therapy

Canine Assisted Substance Abuse Treatment

puppy

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.


Guest post written by Amanda Ingram, LCSW, CAC III

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.

Exploring Equine: Therapeutic Focus and Interventions

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I have lived around horses since I was pretty young and have always been drawn to these magnificent animals. Their size alone fascinates me and the temperament of each horse is as unique as you and I. The relationships between our clients and horse therapist is something that we are not able to provide. Horses seem to have an extra sense when something is wrong or when a person needs a hug, a shoulder to cry on or just someone to walk with. These horses know when a person is struggling with traumatic incidents, self defeating behaviors, self control and low self esteem. 

We have all started to hear more about Equine Assisted Psychotherapy groups and other sessions that involve animals in our practices. The terms are somewhat new to the world and started getting more attention in the 1990’s- many years after we knew the impact on mental wellness that is provided in equine work. Horses are non-judgmental and will easily meet the client where they are at. The types of therapy that we provide at Peace Within Counseling and many other equine treatment facilities is extensive. 

  • Ground work- grooming, leading, obstacles. These activities lead to a greater sense of relationship by being able to touch the horse, telling secrets to the horse and allowing the horse to get to know the human as well as getting to know what the horse likes or dislikes.  Matching the breath of a horse is very grounding. Connections are important, and at times, easy to gain with a trusting horse and companion. However, when putting a traumatized companion with a horse who also has faced trauma it can be a bit of a human challenge.  The person may have numerous hesitancies and extreme anxieties when facing this 1000 pound figure in front of them. However, most times the horse can sense the hesitancy and be able to pull in where no other human can emotionally touch. The horse can bring a comfort that the person may not accept from others. For instance, a young child who recently lost a parent was working with one of our horses. This child was shutting down and afraid to connect or accept others. The horse recognized this and pulled this child in for a huge hug. This boy broke down at this moment and was able to allow the touch and continued to work through his struggles and grief.
     
  • Ground driving horses- a new phenomenon to me as of last month. We had a group of about 30 people join us in a group with 2 Percheron horses- each about 2000 pounds! The group had a chance to bond by brushing, petting, talking and even being able to sit on these gentle giants. Everyone faced a huge hurdle by walking behind these beauties while leading them around the round pen! These humans were able to control 4000 pounds of animals with a slight tug on their reins. We were able to fight the fear of the intimidation of an 18 foot horse that towered over everyone. This was a great time to understand the power that we posses and the control we can have if we allow ourselves to focus. 
     
  • The horse can be another tool to add to ones toolbox. This is where people find total relaxation by being near to the horse. Energy work can be done at this point. We are able to lead the horses around the arena with our energy- no leads, no halter, no whips. Pure energy and pure exhilaration! We can gain a sense of accomplishment, leadership and regain lost self control when we are able to be at one with the animal. We teach the human companion to vision what they want the horse to do and the horse will follow. And when the horse does not listen to our desires, we have a great teaching moment with our humans as to how sometimes life doesn’t go as planned. We all struggle at one time or another and we incorporate these mindsets into our clients. Many times, people can relate to this and compare to a time in their life where things went wrong and maybe even notice the strengths that were gained from this. Then we try again with the horse- maybe some relaxation has happened through this acknowledgment and our horse will listen, maybe not.  
     
  • Riding is another way to use horses in therapy. This is another fantastic opportunity for the human to feel the power and strength under their body. It can be a cathartic experience to be able to lead this horse around the arena with a small nudge or a slight pull of the reins. The movements that ensue are very relaxing and beneficial to those traumatized clients. I’ve known many people who trailride and end up being so relaxed that they have fallen asleep on their companion- not a goal we pursue in therapy, however.

This is just the beginning of understanding Equine Assisted Psychotherapy. Many people become certified in Equine Work through many programs. At PWC we have Equine programs where we ( the therapists) work closely with a horse handler or certified coach- someone to watch and  make sure the horses and humans are safe and to teach the do’s and do not’s of working with horses. Those certified in Equine Work as coaches are going to be able to share activities and sense things within the horses that most of us may not understand. Coaches can teach the roles of the horses in the herd and how we can relate this to our family, social and work dynamics. As a therapist, we are able to help relate to the dynamics that happens before our eyes to what the human is needing at the moment. We are able to focus more on leadership or focus more on boundaries with the obstacles that the coach can help lay out. We can fill in the clinical gaps that the coach may not be able to understand. By having a relationship with our clients, we can give them what they need through the relationships with the horses. It is a fabulous, amazing and miraculous bond to watch form in just moments.


If you would like to learn more about our programs, please feel free to reach out to me at (303) 888-9042. We are offering Individual, Family, Couples and Group sessions this Summer and Fall. We offer kids and teen groups and soon will be adding groups for adults, cancer survivors and those struggling with PTSD and other traumas. We will also be hosting a brunch and team building morning in July for all therapists- watch for info soon.


Guest post written by Nakoma Garcia, MS, LPC

Guest post written by Nakoma Garcia, MS, LPC

Nakoma Garcia, MS, LPC graduated from Indiana Wesleyan University with a bachelor's degree in Social Work in 1997. She later went back to grad school for Professional Counseling at Grand Canyon University. She is a licensed professional counselor in the state of Colorado. She is trained in EMDR and also offers Equine Assisted Psychotherapy in her practice. She has worked with hundreds of individuals and families who have dealt with life changes and helped them find peace and strength. Nakoma is passionate about working with people who feel change is hard and helping them understand that it does not have to be.

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

Beauty Shot

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

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

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

 

1) HSPs Are Probably Already Your Clients

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

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

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

 

2) They Are Your Most Loyal Clients

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

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

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

 

3) They May Be Your Most “Complex” Clients

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

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

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

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

 

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

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

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

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

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

 

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

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

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

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

 

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

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

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

 

Moving Forward

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

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

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

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


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

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

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

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

Engaging Teens: Staying Current in their World

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Teenagers may be reluctant to engage in therapy due to stigma, stereotype, or pressure from their parents or guardians to “get it together,” stop a behavior, or cope with the stressors of their lives. Regardless of why they come into your office, you can support them in ways that allow them to feel safe enough to access emotion and engage fully in their own therapeutic process. Many teens have engaged in therapy in the past and few have positive things to say about their experience. A valuable question to ask in building rapport could be, “what did you absolutely not like in therapy before? Anything you want to make sure I don’t repeat?” This engages the teen to speak plainly about what their needs are in the therapeutic relationship as well as feel heard by you in asking their preferences, a client-centered approach that assures them of their active participation in the therapy process.

 

“I’m not your _______.”

Helping a teenager feel heard is one of many valuable tips in building rapport. Another element at intake to consider is your role in their process. It is important to establish healthy boundaries and clarify your role with teens prior to engaging them in ongoing work. Your explanation may go something like this: “I am your therapist which means I’m here to support you. I’m not your parent, teacher, friend, or probation officer as you may have those in your life already. My job is to be someone you can talk to who is non-judgmental and supports you in finding solutions to things that are stressful in your life right now. How does that sound?” By naming your role and asking for feedback, you are establishing both a professional connection and expectations of your work together from a place of respect and unconditional positive regard.

 

Keeping Secrets

Privacy is important to teens as they build their identities, form new relationships, and begin to seek autonomy in their world. Exploring the limits of confidentiality is vital to supporting them in their process in that they seek clarify of what truly is confidential and what is not. Many teens may be aware of your role to keep them safe if they were to disclose suicidal thoughts or threaten to harm someone else. But do they know you are a mandatory reporter who is required to report any abuse? Do they understand you may monitor the age of their sexual partners to make sure they are of legal age to consent? Do they know what self-harm looks like in working with you? Do they understand the implications of experimenting with drugs and alcohol and how you many need to respond if they are driving under the influence or violating probation? Having conversations about these limits can support a teen in knowing what is truly private and can allow them to more fully be themselves in your office in having a clear understanding of the consequences.

 

Recipe for Success

Now that you’ve gotten the formalities out of the way, what are some ideas for how you can connect with a teen? It is recommended you start by getting to know their interests, friends, and goals. One favorite rapport building intervention is having a teen build a playlist of their life, identifying songs that represent them and their experiences. They can discuss the songs in detail, allowing the therapist to build rapport and gain insight into their life. My personal favorite exercise is a ‘recipe for success’ that involves colored sand art and a teen’s ability to identify what they need to be successful in their life such as love, independence, time with friends, etc. They build a recipe of these elements as they converse with you and the art serves as both a low-risk therapeutic activity and a symbolic reminder of their success that they get to take home.

Below are other therapeutic intervention ideas that could be considered when working with a teen to build rapport:

  • Life mapping their interests and relationships
  • Vision boarding their wants, needs, and goals
  • Self-portrait in paint, clay, pencil, etc.
  • Family tree or genogram

 

Remaining ‘In the Know’

Teens will be the first to give you feedback on how they think therapy is going, but only if you encourage them to have a voice. Once way to do this is to support them in speaking how they wish to, whether it be slang, cursing, or other modern expressions of communication. Encouraging a teen client from the beginning to speak as they would outside of your office can support them bringing their shields down to fully participate. You may want to make sure they understand all ways of speaking are permitted as long as they are respectful to both themselves and you in the room. In response, many teens will express relief in being able to be themselves.

By encouraging teens to speak in ways that feel right to them, you should also be prepared to be honest and open about slang or colloquialisms that you may not have heard before. This demonstration of vulnerability by the therapist can actually support the client in feeling empowered and serve as evening the status quo between therapist and client in the therapeutic relationship. This vulnerability also allows humor, another great tool with teens.

 

Media Influence

One final tool that can increase your success in engaging teens in therapy is remaining aware of the events of their world. Many teens are following popular social media stories, YouTube videos, celebrities, and TV shows that can serve as connections or analogies for concepts you want to explore in therapy. For example, a teen who is reporting difficulty making friends may resonate with the main character from The Edge of Seventeen, a movie that can speak to your teen in identifying similar stressors they could report they are experiencing. By remaining aware of pop culture references, you can engage a teen in comparisons that truly resonate with them, encouraging self-awareness and personal growth.

 

Tips from Teens

In review, there are many elements to keep in mind when engaging teenagers in therapy. A panel of urban teenagers here in Denver, Colorado provided meaningful feedback on how best to engage them in structured therapy. Their answers were both obvious and reassuring and I am happy to pass them on in the hopes that fellow therapists will find success in engaging teens in their therapeutic work!

Teenagers shared with professionals:

  • Don’t talk down to us
  • Don’t censor us
  • Don’t be so much older that we can’t connect with you
  • Don’t read our file and think you know us
  • Don’t say you understand what we are going through when it’s our own experience
  • Don’t label us
  • Don’t tell our secrets to others
  • Don’t be afraid of our tests to see if you are trustworthy
  • Don’t give up on us

“Some are young people who don't know who they are, what they can be or even want to be. They are afraid, but they don't know of what. They are angry, but they don't know at whom. They are rejected and they don't know why. All they want is to be somebody.” 
 Thomas S. MonsonPathways To Perfection: Discourses Of Thomas S. Monson