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

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

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.

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.