6 Steps to Engage New Clients in the First Session

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When I first began in Private Practice, I noticed that new clients were not coming back for the second session. I knew I was doing something wrong in that first session (or free consultation) that wasn’t connecting with my clients. I started experimenting and tracking my conversion rate.

This is a rough guideline of what I have ‘fallen into’ over the years in private practice that has a very high conversion rate (rate of consults that turn into regular clients for me). I find this can be done in either 30 minutes or 60 minutes. Here are the major steps I do with some of the ‘scripts’ I find myself saying often.

 

1. Welcome/Orienting the client to the consultation session

The consultation session is a little different than a regular therapy session, so I make a point to tell the client what we are going to do, and what he/she will walk away with from our meeting.

Here’s a breakdown:

  1. Greet them and normalize that it can be weird, awkward or anxiety-producing to meet a therapist for the first time (or meet a new one).
  2. Tell them what we are going to do during today’s meeting. The important points to hit are:

  

  • This is a time to get to know one another a little bit
  • I’m going to be asking some questions to know what’s been going on for the client
  • I’m going to be answering any questions that they have (I tell them it’s ok if they don’t have any)
  • I’m going to share my thoughts and initial observations about what they shared with me, so that they know what I’m thinking and it aligns with their experience
  • I’m going to share the general outline of what our therapy will look like (although we can pivot later if needed). This includes a preview of tools I will teach them, the order of things, how we will track progress, etc.

 

I know that’s a lot to get through, here’s a script:

 Hi Jane, thanks for coming in today. It’s nice to meet you in person. I know it can be nerve-wracking to meet a new therapist, and I’ll be asking some personal questions today, so I thank you for taking the step to come in. Today we have a little bit of a different meeting than a regular therapy session. Today I will ask some nosy questions so I can really understand what’s been going on. But don’t worry, you can ask me nosy questions right back if you want to. I’ll answer any questions you have today, but it’s ok if you don’t think of any. After I ask my questions, I’ll share with you only my thoughts and observations about what you’ve told me, so you always know what I’m thinking and to make sure I really understand. Then I’ll share with you my initial thoughts and plan for how I’m going to help you feel better. Ok? Great! Let’s start.

 

2. Super-Short and Focused Diagnostic Evaluation

I’ve found the key here is to not get lost in the weeds, but identify the main clinical concerns right away, then ask a few follow-up questions to understand the severity and symptom presentation of that clinical concern. I save a more thorough mental health evaluation for another time. I want the client to feel heard right away.

Here’s a breakdown:

  1. Ask first about the main clinical concern by asking what brought them in, or how can you help?
  2. Normalize and Validate that concern
  3. Ask a few follow-up questions to get a broad understanding of the issue
  4. Ask about previous therapy experiences, and what was helpful and not helpful about those experiences, so you can quickly learn how the client responds to therapy in general (I make sure to incorporate this into the ‘plan’ that I share towards the end of the consult)
  5. Ask if there are any other major clinical concerns.

 

Here’s a script for a client struggling with Anxiety:

Therapist: Ok Jane, I know we spoke briefly on the phone, but I’d like to just start with a really broad question and go from there, so I will ask what brought you in today?

Jane: Well I’ve been feeling really anxious….

Therapist: I’m so sorry you’ve been dealing with that, it’s really hard. We see a lot of that here in the practice, so you are not alone.

*Now I ask some follow-up questions about this clinical concern, such as:

  • When did it start?
  • How bad does it get?
  • Panic attacks? How many and when?
  • How is this impacting your life right now?
  • Medication? Helpful or not? Prescribed by whom?
  • What helps it right now?
  • Who knows about it? Support network?
  • Family history?

Jane answers all these questions, and I normalize her symptoms along the way.

Therapist: Have you ever seen a counselor before for this or for anything? When was that? What was helpful about that? Anything about that not helpful?

*I’m listening for anything that the client found helpful in the past in therapy (if they have done it). Things like a therapist being directive, providing honest feedback, teaching tools, etc.

Jane answers….

Therapist: So I really hear you about the anxiety and am starting to think of some things we can do together that will really help that, but first let me ask, is there anything else going on that you think is important for me to know?

Jane answers…

 

3. Feedback to Client

This is where I thank the client for being so open and talking about difficult things, and provide feedback and a rough/initial diagnostic impression. I’m not rushing a diagnosis, and I don’t use that language (usually) with the client, but just like when you see the doctor, you want to know what they are thinking and that they understand why you came in. I emphasize that I hear them, reflect their own language back to them, and validate that their concern is not ‘just in my head’ but it’s serious enough that they came to a therapist about it, and that they deserve a professional’s help to feel better.

Here’s a script for our client Jane:

Thank you for answering all those nosy questions, Jane. I know this stuff is hard to talk about. It’s very clear to me that you have an above-average amount of anxiety and it’s really impacting your ability to sleep and your job. That must be so hard. You should know that what you have shared with me is not a normal level of anxiety that we all feel from time to time. I hear some markers of an anxiety disorder, and so you’ve been dealing on your own with a clinical issue. You can’t just make it go away by being hard on yourself, which I already hear that you are. If you could kick this by just telling yourself to calm down you wouldn’t be here right now. But you are, and I’m glad you are. You don’t need to be alone with this anymore.

In our next session I’ll ask some more about your symptoms and really make sure we get the right idea of what you’re dealing with, but I’m pretty confident in what I’ve heard that the focus of our work with be tackling this anxiety together.

 

4. Share Your Initial Plan (let the client know that you can help them)

This is such an important step. The client wants to know in a concrete way how you will help them with their issue. You don’t need to do an on-the-fly treatment plan, but as you listen to any clients, ideas pop into your mind of what may work well for the client. This is your time to share that, give examples, and give the client confidence that you are in control, that you ‘get’ them, and that you have a plan.

Things to keep in mind for this step:

  1. Frame the work in terms of ‘we’ rather than ‘you’ or ‘I.’ You and the client are a team now.
  2. Share an honest initial time-frame with the client. You’re not tying yourself down to that timeline, but you will have a sense of how ‘easy’ or ‘difficult’ the client’s issue is, so share that.
  3. Incorporate what was helpful about previous therapy (If there was any)
  4. Reflect the client’s own language in how they describe their symptoms to you, so they feel heard and understood. Don’t use overly-clinical or ‘jargony’ language.

Here’s a script for Jane:

I feel confident that we can get this anxiety under control and you can feel like yourself again. If you choose to work with me, I’m think that first we will jump right in to concrete and practical tools to help with your anxiety in the moment. I remember with your therapist back in college you liked having those tools you could turn to, so we will start there. We will also explore the causes and triggers of your anxiety so we can play offense, not just defense. We want to see those things coming, have a plan, and head them off. I will also work with you on some pretty easy tweaks to your sleep routine to get you some better sleep, which will help with anxiety. I think also, from what you have shared with me, that simply having someone to talk to about all of this will be helpful. You’ve felt alone and embarrassed about it, and I understand. But talking about it will help us move past the shame and implement these tools and strategies. I think we can really see a difference in around 3 months, based on my work with other clients who are going through what you’re going through.

 

5. Answer The Client’s Questions and Wrap-Up (giving them a choice to schedule for follow-up with you).

The last step is to ask if the clients have any questions for you. I usually find that at this stage, you’ve answered all of their questions. However, sometimes they have questions. I answer all of them as transparently as possible. Clients hardly ever ask a personal question. The most common question I’m asked is basically ‘Am I weird’ and ‘Can you help me?’ Those are easy times to validate/normalize and again reinforce your very rough treatment plan.

After that, we wrap-up and I see up the next session. I never want to pressure anyone, or assume that they feel comfortable being my client yet, so I give them a choice between scheduling our next session right now, or getting back to me after they think about it. Almost 100% of the time they schedule right then, but if they don’t, that’s ok too. I always remind myself that ‘you’re not for everyone’ and let it do. Oftentimes, the client that doesn’t ‘sign up’ right away will circle back to me in the future.

Here’s a script to wrap up:

Well Jane we’re almost out of time, I’m sorry to have to stop. We can do one of two things from here. If you feel comfortable that we’d be a good fit, we can go ahead and schedule our next session and I think it would be good for your progress to meet every week. If you want to think about it, that’s fine too. If that’s the case, I’d love your permission to follow-up with you via email in a few days so we can touch base before my caseload fills up again. What would you like to do?

 

6. The Follow-Up Email

I always send a follow-up email, no matter what (unless they tell me not to email them). This lets the client know that you’ve continued to think about them. It’s also an opportunity to offer something of value. I email with a short note saying it was really nice to meet them and, if they have ‘signed up’ to be a client, that I look forward to working with them. I say I have been thinking more about what they shared with me, and it make me think of this helpful article/book/podcast that I wanted to share and include a link. That’s it! Clients tell me they really love this follow-up.

This is also an opportunity to ask if a client wishes to meet again (if they didn’t schedule during the first consult).

Here’s a script:

Hi Jane,

I really enjoyed meeting you yesterday. We talked about some hard things, and I appreciate your openness. I was thinking further about that panic attack you had last week, and wanted to share this article about riding out panic attacks. It may be a good idea to share this article with your husband too, because I remember you mentioned he felt a bit powerless when that happens. Here’s the link to it. If you’d like to meet again and get started on the goals we spoke about, let me know and we will find a time what works with your schedule.

Warmly,

Erin


  Guest post written by Erin Carpenter, LCSW

Guest post written by Erin Carpenter, LCSW

Erin Carpenter, LCSW, is a therapist in private practice and owner of Thrive Counseling, a group practice in Southeast Denver. Find out more at http://www.thrivecounselingdenver.com

Staying Present: Finding Focus in Session

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In my years in practice, I find building a rapport with the client and being able to stay present during intense moments are of utmost importance. In order to make progress, a foundation must be built where the client feels safe and supported. Below you will find useful techniques in building a rapport and staying present with your client during sessions.

 

Building Rapport

  • Ask the client what specific goals they have for therapy.
  • Make sure the client knows that you are there for them, so if perhaps they deviate from the goals they were working on and/or want to talk about something else during a session, allow them to so.
  • Do not impose your views or beliefs on your client.
  • Be nurturing, empathetic and non-judgmental.
  • Ask how we will know they are making progress or have met a specific goal.
  • Each session, ask what the client may need to explore how the session is productive for them.
  • Encourage the client to voice his/her opinion in the session. If the client does not agree or like something you as the therapist says, make sure you create an atmosphere where they know they can bring that up without negative consequences.
  • Stay present with the client during intense moments, and during all moments.

 

Staying Present

Helpful techniques in doing so include but are not limited to:

  • Ask the client what it was like for them to say that (whatever it is they shared that was painful) out loud.
  • Thank the client for trusting you with the information.
  • Validate the client’s feeling during those moments. “that sounds so painful, sad, terrifying.”
  • Be comfortable with silence.
  • Allow the client to process through at their speed.
  • Tell the client you are there for them, with them, that there is no judgment.
  • Before the session ends, ask the client if there is anything they need to help them transition back into their day.
  • Make sure you (the therapist) know what you need to care for yourself.
  • Yoga, meditation, and exercise may help.
  • In order to stay present, we need to be one hundred percent focused on the client; make sure you seek out your own therapist if needed.

I find these tools useful in my practice and hope you will too.


  Guest post written by Trisha Swintom, LPC, LMFT

Guest post written by Trisha Swintom, LPC, LMFT

Trisha Swinton, LPC, LMFT is a Licensed Professional Counselor and a Licensed Marriage and Family Therapist. Trisha is currently in private practice and has been practicing for about 14 years. She currently works with adults providing individual and couples therapy. Her educational background includes a Bachelor’s degree in Elementary Education, a Master’s degree in Special Education and a Master’s degree in Community Counseling with an emphasis on marriage and family therapy.

http://www.trishaswintoncounseling.com

Working It Out

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“A sound mind in a sound body is a short but full description of a happy state in this world. He that has these two has little more to wish for; and he that wants either of them will be little the better for anything else.” 

- John Locke, Some Thoughts Concerning Educations

 

There is a profound connection between our bodies and minds. Despite our best efforts to help clients identify ways to increase their self-care, often getting a client to exercise on a regular basis is a tough sell. So, if you can’t get them to try going for a walk outside of session, why  not try a Walk+Talk session?

We know that one of the best methods to increase self-care is exercise. Its positive impacts on our clients is well documented:

The effects of exercise have been shown to contribute to:

  • maintaining good health (feeling better physically)
  • weight loss or maintenance
  • healthy physical function (aiding digestion and metabolism)
  • increased strength, stamina, and muscle tone
  • improved sleep
  • increased energy 

And while our clients likely know these benefits, they may  not realize how beneficial exercise can be to their emotional wellbeing as well as their physical wellbeing.  

Exercise has a positive impact on our emotional wellbeing by contributing to:

  • powerful shifts of thought
  • stress relief
  • meditation
  • a sense of calm
  • an emotional release 
  • peacefulness 
  • mental and cognitive effects: 
    • cognitive clarity, a sense of control and a clearer head, self-esteem, optimism 

 

Walk+Talk Therapy

One service I offer is Walk+Talk therapy, where we go for a walk during the client’s session. Walk+Talk sessions have been an effective way for busy moms and working professionals to fit in counseling (while eliminating the need for a babysitter for new parents).  

Many people are drawn to it for convenience, but often Walk+Talk clients report that the movement during sessions has made them feel more comfortable, has aided in their memory, and helps them feel more creative and flexible in their problem solving.  

If you’re a runner or do any type of exercise regularly, you’ve likely noticed the same phenomenon: we often feel our best and have our best ideas while on the move.  

In “Working it Out - Using Exercise in Psychotherapy” by Kate F. Hays, he sums up this effect nicely:

“On long runs I seem to be able to pull together information in novel ways, by letting go of conscious linear thinking patterns.  On the surface, these may appear as random thoughts, yet they end up coming together in delightful and meaningful ways. … The extraordinary part of this is that it is so effortless and perhaps that it happens at all.  The kind of thinking that we spend years developing in graduate school is so taxing, time- consuming, linear. Perhaps Jung was correct after all. Rational, linear, conscious thinking takes effort and is not the way the brain naturally processes information. It is this dreamlike thinking—for lack of better descriptor—that is the way we usually process information. We’ve just learned to ignore and devalue it.”

The wonderful thing is, this dreamlike thinking, (otherwise known as a cognitive shift), that often leads to “ah-ha moments” and breakthroughs is available for the therapist and the client—leading to a productive session and further processing after a session.

Walk+Talk also lends itself to a plethora of therapeutic metaphors and symbolism regarding changes in thinking patterns, nonverbal communication, and empowerment.  

 

Research on Walk+Talk Therapy

Despite this being a unique way to offer psychotherapy, there has been research that has supported its effectiveness:  

  • One researcher has consistently noted positive mood among active individuals and athletes. With exercise, negative moods (labeled as tension, depression, anger, fatigue, and confusion) diminish while positive mood states, such as vigor, increased.
  • In a study comparing running with verbal therapy for the relief of depression, the researchers pointed out that “depressive cognitions and affect seldom emerge during running, and when they do, they are virtually impossible to maintain. 
  • Therapists who have used Walk+Talk have suggested markedly beneficial effects on mood, sense of well-being, and self-esteem (Hays, 1994, Jongsgard, 1989, Sime, 1996).  
  • Another researcher said, “even brisk walking seems to ‘loosen them up;’ they become less inhibited and constrained and more in touch with their immediate feelings and experience. He also observed that clients had more energy, were more aware of anger and assertive needs, talked about what they genuinely felt (in contrast to what they thought they should feel), and were more conscious of themselves yet less self-inhibited or self-conscious.
  • In a study of the relationship between exercise and optimism, participants who engaged in aerobic or a combination of aerobic and anaerobic exercise experienced significantly lower levels of trait anxiety than those engaged only in anaerobic exercise.  
  • Another study found that acute vigorous physical activity among women accustomed to exercise was associated with significant improvements in affect and feeling states, particularly feelings of revitalization, positive affect, positive engagement,  and tranquility. Measuring negative affect separately, they observed a statistically significant, although less powerful, decrease in negative affect.
  • Jongsgard’s study showed: 
    • that exercise is a beneficial antidepressant both immediately and over the long term.  
    • although exercise decreased depression among all populations studied, it was most effective in decreasing depression for those most physically or psychologically unhealthy at the start of the exercise program
    • regardless of gender, exercise was equally effective as an antidepressant 
    • the most frequent form of exercise used were walking and jogging
    • the greater the length of the exercise program and the larger the total number of exercise sessions, the greater the decrease in depression with exercise
    • the most effective antidepressant effect occurred with the combination of exercise and psychotherapy 
    • Jongsgard concluded, “the magnitude of change which results from exercise therapy by itself is as great as that associated with a variety of standard group and individual psychotherapies, some of which, in turn, have been shown to be as effective as antidepressant drug therapy” (p.135, “Working it Out”). 

 

Exercise & Stress

Stress, something we all experience to varying degrees, involves heightened levels of both physiological and psychological arousal.  

Thayer has developed a theory of mood that focuses on the dimensions and interactions of energy and tension.  “Mood is assumed to be closely associated with central states of general bodily arousal with conscious components of energy (vs. tiredness) and tension (vs. calmness)”.  

The most negative mood states are those combining both low energy and high tension.  

Optimal levels, alternatively, are the result of activities that raise energetic arousal, reduce tense arousal, or affect both systems simultaneously.  

The good news?  Exercise serves to regulate exactly these functions. And going for a walk is accessible to many of our clients.  

 

What I’ve Learned

I’ve done Walk+Talk for a few years and have learned that with all of the above noted benefits, there are clearly clients and sessions where Walk+Talk isn’t the best option. In general, I’ve learned that:

  • Walk+Talk isn’t appropriate for everyone, and especially not to process trauma
  • Location matters - pick a route that isn’t brimming with people
  • Eye contact matters - I alternate Walk+Talk sessions with in-office sessions to be able to increase eye contact and to be able to access pscyho-education tools such as posters and handouts
  • A discussion of the limits of confidentiality is crucial

 

The Take Away

Walk+Talk may be a great option for some of your clients who feel stuck, need a change, or who need to add some light exercise to the self-care routine and learn well by example. At the same time, there are limits to Walk+Talk—but the good news is that all of the above information is applicable to our clients—and to us! Being able to go for a walk or run before or after a work day can be a wonderful way to get unstuck with clients and tend to our own self-care and wellbeing.  

 

References

  1. Profile of Mood States, McNair, Lorr & Droppleman, 1971, Morgan (1985b)
  2. Greist et al. (1979)
  3. Berger & MacKenzie, (1981).  
  4. Hays, 1994, Jongsgard, 1989, Sime, (1996).  
  5. Jongsgard, 1989
  6. Gauvunm Rejeski and Norris (1996)

  Guest post written by Brittni Fudge, MA, LPC, NCC

Guest post written by Brittni Fudge, MA, LPC, NCC

Brittni Fudge, MA, LPC, NCC owns Kindred Counseling, PLLC, where she provides counseling and parenting support for parents in all stages of parenthood.  Brittni specializes in healing developmental trauma, family of origin issues, and maternal mental health.  As a mother, mental health therapist, Love & Logic facilitator, parent coach, and former school counselor, her mission is to support parents in their own mental health to become Wholehearted so that the next generation can learn from their example.

http://www.kindred-counseling.com/services/

Strategies for Self-Care: Scheduling Intention

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Self-care is a word we hear a lot in our industry, not just for clients but for professionals as well. How does one define self-care? Is it true that we need to implement self- care in order to prevent burnout? To better understand fatigue, burnout, and the concept of self-care, let’s take a closer look at each of these elements and how they contribute to wellness.

 

Symptoms requiring Self-Care

For many professionals, self-care becomes something to explore when functioning declines. Our clients come to us because their lives are being disrupted and self-care may be needed to recover balance. We are our own worst clients in the idea that we can talk about the importance of self-care to others, but don’t always put it into regular practice for ourselves.  The result of limited or absent self-care is burnout, and burnout can be long lasting or pervasive as it spreads beyond our careers into our personal lives and beyond. In order to explore the impact of burnout for ourselves and our clients, we may find the following list helpful (adapted from Vital Hearts).

  • I don’t know how to relax.
  • I feel irritable more than I’d like.
  • I feel disconnected from my emotions.
  • I’ve isolated from my family.
  • Nothing makes me laugh anymore.
  • I take comfort in sweets.
  • I have no energy to listen to my family when I get home.
  • I escape by sleeping more.
  • I have no empathy at the end of my work day.
  • I’m ignoring my relationships.
  • I can’t seem to disconnect from work.
  • I am experiencing more anxiety.
  • I just want to get away sometimes.
  • I’m angry at my clients for asking so much of me.
  • I feel underappreciated.
  • I can’t read or watch the news anymore.
  • I don’t share my work with my friends, they just don’t get it.
  • I don’t socialize with friends much anymore.
  • I feel restless but don’t want to do anything.
  • I have lost confidence in myself.
  • I feel pessimistic as the result of my job.
  • I feel sadness.
  • I feel drained, I have no energy.
  • I feel angry.
  • My health has declined.
  • I feel like nothing I do makes things better.
  • I can’t concentrate.
  • I cry much easier than I used to.
  • My road rage has gotten worse.

For some, the list above starts the conversation about how much and to what degree life has been impacted by factors of our work as helping professionals.  Burnout untreated can lead to long lasting decline in quality of life and connection to others. Burnout can take away the passion of why you do this work. As we struggle to practice what we recommend to others, how do we change our patterns to support reduction of the negative impact of burnout? Below are some action steps.

 

Wellness Recovery Action Plan (WRAP)

Several organizations in Colorado see the importance of self-care, including the Colorado Mental Wellness Network. Selected by the Colorado Mental Wellness Network and endorsed by SAMHSA, the Wellness Recovery Action Plan (WRAP) is being utilized with various populations to support health and well-being. Colorado Mental Wellness Network supports change through peer to peer connection and wellness education. Through these efforts, they continue to implement WRAP plans within various communities, including those experiencing homelessness and within Department of Human Services caseworkers. What they found was that empowering individuals to notice wellness as well as health decline could support putting self-care into action. Below is an example of a wellness plan that can be used for both professionals and clients to best support their process of identifying and implementing self-care.

 

WRAP

 

Building in Boundaries

In addition to exploring and customizing self-care for meaningful change, boundaries may need to be re-evaluated to prevent burnout. For many helping professionals, long hours, after-hours texts, emails, or calls, client crisis, and urges to help, prevent successful disconnection from work. Technology makes it easy to check work emails 24 hours a day and calls may come in from various parties regarding client care. If there is flexibility to re-evaluate the schedule of work versus home life, it is encouraged. However, the schedule assigned may not be in your control. If this is the case, other means of implementing boundaries may be needed and can include the following:

  • Put an out of office message on email and voicemail to notify others of when you will respond.
  • Separate work and home phones to leave the work phone off during days off.
  • Identify a crisis coverage person to give to clients during vacations or other scheduled absences.
  • Schedule time off in your calendar(s) to support appropriate boundaries.
  • Schedule windows of self-care, even if just for 20 minutes, during your work week.
  • Be concrete with hours for yourself and your clients as to when and how they can reach you.
  • Find self-care you can commit to and put it in the calendar monthly or weekly.

It is with hope that we can create momentum from the talk of self-care into action steps as we continue in our roles as helping professionals. Modeling self-care is both in the benefit of our clients and ourselves as we navigate the busy world of demands in hope of positive change. May we all begin to develop quality self-care in order to find wellness in the path of hard work!

Adult Attachment: Creating Connections from Childhood

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I panic when I don’t hear from them. I just want to be left alone. I want to reassure them that I’m here for them. These statements may capture several examples of responses from clients in your office engaging in work around their relationships. One powerful perspective on the functioning dynamics of intimate partner relationships is to look through the lens of attachment. In other words, by exploring childhood attachment and how it sets the foundation for interaction within relationships, we can experience an increased sense of awareness on how attachment translates to current relationships from needs being met or ignored in our early childhood experience.

 

Bonding Background

The study of attachment can first be linked to Mary Ainsworth and John Bowlby in the 1970s. Mary Ainsworth devised the Strange Situation, an experiment that placed babies in a lab with their attachment figure/parent and observed reaction in the baby as a stranger entered the room, as well as each baby’s ability to be soothed when the parent left the room and later returned. Based on Ainsworth’s research findings, we were able to identify three types of attachment: secure, anxious, and avoidant. Mary Main, another colleague, later identified a fourth type of attachment called disorganized to capture responses that were inconsistent and unpredictable when exploring a baby and their attachment figure.  

 

Attachment Attributes

Secure attachment in childhood looks like a distressed infant that is easily comforted when the attachment figure engages them, such as picking them up and soothing them with soft voice, physical touch, and proximity. In adulthood, the secure attachment individual is highly desired for their ability to reassure their partner and present as calm, grounded, and confident in the relationship. Anxious attachment in children can be portrayed as significantly distressed when the parent exits the room, with increased difficulty to receive soothing or reassurance when the parent returns. In adult relationships, the anxious attachment individual’s anxiety prevents them from feeling reassured in the relationship and can drive their behaviors to present as needy, anxious, and sometimes paranoid that the relationship will fail or that they aren’t “good enough” for the relationship to work.  Lastly, the avoidant attachment type in childhood will manifest in a baby as unaffected, cold, disconnected, and unconcerned with the parent leaving the room as well as an inclination to self-soothe, such as engaging in thumb sucking or playing with toys independently. The avoidant attached child has learned to rely only on themselves in not having the parent fully present, which can occur when parents are working long hours away from the child, are inconsistent in their reactions to soothe the child, or can occur in response to a parent’s mental illness such as depression preventing interaction and ability to attach in healthy ways.  In adults, avoidant attachment continues the theme of self-sufficiency and “not needing anyone” in a relationship, preventing them from connecting at a deeper level with others and can be portrayed as reluctance to commit to a serious relationship.

 

Linking to Literature

With John Bowlby’s Attachment Theory in mind, Amir Levine wrote an insightful book called Attached, that explores intimate partner attachment more deeply and offers examples of adult behaviors that can provide insight or identification of attachment styles. For client use, there are also helpful YouTube videos that can provide a brief overview of adult attachment such as the one found here. Another author, Stan Tatkin, took the idea of attachment a step further by providing symbolic representation of attachment that can also help one identify their attachment style.

Secure Attachment: An Anchor

Anxious Attachment: A Wave

Avoidant Attachment: An Island  

The imagery associated with attachment styles can help a client identify their reactions and resulting behaviors in intimate relationships, as well as assist them in identifying their partner’s attachment style and needs.

 

Creating Connection

In supporting your clients with exploring their attachment, you may find yourself pursuing additional training, such as Emotionally Focused Couples Therapy (EFT) that encourages vulnerable connection in couples and supports healing of attachment wounds. Or perhaps you link your attachment work to Gary Chapman’s The 5 Love Languages or communication and connection strategies from John Gottman’s training for couples’ work. Whatever means you choose to further dive into attachment needs, educating your clients on the possibility of positive shifts, such as moving to more secure attachment with their partners, can support movement towards healthier relationships. Levine and Tatkin emphasize that relationship attachment can shift and a person can present differently in each romantic relationship over their lifetime. With this in mind, exploring attachment can support your clients in discovering their own attachment styles as well as assist them in connecting and fostering healthy attachment in their intimate partner relationships.

Pursuing Purpose: Engaging in Exploration

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Purpose. Impact. Fulfillment. All are meaningful words for a desired way of living your clients may want to maintain in pursuit of a quality life. Society may tell them to find what they love to do and do it for the rest of their life. Individuals tell your clients to never settle and keep pursuing their dreams. Regardless of how it’s described, pursuit of purpose, passion, or fulfillment can be seen as the driving force behind behaviors and identity within the world. And when it becomes hard to grasp or remains unfound, it can create distress that engages your client in seeking support to find answers. Influential author and speaker Simon Sinek calls this quest for meaning, “finding your why.”

 

Learning Through Literature

So how does one start the journey in finding their why? For some, it’s engaging in reading material such as Simon Sinek and David Mead’s book, Find Your Why: A Practical Guide for Discovering Purpose for You and Your Team, or exploring your leadership style with Tom Rath and Barry Conchie’s Strengths Based Leadership. Perhaps you explore your client’s personality through the Enneagram, which is increasing in popularity over the Myers Briggs Personality Test in its ability to develop insight into how one interacts relationally with others from reinforcement in childhood experiences. Any of these sources could support increased awareness not only of strengths, but awareness of the psychological driving forces behind motivation and resulting behaviors. A free version of the Enneagram quiz called EnneaApp can be found through the App Store with additional information and the formal assessment can found at the Enneagram Institute (enneagraminstitute.com). Engaging clients in processing the results of the Enneagram quiz can support insight into how they best relate to others when engaging in collaborative activity or to identify strategies for strengthening of their relationships.

 

Vetting Values

In addition to reading or other homework regarding the Enneagram, another approachable option for exploration of purpose and self-discovery can occur through values exercises. Ranking a series of values by level of importance can allow further insight of what motivates a person. By engaging in a values exercise, it allows one to check in on how important values are being experienced both in the present moment and how they can be improved in the future to support feelings of fulfillment.  A free, online resource to engage in exploration of your values can be found by completing the Life Values Inventory (lifevaluesinventory.org). As a helping professional, you may also invest in making or buying value cards that are easy to sort as part of therapeutic activity. The act of sorting presents as a low risk activity and encourages clients to remain aware of their gut reactions rather than finding themselves in analysis paralysis, which allows authentic processing outside of society pressures or others’ values influence.

 

Core Beliefs and Cognitions

Engaging in the progressive work of processing behavior patterns and values can also be explored through therapeutic work. Identifying negative thoughts or core beliefs can create new connections and awareness between actions and reactions. Core beliefs can be described as our deepest, sometimes darkest fears or beliefs about ourselves, usually focusing on negative traits such as feelings of unworthiness, being unlovable, or feelings of failure.  When experienced, core beliefs can engage visceral reactions in the body including intense feelings of shame and fear. When explored through trauma therapy modalities such as Eye Movement Desensitization and Reprocessing (EMDR), healing can be accelerated and supported to re-write client views of negative beliefs to something more positive, thus improving self-esteem, functioning, and relationships with others.

 

Career Counseling

One final therapeutic element that can support clients in pursuing purpose is career counseling. Career counselors, by trade, support individuals in discovering their strengths, possible career paths, and can support clients in preparing for career interviews, resumes, and choice of higher education if desired.

Whether you engage your client in the above-mentioned exercises to improve self-esteem, discover purpose, or develop new insight, reassuring your clients that self-discovery is an exciting, sometimes lengthy process to uncover passion and motivation can set realistic expectations for your therapeutic work.  However they go about engaging in “finding their why,” it is the hope that they enjoy the process and engage fully to uncover their recipe for success and achieve feelings of fulfillment!

Geared towards Growth: Exploring Maslow’s Hierarchy of Needs

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Have you had a client come into your office wanting to work on their relationships? What about a client who wants to work on self-worth and self-esteem? These goals are valuable and achievable, and could greatly benefit your client in their functioning and connection in the world.  However, depending on your client’s stressors and current life events, basic needs may need to be attended to first in order to achieve the growth and progress desired within your therapeutic work.

 

Hierarchy of Needs

Abraham Maslow first introduced the concept of a Hierarchy of Needs in a paper published in 1943. The image found most often in reference to his concept is a pyramid with the bottom representing the building block or foundation for higher functioning. According to Maslow, every human being has needs that must be met and stable prior to advancement to another level of human need. The levels he identified begin with physiological needs, followed by safety needs, love and belonging, esteem, and finally, self-actualization. Below are some examples of needs for each level:

  • Physiological: food, water, oxygen, sex, sleep, excretion
  • Safety: security of shelter, employment, resources, health, body
  • Love & Belonging: family, friends, intimate partners
  • Esteem: confidence, self-esteem, respect by others, respect for self
  • Self-Actualization: Acceptance, lack of prejudice, enlightenment

 

Goals for Growth

So how do the levels of need impact your client’s therapeutic work? For many helping professionals, the awareness of the hierarchy manifest through client psychoeducation around basic needs. Perhaps your client wants to work fully on their relationships, but is impacted by the stress of not having a job to pay their bills. Maybe your client wants to strengthen self-esteem, but can’t identify housing in suffering from an eviction this month. The present crises will require therapeutic attention and intervention first prior to a client allotting mental energy to higher levels of functioning.

Within your work, it can be helpful to normalize and educate your clients on basic needs being the foundation for functioning. You may consider describing the imagery as basic needs being the foundation of a house. If the foundation is crumbling, the other parts of the house become low priority or unseen in trying to stabilize the problem due to risks of it all collapsing around them. With this analogy, clients can absorb the importance of a stable foundation of basic needs requiring their attention before other goals can be successfully met.

 

Accessing Needs

A stable foundation may require other resources outside of your office. As a helping professional, it is in your best interest to be aware of resources to provide additional support to your client. The databases in your state, (Colorado Crisis Services and Colorado 2-1-1 for example) can be helpful in identifying food, shelter, clothing, legal advice and more.  You may also consider coordination with helpful organizations that would warrant a release from your client in order to collaborate.

Assessing needs can also occur from a place of looking at client resistance. One way this may manifest is through your client’s capacity to work on homework or assigned tasks between sessions.  Although some clients don’t like homework out of personal choice, other clients may struggle to articulate the crises that prevent progress on the homework you assigned, including forgetfulness, loss of focus, or stressors demanding their attention instead. This attempt at juggling varying demands could even translate to cancelled sessions in trying to handle the stressors at home or work. By being aware of basic needs, it can help you as the professional to better understand contributing factors that may present like resistance as elements requiring attention to support client progress.

 

Maintenance and Motivation

With collaboration and stabilization of basic needs come the client’s motivation for maintaining the foundation.  It is the hope that client’s basic needs, once addressed, remain in good standing.  However, with clients experiencing poverty, trauma, or other adversity, the fluctuating circumstances of their life can delay progress on higher functioning goals. Encouraging ongoing boundaries and self-care can support the client in reaching higher goals around self-esteem and relationships. With awareness and effort, a client can harness a healthy sense of control and autonomy in their life. Remaining flexible to the stressors that may occur between sessions, it is important that you and your client continue to be mindful of what takes precedence to allow the deeper, meaningful work you both value to occur at the appropriate time.

Supporting Self-Esteem: Tools to Identify Strengths

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“I don’t know what to say. I was raised not to talk about myself. I don’t want to sound cocky.” You are engaging your client in an intake session where you’ve created an intentional, positive shift from an otherwise heavy series of questions about symptoms including details as to why they are seeking therapy. Your new client appears caught off guard by your questions about strengths and they struggle to identify anything that is going well, or things they like about themselves. You make a note to identify a possible goal around self-worth and self-esteem, to be explored with the client upon building more rapport.

So how does one engage a client in exploring their strengths while acknowledging the vulnerability to do so? For many, talking about elements they like about themselves or their resiliency may be difficult when entrenched in negative emotions.  For example, a client experiencing a depressive episode may have a hard time identifying any emotions of hope or former pleasure based on their current negative cognitions around hopelessness and feeling stuck.

 

Look to the Past

For depression and being entrenched in symptoms, it can be easier for a client to recall the events or strengths of the past than experience the present or predict the future. By engaging a client in exploring what would formerly describe their circumstance, you can encourage the initial stages of cognitive reframing and thus rewiring from negative to positive thought. Some examples of questions to support access to the past can be found below.

  • Is there a time you felt confident? Can you tell me more about that?
  • When is a time you felt like everything was going well? What made it so?
  • Wisdom, Sacrifice, Kindness. Can you share a time you demonstrated each of these strengths?
  • What is one thing you are happy or satisfied with in your life?
  • What is one thing you like about yourself?

Engaging a client in reflection on these elements can support new awareness and positive feeling through revisiting pleasant memories. By exploring former experiences, the client may be able to identify ways to rediscover those experiences in the present.

 

Likeable and Lovable

If a client continues to struggle with identifying their strengths, it can be helpful to engage them on the thoughts and statements of others that know them well.  You may find asking them what their mother, sister, friend, partner, or close colleague would say about them if those relationships are healthy. Here are some ways you could explore self-image through the eyes of others:

  • What would your mom say is one of your strengths?
  • What compliments have you received from others about your efforts at work?
  • How would you be described by your best friend?
  • What do you think your partner appreciates most about you?
  • If you were represented by an actor for a movie, who would that be and why?

By encouraging the client to explore loved one’s statements or compliments as a reflection of their own strengths, it may remove some pressure to identify them on their own while still encouraging positive thought and reflection.

 

Sort and Seek

A reflection tool that can further encourage exploration of strengths and thus improve self-esteem is a value sort. A value sort instructs clients to review a list of values and narrow down their choices based on order of importance. This can allow clients to explore their values and make connections to how those values are being represented in their life. A favorite tool is the value card sort, currently being used by mental health professionals and some universities. In the value card sort, a stack of values is sorted into levels of importance including minimal, moderate, and most important. Client are instructed to go with their gut and sort quickly, supporting a narrowing of values to the top seven most important to the client. Reflection can then be encouraged by asking the client the following questions:

  • How are these seven values represented in your life currently?
  • How are these values represented in work, home, and relationships?
  • What needs to be changed or improved to maintain these values for you?
  • How would enhancing or improving these values in your life help you?

For many, exploring their values and current representation in their life can support a movement towards measurable goals to improve those values, thus improving sense of control, pursuit of happiness, and higher self-esteem.

Mastering Mindfulness: Supporting Positive Coping

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“I want to turn off my mind, catch my breath, feel less tension, sleep better.” The techniques of relaxation and mindfulness have been around for centuries, both in definition and in practice in various cultures. For some, the process of mindfulness describes being aware of your surroundings and slowing down your mind to remain in the present moment. For others, it has become a vital coping skill for anxiety or distress to allow grounding, emotion regulation, focus, and a sense of calm in otherwise difficult situations. So how does one present the ideas of grounding, mindfulness, or relaxation to clients in meeting their individual needs?

 

Explore the History

For many, the concept of feeling relaxed or calm is experienced rarely due to elevated anxiety or trauma triggers in everyday life. Perhaps you start a session with exploring the times they’ve felt more at peace or relaxed. Even if it were years in the past, this exercise can provide helpful insight into situations or context that allow your client small shifts or temporary relief from discomfort or anxiety.  Questions that might help you explore this with your client include:

  • Can you remember a time when you felt calm and relaxed? Can you tell me more about it?
  • How does it feel in your body to experience calm or relaxation? What sensations do you experience?
  • What has helped you before in feeling calm or relaxed? What makes that different now?

 

Become Body Aware

Exploring the history of times a client has felt calm or relaxed is but one piece of the puzzle. Depending on the client’s background, trauma history, or the impact fight/flight/freeze reactions, their body may have adapted to the increased stress and cortisol levels in interesting ways.  Some clients will express increased anxiety or panic in response to relaxation, as it feels vulnerable or uncomfortable in their current, adapted state of functioning.  For others, a numbness may exist where they cannot feel their body with possible contributing factors including depression, hypoarousal/freeze response, or desire to maintain self-preservation. Lastly, clients may easily drop into intellectual conversation about their symptoms but avoid experiencing any sensation in their body due to anticipated discomfort or negative arousal.

Keeping client limitations and comfort in mind, it can be helpful to encourage clients to gently become more aware of their body through various therapeutic activities. It is suggested to start with neutral areas of the body and move quickly from one area to another to prevent exacerbation of sensation that would prevent progress or cause a client to retreat from noticing their body out of fear or discomfort. By engaging them in the following activities, you can support a client in building body awareness and distress tolerance in ways that feel safe.

  • Body scan-start at your feet and notice any sensations as you move gently upward to your calves, thighs, hips, waist, etc.
  • Concentrated body scan-have the client identify neutral or safe areas that aren’t associated with negative sensation like hands, knees or feet.  Have them focus on one area in detail, asking questions about temperature, sensation when touched, and encouraging the client to engage in use of textures and varying touch to explore sensation.
  • Colored Glasses-our new favorite intervention from Dr. Dan Siegel in his book Mindsight, obtain or create colored lens glasses for clients to explore varying perspective of objects around them, insight into sensation in low-risk ways, and connection to memory that all support the practice of mindfulness.

 

Use all Five Senses

All of the above exercises support experiential learning in session. Another favorite tool that can support a client who experiences any negative sensation or experiences hyperarousal or flooding during a therapeutic exercise is to move their attention outside of themselves and into the room as a grounding technique. To do this, you can ask the client to become more aware of the chair underneath them or their feet on their floor.  A few of our favorite tools are listed below that can be helpful in engaging a client outside of their own body.

  • 5-4-3-2-1: What are five things in the room that are blue? Four things you can touch? Three things you can hear? Two things you can smell? One thing you can taste?
  • Four Elements by Elan Shapiro: 1) Earth/Grounding: what do you see/hear/smell, 2) Air: Take measured breaths, inhale for four counts, exhale for four counts, 3) Water: Take a drink of water, use gum/mints or think of your favorite food to generate saliva, which serves as a calming agent to activate the parasympathetic nervous system and relaxation response, 4) Fire/Light: think of a place real or imagined that makes you feel calm or safe. Can you describe it using your five senses?
  • 5 Minute Mindfulness: have the client pick an object to focus on, either in their hands or within sight. Gently direct them to notice all qualities of the object including temperature, texture, color, height, etc. for five minutes duration.

 

Modeling of Mindfulness

In addition to the mindfulness exercises listed above, it can also be helpful to create a coping kit of objects that can be engaging and cater to all five senses for client use within your office. Many therapists utilize objects such as essential oils, lotion, touchstones, magnets, putty, carved wooden objects, fur, water, and sand to engage clients in mindful practice. As your client discovers which objects are effective for them to practice mindfulness, you may encourage them to purchase and utilize these objects outside of session as well.

Regardless of which tools or techniques you elect to use in support of your clients, it can be even more helpful to notice your own body and energy in the room. By becoming aware of your breath, posture, and energy levels, you can support client in feeling safe or supported to do this work. By practicing alongside your clients, you model what it means to feel grounded or mindful, which is beneficial not only to your client seeking relief, but to yourself as the clinician mindfully engaging each client in their meaningful work and progress towards health.

Holding Space for Horror, Hurt, and Healing

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Have you ever felt the sensation of déjà vu? The gut feeling that you’ve been here before and thus can’t escape this surreal feeling, like you’re floating, your stomach is full of rocks, and there’s a ringing in your ears? For many of us, February 14, 2018 was a day of déjà vu in its worst form, reliving the trauma and horror of another mass shooting.

For me personally, the sudden anger, sadness, grief, and avoidance that came to the surface were the very same that I experienced after the Aurora Theater Shooting on July 20, 2012.  For others, it felt like Columbine on April 20, 1999.  Many people around the world are affected by the loss and violence surrounding a mass shooting and so many of us want answers. As therapists, we hold space for the questions and the grief, providing a safe environment for processing of loss, fear, and desire to understand. As trauma therapists in particular, we encourage clients to explore fears and needs in order to feel heard, and possibly, to begin the healing process again. And yet there are days we struggle with balance, the effort of holding space for others as well as holding space for ourselves.  If we are completely honest, it may even feel easier to hold space for others rather than think and feel our own emotions.

Professionally, it didn’t occur to me that Aurora would stay with me in my practice, year after year. July 2012 was supposed to be a month of celebration as our cohort had graduated and were seeking our first jobs as therapists. We had bonded in role plays, through projects, on adventures, and with humor. Survived internships, passed exams, and grew as individuals. Aurora would prove to impact the cohort quite rapidly when we found out four of our own peers were present and involved in the violence that took place. It took all day to get answers about their safety, and when we finally did receive word, we came together to grieve the loss of one of our own and trauma to three others. You may know him as the hero who took a bullet for the woman he loved, shielding her from the chaos in the theater. His actions show his character and the person he was in this world. There is so much I could say, but know that he was loved by many and brought humor and lively spirit to otherwise heavy work. We grieved together over the weeks that followed, knowing the impact would go beyond our cohort and be felt around the world.  Before we could blink, the cohort was scattering rapidly, almost like a driving force was pushing us away from one another, and away from the reminders of what we’d lost. It became easier to avoid and attend to others, to embrace their pain and needs for healing by throwing ourselves into the therapeutic work, perhaps hoping to heal ourselves in the process.

And yet with each new tragedy, full of images, horror, and tears, we are transported back to our own dark times. Perhaps triggered to the point of needing breaks, tracking our own emotions, and holding boundaries with our clients to stay present in their grief. Grappling with whether to share our pain with clients out of connection and compassion or decide to lock it away for another, more private time.

Whatever direction you decide in your own grief, know that your efforts to help others through connection and compassion go a long way in recovering from these tragedies. Let us be gentle with ourselves as we are with our clients. Let us acknowledge the hurt and remain open to the healing. Let us recognize the avoidance of pain and the safety needed to face it. And let us hold space when words cannot capture what is felt rather than said.  Only when being true to ourselves and embracing vulnerability can we truly support healing.

In loving memory of Alexander C. Teves