Setting Boundaries with Parents Who Have None

Working with children in a therapeutic setting can be very rewarding and can prevent further problems with mental health and behavioral issues down the road. Most therapists that choose to work with kids are comfortable sitting on the floor, engage easily with children and are comfortable setting boundaries around safety in the play therapy room. Engaging and setting boundaries with parents can be an entirely different ball game. And unfortunately, establishing a supportive and collaborative relationship where firm boundaries are set in place with the caregivers may be as important as your relationship with the child in order to facilitate positive change. If you are in a private practice setting, there is another layer of importance to engaging parents. Your income depends on you maintaining a caseload of happy parents, as well as children who are improving.

You and the child can do great work in the play therapy room, improving self-regulation, verbalization of feelings, and allowing for an unconditional, child-centered relationship to allow the child to process the most difficult situations and it can be completely unraveled once the child returns home for the week if they are not set up for success at home. Taking two steps forward and then one or two steps back each and every week can be disheartening for the child, caregivers and us as therapists. This is why it is paramount to engage your parents to be a helpful partner in this process. So what do you do if a caregiver to one of your kids is unwilling to make changes or is so stuck in their trauma or emotions regarding a divorce that they are not acting as your partner in the therapeutic process? What if all they are looking for is for you to provide testimony in family court that supports their beliefs about the family situation? How can we as therapists, advocates, and potentially the only objective person in the situation bring about positive change in the lives of these children?

Thorough Preparation is Key

In my twelve years of experience working with children and teens in a therapeutic setting, I have learned that the most important aspect of creating an appropriate and collaborative relationship with caregivers where boundaries are respected and maintained starts before your first interaction. It is important to have a clear understanding of your scope of practice, what you are or are not willing to provide for families, the laws around decision-making and custody in your state, the laws of age to consent to mental health services in your state, and the policies and procedures for your practice or the agency you work for before you call that parent back to set up an initial session. If you are not clear in your own mind of these things, you are more likely to set up a relationship where you have to back track or get stuck in a situation later on.  For example, if a parent calls to get their child in for counseling with you and you do not inquire if there are any issues with custody or if any other parent shares decision making responsibilities in that initial phone call, you do not know if you are able to see that child. You are putting yourself and credentials at risk by not asking the right questions during that initial phone call. If there is shared decision making responsibilities, then you can educate the parent about the laws of your state and request the appropriate court documents to show any current orders in place. Along with having clarification in your own mind about these issues, you also have to have them represented in your initial paperwork so that you have a way to discuss all of these issues with the caregiver. It is important to have fees, policies around communication, policies around providing court summaries or court testimony (including fees), and the rights of the child in your disclosure and consent. This way, the parent has the information upfront and has signed in agreement that this is in fact how you will be running the show. And then, it’s up to you to put it into practice.

Documentation

How do you engage parents and maintain this engagement even when they do not agree with you or have a specific agenda they expect from you? Even if you have started off the relationship with strong boundaries, many parents are still so stuck in their own stuff that they will test your boundaries. Working with these parents is frustrating to say the least.  You see the positive changes that the child is making in session and know that they could improve significantly more if the parent followed your recommendations or if they weren’t so focused on making the other parent look bad. Two things…continue making the recommendations that will benefit your kiddo, continue being their advocate, and document, document, document. Unfortunately in our very litigious culture, you will need to have good documentation of what was recommended and why, as well as if caregivers followed through with the recommendations. If you are ever grieved, you have everything you need documented to show appropriate care.  It can also be helpful for you to keep track of specific recommendations that were attempted, versus the ones that are not. This can inform the recommendations you make in the future.

Communication Strategies

Another area that I have consulted with many child therapists on is how to manage parents going through a conflictual divorce, specifically so that they are not being triangulated into the relationship and can continue to focus on the best interest of the child. Again, the importance of having the discussions around your policies is paramount. I typically have two separate intake sessions if I have the chance, so that I can go through the information thoroughly and so that there is not the perception that I have a better relationship with one parent or the other. I also recommend that most correspondence is done through email (if both parties agree to using email for therapeutic information after understanding the possible issues with confidentiality), and that all correspondence is sent to both parties. This way there is less possibility for he-said-she-said concerns about what your recommendations are. I stick to this policy unless there is a significant safety concern or if there is a no-contact or restraining order in place between parents. I ask that caregivers put the other parent on any emails sent directly to me, however this boundary is always broken. I have already let parents know that anything I send out will go to both parents, so if they need a reply, it will get sent to both parents. If it does not need a reply, I keep the emails as documentation, reply that it is important that all emails go to both parties unless there is a safety issue, and use it as data for my own conceptualization of the case.

There are many other logistical tips that could be provided to working with difficult parents. The tip that I have found the most helpful in maintaining positive relationships with parents that I have to continually challenge or set firmer boundaries is to remember that they are human beings with their own histories. I believe that most parents are doing the best they can with what they’ve got at the time. This may not be very good at all, but there are reasons for their behavior. Remembering this allows me to be personable with them even when extremely frustrated. And remembering that you may be the only safe person in your child’s world at this moment, provides enough incentive to do the hard work of managing their caregivers.

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Guest post written by Sybil Cummin, MA, LPC, ACS

Sybil Cummin, MA, LPC, ACS is the owner and clinical director of Arvada Therapy Solutions, PLLC. Sybil's specialties include working with children, teens and families dealing with family trauma including conflictual divorce, child abuse and neglect, sexual abuse, and domestic violence. As an Approved Clinical Supervisor, she also supervises Master's level interns and clinicians working towards licensure, as well as providing business consultation to therapists embarking on the world of private practice.

The Power of Ritual in Healing

As a long-time bereavement counselor I have had the privilege of working alongside clients whose grieving is both complicated and intense. Even as we together tease out the knots and kinks that make relationships tangled and messy, we also focus on the beauty, the memories, and the pain. Whether it is the individual flow of mourning or grief that is heightened by society’s focus on anniversaries or holidays, using rituals and ceremonies to move through the grief is something I encourage all therapists – and clients – to be open to.

What causes us to tear up over a favorite song or poem that reminds us of our loved one? Our body provides us with a natural healing outlet for our grief when we are confronted with memories that trigger our emotions. Not everyone sheds tears easily or willingly after a loss, but the process of grieving can allow us the opportunity to work through this physical pain.

What can we do to encourage our own healing in way that is both respectful of the death and mindful of our life? Memorials and rituals are excellent ways to personalize the life of the person who has died. While many traditions encourage the sending of flowers or food to the bereaved family immediately after the death, there are other, longer-term gifts, memorials, or rituals that can carry forward the meaningful life that is no longer on this earth. 

In our Western culture, many have found solace in placing a tombstone where they can visit the deceased on a regular basis. We have also begun seeing additional options for creating a living memorial. Purchasing park benches, planting trees, buying a brick at a museum walkway, making donations to a cause that inspired your loved one are all options that are lasting reminders. But beyond the public shows of support, there are smaller daily or weekly things that can help keep the conversation open in your heart. Finding a place or creating a time for “sacred space” is a way of elevating the emptiness to a different level within your consciousness. 

Individualizing the loss

Consider a theme that resonates with you and the person who is gone: nature, sports, travel, music, food. Think about how you remember that person. Create a process or memorial that embodies that idea. Spend some time thinking about what feels authentic and what you feel comfortable with. Begin your journey when you feel ready.

• Perhaps nature is a theme. Collect small rocks from your hikes or nature walks that you keep in a spot in the garden or in a glass jar. Allow yourself the freedom to know your loved one was with you as you enjoyed nature and that you are respecting his or her presence by bringing it home.

• Hobbies can offer us a way to connect. Be mindful of the time you spend allowing your emotions to be present while you garden, bowl, or cook. Make a decision to incorporate your loved one in the process – cook his favorite meal once a month, print her name on your bowling bag or plant their special flowers annually. 

• If you are so inclined, take on an activity that you dedicate to do as an internal connection with your loved one. Take an art class, begin blogging, volunteer to read in an elementary school. Embrace the feeling of doing the activity together in your heart.

• Meditate or spend a portion of time each day in a safe spot for you to grieve and remember. Read a favorite poem, look at photos, or play a special song and let yourself cry or laugh.

What I have found is most effective in soothing the grief is to work with clients to discover what makes them connect with the soul of their loved one. It matters not at all that others don’t “get” it – it can be an inside joke. One woman felt comforted going to the golf course where her father used to play; another donated her husband’s clothes to a shelter where he had volunteered; another family whose young child died collected donations to enhance the playground at his school. And for those whose memories were bitter, I’ve suggested planting herbs or vegetables whose sharp quality can ultimately become something valuable. Making meaning of their life and honoring that which feels good and familiar is the key.

Grief and the (many) holidays

Being in a vulnerable state during the holidays can cause anxiety and depression. While those around you are celebrating and enjoying what they have, you may be feeling the loss of what you no longer have. The rule for observing a holiday is: trust your gut. If you don’t feel able or celebrate with others, don’t – you are allowed to say NO. Change it up. Have Thanksgiving with a neighbor, go away for the week, volunteer at a shelter for Christmas, have another family member host the Easter or Passover dinner.    

While seeing the trappings of public holidays can cause pain, there are other more personal observances that no one may be aware of or choose to remember, and the same principle of ritual can help. Whether you share these moments with others who can support you or you gain strength from the intimacy of privately remembering, know that your journey is unique and unless your activities are taking you out of living, you should feel comfort in your rituals.

• Create a special memorial cup that celebrates your loved one, and use it only on holidays, anniversaries or birthdays. 

• Offer a toast or a blessing or a prayer with those you love.

• Visit the gravesite or a spot sacred to you in the weeks prior to a remembrance date.

• Buy an ornament or decoration that acknowledges the loss and display it .

• Wear an item of clothing or jewelry that brings to mind your loved one; keeping a physical reminder can be comforting.

• Buy or make a card and write loving thoughts on an anniversary; keep it as long as you wish.

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Guest post written by Tia Amdurer, LPC, NCC

Tia Amdurer, LPC, NCC, has her private practice, Heartfelt Healing Counseling, in Lakewood, CO, where works with individuals healing from grief, loss, abuse, low self-esteem and family of origin issues. She is the author of Take My Hand: The Caregiver’s Journey (www.TakeMyHandJourney.com ). www.HeartfeltHealingCounseling.com

Getting To The Goals - The Journey of Setting Them And Getting Them

When doing a “goals list” exercise in therapy sessions, start by telling telling clients to DREAM BIG!

Formulating a goals list is different for every individual. Counselors can be interested not only in the goals people choose but also in their reaction to creating the list itself. Sometimes people say they can’t think of any goals, which is an informative statement. It sends an important message about the person’s sense of value in the world. When a therapy client makes this statement, he/she provides the counselor with incentive and direction. It is rewarding to watch clients who start out by saying they have no goals, or can’t think of any goals, only to end the session with a goals list to take away with them for future reference.

In developing this exercise, counselors can work with clients to tap into their resilience, a tool which is helpful when attempting to work through a personal or professional setback. Also, the hope is that by creating this goals list a client will be improving their positive self-esteem. Next is the hope that a client will utilize the goals list to open his/her mind to a positive outlook - a world where the glass might be half full as opposed to half empty. Even if the goals list is not ‘realistic’ in terms of real life, just the actual act of writing down any dream or thought or hope a client might have is an exercise for the mind and the spirit.

Some clients have no problem coming up with long and varied goals lists. For them, the challenge is the move toward action in achieving the goals on their lists. In other instances, however, clients say they can’t think of goals because they believe they are not “allowed” to have goals for themselves. For whatever reason, throughout their lives, these clients were “programmed” not to consider their own individual thoughts, feelings, hopes, plans and dreams. Resistance is high with these clients, and asking them to think of goals for themselves stumps them, because it almost feels “wrong” for them to consider what THEY want.

There are other clients who come up with well planned and realistic goals, only to reject them because to follow these would somehow be “too good.” It’s as if they are so invested in the chaos of being “stuck” that even a glimmer of the possible is too scary, because then they have to give up a lifetime of investment in the chaotic lifestyles they have come to find “safe” or “comfortable” which is really code for “familiar” or “known.” Again, this gives the counselor clues in terms of directions forward therapeutically, in that the counselor is faced with massive resistance to change, even though the client talks the game of wanting change - a typical paradox.

When formulating goals lists with clients, there are some guidelines. First and most important, the items on the lists are to be goals they want for themselves, not based on the others in their lives, and not based on what they think they are “supposed to” want as goals. For example, of course I’m not opposed to the “get married and have a family” goal or the “graduate from college” goal, if those are on someone’s list. However, that still seems like something someone else (society, our parents, peers, etc.) tells us we’re “supposed to” want or do.

In terms of considering goals, counselors can encourage people not to think in terms of “supposed to.” Also, there are no restrictions - money or time or age or marital status or children or aging parents - or any of the other “reasons” people will identify as obstacles preventing them from achieving their goals. For example, people with children don’t need to write down, “I want to see my kids grow up and be happy and successful.” Counselors can remind people who are parents that the goals lists are to be about nobody else but themselves. Also, there can be no time deadlines - the “by a certain age I have to make a certain amount of money,” kind of thinking. And regarding the the subject of money, there can’t be dictates from others about how much money is “enough,” or that earning some amount of money will imply success. Again, it’s about what the individual believes for him or herself, not what someone has “programmed” the person to believe about money or success.

As mentioned above, the point of this exercise is to help clients open their minds to the limitless possibilities of life. For some, this is a difficult concept because they believe life is about a certain way of doing things, usually whatever way they were taught to believe as they were growing up. Then the ideas they were taught were further reinforced by others in their peer group. After all, most people want to “fit in” or be the “same as.” To be different from, or be the rugged individual in the group is sometimes to feel isolated and outcast. However, at this stage, clients are in a counselor’s office because of trying to fit in or be like everyone else, and discovering the emotional problems that go along with those efforts. They come in with their resistance, their unwillingness to change, even as they are acknowledging that they want things to be different from how they have been in the past. A paradox to be sure.

With the goals list, therefore, the counselor introduces the concept of all things possible, including the exercise of thinking about themselves in a selfish way. The counselor challenges clients to put their own needs first, to think in terms of their own personal priorities. The counselor encourages clients to define success as it relates to them personally, not in terms of money or possessions, but in terms of emotional well being. The role of the counselor is to provide a brainstorming conversation with the client in which resistance may be addressed, because there may be resistance to even attempting a goals list. Sometimes clients ask why they even need to have goals. Just the fact that they choose the word ‘need’ answers the question, doesn’t it?

Once the guidelines are out there, counselors can again encourage people to dream big! Some folks have an understanding of how this is helpful, and they start to write down their goals - large and small, real or imagined, practical or impractical, perhaps possible, perhaps not. For others there are still difficulties around feeling compelled to “be practical” or using phrases like, “that could never happen.” Not everyone is able to envision right away what it feels like to be selfish in a good way, thinking of self not in terms of anyone else. For them, the counselor can encourage continued talking and thinking and imagining. Eventually, just about every client understands how this exercise is worthwhile, because it takes clients out of the problem place and into the possible place - never a bad thing, right?

Do you have a goals list? Try it for yourself, and then keep it and refer to it from time to time. For one thing it’s a chance to dream, always worth some head time and space. For another, isn’t

it satisfying to achieve what you strive for? And lastly, it keeps clients in touch with forward motion, with listening to and following their hearts and thinking from a self place. Remember, when clients learn to put themselves and what they need at the head of their lists, they have that much more to give to the others in their lives who are valuable to them. Learning to do that and then putting it into action is in itself an excellent goal. When this is achieved, so much else is able to be done, and clients will know what it is to live life in that possible place.

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Guest post written by Valerie J. Shinbaum, MS, LPC, MAC, NCC

Valerie J. Shinbaum, MS, LPC, MAC, NCC, is a practicing psychotherapist since 1992. She is a published author, national speaker, college professor, and former radio talk show host. Ms. Shinbaum is a Licensed Professional Counselor, Master Addictions Counselor and National Certified Counselor. She works with individuals, couples, teens, and families. Her areas of expertise include addictions (process and substance), marital/couples treatment, adolescent issues, family of origin/inner child work, empowerment/self esteem building, career choices/changes, trauma, learning differences, relationship obstacles, mindfulness, grief/loss, and more. www.bodymindandbalance.com.

The Misjudged Millennials

We’ve been labeled by previous generations and these stickers have unrecognized negative implications. When we hear lazy, delusional, insincere, pampered, or even narcissistic, it not only diminishes the authentic experiences of Millennials, but creates an overarching stereotype that spreads ongoing divide. 

There are clear cultural and normative distinctions between Boomers, Gen-X, and even our most recent Gen-Zers. The beauty of specific generations are their unique values and attitudes about themselves, others, and the world. Every generation receives feedback and criticism; however, it seems that Millennials are gaining a fascinating reputation.

Millennials embody particular characteristics that perpetuate internal struggle especially in a world that operates quite differently than Millennials expected. That being said, its crucial to walk through some of the positive attributes and then segue to the misconstrued experiences of Generation Y.

It is shown through research that Millennials are mindful and filled with awareness regarding health, social, economic and environmental issues. Millennials are shaking our current system and showing up as critical thinkers.

Millennials embrace balance and hold a strong desire for career flexibility and self-care. These individuals are authentic, transparent, broadminded, and exploratory. Millennials promote individualism and believe in the importance of “doing whatever makes you happy.” Lastly, Millennials don’t accept existing conditions because they know improvements can be made and innovation is the golden ticket. 

Some of you reading will find what I’ve described above to be beneficial and helpful to our planet, however, there will be plenty of folks who may interpret it with a different twist. Nevertheless, the above narrative is paired with intense distress. 

Millennials endure higher levels of stress, emotional discomfort, anxiety, depression, and choice-overload compared to previous generations. These researched statistics are not only misunderstood but translate into the negative labels attached to the generation. Stress is labeled as lazy, critical thinking is stamped as delusional, and self-care is marked as narcissism.

Let me be clear that there are plenty of individuals in the generation that may be in fact lazy, delusional, insincere, pampered, or even entitled, however, creating a generalization is not the solution to the genuine troubles of 18-38-year olds.                   

Instead we need to view these researched issues as valuable and give Millennials the skills to thrive and flourish. We need to teach Millennials how to cope with disappointment, emotional discomfort, and instill realistic expectations.  These tools alone would allow Millennials to better manage stress, anxiety, and depression, and in return, show up as more productive, dynamic, and constructive individuals.

Additionally, we need to guide Millennials in finding what is important and meaningful in their lives. By promoting this type of exploration, we will help to support, enthuse, and motivate Millennials to set goals, achieve those goals, and enhance their lives.

In conclusion, I invite you to absorb this information with curiosity and surrender to some of the currently held beliefs that you may be gripping tightly. Remember that Millennials are currently the largest generation and we need them to create a future generation that blossoms. In order for this to occur, we need to support Millennials RIGHT NOW and by setting aide embedded judgment, we can begin that process.

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Guest post written by Paulina Siegel, MSW, LCSW, CAC II

Paulina Siegel, MSW, LCSW, CAC II is a Licensed Clinical Social Worker (LCSW), Certified Addiction counselor (CAC II) and master-level trained in mindfulness practice through Be Mindful. Paulina has extensive clinical experience working with teens and millennials struggling with dual-diagnosis, and had the privilege of working with these individuals throughout her community mental health journey (2012-2017). Paulina recently launched her private practice in the Wash Park neighborhood (Courageous Paths Counseling) and exclusive serves teens and millennials (15-38 years of age). Lastly, Paulina is a Gen-Z and Millennial researcher and speaks about the literature in the Denver Metro Area specifically focusing on generational issues. https://courageouspathscounseling.com

Age Discrimination in the Workplace: Tips and Tricks to Help Protect Your Clients

Age discrimination in the workplace involves treating an applicant or an employee less favorably because of his or her age. Fortunately, according to the Age Discrimination in Employment Act of 1967 (ADEA), the federal Equal Employment Opportunity Commission (EEOC), human resources, and employment attorneys, clients that feel they have been discriminated against have protection. However, age discrimination happens all too often and in many cases, is difficult to prove there is guilt on the side of the employer. As a result, it is important to assist our clients in protecting themselves against discrimination so they have equal opportunity in having access to gainful employment.

For therapists working with clients who are going through career-transition, the world of work can cause obvious emotional stressors as a result of not receiving a paycheck, not having health insurance, and lacking other retirement benefits. In fact, these stressors can be compounded if that individual does not have adequate financial resources in which to fall back on if they are out of work for a long period of time. In addition, to add insult to injury, if those clients have previously have been employed for a decade or more, they may be unaware of the current job-market and what it takes to get employed again.

The good news is that there are simple ways to assist your clients in protecting themselves from age discrimination and making sound career choices for the future.

1) Revamp Your Resume

Make sure that your clients are adhering to the latest trends in how resumes are constructed. Advise them to only go back 10 years in their work history and eliminate all dates of graduation from Universities they attended. Now this is true for every job applicant regardless of age; however, it’s paramount to individuals who fear age discrimination in their search.

2) Use Updated Email Addresses

Now this may seem silly, but using an email address from Hotmail, AOL, or even Comcast is a dead giveaway. Have your client switch to Gmail. If they still want to keep that old email, just have them forward their Gmail address to their old account.

3) Get on LinkedIn

Yes, they must go digital! Almost every future-employer is going to Google them. Age discrimination happens for a variety of reasons, but one of the main factors is the belief that “old” people are not tech savvy. Well, obviously that is not true and just being on LinkedIn won’t solve all of those concerns; however, it will show employers clients are willing to engage with technology. Also, a profile picture could be a giveaway of age - just make sure it is updated and professional.

4) Network, Network, and Network Some More

Encourage your clients to re-engage with past colleagues, go to career fairs (even your alma mater!), do informational interviews, join professional associations, and job-search groups. Most good jobs (85% of them) are found through colleagues or colleagues of colleagues. All too often, it is who you know and participating in an active job search is a better utilization of their time versus solely applying online. Advise them to seek people out one-on-one, especially if they have a preference for introversion.

According to AARP research, age discrimination is first being reported or “felt” around age 50. Yes, that’s right - 50! And, not that this is a big shocker, but given societal stigma, women tend to feel or report it more frequently over men. Sadly, although it’s hard to gather metrics around these happenings, this scenario is most likely true. Not that we can control external variables about how employers choose potential candidates, we can control how our clients view themselves and we can assist them in making competent future career decisions. Here are a few practical ways to engage with clients that often lead clients to a better sense of clarity around their strengths, desires, and congruence with a future employer.
 

1) Strengths

First off, have them take a strength-based assessment like the StrengthsFinder. There are many out there, but this one is low-cost, quick, and will provide clients with their top 5 strengths. We do know that working from a place of strength will warrant far better results versus trying to fix our deficits. Have the client tell you stories about how they agree or disagree with each of the top 5. This will allow them to connect with their intrinsic motivators and help them market themselves with strengths + instances of past success when they get that interview.
 

2) Values

Talk with your clients about their values. You can use something like the Values Cardsort from Knowdell. When was the last time they did an inventory on their values? Chances are that it has been long time or….never! Taking an inventory of these will help them engage with what they want and need in career and life. We are different people at every age and stage of our life so connecting with these systems allows the client to see if there is a congruence between the company, the corporate culture, and if they would be a suitable fit.

3) Fit

Talk to your client about company fit. In many cases, you can tell a lot about a company in how they onboard their employees. How was the application process? How was the introductory email, the call from the hiring manager - the recruiter, how was the phone screen, and how did the in-person interview(s) feel? If the company is unorganized on the front end or if they are rude, it is most likely not any better after they get hired. I know it can be tempting to get a job quick especially if your client needs money; however, if they are looking for optimal fit and happiness, turning down a potentially toxic work environment is the right call. Taking a job and quitting quickly never reads well on a resume.

Age discrimination is likely to almost always occur as long as future employers harbor false beliefs about the abilities of this segment of the workforce. As a result, helping your clients protect themselves, giving them resources about their rights, and helping them to connect to their strengths and values will ensure that they are interviewing the future-potential company just as much as they are being evaluated. According to another AARP study, contrary to many stereotypes, workers aged 50 and above are the most engaged members of the workforce. They also have lower instances of turnover and greater levels of experience. For therapists, guiding clients around issues pertaining to negative self-beliefs and establishing clarity around value systems is in many ways, more important than the nuts and bolts of job search.

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Guest post written by Brad Graham, M.Ed., LPC

Brad Graham, M.Ed., LPC is a Licensed Professional Counselor who works with individuals of all ages and stages in the midst of career-transition. In his Boulder, CO practice, Collaborative Careers™, he combines the use of counseling interventions with career-related assessments to help bring clarity, direction, and action within his clients. He takes a process-oriented, holistic approach and honors his clients for taking ownership over their lives and their relationship to the world of work. Brad can be found on the weekends running the trail systems, cycling the roads, or fly-fishing in Colorado's beautiful rivers. More can be found on his website collaborativecareers.com about his work.      

Exploring Equine: Therapeutic Focus and Interventions

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.

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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.

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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.

Navigating the World of Public Schools

“Education is the most powerful weapon which you can use to change the world.”

-Nelson Mandela

As a therapist and school counselor, I would like to provide some resources for those of you who work with school-aged children. The main questions I’ll attempt to answer are: Why would you need resources; What resources might be helpful; and How would you access the resources available.

First, Why would you, as a non-school based therapist need to worry about what is happening for your client at school? Your child client likely spends a great deal of time at school. This is a very different environment from home, and children’s behavior sometimes looks quite different between the two settings. For example, a child may be described as displaying difficult, acting-out behaviors at home but quiet and well-behaved at school.

There are also plenty of cases where a child might not display any distressing behaviors in the home environment but is struggling at school. You may get children referred to you because of their school behavior, so in that case you would have an easier time treating your client by finding out first-hand about the school and child’s experience there.

Even if school does not appear to be the issue for your client, it can be helpful to find out about their experience of their school environment and what is working well. This gives a more complete picture for you as you set out to determine best practices for working with them.

Through my years of work in schools, I have seen a variety of behaviors. There are some patterns of behaviors to look out for because they happen more frequently for some individuals in schools. For example, staff tend to grow alarmed when they see children running out of the classroom, throwing objects (sometimes very large such as desks and sometimes in a dangerous way such as at other people), and yelling or causing general disruptions or defiance within the classroom. Other common concerns include children who do not speak at all, who sleep during the class day, and those who hide under desks. Social skills are put to the test in a major way at school, so this is another area where some children get identified as having concerning behavior. This could include sexualized or aggressive behavior towards other students.  

For middle school students, behavior may include a greater frequency or intensity of defiance and aggression within the classroom or with peers. Suicidal ideation and other mental health concerns may be noticed more as the child grows older. In high school, mental health concerns may become a more common factor causing children to seek treatment with you.  

At any level, children who act out and externalize their feelings with uncontrolled body movements and/or verbalizations will more likely get noticed. Adults may not so easily recognize the needs of students who internalize their feelings and do not act out.

When school staff or parents are at a loss for what to do, they often turn to therapy in the hopes that this could help change a child’s behavior. Sometimes, they are at a loss to explain the child’s behavior and are hoping the therapist will be able to uncover the true secrets as to what is going on with the child. This is where you might get involved.

As an outsider to the school community, there are some helpful things to keep in mind as you are working with the child and family. A child’s behavior is a function of his or her environment, so it will help you to get to know the child’s school for yourself. For example, some school staff or faculty have a pattern of engaging in power struggles with students, but this is likely not the information you will receive just by talking to the adults in the child’s life. You will have to dig deeper by looking at data or making your own observations at the school. Through this kind of investigation, you might find the true reason for the child’s behavior really has to do with someone else’s behavior. Finding out this information will give you a better chance at coming up with effective interventions that align with your client’s experience.

This leads us to the next question topic: what information might you look for within the school setting?  Some basic questions you might do well to ask include the following:

1. What is the child’s behavior at different points throughout the day? There are grids that staff use to denote what a child was doing every 5 or 10 seconds for a 20 minute period. That child’s behavior is compared to a variety of peers and what they are doing at the same time as the client. If this is done at a variety of times, subjects, and settings, it can give you good information about potential reasons for your client’s behavior. Ask someone at school if you can have a copy of this information or if the information hasn’t yet been collected, see if they would be willing to do so.
    
2. After identifying a particular behavior you want to learn more about, find out what happens just before the behavior occurs (antecedent) and what happens just after (consequence). This may inform you as to why the child is behaving as s/he is. For example, many times in school settings a child is inadvertently rewarded for behavior that the school staff actually wish to extinguish. Examples of this include when a child leaves the classroom, they might be allowed to go to a different setting, spend time with a preferred adult, or not be required to do the classroom work; or, if a child makes noise or otherwise disrupts in the classroom, perhaps they receive attention from staff or students.
    
3. What are the goals that the child has and how do those goals compare to the goals of school staff and caregivers? If you are able to speak to staff at the school where your client attends, you could learn a lot about what is working well and where some potential difficulties are arising just by talking to people and gathering anecdotal information.

If you work exclusively outside of a school setting, you may be wondering how you would go about navigating the system to get the information you are looking for. One good place to start would be with your client and/or their caregivers. Ask them to set up a meeting between you and school personnel so that you can begin getting to know the people in your client’s school environment.

Once you build relationships with some school staff, you could ask for some help gathering the more time-intensive data that is involved in tracking a student. If the student’s behavior is especially troublesome for the school, they likely will already have this type of data on hand as it is required for moving forward in a process of getting a student more intensive resources.

In your efforts to help a client make changes in their life, gathering more information about their experience in the school setting will better inform you and your practices. It will take time, but may well hold some keys as to what is really motivating your client’s behavior. In that way, learning more about your client’s school setting can be well worth the extra time and energy you put into it.

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Guest post written by Jenny Pelo, MA, LPC, NCC

Jenny Pelo, MA, LPC, NCC is a school counselor and community-based therapist in the Denver area. She has worked with children and adults at a variety of ages and developmental levels. She enjoys helping others heal from trauma and finding meaning in their lives. Spending time outdoors, rock climbing, and being involved with a meditation community bring her great joy in her own life. http://jennypelo.com

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

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.

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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. 

Bedroom Bliss: Have Better Sex Tonight with this Trick!

Now that I have your attention...

I want to talk about mindfulness. Not the sexy topic you may have expected, but bear with me, I promise I wasnt just teasing you with some clickbait blog title. 

Sex is pleasurable and fun and connecting and even spiritual at times. But F### what Cosmo or Maxim might say, the way good sex happens is not through circus act moves or potions or having the perfect body. Its by being mindful.

Mindfulness is paying attention and choosing your focus on purpose. You can have the best techniques and all the right moves, but if youre doing your taxes in your head or critiquing the size of your butt, you're missing out. You need to be mindful to fully be there to notice your own feelings and pleasure, and to communicate what you need, and to be fully present and connected with your partner. 

Now Cosmo and Maxim aren't totally wrong. New moves, exotic smells, and feeling sexy thanks to the latest health and fashion tips may help. But why do they help?? Because trying something new, using your senses, and feeling confident aid us in staying present and being focused on the moment. 

But you cant expect to go around being a mindless robot, thinking of the past or the future or not thinking at all, and then expect to suddenly be good at staying present for sex. That's crazy. We get good at what we practice. So practice being in your body. Notice when it feels good. Notice what makes it feel good. Get good at staying present with your self. 

Good times to practice tuning into your body are: 1. when you're getting dressed (notice what clothes and textures make you feel sexy and sensual), 2. when you're bored (often we self soothe when bored. Do you play with your hair or rub your neck or tickle your arm or ???), 3. When you dance or exercise (its a great opportunity to be in your body and pay attention to sensations in your body that give you pleasure) 4. When you masturbate (if you don't know how to turn yourself on, you will struggle to guide your partner)

Another quick mindfulness practice to jump start your practice. Do this as often as you like to use your five senses to be more aware of the present moment.

1. Notice 5 things you can see right now
2. Notice 4 things you can hear right now
3. Notice 3 things you can touch right now
4. Notice 2 things you can smell right now
5. Notice 1 thing you can taste right now.

So, since sex sells, heres reason #592 for practicing mindfulness consistantly: being more mindful will make you a better lover!

Namaste. Happy practicing!

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Guest post written by Erika Holmes MA, MFT

Erika Holmes MA, MFT, lead clinician at Colorado Couples and Family Therapy (www.coloradocft.com) is a  native Californian who now lives and works in beautiful Denver Colorado. With over 10 years of clinical experience both in agency work and in private practice, her work has included individual, couples, and family therapy, group therapy, parenting classes, behavioral assessments, and professional consultations. Her special areas of interest and training include working with 20 – 40-year-old sassy women, people in distressed relationships, people with mood disorders, trauma, eating disorders, and borderline personality disorder. She has also been privileged to contribute to "Rehab with Dr. Drew" and "The Mental Illness Happy Hour" podcast and "Paleo Baby" podcast. 

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