiding the stress or have worries that it will become unbearable when talking about it. With healthy communication, you can name what’s going on for you and process the outcomes with your therapist. Here are some examples of how you might start the conversation:

• In response to running late: “I’m struggling to get here on time and it feels rushed lately, like we have to fit it all in. Can I talk to you more about what that’s like for me?”

• In response to staying surface-level: “I have to admit, it’s easier to talk about the lighter things than the deeper, more stressful stuff. I think I’m worried that if we talk about it, it will just make me feel worse.”

• To encourage connection: “I feel very disconnected from my body, like my head is fuzzy and floating and I just want to be numb rather than this stressed all the time. Can you help me feel more like myself?”

• To encourage feedback: “I’m needing something different in our sessions to help me. Can I talk to you more about that?”

• To name fears: “I’m afraid that if we talk about these things, I won’t be able to function or get things done afterwards,” or “I’m reluctant to talk about this now because we won’t have our next appointment until after the holiday.”

Any of these statements can lead to a supportive conversation with your therapist to further identify and explore your needs. These sessions can prove to be some of the most impactful and fruitful in not only holding space for emotion and processing of stress, but also supporting vulnerability and self-advocacy in exploring how you can engage all of your supports in ways that feel beneficial to you.

Hear me

Vulnerability is hard. Yet for many of us, the power of being seen, heard, and understood makes engaging in vulnerability worthwhile. Your therapist, engaging you from a place of compassion and empathy, can better understand your needs when you speak of them. Your therapist can offer a neutral curiosity with ongoing optimism conveys the message that, together, you can find relief. Whether it be concrete tools for coping or holding space for your emotions, your therapist can create a safety net to address any fear, guilt, or shame you may be harboring in these moments of distress. Engaging in holiday travel, consider your therapy sessions a roadmap to relief! With direction and insight, you can address avoidance and attendance from an authentic, supportive place to best serve you during the hustle and bustle of the holiday season.

“You are as amazing as you let yourself be. Let me repeat that, you are as amazing as you let yourself be.” Elizabeth Alraune

Mirroring in Relationships: Manifesting and Maintaining Connection

What does it mean to feel connection with another person? How do you know when you are building rapport in your interactions with others? For many of us, connection starts with body language and conversation when determining relatability and ongoing engagement. Engagement can lead to belongingness and belongingness is a crucial element of positive mental health and overall wellness. So why wouldn’t we want to pursue belongingness and connection in our relationships and throughout our lives in support of optimal wellbeing?

Monkey See Monkey Do

Connection can be measured externally in how we interact with one another, but also internally through brain activity. Mimicking one another, often described as mirroring, was first discovered by Giacomo Rizzolatti, MD and his colleagues when studying monkeys.  Rizzolatti recognized that there was similar, observable brain activity indicating pleasure when a monkey consumed a banana as when the monkey observed a researcher consuming a banana. This brain activity involving neurons, called Mirror Neurons, provided implications that our brain activity responds in relation to others, thus encouraging development of an empathetic response. A more recent article was published in the UK on research involving infants and their mothers. With eye contact, the brain waves in the infant responded and attempted to synchronize with their mother, implying efforts at deeper connection and communication, according to scientists at the University of Cambridge.

Bonding in Business

Mirror neurons are important for close relationships; however, they can be influential in working relationships as well. Business gurus have developed interpersonal programs to support connection and reciprocity in business interactions, including awareness of body language, eye contact, and mannerisms. These programs can teach a person to be more aware of cues in social interactions and introduce subtle mirroring behaviors to increase engagement, likeability, and reciprocity. 

Mirroring behavior in conversations is adaptive, such as noticing when one party begins to unconsciously mimic the other in their posture, speech, and/or gestures during an interaction. As you can see from the picture we’ve chosen above, several members of the group are mirroring one another in their hand gestures, indicating connection or attempted connection in the moment. When learning these interpersonal skills for yourself, you may experiment with subtly shifting your posture to mimic the other party, exploring any observable differences in the interaction, including how you each feel towards one another. Mirroring research shows that when you make subtle attempts to mirror another person, they will find you more approachable, likeable, and connected, all which can be valuable when conducting working interactions or achieving rapport.

Generational Gaps

Engagement in working and personal relationships can support successful interactions, and it can also change how a person feels about themselves, including shifts in self-confidence and self-worth. Jean Twenge, a Psychologist researching generational differences including mental health, substance use, technology, and social engagement, speaks of this in depth in her book iGen. Her book highlights the dramatic shift in social interaction away from face to face contact to more technology-based connection. Her book also highlights a possible correlation between technology and lack of belongingness, even when those surveyed reported, on average, more than three hours per day of technology use including social media. Twenge’s research identifies some concerns about connection, including individuals reporting minimal person to person engagement, low self-confidence or preparedness in social situations, and thus identifies questions needing to be answered around technology and mental health.

Regardless of how we measure it, connection is important. One way of encouraging connection is getting out in the world and finding people who have things in common. This can be a pleasant opportunity to engage over shared interests and build relationships. Identifying activities you enjoy can be a starting point to engaging others around shared interests, with organizations like Meetup.com bringing groups of people together around enjoyable experiences. Pushing yourself to get out and meet people can have a positive result, as belongingness and social interaction continue to be vital parts of what it means to be human.

“You're imperfect, and you're wired for struggle, but you are worthy of love and belonging.” Brene Brown

Engaging Adolescents and Caregivers in Family Therapy

“Do I have to do family therapy?”

Yep, that's such a common question I get from my adolescent clients at the start of therapy. Here are some other common questions and statements a therapist may receive in regards to parents and caregivers being a part of an adolescent's therapy process:

"So how much are you going to tell my parents?"

"I hate these family things; i just feel so awkward."

"Do I have to be in the room when you talk to my mom/dad/guardian?"

“I’ll talk to you, but I will not talk to my parents about this!”

“Why try, nothing is going to change!”

“They/she/he just doesn’t understand me.”

Do any of these sound familiar in your therapeutic work?

When reflecting on these common initial responses and questions about family therapy, it has been my professional experience that I see a clear pattern of fear, lack of trust and shame arise as barriers to adolescents getting their needs met by their caregivers. Additionally, many adolescents seem to have a common misunderstanding (and caregivers too) that family therapy is about pointing fingers and being the “problem” of the family. So with this in mind, I’m excited to share some strategies I use to build rapport, connection and trust with adolescents to empower them in engaging with caregivers in family therapy.

1) Be Transparent! In other words, BE REAL with your client. Adolescents are smart, clever and can read through any BS or tip-toeing going on in the room. I give them the direct and transparent version of confidentiality and expectations of what therapy entails. 

“I know you may or may not be wanting to communicate certain things with parents, but I want you to know what I must report immediately. Any safety concern including suicidal ideation/planning, abuse, neglect, witness to violence, and self-injury must be reported to caregivers or appropriate authorities. With that being said, there may be things that come up that you are not open to sharing but would be beneficial to do so in order to get your needs met from your parents/guardians. When this happens, I want you to know I will challenge but not force you, and together we can figure out the best way to schedule a family session around it when you are ready.”

2) Build trust immediately: I know this one is a given, but I start with every first session letting my adolescent client know that I don’t expect them to trust me right away in an effort to ease any tension or pressure someone might feel.

“I want you to know that I don’t expect you to trust me right away. Trust takes time and is earned so that’s exactly what we are going to do. We will take time to get to know each other. You can ask me any questions you need to about myself or the process. I’ll let you know if I can’t answer it for any reason. And I want you to know if I ever ask or discuss something that you are not ready to answer, you say so, and we will use the time for what you are ready for and need. This is your time and space, and I want you to feel safe.”

3) Share the responsibility and “workload”. It’s essential to dispel any myth or belief with the adolescent and caregivers that a) they are the problem child and b)your job is to “fix” them in some way. Again, this is where I use transparency in the first session or parent consult (as well as throughout ongoing treatment) to set clear expectations for all involved.

To caregivers: “I want you to know that if i’m working with your child, I’m working with you also.  In many ways, this work can be equal or more for the parent.  My job is not to “fix”. Rather, i’m here to provide assessment, education, skill-building and a safe space to process and build awareness so that you and your child can more effectively communicate, understand one another and connect in a meaningful way to address the barriers.” I always let adolescents know that I’ve had this conversation with the caregiver(s) as well so they know it’s a joint effort.

4) Empower the adolescent voice. I like to give my adolescent clients as much choice and opportunity to lead as possible when it comes to parent involvement. Here are a few different ways, I frequently go about this in session:

“Would you like me to check in with mom/dad alone or with you it the room?”

“Is there anything you’d like to share with mom/dad/caregiver from our session today?”

“Is it alright if we bring mom/dad in at the end to share any skills we worked on so they can practice it too?”

“Is it ok if I emailed mom/dad about (a specific one or two things from session) so that they can be more aware and better understand what you are going through or how to support you?”

“Is there anything you want to teach mom/dad today?”

“Would you like me to explain (specific pattern or skill) for you to caregiver with you in the room?”

“Would you want to do a family session with mom/dad on this? If so, when do you think you’d like to do it?”

5) Parent Coaching Sessions are a must! Along with letting parents and adolescents know that this is joint work, I let them know that some sessions will be just with the parent(s). I am transparent with the adolescent and parents about the purpose of these sessions from the start.

“These sessions with your mom/dad are NOT to report all that you’ve said or processed in session. Instead, they are an opportunity for you parent to explore their own barriers getting in the way of supporting or connecting with you. I will always let you know when i will be having a session with you parents in case you have any questions or anything you would like me to share or work on with your mom/dad.”

To caregiver: “These are sessions where you can explore challenging emotions, patterns, behaviors that you are struggling with that might be acting as barriers to your relationship with your child. The main goal is to empower you as a caregiver and strengthen your relationship.”

6) Provide Outside Resources to Caregivers and Adolescents from the start.

At the end of an initial session or consult, I provide at least one book and internet-based resource that will help parents get a head start on some of the topics and ideas we will be addressing in therapy. Throughout the process, I continue to provide both the caregivers and the adolescent ongoing supports based on what is coming up in therapy and what the family barriers may be.

Some of my favorite resources are:

Ted Talks: Especially for the adolescent and caregiver to watch together at times.

Wellcast videos: Here is one of my favorites, but they have them on all topics! I often show to adolescent in session and send to both caregiver and adolescent after session. https://www.youtube.com/watch?v=UMIU-Uo8cZU

Phone apps: mood meter, calm.com, Headspace are just some of my favorites.

Books: there are so many; here are a few favorites

The Gifts of Imperfection, Daring Greatly and Rising Strong by Brene Brown (also has great ted talks to introduce the concept of vulnerability and shame)

Whole-Brain Child, Yes Brain and Brainstorm by Dan Siegel and Tina Payne Bryson

Emotion Focused Family Therapy resources: This includes caregiver webinars and in-person workshops, book recs, links to articles, etc. All greatly support parent coaching and family work. http://www.emotionfocusedfamilytherapy.org and http://www.mentalhealthfoundations.org are two helpful websites.

Review/summary emails: These I send with adolescent permission to specifically review a skill, idea or new strategy that would be helpful for the caregiver or adolescent from session. This way, they can refer back to it as needed.

Engagement with adolescents and parents can be difficult at times, but I have found the more i’m able to focus on empowering families and setting clear expectations of what family work is and isn’t, the more willing adolescents and caregivers are to engage in the process. My goal is never to be the one the adolescents trust or “go to” the most, it’s to help them build that with their parent(s) or caregiver to be able manage their challenges and barriers in life in a sustainable and connected way.

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Guest post written by Meaghan Burns Sablich, LCSW

Meaghan Burns Sablich, LCSW is a Licensed Clinical Social Worker, Licensed Colorado State School Service Provider and clinical supervisor with 10+ years experience in the field. Meaghan received her Masters Degree in Social Work from the University of Denver with a concentration in Families and Children. Meaghan has worked in a variety of therapeutic settings including inpatient hospital, residential treatment center, day treatment center, schools, non-for profit organization and private practice. Areas of clinical focus include: depression, anxiety, ADHD, eating disorders, family therapy and parent coaching, grief and loss, school/learning concerns and self worth work.

Canine Assisted Substance Abuse Treatment

Imagine that you have a guarded new client with a history of substance use. You try everything to make them feel comfortable and they still show reluctance to engage in treatment.  There may be several valid reasons for being closed off. This can lead to an increase in the stress hormone cortisol, possibly causing cravings for relapse. The next session you bring your certified therapy dog. The dog is welcoming, non judgmental and accepting of your client and is happy when they arrive. What has just happened in the client’s body? Meeting the dog caused their cortisol level to decrease. Their bonding hormone, oxytocin, has increased. They used to get the release of dopamine from their drugs but now they are getting oxytocin from your dog instead. Their heart rate has stabilized, their blood pressure has reduced and their frontal lobe is back online (Odendaal and Meintjes, 2003). Now, they may feel less guarded and more comfortable in therapy.

Often times, clients are more willing to trust a canine therapist versus a human therapist. They are more open to touch and comfort when it comes from a dog. They feel the attunement from the therapy dog and get to experience what a healthy attachment feels like. They finally feel heard and seen. As a certified canine assisted therapist you notice when your client and dog have bonded. The therapeutic relationship has accelerated and you are ready to try many different interventions over the course of their treatment. You come up with a few interventions to try. One might be having the client teach the dog a trick to help them practice healthy communication and relationship skills. Another intervention to try might be discussing what they have in common with the therapy dog. This can be drawn out to increase empathy for the dog and themselves. Now that they have the experience of a healthy attachment with your dog, they can move on to practice attaching to healthy people in their lives. Now they are ready for canine assisted family therapy to start. Eventually the desire to use substances begins to diminish.

Practicing animal assisted therapy comes with many challenges and it’s no easy feat. I have been practicing canine assisted therapy since 2005. I’ve seen 65% of my clients obtain sobriety which is double the national average. I incorporate it in individual, couples and family therapy sessions. It is extremely important that you and your dog have proper training and that your dog enjoys the work. It is necessary that you know your dog’s calming signals and can advocate for them. In order to ethically practice canine assisted therapy you need to follow the recommended animal assisted therapy competencies written by the American Counseling Association. They suggest attending a canine assisted therapy training, having your dog pass the canine good citizen test and obtaining regular consultation among many other things.

If you want to learn more about canine assisted therapy go to my website:
http://www.pawsitivetherapeutic.org/aat-qa/

References
Odendaal, JS and RA Meintjes. “Neurophysiological Correlates of Affiliative Behavior Between Humans and Dogs.” Veterinary Journal, May 2003, pp: 296-301.

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Guest post written by Amanda Ingram, LCSW, CAC III

Amanda Ingram, LCSW, CAC III, graduated from the University of Denver (DU) Graduate School of Social Work with an Animal Assisted Therapy (AAT) Certificate in 2007. She also trained Guide Dogs for the Blind for seven years. Ms. Ingram currently owns Pawsitive Therapeutic Interventions, LLC where she trains mental health providers in animal assisted therapy and also offers individual, couples and family therapy in the Stapleton community.

Tuning into Your Body for Information as a Therapist

When you are sitting with a client, do you ever notice yourself leaning in or tensing up?

I’m sure you have heard the term mirror neurons and how our body (especially our facial expressions) are hard wired to mirror others’ body language to increase our non-verbal sense of connection. But did you know that you are also constantly analyzing and responding to nonverbal expressions of emotion and belief patterns in your clients?

Our bodies hold a wealth of information that we are often in denial of, bypassing emotionally, or defended against. Our bodies are truth tellers. Somatic indicators of repressed emotions and fears can be seen in people’s body language and patterns of tension/holding in their bodies.

I often notice when sitting with a client what my body is doing. Of course, being trained in Sensorimotor Psychotherapy, a somatic psychotherapy, has taught me to do so. I notice when I am leaning in or pulling away, crossing my limbs, lowering my volume, increasing my energy, and when i am holding patterns of tension in my body. These are important indicators of what is happening in the client’s body. Often I will mirror my clients’ nonverbal cues in this way.

And what does it mean, you may ask. Well, if you are holding tension in your heart space, you may feel that the client is struggling with a matter of the heart and soul path. If you notice forward movement in their body, the client may have a pattern of hustling to keep busy in order to avoid difficult emotions. If you notice yourself tangled up in your limbs, your client may feel small and a need to protect their body from others. While there is not manual on what each body cue means, simply checking in with your client can be an incredible intervention.

When you check in with a client about a body cue you are noticing, you bring awareness to information the body holds in the less conscious part of their brain. Often our bodies give away how someone is truly feeling, bypassing their intellectual defenses.

Additionally, you can even hold space for clients to find a reparative experience by slowly shifting your body language to a more relaxed and open state. The client will likely mirror your calm body state and shift to a more calm state in themselves.

So next time you are sitting with a client, check it out! Notice what is happening in your body and check in with your client. You may be able to provide valuable insight through simply noticing and bringing awareness to what their body is trying to tell them.

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Guest post written by Kimberly Massale, MA, LPC, ATR-BC

Kimberly Massale, MA, LPC, ATR-BC is the owner and founder of Brave Embodiment Counseling LLC in Capitol Hill Denver. Brave Embodiment is a team of holistic healers specializing in guiding women to heal from trauma and self-defeating behaviors. Our therapists are specially trained in cutting edge scientifically proven trauma and attachment based methods to get you "unstuck" from old patterns that hold you back from your full potential. We use alternative methods that ease and accelerate the healing process including Trauma Sensitive Yoga Therapy, Art Therapy, EMDR, Psychospirituality, Somatic (Sensorimotor) Psychotherapy, Acupuncture, and energy healing and can guide you in your journey of complete transformation from the inside out.

6 Steps to Engage New Clients in the First Session

When I first began in Private Practice, I noticed that new clients were not coming back for the second session. I knew I was doing something wrong in that first session (or free consultation) that wasn’t connecting with my clients. I started experimenting and tracking my conversion rate.

This is a rough guideline of what I have ‘fallen into’ over the years in private practice that has a very high conversion rate (rate of consults that turn into regular clients for me). I find this can be done in either 30 minutes or 60 minutes. Here are the major steps I do with some of the ‘scripts’ I find myself saying often.

1. Welcome/Orienting the client to the consultation session

The consultation session is a little different than a regular therapy session, so I make a point to tell the client what we are going to do, and what he/she will walk away with from our meeting.

Here’s a breakdown:

1. Greet them and normalize that it can be weird, awkward or anxiety-producing to meet a therapist for the first time (or meet a new one).
2. Tell them what we are going to do during today’s meeting. The important points to hit are:

• This is a time to get to know one another a little bit
• I’m going to be asking some questions to know what’s been going on for the client
• I’m going to be answering any questions that they have (I tell them it’s ok if they don’t have any)
• I’m going to share my thoughts and initial observations about what they shared with me, so that they know what I’m thinking and it aligns with their experience
• I’m going to share the general outline of what our therapy will look like (although we can pivot later if needed). This includes a preview of tools I will teach them, the order of things, how we will track progress, etc.

I know that’s a lot to get through, here’s a script:

 Hi Jane, thanks for coming in today. It’s nice to meet you in person. I know it can be nerve-wracking to meet a new therapist, and I’ll be asking some personal questions today, so I thank you for taking the step to come in. Today we have a little bit of a different meeting than a regular therapy session. Today I will ask some nosy questions so I can really understand what’s been going on. But don’t worry, you can ask me nosy questions right back if you want to. I’ll answer any questions you have today, but it’s ok if you don’t think of any. After I ask my questions, I’ll share with you only my thoughts and observations about what you’ve told me, so you always know what I’m thinking and to make sure I really understand. Then I’ll share with you my initial thoughts and plan for how I’m going to help you feel better. Ok? Great! Let’s start.

2. Super-Short and Focused Diagnostic Evaluation

I’ve found the key here is to not get lost in the weeds, but identify the main clinical concerns right away, then ask a few follow-up questions to understand the severity and symptom presentation of that clinical concern. I save a more thorough mental health evaluation for another time. I want the client to feel heard right away.

Here’s a breakdown:

1. Ask first about the main clinical concern by asking what brought them in, or how can you help?
2. Normalize and Validate that concern
3. Ask a few follow-up questions to get a broad understanding of the issue
4. Ask about previous therapy experiences, and what was helpful and not helpful about those experiences, so you can quickly learn how the client responds to therapy in general (I make sure to incorporate this into the ‘plan’ that I share towards the end of the consult)
5. Ask if there are any other major clinical concerns.

Here’s a script for a client struggling with Anxiety:

Therapist: Ok Jane, I know we spoke briefly on the phone, but I’d like to just start with a really broad question and go from there, so I will ask what brought you in today?

Jane: Well I’ve been feeling really anxious….

Therapist: I’m so sorry you’ve been dealing with that, it’s really hard. We see a lot of that here in the practice, so you are not alone.

*Now I ask some follow-up questions about this clinical concern, such as:

• When did it start?
• How bad does it get?
• Panic attacks? How many and when?
• How is this impacting your life right now?
• Medication? Helpful or not? Prescribed by whom?
• What helps it right now?
• Who knows about it? Support network?
• Family history?

Jane answers all these questions, and I normalize her symptoms along the way.

Therapist: Have you ever seen a counselor before for this or for anything? When was that? What was helpful about that? Anything about that not helpful?

*I’m listening for anything that the client found helpful in the past in therapy (if they have done it). Things like a therapist being directive, providing honest feedback, teaching tools, etc.

Jane answers….

Therapist: So I really hear you about the anxiety and am starting to think of some things we can do together that will really help that, but first let me ask, is there anything else going on that you think is important for me to know?

Jane answers…

3. Feedback to Client

This is where I thank the client for being so open and talking about difficult things, and provide feedback and a rough/initial diagnostic impression. I’m not rushing a diagnosis, and I don’t use that language (usually) with the client, but just like when you see the doctor, you want to know what they are thinking and that they understand why you came in. I emphasize that I hear them, reflect their own language back to them, and validate that their concern is not ‘just in my head’ but it’s serious enough that they came to a therapist about it, and that they deserve a professional’s help to feel better.

Here’s a script for our client Jane:

Thank you for answering all those nosy questions, Jane. I know this stuff is hard to talk about. It’s very clear to me that you have an above-average amount of anxiety and it’s really impacting your ability to sleep and your job. That must be so hard. You should know that what you have shared with me is not a normal level of anxiety that we all feel from time to time. I hear some markers of an anxiety disorder, and so you’ve been dealing on your own with a clinical issue. You can’t just make it go away by being hard on yourself, which I already hear that you are. If you could kick this by just telling yourself to calm down you wouldn’t be here right now. But you are, and I’m glad you are. You don’t need to be alone with this anymore.

In our next session I’ll ask some more about your symptoms and really make sure we get the right idea of what you’re dealing with, but I’m pretty confident in what I’ve heard that the focus of our work with be tackling this anxiety together.

4. Share Your Initial Plan (let the client know that you can help them)

This is such an important step. The client wants to know in a concrete way how you will help them with their issue. You don’t need to do an on-the-fly treatment plan, but as you listen to any clients, ideas pop into your mind of what may work well for the client. This is your time to share that, give examples, and give the client confidence that you are in control, that you ‘get’ them, and that you have a plan.

Things to keep in mind for this step:

1. Frame the work in terms of ‘we’ rather than ‘you’ or ‘I.’ You and the client are a team now.
2. Share an honest initial time-frame with the client. You’re not tying yourself down to that timeline, but you will have a sense of how ‘easy’ or ‘difficult’ the client’s issue is, so share that.
3. Incorporate what was helpful about previous therapy (If there was any)
4. Reflect the client’s own language in how they describe their symptoms to you, so they feel heard and understood. Don’t use overly-clinical or ‘jargony’ language.

Here’s a script for Jane:

I feel confident that we can get this anxiety under control and you can feel like yourself again. If you choose to work with me, I’m think that first we will jump right in to concrete and practical tools to help with your anxiety in the moment. I remember with your therapist back in college you liked having those tools you could turn to, so we will start there. We will also explore the causes and triggers of your anxiety so we can play offense, not just defense. We want to see those things coming, have a plan, and head them off. I will also work with you on some pretty easy tweaks to your sleep routine to get you some better sleep, which will help with anxiety. I think also, from what you have shared with me, that simply having someone to talk to about all of this will be helpful. You’ve felt alone and embarrassed about it, and I understand. But talking about it will help us move past the shame and implement these tools and strategies. I think we can really see a difference in around 3 months, based on my work with other clients who are going through what you’re going through.

5. Answer The Client’s Questions and Wrap-Up (giving them a choice to schedule for follow-up with you).

The last step is to ask if the clients have any questions for you. I usually find that at this stage, you’ve answered all of their questions. However, sometimes they have questions. I answer all of them as transparently as possible. Clients hardly ever ask a personal question. The most common question I’m asked is basically ‘Am I weird’ and ‘Can you help me?’ Those are easy times to validate/normalize and again reinforce your very rough treatment plan.

After that, we wrap-up and I see up the next session. I never want to pressure anyone, or assume that they feel comfortable being my client yet, so I give them a choice between scheduling our next session right now, or getting back to me after they think about it. Almost 100% of the time they schedule right then, but if they don’t, that’s ok too. I always remind myself that ‘you’re not for everyone’ and let it do. Oftentimes, the client that doesn’t ‘sign up’ right away will circle back to me in the future.

Here’s a script to wrap up:

Well Jane we’re almost out of time, I’m sorry to have to stop. We can do one of two things from here. If you feel comfortable that we’d be a good fit, we can go ahead and schedule our next session and I think it would be good for your progress to meet every week. If you want to think about it, that’s fine too. If that’s the case, I’d love your permission to follow-up with you via email in a few days so we can touch base before my caseload fills up again. What would you like to do?

6. The Follow-Up Email

I always send a follow-up email, no matter what (unless they tell me not to email them). This lets the client know that you’ve continued to think about them. It’s also an opportunity to offer something of value. I email with a short note saying it was really nice to meet them and, if they have ‘signed up’ to be a client, that I look forward to working with them. I say I have been thinking more about what they shared with me, and it make me think of this helpful article/book/podcast that I wanted to share and include a link. That’s it! Clients tell me they really love this follow-up.

This is also an opportunity to ask if a client wishes to meet again (if they didn’t schedule during the first consult).

Here’s a script:

Hi Jane,

I really enjoyed meeting you yesterday. We talked about some hard things, and I appreciate your openness. I was thinking further about that panic attack you had last week, and wanted to share this article about riding out panic attacks. It may be a good idea to share this article with your husband too, because I remember you mentioned he felt a bit powerless when that happens. Here’s the link to it. If you’d like to meet again and get started on the goals we spoke about, let me know and we will find a time what works with your schedule.

Warmly,

Erin

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Guest post written by Erin Carpenter, LCSW

Erin Carpenter, LCSW, is a therapist in private practice and owner of Thrive Counseling, a group practice in Southeast Denver. Find out more at http://www.thrivecounselingdenver.com

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.