Humanity: Transforming Therapy into an Art of Holding Space

“Do you know what it’s like? Has that ever happened to you? Have you experienced it too?” Your client sits across from you, disclosing some of their most personal experiences in a desire to connect and be seen. In a genuine effort to maintain rapport, you nod your head, agreeing with them. You think to yourself, “Yes, I can connect with just about everyone! This is such meaningful work!”  But then it happens, they’ve sensed something and they begin to pull back, both physically and emotionally as they sit in your office.  They are shutting down and you can feel the energy shift in the room as they begin to disengage, to retreat. What will you do?

What would it cost us as mental health professionals to be transparent and thus more vulnerable in session? Is your client seeking an expert, a confidant, a compassionate ear? Or perhaps they want someone to hold space, to witness their pain. Research tells us that the most important and meaningful indicator for progress and healing is the therapeutic relationship, that the best fit relationship catalyzes positive change. We as mental health professionals desire to help others, to support them in their journey to self-awareness and growth, yet there are times we will witness their story and wonder if what we provide is enough. Our ability to be human and connect can help.

Transparency

Back to our scenario. You sense your client is pulling away, disengaging in an attempt to protect themselves. Can you name that in the room, support them in acknowledging what is happening for them in an effort at self-awareness and retained connection? Can you ask them to help you understand what just happened for them in their experience? The client responds by saying, “I just feel like I can’t trust you, that you are judging me.” So, you respond by acknowledging how important trust is and how you want to understand where they are coming from. They share more information, disclosing how they need you to hold space for their processing and truly connect with them. You agree to the importance of connection and ask for feedback on how you can support them in building trust for the work you will do together. You offer a genuine apology for any misunderstanding and resulting hurt. Your client visibly relaxes, feeling seen and heard by you in this moment of vulnerability. You continue the positive momentum, supporting them in exploring other times they’ve felt this way in their community and bear witness to their experience.

Vulnerability

Asking a therapist to be vulnerable with a client in session can be intimidating and anxiety provoking. Depending on our own background, experiences, and training, we may feel uncomfortable connecting in this way. There are therapy modalities that deter us from showing emotion or advise against self-disclosure. Yet when you ask therapists in the field about how they use emotion or self-disclosure to connect and support their clients, there are those of us who can recall vulnerability leading to some of the most powerful and meaningful work of our career. As Brene Brown states in her book Daring Greatly: How the Courage to Become Vulnerable Changes How We Live, Love, Parent, and Lead, “Vulnerability sounds like truth and feels like courage. Truth and courage aren’t always comfortable, but they’re never weakness.” Our vulneratbility and truth can show up in the room with our clients in the following ways:

• Admitting we can’t fully understand their experience as they know it but want to know more what it was like for them.
• Admitting we don’t understand slang or other word choice and can they educate us so we can best support them.
• Acknowledging their pain and the tears that show up in our eyes as we witness it.
• Apologizing when we misunderstand or unintentionally offend.
• Accepting responsibility for our actions and showing their concerns are heard and can be addressed in our work together.
• Self-disclosing with the purpose of connecting to their pain, providing validation or humanity, and not for our own gain.
• Rescheduling due to illness and letting them know we want to give them our best.
• Recognizing our own triggers and how they show up in the room.

“Courage starts with showing up and letting ourselves be seen.” Brene Brown in Daring Greatly: How the Courage to Become Vulnerable Changes How We Live, Love, Parent, and Lead.

Holding Space

Transparency and vulnerability interact in developing a human connection. The art of showing up and staying connected can be further defined as the concept of holding space, written in detail by Heather Plett. Heather writes, “holding space means we are willing to walk alongside another person in whatever journey they’re on without judging them, making them feel inadequate, trying to fix them, or trying to impact the outcome. When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.” As therapists, let us support transparency, vulnerability, and holding space to best serve our clients in being their own agents of change, thus engaging in a process of healing we are fortunate to witness.

For more information on vulnerability, visit brenebrown.com. For more information on holding space, please visit heatherplett.com.

5 Things to Know Before Creating an App in Private Practice

Cell phones, tablets, laptops, oh my! Technology is providing us with new tools and a media presence that can jump-start a private practice! It can be both exhilarating and intimidating. Luckily there are supports out there for those who want to explore the benefits of media in their marketing and branding. Consider media experts who support mental health professionals, such at FYLMIT.com, which provides professional marketing videos to therapists around the country in support of growing practices and facilitates a connection between the therapist and a potential client.

If you are in a place of wanting to explore secondary income within your private practice, consider developing an app that could support your clients or community. The following tips and helpful hints can help you feel prepared for navigating the journey into technology of creating an interactive app!

Know how to select the best developer

Have a clear vision about what you are trying to accomplish by developing an app. Create a written, detailed plan and place it on a freelance site such as upwork.com to receive proposals from interested parties. Review proposals from freelance web developers and computer programmers and explore their ratings on the site, including response time to inquiries, availability to take on a new project, and references from former clients. Lastly, don’t hesitate to interview your top choices to get a sense of their communication skills and strengths as you will be communicating a lot with them should they join you on this project!

Know your budget

The costs of an app can be broken down into start-up costs and ongoing costs to maintain the app once it’s live. Depending on the complexity and components of your desired app, expect a quote from a web developer between $4,000-$20,000 to create it. Consider the ongoing costs of maintaining, updating, and structuring the app features to support your desired audience. In addition, explore each web developer’s payment plan to determine if they invoice for the work completed, expect a certain amount at the beginning of the project, and/or are willing to develop a payment plan with you.

Know your audience

Who are your desired users and how can you reach them? If your app utilizes several internet sources, perhaps it the best fit to develop a web app that requires internet connection and is built on a web browser. Or maybe your desired audience is accessing your app more on their phone where a mobile operating system first builds the app which is then pre-installed on their phone through an app store. Identify how your desired audience will find and use this app and select the option that gives them the greatest access. Also remember to think long-term about costs of maintaining or updating the app and how updates can be built into the app program to keep your audience engaged.

Know the legal implications

Engaging clients or community partners through an app can have it’s challenges. Be sure to consult with a legal representative on confidentiality and client identifiers. You may be advised to develop and use liability disclaimers to not assume responsibility for misuse of your app by those who use it. Explore intellectual property law with a free consultation by a trusted legal source to determine if trademarking, copywriting, or patent are appropriate options for content of your app. Finally, don’t forget to also consider having your web developer sign a non-disclosure agreement (NDA) to protect the content you create from being shared or sold to a third party.

Know what sets your app apart

Your app is in production, now it’s time to determine how to market it. Researching apps that others use in our field can assist in determining the value of offering your app as free, having a one-time fee, or ongoing costs to a user that are justified as improvements or additional features as part of an upgrade. Consider the audience interest of your app by exploring if there are similar apps out there in use. Know your competitors and explore what would encourage a user to select your app over the competition, such as a streamlined, more user-friendly interface or affordable price.

Finally, your app is ready to go live! Working with the tips above, you will have invested in a piece of your business that reaches new audiences beyond your private practice and an interactive component of technology that can have a lasting impact! To learn more about our personal experience in creating an app, check out our guest podcast with The Private Practice Startup here.

Sufficiency through the Storm: Needs During and After Crisis

“What will I do now? Where will I go? How do I survive?” At any time, a client may walk into your office sharing a crisis situation that creates even more stress and anxiety in response to the unknown. Whether it be stressors of eviction, homelessness, loss of employment, disability, or financial strain, it can make it that much more difficult for a client to continue their therapeutic work around self-esteem, coping, or relationship development due to fear.  Fear of where they will sleep, fear of when they will eat, fear of what they will do to support their family, fear of not being able to find a job. As therapists, it becomes even more important to meet our clients where they are in a situation like this, not asking too much of them as they navigate their basic needs.  Needs for shelter, food and water, needs for safety and security. According to Abraham Maslow when introducing his hierarchy of needs, only then, when these basic needs are achieved and maintained, can a person advance to the next level of work on relationships, self-esteem, and creativity or purpose.

Hierarchy as a Roadmap to Change

Maslow first introduced the concept of a hierarchy of needs in studying extraordinary individuals in a quest to understand their happiness and ways of life. His concepts have since been applied in medical and mental health spheres to better support patients and clients as they navigate through difficulty and a variety of stressors. It is helpful to look at the healing journey through the lens of a hierarchy of needs to best support a client with treatment planning as well as identifying valuable resources to support growth and stability.

Access to Resources

Depending on their needs, knowing where to find valuable resources can be an immense help in supporting our clients through crisis. In Colorado, we can access resources through a variety of databases that allow searches for food banks, clothing, shelter, free legal services, and more. Colorado 2-1-1 and Metro Crisis Services both offer a “service finder,” accessing up-to-date resources throughout the state. The Community Assessment and Coordination of Safety (CACS) is a web tool for professional helpers that allows one to search for mental health and substance referrals including providers, self-help, and community support groups by level of need, city, region, and age. One final resource in Colorado that could be beneficial is offered by Mean Street Ministry, a 16-page resource guide with locations, hours, and type of service offered throughout Colorado that can be meaningful for client exploration and self-advocacy.

Awareness and Advocacy

In addition to being aware of appropriate resources, it is important to be aware of client limits in taking in new information during a crisis. For many providers, it is expected that we slow down our goal progression, maybe even put a topic or intervention on hold in order to support the client with the here and now, the need for stabilization. By remaining present with the client in the current moment, we can still serve them by identifying next steps and possibly advocating for their needs in connecting them to a variety of support services. Whether its providing them with a list of resources or connecting them to the most appropriate referral, our response to their needs in crisis can support them in personal advocacy and growth with an opportunity to gain control and practice coping skills to manage the existing stressors.

How We Can Help

For many clients, our ability to hold space for their fear, anxiety, and grief is healing in and of itself. Recognizing the immense stress crisis and unanticipated change can have on our clients, acknowledging their fears, and conveying they are not alone can be powerful catalysts for change. Helping to stabilize the crisis is necessary before other therapeutic goals and work can progress. In light of Hurricanes Harvey and Irma, many therapists are signing up to support those most in need and devastated by crisis, by volunteering their time to offer caring, compassion, and space to grieve and heal. There are several ways to help those in need. For more information on how to support our communities impacted by natural disaster, please visit www.redcross.org.

More information on resources in Colorado can be found at https://211colorado.communityos.org/cms/home or by calling 2-1-1, http://www.metrocrisisservices.org, or www.cacs-co.com

Suicide Assessment: Starting a Conversation

Are you thinking about suicide? Do you want to kill yourself? Several of the most respected trainings nationwide, including Applied Suicide Intervention Skills Training (ASIST) by LivingWorks and Collaborative Assessment and Management of Suicidality (CAMS) by Dr. David Jobes, are providing the skills to encourage professionals to start a conversation with a person at-risk of suicide. September is National Suicide Prevention Month! It’s time we talk about suicide, and not just in the month of September. 

Many health organizations are participating in the Zero Suicide Initiative and schools are developing protocols to support our youth as they pursue their education. Research continues to explore findings around trends in certain populations, such as our transgender individuals, Veterans, and those suffering from Anorexia, all possessing factors that may put them at a higher risk of suicide. How do we, as mental health or helping professionals, address the stigma to start a conversation to better understand suicide?

In support of professionals who are passionate about helping at-risk individuals, please allow me to introduce an interactive tool meant to engage a person at-risk in facilitating a conversation about their experience with the help of a trained professional. The Community Assessment and Coordination of Safety (CACS) is an interactive tool that supports mental health professionals and other community partners such as school staff, non-profits, caseworkers, and public safety to have the words and the tools to start a conversation on suicide. 

The Details

In using CACS, a helping professional can access standard suicide assessment questions including but not limited to risk factors, family history, and recent stressors. When a professional desires more information as to the purpose of a question or how to ask a clinical question within the risk assessment, CACS provides helpful hints, such as suggested questions you can ask to explore a particular component in more detail for the most accurate results. The assessment then uses an algorithm to determine a risk level and populates a list of resources throughout Colorado in order to identify appropriate referrals that could best help the person at risk.

In addition to using an algorithm, CACS provides an electronic, user-friendly platform to assess and explore a person’s experience, all while allowing the flow of supportive conversation with a person they can trust. CACS can take into account various information entered into the app to calculate a level of risk based on an algorithm that factors in current research trends on suicide.  Individuals found to be at high risk would be directed to resources such as hospitals, inpatient programs, or Crisis Walk-in Centers. Individuals found at moderate or low risk could explore current resources for mental health, substance use, community support, and wraparound services with filtering options of location, service, and age group served. 

Lastly, CACS allows the helping professional to complete a wellness safety plan with the person at risk, empowering them to identify facets of their life that they can track and address with positive coping skills or engagement within their communities. Research is pointing us to the power of communities, therefore it could be valuable to explore how communities can support or enhance our interactions in pursuit of personal wellness. 

Resources

Let us begin a conversation and demonstrate our willingness to speak of the challenges in order to support those that need it most. You can learn more about the Community Assessment and Coordination of Safety (CACS) at www.cacs-co.com.

If you are interested in a suicide assessment training, check out ASIST by LivingWorks at livingworks.net or CAMS Integrated Training at CAMS-Care.com.

If you are feeling suicidal and need immediate support, please call 9-1-1 or go to your nearest emergency room. Trained professionals are available 24/7 at the National Suicide Prevention Hotline by calling 1-800-273-TALK.

Bolstering Boundaries: Exploring Needs in Community Practice

She calls at 10pm, he gives you a present, they ask for a hug, she asks for a ride.  How do we navigate the gray area that is clinical practice in community or home settings? Mental health professionals have found several benefits to working with clients in their homes or communities, including more consistent access to resources by meeting clients in alternate settings. Perhaps the client can’t get to an office due to transportation limitations or anxiety preventing them from feeling comfortable in your office? Could the family dynamic be better observed in the home to support current treatment goals?

Boundaries continue to be important in conveying professional roles and limitations to clients, including interaction with their therapist outside of scheduled sessions. Boundaries can look different to each individual, including being physical, such as proximity and touch, or emotional, such as how much we disclose about ourselves to clients in our effort to build rapport. Boundaries are necessary to prevent burnout, which can manifest as fatigue, avoidance, and increased irritability and concern of clients taking advantage of us when boundaries are inconsistent.

Self-Exploration

Can you ask yourself how you would respond to the following questions?

• Do you feel taken advantage of by those you care about?
• Do you tend to meet other’s needs before your own?
• Do you say yes to avoid a confrontation?
• Do you worry about the loss of a relationship if you say no?

If you answered yes to all of these questions, you may want to look further at your boundaries and their limits in supporting your well-being. Many mental health professionals are inspired to help and serve others, sometimes at the risk of our own health. It would benefit each of us to explore and strengthen our boundaries to allow the most supportive interaction between us as providers and the clients we serve.

Bolstering Boundaries

So how do we navigate implementing boundaries? Has your agency supported you in providing expectations of your role in writing to your client? Does your disclosure statement clearly identify your limits in communication outside of scheduled sessions? Can your voicemail redirect callers after hours to a crisis service? These are just a few examples of boundaries in the mental health workplace that can provide the consistency we are seeking in implementing healthy boundaries with our clients. Just as when we guide clients in developing boundaries of their own, new expectations take work to implement and remain consistent. Anticipate push-back from those who are used to old patterns, as they may struggle to accept the change. Remain firm with new boundaries to allow adjustment and acknowledge any anxiety or fear that can come with implementing new boundaries. Lastly, consider putting boundaries or expectations in writing to discuss with your client so that they may have a copy for future reference and can consider signing a copy for your records.

Support from Others

Implementing boundaries can be easier with the support of supervisors, consultants, and colleagues. Consider reaching out for support around implementing boundaries with a client, as many professionals have experienced similar concerns and have had to navigate the discomfort of boundary setting in their own work. Would they take the same steps you are considering when reinforcing boundaries? Can they support you when your feelings of guilt or anxiety attempt to derail the boundaries you’ve created? It can be helpful to share your boundary goals so others can support you and you can do the same for them.  

Burnout

Burnout can be the result of poor or unhealthy boundaries. Can you relate to any of the following symptoms of burnout?

• I don’t know how to relax.
• My road rage has gotten worse.
• I feel disconnected from my emotions.
• I escape into eating sweets.
• I’m ignoring my relationships.
• I can’t seem to disconnect from work.
• I’m self-critical.

These are just a few symptoms of burnout that other professionals have reported as signs of their fatigue and ongoing challenge in the workplace. Boundaries can help address burnout along with communication, exploring your values or what drives you, and creating a wellness plan. The Professional Helper Healing Training: Supporting Boundaries to Prevent Burnout is one training in Denver, CO that supports professionals in these tasks and there are others! For more information, visit us at catalystcounselingpllc.com and search professional workshops.

Safety Planning with At-Risk Families: Exploring the Benefits

Warning signs, safety measures, plan of action, and supports. These are all vital components of crisis response and safety planning in the field of mental health. Safety planning can be considered a helpful resource to assess safety needs for each family member and develop awareness of individual needs by loved ones when participating in discussion. It can also serve as an empowerment tool to allow advocacy and engagement in positive coping skills when the family is experiencing conflict. Due to family systems becoming more diverse to meet the needs of support and connection, the term family can be defined in non-traditional ways. Not only does it capture the nuclear or biological family, it may also comprise of blended families, extended family, step-parents, foster siblings, or “chosen family.” Chosen family can include but is not limited to, close friends, mentors, and godparents.

Bringing individuals together in their roles in the family system, it has become increasingly important to include all members in safety planning when addressing mental health and safety in order to unify the family and achieve meaningful results. In serving at-risk youth and families in the Denver Metro Area, safety planning has proven to be invaluable in exploring awareness of triggers for disruption and conflict, safety needs; thus engaging the family in exploration to foster empowerment and change. Safety planning allows the whole family to explore their needs rather than isolating one individual as the “identified problem.”

The Benefits

The benefits of safety planning can be demonstrated for one family of seven suffering from neglect, domestic violence, and substance use that lead to Department of Human Services involvement due to ongoing safety concerns. The family system consisted of mom Jenna* (36), boyfriend David (27), daughters Fiona (16), Margot (14), Patricia (6), and sons Julian (9) and Bobbie (2). Jenna and her family were referred to in-home family therapy due to safety concerns with Jenna’s Post-Traumatic Stress Disorder (PTSD) resulting in substance use, domestic violence with her boyfriend David, and neglectful parenting that was negatively impacting each child.

It was the hope of the Department of Human Services to support the family in reuniting and repairing their relationship now that Jenna was sober from substances and ready to actively parent in the household.

Observing and engaging the family in rapport building, it was quickly apparent which role each member played in the family system. Jenna was able to identify her challenges in parenting her children in that they were each struggling with her absence in different ways. Fiona identified her anger that lead to running away from home and engaging in fights at school. Margot reported being a strong student and keeping to herself in her room when not parenting her younger siblings in Jenna’s absence. Patricia was observed to be childlike with attention-seeking behaviors younger than her biological age, whereas her older brother Julian escaped into video games to remain unseen. The youngest, Bobbie, was observed to struggle with meeting developmental milestones and resorted to screaming and hitting himself and others when emotionally dysregulated.

Through engaging Jenna, David, and the kids in a safety planning therapeutic activity, they were able to begin to recognize each of their individual differences regarding warning signs, as well as the coping skills needed to support connection and emotion regulation.  Jenna began to learn more about her children and their needs through identifying warning signs such as isolation, anger, and behavioral changes signifying distress for each child at their developmental level.

Jenna also identified her own triggers and reactions to her children as they related to her trauma and urge to escape.

Connection

When Jenna couldn’t escape her PTSD symptoms through work or substances, she was able to recognize the increased risk of conflict and aggression leading to fights with her boyfriend David. The safety planning served as a tool of discovery for family members and empowered each of them to advocate for their needs through healthy communication. For Jenna and her family, the safety plan served as a means of taking action to support the family in times of conflict and crisis.

Through this process, the children felt heard, Jenna identified goals for ongoing individual therapy work to maintain sobriety, and David and Jenna were able to identify new ways of communicating as a couple in order to bring the entire family closer together. Safety planning can be introduced and implemented early in the therapeutic process to explore family patterns, coping skill needs, and foster trust and safety while empowering families to remain together, connected and aware. A safety plan template is available for professional use along with a suicide risk assessment called the Community Assessment and Coordination of Safety (CACS) at www.cacs-co.com.

*Names have been changed to protect confidentiality