Topic 5: Initial Assessment in Counseling {by 6/18}

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 clients.  (Keep in mind, you will learn a lot more about responding to suicidal clients in future classes and on your practicum/internship.)

 

Your original post should be posted by 6/18.  Post your two replies no later than 6/20.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

36 Comments (+add yours?)

  1. Haley Scola
    Jun 13, 2020 @ 20:13:00

    1. It is important to get an accurate understanding of the client’s problems early in therapy because as a clinician we will learn to create case formulations. These case formulations include the treatment plan. This will be the driving force of the treatment goals and interventions which are is the most vital part to the therapy. Another reason knowing your client’s problems early on is in the attempt to prevent underestimating the severity of your client’s problems. This is one of the main reasons for therapy failure. As a clinician we want to be a helper to our clients and underestimating the severity is a way in which the client may been misunderstood, cause further issues, and diminish the rapport.
    2. Some of my initial concerns when confronted with a suicidal client is the feeling of responsibility I may feel over the client. I’ve actually thought about this topic a lot of if I have client who is suicidal and they commit. I think it would make me feel responsible for their death and that I must be bad at my job. I think not being able to help people who specifically come to me for help would be one of the worst feelings I can imagine. I’m basically just worried about how their death may affect me (a little selfish but this is my main concern). I work in a program of adolescence that are suicidal so it’s a locked facility, meaning everything is locked including things like their bathroom. I think working here has made me a bit numb to the idea because so many of them have told me they do it for attention, which makes me feel so sad for them that they feel the need to go to such extensive lengths for attention. At the same time, it makes me wonder how well I’ll be able to differentiate between someone who has the actual want to die and people that are saying they are for the attention it brings.

    Reply

    • Francesca DePergola
      Jun 17, 2020 @ 18:49:37

      Hi Haley,

      Yes, the treatment aspect is such an important one and something I forgot to mention within my post. Treatment can have such a positive impact on a client and might be able to improve their condition immensely. To think that the very few sessions, given that more information will come along later, are so crucial for the client to continue therapy is daunting, but a good challenge for the therapist to execute the first few sessions as well as they can. Treatment plans can be updated and changed throughout the therapy process, but to have a foundation in which a counselor can work on is important as well.

      Reply

    • Althea Hermitt- Mcpherson
      Jun 17, 2020 @ 19:39:24

      Hi Haley, I agree with you that we need to be keen on asking those pertinent questions in order to assess risk and prevent unfortunate occurrences. It’s definitely sad that some people feel like they need to go to such attention-seeking extremes, however, we cant take for granted that they are always attention-seeking because emotions can change so quickly and they could be serious and we miss that opportunity to save a life because they always cry wolf. Nonetheless, we still need to question, persuade, and refer whenever anyone makes a suicidal statement no matter the perceived or reported intent. As you said its really an uncomfortable situation to be placed in because suddenly you feel like someone’s life is your sole responsibility, which is an astronomical responsibility.

      Reply

    • Michelle McClure
      Jun 18, 2020 @ 17:57:47

      Hi Haley. I understand how you feel I think it would be hard for anyone losing a client to suicide. I have a friend that has been a therapist for years who also graduated from Assumption and she had a client that went through with a suicide attempt and died from it. She has talked to me about how she has never forgotten that client but she never let it question her confidence or integrity as a clinician. I think we have to understand that no matter how skilled we are as clinicians that sometimes unfortunately things take a turn for the worst and there is a limit of what even the most skilled clinician can do. As a clinician some cases will be more successful then others and some cases will feel like you were unable to help at all but its important to stay confident in your abilities to help your clients and not to let the less successful cases get you to doubt yourself and your skills.

      Reply

  2. Madi
    Jun 17, 2020 @ 09:24:41

    1. It is so important to get an accurate understand of the client’s problems early in therapy. For if you don’t have an accurate understand of the problems that a client has then as a counselor you are unable to help and treat the client successfully. In an intake session the client is not going to tell the counselor in depth everything for that therapeutic relationship has not yet been formed. But it is still important for the counselor that get that big picture of what is going on with the client. For it is in the early stages that a counselor will work on a treatment plan and without have an accurate picture of the client’s problems then an accurate treatment plan cannot be created.
    2. I currently work with a client who has suicidal ideation. In the beginning it was slightly uncomfortable but the uncomforted quick dissipated because if I did not ask the question “Are you suicidal?” or “Do you have a plan?” then my client could have easily committed suicide. It is in asking those though questions that lives are saved. Working in community psych has really opened my eyes up to how some clients do need those helping hands even outside of therapy. I have also found that when working with this client that it because much easier once they disclosed their plan. The plan mean that they have to leave in the car so as long as they were still at the program the client was safe. With exposure working and talking about suicide with the client because easier and less awkward.

    Reply

    • Francesca DePergola
      Jun 17, 2020 @ 19:19:06

      Hey Madi,

      I think you have a great point about asking questions and how it allows for insight into the client’s mind. A fear of mine was overthinking the situation and being afraid of possibly asking too many questions, too little questions, or wrong questions. I think your situation proves how important the little things are because getting to know the client more allowed you to be able to feel confident they would not take action knowing that as long as they did not have a car they were “safe.” I think it is true that these steps can help save lives and why it is important for counselors to be aware of the severity of a client’s condition. A fear of mine in that situation though would be whether or not I would take the step to break confidentiality or not because of those “what ifs.”

      Reply

    • Yen Pham
      Jun 18, 2020 @ 10:54:56

      Hi Madi,
      I regard to your thoughts on question two, I like your points to directly asking clients if they were suicide or they did have a plan. When we are confident to ask clients those sensitive questions, I think it will help them have a chance to tell counselors their feelings and thinking. Besides I think that it is important to ask clients why they are feeling suicidal instead of only focusing on their behaviors. Many clients may have unresolved feelings surrounding earlier traumas and need to have these issues addressed in treatment. We need to treat the client, not just the symptom.

      Reply

    • Brigitte Manseau
      Jun 20, 2020 @ 22:16:13

      Hi Madi,
      I agree it’s important to accurately understand the client’s issues within the first few sessions since case formulations are created early on. A therapist cannot create a proper treatment plan if they do not know about each issue the client has and the range of severity for each issue. If a therapist were to focus just on one issue the client would not be getting the most effective treatment. In regards to assessing suicidal clients, unlike you I have not had first-hand experience working with suicidal clients. Your post made me realize that I’ll become more confident in my ability to assess suicide through experience. Also, I like how you mentioned the importance of asking the “hard” questions. It’s vital to ask if a client has a plan so, we can hopefully prevent the client from following through with that plan. The questions you provided in your post are straightforward and effective. Saving an individual’s life clearly outweighs the initial discomfort and anxiety of assessing suicide. I look forward to learning more about responding to suicidal clients in future classes.

      Reply

  3. Francesca DePergola
    Jun 17, 2020 @ 18:43:39

    1. Building rapport and facilitating a consistent and supportive therapeutic relationship is key to the therapy process. In the class lecture, we learned that a client averages 1-3 meetings before terminating. This is interesting because it shows how critical those first few meetings are not only for the therapist to build on the relationship but also for the client to choose whether to stay or not. It was also said that the quality of the relationship between therapist and client early on can predict long-term positive results which also illustrates just how key the initial sessions are. Another reason the start of the therapy process is so important is that it allows the therapist to be aware of the presenting problems. If they do not have an accurate understanding of the client and the issues they are trying to resolve they might underestimate the severity, misinterpret issues, and so on, that could lead to negative results and the maturation of additional problems that were not present before. This could even be dangerous for the client.

    2. I think as a beginning therapist, the thought of assessing suicide can most certainly be anxiety-provoking. At two different internships, I have encountered children and adolescents that have confided some of their feelings about wanting to die. Being confronted with suicidal “clients” I saw myself overthinking a lot of what I was saying and either overreacting or underreacting to some. I think it stood out to me when it was said in the lecture that underestimating the severity was something I could relate to. So, I think a few of my concerns would consist of underestimating the client and overthinking the steps too much. I think both could pose a very dangerous situation to a client if a counselor were to overthink or underestimate the situation and it is undoubtedly one that I think about being confronted with often.

    Reply

    • Althea Hermitt- Mcpherson
      Jun 17, 2020 @ 19:24:18

      Hi Francesca, your response to question one is similar to mine so I totally agree with you here I also liked that you incorporated the fact that some clients only do ne session and how vital that one session must be in order to catch the persons attention as well as motivate continuance. I also think that giving the client something to look forward to each session can be helpful for continuance. You don’t want to come off as a know it all, however, you definitely need to get it right in terms of the presenting problems and treatment goal or plan of action. This statement you made about not having an accurate understanding of the client and its negative results or leading to the maturation of additional problem is pretty crazy, imagine instead of helping you are actually doing more harm.

      Reply

    • Madi
      Jun 18, 2020 @ 15:22:01

      Hi Francesca,
      1. I liked how you talked about the fact that clients usually only have 1-3 sessions which shows how important the early sessions are. I had not thought about it like that and found your point to be very insightful. But I felt as thought you did not flush this idea out completely. For you could tie this to the fact that it is even more important then to get an idea of the client’s problems within the first session since they are most likely to terminate treatment after 3 sessions.
      2. I agree that I can be anxiety provoking. But I don’t think there is any “correct” way to respond to a client talking about suicide or death. While overestimating and underestimating could be issues, I think the true value comes from a client being able to be open with a therapist about feeling suicidal. Once you can have a conversation about it that it where the real work can be done.

      Reply

    • Haley Scola
      Jun 20, 2020 @ 11:10:32

      Hi Francesca,
      I had the same thoughts towards the average amount of sessions being 1-3. I feel as if it put a lot of pressure on those three sessions specifically because you want to ensure you’ve made some sort of therapeutic progress in which the client feels this is helping in order to continue sessions. The quality of the therapeutic relationship is also vital to positive outcomes. This makes me feel as if we need to work hard in those few sessions to make out client feel comfortable and heard. I completely agree that assessing suicide will most likely be very anxiety-provoking. Both underestimation and overestimation can be detrimental to the client so it puts a lot of pressure on us as clinicians to make sure we are making assumptions too quick or transcending any of our beliefs from our prior clients on the new ones.

      Reply

  4. Althea Hermitt- Mcpherson
    Jun 17, 2020 @ 19:10:59

    (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).

    Intake and the early session are pertinent as this helps the Counsellor and the client to build rapport and highlight the positive expectations of the counseling process. This will allow for a positive helpful therapeutic relationship which is vital as it can determine the outcome of therapy. During the intake and early session, counselors need to be able to engage and motivate the client in order to help them to commit to sessions and treatment. Similarly, it is important to get an accurate understanding of the client’s problem early in therapy as this is fundamental to developing treatment goals or interventions that are geared specifically towards addressing the clients’ reported and underlining problems. A counselor would want to know if a client is suffering from any other issues, for example, physical abuse, drug abuse, or addiction because these factors can affect the effectiveness of treatment if not addressed. Therefore an understanding of all the clients’ problems is essential to make more informed decisions and also to help the client feel like the sessions are helping to change the problems they are working on. It also gives an idea of the magnitude of the problem so counselors can decide if the issues are outside the scope of there practice and require additional support or a change to a clinician that is more adept in that area. Getting an accurate understanding of the clients’ problems early in therapy can aid the clinician in knowing from the client’s perspective, why they want to pursue therapy, their level of motivation, and whether or not they feel like the problem is changeable.
    Not underestimating the severity of client problems can be problematic and ultimately result in negative outcomes.
    (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.)

    Suicide being the 10th leading cause of death in the United States and the 10-34 age range being extremely vulnerable on its own is extremely scary, however, being responsible for not recognizing or catching someone before they commit suicide is even scarier. Initial concern for me would be feeling responsible for their death if it should occur. Also as a counselor not catching on to such important information would be devastating, this could cause someone to question their expertise. As a counselor, you should probably always assess for suicidality because emotional states can change quickly which makes it very difficult to predict. However, counselors must be very keen to warning signs such as threats to harm or kill oneself as this is very important and need immediate attention, however, less imminent warning signs such as hopelessness, loss of a relationship, anger, revenge-seeking, recklessness, feeling trapped, withdrawn, anxiety, agitation, no sense of purpose are just a few other signs that when they are seen in combination can be problematic. Counselors should also encourage protective factors such a family supports, as well as err on the side of caution if there is any indication that someone might be unsafe.

    Reply

    • Michelle McClure
      Jun 18, 2020 @ 17:39:42

      1. Hi Althea. I really liked how you pointed out that as counselors highlighting the positive expectations of therapy for our clients is so important. When our clients feel like as clinicians we can actually help them meet their mental health goals that increases the clients engagement in therapy and the more engaged the client is in therapy the more that the client will take from therapy. As you mentioned in your post the more engaged the client is in therapy the less likely the client is to cancel or no show appointments.
      2. I remember when I found out I would be working with a suicidal/self harming 14 year old. It was very intimidating and I questioned for a moment if I was capable of helping or if I was out of my league. I ended up meeting this client during a crisis, she had wrote a suicide note and had a plan the first day we met, there was a DCF worker there and mobile crisis had been called and we were waiting for them to show up. I was very new to my job as a family service provider and had no experience working with a suicidal or self harming client until this client. The first day I met with this 14 year old we were able to talk and she almost immediately took to me and told me all about getting bullied at school and how she was feeling. She ended up going to the hospital later and in a in patient placement for a couple weeks but when she came back home my team was able over the course of a year to really help this child who was constantly going inpatient placement stay at home safely. To this day it remains a great case experience and reminds me why I want to continue to work helping clients.

      Reply

  5. Michelle McClure
    Jun 17, 2020 @ 19:51:46

    1. It is important to an accurate understanding of your clients problems early in therapy because if you do not have an accurate understanding of what your client needs then you cannot come up with the proper treatment plan. The more you take the time to understand the multidimensional factors that are making up and influencing your clients mental health problems the more effective you can be as a counselor, coming up with more effective case formulations, treatment plans and interventions. Also the more you understand your client’s problems early in therapy the more effective you will be at building the trust and rapport that will keep the client engaging in therapy, and keep the amount of times they cancel or no show appointments at a minimum. This will ensure that you can provide the best treatment for your clients which will lead to the best overall outcomes for your clients.
    2. I have already worked with suicidal and self-harming clients so the initial anxiety over working with suicidal and self- harming clients has reduced significantly through experience. I will say that the biggest challenge in working with suicidal and self-harming clients I have found is you really need to build a strong rapport and trust with the client as soon as possible in the therapeutic relationship. I also found that when working with suicidal and self-harming client’s that hope was one of the biggest factors on the overall outcome of the case, my clients that I could help see that they had hope that things could and would improve through discussions and interventions had better overall case outcomes.

    Reply

    • Yen Pham
      Jun 18, 2020 @ 11:10:18

      Hi Michelle,
      I have the same opinion about you as an counselor’s first challenge when confronting a suicidal client, I believe we should build a good relationship with them as soon as possible. The trust our clients have for their counselor is very important for them to be open to sharing with us their suffering that they are experiencing. They want to find a way out of those sufferings. So, counselors are responsible to help them to consider taking their own lives find reasons to live. Indeed, counselors should consider to build up a good rapport with clients at the beginning interview. Counselors must possess a strong set of interpersonal skills to help establish rapport quickly with clients and develop strong relationships. They must give their undivided attention to clients and be able to cultivate trust. Clients who perceive their counselors as trustworthy, expert, and attractive have better outcomes in counseling than clients who don’t have these perceptions of their counselors.

      Reply

    • Madi
      Jun 18, 2020 @ 15:26:44

      Hi Michelle,
      1. I liked how you focused on treatment plans in your response. I did not focus on this in my response, but I think it is an incredibly important element to the beginning of therapy and therapy as a whole. For without the big picture you cannot really create a solid treatment plan.
      2. I agree completely with you about having that rapport with a client is very crucial to being able to help a client in times of crisis. For without that rapport why should a client go to someone they don’t know or trust when they are in that crisis moment? We go to the people we trust with our problems; we don’t go to strangers. So, it would make sense that clients only talk to people about their toughest problems with the counselors that they trust.

      Reply

    • Selene Anaya
      Jun 19, 2020 @ 12:49:01

      Hi Michelle! Your points about why an accurate understanding is so important early on were similar to mine. I like how you included the importance of understanding multidimensional factors because it is true that there are so many factors that impact an individual’s mental health. First impressions matter a lot in therapy, so it is especially important to use the skills we are learning to build rapport and make clients feel comfortable and motivated to keep coming back for sessions. If we don’t instill trust, it is likely that the clients won’t return. I thank you for sharing your experience with working with suicidal and self-harming clients. I have never experienced that, so hearing from you was very helpful. I am comforted to hear that through experience, the anxiety from working with these particular patients will decrease a little. I think the situations will always still come with some uncertainty just because in lecture it was said that moods can change so quickly, and a patient could give you their word that they won’t act but you don’t know for sure, so what is the extent of trust you put towards your client’s word in this case? Other than that, I can understand how the feeling of hope can be a huge difference in outcomes for clients who are suicidal. Even believing just a little bit that things can get better can mean so much for both the client and the clinician.

      Reply

    • Haley Scola
      Jun 20, 2020 @ 11:18:09

      Hi Michelle,
      I also pointed out the importance of having an accurate understanding of our client in order to create a proper treatment plan. I think it is extremely helpful to really dig deep during the exploration stage with your client in order for them to optimally benefit from the therapy. I thought it was very surprising that the average amount of sessions is between 1 and 3. This alone puts a lot of pressure on us as clinicians in order to help our client as much as possible and allow them to feel a sense of being understood or heard by us. I think that your point about building a strong rapport with the client as time efficient as you can be very helpful. Your point about hope caught my attention the most because I think this is such a great point. As clinicians we need to ensure we are helping our client see the possibilities that life has to offer.

      Reply

  6. Yen Pham
    Jun 18, 2020 @ 00:17:43

    (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).

    Clients’ problems are rarely related to one factor, are usually multidimensional, and typically occur in a social context. In addition, clients often seek counseling for multiple issues rather than one specific problem. Therefore, it is important to get an accurate understanding of the client’s problems early in therapy because it helps a counselor to balance gathering information and building a therapy or significantly predicts long-term positive results. In other words, when a counselor understands the defining the client’s problem which in turn helps a counselor to eventually develop a solid case formulation that will be driving force of their treatment goals and interventions to clients more successful.

    (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 clients.

    I think that it’s important for counselors to understand that dying is not client’s true desire. People who are suicidal do not want to die. That is not their goal rather than they want the pain to end. They are looking for some relief. From a counseling perspective, that is a really positive thing. What it means is we can help people work through that intense psychological pain and find a way through it. So, I will say that my initial concerning and challenging in in working with suicidal clients is to build up a good relationship with clients by my empathy, compassion, and listening skills. I believe that listening is so important thing to prevent suicide. We listen without judgment, without bias, without prejudice that we were allowing the patients to space really to vent or they can express their mental and/or physical pain. Thus, even we may not be able to guess the type of pain or the source of the problem, we are not able to fix it but we are able to listen with all my heart and sympathetic. Later on, clients who perceive their counselors as trustworthy, expert, and attractive they are willingness and openness to share their thought and feelings. In turn, it helps counselors to provide the best therapy helping suicide clients considering taking their own lives find reasons to live.

    Reply

    • Christopher LePage
      Jun 18, 2020 @ 18:36:04

      Hi Sister Yen, I really enjoyed your point about patients having multi-dimensional problems is vitally important when completing an assessment, and it is something that I had not considered. Thinking about it now, it is so true that we are seeing more and more cases of comorbidity diagnosis, and with that brings more complex problems for clinicians to work through. By having an early start on what these problems are, it is much easier for clinicians to help create a plan for beneficial long-term results. With regard to your discussion of suicidal patients to be very interesting. I enjoyed that you spun it in a more positive way where you say that dying may not be the actual desire of the suicidal patient, as it often times is not. When dealing with a topic as morbid as suicide, I do think that it is important as mental health professionals to see this as an opportunity to help out an individual, rather than looking at the situation and be fearful of it.

      Reply

    • Dawn Seiple
      Jun 19, 2020 @ 17:24:50

      Hi Sister Yen,

      As scary as it is to think about being confronted with suicidal patients, I found it comforting to think about it as an opportunity to help people who are intensely suffering. The point you made about suicidal people not really wanting to die was very insightful. Thinking about helping patients end their pain rather than their lives was inspiring and somehow made it less frightening. I personally find you do inspire hope when you speak. I can easily imagine you listening to patients and providing empathy and compassion without judgment. I truly believe your future patients will feel you care, will appreciate your peaceful affect and will trust you can help them.

      Reply

  7. Dawn Seiple
    Jun 18, 2020 @ 14:08:27

    Where the average number of therapy sessions a patient attends is 1 to 3, it seems clear that many people are not having a great first experience in therapy. There are already challenges to receiving therapy. A person has to find a therapist who is taking patients at a time that is mutually convenient and who takes their insurance. Otherwise they have to pay out of pocket which can be prohibitive. If they clear these hurdles, then they can schedule an intake meeting which may already be delayed due to one or both parties being unavailable. The meeting itself may be difficult because it requires patients to open up about potentially painful, emotional or embarrassing topics with someone they are meeting for the first time. With so many challenges, it is imperative that the first meeting go well. To inspire the patient to return, the therapist needs to be able to provide the patient with hope and optimism about receiving treatment. Early in the process, the therapist needs to understand the patient and their problems or the patient may not return. To accomplish this, the patient needs to feel comfortable sharing with the therapist and needs to believe that the therapist understands what they are going through. The research shows that if early sessions go well, the long-term prospects for therapy are much better. This puts a of pressure on the therapist to connect with a patient right away.

    Yesterday, right after listening to the lecture related to identifying suicidal patients, I received a call to inform me an acquaintance had taken their own life. I knew this person had developed a serious substance abuse problem in response to some personal challenges, but I had not seen him in quite a while. My brother was closer to him and I spoke to my brother about how difficult it had been to know how deeply pained and self-destructive this man was and to be unable to motivate him to get further help. My brother had provided emotional and financial support over the years, but this man could not seem to make permanent changes. Despite past stays in rehabilitation, this individual could not recover from his addictions. He ultimately was so desperate that he took his own life. My brother and I talked about his feelings of guilt, frustration and sadness. It was a very timely discussion as I had been thinking about the great personal responsibility one assumes when they counsel someone who is feeling suicidal. As a mental health professional, it is imperative that you take every step possible to help your patients. However, even when you do everything one could reasonably expect, sometimes it is not enough. As a therapist, you may be left questioning if you did enough. You may just be left with sadness at the loss of someone you had a connection with. I would have to think this is the most difficult situation for any therapist. The hope is that for every person who cannot be helped, there are many more for whom you do make a positive impact.

    Reply

    • Christopher LePage
      Jun 18, 2020 @ 18:28:08

      Hi Dawn, Thank you for sharing such a personal story in your life, I think it goes to show just how applicable these topics that we cover can be to our own lives. Your point of counselors (as well as other individuals involved in the situation) can feel as if they did not do enough for the person/client. This is such a big factor to consider when taking a position such as ours, because at times we may not be able to do as much for the client as they needed, or as they would have liked. Having a situation where one did not feel they did enough can in turn make that person experience shame, guilt, or feel that they should be held accountable for that other person’s actions. That is why I appreciated your example so much, because it demonstrates this feeling of accountability.

      Reply

    • Selene Anaya
      Jun 19, 2020 @ 13:03:34

      Hi Dawn! Thank you for sharing your personal story with us. I agree with Chris, it really does bring to light how applicable the skills we learn and the knowledge we are acquiring will play an important role in our lives not only as counselors but in everyday life as well. One of my main concerns was about questioning my actions and my words if that were to be a situation I was a part of. The personal responsibility would definitely be a hard one to shake. I think the point you made about sometimes everything you can possibly do just isn’t enough would definitely be one of the most difficult situations for therapists because we are the people who are supposed to understand and have the skills to be enough. However, I was comforted with your statement about hoping that for every person who cannot be helped, there are many more individuals we do help. Going back to your first response, I was also very surprised by the average number of therapy sessions a patient attends. It just leaves me to wonder what other counselors are doing or what else is causing this number to be so low. I didn’t even think about the financial perspective of therapy, which definitely could be a barrier. My hope is that there are ways to make it work for these individuals, and if not, I do hope to figure out a way one day.

      Reply

    • Brigitte Manseau
      Jun 20, 2020 @ 22:40:29

      Hi Dawn,
      I appreciate you sharing your personal story relating to assessing suicidal clients. In regards to the first part of your post, I like how you pointed out the difficulties that may arise even before the initial meeting. It brings to light how tough it may be for a client to get to the point of meeting with a therapist. It can be daunting after the initial struggles of finding a therapist who accepts the client’s insurance, who has a compatible schedule with the client, and who is located near the client. A therapist who accurately understands the client and their problems may encourage the client to continue putting forth the extra effort. I also like how you mentioned the importance of hope and optimism. After putting in the effort to meet with a therapist, it is super important to bring hope to the client in regards to treatment. The optimistic and hopeful attitude a therapist brings to the table may make a client feel like their efforts to start therapy were all worth it. A client knowing that the therapist understands their issues and has the ability to help them through their issues will encourage the client continue with therapy.

      Reply

  8. Trey Powers
    Jun 18, 2020 @ 16:32:07

    1.
    It is essential to establish a solid understanding early in the therapeutic process of a client’s presenting problems, as well as any underlying issues or contributing factors. This is not only necessary for establishing the therapeutic relationship, but also for increasing the chance that the client will return to counseling in the future. Gathering a thorough understanding of all the issues that a client is experiencing makes the client feel as though they are being taken seriously, that the counselor is adept and credible, and that their needs will be met through the therapeutic process. If a client does not believe these things, they may distrust their counselor, or feel as through the counselor does not know what they are doing. They may also feel as though the counselor is discounting their feelings, which can dissuade the client from being open and honest. Worst of all, the client may feel no confidence that counseling will work for them, leading them to discontinue therapy and not seek the help they need. An additional issue related to properly identifying presenting problems early in the process is for the client’s safety. If the client is engaging in dangerous activities as a result of their disorder, or they are actively suicidal, it is important to catch these symptoms early in order to provide immediate interventions. If the counselor does not adequately assess the client and their symptoms, the client may end up either dying as a result of their risky behavior, or taking their own life.

    2.
    There are several things that have been on my mind regarding encountering a suicidal client while I am practicing, especially early on in my practice. First, I feel as though I may hear of the client’s thoughts of taking their life and freeze, not being able to determine the proper course of action because of how taken aback I am. Second, I am worried that if I do believe a client is actively suicidal and call for an evaluation, the client may leave without my being able to stop them. Third, I am concerned as to whether there are legal consequences for failing to identify a suicidal patient, not to mention the sense of personal guilt that I am sure I would feel. I am particularly concerned about this, as I know that people are often quite good at hiding their suicidality from others, especially those they do not know, which would be my situation in the case of a new client. Finally, I worry about the damage, both psychologically and to the therapeutic relationship, that having a patient evaluated when they are not, in fact, actually suicidal may cause.

    Reply

  9. Christopher LePage
    Jun 18, 2020 @ 18:16:03

    1. One of the reasons I believe it is so important to understand your client’s problems early on is because it helps build rapport. Going into a therapy session (especially early on), the client is going to want to know that you are being attentive to their issues. By communicating with your client that you are understanding what is going in their lives you are also building trust. Having this trust is a great foundation for a relationship with a client. By having trust, the client in turn is going to have more faith that your treatment plan is going to be beneficial towards them. I also believe that the more that you have a client’s trust, the more likely they are to put in the work on their end (in terms of treatment plan and being honest in their communication with you). Having an understanding of their issues early on also benefits you as a clinician, because you are able to help come up with the best, most effective treatment plan for your client.
    2. One of the biggest concerns in regard to dealing with a suicidal patient is knowing whether or not they are going to cross the line and actually go through with suicide. While there are many cases where people may have suicide ideology and never in attempt suicide in their lives. There are also people who self-harm who also never make this attempt. Seeing a patient it can be hard to see them come in if they are exhibiting self-injurious behavior (or maybe even attempted suicide in the past), and not try to be overwhelmingly cautious with them. Clients who come in expressing these feelings want to feel safe and protected by you, and may not want to think that you are going to just lock them away in some facility. With that being said these conditions make a difficult situation to be in even more difficult. It is hard to know if you are being overly protective/cautious with a patient and that may scare them from continuing to get help. What is even more difficult is having that worry in the back of your mind that after a session with you a client may exhibit any form of suicidal behavior. For me, that is probably my biggest concern, gauging whether or not to take serious preventative action regarding a suicidal patient.

    Reply

    • Dawn Seiple
      Jun 19, 2020 @ 16:34:47

      Hi Chris,

      When discussing the importance of establishing a trusting relationship with a patient early in the therapy process, I thought you made an important point about client engagement. Where we will primarily be using cognitive behavioral therapy, it is essential that our clients be engaged enough to put in the work between sessions. Unlike some forms of therapy where the client just talks through how they are feeling, we will additionally be asking them to be engaged in the therapy process when they leave. The client needs to have a high level of confidence and trust to go home and believe that what their new therapist has asked of them is worth their time. If the patient does not understand why they are being asked to do this homework, they are less likely to do it. In addition to instilling trust and establishing a good rapport, the therapist needs to motivate the patient to collaborate in the process. This is a lot to accomplish in a what might be just a few sessions.
      In your comments regarding being confronted by suicidal clients, I thought you made a good counterpoint to the risk of missing that a patient is truly suicidal. Obviously, every therapist will want to keep their patients safe and not miss any patients who pose a true threat to themselves. However, your point about not being over-protective also has merit. If a patient were simply discussing suicidal ideation to demonstrate how truly pained they were, but did not have any actual inclination to follow through, having them committed to a hospital would be excessive and counterproductive. That patient may lose trust in you and in therapy and sever the relationship. This could be very detrimental as well. Assessing the true risk seems very challenging. This dilemma absolutely seems to be the most difficult part of being a therapist.

      Reply

    • Casey Cosky
      Jun 20, 2020 @ 16:20:18

      Hi Chris! I completely agree with you emphasizing the importance of building trust so strongly. A client is not going to want to open up about such personal problems if they feel that the therapist isn’t fully paying attention or doesn’t care about what they have to say. You’re totally right about the client being more willing to put the work in on their end if they trust the therapist too. Therapy sessions can only help so much if the client isn’t actively working on themselves outside of sessions as well.

      Reply

  10. Selene Anaya
    Jun 18, 2020 @ 19:04:07

    1. It is important to obtain an accurate understanding of the client’s problem early on because it can impact the client’s return to therapy. Identifying a clients issues and building positive expectations about the process can have a significant impact on the outcome of whether or not the patient will come back for more sessions. As mentioned in both the book and lecture, first impressions are crucial for positive outcomes of therapy. If a client feels in any way that their problems or symptoms are not being addressed, or the relationship does not feel genuine or right, they are likely to not return. Establishing a trusting relationship is extremely important at the start because in therapy, the client will share deeply personal information, and the client needs to first feel comfortable enough to do so. Also, engaging the client right away and accurately understanding their concerns will motivate and assure the client that they will gain something positive from therapy. An accurate understanding of concerns also means that we need to make sure we do not undermine any behaviors. If a client comes in and is majorly depressed and it is either not explored in depth or the focus is taken away by another concern that is also mentioned, it can be overlooked and it could result in a negative outcome (fatality). It was also mentioned in lecture that an accurate understanding of concerns can let us know if the individual needs additional support or a counselor who specializes in their condition. This way, we can assure the client is receiving the best support and treatment possible.

    2. As someone who has never had first-hand experience interacting with an individual with suicidal thoughts or behaviors, the thought of assessing suicide is extremely anxiety provoking. One of my main concerns is saying something wrong, or not being able to get much out of the client to where it is overlooked. I know with practice and the skills I will learn through this program will teach me well so this does not occur. I also know that I will feel personally responsible for whatever outcome results from the situation, so separating my personal feelings from work will be hard to do. Or is that something that isn’t really humanly possible regarding this specific situation? Being too cautious (which I would probably do) and either giving the idea to an individual or offending them would be another concern of mine. Given that I have never been presented with the challenge, and I learn best through experience, I am worried that I will tense up and really question what I say when it is happening. Again, through practice, it will become more familiar, but I also know sometimes practicing does not allow us to experience the fear or anxiety that comes along with the situation in real life. I always tend to think too much about certain situations, but thinking about this specific situation occurring is important because it most likely will happen, and recognizing the feelings that might occur could help with the way it is actually dealt with.

    Reply

    • Casey Cosky
      Jun 20, 2020 @ 16:29:56

      Hi Selene! I can really relate to the anxiety of interacting with a suicidal client. One of my main concerns is also saying the wrong thing or not realizing that they are suicidal until it’s too late. I also worry about the difficulty of separating my personal feelings from work. I do know that that can be the sign of a good therapist though because it shows that you care! I also feel like it will get easier to do as time goes on. I’m sure it will still be difficult at times, especially with clients who you form a strong bond with, but it definitely will still be manageable. I also agree with you about not wanting to offend a client. When someone is in a vulnerable state it’s so important to choose words wisely. But like I said, we’ll definitely get the hang of it with more experience.

      Reply

  11. Casey Cosky
    Jun 18, 2020 @ 19:56:59

    It is important to gain an accurate understanding of the client’s problems early in therapy because it helps you know where to start, what issues to prioritize, and any histories that are important. As part of an in home therapy team I have had to do a lot of intakes and they’re incredibly beneficial. I still use my intake notes multiple sessions later to refer back to the information that they gave me when necessary. The therapist cannot accurately form a treatment plan if they do not know what they are treating. Not only that, but when the client gets the chance to get whatever they want to off of their chest and feels validated afterward, it helps to build rapport and improves treatment results. Most people who attend therapy will only attend 1-3 sessions before deciding not to come back, so building a relationship and trust in the intake/first few sessions is essential. Knowing the person’s background is also a very important aspect of an intake because some of the information you learn will help provide an explanation for the state of their mental health. For example, it’s helpful to know if a person has a history of suicidal ideation, if they are working a job that is extremely stressful, or if their family members also have a history of mental illness. The therapist should also be informed of past counseling experiences so they can gain a better understanding of what works and what does not work best for the client.

    The biggest concern for me in regards of a suicidal client would of course be their own safety. I feel that part of me may invest a lot of time and energy into worrying about them taking their own life after disclosing that to me, even if I then take the appropriate steps to get them more help and keep them safe. I also worry that, unfortunately, reporting it (which I know is necessary and typically beneficial) will sometimes do more harm than good. Sometimes people express their suicidal ideation in a way that means they don’t want to necessarily kill themselves, but they don’t want to be alive. They won’t have a plan or feel strongly enough about it to actually commit suicide, but they will fantasize about it as a possibility. Sometimes it’s difficult to know how serious someone is about it. I also know that unfortunately, experiences in psychiatric facilities can sometimes be very dehumanizing and even discourage someone from opening up about their suicidal ideation again in the future because they fear having to return. Knowing I’d be taking that risk, even when it’s essential, would definitely be difficult. This is especially applicable to the clients who will feel that the trust has been broken if they are reported.

    Reply

    • Trey Powers
      Jun 24, 2020 @ 18:34:58

      Hi Casey!

      I also had the worry regarding having someone evaluated in a hospital who is not entirely suicidal. I think you bring up a good point about people not wanting to kill themselves, but wanting to not be alive. I’ve encountered people before who have expressed this. Just ceasing to be for a period is something that seems attractive for some people, as it allows them to be rid of all the pain and burden that they had been struggling with, but without the permanency and repercussions of actually killing oneself. It seems like a fine line between the two, however, and a person may lean further on one side or the other depending on how they feel on a given day.

      Reply

  12. Brigitte Manseau
    Jun 19, 2020 @ 00:00:03

    1. It’s important to get an accurate understanding of a client’s problems early in therapy. An accurate understanding of a client’s issues will help build rapport and the therapeutic relationship. Individuals are multidimensional so it’s important for a clinician not to hone in on one specific issue during the initial sessions. Accurately understanding the client’s various issues will help build trust and allows the clinician to create a case formulation. Another important point is that the first few sessions are crucial in predicting whether the individual will continue therapy. One of the main reasons why an individual will not continue therapy is that the clinician underestimated the severity of the individual’s issues. It is vital to accurately pinpoint the severity of a client’s problems so the individual can trust that the clinician knows what they are doing and that they can truly help the client.

    2. I haven’t experienced working with suicidal individuals so it is nerve-wracking not knowing what to expect. The textbook shared a session in which suicidal ideation was explored. In the session the clinician asked the client for assurances that the client would not hurt themself. One of my concerns is differentiating between a client who truthfully says they won’t hurt themself and a client who says they won’t hurt themself but doesn’t mean it. I feel like it would be easier to trust a client who you have good rapport with. I am nervous assessing suicide with a client I barely know. It is harder to trust someone you barely know. Also, I am particularly interested in working with LGBT individuals. According to the CDC LGBT adolescents are five times as likely to attempt suicide compared to their heterosexual peers. The textbook also mentioned 71% of clinicians have worked with clients who have attempted suicide and of that group 28% had a client who passed away by suicide. Reading those statistics really made me realize how likely it’ll be that a client I work with will die by suicide. It’s very anxiety-provoking to think about. I am nervous about the guilt I could feel if one of my clients do commit suicide. I can see it shaking me up and making me question what I could have done to better help the client.

    Reply

    • Trey Powers
      Jun 24, 2020 @ 18:30:50

      Hi Brigitte!

      Your concern over a client saying that they won’t hurt themselves is a good point. I hadn’t thought much about this issue, but now I realize this is one of my concerns as well. It is tough to decide whether someone is being truthful in their promise not to hurt themselves. It almost sounds inadequate to simply ask for a promise from your client with something as serious as suicide. I know I would likely be feeling nervous between sessions after something like that. I also think it’s great that you want to work with the LGBT population, and especially adolescents. I am also interested in this population. Both adolescents and LGBT individuals need as much mental health support as possible, as we currently are not doing a very good job serving them.

      Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

Adam M. Volungis, PhD, LMHC

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 58 other followers

%d bloggers like this: