managing the helping session

intake interview content

the intake is an information gathering interview, here is an outline of topics to cover and the rational for their importance. an assumption behind the intake interview is that the client is coming to counseling for more than one interview and intends to address problems or concerns that involve other people, settings, the future, and the present. most helpers try to limit intake interviews to an hour or 90 minutes, no more than 45 minutes for younger clients. to do this, you must assume responsibility and control over the interview. variations in this outline will occur depending on the setting and on certain client variables, such as age, gender, race, class, ethnicity, sexual orientation, and health and ability/disability status. I. Identifying data A. clients name, address, and telephone number at which a client can be reached, for when the helper needs to contact the client between sessions, the client's address also gives some hint about the conditions under which they live (large apartment complex, student dorm, private home, etc.) B. age, gender, gender identity, ethnic origin, race, partnered status, occupational status, and educational status as well as languages, citizenship, and immigration/refugee status. this info lets you know if the client is still legally a minor, provides a basis for understanding info that comes in later sessions II. Presenting issues, primary and secondary It is best when primary and secondary presenting issues are described exactly how the client reported them. if the issues have behavioral components, these should be recorded. these questions can reveal this info: A. how much does the concern interfere with the client's everyday functioning? B. How does the concern manifest itself? what are the thoughts, feelings, and so on, associated with it? what observable behavior is associated with it? C. how often does the concern arise? how long has the concern existed? D. can the client identify a pattern of events surrounding the concern? when does it occur? with whom? what happens before and after its occurrence? E. what caused the client to decide to enter counseling at this time? III. Client's current life setting how does the client spend a typical day or week? what social, spiritual, and religious activities, recreational activities, etc., are present? what is the nature of the client's vocational and/or educational situation? what is the client's living environment like? what are the client's most important current relationships? what sorts of financial stressors is the client experiencing? IV. Family history A. recognize the plurality in contemporary practice of the definition of families. be careful not to assume that the client's family is like your own. ex. leave room for the possibility that the client may have a family of choice to describe rather than a biological family. once the client has identified something about their family, you can assess for family history by using the following as examples. B. names, ages, and order of brothers and sisters, and relationship between the client and siblings if siblings, either biological or adopted, are present. C. is there any history of emotional disturbance and/or substance abuse in the family? D. description of family stability, such as number of family moves, significant losses, and so on. this info provides insights in later sessions when issues related to client stability and/or relationships emerge E. if the client is a minor and the biological or legal custodial parents are divorced, obtain a notarized copy of the custody agreement bc this will have an impact on informed consent for counseling. you cannot counsel a minor of divorced parents unless all custodial parents give consent V. Personal History A. medical history: has the client had any unusual or relevant illness or injury from the prenatal period to the present, including hospitalizations, surgeries, or substance use? does the client have any disabilities? B. educational history: what is the client's academic progress through grade school, high school, and post-high school. this includes extracurricular interests and relationships with peers C. military service record: has the client served on active duty? has the client or members of the client's family been deployed? has the client experienced war, terrorism, or natural disaster service of any kind? note setting and duration D. vocational history: where has the client worked, at what types of jobs, for what duration, and what were the relationships with fellow workers? has the client suffered any employment termination or job losses. E. spiritual and religious history: what is the client's prior and current faith heritage, religious values and beliefs, and spiritual practices? F. legal history: has the client had any run-ins with the law, such as speeding tickets, accidents, time in prison, bankruptcy, divorce and custody issues, fights, weapons, or violence? G. substance use history: what is the client's past and current use of substances? note the client's drugs of choice, including prescription medicines, frequency of use, the amount of substance use daily and weekly, and any particular consequences of substance use the client has experienced. H. sexual relationship history: be careful not to assume the client's sexual orientation in exploring sexual history. use with discretion questions such as: where did the client receive sexual info? what was the client's dating history? any engagements, marriages, and/or partnerships, legal or nonlegal? other serious emotional involvements prior to the present? reasons that previous relationships terminated? how and in what way, and with what effects? are there any children? I. Counseling experience: what experience has the client had with counseling, and what were client reactions? who referred the client? J. traumatic experiences: has the client encountered neglect or physical, emotional, or sexual abuse? medical traumas or accidents? natural disasters? oppression, discrimination, immigration? wars or war-related trauma, dislocations from country of origin? VI. description of the client during the interview. you can overview some of your primary observations and impressions about the client, but be careful not to impose your own cultural biases, norms, and value judgements. example observations and impressions could be included here: the client's physical appearance, including height and weight, dress, posture, gestures, facial expressions, voice quality, and tensions, how the client seemed to relate to you in the session, the client's readiness of response, motivation, warmth, and distance, etc. do there appear to be any perceptual or sensory functions that intrude on the interaction? document with your observations. what are the stream of thought and rate of talking? are the client's remarks logical? connected to one another? what is the client's first language? second language? what info have you gathered about client race, ethnicity, and general cultural affiliations? how might this info affect your impressions and observations? VII. Summary and recommendations acknowledge any connections that appear to exist between the client's statements of a problem and other info collected in session. what is your understanding for the problem? what are the anticipated outcomes of counseling for this person? what type of counseling do you think would best fit this client? if you are to be this client's clinician, which of your characteristics might be particularly helpful, and which might be unhelpful. how realistic are the client's goals for counseling? how long do you think counseling might continue? is there anything in the client's history that seems like a red flag for you? in writing the intake interview, the follow cautions should be noted. first, avoid psychological jargon. it is not that understandable. second, be as concise as possible and avoid elaborate inferences, an inference is a guess, sometimes educated. an inference can be wrong. try to prevent you own biases from entering the report. only include info that is directly relevant to the client and counseling services to be offered. remember that it is your responsibility to take steps to safeguard client privacy and confidentiality of communication. make sure that the word confidential is stamped on the report itself, on each page of it if it is more than one page in length, do not leave drafts of the report on your desk or in your mailbox or open on your computer screen.

when should termination occur?

some counseling theories provide guidelines for the timing of termination, including possibilities such as letting the client determine the timing or having the clinician establish the date of termination at the outset of the helping process. such issues depend on your own theoretical orientation. however, there are some pragmatic factors that contribute to the question of timing. ex. the client may be under a managed health care plan that dictates a certain number of sessions per year, such as 20. at the end of the specified number of sessions, several scenarios could occur. the helper may be able to negotiate with the client's plan for a few more sessions if the goals have not been reached. alternatively, the helper and client may reach some kind of private payment agreement if termination does not seem clinically indicated. if the client is unable to pay and the insurance company does not authorize additional sessions, however, helping professionals "still have a fiduciary obligation to assist, stabilize, and/or refer those clients who continue to need care. summary of these pragmatic considerations in termination: -when counseling has been predicated on behavioral or another form of contract, progress toward the goals or conditions of the contract presents a clear picture of when counseling should end -when clients feel that their goals have been accomplished, they may initiate termination -when the relationship appears not to be helpful, termination is appropriate -when contextual conditions change, for example, the client or helper moves to a new location, termination must occur

handling subsequent interviews

this involves several dimensions and tasks, including reestablishing rapport, eliciting essential info, and focusing in depth. once you have established a relationship or rapport with your client, subsequent interviews require that you reinstate the relationship that has developed, which usually amounts to acknowledging the client's absence since the last interview. this includes being sensitive to how your client's world may have changed since your last contact and your reactions in seeing the client again. this can be done with a few short statements, such as "Hello, name, it's nice to see you again>" this might be followed by some observation about the client's appearance, such as "you look a little hassled today: or "you're looking more energetic today." or you might be asking "how are you feeling today?" these types of questions focus on the client's current or immediate condition and reduce the likelihood that the client will spend the major part of the session recounting how the week has gone. if your client needs to a bit of small talk to get started, it probably means they need time to make the transition into the role of helper seeker or client. the important point is that you probably do not need to go to the same lengths in establishing rapport as was necessary when counseling was first initiated. however, keep in mind that some degree of relationship building occurs in every session. in addition to rapport building, subsequent interviews are also characterized by gathering info and focusing in depth. the question becomes "what does the helper do with info that's gather during helping interviews?" basically, the helper uses such info to make clinical judgments and inferences; such judgments and inferences are the basis for the clinician's assessment of the client's personal style and level of functioning, determinations about who is the actual client and how much therapy may be needed, decisions about the client's diagnosis, including diagnostic formulations and areas of strengths, and ideas about the most appropriate or efficacious approach to take with a particular client. another way in which helpers make use of clinical info is to help clients focus more in depth during subsequent interviews. ex, some clients out of fear or lack of trust, may withhold important parts of their story in initial interviews and may not reveal issues that bear significant weight until they feel vert safe with the helper. sometimes, clients presenting issues will shift significantly in subsequent situations, often due to internal processing, to external situations, or both. ex., Mark was working with Joe, who was exploring issues related to his partner when Joe's mother passed away suddenly and unexpectedly. at this point, the focus shifted somewhat away from the initial concern to the more immediate situation at hand and to Joe's grief and sadness. at a later point, additional sessions shifted back to Joe's ongoing concerns w/his partner. practitioners can help clients focus in depth in several ways, including for the helper to explore and assess the cognitions of clients bc thought patterns, beliefs, and attitudes are also powerful determinants of behavior. ex. focusing in depth on cognitive patterns may reveal dogmatic or rigid thinking, misinterpretations, and nonproductive beliefs. kinds of questions for focusing in depth on cognitions include: -how did you come to that conclusion? -what meaning do you make of that? -how do you explain what happened -what are your views or beliefs about that? another way is for the helper to assess and tune into the client's affective or emotional functioning because these patterns can affect the client's behavior in many contexts and can also provide clues about the client's interpersonal functioning. ex. the helper may use questions to focus in depth on affective functioning, such as the following: -what feelings related to this concern have you been experiencing? -do you ever feel sad, afraid, angry, or ashamed in this situation? -do these feelings help you resolve things or do they make things worse? -are there other emotions you might be feeling at a deeper level? -are there feelings you express in order to get a reaction from someone? -which emotions are you likely to express, and which do you tend to hide? -are there times when your feelings seem too intense for the current situation? -do you ever feel like your emotions are restricted or muffled or you can't express what you're really feeling?

client reactions to initial interviews

client reactions to initial interviews often depend on whether they have had any prior experience with counseling and whether the experience was positive or negative. clients who have had positive experiences with the helping process are not as likely to have the same fears and reservations as clients who have had negative or mixed experiences or who have never seen a helper before. most clients approach initial helping sessions with some mixture of both dread and hope. all clients need to feel a sense of safety or they are unlikely to return for more sessions. it is the helper's task to provide safety and security and to recognize and address any client fears and reservations. from the start, helpers want to create a new kind of environment for clients. a general principle to remember in initial sessions is that the safer a client feels, the wider the range of self-exploration that ensues. common client fears at the beginning of the helping process include concerns about whether the practitioner is competent, helpful, understanding, and trustworthy, as well as anxieties about being pressured or judged. for some culturally diverse clients, their fears and trepidation are initially centered on concerns such as self-disclosure, racism, and cultural understanding on the part of the helper. these kinds of client concerns are likely to appear in initial interviews, regardless of whether you approach the initial interview as a time to establish the relationship or a time to gather pertinent info, as in an intake interview.

ethical issues in termination

in the US, Canada, and the UK, numerous ethical complaints made by clients have to do with termination issues that clients felt were handled improperly. terminating the helping relationship does pose potential ethical and legal issues for helpers if not managed appropriately. generally, it is important for helpers to avoid sudden endings. if a situation, such as a helper's severe illness, requires a sudden termination, the helper still has continued responsibilities for the welfare of the client. when incapacity or absence suddenly strike, psychotherapists must make sure that those being treated have access to emergency resources, and if the psychotherapist is unable to return to practice within a reasonable time, appropriate referrals must be arranged. the helper has certain ethical responsibilities in the referral process, including protecting the client's privacy and confidentiality unless there is a written client release on file, providing the client with choices of several other professional helpers, ensuring that these other helpers are regarded as competent and ethical professionals, and facilitating a smooth transition. when a helper is incapacitated in a sudden and severe manner, other qualified helping professionals will need to fulfill these responsibilities. helpers cannot terminate services with a client just because they feel like it, don't like working with the client, don't agree with the client's values and/or worldview, etc. this constitutes abandonment and has legal and ethical implications. the one exception allowed by most of the helping profession's codes of ethics is the rare case when a client or someone connected to the client poses a risk of harm to the helper. it is also important to remember that clients who have not received any structuring about the termination process at the outset of the helping process may be more likely to feel abandoned and angry when the practitioner suggests termination is appropriate or when the practitioner becomes ill or moves away. an important ethical issue in terminating the helping process effectively involves discussion of this issue as a part of the informed consent process. in reality, effective termination begins during the initial psychotherapy session in which matters of informed consent are discussed... through this mechanism, practitioners explain the details of the treatment relationship and make contracts with patients regarding what the psychotherapist will and will not do. this is also the time for the practitioner to explain what they expect of the patient. it is through this clarification of the professional-patient relationship that much of the difficulty associated with the closure of psychotherapy can be avoided. part of this discussion about termination should very clearly include client financial obligations and insurance limitations. if a client is using health insurance and has a very restricted plan, it is important to explain this before counseling ensues to ensure that client expectations are reasonable and realistic and that the client still retains the potential choice to consent or not consent to treatment under these conditions. another potential ethical issue in termination involves continuity of care. perhaps the client decides to terminate and return to see you at a later point. or perhaps the client takes a break and later returns to your setting and sees another practitioner. in either case, a written summary of your progress with the client provides the basis for you or someone else to begin sessions with the client at a later date without having to start all over again. the structure of discharge summaries or termination reports varies among settings. generally speaking, most termination reports consist of the following kinds of info: -identifying info about the client (name, age, gender) -duration of counseling; dates and number of sessions with the client -summary of client's presenting issues and possible diagnostic codes for problems -type and method of counseling (treatment and intervention strategies) -summary of counseling and therapeutic progress -recommendations for future treatment the need for a more detailed summary is evident when the termination occurs prematurely and/or when the client objects to it. in these cases, the record should include documentation that allows the reader to understand the rational for ending therapy as well as the ethically appropriate and clinically indicated steps the practitioner took to do so in a reasonable manner.

confidentiality

confidentiality refers to an ethical duty to keep client identity and disclosures secret. you will want to emphasize the issue of confidentiality to new clients and what it implies, including if you are observed by a supervisor or recording the session. will you keep a written record and if so what are the client's guarantees that it will be kept confidential? what about emails or faxes? according to ethical guidelines for helping professions, the helper is generally obligated to treat the client's communication in a confidential manner, the helper agrees not to share the info given by the client with others. there are some exceptions such as when the client requests release of info, when a court orders the release of info, when the client is involved in litigation, and when the client's condition indicates harm to self or others. the current ethical codes of most helping professional orgs are written so mental health professionals can disclose confidential info (with certain restrictions) when they believe the client is of immediate danger to others, base don some kind of risk assessment procedure that assess the client's capacity and history of violent behavior. this exception to confidentiality stems from a court case in 1974, which has evolved over the years so that in some but not all states, the helper has a duty to warn or a duty to protect the one in danger or at risk from the client's threatened actions. these actions often include notifying or warning the intended victim and protecting them by securing protection from loved ones or the police, by increasing the frequency of sessions with the client, or by hospitalizing the client. in the case of self-danger (when the client is at immediate risk of suicide), the legal and ethical responsibility to protect the client from harm is unequivocal. all of the 50 US states have legal statutes that require helpers to report instance of child and elder abuse. all 10 provinces and 3 territories in Canada have mandatory reporting for child abuse, while some have mandatory reporting for elder abuse. bc these statutes vary by state and province, it is important to know the guidelines for your particular place, to consult w/supervisors and colleagues about clients at risk, and to document in writing all actions and decisions. with respect to clients and initial interviews, the important point to discuss with clients both the protection and the limits of confidentiality as part of the structuring process. example: we have about an hour together. I'm not sure what brings you here, but I'm ready to answer any questions you have and also listen to whatever you tell me. you can talk about whatever you wish, this is your time and whatever you do talk about is kept between you and me. we call this confidentiality. it means that I keep what you say to myself. this is very important to me and to you. however, I do need to let you know there are some exceptions to this I need to share with you upfront so you're aware of what they are. if you tell me about abusing a child or an elderly person, I am mandated to report this, as these are both against the law in this state. and the other exceptions would be if I was ordered by a court of law to provide info or if you were involved in litigation, and it you requested that I share info. finally, if you gave me info that led me to conclude there was a serious risk of harm to yourself or someone else, there would also be some limits to the complete confidentiality of this material. I want to be sure that you understand what this may mean before we get started here today, so let's take some time to talk about this because your safety and privacy are important to me and you. do you have any questions before we get started? if you are working under supervision, also add that you will be consulting with your supervisor, who is also obligated to honor the confidentiality of the client's communication except in the instances just noted. sample informed consent documents are available through the website at the Center for Ethical Practice at the University of Virginia

using intake interview info

following the intake interview but before the second session, review the write-up of some of the intake interview. helpers develop different approaches to using this info. some practitioners look primarily for patterns of behavior. ex. one helper noted that her client had a pattern of incompletion in her life, she received a general discharge from the army prior to completing enlistment, dropped out of college twice, and had a long history of broken relationships. this observation provided food for thought. what happens to this person as she becomes involved in commitment? what has she come to think about herself as a result of this history? how does she anticipate future commitments? another practitioner uses the intake info to look for signals that suggest how this client might enter the helping relationship. is there anything to indicate how the client might relate to females? is there something in his life at present that common sense would suggest is a potential area for counseling attention? ex. is the client in the midst of a divorce? is the client at a critical developmental stage? the main caution is to avoid reading too much into the intake info. it is far too early for you to begin making interpretations about your client. many practitioners supplement the intake interview info w/some additional sort of structured assessment that may include diagnostic questions about the client's presenting concern, such as depression, anxiety, or substance abuse. it may also include the use of formalized, written questionnaires and instruments, such as inventories that measure depression or anxiety and that yield additional info about potential diagnoses and client concerns and strengths. such instruments can often be administered at the end of the intake interview or near the beginning of the follow up interview. these can be introduced to the client simply by indicating that you would like them to complete a form or two to assist them in determining more about the client's presenting concerns and in formulating a plan for treatment. once such forms are used, it is important to score them properly, use the info they provide efficiently, and provide feedback to the client about what the instrument yielded.

cultural variables and termination

it is important to recognize that not all cultural groups share the same values and beliefs about the dimension of time, and this can also affect the termination process. ex. European Americans generally have a highly structured and future-oriented view of time, but some clients from other cultural groups have a much more casual view of time. in cross-cultural helping situations, the time element of termination also needs to be discussed, negotiated, and understood from the client's perspective. also, many clients of color terminate the helping process at a much earlier time than other clients. often, these clients are the decision makes about when to stop counseling presumably because it is not relevant enough to them and their experiences, particularly their culturally linked ones. it is presumptuous to assume that in all situations control of termination is in the helper's hands

timing of confidentiality

most ethical codes for helping professions require that confidentiality and its limitations be discussed as early as possible, usually at the beginning of the helping process during the initial interview. this early timing is important for several reasons. first, it is intended to give clients enough info to help them become informed about and consent to the conditions under which counseling occurs. many clients are unaware that confidentiality is not always absolute. second, should a disclosure by the counselor become necessary during the course of subsequent sessions, lack of information about it is not only unethical but also contributes to a client's sense of betrayal.

open-ended and closed questions

open ended questions require more than a minimal or one-word response by the client. this type of question is introduced with either what, where, when, or how. you will find that it is very difficult to ask questions that clearly place the focus on your client. helpers fairly often ask questions that allow the client to respond with either a yes or no. the result is that the client assumes no responsibility for the content of the interview. the purpose of open-ended questions is to prevent this from happened. however, when you want the client to give a specific piece of info, a closed question can be the best approach.

other termination strategies

often, a brief and to-the-point statement by the helper is sufficient for closing the interview: -it looks as if our time is up for today -well, I think it's time to stop for today this type of statement may be preceded by a pause or by a concluding kind of remark made by the client. another effective way is to use summarization. summarization provides continuity to the interview, is an active kind of helper response, and often helps the client to hear what they have been saying. this response is essentially a series of statements in which the helper ties together main points of the interview. should be brief, to the point, and without interpretation. an example of summarization used to end the interview is here: "essentially, you've indicated that your main concern is with your family, and we've discussed how you might handle your strivings for independence without their interpreting this as rejection" another possible termination strategy is to ask the client to summarize or state how they understood what has been going on in the interview, as in the following example "As we're ending the session today, I'm wondering what you're taking with you;" if you could summarize this, I think it would be helpful to both of us" Mutual feedback involving both the client and helper is another possible tool for termination of an interview. if plans and decisions have been made, it is often useful for both individuals to clarify and verify the progress of the interview, as in this example: "I guess that's it for today. I'll also be thinking about the decision you're facing. What things do you want to do before our next session?" mutual exploration involves the client and helper assessing the experience of the helping session or sessions together. whether the process has gone well or poorly, mutual exploration provides a chance to process wheat the experience has been like, as in this example: Now that we're about out of time for today, can you share with me what it's been like for you?

privacy requirements

a federal government rule called the Health Insurance Portability and Accountability Act (HIPAA) also affects helpers and confidentiality in the US. while technically HIPAA also applies strictly to health care providers and electronic communication, it is also applicable to any provider (called a covered entity) who employs email, fax, or sends a text to even one client. part of the HIPAA law is designed to protect client privacy by delineating the steps that providers have to take to secure client info. Under HIPAA, all health-care (including mental health) professionals are required to provide clients with a notice of privacy practices (NPP) that tells clients what info can be released under HIPAA without explicit consent and what clients can do if they believe their personal health info was disclosed in unauthorized ways. this notice does not substitute for an informed consent discussion) this notice of privacy practice must be posted publicly in the office setting, with a copy given and explained to each individual client. each client signs an acknowledgement of receipt and understand of the notice. HIPAA applies not only to direct health care providers but also now extends to business associates, such as billing services and document storage companies, than an agencies or practice may employ. in addition to the privacy rule of HIPAA, the security rule requires the health care provider to implement a number of safeguards to ensure the confidentiality and availability of electronic records. the law that covers the security safeguard for eelctronic client records is known as the Health Information Technology for Economic and Clinical Health Act (HITECH) ex. clients may now ask for copies of their electronic records in electronic form. if a security breach is detected, the health care provider must perform a risk assessment and try to mitigate the breach, and also report the breach to the client a breach means the improper acquisition, access, use, or disclosure of protected health info). for additional info on HIPAA, go to the website for the US Department of Health and Human Services, which has a link for covered entities and business associates, as well as a link for consumers. In the US, be aware that many states also have established laws regarding client privacy. if the law in your state differs from the federal law, the more stringent law takes precedence. bc issues around confidentiality and privacy are complex, it is wise to consult with your supervisor, a colleague, or a trusted attorney when questions about these issues arise.

encouraging the client to talk

after providing this initial structure, you and your client are ready to begin work. the obvious beginning is to get your client to talk, to indicate their reason for entering counseling, and perhaps indicate some form of what they hope to achieve as a result of counseling (the client's first statement of goals). your beginning will be an invitation for the client to talk. the nature of this invitation is important. a good invitation is one that encourages but does not specify what the client should talk about. this is called an unstructured invitation or an open-ended lead.

preparing clients for termination

clients should be made aware throughout the helping process that there will come a time when counseling is no longer appropriate. this does not mean that they will have worked out all their issues or that they have acquired al the tools and awareness necessary for a satisfying life. it does mean that they have grown to the point at which they have more to gain from being independent of the helping relationship than they would gain from continuing the relationship. an important indicator of client readiness for termination is their ability and willingness to discuss reasons for wanting to terminate. human beings are happier and more self-fulfilled when they are able to trust their own resources. healthy people rely on others, but they do so out of self-perceived choice rather than self-perceived necessity. occasionally, you will know in the first session with your client that the relationship will last a certain length of time. ex. if your client is seeking premarital counseling and the wedding is in two months, the time constraints are apparent. people going to university counseling centers may know that vacations dictate the amount of time allowed for counseling. in such cases, it is appropriate to acknowledge throughout the relationship that these time constraints exist. when the relationship is more open-ended and determined by client progress, the termination stage begins well before the final session. the client's presenting concerns, goals for counseling, and progress in counseling should be reviewed from time to time, through the form of termination by degree. for any relationship that has existed for more than three months, the topic should be raised at least 3 to 4 weeks prior to termination. this allows the client time to think about and discuss the ramifications of ending counseling w/the helper. termination should also take into account both the nature of the client's issues and the nature of the helper's theoretical or treatment approach. clients with more severe issues usually require a longer termination period that provides more follow up care than those with less severe issues. terminating with a client after a long-term psychodynamic relationship is somewhat different from terminating with a client who was seen briefly with a cognitive behavioral approach

unstructured invitations

has two purposes: gives the client an opportunity to talk, and prevents the helper from identifying the topic the client should discuss. an unstructured invitation is a statement in which the helper encourages clients to begin talking about whatever is of concern to them, such as" "please feel free to go ahead and begin" "where would you like to begin today?" "you can talk about whatever you'd like" "perhaps there's something particular you want to discuss" "what brings you to counseling?" "what brings you to see me now?" by contrast, a structured invitation, one that specifies a topic, gives clients little room to reflect on the motives, goals, or needs that brought them to counseling. an example of a less desirable structured invitation to talk might be "tell me about what careers you're considering" the client is obviously tied down to a discussion of careers by this invitation, thus delaying or even negating a more relevant issue. if careers are what the client wants to discuss, an unstructured invitation allows this topic to emerge the same as a structured invitation would. other responses that solicit info include open ended, closed, and clarifying questions

structuring of initial moments

in an opening interview, some logistic require your attention. an initial guideline is to be on time, which communicates respect. the beginning point can be as simple as a smile and greeting from you, along with a simple introduction and a motion to show the client where to sit. ex. "Hello, I'm Bill Smith. Please have a seat here or in that chair if you wish. I realize this is our first meeting together, and I'm interested in getting to know you and something about what brings you here today." in initial moments with clients, the helper sets the tone. you want to welcome the client and begin the interview in a warm, friendly way. then proceed to give the first interview some structure. questions must be resolved. how long will the interview be? often, the length of the interview depends on the client age, with shorter interviews for kids and elderly clients. how do you want your client to address you? what should your client expect the sessions to be like? what are your client's rights? what will be your role? answers to these and other questions provide the structure for the relationship. structuring has been defined as the way the clinician defines the nature, limits, roles, and goals within the helping relationship, including comments about time limits, number of sessions, confidentiality, possibilities and expectations as well as supervision, observation, and/or other procedures. describing the helping process and providing structure reduces the unknowns and thus reduces client anxiety. it also permits clients the opportunity to check out their expectations. structuring conveys to clients the message that they are not going through counseling alone. effective ingredients of structing in initial sessions: -providing a general overview and preview of the helping process -assessing the client's expectations and promoting positive ones -describing the helper's expectations -orienting the client to a new language and new behaviors -helping the client to increase tolerance for frustration and discomfort -obtaining client commitment not only does structuring provide a sense of safety for clients, but fulfills the helper's obligation to inform clients about the nature of the helping process at the outset. there are also aspects of structuring to consider in working w/diverse clients. ex. with children, structuring is more limited, and much of it occurs with the adult who is giving consent for the minor to be seen by a helper. with culturally diverse clients, structuring needs to occur in a way that generates a mutually satisfying set of procedures that honor the cultures inherent to the therapy, therapist, and the client. one of the most important aspects of providing structure to clients has to do with giving info about the process, known as informed consent, and clarifying concerns about confidentiality

informed consent

informed consent has to do with providing info to clients about the potential helping process, benefits and risks as a client, securing the client's agreement about the process. not providing informed consent before or at the beginning of counseling takes away the option from clients to leave or to not participate in the counseling as well as the information to contemplate such a decision. in the helping professions, we are required by ethical codes to disclose to clients some info about the benefits, risks, and alternatives to treatment procedures. professionals have a responsibility to their clients to make reasonable disclosure of all significant facts, the nature of the procedure and some of the more possible consequences and difficulties. informed consent is also a legal issue. it is not just a matter of providing info to clients about the helping process (also called notice), but also of negotiating an agreement with the client based on such info and facts. clients must have the capacity to make an informed decision, the comprehension to understand the info supporting their decision, and the competence to make an informed consent decision without being pressured or coerced. there are some primary issues that helpers need to address to assist in obtaining consent with clients at the beginning of a helping relationship. these issues affect the beginning of the helping process, and they potentially structure and given notice about the termination of the helping process. they include: -what are the goals of the therapeutic endeavor? -what services will the helper provide, and what are the qualifications of the helper to provide these services? -what is expected of the client, and what is the client's role in the process? -what are the benefits and risks of engaging in counseling for the client? -what are the financial arrangements? -what might the approximate duration or length of the helping sessions be? -what are the limitations of confidentiality, and in what situations does the helping professional have mandatory reporting requirements?

introducing termination

introducing termination can be done by saying something similar to this: we've been dealing with a lot of issues, and I believe you've made a lot of progress. one of our goals all along has been to reach the point where counseling is no longer needed. I think we're reaching that point, and probably in about three or four weeks, we'll be stopping. you can try and anticipate some of your client's reactions to this. they may feel good about their progress, nervous about the prospect of being on their own, or sad to see a significant relationship ending, etc. it is important for the client to summarize both what has been achieved and what remains undone. occasionally, it is appropriate to terminate gradually. this can be done by spacing the time between interviews. if you have been seeing your client weekly, change the appointments to every other week or once a month. or you may schedule a six-month check in that that gives you client the sense of an ongoing relationship, one that leaves the door open if necessary. even with these gradual transitions, you still have a major concern of the transition of a significant relationship. in all cases, it is important to emphasize the client's continued growth once counseling has ended. this includes summations of what the client has learned, discussion of other resources and support systems the client can make use of in their life, and the invitation for follow-up sessions as necessary. some people believe that therapy never ceases, that clients continue their dialogues with helpers for the rest of their lives. occasionally the ending of a helping relationship has a character of finality, such as you or your client moving, you are referring your client to another helping provider, etc. in these instances, there may be a grieving process connected w/termination/ it is appropriate to view this grieving process as necessary and therapeutic in its own right. it is as important for the helper as it is for the client. a client may occasionally terminate simply by canceling the next appointment and there is no formal termination that occurs, yet the helper may still feel some grief. it is a symbolic or ceremonial conclusion, an acknowledgment that the relationship had importance and that reality dictates that it ends. in such cases, it is better not to hang on to it bc that would only make the transition more difficult. if you are making a referral to another practitioner, you must give up your role as helper for both ethical and practical reasons.

boundary issues in terminating an interview

it is up to the helper to set boundaries for terminating a session; however, some clients challenge these limits for various reasons, such as anxiety, dependence, or reactivity. ex. a client may abruptly end a session and say "that's it for me today" before the allotted time has occurred. other clients may wait until you initiate termination and then say something provocative, such as "well, actually the real reason I came today is because I had to file for bankruptcy yesterday" or "I have something urgent I must tell you before I leave today." in both of these situations, it is the helper's responsibility to maintain time boundaries established at the beginning of the session, which will vary with the age of the client and your work setting. the rare exceptions to this would be with a client who is desperately anxious to leave early and with a client who brings up a recent traumatic event or a series threat against oneself or someone else, such as "last night, I got in the car with a loaded gun and drove over to the house of the man who is having an affair with my wife." Beginning interviewers often feel guilty about maintaining time boundaries, but disregarding these boundaries usually does not serve clients well in the long run.

terminating the interview

the beginning practitioner is often unsure about when to terminate the interview and may feel ready to conclude either before or after the client is ready. a general guideline is to limit the interview to a certain amount of time, such as 45 or 90 minutes. rarely does a helping interview need to exceed an hour in length bc both client and helper have a saturation point. with kids, the session may be only 20 to 40 minutes in duration, and some part of this may be spent in play therapy. there is also a minimal amount of time required for counseling to take place. interviews that continue for no more than 10 to 15 minutes make it very hard for the helper to know enough about the client's concern to react appropriately. indeed, helpers sometimes require 5 to 10 minutes just to reorient themselves and to change their frame of reference from their preceding attention-involving activity to the present activity of counseling. acceptance of time limits is especially important when the client has a series of interviews. research has shown that clients, like others, tend to postpone talking about their concerns as long as possible. without time limits, the presumed one-hour interview may extend well beyond an hour as a result of this postponing tendency. it is the one instance in which the client can easily manipulate the helper. if the client introduces a new topic near the end of a session, the practitioner can suggest discussing it at the outset of the next session. the rare exception would be when the client presents a truly urgent and immediate concern

terminating the helping relationship

the process of terminating the helping relationship can evoke various and even conflicting reactions for the helper. some may think of it as a loss of experience or a letting go if the relationship has been highly meaningful. other may consider termination to be like an index of the helper's success or failure. from the client's POV, termination may be a symbol of success or may be a reenactment of many former goodbyes in life. whatever the interpretation, it is apparent that termination possess an emotional dimension that can be intense. often, it evokes an awareness of what the client means to us and vice versa. through the process of termination, both helper and client are usually changed. perhaps the most useful way to conceptualize termination is to think of it as a transition rather than an event. as the helping relationship develops and the as the client is able to address and resolve the issues that necessitated counseling, the prospect of termination becomes a therapeutic stage in the process. more often than not, the helper becomes aware of the approaching termination first. concerns related to the timing of termination, the prep for it, and the anticipation of therapeutic problems related to it become dominant in the helper's mind

challenges to termination

there are a number of possible different challenges to the termination of counseling and psychotherapy. ex. clients sometimes leave suddenly and/or prematurely for fear of losing their own power. the whole ending process involves questions about who has the power and whether it can be given up or shared. studies have revealed that one-third of all clients do not return to counseling after only one or two sessions. these are likely to be clients who did not find counseling to be very useful for them. in other instances, clients just stop coming to see you because they feel ready to leave but are afraid to raise the issue of termination or do not see a way to exit. other clients may terminate prematurely because they have difficulty in regulating affective reactions, are emotionally unstable, and may be upset or irritated with the helper and yet avoid communication about their feelings. in these situations, aa note or phone call may be useful to collaborate with clients about various options: terminating their file, coming in for a review sessions, returning to counseling with you or someone different, etc. a review of over 35 years of scientific literature on premature termination resulting in a number of other recommendations for preventing counseling dropout including preparation, time-limited counseling, negotiation, case management, motivational interviewing and enhancement, strengthening the therapeutic relationship, and facilitating a safer environment for the expression of client feelings. at the other end of the continuum are clients who fight the termination process and have trouble saying goodbye for fear of losing the helper and their compassion. even in instances where the termination point has been decided at the outset of the helping process, like in time-limited counseling, challenges to the termination process can and do still occur. ex. it is not uncommon for clients to have a crisis as the contract end approaches. often, they may try to persuade the helper to work beyond the agreed-upon ending time. in most cases, the helper should keep faith in the client and abide by the agreed-upon ending date. in time-limited work, the therapist must be prepared to work for an ending right from the beginning and must not waver from the view that an ending is desirable. before agreeing to any changes in the termination date, helpers should search themselves and their own motivations for extending time. for any exception that may be made to the original contract, it is better to initiate a new contract than to extend the existing one. challenges to termination often occur bc the attachment produces a fear of loss. the greatest difficulty of termination in counseling lies in hidden anxieties about this loss. the fear of loss can result in emotions such as anger and jealousy in addition to sadness. occasionally, clients' fear of loss may be so great that they even pursue helpers by stalking them. there is a great deal that helpers can do to promote healthy attachment with clients and to avoid unhealthy attachment, such as extreme dependence or adoration.

introduction

we have discussed the qualities of a therapeutic relationship and how effective helpers attend to and understand the client, but we have not yet discussed the structure within which this all occurs. experiences helpers enter each session with a sense of who they are, what they wish to do and be in the session, and how they will represent themselves to the client. this is true in the first session as well as in the tenth. experienced helpers develop a person style that they carry into the relationship. that style provides the structure for how to begin, develop, and end the process. there are some awkward and sensitive times to consider in the helping relationship that require structure. many helpers and clients have difficulty w/beginning and endings, whether the beginning or ending of a helping interview or of a helping relationship. there are suggestions and thoughts that may help in making smoother transitions into and out of these moments. there are two types of beginnings to examine, the beginning of the first interview you have with a client and the beginning of subsequent interviews. there are two types of termination: termination of a session and termination of a helping relationship. there are also ethical issues surrounding these two key transitional times in helping sessions and some ideas for managing between helping sessions.

cultural variables and the first interview

whether you choose to focus on establishing a relationship or gathering info in the initial session depends somewhat on your setting and the client's cultural affiliation. some settings specify that the initial session be an intake interview; this initial history-gathering session may even be conducted by an intake worker rather than the assigned counselor. the client's culture also influences your focus in the initial interview. some culturally diverse clients may approach the helper initially with caution, not feeling safe to self-disclose unless the helper self-discloses first. this trepidation may be reinforced with white counselors whose sole focus in the initial session is individualistic rather than contextual, viewing the client's problems as residing within them rather than society or the context and environment the client resides in. some research has found that many Asian-American and African-American clients prefer a more structured and logical approach (e.g. an intake info session) to an affective and reflective one. in any initial session, regardless of approach, helpers need to exert caution and move slowly. asking very personal questions in an initial session may be perceived as lacking respect. it is important to be flexible enough in your helping style to adapt your style in an initial session to meet the cultural diversity of your clients

the first interview

your first interview with a client will have a special set of dynamics. it is the beginning of a potentially significant relationship. there are hopes and expectations, fears, reservations, acute awareness of some conditions and total lack of awareness for other conditions, all have a bearing on the session. w/so many emotional issues operating, how does one have a successful first interview. helpers deal with this issue in one of two ways. some choose to work with relationship dynamics that are operating. others choose to make the first session an intake interview and collect needed info about the client. regardless, you must attent to the opposite choice later. if you focus on interpersonal dynamics in the first session, in the second or third interview you will want to collect info. if you use the first session as an intake session, you will soon after need to acknowledge relationship dynamics. if you wish to focus on relationship dynamics, you will want to achieve an accurate sense of the client's world and communicate that understanding back to your client. learning to understand means putting aside your own agenda to allow the client's world to enter your awareness. it means not worrying about yourself/if you are doing the right thing and avoiding analysis paralysis. until you have had the experience of several beginning sessions, this will be hard. there is an underlying set of objects in the beginning session -reduce the client's initial anxieties to a level that permits them to begin talking -to refrain from excessive talking bc that takes time away from your client -listen carefully to what your client is saying and attempt to reconstruct in your mind the world they are describing -to be aware that your client's choice of topics gives insight into their priorities for the moment