Reasoning Strategies #2

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**When NOT to Confront client:

  • First appointment/initial assessment
  • The client is in a vulnerable/crisis state

**MAY confront client when:

  • Time limit/brief therapy
  • Acting out / not completing homework after seeing you for a while

**Therapist’s Countertransference:

  • If issue arises during a session, FIRST be aware of the issue, move forward without bias
  • NEXT, seek consultation or supervision

**If detect DUAL relationship risk:

  • Bring it up and discuss with the client
  • Do NOT avoid it. Never ask the client to terminate their relationship or terminate  your existing relationship
  • Acknowledge the client discretely if unexpectedly run into you outside of session, then discuss with the client in session. Don’t ignore client.
  • REFER out if any family members of client want therapy with you
  • If dual relationship far removed enough, the client still wants treatment, discuss with the client about the RISKS.

**Couple therapy

  • NO-Secret agreement!
  • If either partner/spouse called to confide, ask to bring up in therapy
  • If the couple are not on the same page, BRING UP the differences
  • If they got frustrated with each other due to assumptions, discuss COMMUNICATION skills
  • Address any type of normal transition problems (new baby, new house, lost job, retirement, empty nest, etc.)
  • NEVER see either partner individually if started out as a couple.
  • Couple therapy is to treat the RELATIONSHIP, not individuals.

**For questions with depressive symptoms :

  • If detect a sense of HOPELESSNESS, FIRST assess Suicide risk
  • If RECENT ( < 6 months) STRESSORS were mentioned, think ADJUSTMENT DISORDER
  • Before putting any MDD Dx, LOOK for DURATION of 2 weeks or more
  • If MDD duration not mentioned/not met, and substance was there, think SUBSTANCE ABUSE (assess for/Dx)
  • Don’t miss the obvious (In a clinical setting, do a psychosocial assessment, in non-clinical setting (school SW), talk to student INDIVIDUALLY, determine for symptoms of MDD before taking action )

** A few words about SCHOOL social work:

  • If teacher referred a student, and the problem stated was vague, clarify with the teacher
  • if already meeting with student, teacher’s report is specific, contact parents to gather more info.
  • If you hear specific complaints from a teacher, MEET with student INDIVIDUALLY to access.
  • If signs of abuse are suspected, report.
  • Always consider family issues as a reason for acting out FIRST, before you consider possible eval for oppositional defiant disorder, ADHD, etc.
  • Rule out learning disorder before ADHD/poor academic performance

**More SCHOOL Social Work – intervention

  • SOCIAL SKILLS group/training is recommended for ADHD
  • Applied Behavioral Analysis is an evidence-based treatment for Autism
  • Provide psychoeducation for parents for “normal developmental crisis/ normal defiant behavior in adolescent”
  • If physical/medical problem occurs, refer to a physician
  • Unless question stem indicated that you are in school to do therapy, don’t try to diagnose or treat.
  • ADVOCACY, ADVOCACY = SW takes appropriate action
  • EMPOWERing Parents = encourage parents to take appropriate action

**Therapist seeing Parent + Child

  • Ask about family function, any stressor at home
  • Get parent/guardian’s consent to speak with a teacher for complete assessment
  • ADHD: 2 settings, rule out learning disorder, home issue, abuse, trauma
  • Refer to medical/physician if physical symptoms occur
  • Always consider treat child as part of family, not as individual alone.
  • If child’s privacy (diary, phone message) is violated, ask how the child feel about it in session.

**About LGBT minor:

  • Work on processing issues with identity; validate, emotional support
  • Work on understanding possible outcome, timing with the client before coming out to family (if family is not supportive)
  • Coming out is the hardest /most stressful process
  • Parents have the right to confidentiality

**Minor has sex with minor

  • Educate about risk
  • Not consider sexual abuse

**Questions about DSM Diagnoses: Always look for DURATION if suspect:

  • Major Depression (2 weeks)
  • Persistent Depressive Disorder (2 yrs-adult, 1-year children)
  • Adjustment disorder (new stressor less than 6 months old )
  • Brief Psychotic Disorder (0-1 month), Schizophreniform (1-6 mons), Schizophrenia (6 months)
  • Acute Stress Disorder (less than 1 month), PTSD (1 month +)
  • Generalized anxiety disorder (excessive worries 6 months +) 

14 COMMENTS

  1. Thank you for sharing these tips and not even looking to make money from it. You are a very kind person. Hope you continue in your success.

  2. Hi Chinh, can you explain #1 in a little more depth, not clear enough for me. In addition, can you explain #2 further in what you mean by this statement….. Thanks!

    1. NEVER see either partner individually if started out as couple

    2. Parents have the right to confidentiality

    • Hi Chris,
      1. Couple therapy is to treat a relationship, not individual. It’s not ethical to see an individual partner separately in addition to couple therapy. We can encouraged the partner to seek individual from another therapist.

      2. With a minor, parents have the right to records. However, some States does have certain regulation with adolescent’s rights to confidentiality. If the exam question asks and clearly stated that state law, you want to follow the law.

  3. Hi Chinh. Thank you for these helpful tips. Can you clarify the difference between addressing resistance during an initial session/first meeting and confronting a client in later sessions? I understand when not to confront. Thanks

    • Hi! sorry Kathy for my late response. It’s normal for some clients to feel anxious and sometimes quite defensive, which may cause some therapy resistance. We have to address it by discussing their feeling about therapy at the beginning. Toward the later sessions sometimes we might see “acting out”, such as substance use and not following treatment recommendation that was agreed on, we might want to consider confrontation. Hope it helps

  4. HI, I’m confused with the dual relationship session.
    In 1.06 it says “In some cases protecting clients’ interest may require termination of the professional relationship with proper refer of the client.”

    You said to never terminate your relationship or their existing relationship. If encountered on the exam, I’m not clear on how to answer the question.
    helppppp, lol, thanks.

    • Hi Amanda, yes, the code of ethics did state that but we always want to follow the principle of “giving a reasonable effort” to discuss with the client first. I always advise that we need to bring the issue up with the client before terminating, so it won’t be considered abandonment. I hope it helps!

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