Friday, March 27, 2015

Are You Making These Mistakes In Writing Your Case Notes & Evaluations?

If you haven't encountered it yet, you will. The request to write a professional evaluation, or to surrender notes, for the purpose of integration of care or consideration for disability, work absences, or child protective services, among many other things. 

When this happens, we have two responsibilities in tension. One is to fulfill the requests that have basis in legal or client-related needs.  But the other is to govern what is best for the client, within the perspective we have of the potential damage it could do. We have to strike that balance between supporting the client in making their own choices no matter our opinions on the matter, and making sure they are well-informed and protected from any blow-back.

The reality is, an evaluation by a counselor can play a role in a person's ability to get a job, disability support, and student financial aid. It could affect potential courses of treatment taken by fellow healthcare and helping professionals, and even influence maintaining custody of the client's children.

The bottom line? The client might be asking for something that's actually more potent than they realize. 

Which is why I encourage you to explain the risks and rewards of their petitioning you to write an evaluation or share their records on their behalf. Especially in situations in which they (or you) have no choice, explain the potential positive and negative outcomes of writing this evaluation or surrendering your notes. 

Discuss topics like this: 

  • The client may have feelings related to seeing what you've written about them (assuming they do see them.) These could be positive or negative, and lead to over-attachment or rejection of you the therapist, or have no impact at all. 
  • You are not going to be in control of what the other party does with the information you share with them, so it's up to the client to determine how the party will protect their information from there.
  • You will not be in control of the outcome, despite what you write or what it says in your notes. Unless you are a psychologist, you cannot conduct psychological testing. Unless you are a doctor, you cannot recommend medical treatment. Unless you are employed by CPS, you can't decide how they will rule for the client. This means legally and medically your notes have no deciding power, though they may influence the outcome.* This is important for the client to know, so that they don't automatically blame you if things don't turn out the way they like.
  • If your notes are used in legal proceedings, you are not legally allowed to edit or redact information you have already committed to paper. That means that anything you have written about the client might be discussed in open court. If the client is the one requesting the notes from you, encourage them to review the notes before formally requesting to make sure that the client is comfortable with what is written. 
  • Whether or not the therapy goals have changed or need to change due to the change in situation. 
Sharing written records, or writing on a client's behalf, is often part of our job. Sometimes (especially in cases of collaborative healthcare) it can be quite beneficial. But the problem I seem to see on a regular basis is that clients assume it will always be universally positive, and that is simply not the case. Sometimes it will, and sometimes it won't.

I found this out the hard way when I was alerted my notes might be subpoenaed for an active court case, for a client who had undergone a sexual assault. Thing was, the court case was for a completely unrelated issue, and I knew the client wouldn't want the sexual assault history to come out in court. 

That's when I developed the policy of requiring clients to check whether or not they were involved in a court case on their intake forms. That way, I could explain the benefits and drawbacks of including our treatment in the court proceedings before it ever became an issue. 

In addition to being proactive and discussing the situation with your client as shown above, you can greatly minimize negative impact of clinical evaluation and note requests by following two basic guidelines in your regular practice of documentation. 

Follow the principle of MNI: Minimum Necessary Information.

I know how hard this drive is towards facilitating understanding in others, which often means thorough explanations. But in the written word, you do not have at hand the same nonverbals as you'd normally use in speaking to support the meaning you intend. 

It's easier to misinterpret. It's also easier to loose secrets that don't need to be revealed by you. You want to write enough down that you will remember, but consider the difference between something like this: "Cyndi used to write the name of her math teacher Mr. Sorenson over and over in her notebook and draw their names together in hearts" versus something like this, "Cyndi shared she used to have a crush on her teacher." Which would Cyndi rather have come out, if those notes would ever be shared with others?

Ask, "Who Needs To Know?"

We feel compelled sometimes to write detailed notes simply because that was what happened in session. But here's the thing. Why is that a reason? 

We write case notes for a few reasons:
1) To provide reminders for ourselves of past session work and guide ourselves in future treatment planning.
2) To document that service was provided and interventions were offered to help the client with their situation.
3) To provide a clinical record in the case of another professional taking over treatment with our client.
4) To detail treatment for the client, should they ever request their clinical notes. 
5) By default (though not by design) to provide evidence of a client's mental state for the purposes of determining the status of a non-counseling case. 

So I encourage you to ask, when you're writing a case note - who needs to know?

If the answer is not: 

  • You.
  • The client.
  • A fellow healthcare professional.
  • Someone determining client status, such as custody, commitment to treatment, governmental benefits, etc.
Then consider whether or not to even write it. Please note: I am not and will never suggest you leave out important, relevant information from your case notes. That would be unethical and possibly illegal. Instead, I refer simply to trimming the fat.

If you plan for the eventuality that any and all of the above groups of people - you, the client, fellow professionals, or a person determining client status - will see the notes at some point, then you will practice cautious writing whether they do end up seeing the notes or not! 

What other questions do you have about best practices in writing case notes & evaluations? Post them below!

*This is true to the best of my knowledge. If you know of a state or situation in which a counselor has deciding influence, let me know.

Thursday, March 19, 2015

Help! The Client Likes Me!

An updated version of a classic blog post for you. Enjoy! Originally Published 4/8/11

Q: What do I do if a client expresses attraction to me in session?

First, don't freak out. I know that's the temptation. In fact, that's what I did the first time this happened to me. I stammered a little, and I think I said "thank you", which wasn't the best thing I could have done. But it was awkward. It was really, really awkward.

I have a philosophy that every feeling we (the counselors) have in a counseling session means something. This situation, trust me, will cause you to have feelings, so I ask you, what could your feelings in this situation mean? First, here are some common feelings you might find yourself having:
  • Awkwardness
  • Concern about ethical issues
  • Reciprocal attraction
  • Fear/Vulnerability
  • "Stuck" (What do I do next?)
That's a lot of feelings! And any one of those makes it really hard to think of what to do in the moment. That's why it so good that this question came up. It's one of those that's really best to address ahead of time if you can.

Of course, with so many different directions, it's hard to declare just one definite answer. So don't try. Just think through as much as you can. A rule of thumb: if you have any reciprocal attraction, hear warning bells. You need to immediately refer and consult with a colleague to work through those feelings. You'll be getting yourself in dangerous territory if you do not! 

If it's not a mutual attraction, realize getting you to refer to someone else might be the point of expressing the attraction. The first time this happened to me, it was on the first session with a guy who was a serial adulterer and didn't have a lot of respect for women. His wife wanted him to come to counseling, and he had no use for it. It is my belief that he knew he would fluster me by bringing that up. He wanted to get off of the topic at hand, which was his problems. Unfortunately, it worked. But now, at least, I know better than to have it happen again.

Everything that the client does is a clue...

Changing the relationship dynamic is a way that clients can try to manipulate you or change the power dynamic in an unhealthy way. Remember that the power dynamic should be different but balanced - you should not feel victimized by the client any more than they should by you. 

As with all client-counselor interest conflicts, you can get through this by remembering that you are in charge. You're the counselor, and you have the capability to deal with anything that comes your way. (Even if it might take a little fumbling....) You are the professional, and you will get through this in a professional manner. In the moment, ask yourself "why?" and remind yourself that you can handle it. Even though it seems so scary, attraction to the counselor, in the end, is just another symptom for you to explore. 

Have you ever had a client express attraction to you? If so, how did you deal with it? (PLEASE REMEMBER  - DO NOT SHARE specific details about a client or a counseling situation such that the client could possibly recognize themselves. That is not ethical and it leaves you legally liable.)

Friday, February 27, 2015

SAQ, Part 2: How To Be A "Real-World Authority"

Last week you may remember I wrote about the questions I thought that Beginning Counselors should be asking (SAQ) instead of the questions that are most frequently asked (FAQ.) While I don’t blame you – I certainly didn’t know I needed to ask these questions, I want you to thrive as a Beginning Counselor, not just survive.

This week’s “should-ask” question is “What do I need to do now to become a real-world authority on the needs of my clients?”

What do I mean by Real World Authority”? Well, fresh out of school, we know theory and academia inside and out. We don’t often know, though, what else is going on outside of this. In other words, we don’t know what is going on in the real world.

Our clients will turn to other people and resources outside of our services before coming to us. Sometimes, they will want to use those resources in conjunction with our services as well. If you don’t know what resources they are using, you are putting yourself and your clients at a major disadvantage.

If you don’t know what your clients are reading, who they’re listening to, and what else they’ve already tried to do to help their problem, then you don’t know:
  • What assumptions they’ve taken in about the way things are…some of which may be completely contrary to your methods of counseling or even established scientific facts.
  • What level of knowledge they already have about the subject at hand; they may be more advanced than you are expecting, or perhaps their knowledge is more basic than you've realized.
  • How you can develop the skills and techniques you offer them in contrast to those other resources that they are using, giving them a different value for their time and effort than what they’ve already experienced.
  • Whether you need to warn them about certain choices they are making. (Did you know that taking St. John’s Wort – a common ‘natural’ remedy for mild to moderate depression – in conjunction with other medications, such as birth control, can render them ineffective? That’s certainly valuable to be able to share that information with someone who doesn’t want to get pregnant!)
Every counselor needs to have a strong working knowledge of what resources are available to their clients to solve their problems in addition to their services as a counselor. Pop quiz: would you know what to say in response to any of the following questions?

If you don’t know what quality resources are out there to enhance your therapy work, then you risk:

  • Having both you and your client work harder than would be necessary if they took advantage of some of the other things that are out there for them.
  • Losing valuable talking points that can come from introducing another’s ideas into the therapeutic conversation.
  • Overlooking helpful homework assignments.
  • Providing care in a way you can’t on your own. (Therapeutic tools, alternative methods of healing, and so forth.)

It takes TIME to develop these knowledge bases, however. Which is why the perfect time to start for you is NOW. Here’s how you can start making that happen, today.

First, choose a general area to start researching. If you know who you want to work with specifically, you have a bit of a head start, because you can narrow down your research to that major area or topic. But if you’re not sure which group you want to work with, don’t despair.  You can still do your research, your topic will just be a bit broader.

Then, ask yourself two questions:
  1. How will they look for help?
  2. What will they not know to look for?
Discovering the answers to these questions and compiling a shortlist of recommended resources will be how you can become a real-world authority for your clients. As a result, you'll be a more informed  - and more effective counselor. 

I realize though, that this is easier said than done. Which is why I'm providing a little extra help. I've created a free 2-page worksheet for you that you can use to help you on your way to being a Real World Authority. Click here to instantly download.

Was this second SAQ helpful to you? Do you have any questions about becoming a Real World Authority? Post in the comment section below!


Thursday, February 19, 2015

Not a FAQ...A SAQ!

That is, the questions you should be asking as a beginning counselor.

When you're don't know what you don't know...obviously.

That means, you don't know what questions you SHOULD be asking to get the answers you want or need to thrive as a Beginning Counselor.

Here's one of the questions I wish I'd asked when I started out...and you should start thinking about RIGHT NOW!

What kind of counseling do I want to do?

Preparing for an agency job is different than preparing for a private practice. In the former, you want to start understanding the nuances of nonprofits and social work aspects of agency-style counseling. Things like, how to qualify work you do in terms of a grant proposal. (Unless your organization's grant writer is also a counselor, he or she will be asking you to help them create solutions that can be legitimately covered by grant writing, without sacrificing the integrity of your work.)

For agency work, you also want to prepare how to make your counseling valuable for people who aren't paying for it, or aren't paying very much for it. We will value less what we don't pay for, and if the clients aren't paying for it, they risk not absorbing the full value of counseling. We don't want that! But there are options to increase the client investment in counseling when the counseling is free. Options like: enforcing time boundaries, not rescheduling within 48 hours for last-minute cancels, expecting homework responses, and so on...

If you want to end up in private practice, your time is best spent in learning about the business of private practice. I hear a lot of questions about how to get on insurance panels, but that's not the hard part. The hard part is how to find out which panels are the "good ones" for your area and how to create a billing system that doesn't end up costing you more than it earns you in time and effort.

You also want to invest time in learning about marketing your practice. How do you engage clients in a way that feels non-slimy? What do you do when you "throw a party" and no one shows up? How do you network with referral sources without them shutting you down or hanging up the phone?

In addition to preparing for the different work settings, now is also a great time for you to start figuring out what kind of counseling topics you want to handle and what kinds of clients you want to serve. I can hear you panicking right now...please know, this doesn't mean that you have to make a permanent decision now. Far from it. In fact, your interests and desires will evolve over the course of your career. But you do need to pick SOMETHING and start exploring your interests.

Why? Because there will be other counselors applying for your desired agency job, and the one with specific experience in that agency's area (domestic violence, drug & alcohol, etc.) will likely be the one who gets the job. Another why...if you're marketing yourself in private practice, you need a "hook" to start attracting clients to your door - the right clients. In fact, it is my belief that the counselor who markets to a specific group - no matter WHICH group it is - gets 2-3 times the client referrals of the counselor who markets to everyone.

In summary, ask yourself what kind of counseling you want to do now in regards to:

  • Agency vs. Private Practice
  • Populations You Wish To Serve
  • Types of Mental Health Issues

If you do, you'll:
  • See more clients OR be more likely to get the job.
  • Be able to prepare NOW for your business or future agency career (rather than waiting till you have no free time and desperately need a paycheck to prepare.)
  • Have better skills with your clients from Day One - rather than running into things you didn't expect. 
  • Feel better about yourself. 
That is why I think that this is a "SHOULD-BE-ASKED" question.

What do you think?

Do you think there's value in asking yourself this question now? Would you like to see more "SAQs" in the future? Post your answer below!

Thursday, February 5, 2015

When The Counseling Field Sucks

There are times when I'm just so disappointed in our profession.

Like when an intern tells me that his group steals clients he pays to attract.

Or when supervisors tell student counselors gossip about clients.

Or the fact that we have tons of training and yet might be subject to lawsuits if we practice life coaching over state lines, while untrained, unlicensed life coaches can do the same with much less liability.

I can think of a half-a-dozen more things to complain about in the field of counseling. Legitimate things. The invasion of privacy by insurance companies. The questionable choices made in the DSM-V. The lack of business training in counselor education. The poor compensation offered most counseling interns, after exiting a prohibitively expensive educational path.

You can probably add your own. There's a lot to be frustrated with about this field. I'm sure there are similar frustrations with every field  - but in some ways the injustices and complications are harder to accept within the world of counseling.

Has it ever felt that way to you?

It has to me, because I tend to feel that since we're doing a good thing - helping people heal emotional wounds - we should be supported in that effort.

Even as I write that, I think how entitled that sounds! We should get a break, why, because we're "good people?"

The truth is what we all know but struggle to accept when it applies to us. Life's not fair and sometimes good is not rewarded in the way we expect.

Yep, there's a lot of things that aren't fair about the counseling profession - or counselor training - right now. 

So what are we going to do about it? 

If you agree that this situation isn't where it should be, you have three options (at least the way I see it).
  1. Leave the profession. Sadly, that's what some counselors do. I sympathize - but I hate it!
  2. Stay in the profession and grow bitter. Unfortunately, that's what a lot of you guys tell me in confidence that the older counselors around you have done!
  3. Claim your internal locus of control, and refuse to let the circumstances dictate your ability to do your job as you were called to do it.
    • Lobby for change. 
    • Leave managed care if you can't come to a satisfactory agreement. 
    • Charge no-show rates or private pay alongside more inexpensive options, or instead of those options if that's what you must do to be in business.
    • Hold clients to accountability if that's what's best for them. 
    • And so forth!

Think that's impossible? Honestly, if you lead with your values and your calling it is absolutely possible. Let me give you some examples:
  • Your state suggests a law that potentially reduces access to counseling care in rural or underserved areas. Spread the word and change the law like we as a beginning counselor community did in August 2013.
  • Your managed care company demands that you justify your client's treatment in more detail than you know is ethical to share with the representative. (It happened to me.) Explain to your client the situation and have them reach out to the insurance company to share the info, if they so choose, or offer a reduced rate to forgo managed care altogether. 
  • Your client calls 15 minutes late to cancel for the second time in a row. Add the no-show rate to your bill, explaining, "I understand, but as we discussed that means that the time is still billed to you because we have to have 24 hours notice." Your agency won't let you charge? Wait a few days or a week before you reschedule, so that they client learns to value this time as much as you do. 
I'd guess those last two examples might cause indignation or fear. It seems like we're being mean when we put up boundaries with clients, but unless we're only doing it to be mean, we're not. Ultimately, it's healthier for clients if we have strong boundaries driven by concern for their best. It's not good for a client's secrets to be at the mercy of a managed care corporation. And the client gets nothing out of therapy if they don't show or they don't respect it. And so on...

In my experience, you the interns are the most generous and ethical of all of us. The only thing that you don't realize is that it's okay to ask for what is right on behalf of you, and on behalf of your clients. You don't think you know enough or have enough experience to justify it. 

Maybe you don't. But what would it hurt to ask yourself (the next time you come across a situation that feels odd or unfair, even unethical) "What can I do to make this better for myself and my clients?" 

"What might it help?" 

Have you ever been in a situation where you knew the right thing to do, but lacked confidence in yourself to do it? How did you deal with it? Share with us below!

Thursday, January 29, 2015

7 Ways To Practice Confidence With Your First Clients - Even When You Don't Feel It Yourself

The first time that you meet with a client is a heady mix of thrill and terror. It will probably seem both like it came too quickly and you've been waiting way too long for it

And one of the biggest things on your mind during those first few meetings? 

"How can I inspire trust in my clients so that they can open up and get the help they need?" 

One of the most effective ways of inspiring trust is displaying confidence in your own ability to help your clients. When you trust yourself, your clients will trust you. But how can you display confidence in your abilities when you're struggling to feel it yourself? 

Though I dislike the connotation of the maxim, "fake it till you make it," I have to admit the principle applies here! The more you practice self-confidence, the more you will feel it - and conversely, the less you practice self-confidence the more likely you are to get stuck in a cycle of feeling like a failure. You practice self-confidence by identifying the anxieties in your mind that are attacking your faith in yourself, and creating a new framework of understanding to operate from going forward. 

7 Ways To Practice Confidence With Your First Clients - Even When You Don't Feel It Yourself

  1. Instead of worrying over what you don't know, take stock of what you DO know. What do you do well? What did your professors praise you for in class exercises? Try to come up with at least 5 things that you can pull out in situations in which confidence is hard to to find.
  2. Check their expectations - which are probably not what YOU think they think. We can pretty easily work ourselves up wondering if this client is thinking we're messing things up, or that we're no good at what we do. But really, how likely is it that that condemning US is what's most on their mind right now? Practice telling yourself that they have other things to worry about then our abilities, such as the reasons they are coming in to get help from a counselor. 
  3. Get a yay-sayer in your life. Everybody needs someone encouraging around them on a regular basis! For many of you that will be your clinical supervisor, but if not, connect with a fellow counseling student or layperson friend who can tell you that the small things you are agonizing over really aren't that big of a deal.
  4. Pre-settle the "experience" question. A lot of us in the student stage get ensnared by the experience question, i.e. "How can you know what I'm going through? Do you have (fill in the blank) kids/husband/wife/traumatic experience/death of a loved one. You're never going to "win" by a direct yes or no answer to this question, because there will always be some experience you have not shared. Plan on how to deal with it using a version of these two responses: 1) Getting at the real question: "Why does it matter to you if I've been through that? Your experience is what matters." And 2) Getting clear on the fundamentals: "I may or may not have been through _______ but I've felt pain before, and pain is pain no matter where it comes from." 
  5. Don't be afraid to say that you don't know. You might think the worst possible thing you can say for inspiring trust is "I don't know." But you can't possibly know everything! It's all in the attitude. If you calmly and evenly say, "You know what? I don't know the answer to that right now, but it's important to me and I will look into it before our next session" it will both inspire trust and provide excellent client care.
  6. Remember the "get-to-know-you" gap. When you first meet a new client, it honestly takes a minimum of 1 1/2 sessions to start to get a handle on the least it does for me! Before then, we may have some idea, but we don't have enough information to move forward. So don't pressure yourself to know everything right away. No one does!
  7. LISTEN. Sometimes, you don't have to have the answers to inspire trust. Sometimes, you just have to be willing to listen. 
When you struggle with self-confidence in beginning counselor training, what do you do or say to yourself to remind yourself of what you have to offer?