Time-Limited Treatment

CBT, and some other models of treatment, advocate for beginning therapy with predetermined time limits. For example, manualized CBT for Eating Disorders involves 20 sessions for most clients, and 40 for markedly underweight clients. The authors of the manual discourage extending treatment except to compensate for disruptions in treatment due to life crises, etc., or in cases where there are symptoms that "continue to interfere significantly with the patient's functioning and are unlikely to resolve on their own." That means that treatment may end even in the presence of continued symptoms, as long as the client is making progress.

There are a few reasons given for this approach.

1) Having a set time-limit from the beginning creates and maintains momentum throughout treatment, by putting pressure on both therapist and client to make the most of the time they have.

2) Ending treatment before symptoms have completely abated, assuming that the symptoms will continue to improve naturally without further intervention, based on the treatment already provided, serves to foster client self-confidence, and reduce dependence on therapy or therapist.

3) Scheduled endings are more likely to be planned rather than unexpected, which allows necessary time to be spent consolidating gains and engaging in relapse prevention.

Of course, advocating a time-limit requires determining how many sessions over what period of time is most efficacious for various client groups with various presenting problems. It also does not address the possibility of multiple comorbid conditions that influence each other and cannot be separated to address sequentially. There are probably other potential logistical difficulties as well.

I find myself somewhat dubious of this sort of predetermined time limit, but can see why it makes sense to some theorists and clinicians; I just have not had enough experience with time-limited formats to make an educated comparison. Have you had experience with both time-limited and ongoing treatment formats? If so, what do you see as the benefits and drawbacks of each?

Goodness of Fit in Therapy

The Ecological Theory of human behavior in the social environment suggests that how well someone functions in life is the direct result of the "goodness of fit" between the person and their environment. So, for example, how well a student learns is heavily influenced by the degree of fit between the teacher's teaching style and temperament, and the student's learning style and temperament. Similarly, two children with different temperaments may respond very differently to the same parenting; for example, what one experiences as playful roughhousing the other may experience as overwhelming or threatening.

Goodness of Fit is also a factor in the therapeutic relationship. Different clients respond differently to different therapists' styles, manners of interacting, and intervention approaches. When the fit is good, outcomes may be better than when the fit is less good. It's also likely to be more satisfying for both client and therapist. In contrast, if it's a bad fit, the client is more likely to be guarded, defensive or resistance, and the therapist may be less likely to be empathic and patient. As a result, the process is less likely to be therapeutic, and may even be counter-therapeutic.

Working in agency settings, at least in the settings where I've worked, "fit" is rarely a consideration - or at least, not a deciding factor. The decision tends to be more about numbers - what clinician(s) have room in their schedule or a smaller caseload. Sure, if multiple clinicians are available, the person assigning cases may consider who may be a better fit. However, once the assignment is made (i.e., by the time the clinician and client meet for the first time), it's usually a "done deal" - clients and therapists are typically discouraged from requesting reassignment.

Private practice is a totally different ballgame. Both clients and clinicians have a lot more choices, and the ability to "shop around" for the right "fit." Granted, clinicians don't necessarily want to be too picky, especially starting out, and clients may also find the process of trying out various therapists (and repeating the intake process over and over) becomes onerous if they are too picky. Nevertheless, both have significantly more control over whom they see.

So, what makes for a good "fit" in therapy?

From the perspective of the client, trying to choose the right therapist, you should:

1) Feel comfortable enough to be open about what you're experiencing...without expecting that you'll feel totally comfortable. This is a stranger, after all, with whom you're sharing very personal information. If you expect total comfort from the beginning, you will discount providers who could actually be a really good fit for you. You want someone who challenges you in some way - that's what produces change. It should feel different than talking to a friend.

It's also common to experience whatever relationship issues you may have in life getting played out in relationships with therapists - this is actually good and productive, and helps resolve those issues if you can stick it out. Deciding that it's a sign the therapist isn't a good fit just means that you're putting off an issue that is likely to come up again with the next therapist.

2) Feel like the therapist can help you (i.e., they know something about what you're dealing with), and find their approach acceptable. You don't have to totally understand or believe in all aspects of someone's approach, but if you're operating from totally different worldviews, that can be an obstacle.

3) Consider the logistics - does the therapist's availability work for you? Does the location make sense for you? Is the therapist's financial policy acceptable to you (for example, whether they will go through your insurance, what your copayment or fee is), and do you understand no-show or cancellation policies? If these logistics aren't acceptable to you, they are bound to become barriers in treatment.

From the perspective of the therapist, the consideration of fit has to consider:

1) Our ethical obligation to clients. Specifically:Do you feel you can competently treat this client? Do you have knowledge and expertise with the client's presenting problem? And, although this piece is rarely acknowledged, do you feel able to empathize with the client? If you can't establish empathy, the treatment is not going to work, and while we probably all pride ourselves on our empathy, sometimes there really just is a bad fit, and our own "stuff" gets in the way. Our responsibility, when we don't have the expertise, or empathy for a particular client, is to make a referral to another professional who might be a better fit.

2) Workload balance. Our practice is only likely to feel manageable if we maintain some balance in the work we take on. If we already have several high risk clients, it may not be feasible to take another one. Similarly, there may be a limit to the number of clients with personality disorders we can manage, or the number of cases with a lot of collateral involvement, etc. We have to recognize and listen to our own limits.

3) Logistics: Like the client, we have to consider our schedule and availability (whether we are able to take a client during the time(s) the client is available), and financial agreement (whether we can take the client's insurance, for example).

There may be other considerations on either side. How do you think about finding the right fit between therapist and client?

The Sweet Spot

When it comes to how long clients stay in treatment, there seems to be a "sweet spot." When clients discharge prematurely, they are at greater risk for relapse, either because there are more residual/unresolved/partially-resolved symptoms, or because progress/changes made in treatment are still new and therefore harder to sustain (or both reasons). These risks seem relatively obvious - widely accepted among practitioners, and cited in textbook discussions on termination.

Less widely known/discussed are the risks of clients staying too long in treatment. There seems to be a window during which clients are ready for discharge, and able to sustain progress without treatment at the current level of care. Symptoms have resolved sufficiently, and their developmental momentum is in the direction of health and recovery (helping them continue forward movement after treatment ends). However, if they linger too long in treatment, the momentum shifts - the treatment may stagnate, or even regress. Symptoms may reemerge and motivation may flag. Discharging a client with this kind of momentum - away from, rather than toward, health and recovery - also poses a greater risk of relapse...perhaps even more so than clients who discharge too early.

While it is easy to describe this "sweet spot," in practice, it can be deceptively hard to hit. There are several factors that make it challenging to gauge a client's readiness for discharge:

1. Uncertainty about whether symptoms are resolved "enough" (given that there is probably no person on earth who is truly free from all mental health symptoms!) - clinicians may find themselves second-guessing whether the client is actually free of "clinically significant distress," or whether residual symptoms are harbingers of a coming relapse.
2. The client's own anxiety about discharge - often, clients doubt their own ability to maintain changes without the support of treatment, and the idea of discharge may send them into a tailspin. Clinicians may be reluctant to discharge a client if s/he is uncertain about wanting discharge, and/or the client's anxiety may be contagious and make the clinician also doubt his/her readiness.
3. Attachment - the client's attachment to us, and our attachment to them, may make both parties reluctant to discharge due to anticipated grief.
4. Agency culture - Some clinics operate on the principle that clients should receive as much treatment as insurance companies will authorize. And while insurance companies do their best not to authorize more treatment than the client genuinely needs, it's not a perfect system (after all, all they have to go on is what clinicians tell them!). Accrediting bodies (which are different than payors!) require that clinical decisions be made based on clinical presentation and not on insurance. While it may be...profitable...to keep clients in treatment as long as possible, it's not good for clients, and it's not ethical practice. We all need to be in the habit of using our clinical judgment rather than being guided by insurance.

How do you think about readiness for discharge? How do you find the "sweet spot," and what makes it difficult?

Face Time? Reflecting on Cell Phone Use in Treatment

We have interesting relationships with our phones these days. They keep us continuously connected to one another, least of all by phone calls, and more and more via text, email, social media, and even sometimes "facetime" (like a phone call with video). We live in a world where we expect instant access, instand information, to be constantly reachable, and to reach others constantly. It's almost an addiction.

An like an addiction, we may go through withdrawal if we have to be away from our phones and out of contact. I know that I, for one, get anxious and start to imagine what I might be missing. And I don't even use my phone that much (since it's web applications are too slow!).

Given the significance of the phone in our culture, what is its significance for treatment? Here, I'm setting aside the complex question of telephone calls between therapist and client, and simply thinking of the client's phone and what it represents.

There are layers to this question, as there seem to be layers to so many things in therapy. One interesting dynamic has to do with the role of phones in substance abuse treatment. If you've worked with this population, you know that they cannot have their own phones in treatment programs. The reason is that their phones represent a connection to the drug world. Not only do they most likely have contact information for deals and people they used with stored in the phone, but those people most likely also have the client's information, and may call to offer drugs, invite the person to "hang out" (and get high), or to ask the client to get drugs for them.

However, amputating people's phones doesn't really solve the problem. Not only can they still get drugs if they really want to, they also can't get in touch with supports for recovery. They can't call their sponsor, or other people from 12-step meetings, arrange rides to meetings, reach or be reached by their providers. It's always a frustration to me when I work with clients who are in a program and have no phone, because inevitably there is some occasion when they or I have to miss a session, and rescheduling is practically impossible.

Phones can also influence other kinds of treatment, particularly at any level of care other than standard outpatient individual therapy. People on inpatient units typically cannot keep their phones with them, and don't have phones in their rooms, with public payphones the only option. I understand the rationale. In medical facilities cell phones can disrupt certain medical devices, and in psychiatric facilities, there's always the risk that interacting with people from outside could be a stressor and lead to decompensation, or even aggression. However, as with substance abuse treatment, removing phones also isolates people from supports that could help the person stabilize and feel more hopeful about life outside the hospital. And more selfishly on my part, I'd like to be able to reach clients in the hospital, since all too often I'm not even notified if a client of mine is admitted.

In group treatment, phones take on a different role. Since most phones have cameras on them these days, phones represent a potential breach of confidentiality if people take any pictures during treatment. Texting and web access also open the possibility of breaking confidentiality, or even "subgrouping" - contacting other people in the group during or after group to talk about what is going on. However, in psychoeducational groups, phones with web access could be a way to check or gather related information. On the whole, however, phones seem to be at best a distraction, and at worst a way of derailing group process. However, with a large group it may be hard to always know if someone is texting, or just looking at their labs...particularly if the group is sitting around a table.

How do you see cell phones playing into treatment dynamics? Are there particular populations or settings where they seem most positive or negative to treatment?

Electronic Medical Records in Therapy

We all know that electronic medical records are the wave of the future. The very near future. In fact, the wave is washing over me as I write this! The outpatient clinic where I do some fee-for-service transitioned this week from paper progress notes to computerized ones.

The change was accompanied by the usual technological glitches (I didn't have access to the drives when I got there, which was a definite issue!), and special trainings for those unfamiliar with the new format. Some of my colleagues have been resistant to the whole idea, but in general, I'm like the idea of going electronic. For one thing, all that writing takes a toll on my hand! I'm especially looking forward to being able to cut and paste things that are the same each time, but I've had to write out again and again anyway. It's also more convenient to reference past notes, assessments, and treatment plans, and makes it much easier to find out what other providers (e.g., prescribers) are doing with a client (not to mention being able to read what others have written!).

That said, there are also some drawbacks. For one thing, most clients are fairly comfortable with the idea of therapists writing during a session. Typing is another thing altogether. We're slowly getting used to medical doctors using a computer during consultations, but many people still feel like the computer distances patient from provider, or even complain that doctors don't seem to be listening (because they're looking at a screen). Since such a crucial part of therapy is feeling heard, anything that interferes with feeling heard is a problem.

Even if we position the computer strategically and touch-type so that we can maintain eye contact while making notes, we still have to think about the sound typing makes, and what effect that might have on the client. Hand-writing can be pretty unobtrusive - someone who is engaged in affective processing is probably not paying much attention to whether or what I'm writing. However, if I'm typing, it's clear when I am - and am not - writing. My prediction is that more clients would wind up wondering what I was writing as they began to notice the timing of writing - and to engage in projection and possibly transference about it.

From these reflections, it seems clear that typing notes (at least during sessions) would result in some changes in the feel of the session. The obvious solution, of course, is to NOT type notes during sessions, but do it after. That sounds like a great plan - but it assumes the luxury of 50 minute hours, with that ten minutes at the end for mundane things like paperwork. I don't know about you, but I don't live in a world of 50 minute hours. I live in the world of 45 minute back-to-back sessions before I have to run out the door to make it to my other job on time. Everyone I know who isn't in private practice has to think about productivity, and would have to do any paperwork that doesn't get done during the session on their own time.

So what's the solution? I don't really know. Better pay for lower productivity? We can only dream. Clients resigning themselves to typing during their sessions? I fear that's more likely. What do you think about how electronic medical records will or should be integrated into mental health treatment?

Ink

About 25% of people under age 50 have tatoos, and that number goes up when you look at younger segments of the population. It seems like it's almost a rite of passage these days to get "ink." While I don't actually have one, many of my friends and colleagues do. More conservative folks may get tattoos in areas they keep covered, but it's becoming more and more mainstream to have tattoos on places much harder to hide - hands, forearms, neck, ankles, feet (yes, I know feet can be hidden - but I wouldn't want to wear socks all summer!).

However, for better or worse, the corporate world - including healthcare - has not caught up with the times. Every company I've worked for has a policy barring visible tattoos. While enforcement of that policy seems to vary widely based on the agency and position, I can see how many clinicians in my age group might face tattoo-related difficulties at work.

When such difficulties arise, it may be tempting to abandon agency life for the freedom of private practice. However, regardless of the setting, it's important to consider the possible impact of tattoos on the treatment process.

The senior managers who establish tattoo policies are probably doing so based on their ideas about "professionalism" - along with other decisions about dress code, and the like. While a professional presentation is certainly important for therapists, I also think it's possible to appear professional with visible tattoos (if they are tasteful and unobtrusive). The bigger concern for me is how clients will interpret the tattoo.

Tattoos are a mode of expression, so we have to assume they will express something to clients - but much of their own individuality shapes their interpretation of the tattoo's "message." It would be a mistake to make assumptions about what that interpretation might be. When in doubt, and it seems that a visible tattoo is drawing a client's attention, I would say the best bet is to make it a manifest, rather than latent, part of the conversation - it's all grist for the mill, after all.

The tattoo may also shape the client's transference to the therapist. After all, a tattoo, as a form of self-expression, is the opposite of the "blank screen. It may influence what other relationships get layered over the therapeutic relationship, what associations are called up, and therefore significantly shape the content and context of therapy.

Whether or not transference becomes a factor, tattoos are inevitably a form of self-disclosure, and should be considered with the same care as other forms of self-disclosure. Will it help, hinder, or be neutral to the therapy? What would it be like for you to have the client interpret (and possibly misinterpret) it? What might it say about who you are, and how might that influence the client?

In all of these considerations, the population matters quite a lot. With some populations, a tattoo may make the therapist feel more accessible, and be a way of joining with clients. In other populations, it might lead to negative judgments of the therapist, or (with kids, for example) be seen as advocating a lifestyle key stakeholders (parents, funding sources, the board) don't support.

The bottom line is that, while you might not even think about your tattoo that often, if it's visible, you need to think about how that might impact your clinical work. If you're thinking about getting a tattoo, you might want to consider one you have the option of hiding if necessary (rather than wearing a band-aid all the time, as one of my colleagues had to do). If you're bent on a spot that you can't hide easily, consider the tattoo and it's message carefully - it will become part of your presentation as a professional!

Continuity vs. Cohesiveness

I work at an agencies that provides a continuum of care including inpatient, residential, partial, and intensive outpatient levels of care. In these programs, and in similar programs where I've worked in the past, there has been significant emphasis on the multitdisciplinary treatment team.

The idea of the treatment team is that the various professionals (psychopharmacologists, social workers and other clinicians, nurses, dieticians, program directors...) staffing a given program at any level of care will meet regularly to discuss each client's treatment and develop a coordinated plan of care moving forward. For individual clients, the benefit of this team approach is that everyone is on the same page, supporting the same treatment goals with complementary interventions, rather than duplicating efforts or accidentally getting in the way of each other's interventions. It also gives staff the opportunity to share insights, and any new information gathered. Clients appreciate not having to tell their story repeatedly, and I, for one, appreciate having a little background on clients I don't work with individually but do have in groups. Finally, from a program perspective, all of the treatment (groups, family meetings, individual sessions and case management) is being done by members of the team, so a cohesive treatment program can be developed with contributions from each team member.

Sounds logical and beneficial, right? The only down-side relates to the concept of a continuum. By virtue of their cohesion, treatment teams may contribute to each program feeling separate and distinct from other programs on the continuum. Whether that is problematic depends on the program and agency goals. If programs aren't meant to be connected, and are even run by different agencies, they will obviously be separate. However, when the continuum of care exists within one agency, with the goal of smooth and seamless transitions between levels of care...separateness can be seen as a barrier.

Thus, my agency is shifting the way treatment teams function on its main campus. Specifically, a plan is being implemented such that each client will keep the same social worker/clinician as they move between levels of care. It is supposed to allow for deeper and more effective individual work, less repetition in the form of new assessments at each level of care, and a sense of continuity during transitions.

These goals also sound logical and beneficial. The problem I see is that the move toward continuity comes at a cost to cohesion. When the clinician is part of the treatment team, running groups etc. at one level of care, but managing cases at multiple levels of care, it becomes challenging to know what's really happening with clients in treatment in the programs where the clinician spends less time. There may be miscommunications over program policies and expectations, a delay in communicating concerns that arise, and misunderstandings over interventions and treatment goals. Communication is just less effective, because the number of people involved has increased and the face-time has decreased.

So, what matters more to effective treatment: cohesion or continuity? I don't have the answer, but I do think it's important to ask the question! What do you think?

Therapists Take Vacations Too

When you're a therapist, taking time off isn't as simple as putting in a request for vacation. Because the primary tool of the trade is the therapeutic relationship, we have to consider the implications of our absence for each of our clients. Of course, that doesn't mean that we should avoid taking time off because of a client's possible reactions - time off is necessary for self-care, to prevent burn out and keep us available to our clients during the many weeks we're not on vacation.

However, it does mean that we should prepare for our clients' possible responses to our absence, using both preparatory empathy (imagining by ourselves how the client may think, feel, and act), and in-session processing of clients' reactions. (And, of course, be sure we have emergency coverage available for clients during our absence).

For some clients, a vacation may cause minimal disruption or anxiety. These clients tend to have a secure attachment style, and are therefore able to maintain a sense of connection even in the therapist's absence. With these clients, there may be some loss of momentum due to the therapist's vacation (a longer time between sessions means less clear recollection of the conversation, and longer breaks may get clients out of the "habit" of self-reflection), but no loss of trust.

However, many clients have insecure attachment styles. These clients experience more uncertainty and anxiety about relationships, and may therefore have a stronger reaction to the therapist's absence. Clients with dismissive attachments may minimize the significance of the disruption...but may simultaneously demonstrate the disruption by becoming distant, picking a fight, and/or missing sessions. The intervention may be naming the dismissiveness, validating the insecurity the client is feeling about the relationship, and reaffirming the continuity of the relationship in spite of the break.

Clients with preoccupied attachment styles are more likely to become anxious about whether the relationship will withstand an interruption like a vacation. They may appear or express anxiety directly, or may seem less certain of the therapist's availability or interest before or after the break. They may seem needier, with more urgent needs, questions and requests, more frequent calls, and more need for reassurance or encouragement - all subconscious ways to test the strength and continuity of the relationship. The intervention is to name the anxiety, provide reasonable (but not excessive) reassurance, and demonstrate continuity by having established appointments before and after the break, a consistent level of availability and empathy.

Clients with unresolved attachment styles may demonstrate a mix of the above responses, and are the most likely to regress before and after an interruption in treatment (though others may also show some regression). The best response may be to name and validate the mixed response (anger, anxiety, dismissiveness, etc), provide concrete reassurance about the stability of the relationship, and be available, reliable and consistent before and after the break.

How do you handle clients' responses to vacations? Are there responses or difficulties your clients have that I haven't included? What seems to minimize the disruption for clients?

Personal Space?

For the first time, I'm working at a clinic where I have my own office. It's exciting after years of competing for space, and carrying my supplies and paperwork around like a nomad, to have my own space. I have a bookshelf where I can keep my professional books, resources, toys and art supplies. I have a clock (two actually). I have a windowsill perfect for plants (which I can't keep at home, because the cat won't leave them alone).

I also have four white walls and a lot of desk, bulletin board, and empty desk and shelf space. What to do with it?

There's disagreement amongst clinicians about what "should" appear in an office used for therapy.

Some clinicians would never use overhead lights, preferring the indirect lighting of floor or table lamps to create a more intimate space for conversation. I prefer to have the overhead lights on - it makes me feel more awake.

Some clinicians hang their diploma or license, while others do not. I did, only because I didn't have much else to hang on the wall. However, I hesitated, self-conscious about the privilege of my education in contrast to so many of my clients. I ultimately figured that all of my clients already one has to have a graduate degree to be a therapist, so it's not like I can pretend otherwise by NOT hanging the diploma. I've noticed that some clients feel comforted by it (as sign I might know enough to help them), while others seem mildly curious, or completely unaffected. No one has seemed to react negatively.

Some hang abstract art or prints of nature on their walls. I have some photographs of nature to use as examples of "safe space" imagery. These are pretty neutral and unassuming.

I have a whiteboard for making lists, drawing diagrams, or just writing quotations. I also have a bulletin board where I keep important phone numbers, and little cards and pictures. Lastly, I have some knick-knacks or personal significance - a few photos, a stress ball, a few cat things, a rubber duck, a plaque with a quotation on it. These things have been given to me by colleagues, friends, or family.

The things listed in the last paragraph are quite a bit less neutral. I would guess that old-school therapists or analysists would not approve of any of these things: quotations, cards and drawings can all suggest a particular perspective (and in fact I use them that way intentionally, as a kind of cognitive restructuring), while personal objects and photos influence the client's view of who I am, and therefore, their transference to me. I obviously don't use these objects to shape transference intentionally - I like to have them at work because they are soothing and grounding for me. However, it bears careful consideration how this might affect the content and process of therapy.

The possible impact of my knick-knacks came to my attention after a client I see at my other job (where I'm in someone else's office) shared with me that he had attacked a cat. As I worked through my reactions to this disclosure after the session, I started to think about the cat things I have in my own office, and wondered if he would have been able to tell me what he had done in that setting, and if he did tell me, how the experience would have been different for him.

I had thought that being a cat person was a pretty inconsequential part of me, that wouldn't be of much clinical significance. However, I'm beginning to think that any aspect of who I am could be clinically significant, depending on who walks through the door. So the question becomes, do I remove as much of myself as possible from the office to minimize the impact of the environment on the clinical work as much as possible?

I considered doing so, and at least for now, have decided to leave things as they are. Why? Because I've also learned that any little thing can be seen by clients as a piece of who I am. There's no way to predict and prevent everything. None of my clients have commented on the cats. They HAVE commented on my water bottle or a coke can from lunch, the kind of tea I drink (from the tea bag wrapper in the trash), a piece of jewelry or clothing, my pen. Things that seem innocuous, and which would be hard to avoid (short of not having any liquid, food, or writing implements visible anywhere).

It seems much more feasible to take clients' reactions to the environment as grist for the proverbial mill - information about who they are, or transference material that can allow entry into important personal dynamics. However, a small part of me wonders if it's possible for a client to have such a strong reaction to something in the environment that they can't or won't work through it, and feel the need to stop our work instead. So, I'm wonder what others think about this topic. Do you try to keep everything in your office neutral, or do you have a few personal things? How do you see real or perceived elements of the environment impacting your work, and what do you do about or with this dynamic?