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Transcript
Jonathan Singer: Today’s episode is the foremost of a three-part serial on the arc of therapy – the beginning, middle too end.I’d similar to give thank yous TheraNest for sponsoring these 3 episodes. TheraNest is uncomplicated too affordable practise management software that makes it easier for a solo practitioner or entire agency to acquire through the administrative constituent of beingness a therapist that, quite honestly, no i likes. TheraNest has geeky background materials similar HIPPA compliance too encrypted information transfer, AND cool forepart terminate materials similar a create clean professional person interface, intake assessments, progress notes, too top rated client support. I thought TheraNest was the perfect sponsor for these episodes because solely inwards fantasy set down (or graduate school) tin flame yous verbalize well-nigh therapy without talking well-nigh paperwork.
While I’m giving call outs, I desire to give thank yous a special grouping of people who have got generously donated transcripts. One of the most oftentimes requested resources on the podcast is transcripts of the episodes. I desire to give a big old Thank yous to the next rockstars for generously donating transcripts:
- Meredith Amshoff, a recent MSW graduate of Boston College, currently working amongst Catholic Relief Services inwards Kampala, Uganda.
- Amy Smith, an early on childhood special pedagogy paraprofessional
- Raashida M. Edwards LMSW, Couples Therapist, Institute for Contemporary Psychotherapy inwards New York City.
- Tierra Montgomery, a math student
- and Kelsi Macklin from California.
If yous are interested inwards donating a transcript, delight ship me an electronic mail at jonathan.b.singer@gmail.com
And earlier nosotros laid out the outset I desire to arrive real clear that I’m non talking well-nigh therapy equally a place. Sometimes nosotros think well-nigh therapy too nosotros imagine a sweetness old private practise business office amongst that chair that clients tin flame gyre upwardly inwards too the fine art piece of work that mightiness live a projective assay or simply something that the therapist could afford inwards the early on days earlier they had a waiting list. What I’m talking well-nigh over the adjacent 3 episodes for sure fits that place. But I’m talking well-nigh therapy equally a lens or approach to working amongst people that tin flame come about anywhere. Some of the most profound therapy sessions I’ve had amongst my clients took seat inwards a McDonalds on a hot summertime solar daytime inwards Texas piece eating a mutual depression temperature H2O ice cream cone, or inwards the waiting room of dentists’s business office amongst a client who had been suffering amongst rotten teeth for besides long. In today’s episode I’m going to verbalize well-nigh some conceptual issues similar what do people desire when they come upwardly to treatment, too how should yous live amongst clients? I’m also going to review some of the to a greater extent than concrete aspects of the outset of handling similar biopsychosocial too DSM assessment, talking well-nigh confidentiality too billing. I’m mixing it upwardly because I desire this episode to live interesting whether you’re a foremost twelvemonth social piece of work pupil or a 35 twelvemonth veteran of the field. And now, without farther ado, on to the constituent of therapy that some people dear too some people hate… Beginnings.
Beginnings
How does it all begin?It is helpful to retrieve that the somebody or brace or seat unit of measurement that is coming to consider yous would rather live doing almost anything else. They mightiness live polite to you, or fifty-fifty excited to talk. But for most people, talking to a therapist is anxiety provoking, frustrating too some fifty-fifty consider it equally a shape of combat. In the outset it is helpful to live curious too retrieve that they have got no argue to trust you. In episode eighty when I talked amongst Nancy Smyth well-nigh trauma informed care, she reminded us that lots of people who come upwardly to therapy have got had some sort of experience or experiences that give them argue to distrust adults or mental wellness professionals. Communities of color have got a long history of abuse too mistreatment past times mental wellness professionals, thence much thence that nosotros demand to assume a score of cultural mistrust, especially betwixt white providers too clients of color.
So, given all this, earlier someone walks into your business office – or yous walk into their abode – yous have got to assume that at that spot was some sort of breaking point, i or to a greater extent than people either suggested or required (like a guess or a spouse) that the somebody to acquire help. Sociologist Bernice Pescosolido (I dear maxim that name) she came upwardly amongst a theory of help-seeking called the Network Episode Model. Her enquiry on adults too mental wellness handling found that it takes entire communities to force folks into treatment. It is possible that someone made the appointment for them. There mightiness have got been a telephone screening or intake, fourth dimension passed – everything from a solar daytime to several weeks… The postmodern therapies similar Solution-Focused too Narrative helped us to consider that modify is constant. We have got to assume that some things changed betwixt the when the client made the appointment too when they demo upwardly inwards your business office (or yous demo upwardly inwards their home). The modify mightiness have got been something direct related to the presenting work or argue for referral, or perchance not. But simply similar the human relationship betwixt the butterfly that flaps its wings too the seismic sea wave that wreaks havoc on a shoreline halfway around the world, nosotros should never discount the importance of the little stuff, especially if that little materials is really the big stuff, similar people non trusting us or non wanting to live inwards therapy.
Agency referrals
Someone is already inwards the organization too you’re getting some other client on your caseload. Since the client is in-house, you’ll probable have got access to their medical records too live eating luncheon amongst their one-time therapist too mightiness have got fifty-fifty been staffing the instance inwards weekly meetings. The challenge inwards this province of affairs is to consider the client amongst fresh eyes, fifty-fifty though at that spot is all this information available.Private practice
You mightiness acquire a client from some other therapist or primary aid provider or mandated past times a courtroom lodge to acquire help. Really of import to acquire release of information forms signed amongst all the right people inwards all the right places. If you’re referring a client to some other therapist, yous can’t follow upwardly too say “Hey, did Domingo brand an appointment amongst you?” Because… confidentiality.At the real to the lowest degree yous desire to know: referral source, presenting problem, prior handling history, too electrical flow goals.
What do people desire when they come upwardly to therapy?
This is such a basic question, but it isn’t ever like shooting fish in a barrel to answer. Think well-nigh your ain life for a moment. If yous were to telephone band upwardly a therapist too brand an appointment, what would yous desire to acquire out of treatment? Of course, it is probable that yous don’t think yous demand to acquire therapy. So, to a greater extent than realistically, why would someone else desire yous to acquire therapy? If yous did come upwardly for therapy what would yous similar to change? What thoughts, feelings or behaviors are getting inwards the way of yous getting what yous desire inwards life?
This enquiry of what people desire out of therapy is really interesting. My dissertation enquiry was on mothers who took their children for mental wellness services. I found something really interesting. And it was interesting plenty to the 4 people on my commission that they gave me a Ph.D. Yeah, simply similar that. Super easy. What I found was that moms brought their kids to mental wellness services because they wanted i of ii things: to know what the work was, or to know how to solve it. One grouping of moms was looking for answers. They couldn’t figure out what the work was. They knew something was incorrect amongst their kid. Their teachers, their friends, their pastors, fifty-fifty their employers had said “something is wrong.” But they didn’t know what. And no i around them knew what. So, they were bringing their kid to the professionals to discovery out what was going on. It is of import to emphasize that these moms had already done an exhaustive investigation into the work earlier they got to therapy services. I’m highlighting this because therapists often think that they are the foremost halt inwards the help-seeking process. The truth is that they are solely most recent. These moms wanted a thorough assessment too diagnosis. Now, I’m non using the term diagnosis to hateful DSM diagnosis. I hateful that they wanted the professional person to allow them know that a, b, too c were related too they were in all probability related to d, too that agency e. For example, they wanted the therapist to say “the fidgeting, outbursts, too social ostracism you’ve seen at abode too at schoolhouse are related to his difficulty paying attending too hyperactivity. We think at that spot are in all probability biological too environmental reasons why this is happening.” So that’s the thorough assessment. If you’ve been inwards the champaign for a piece yous mightiness hear this equally a full general description of ADHD too are in all probability anticipating the adjacent constituent of the conversation – the i where the psychiatrist recommends a psychostimulant too the therapist plant amongst the kid on social skills grooming too fourth dimension management, too plant amongst the parents too teachers on beingness on the same page amongst structure, consequences too rewards. But that 2nd constituent of the conversation well-nigh handling jumps ahead a chip besides soon. Remember, we’re talking well-nigh moms who don’t know what’s incorrect too desire to discovery out. They are non necessarily looking for the therapist to create the problem. Why? Because they saw it equally their job, equally the moms, to create the problem. Yes, they needed the professional person to say what was wrong, but i time they got that, it was their responsibleness to create the problem. For these moms, a xv infinitesimal intake too 3 sessions of “let’s acquire to know each other” was the worst sort of services. They wanted xv minutes of “let’s acquire to know each other” too a 3 session assessment.
Now the other grouping of moms came to services because they knew what the work was but they didn’t know how to create it or they had tried too couldn’t fixing it on their own. So, they mightiness know that ADHD was the probable diagnosis for their kid who was fidgeting, having outbursts too experiencing social ostracism because they were the same way equally a kid, or because they have got some other kid amongst the diagnosis, etc. But they don’t know how to create the work thence they are coming to the professionals to do it. For these moms, xv minutes of “let’s acquire to know each other” too a 3 session assessment was the WORST services. They wanted the xv infinitesimal intake – someone to accolade too honor their expertise equally the mom too select them seriously when they said “here’s the problem, I demand to know what yous tin flame do to create it.”
Again, the moms had ii unlike reasons for coming in. One was to discovery out the problem, the other was to create a known problem. If yous tin flame acquire a conduct maintain on which i of these is the principal focus for seeking treatment, too then you’re farther along than most folks.
So, a quick summary – most clients don’t desire to come upwardly to therapy, too when they do yous should know if they are looking to discovery what the work is or piece of work on fixing it.
Biopsychosocial assessment
I verbalize well-nigh the basic biopsychosocialspiritual (BPSS) assessment inwards episode 2. For our purposes retrieve that the BPSS provides a context for why someone is seeking services. What’s going on amongst the person’s neurobiological functioning, physical health, seat unit of measurement medical history or other medical handling including medications? The psychological assessment includes things similar agreement their personality style, attachment style, interpersonal relationships, whatsoever existing diagnoses. The socio cultural assessment looks at issues similar cultural beliefs, community norms, external stressors. The spiritual assessment looks at several factors related to organized faith too spirituality. David Hodge, inwards his 2015 text, synthesizes several existing religious too spiritual assessment models into the acronym ICARING. When yous do a spiritual assessment yous desire to discovery out: I - important: How Important is spirituality or religion? C - community: Is at that spot participation inwards a religious or spiritual Community? Influenza A virus subtype H5N1 – assets too R – resources: Are at that spot spiritual beliefs too practices that serve equally assets too resources? I – influence: What is the Influence of spirituality too organized faith on the electrical flow situation? northward – needs: Are at that spot spiritual Needs that should live addressed? G – goals: Is incorporating spirituality into handling i of the client's Goals? If so, how? So, again, if you’re interested inwards learning to a greater extent than well-nigh the BPSS, banking concern check out episode 2.In contrast to the BPSS which provides a context for the presenting problem, a diagnostic formulation places the work inwards a category. The DSM is the most widely used organization for categorizing mental wellness problems, but it’s non the solely one. For a history of the foremost DSM upwardly through DSM 4, banking concern check out the real foremost episode of the social piece of work podcast. And for a scathing critique of DSM-5 yous tin flame banking concern check out my interview amongst Jeffery Lacasse inwards episode 101.
If you’re doing a DSM diagnostic interview, a keen resources is the cultural formulation interview available for gratis on the DSM5.org website. Anyone doing a DSM diagnosis should usage a cultural formulation. As constituent of the diagnostic interview, clinicians are expected to assemble too summarize information inwards 4 areas:
- The foremost surface area is the cultural identity of the individual. This includes ways inwards which the person’s cultural, racial, too ethnic identity may “influence his/her human relationship amongst others, access to resources, too developmental too electrical flow challenges” (APA, 2013, p. 750).
- The 2nd surface area is cultural conceptualization of distress. This includes “cultural syndromes,” “idioms of distress,” too “explanations too perceived causes.”
- The 3rd surface area is psychosocial stressors too cultural features of vulnerability too resilience. This is the constituent of the cultural formulation that covers the one-time Axis IV from DSM-IV – psychosocial stressors.
- The 4th surface area is cultural features of the human relationship betwixt the private too clinician. This asks the clinician to consider such issues equally linguistic communication barriers, cultural mistrust of professional person services/providers, too how those cultural features may effect therapeutic alliance.
If you’re listening to me verbalize well-nigh the BPSS too the diagnostic interview too you’re starting to panic, select a deep breath. Your agency or practise in all probability has a touchstone intake form. If they don’t, practise management organization similar TheraNest at that spot are intake assessment too diagnosis forms built into the software. You tin flame modify these forms or create your own. When you’re done yous tin flame electronically sign too impress to PDF or inwards hard copy. TheraNest makes it like shooting fish in a barrel discovery diagnostic codes too names amongst the click of a button.
It takes fourth dimension too practise to larn how to do thorough assessments. New forms, novel information… figuring out what is of import takes fourth dimension too makes novel social workers too novel employees slow. You’re thinking through all the options too this makes your thinking slow. So how do yous speed upwardly your thinking? This number of fast too tiresome thinking was such a big bargain that the guy who figured it out got a nobel prize.
Daniel Kahneman, the psychologist who won the Nobel prize for his piece of work amongst Amos Tversky, talks well-nigh this experience of thinking fast too slow. Fast thinking, originally called System 1, is what experienced clinicians do all the time. After v minutes on the telephone amongst a teacher, 3 minutes of beingness inwards a room amongst a kid, too ii minutes of talking amongst the rear you’ve got a pretty goodness thought that the kid meets criteria for ADHD. Did yous perform a thorough assessment inwards 10 minutes? No. But yous have got plenty expertise to recognize a blueprint based on minimal information. You become through a complex laid of mental events too everything coalesces around this diagnosis of ADHD.
Fast thinking is keen unless yous can’t articulate why yous came to the conclusion. The conclusion is essential for documentation too conveying to judges too lawyers why yous did what yous did. Lawyers dear cross-examining so-called practiced witnesses who are unable to explicate how they came to their conclusion.
If you’re supervising an intern, this “fast” thinking tin flame live confusing or frustrating. Fast thinking tin flame also live fascinating. It is what makes experienced therapists seem similar magicians.
The flip side of fast thinking is what Kahneman called “slow” or “system 2” thinking. Beginner thinking is “slow.” Kahnemen doesn’t usage this equally a pejorative, although supervisors too interns often think of it that way. Thinking tiresome agency beingness deliberate. If yous don’t know what the information agency yous select fourth dimension to sort it all out. Some of the tools used inwards tiresome thinking are algorithms, catamenia charts, logic models, too instance formulations. Slow thinking often avoids the biases too errors of fast thinking. Fast thinking, on the other hand, forces a conclusion too moves things along when tiresome thinking mightiness have got us assemble information too pass an inordinate amount of fourth dimension sorting out what to do.
In an ideal world, fast too tiresome thinking piece of work together for optimal decision-making. I would fighting that if the supervisor is a fast thinker too the intern is a tiresome thinker that they tin flame live a ameliorate squad past times talking through those differences. If you’re interested inwards learning to a greater extent than well-nigh Thinking Fast too Slow I highly recommend Kahnamen’s 2011 mass of the same name. If yous desire some podcast episodes well-nigh Kahnamen’s work, simply banking concern check out the Freakonomics podcast. It seems similar well-nigh one-half of their episodes reference Kahnamen too Tversky.
Establishing rapport
Rapport isn’t something yous found once. Rapport ebbs too flows inwards therapy equally it does inwards every relationship. The fancy phrase that nosotros usage inwards therapy is “Therapeutic alliance”. How rigid is the alliance betwixt the therapist too the client? Alliance turns out to live VERY IMPORTANT inwards client outcomes. I don’t aid how goodness yous are at identifying automatic thoughts, rooting out core beliefs, too dismantling the cognitive triad – if your client doesn’t similar yous you’re non going to brand progress.Therapeutic alliance is i of the mutual factors inwards psychotherapy. Common factors are affair that are introduce inwards all therapeutic relationships, regardless of the specific handling approach. For example, a goodness CBT therapist too a goodness psychodynamic therapist volition conceptualize client problems too approach handling real differently, but both volition have got rigid alliances amongst their clients.
Some of the other mutual factors are: agreeing on goals, collaboration, genuineness, positive regard, too expectations. Now, yous mightiness live thinking to yourself “hmmmm… those sound an awful lot similar the 3 weather that Carl Roger said were necessary too sufficient to run into the needs of clients: empathy genuineness, too unconditional positive regard.” You’re right. Carl Rogers said that those 3 components were. As I talked well-nigh inwards episode 8 these 3 weather are necessary, but inwards many cases non sufficient for people to acquire better.
Several years agone I worked amongst a adult woman inwards her mid-50s. She was lately unemployed, single, no children, too struggling amongst fiscal stressors too debilitating depressive symptoms including thoughts of suicide. There’s no doubtfulness that I had to live empathic, genuine too have got unconditional positive regard for this woman. She said that her peers looked upon her amongst compassion – they were married. If divorced, at to the lowest degree they had children or grandchildren. If divorced too no children at to the lowest degree they had their careers. These were some of the things that fed into her depression. My validation that she was valuable too cared for was inwards too of itself therapeutic. It was necessary for handling to work, but non sufficient. Medication helped amongst the depressive symptoms. I helped her think of her electrical flow province of affairs equally temporary. We framed it equally a role transition, important she was depressed inwards constituent because she was grieving the loss of her previous role of partner too married adult woman (and all the accompanying status too fiscal safety that came along amongst that). I subsequently found out that role transition is i of the big 4 issues that Interpersonal psychotherapy, which I verbalize well-nigh inwards episode 10, focuses on for treating women amongst depression.
Now, I bet you’re listening to this too maxim to yourself, “wait a infinitesimal Jonathan, yous were simply talking well-nigh the mutual factors inwards therapy, too and then yous gave an instance of how an empirically supported handling was the affair that made the departure for your client.” Ok. Nice catch. Here’s the deal: The enquiry on what makes psychotherapy piece of work has found that when yous compare treatments that work, the things that are most helpful are these mutual factors. The enquiry does non say that whatsoever handling volition work.
Ok – straight off where was I? Oh yeah. Rapport. Hahaha. That’s right I was talking well-nigh edifice rapport too how that isn’t something that happens i time too and then you’re done.
One of the best ways to found rapport is to discovery out what your client likes, what they are goodness at, things that brand them experience goodness well-nigh themselves too that give yous a endangerment to live impressed past times them. We similar it when others are really interested too impressed past times us. This effect is magnified when you’re sitting inwards the therapy room talking amongst someone who already knows some pretty embarrassing or shameful things well-nigh you, or is well-nigh to. So, little talk. But non simply for the sake of little talk. For the sake of starting to create a therapeutic alliance. How do yous know when you’ve established plenty rapport to motion out of little verbalize too into the adjacent stage of treatment? Guy Diamond too Suzanne Levy, the co-developers of Attachment-Based Family Therapy, similar to say that yous know you’ve spent plenty fourth dimension on little verbalize when your client doesn’t have got their guard upwardly – when they start to respond questions unselfconsciously, freely, too spontaneously. Once this happens, yous tin flame experience to a greater extent than confident that they volition live to a greater extent than honest too genuine amongst you. And, equally I talked well-nigh inwards my digression a few minutes ago, honesty too genuineness are necessary components to effective treatment.
You demand to review confidentiality, specifically what happens when someone mentions Harm to self, ongoing abuse of minors, older adults, or people amongst disabilities, too inwards states covered past times threat to impairment others. You desire to brand sure they sympathise billing too payments. You also desire to concealment for pith use, suicide risk, too endangerment for interpersonal violence.
Quick review:
Assume people don’t desire to come upwardly to therapy, but they are hither anyway. Your chore is to create rapport, develop trust, too figure out why they are inwards therapy. It mightiness live to figure out the problem, inwards which instance a thorough biopsychosocialspiritual assessment too diagnosis is great. All assessments should live done through a cultural lens. If it is because they know what the work is but don’t know how to solve it, too then the focus should live on solutions.
Case conceptualization
One of the most of import things to do inwards the outset of therapy is to figure out what this is about. Influenza A virus subtype H5N1 term that people often usage is “Case conceptualization.” Your conceptualization could live from a specific theoretical perspective such equally CBT or psychodynamic. In episode 52 I spoke amongst Joe Walsh (the professor, non stone legend) well-nigh theories for clinical social piece of work practice. He suggested that people have got i or ii dominant theoretical perspectives.James Morrison, writer of the real pop Guilford Press books, “DSM Made Easy” too “The First Interview” has a keen instance of how a unmarried presenting work tin flame live understood from vastly unlike perspectives. Take the instance of a married adult woman who drinks besides much alcohol (Morrison, 2014, p. 3):
- Dynamic. Her overbearing hubby resembles her father, who also drinks.
- Behavioral. She associates drinking amongst relief from the tensions induced past times these relationships.
- Social. Several girlfriends drink; drinking is accepted, fifty-fifty encouraged, inwards her social milieu.
- Biological. We should also consider the genetic contribution toward alcohol misuse from her father.
Morrison correctly says that nosotros should live able to consider the number from all of these perspectives simultaneously.
Ending the foremost session
We have got to live prepared for the possibility that our foremost session mightiness live our last. Research past times Gibbons too colleagues looked at services usage inwards community mental wellness clinics inwards 1993 too i time to a greater extent than inwards 2003. What they found was that the modal number of sessions that people attended was one. Now, the average number of sessions was higher because some people attended to a greater extent than than one. But most people solely attended i session. The brief therapy approaches address this issue. One of the most valuable insights to come upwardly out of brief therapy is the thought that nosotros tin flame usage fourth dimension equally a motivator. If yous know yous solely have got i session, yous tin flame think of your session equally beingness the outset middle AND end. We’ll verbalize to a greater extent than inwards depth well-nigh the middle too terminate inwards the adjacent ii episodes. But, suffice it to say that yous should ever think well-nigh the END of therapy inwards the beginning. What volition allow yous too the client know they no longer demand or desire services? How volition yous mensurate change? What information volition aid yous acquire to where yous demand to go, too what information volition tiresome yous down? What is your move out innovation – i.e. what sorts of issues are introduce that cannot live addressed inwards your piece of work but that would live of import for someone else to address (hint: those are some of your referral sources).Documentation
Let’s imagine you’ve had an amazing foremost session amongst your client. They were anxious but your gentle too curious questions helped them to relax. You uncovered some of import information well-nigh how they got hither too what they were looking to acquire out of therapy. They curled upwardly inwards that big chair of yours, or they really enjoyed their H2O ice cream cone. The session ended amongst a commitment to come upwardly dorsum for to a greater extent than sessions.Now it is fourth dimension to document. If you’re doing an intake it should live thorough, but it won’t live complete. You’ll larn things equally yous run through the course of report of therapy. Assessment is ongoing. When yous larn novel information or demand to revise old information usage your progress notes to document what you’ve learned too create addendums for your assessments. As I mentioned before, if you’re using a computer programme similar TheraNest, documentation mightiness non live fun, but it is easy. It has intake forms, progress notes, too yous tin flame create your ain customized forms. Submit electronic insurance claims, have got credit cards, create invoices too superbills. For an extra fee yous tin flame create a client portal to allow your clients to submit intakes forms too fifty-fifty schedule appointments online. Try TheraNest for gratis too have 20% off your foremost 3 months when yous sign upwardly at theranest.com/SocialWorkPodcast.
The 2nd too 3rd episodes inwards this serial volition encompass the middle of therapy too the terminate of therapy. If yous desire to a greater extent than information well-nigh the episodes too enquiry I’ve mentioned inwards this episode yous tin flame discovery links on the website at socialworkpodcast.com. If yous desire to bring together the huge community of podcast listeners, delight become to our Facebook page at facebook.com/swpodcast or follow the Twitter work concern human relationship @socworkpodcast.
If yous are interested inwards donating a transcript, delight ship me an electronic mail at jonathan.b.singer@gmail.com
APA (6th ed) citation for this podcast:
Singer, J. B. (Producer). (2017, June 15). #110 - The Arc of Therapy: Beginnings (Part 1) [Audio Podcast]. Social Work Podcast. Retrieved from /search?q=beginning
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