rapport

Mandatory: Making it Worthwhile

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“I don’t want to be here. I’m not going to say anything. I don’t know. Why should I talk to you?” You may find yourself thinking or saying thoughts like these in response to pressures to engage from a program, family, or friends. Perhaps you aren’t ready to share what’s brought you here, or what the challenges are that you are facing in this moment. Perhaps you feel like your personal freedom has been taken away, your choice to participate of your own free will. Understanding that you may feel angry, resentful, or withdrawn, please consider the following in support of getting the most out of something that is identified as mandatory.

 

Blocking or Belonging

You may come from a different background or hold different values from those you come into contact with, so what brings people together in this process? Shared experience around homelessness, financial instability, substance abuse, conflict in relationships, or a lack support can help one feel less isolated and alone in their experience. Although each person’s story is their own, the feeling of connection to others and belonging can go a long way in having an experience feel less mandatory and more voluntary. When you observe others engaging in the program or group, you may find yourself asking:

  • Do I feel I can relate to others in the group?

  • Do I feel this community is healthy, approachable, supportive, and willing to engage me in this process?

  • Do I feel supported by staff and helping professionals to achieve my goals?

  • Do I feel comfortable opening up and working on myself in the presence of others?

For many involved in Alcoholics Anonymous (AA), they speak of the community as an equally powerful element as the 12 Steps in to their ability to actively participate in their own sobriety. Due to the friendships they make, they feel they have a connection to others in ways that feel encouraging and uplifting in moments of challenge or struggle.

 

Building Perspective

In addition to identifying a supportive community, how you approach the experience for yourself matters. Do you have realistic expectations of what you can accomplish both short and long term? Can you set yourself up for success in your work with others? When starting this process, it is helpful to understand basic needs as the foundation for progress. Educating yourself on how basic needs such as food, safety, and shelter provide the foundation of stability gives you permission to organize goals for success. Abraham Maslow, who identified this relationship in the Maslow Hierarchy of Needs, emphasizes that only when basic needs are met can one focus on higher work around self-esteem, sobriety, and relationships.

 

Relational Rapport

When exploring relationships, research tells us that therapeutic rapport accounts for more than any other factor when measuring progress towards goals set in therapy. In other words, the therapeutic relationship, unconditional positive regard, and power of feeling seen, heard, understood, and supported has positive results on goal progression. If your past experience involves trust or mistrust, being aware of how therapy and/or relationships have helped or hindered you in the past can put current resistance and reluctance in perspective. A few questions that you may find helpful at ask at the first meeting with a helping professional include:

  • What kinds of clients have you worked with before?

  • How do you work with people who are uncomfortable with therapy?

  • What do you do with feedback from clients?

  • What can I expect from working with you?

All of these questions encourage healthy discussion around the therapeutic process and can provide insight into expectations and measurable goals when engaging a helping professional in your own growth process. 

Mandatory can feel restrictive and stressful when viewed as a loss of control or freedom. What better way to reframe it than to ask yourself, what can make it worthwhile? 

“If you change the way you look at things, the things you look at change.” Dr. Wayne Dyer

6 Steps to Engage New Clients in the First Session

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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


Guest post written by Erin Carpenter, LCSW

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

Staying Present: Finding Focus in Session

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In my years in practice, I find building a rapport with the client and being able to stay present during intense moments are of utmost importance. In order to make progress, a foundation must be built where the client feels safe and supported. Below you will find useful techniques in building a rapport and staying present with your client during sessions.

 

Building Rapport

  • Ask the client what specific goals they have for therapy.
  • Make sure the client knows that you are there for them, so if perhaps they deviate from the goals they were working on and/or want to talk about something else during a session, allow them to so.
  • Do not impose your views or beliefs on your client.
  • Be nurturing, empathetic and non-judgmental.
  • Ask how we will know they are making progress or have met a specific goal.
  • Each session, ask what the client may need to explore how the session is productive for them.
  • Encourage the client to voice his/her opinion in the session. If the client does not agree or like something you as the therapist says, make sure you create an atmosphere where they know they can bring that up without negative consequences.
  • Stay present with the client during intense moments, and during all moments.

 

Staying Present

Helpful techniques in doing so include but are not limited to:

  • Ask the client what it was like for them to say that (whatever it is they shared that was painful) out loud.
  • Thank the client for trusting you with the information.
  • Validate the client’s feeling during those moments. “that sounds so painful, sad, terrifying.”
  • Be comfortable with silence.
  • Allow the client to process through at their speed.
  • Tell the client you are there for them, with them, that there is no judgment.
  • Before the session ends, ask the client if there is anything they need to help them transition back into their day.
  • Make sure you (the therapist) know what you need to care for yourself.
  • Yoga, meditation, and exercise may help.
  • In order to stay present, we need to be one hundred percent focused on the client; make sure you seek out your own therapist if needed.

I find these tools useful in my practice and hope you will too.


Guest post written by Trisha Swintom, LPC, LMFT

Guest post written by Trisha Swintom, LPC, LMFT

Trisha Swinton, LPC, LMFT is a Licensed Professional Counselor and a Licensed Marriage and Family Therapist. Trisha is currently in private practice and has been practicing for about 14 years. She currently works with adults providing individual and couples therapy. Her educational background includes a Bachelor’s degree in Elementary Education, a Master’s degree in Special Education and a Master’s degree in Community Counseling with an emphasis on marriage and family therapy.

http://www.trishaswintoncounseling.com

Avoidance and Attendance: How to Address Each in Therapy

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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.