Topic 5: Initial Assessment in Counseling {by 10/1}

Based on the text readings and lecture recording due this week consider the following two discussion points: (1) Share your understanding on why it is important to get an accurate understanding of the client’s problems early in therapy (i.e., intake/early sessions).  (2) Understandably, especially as a beginning therapist, the thought of assessing suicide can be anxiety provoking.  Share a few of your initial concerns when (not if) you are confronted with a suicidal client.  (Keep in mind, you will learn a lot more about responding to suicidal clients in future classes and on your practicum/internship.)

 

(3 – Prepare for Class [do not blog]) You will notice on my website (Class Lectures & Recordings) a short video “Assessment Review Introduction,” an “Assessment Review Reflection Questions” template, and five assessments.  Please review and complete these assessments (the first four) before class.  Then, take some notes using the Assessment Review Reflection Questions.  For at least the second half of class (or more) we will spend time discussing these assessments.  I will put you in breakout rooms with a few of your peers to discuss each assessment.  We will then discuss these assessment in class, including myself providing feedback and tips/advice for each assessment.

 

Your original post should be posted by 10/1.  Post your two replies no later than 10/3.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

76 Comments (+add yours?)

  1. Destria Dawkins
    Sep 27, 2020 @ 18:43:09

    1. From my understanding, it is important to get an accurate understanding of the client’s problems early in therapy because if the professional waits until the 5th or 6th session to begin asking certain questions to gather information, it might already be too late to try and help resolve the issue. If the professional already knows the client’s problems in the earlier sessions, the problems that the client is facing, has a higher chance of being resolved. If the professional waits, there could possibly be more problems adding on to the problems that the client is already facing. For example, if a client is currently going through a divorce and that is the reason for them feeling depressed/stressed, it is important for the professional to know the reason as to why their client is feeling this way because it prevents the client from being misdiagnosed.
    2. One of my concerns when it comes to a client talking about suicide, is that I am afraid that I might get too nervous and not know exactly what to say to the client. Getting stuck and nervous about what to say is one of my weaknesses that I have to work on. Another concern would be not being able to tell whether a client is actually going to commit suicide or not and how to report it, if a client is actually planning to commit suicide.

    Reply

    • Abby Robinson
      Sep 30, 2020 @ 12:42:33

      Hi Destria!
      I think that gathering all the appropriate information in the beginning sessions is so important because if a therapist waits too long, there may be problems in the long run that were never addressed in the beginning. I like your example about a client feeling depressed from a recent divorced because it shows that the therapist needs to gather all the past history information soon into the sessions to make an appropriate treatment plan and make appropriate goals for that client. If the therapist didn’t gather all that information in the beginning, they could make a mistake by setting unrealistic goals for their client which leads to more problems.

      Reply

    • Lilly Brochu
      Oct 01, 2020 @ 18:12:34

      Hi Destria,
      I think it is very important to ask the right questions early on because not only does it show the client that the therapist is invested in helping them, but it also helps the therapist gather as much information as possible about the client. It is important that there is a substantial amount of information obtained in earlier sessions because it helps to paint a clearer picture of what is really going on with the client. It helps to set a focus on the client’s problems and can be used to guide the therapist in choosing the correct treatment options and what the client’s future goals should be. Additionally, I think it is natural to freeze up and become anxious when a client expresses that they are suicidal. It is difficult to know what the right response is and how to say it. I think that it will take training and practice to let go of how it makes us feel in that moment and how to fully immerse ourselves in how the client is feeling, and how to go about performing the proper steps to help them.

      Reply

      • Destria Dawkins
        Oct 02, 2020 @ 11:47:44

        Hi Lilly! I agree that gathering as much information as possible in the early sessions, can help paint a clear picture of what is really going on in the client’s life.

        Reply

  2. Bibi
    Sep 28, 2020 @ 14:02:13

    1. I think it is important to understand the client’s problems early in therapy because you want to develop a plan based around those problems. If you spend too much time in therapy on the wrong thing (or you assume something minor is the primary problem) then you end up not being as effective in therapy. Hill talks a lot about using the exploration stage for this purpose of learning about what your client’s presenting complaint is so that then you can later develop a therapy plan. You also need to assess to find out if your client is at risk for suicide or using substances because those can significantly affect how you respond and create your treatment plan.
    2. I think that I would be really worried about failing to recognize a suicidal patient. I have read a lot in other courses about ethical responsibility in identifying suicidal patients and I think my biggest worry would be deeming that someone isn’t at risk when they are, which could result in an avoidable death. I just worry about failing to notice something important.

    Reply

    • Viviana
      Sep 30, 2020 @ 20:22:10

      Yes, Bibi, the development of the treatment plan is imperative for therapy and as clinicians is a huge responsibility to create these plans since the beginning of the sessions. Spending too much time in a topic that is not eve relevant to the major issue, the client could distrust the clinician and the therapeutic relationship would be damaged. Consequently, the effectiveness of the treatment is not as expected. Sessions usually last within 45 to 60 mins, I wonder the set of skills a clinician needs to have to create the space for a therapeutic rapport and maybe time to assess suicidal risk or substance abuse as the first assessment could potentially minimize the risk of suicide if an immediate intervention is given after obtaining the evaluation results.

      Reply

    • Destria Dawkins
      Oct 01, 2020 @ 20:36:25

      Hi Bibi! I agree that it is important to recognize the client’s problem earlier rather than later because if not, you could end up not being as effective as you intend to be with your client. As a professional, you cannot ignore any details that your client discloses to you in the early sessions because you could possibly miss pieces of information that could be useful in helping the client.

      Reply

  3. Anne Marie
    Sep 28, 2020 @ 18:42:21

    It’s important to get an accurate understanding of client problems early on in therapy so that you can work with the client to develop meaningful goals. A measurable goal will help lead strategies to achieve them. It will also give you a baseline to work from to know if you are making effective change or not. Therapy can lack focus and direction if you don’t establish why a client is seeking treatment. It is just as important to create steps to address it.

    For me, suicide is the ultimate fear. The idea that as a clinician I could have missed something that could have led to more appropriate interventions is very scary. Currently, I work in the school system so I have a team of people to collaborate with if there is a concern. My fear is that if I ever work in a private practice I may not have that same level of support. I am not afraid to ask uncomfortable questions about suicide or suicidal ideation which is a strength. However, I would be devastated if someone I was treating attempted or committed suicide.

    Reply

    • Abby Robinson
      Sep 30, 2020 @ 12:55:11

      Hi Anne Marie,
      I completely feel the same way about assessing a suicidal client. I also mentioned that I am nervous about critical information in a suicidal client and have a negative outcome. Something I have read in a text for another class, though, is that if you are worried about information about a client or uncomfortable about something, you can always ask your supervisor for more information or ask them for some advise. I think that this would be helpful when dealing with a suicidal client because you’s have another professional to collaborate with.

      Reply

  4. Abby Robinson
    Sep 30, 2020 @ 12:36:33

    My understanding of why it is important to get an accurate understanding of my client’s problems early in therapy is that it’s very important to start to develop a relationship from the beginning sessions. The relationship is very important in therapy because I want my client to trust me to share their personal feelings with me and not feel judged. If there is a strong relationship my clients may be open to changing the problems more so than if they didn’t feel comfortable with me. Also, it is important to get an accurate understanding of client problems so I can understand where the problems are coming from. With a deep understanding of problems and in what context they occur, I will be able to develop appropriate goals and treatment plans. It is also important to note the severity of the problems in my client’s early sessions so there isn’t a negative outcome later on or there is no development of more problems later on too. This shows that there needs to be a balance of building a relationship and also gathering information in the first sessions with a client. This can help provide the best, most appropriate treatment plan.
    My concern with assessing a suicidal client is that I won’t see the severity of the problems. I am nervous that if I miss critical information in the sessions that may lead to a negative outcome that I could’ve assessed or prevented. This stems from being uncomfortable to ask certain questions about suicidal thoughts to a client. I am worried about getting uncomfortable or not confronting my client about suicidal thoughts.

    Reply

    • Elizabeth Baker
      Sep 30, 2020 @ 15:49:58

      Hello Abby,
      Your point about having a strong therapeutic relationship with clients is the first and most important step. Building rapport with clients can help them feel more at ease with their helper, and lets them understand that they are in an inviting and non-judgmental space, which can help them communicate their situation. It’s important for the client to feel like they can communicate their situation to their helpers without feeling like they have to filter important information out, in fear of possibly upsetting or offending the helper. That way, as you said, the helper can come being to create specific treatment plans that can help the client.
      Your worries about confronting a suicidal client are some of my worries as well. The book explains what signs to look for when discussing or observing a client who’s suicidal or potentially suicidal, but actually experiencing that process can be more difficult. I hope as we continue with courses that educate us on how to support suicidal clients, have internships where we can shadow helpers who are experiencing therapeutic relationships with suicidal clients, and future first-hand experiences with suicidal clients, that we feel more confident in our skills as helpers and are able to push our doubts aside and focus on using our skills to best support our clients.

      Reply

  5. Connor Belland
    Sep 30, 2020 @ 13:18:03

    Its very important to get a good understanding of a clients background early on in the therapy process. Gathering as much important background information on a client as early as possible in therapy or an intake is ideal for an effective therapy session with the client. Knowing specific details about a client will help you build their treatment plan around those details. The clients therapy should be based upon their specific needs and problems and they should be treated accordingly. You also want to do this to make sure you are treating the most immediate problem in the clients life first and get to know where some of these problems might be coming from. Gathering this information early is also important because it helps build a stronger relationship with the client and we all know how important it is to have a strong rapport with a client to improve the effectiveness of therapy sessions. You want to really know the client your working with if you want to effectively help them.
    Working with a client that is suicidal is definitely pretty scary to me. I worry about not seeing a sign of suicidality and missing something crucial that could end badly for the client. I also worry about when I do see the client is suicidal and I am not able to effectively counsel them so that they don’t attempt suicide. It is definitely uncomfortable for me to talk about suicide about with clients but I think I will be able to do it when I need too, I am worried that I may try to avoid it in some cases though when it shouldn’t be avoided.

    Reply

    • Elizabeth Baker
      Sep 30, 2020 @ 15:24:06

      Hello Connor,
      Knowing how to gain relevant information from clients to gain an accurate understanding of their problems is so important. The initial interview stage is probably the most nerve-wracking for both the client and the helper, so having reliable material that can help the helper structure their interview to best gain information that helps in understanding the client’s problems.
      You make good points about worries with being confronted with a suicidal client. I wonder if our worries come from a place of feeling incompetent, since we haven’t had much or any experience with helping someone who’s suicidal or having enough information to be able to properly support them. I can say that from my own experience dealing with a friend who was suicidal, I felt like I was to blame since I didn’t know what to say or do to help him, or I would say the wrong thing and make him upset. I hope we can all support one another with gaining more information on how to help clients who are experiencing suicidal ideation or suicide attempts.

      Reply

    • Destria Dawkins
      Oct 02, 2020 @ 11:42:49

      Hi Connor! I definitely agree that is very important to gather as much information about the client as you can, early on because each client is unique. I agree that knowing specific information about each client can help professionals treat the immediate problems in each client’s life. For example, not every client you see will be experiencing the same type of depressive symptoms at the same time. One client might be suffering from lack of energy and insomnia due to depression, while another client is dealing with suicidal thoughts and cutting. I also agree that it is important to treat each client according to their specific needs because it does help build a stronger therapeutic relationship. I also agree that working with clients who are suicidal can be scary, especially for us beginners in the field! I also worry that I may miss important details and fail at helping the client.

      Reply

  6. Elizabeth Baker
    Sep 30, 2020 @ 14:58:35

    1) My understanding on the importance of getting an accurate understanding of the client’s problems early in the therapeutic experience is that doing so allows helpers to best guide the client’s through understanding their situation; it also helps helpers predicting future assessments that can be used to come to a future/potential diagnosis. Helpers should make sure that they have an accurate understanding, so they don’t provide unhelpful support and deter clients from continuing the therapeutic experience. In other words, it’s important to gather relevant information to help clients who are experiencing depression, substance abuse, suicidal ideation or attempts, to get immediate support. Clients who don’t receive immediate help may resolve to risky behaviors that can harm themselves and others. Gaining an accurate understanding of the client’s may also decrease the chances of preventable death.
    2) My concern about confronting a suicidal client is that I won’t be able to properly support them. I know we will be trained on how to support suicidal or potentially suicidal clients, but my worry is that I won’t be able to get through to them. Failing to pick up on the signs of a suicidal client, changing my facial expression when it comes to something as serious as this and potentially upsetting or offending the client, saying or asking a question that unintentionally upsets or offends the client, or not being able to know what to say are also worries of mine.

    Reply

    • Elizabeth Baker
      Sep 30, 2020 @ 15:40:44

      I want to correct something I’ve said. Instead of saying that having an accurate understanding can help chose future assessments that will be helpful with potential diagnosis, I want to add that it will also help with creating future treatment plans as well.

      Reply

    • Beth Martin
      Sep 30, 2020 @ 20:44:16

      Hi Elizabeth!

      You make a great point on the immediacy aspect! I hadn’t necessarily focused on that from the reading, but your explanation highlighted for me how important it is to quickly (but accurately) get to the issues for clients. No matter how strong a therapeutic relationship is otherwise, I think not getting answers for a long period of time would make me second-guess whether I wanted to be in therapy.

      I feel the same about worrying if we say the wrong thing to a suicidal client too! I’m sure we’ll get more confident and deliberate in our communication throughout the program, but I do worry that if I say the wrong thing at the wrong time, it’ll just make things worse for the client.

      Thanks for posting!

      Reply

    • Maya Lopez
      Oct 01, 2020 @ 17:07:38

      Hey Elizabeth,
      I really like that you touched on the fact that helpers are helping the client to understand their situation and guide them through the process of healing. The therapist wouldn’t be able to do this if they didn’t have an accurate perception of the disease and symptoms but also how to recognize it in a client. I remember hearing about that in the lecture that it will make us come across as more confident and competent to be able to explain what we think is occurring with the client. I also agree with the last sentence you said in that the more we can accurately understand what the client is going through the better the treatment plan we can formulate to help prevent suicide from occurring. It is certainly very nerve-wracking to picture us now as helpers with a suicidal client as I am weary as you are, that one slight mistake could push them over the ledge. I often worry that therapists seem to always be the last stop for help for those who are suicidal and that we cannot tell them “oh you should really talk to somebody about how your feeling” because we are those people who are supposed to talk them down from the edge. I’m sure in time we feel more comfortable in what to do during those situations with suicidal clients but for now, the unknown seems scary. And at that, I know we may feel more competent in what to say with these clients but I’m sure it is one of those things that will always be hard.

      Reply

  7. Viviana
    Sep 30, 2020 @ 20:12:19

    1)It is important to get an accurate understanding of the client’s problems early in therapy because it creates a positive therapeutic platform for both the therapist and the client. A positive clinical environment needs to have clear understanding and expectations since the beginning in order to have a good therapeutic report. When the client feels his needs are being heard and understood, the results bring long and positive effect. It is also important for the clinician to assess the severity of the problem as a safety plan might need to be created to mitigate the risk suicide, for example, until further sessions. Also, when the therapist conceptualizes the client’s specific issues since early in therapy, following sessions could be more effective as concrete and well-stablished goals and objectives were created since the initial session.

    2) As a beginning therapist and having to assess suicide would be extremely anxious. Just the thought if as the clinician could’ve asked certain questions to prevent it or if I missed critical cues during sessions that could’ve helped the client to take another approach. Throughout the master I am sure I will get trained and educated to assess suicidal risk and learn how to ask questions and investigate if whether there were suicidal attempts in the past or even if there are suicidal ideation in the present. As it was presented in the lecture, suicide is a major public health concern and it is the leading cause of death in USA, so the chances for me to have a suicidal client is pretty high and I want to be ready and well trained to reduce the risk.

    Reply

    • Beth Martin
      Sep 30, 2020 @ 20:41:14

      Hi Vivianna!

      I think the anxiety you describe about second guessing yourself is certainly something I would worry about too (but couldn’t find words for). It sounds like you’re mindful of it, though, and like you said, hopefully we’ll be well-prepared for encountering these clients when we’re done with the program!

      I was surprised to read that some counselors will underestimate the severity of their clients issues, and I’m wondering if that contributes to the high suicide rates you’ve mentioned. I know a considerable amount of people who struggle do not seek help, but I can imagine that, if you are seeking help and your counselor hasn’t accurately understood how much you’re hurting, it has to be incredibly disheartening/alienating.
      Thanks for posting!

      Reply

  8. Beth Martin
    Sep 30, 2020 @ 20:38:10

    I believe it is important to get an accurate understanding of the client’s problems early in therapy as it makes sure that a counselor is treating the problem the client wants help with. Some individuals can present with multiple issues, and they can also underestimate the severity of their uses. Some individuals may have multiple problems, but only feel like they need help in one specific area; counselors should focus on the most immediate concern. If a counselor has a good and accurate understanding of what the client is having issues with and wants help with, this means they can tailor assessment and therapy accurately. Otherwise, you run the risk of ignoring your client’s needs, which will make it incredibly difficult to keep a client in therapy, or build a therapeutic relationship. This relationship is crucial in helping clients to trust you, feel like they won’t be judged, and openly communicate their issues (both personal and within the session). Additionally, having an accurate understanding of the client’s problems means that you have an accurate baseline on which to measure progress. You cannot accurately assess how a client has improved (or regressed) if you were inaccurately measuring the severity of their issues to begin with. This also allows counselors to set realistic goals. If you are underestimated how severe issues are, you may expect more improvement from a client than they are currently capable of. Doing otherwise may prevent clients from seeking help in the future, so it’s incredibly important that they feel like they are being listened to, and that clinicians are accurate in their assessments.

    My concern about confronting a suicidal client is that I won’t be able to do enough to help. I’m sure, once I’ve received training, I’ll feel more confident in this, but right now I cannot possibly fathom what I can say or do to support an individual through that in a professional capacity. I also concerned that I’ll get a strong emotional response (too strong, perhaps) and that I’ll lose a bit of objectivity. I’m fairly good at leaving work at work, but when I’ve had experiences with clients that are in danger, I find it incredibly hard to not worry about them when I’m at home. I imagine I’ll have that issue the first few times I encounter suicidal clients, and that worry may make me lose sight of what’s necessarily best for them, even if they may not want it (hospitalization, reaching out to family etc.).

    Reply

    • Tanya Nair
      Sep 30, 2020 @ 21:14:37

      Hi Beth! Thank you for your post. I like how you brought up the point about individuals presenting with multiple issues and clinicians focusing on a specific area. I did not consider that individuals may have multiple problems but only consider getting help for one area. I think this makes it important for clinicians to realize the main problem as one of their problems may be closely related to another. It appears you have understood your strengths and weaknesses through this discussion. I am certain that after practice in our internships/practicums that we will feel ready and know how to act professionally when we are in such situations.

      Reply

    • Lilly Brochu
      Oct 01, 2020 @ 18:08:07

      Hi Beth,
      I totally agree with everything you said about the importance of building a comfortable and nonjudgmental atmosphere in the therapeutic relationship. If there is an uneasiness or awkwardness about the relationship, this could have a negative outcome for the client as they try to open up and express their problems and concerns. This could lead the therapist to be unaware of any underlying problems, or even a misdiagnosis. By exercising a comfortable, transparent, and honest therapeutic relationship, this could provide a more accurate measurement of the client and their progress. As for your feelings about attending to a suicidal client, I share the same feelings as you. I feel as though at this point in my life, it would be difficult to help them fully, but with training, I would feel much more confident. Additionally, I have trouble letting go of work when I’m at home, but I know how important it is to separate the two for the sake of our own mental health. I hope that through our program, we will learn how to unpack our feelings from work in a healthy way instead of letting it overshadow other areas of our life.

      Reply

  9. Tanya Nair
    Sep 30, 2020 @ 21:06:56

    It is important as clinicians to understand the client’s problems early in therapy as it predicts long-term positive results. For instance, building positive relationships early on will better allow the clinician to understand the client more thoroughly. It also has a significant influence on outcome because understanding problems earlier will allow the clinician to treat the problem earlier as well. The severity, duration, and the motivation of the client to change are all important aspects that the clinician needs to know early in the therapeutic relationship in order to make informed decisions about treatment plans and goals. As a beginning therapist, the thought of assessing suicide seems scary. I fear that being nervous in the session may come off as reserved making my client reluctant to sharing information with me. For instance, both verbal and non-verbal behaviors are important to making sure the client is comfortable. I also have concern about making sure I can catch when a patient is suicidal and not misjudging them. My ultimate fear is if one of my patients commits or attempts suicide. I feel as though I would be devasted and guilty that maybe I could have done something better to treat them.

    Reply

    • Cailee Norton
      Oct 01, 2020 @ 13:37:54

      Tanya,

      I think your fears are completely understandable. It would be heartbreaking if such an occurrence were to happen. I think we place a lot of pressure on ourselves as beginning helpers and it can be overwhelming to see the vast possibilities of what could walk through our doors. Suicidal thoughts are something that we will be confronted with (especially as Dr. V says when, not if), however I think that these skills we are learning here are important to catching a patient, as you say. I love that you say that verbal and nonverbal cues are important to pay attention to, because I think some clients say one thing and really show something else with their body language, pace of speech, or even eye contact. Picking up these little hints are the best way for us to “catch” such possible clients, and I’m really glad we’re able to discuss these concerns and learn techniques and measures to take in order to provide the best level of care in which we hopefully won’t underestimate the severity of our clients problems. Great job on your post!

      Reply

    • Elias Pinto-Hernandez
      Oct 02, 2020 @ 10:46:43

      Hi Tanya, we agree on how critical it is for the therapist to gather the most relevant data and to understand the client’s situations in early sessions. I believe that is the clinician’s responsibility to collect the information in a way that assists them in developing a case conceptualization, treatment plan, and treatment sessions. In addition, it will also help build rapport and respect if the client understands that the therapist is following a scientific methodology and not just chatting.

      Reply

  10. Lilly Brochu
    Sep 30, 2020 @ 21:18:43

    Generally, when a client comes to counseling, they are experiencing many thoughts and feelings that involve different contexts spanning across several experiences of their life. Clients may be overwhelmed or unsure of how to put their thoughts and feelings into words. Additionally, they can be vague, or they are just not ready or trusting enough to disclose their problem(s) to the therapist. One of the most important steps in setting the foundation for the relationship is establishing a positive and safe space for the client to be honest and open about how they are thinking and feeling. If the therapist fails to do this early on, this can affect the therapeutic relationship negatively and may lead the client to stop attending sessions in the future. However, by getting a grasp on the client’s problems early on in therapy, the therapist can collaborate with the client to establish long-term goals and can provide the tools they need along the way. If the therapist collects enough background information on the client as well as focusing on the client’s current concerns, the therapist is able to create a strong and efficient therapy plan going forward with the client.

    One of the major concerns I have regarding being confronted with a suicidal client is the possibility that I may fail to recognize the client’s struggle, and thoughts and feelings of suicide. I also worry that the client may have difficulty being honest about communicating their suicidal thoughts and feelings to me, and that they would hide from themselves rather than being open about what it is like for them. I would be nervous that the client would ignore their own feelings to “appease” or reassure me that they are “okay”. When being confronted with this situation, I hope that I am able to really help someone and can be the support system they need. I am intimidated by working with a suicidal client, but I have confidence that I will be able to handle it appropriately when the time comes.

    Reply

    • Lina Boothby-Zapata
      Sep 30, 2020 @ 21:31:46

      POST

      Dr. V’s recording/lecture highlights the following information; the importance of defining the client’s problem is to develop a stable case formulation eventually and that will trace the direction for the treatment goals and interventions. I see defining the client’s problems like the initial foundations to begin construction; however, the case formulation is malleable over time as new information is learned. Dr. V also highlights the effects of underestimating the client’s problems can result in a negative outcome. In summary, accurately defining the client’s problem is crucial because it will allow the counselor to obtain a solid case formulation, diagnosis and will provide the content and the direction for the treatment plan, goals, and intervention. The reading and the recording/lectures explain that during these initial sessions, two circumstances are happening simultaneously. The counselor is building the initial rapport with the client to create a relationship (transference – contra transference) that will maintain the therapy process, and the counselor is assessing the client’s problems, answering why he/she is coming to therapy. If the counselor can’t grasp the real problem, then the therapeutic process lost direction because the content that was provided and gathered to create the case formulations, treatment plan, and goals is not correct. As a consequence, the therapy process lost direction.

      Dr. Whiston stated that there are specific problems that they need to be assessed during the initial sessions; Depression, Suicidal Potential, and Substance Abuse, carelessness about the exploration of these topics could be detrimental for the client and the therapeutic process. With the clinical vignette provided by Dr. Whiston related to Suicidal Ideation, I found it overwhelming; I thought that the counselor needs to ask these questions about suicidal thoughts, plans, previous attempts, and access to lethal objects. I believe that the counselor needs to have a lot of clinical experience to have these difficult conversations with the client and decide what type of intervention is necessary at that moment. In the vignette, I thought about this counselor doing a “Safety Plan” and crisis intervention with his/her client. Another thought was that the counselor needs to assess and answer questions such as; Should I call the police and ask them to file a Section 12 or 35 for this client? Does my client need to be referred to ER-DMH? How to calculate that this information can be confidential? Should I consult with the interdisciplinary clinical team if I have one or at least the client’s psychiatric or my Supervisor? Should I reach out to the client’s family members? And finally, with the support of my Supervisor will be fundamental to have a clear plan about what to do if an emergency happens and complete a thorough assessment and continuously utilize instruments such as hopeless scale cand suicidal ideation at least until the client is stable.

      Reply

      • Tanya Nair
        Oct 01, 2020 @ 10:52:36

        Hi Lina! Thank you for your post. Yes, it is important to build a therapeutic relationship as a foundation to begin treatment. I enjoy how you bring up your work experience and expertise by including things you may have done at DCF as multiple questions here. I think it relates very closely and gives you good experience when working in the future with people going through suicide attempts or thoughts. It appears that you have a good background to know what to do in such situations as shown by your thought process. I am also hoping to feel confident after taking a few more classes and engaging in the practicum/internship section of the Clinical Counseling program.

        Reply

        • Lina Boothby-Zapata
          Oct 01, 2020 @ 15:35:30

          Hi Tanya, thanks for being so kind 🙂 I really did all these questions because in these types of situations you want to make sure that you are covering all your basis, perhaps you end it up being subpoena by the court and I guess you would like to say to the judge that you did everything that you could to help this individual.

          Reply

      • Tayler Weathers
        Oct 01, 2020 @ 14:47:42

        Lina, you’re right that it seems overwhelming! I would assume most places we’ll work would have a protocol, but calling the police is a good question. What level of reaction is going to not only protect the client but also protect the therapeutic relationship? I’d be worried that if I do something that feels drastic, like call the police, and they detain the client or otherwise act in an obvious and maybe startling way, the client won’t feel comfortable with me anymore. But how do we balance that with actual concern for a client’s safety? In my experience in counseling centers, “safety plans” are okay, but they aren’t perfect – most of the time, I’ve just seen worksheets like “what will I do when I’m stressed? Who can I go to for help?” with phone numbers and action steps. They’re a good reminder for a client, but what if the client still chooses not to engage in any of the steps? It would also be tough if you had no idea this was happening until much later – I feel like that would be overwhelming, too!

        Reply

        • Lina Boothby-Zapata
          Oct 01, 2020 @ 15:55:02

          Hi Tayler, thanks for your comments!
          I believe that having a drastic decision like call the police, for sure will affect our therapeutic relationship with the client. If my assessment is right as a counselor in filing a Section 12 then I will be okay with the client’s reaction because during this moment I am weighing between the client’s safety or the therapeutic relationship. If I may, when I say to call the police/ambulance is not to incarcerate the client, is with the intention of calling for an assistant to transport my client to the hospital and filing Section12 these petitions can be requested by police, nurses, physicians, LICSW social workers, and LMHC counselors. Then ER at the hospital assessed and referred the client to a Mental Health Hospital. I understand that this could be an extreme and random situation but DCF receives cases where mothers are being sectioned 12 after they give birth and the newborn is being removed from the hospital and given into DCF custody. I guess Doctor V can talk more about this process, personally, I have witness Section35 the only difference is that family members filing in Probate court.

          Reply

      • Anne Marie
        Oct 03, 2020 @ 17:14:50

        Hi Lina, I thought you brought up important points including that the information that you initially receive from a client may be reshaped as you obtain new details. Digging deeper to what is going on for a client can be critical in formulating measurable goals. I also thought that mentioning that normalizing a clients symptoms can be trivializing is accurate. While therapists may be inclined to downplay symptoms, I think it takes a lot for people to seek out treatment and the reason for doing so is usually significant. I found it alarming that the majority of clinicians will work with a suicidal client at some point. I agree with you that assessing for safety and determining the level of severity would be intense.

        Reply

    • Zoe DiPinto
      Oct 01, 2020 @ 13:14:52

      Hey Lilly, you make a great point that I forgot to include in my own response about the importance of acquiring all the contextual information around the client as part of the initial identification of problems. Of course it is important to gather information about the problems that lead a client to seek therapy, but before jumping into creating a treatment plan immediately, a clinician must gather all the background information to create viable interventions and goals that are specific to their experience. You raised a great point and made me think about how this process must differ depending on the individual.

      Reply

    • Tim Cody
      Oct 03, 2020 @ 20:54:50

      Hi Lilly,

      I really liked your response one establishing rapport with your client in order ensure long term goals in the therapeutic relationship. It is difficult to display an open atmosphere that encourages honesty and openness in the first few minutes of the therapeutic session, but by letting the client control their thoughts and emotions, they are able to guide the therapy how they see fit while the counselor provides their feedback and encouragement along the way. This will allow any client who approaches you with suicidal thoughts or actions to be open with you about their experiences. It is okay to feel nervous with these patients, and it is important to know that you are not alone in the process. Do not alone feel that you need to be the one to save the person from their suicidal thoughts and actions, but rather you, other therapists, their family and friends and even the patient themselves will play a role into guiding better thoughts and behavior.

      Reply

  11. Wyndryder11!
    Sep 30, 2020 @ 21:26:20

    It is very important to get an accurate understanding of a client’s problems early in therapy because it allows you to build the best treatment goals for them, as well as, truly gain insight into why they’re seeking therapy. Furthermore, by identifying problems early on you can assess a client’s risk to themselves and others, which is vital information. By understanding the clients problems and their perspective you are able to gain increased awareness of why they are reaching out for therapy, how relationships in their life seem to be going, their medical history, past experiences driving their need for counseling etc. Furthermore, when the client feels heard and understood they are more likely to stick with that counselor and have better success down the road with their treatment. In addition, a client’s problems are not just based on one variable, so it is important to weigh all of their concerns and try to identify where they may be coming from/what is driving them. If they appear to believe that these problems are unfixable or that they do not have the confidence in themselves to create real change, this can completely halt the treatment process. Thus, it is important to give them small goals to focus on that target the main problem/issue causing the most distress, first.
    My main concern when anticipating working with a suicidal client is that I will not say the right thing. This behavior is extremely high risk and if I do not effectively diffuse the situation, so to speak, there could be extreme consequences. I am also concerned that I may lose my counseling skills in the moment, due to my concern over the severity of the situation. I should ideally try to tease out what is provoking this and provide serious intervention, but I am nervous that my mind may freeze and I could end up giving responses that I may give to a friend in panic. Obviously as I learn more behavior specific techniques for suicidal clients I will eventually feel more comfortable with this. However, the responsibility of having someone’s life in your hands is extremely daunting and overwhelming. It also opens the possibility up for self-blame and serious pain if the client were to act on this inclination or intent; causing you to question what you could have done differently.

    Reply

    • Cassie Miller
      Oct 01, 2020 @ 16:26:39

      Hey guys, this is Cassie Miller. For some reason my response posted with this random handle instead of my name. It autocorrected at the last second, but I have no idea where this name came from! Just didn’t want you all to think some weirdo was on the discussion board haha.

      Reply

      • Tim Cody
        Oct 03, 2020 @ 21:06:02

        Hi Cassie,

        My response to your second answer is to know that in these situations, you will never be operating alone. Confidentiality is important, but is also permits you to tell another professional counselor if the patient appears to be a life risk. You will never have to handle someone else’s life in your hands. In fact, Cognitive-Behavioral Therapy teaches that the relationship is a two way street, primarily on the patient. It will be the patient’s responsibility to decide how much they need from you and for you decide through the proper training how much you can help. Even in terms of preparing for patients like this and the fear of not knowing what to do in the moment, you are not alone. Based off of most people’s Blog posts, none of us are entirely comfortable with this topic and are nervous when we face it. So long as you create an environment where the patient feels open and welcomed at the beginning of the session, you will be able to handle all situations accordingly from then on out.

        Reply

  12. Pawel Zawistowski
    Oct 01, 2020 @ 11:35:48

    1. It is important to get an accurate understanding of the client’s problems early in therapy for several reasons. First being, is that the average amount of therapy sessions for clients is between 1-3. Many clients come in just for the intake and maybe a session or two after that and will not feel the need to come back after that. Because of this it is important that therapist begin to build rapport early on. Identifying problems and building a strong and trusting relationship early in the therapy process will encourage the client to come back for future sessions and the client will view the therapist as trustworthy. Identifying the problem early will also allow a therapist to begin to develop a solid case formulation and start thinking about treatment goals and interventions. Having such things in place will give the client a purpose to continue seeking treatment. One thing to keep in mind is that the client has most likely been feeling a certain way (e.g. depressed, anxious, etc.) for a long time before seeking treatment and there has been something that finally motivated them to seek professional help. Seeking information such as the precipitating factors and what they are doing to maintain can give the therapist important insight about how the client is doing and their conflict.
    2. I believe my biggest worry when working with suicidal clients is not being able to apply appropriate intervention or being unable to identify the hinting factors of suicide. I think failing to use an instrument such as the BSS when client has been expressing depressive symptoms and not utilizing such instruments in a timely manner would be one of my biggest concerns. Failing to do so can pose serious harm to the clients as we are responsible for providing the care they need. The risk of suicide for someone I am providing treatment for is anxiety provoking on its own as we share a connection with our client and we are responsible for the treatment they receive. I think I would also worry that I could have done more to help the client and bring such worries home with me and worry about my client when they are not in therapy.

    Reply

    • Zoe DiPinto
      Oct 01, 2020 @ 13:09:12

      Hey Pawel, I think it’s very interesting that your concerns lay in not being able to detect a suicidal patient in the first place. It’s a terrifying thought of having a client commit or attempt suicide that the clinician never suspected of suicidal tendencies. My concerns fell more towards having a client disclose being suicidal and then having thoughts of “okay… what now? Where do we go from here?” Even when we know the client is suicidal, they are still fragile and there is tremendous pressure on clinicians to relieve their pain. I definitely agree that I fear it will be difficult not to worry about clients like these outside of therapy sessions.

      Reply

    • Christina DeMalia
      Oct 03, 2020 @ 21:21:00

      Hi Pawel,

      Your point about bringing your work home with you is a very important one to make. I think that many people get into this field because they care about people and want to help others. So naturally, we are going to be worried about the safety of our clients, especially when we think they might be at risk of committing suicide. Drawing the line between caring immensely about the work we do, but also being sure to not bring our work home with us seems like a difficult task. I’d be interested to see if as our classes progress in this program if we don’t learn more about how to still care, but be able to keep work separate when necessary. Burnout in this field is so high because of the difficulty so many people have with taking work home and feeling personally responsible for the outcome of our clients. I know so many of us talked in our responses about the guilt we may feel if our client were to attempt suicide, so I am definitely looking forward to learning more about how to prevent that in the first place.

      Reply

  13. Zoe DiPinto
    Oct 01, 2020 @ 13:02:44

    1. As the lecture states, it’s important to get an accurate and thorough understanding of a client’s problems as early as possible in therapy. The sooner a therapist can understand a client, the sooner they can collaborate to develop a case and agree upon a treatment plan, interventions, and goals. These can be adjusted as the client continues through therapy and the clinician learns more information. Many people want satisfaction that the money they are spending in therapy is going towards a specific goal. This may encourage clients to stay in therapy for longer. This being said, it’s also important this process is fully thought-through and not rushed.
    2. I’ve thought about what my reaction would be to a suicidal client. Emotions that are likely to present in myself are fear, desperation, and anxiety. I’m still not sure how I would respond to a hopeless client who persistently makes remarks such as “I’m not sure what it’s all for, what’s the point of living?” Like many clinicians, I’m worried I won’t have the answers they are looking for or I may say the wrong thing. There have been a handful of suicidal people I’ve become close to in my life, and as a friend I’m willing to respond with love, warmth, compassion, and conversation. However, I expect a professional’s experience with a person with suicidal tendencies to be different. How will I know if my professional challenges and insights are helping or hurting? What if I am too fragile with the client and hold back important insights out of fear of saying the wrong thing?

    Reply

    • Cailee Norton
      Oct 01, 2020 @ 13:31:08

      Zoe,

      I find it interesting you bring up the differences in the tendencies people would have if a friend presented with suicidal thoughts versus the experience of a professional experiencing a client with suicidal thoughts. I agree that the way you would go about conversing with an individual would be likely very different. You raise a lot of the issues I raised in my post especially that of self-confidence in my abilities to intervene and say the right thing. I think you’re right that there is a different level of conversation that occurs, but I hope that in a professional setting that I would be able to provide an environment in which an individual can bring up a comment about hopelessness (as you mentioned a perfect example) and I’ll have the right skills and insight to use proper assessments and discussion tools that can make a difference. Great job on your post and thank you for sharing your experiences with the topic.

      Reply

    • Tayler Weathers
      Oct 01, 2020 @ 14:48:03

      Zoe, the money element of understanding a client’s problem was a good point! I know in my life if I don’t feel like a doctor or other professional listens, not only am I not likely to go back, but I don’t feel good about having spent money on it. This would especially be of concern in lower income clients, as they don’t have money to “waste.”
      I also think your point about emotions is good. It’s tough to think about being a clinician in that situation because I think I have this idea that once I’m a clinician I’ll know a lot more than I do now (which is true, because training), but that doesn’t mean my knowledge is perfect, or that I still won’t be blindsided by anxiety about my client’s safety!

      Reply

    • Brianna Walls
      Oct 01, 2020 @ 18:33:09

      Hi Zoe! I think it was important that you mentioned that this step in therapy should not be rushed. It is important that you understand the client’s problems and concerns so that you as a therapist can work with the client to overcome them in an affective manner. If the therapist does not understand the client’s issues the client may get nothing good or appropriate out of therapy and therefore be a waste of time for the client and therapist.
      In response to your concerns about a client coming into therapy with suicidal thoughts I too would think that I would feel anxiety, fear, and desperation. As you said I would be afraid that I wouldn’t know what to say or how to react and in return what if I wasn’t helpful to the client at all?

      Reply

  14. Cailee Norton
    Oct 01, 2020 @ 13:23:15

    When looking at the intake process it is vital to get an understanding of what the clients problems are. The book discusses the importance of these initial sessions as they have a big influence on the therapeutic relationship that is developed and fosters true change for that client. The ability for a counselor to conceptualize relevant issues presented by clients must be done with a certain degree of accuracy (to the best of your ability) as well. With your understanding of the clients issues presented, and in finding out these topics through a nonjudgmental and empathetic manner clients are able to fully explore their issues and find coping mechanisms that work for them. One of the things that struck me the most in the book was the idea that one of the biggest reasons counseling can have negative outcomes is through the underestimation of the severity of the client’s problems. By fostering an environment of openness with proper skills in uncovering the relevant issues, the goal is for these negative outcomes to be side stepped in a way. The importance can be clearly connected to clients that bring up issues of suicidal ideations and depression. If these topics are underestimated as a clinician, it is clear the outcome of this could be life and death. By taking great importance to these beginning sessions and gathering information thoroughly we are able to better aid our clients in getting them the help they need as well as deserve.
    I think my concerns about dealing with clients that present as suicidal to be that of my other colleagues. There’s tremendous fear in that I won’t be able to do enough to help that client, that I could have said something incorrectly, that I didn’t know enough skills or techniques to truly help that client. Due to the finality of suicide, I think such fears are completely normal and to be expected. What’s most important is to understand these fears, attend to them, and learn ways in which I would be prepared as much as possible for this instance. It’s important to remember that some struggles take time to uncover, but through being attentive and providing an open space in which clients can feel comfortable disclosing I will hopefully be able to make a difference for such a client.

    Reply

    • Pawel Zawistowski
      Oct 01, 2020 @ 18:24:36

      Hi Cailee, I like that you brought up the point that one of the biggest problems that a client can face in therapy is underestimation of their problems. By doing so the client will not build trust with their therapist and are less likely to come back for another session. I think that it is very important for a therapist to recognize the client’s problem as very much real so that they can build a therapeutic relationship, accurately identify the client’s problems, and begin on developing treatment plans and goals early on.

      Reply

    • Elias Pinto-Hernandez
      Oct 02, 2020 @ 10:45:39

      Hi Cailee,
      We are very concern and even fearful of the suicidal topic. It may be due to the lack of training and experience. Not sure, however, my most significant fear or concern at this point is that the client makes an attempt on his life in front of me. I am currently working as a case manager and about two weeks ago, I met with a client with a suicidal history the client expressed that he was tire of being homeless, and he expressed he would kill himself. The client was speaking in such a way that I assumed it would be something he would do right then and there in front of me. I immediately, contacted the clinic director and informed her of the situation, and before the client left the building, he met with a BH staff. The situation got me thinking. I agree with you, that this is one of the reasons we are here, I believe we would be prepared for this kind of situations.

      Reply

  15. Tayler Weathers
    Oct 01, 2020 @ 14:41:06

    It’s important to get an accurate understanding of the client’s problems early for two reasons. First, a client is not likely to come back if they don’t feel that you understand (or at least are working to understand) their problems. It’s very discouraging to go to a professional and have them not understand you. Second, and most obviously, if you don’t understand the problem, how are you supposed to make a good treatment plan? You can’t treat something you don’t have a good grasp of.
    I think my initial concern when presented with a suicidal client is liability. Obviously, I don’t want a client to commit suicide, and will endeavor to do everything I know to do to prevent that if necessary. Assessments are good because they can help you understand what (if any) action is needed. The problem is, what if the client dies by suicide anyway? Especially early in the process, you may not have a good gauge of how serious an individual is, especially if they are really depressed. So, what do you do if they do die by suicide? What are you liable for? I would like to think that doing all you can will cover you legally, but it’s scary to think you may have missed something, and that will mean you lose your license and career. I think the best way to mitigate that would probably be seek supervision and make sure you cover all your knowledge bases. But what if that still isn’t enough?

    Reply

    • Nicole Giannetto
      Oct 01, 2020 @ 16:53:25

      Hi Tayler! I liked that you brought up assessments when discussing your feelings on dealing with a suicidal client. I feel that checklists and rating skills may be especially useful in these instances so that the clinician can have clear evidence of where their patient falls on a dimensional scale. But of course, like you had mentioned, assessments can’t always predict the outcomes. So if none of the assessments show a big red flag next to experiencing suicidal thoughts or behaviors, than there is a bigger problem that needs to be addressed in order to keep the patient safe and continue through treatment.

      Reply

    • Maya Lopez
      Oct 01, 2020 @ 17:18:31

      Hi Tayler,
      I think the first point you highlight is the most important one. The client will most likely not come back if they do not feel heard or understood. They may feel the therapist is not good and does not know how to handle such situations or themselves. This could make the patient feel even worse about attempting to get help and realizing they should have not attempted to at all. It could make the client feel more alone than they did before. Additionally, as you said, they won’t come back so who knows if they will get the help they deserve. Also, to your second answer, I am a bit taken back because I have never even thought about this. You raise an interesting question that I have not pondered. Now I am wondering, are there legal cases where the therapist was found to have blame in the clients suicide? What were the circumstances? How did it play out? Is this a common thing to occur? Thank you for provoking a differing take and interest!

      Reply

    • Brianna Walls
      Oct 01, 2020 @ 18:52:38

      Hi Tayler! I agree with your point, that if you do not understand the client’s problems or are at least try to understand them the client is going to get discouraged and they most likely won’t come back for a second session. In addition the aspect of therapy is to help the client deal with their problems and if you do not understand them how will you come up with a treatment or goal for them to work towards?
      In response to your concerns about a suicidal client I too think I would be nervous about loosing my license and career (I’m not sure if this can even happen) but in a sense I would feel responsible for the clients death. I want to make sure I do everything in my power to help my client.

      Reply

    • Lina Boothby-Zapata
      Oct 01, 2020 @ 22:37:21

      Hey Tayler, with the questions that you are asking about what will happen if, in effect, the client kills himself. I was wondering as an independent license counselor; is there any protocol that you need to follow or any paperwork that you need to file when these types of circumstances happen. The Mental Health Institutions have their protocol but about when you have your own practice? Just a thought, probably Dr.V can answer this..,

      Reply

  16. Karlena Henry
    Oct 01, 2020 @ 15:20:08

    I think establishing rapport with the client right away is important for a couple of reasons. That initial interview is incredibly important for both participants, but especially for the client. For the client, they need to feel comfortable enough to open up to the practitioner, given they need to reveal inner challenges that are most likely difficult to talk about. If the client feels uncomfortable with the practitioner, they will be less likely to reveal significant issues. Those issues could be the most concerning, and it would limit the practitioner’s ability to form an effective treatment plan. As Dr. V said in his lecture, for many clients, they give up quickly if they do not feel it will be a productive relationship.
    I’ve thought a lot about how difficult working with a suicidal client would be. This especially concerned me while studying during my undergrad. How would I emotionally handle if a client in my care successfully committed suicide? Was it my fault? Was there anything I could have done to prevent it? Since graduating and working in the field, my view has changed. As a therapist (especially someone practicing with CBT) all we can do is give the client tools to deal with their problems and give them a safe space to vent without judgement. If they cannot work through it on their own, anything we do would only delay their efforts. If I believe I did everything I could do to help them and they still took their own life, the true responsibility will not lie with me, but with the client. There will be some remorse, of course (as I am certainly sure I care about my client), but I think it would be manageable.

    Reply

    • Pawel Zawistowski
      Oct 01, 2020 @ 18:35:41

      Hi Karlena,
      I also felt like emotionally dealing with a client who is at risk of suicide may be very difficult for me. I already tend to spend time at home thinking about little mistakes I made at home. I imagine it would be something I spend a lot of time at home thinking about and if I am providing the right care for the client. However, I do disagree with your statement that all therapist do is just give them tools and let them vent out their problems in a safe place. I think our purpose is much bigger than that and part of the therapeutic relationship is helping the client discover what their conflict is, how to work through it, provide a support system, as well as point them to the services that are available to them and much more. But I do agree with your statement that if we have helped the client to the best of our ability, we should not blame ourselves because many things will be out of our control.

      Reply

  17. Maya Lopez
    Oct 01, 2020 @ 15:57:04

    It is so crucial to get an accurate understanding of what the clients presenting problems are and the severity of them. Underestimating the problems could lead to negative outcomes in therapy. We also want to make sure we are not going to have a false negative understanding and think that the client is not depressed, suicidal, or has a substance abuse problem when they really do have one, because overlooking that or not understanding it could lead to death. It also is beneficial to the therapeutic relationship to understand the client’s issues as much as possible in that they will feel heard and understood. The better the therapist can fully get a sense of what problems are occurring in the client’s life, the better they can assess and form a treatment plan
    I am quite nervous when it comes to this because I haven’t had any proper crisis training. I am eager to begin learning how to work with clients who have been through trauma and are in crisis so that I may feel more comfortable. With more knowledge of skills and techniques to use during these critical times I think I would feel much less anxious. For now, I would feel completely unprepared and am happy I still have time and classes to teach me how to be better. I am only nervous because of my lack of knowledge however I know university and books will only teach me so much and most of my learning will come from experience. The part that makes me the most nervous is if I have a client who does commit suicide and how that will make me feel in terms of my confidence and competence as a helper.

    Reply

    • Nicole Giannetto
      Oct 01, 2020 @ 16:49:10

      Hi Maya! I also am a bit apprehensive to how I may fair in a setting where I am dealing with a suicidal or very depressed client. I believe that by practicing how to treat these types of situations, we will become more comfortable as clinicians for sure. I also think it may be anxiety-provoking, because we as clinicians are still individuals who can still feel insecure with presenting our knowledge and applying our skills, but if we acknowledge that the skills we have are important and that we do possess the capabilities to help someone because of our education in psychology, I think it may blow the worries over somewhat.

      Reply

  18. Tim Cody
    Oct 01, 2020 @ 16:04:11

    It is important to know a problem’s clients as soon as possible in order for the counselor to decide going forward how to best help them. First off, the expectation for how the counselor will handle the problem in the initial session will build upon the therapeutic relationship. If the client does not believe that the therapist can correctly handle their problems from the early stages of the sessions, they may be less prone to the idea of receiving additional help from the counselor later on. Trust needs be built early on in the session so that long-term results can be accomplished. Secondly, the therapist’s capabilities to build the therapeutic relationship early on will determine the likelihood of a positive outcome in the long run. Thirdly, it is important for the helper to know if there is more than one underlying problem the client is facing, and knowing that early on will help determine what kind of help they are able to provide to their client. They will not wish to start providing them advice on suicidal thoughts if they learn later on that they are also facing depression. The helper needs to be aware of all underlying mental and medical health issues and other background information in order to provide the most insight to the therapeutic relationship.

    It is interesting that this question has come up this week because recently I was made aware of a student in my Resident Hall who has been contemplating suicide. My initial thoughts are if I am capable of helping him as a Minister in Residence and not a Counselor. I do not know this particular student very well, so I did not wish to just knock on his door and ask him if his suicidal thoughts have subsided. Our relationship is nonexistent and there is no trust between us yet. I also realize that I am not an expert in this area since I am only a Graduate Student. Luckily this student has been referred to the Counseling Services on Campus, is seeking Professional Help, and is not a danger to himself or others on this Campus. But my mind immediately went to what I should be doing and if this sort of situation were to arise in my Professional Career as a counselor in the future. I am nervous about this topic because I know ultimately in Cognitive-Behavioral Therapy, it is not only the Counselor that has a responsibility to the patient’s well-being, but it is also the patient’s responsibility as well, and I am worried if my future patients would have difficulty believing they are in control. How can the Counselor convince or help them to believe that they have control of their lives and destiny and that there is hope? I hope that as time passes, I am more knowledgeable about what to do in these situations and how Counselors and Therapists can best help prevent someone with following through with their suicidal attempts.

    Reply

    • Connor Belland
      Oct 03, 2020 @ 23:21:45

      Hi Tim, I agree with you about the many reasons why gathering an accurate background on a client early in a therapy session. I think it makes for a more effective therapeutic relationship, which is important early on like you mentioned because the client is also evaluating the therapist to see if they would be a good fit, and they are going to want their therapist to take the the time to get to know them so that they can be as helpful as possible as therapy progresses.

      Reply

  19. Nicole Giannetto
    Oct 01, 2020 @ 16:44:07

    1. The more accurate the information a clinician can gather during either the intake session or early sessions, the more likely that treatment will be effective for the client. As clinicians, we want to get a clear idea and understanding of our client”s background, including topics such as their medical history, experience with previous treatments if any, demographic, and severity of and distress experienced from presenting symptoms. This information paints a picture for the clinician and helps to guide them to choose which direction they believe treatment should head. For example, in the 5 Stage Theoretical Model of Change, there are five different stages that clinicians can reference when determining where their client typically falls in their experience with their presenting problems. Some clients may come into an intake session without any awareness that they have a problem, and may have been coerced to go to therapy, while other clients may have sought out therapy because they are “stuck” in the contemplation stage, and need assistance moving to the preparation stage of change.

    2. The thought of having to assess suicide is definitely an anxiety-provoking one. I personally would be afraid of saying the wrong thing that may not be helpful for the client, or worse, it could trigger the client into delving deeper into their suicidal thinking and planning. A clinician who works with a suicidal client, a depressed client, or even a client who suffers from substance abuse problems may find it difficult to carry the load of pain and suffering expressed from a client, even though it isn’t ideal for the clinician to absorb the weight of their client’s problems. The job of the clinician is to empathize and feel for their client, but when they become to attached with these devastating realities, it can negatively impact their effectiveness to treat their client. It can appear hard to separate yourself from focusing on how painful the reality of the situation, so that you can focus on fixing the problem with a clear head, especially since you are in the business of practicing empathy as a clinician.

    Reply

    • Anna Lindgren
      Oct 02, 2020 @ 13:35:53

      Hi Nicole,

      I like that you brought up Prochaska’s Transtheoretical Model. Once we begin seeing clients, I’ll be interested in taking note of what “stage” they are in during intake. I think you’re right that some people will be more aware of their problems than others. For example, someone who is in counseling because of a court mandate might be more likely to be in precontemplation and not think that they have anything to change, because it was an external factor that put them in therapy. My guess is that clients that are intrinsically motivated to change will be in the contemplation or preparation stage and be more open to changing behavior. But of course, no matter what stage the client is at during intake, it will be on us to motivate them to want to change their lives for the better. I’m looking forward to learning some skills for motivating clients in our future classes.

      Thank you for your thoughts!
      Anna

      Reply

  20. Brianna Walls
    Oct 01, 2020 @ 17:41:53

    1. It is crucial that the clinician understands accurately what the client’s problem(s) are early in therapy. One reason is because it is important for the clinician to have a clear understanding of the issues the client is presenting and their concerns so that they can come up with a treatment plan and/or goal. In addition it is extremely important that the clinician does not underestimate the client’s severity of their problem(s). If the clinician underestimates the client’s severity it could result in a negative outcome. It is also important to note that many clients come to therapy seeking help with multiple issues rather than one specific problem. Therefore, it is crucial for the clinician to identify with the client the most important issue in their life and then explore each problem in greater detail one by one. Another reason why it is so important for the clinician to understand the client’s problem(s) is because of how crucial it is to establish rapport. By understanding and listening to the client’s issues this will create a therapeutic relationship within the client and clinician. If there is no rapport between the two individuals then therapy sessions may be a waste of time. This is because the client may think the clinician either doesn’t understand them or doesn’t want to help them.
    2. One of my concerns about being confronted by a suicidal client is failing to recognize that my client is suicidal or failing to recognize the severity of the client’s suicidal ideation. I would feel like a complete failure if I heard one of my clients successfully committed suicide because they came to me for help and I failed them. I would feel like there was something I could have done to prevent this outcome. Another concern I have is deciding whether or not I should report/admit a patient. Hopefully with more training and learning about this situation it will become clearer to me on how to react to a suicidal client.

    Reply

    • Cassie Miller
      Oct 03, 2020 @ 12:39:22

      Hi Brianna,

      I think that this underestimation of a client’s problems that you bring up in your response is something that needs to be talked about. Much like our class discussion of false negatives and false positives, sometimes, depending on the situation, it is better that we look at a client’s problems in one of these ways. For example, with suicidal ideation it is much better that we make a false positive error, thinking that they are suicidal, than ruling them out as a false negative, which can put them directly in harms way. As far as this goes it is much better to be safe than sorry. There is also so much pressure on a clinician to “get it right” so to speak, which can create a lot of stress for them, possibly making them question their own decisions. The more experience we get, however, the more confidence we will gain in our own interpretations of assessments.

      Reply

  21. Carly Moris
    Oct 01, 2020 @ 18:07:22

    It is important to have an accurate understanding of the clients problems early in therapy because how you begin therapy is critical to the eventual effectiveness of counseling. Research has shown that the expectations clients build during initial sessions have a significant impact on the outcome. You want to make sure you addressing the clients presenting concerns, and make them feel like they are being heard and understood. The majority of clients only attended one to two sessions, so gaining an accurate understanding early on is crucial for establishing a therapeutic relationship and getting them to continue therapy. Addressing a clients presenting concerns have also been associated with better treatment outcomes. You also want to have an accurate understanding of the clients problems early on so you can determine the course of treatment. Many clients present with multiple problems so it is important to gather information about each major problem, so that you prioritize their order of treatment. It is also important to have an accurate understanding of what stage of change the client is in. Different clients will enter therapy at different levels of readiness for change. Research shows that tailoring your approach to treatment based on the clients stage of change significantly increases the likelihood of clients returning for more sessions.

    One of my biggest concerns about being confronted with a suicidal client is how do I know if the intervention I use is successful. I know it’s important not to let your client leave if you think they are going to kill themselves and that you want to make sure they are not going to commit suicide before they leave. But how do you make sure? If your client is at risk for suicide how do you know when it’s safe to send them home or if they should be sent to in patient care? This can have a huge impact on the persons life. If you send them home when you shouldn’t there is a chance they may kill themselves. But committing them to inpatient care can have negative consequences too. Another concern I have is what to do if someone is using suicide as a threat to manipulate the therapeutic relationship. I realize that is is probably not common and that all suicide threats need to be taken seriously. But I have known people who have threatened to kill themselves after a fight, or made comments about suicide if things didn’t go their way. How should this be handled in a therapeutic relationship because you want to make sure your client is okay, but you also need to set clear boundaries.

    Reply

    • Alexa Berry
      Oct 03, 2020 @ 20:38:19

      Hi Carly,

      I liked the point you brought up about how clients expectations for therapy are built during the initial sessions. This was something that stood out to me as well when i was reviewing the material. I thought that generally clients built their expectations about therapy before they went in and if the therapist didn’t meet their expectations then they did not return for more sessions. Your concern regarding the uncertainty of interventions when working with suicidal clients was interesting to me because it wasn’t something I had considered myself. Hopefully you will feel confident in the interventions you are using and will have support from other clinicians!

      Reply

  22. Anna Lindgren
    Oct 01, 2020 @ 18:35:05

    It is crucial to gather plenty of information about the client’s problems in the first session or two because on average, people only come to therapy for 1-3 sessions. Evidence has shown that therapeutic outcome can be largely predicated on the success of early sessions, based both on how much information the clinician is able to gather about the client’s problems and how strong the therapeutic relationship is. So it’s important to balance getting the information that you need and also making sure that the client feels comfortable, supported, and that they are being treated with empathy. The last thing you want is for them to feel like they are being cross-examined so you can get the information in an unsupportive way.

    My biggest concern for encountering a suicidal client is knowing how to react and saying the right thing. I would hate to be caught off guard by their disclosure and react in a way that was harmful to the therapeutic relationship, make them lose trust in me, or make them feel bad for having shared that. Beyond that initial moment and reaction, if I were to implement some treatments and interventions that seemed to work for the client, I think I would always have a little worry in the back of my head about them. I wouldn’t want to “take my work home with me” so to speak, but I think with something like suicide it would be hard for me to not think about it outside of work if I had a severely suicidal client. An even worse situation to imagine is that they end up committing suicide. I can only imagine that would be a really hard thing to cope with, and not feel like you as their counselor had failed them. I’m sure that throughout the program we’ll learn ways of separating work life from our personal life effectively in this regard.

    Reply

    • Cassie Miller
      Oct 03, 2020 @ 12:32:10

      Hi Anna,
      I think that it is so important that you brought up the average number of counseling sessions in your response. This really helps to reinforce why the initial session is crucial to a clients progress. If it does not go well, they may seek out another counselor immediately, or lose their motivation to find proper counseling to begin with. Furthermore, I like your discussion about being personable. There is such a balance when relaying assessment information, since you are trying to be both respectful and empathetic, as well as, informative and clear.
      When you discuss having a suicidal client you bring up an important variable, “taking work home with you.” In this line of work it is so hard to not leave work at work. You really have to establish a boundary for yourself in so that you are compassionate towards your client, but do not take complete responsibility for their actions. You can do what you can in the moment, but it will start to have negative effects on your own well-being if you cannot allow yourself to let certain things go. This is much easier said than done.

      Reply

  23. Christina DeMalia
    Oct 01, 2020 @ 18:38:52

    (1)
    It is important to gain an accurate understanding of a client’s problems early on in the therapy setting because many of the outcomes for that client can depend on how well the problems were identified and understood during those early sessions. Attending to a client’s presenting concerns is connected with effective outcomes, but this means the severity and specifics of those presenting concerns should be fully understood. A client will likely have multiple issues rather than one specific problem, so if only one or some of those issues are addressed rather than all, the outcomes could be worse. There could also be negative outcomes from therapy if the significance of those problems are underestimated.

    Gathering specific information about the problems they are facing and gaining multiple perspectives when possible can help in better understanding their problems. A client may have a personality disorder that makes it hard for them to identify some problems, whereas a family member may be more consciously aware of the effects it is having on the client. Also obtaining information about how the client feels about the problems, how much they believe they can change, and how they have tried dealing with the problems in the past will allow the counselor to better determine a treatment plan. Understanding the problems and their scope early on will help to prioritize the problems by which requires the most attention first.

    If a problem is overlooked in the intake and early sessions, it could result in the client not receiving the treatment they most need. This is a serious issue no matter what the overlooked problem is, because no matter what it means the client’s treatment is being hindered by the lack of information or attention. However, some issues could have more significant negative results than others. If someone is suicidal and that is overlooked initially, the client may attempt suicide when that attempt could have otherwise been prevented.

    (2)
    For myself, when I was presented with suicidal clients was as early as 5 years ago. As an 18 year old residential clinical counselor, I was often in positions of dealing with suicidal clients despite the severe lack of training I had regarding it. Due to lack of funds, administrative support, and clinicians on call, I was faced with dealing with people stating suicidal intents as well as carrying out suicide attempts extremely often. This was definitely something that was very anxiety provoking, emotional, and terrifying at times. However, the one advantage to that is I am now able to remain very calm when someone tells me they are having suicidal thoughts or intend to commit suicide. With the nerves gone, it was easier for me to follow protocol and get them the help and support they needed as quickly as possible.

    Although my previous experience calmed my nerves in some ways, I am most nervous about how different my role would be as the professional clinician/therapist. In my previous role, if someone said something like “I want to kill myself” I was not only able to, but required to place them on a safety status. This meant removing everything from their room, having them in eyesight at all times, even watching them shower from the other side of a bathroom stall or talking to them and keeping constant verbal contact while they used the bathroom. This gave me some reassurance because I was able to immediately stop them if they tried to harm themselves in any way. In the role of a therapist, I would be most worried about learning of suicidal ideation from my client, such as them scoring high on an assessment, and then letting them leave the session. I know that there are steps that can be taken if the threat of them committing suicide seems immediate. My biggest fear would be knowing the client is suicidal, but them not showing enough signs for immediate action, and that client later attempting to commit suicide. I think I would have a hard time not feeling guilt or like I should have done more.

    Reply

    • Anna Lindgren
      Oct 02, 2020 @ 13:15:45

      Hi Christina,

      Wow, that previous experience does sound like it would be really valuable in treating suicidal clients in the future. I can relate to the nervousness of being the “one in charge” in those situations, but luckily based on what I’ve heard, when we’re working pre-licensure I think we’ll still be reporting suicidal thoughts to our supervisors for help with implementing a plan. But I get the feeling that it’s never an easy situation, and I think you’re right that the hardest thing would be working with someone outpatient who has suicidal thoughts because they can’t be monitored.

      Thanks for your insights!
      Anna

      Reply

    • Alexa Berry
      Oct 03, 2020 @ 20:21:43

      Hi Christina,

      It sounds like your previous experience was really beneficial to your ability to work with suicidal clients in the future. I’m sorry to hear that your first experiences with suicidal clients didn’t go so well in the sense that you weren’t as supported as you should have been. I agree with you that despite having prior experience, if a client attempts or dies by suicide it would be difficult not to feel guilty about this. Your point about placing clients on a safety status made me think further about what would happen if a client had to be involuntarily admitted. Although a client could be upset with this decision, it could save their life. I think the best thing we can do to prepare ourselves for working with suicidal clients is familiarize ourselves with the protocol, interventions and practice implementing them.

      Reply

      • Christina DeMalia
        Oct 03, 2020 @ 21:29:30

        Hi Alexa,

        I think clients that are involuntarily admitted to programs definitely shift a lot of what we have talked about in our classes so far. They could absolutely be at the point where they are trying to commit suicide, in which case being in an inpatient/residential program would be best for them. The client rarely sees it that way, though. They were almost always mad about being there, convinced that therapeutic interventions wouldn’t work, and were resentful of us for keeping them “trapped there”. When someone feels suicidal, but is actively seeking therapy, we at least know they already have that motivation and likely the hope that things can get better. Working with someone who is forced to be in treatment that has not hope or motivation to get better makes things a lot more difficult.

        I also agree that our classes within this program will make us much more comfortable with the correct protocol and how to handle suicidal people who are outpatient. I also know that we will have a lot of supervision at the beginning of our work which will help me feel more confident in the decisions that are made for a client.

        Reply

  24. Alexa Berry
    Oct 01, 2020 @ 18:51:42

    It’s important to get an accurate understanding of a client’s problems early in therapy, such as during the intake session for a few reasons. Most importantly, gathering detailed information about the presenting problems provides a foundation for the selection of intervention and treatment approaches. Since many clients do not return for a second session, it is also important to learn of their problems early on to try and negate this effect. If a client thinks their therapist has done well identifying their concerns and building positive expectations about the counseling process based on this assessment, they may be more likely to return for subsequent sessions. In contrast, if a client thinks their counselor has done a poor job in identifying and assessing their problems, they will think that this person is unfit to help them, and they will not return for more sessions. The textbook states that client expectations about therapy are generally formed during the initial sessions, and have a significant influence on the outcome. Thus, the accurate identification of client problems can aid in building a positive experience and therapeutic relationship. In general, the intake interview should focus on identifying the client’s problem or problems so that counselors can then explore the most important concerns in detail. This process is critical for the effectiveness of the overall therapeutic process.

    My most pressing concern when I think about confronting a suicidal client is a general concern that they will die by suicide when under my care. Although it can be at times hard to predict when some clients will decide to carry out their suicide plan, or when a client will formulate and carry out one quickly or impulsively, I think losing a client to suicide would have a profound impact on me. I have lost a loved one to suicide before and it can be difficult to not internalize the guilt and feel as if there was something you could have done for them (even if you couldn’t). I think this is amplified in the role as a counselor because in a sense there is always something you could have done- you can thoroughly assess whether a client is suicidal, do frequent suicide checks, do a wellness check, provide resources, notify authorities, etc. Even with all these interventions there still remains the possibility that someone decides to take their life. Because of this, I think I will always have some concern that I’m not doing enough when it comes to treating and supporting a suicidal client.

    Reply

    • Anne Marie
      Oct 03, 2020 @ 17:30:50

      Alexa, I thought it was worth noting that most clients only attend a few sessions when initially starting therapy. It is critical to begin building a positive therapeutic rapport from the time introductions occur. I think having distressed clients feel connected, validated and heard can go along way. If they believe they are working with a competent professional who can assist them in finding relief to their symptoms, they are definitely more likely to return. I was sorry to hear of your loss. Suicide is such a tragedy. I believe I would also be profoundly impacted if a client attempted suicide. We are entering this field as helpers. I imagine that I would feel like I failed in some way if a client took their life. I believe we can never take full responsibility for other peopleś actions but the pressure to prevent it is certainly there.

      Reply

    • Connor Belland
      Oct 03, 2020 @ 23:28:35

      Hi Alexa, I think its important that you mentioned clients only come for an average of two therapy sessions and we gather this information to try to get them to stay longer. Its hard to make real, lasting progress with the treatment of a client with just one or two sessions. So the more clients we can make feel that the relationship is a good fit and will be effective, the more we can help them. Clients come in with these expectations of their therapists right from the beginning so its important that the therapist makes them feel comfortable and really listened too.

      Reply

  25. Elias Pinto-Hernandez
    Oct 01, 2020 @ 20:19:39

    The therapist needs to understand the client’s problems early in therapy and gather reliable clients’ information to match the treatment to the client’s problems. Research shows that when harmonizing the treatment to the clients unique complications or difficulties, the better the results and the strongest the therapeutic relationship.

    My biggest concern at this point is to meet with a suicidal risk client that attempts to end his life in front of me

    Reply

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Adam M. Volungis, PhD, LMHC

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