What is Psychotherapy What is psychotherapy Psychotherapy is

What is Psychotherapy?

What is psychotherapy? Psychotherapy is a different kind of relationship than any other relationship People who are good at talking to friends, neighbors, spouses, etc. are not necessarily good at psychotherapy

Beginning Psychotherapy Pitfalls Being too “helpful” denies the patient opportunities to developing coping skills or find their own solution Do not assume similar personal experiences, thoughts, feelings are relevant to understanding your patient The only way to learn about your patient is to ask them Fears of being perceived incompetent rarely drive good therapy You may undermine a patient’s confidence by disclosing inexperience You may provide bad therapy, because you will think it would look incompetent to say “let me discuss with my supervisor” or “let me think about that and we can discuss next week”

Ethical and Legal Issues You are operating under the license of your supervisor Your supervisor has primary liability unless you do not keep your supervisor fully informed or fail to follow through on what is discussed in supervision Timely complete documentation is essential Your best defense is your note. If you did not document it, it did not happen. Confidentiality should be maintained at all times Limits should be clearly explained to patient (child/elder/dependent adult abuse; your supervisor) Represent yourself accurately Patients should know you are being supervised and they are being seen in a training clinic

Preparing for the Intake Psychotherapy requires a much more in depth understanding of the patient than other types of professional relationships The patient’s diagnosis is just one piece of information you need to create a case formulation and treatment plan You should review a patient’s chart and anything else known about the patient and discuss a patient with your supervisor before the first visit Do not form an opinion before meeting the patient, but generate hypotheses, so you ask good questions during the intake, this reduces the amount of thinking on your feet Otherwise, your answer to every follow-up question your supervisor asks will be, I don’t know (“Why does he live with his mother? ”“He’s seen 9 different therapists in the past 5 years. How does he explain that? “He’s on disability. Which condition is the basis for that? ”) You also may fail to form an initial therapeutic alliance and the patient will not return

The Intake Goals Establish a comfortable, accepting atmosphere Gather sufficient, relevant information to formulate a treatment plan Logistics Determine where you will sit and where the patient will sit Collect the patient from the waiting room, walk them to the office, point to the chair in which they should sit

Informed Consent– explain the purpose of the visit and what will happen, confidentiality, who your supervisor is, whether or not you will be recording, etc. and confirm that the patient understands and wants to continue

What Information to Gather Presenting problem – a thorough account of the patient’s current problems and how the patient sees them What they are and how they developed Why seeking treatment now Emotional reactions to them (both reported and observed) Then you must fill in enough information for the psychiatric diagnostic CPT code You must also assess safety. Do not leave this to the end.

Using Self-Administered Tools Having the patient complete 1 -2 forms in the waiting room (or more) is a good use of your time and the patient’s DSM-5 Level 1 Cross-Cutting Measure quickly lets you know what you need to query (except PTSD) If you know why the patient was referred (Depression, Anxiety, PTSD) a specific in depth measure can also facilitate substantially [don’t violate copyright – there are plenty of measures that are legally reproducible]

Using Diagnostic Interviews There is not time to administer a full diagnostic interview during a initial visit. But having one on hand can be really helpful. If you can’t recall the criteria for X, just say “I’d like to ask you a few more specific questions to make sure I really understand”. Flip to that page of the interview and ask You need to have a substantiated diagnosis by the end of the visit and you don’t get to jump out and consult your attending or the DSM before the patient leaves

Gathering Outside Information If the patient has had prior treatment, particularly in the past few years, it is important to obtain a release of information and try to get information about that treatment Attitudes toward therapy Difficulties that occurred in prior treatment Crisis Issues

Ending the Intake Summarize what has been discussed Ask the patient if you are missing any important details Arrange for follow-up during which you will discuss your recommendations and discuss psychotherapy In early psychotherapy practicum it is better not to talk too much about what psychotherapy will entail, because part of that will be decided with your supervisor

Session 2: Giving Feedback & Contracting Present your professional opinion of the patient’s situation (case formulation) and seek their reaction Provide reassurance Assess the patient’s goals for psychotherapy If we are successful in our work together, what will be different? What are your hopes for how psychotherapy might be helpful to you? Present treatment plan Don’t get too specific (this can be overwhelming) but give the patient an idea of what they might do if they returned to continue therapy Describe the logistics of how therapy will work and get an agreement from the client to begin Session frequency, policy around missed or canceled appointments, fees, etc. Summarize and discuss plan for next visit

Refusing Treatment Sometimes for various reasons you will decide not to treat a patient The patient may need or desire another type of therapy The patient may have a presenting problem that is too severe or not appropriate for the setting The patient may require a more experienced therapist Explaining the reasons and helping patient get help elsewhere will make this go more smoothly

To Type or Not to Type Some psychotherapy guides recommend no note taking of any sort during psychotherapy (even intake) The important thing is that note taking should not interfere with the flow of conversation Typing while delivering psychotherapy or any kind of care invariably disrupts the flow of conversation (since EPIC several patients have complained about some providers typing and talking or taking long pauses to type in the computer during patient’s visit) Jotting down brief notes to help you remember key content is okay. Writing copious notes throughout is not

Beginning a General Psychotherapy Session Four Primary Options Say nothing This can be good with patients you have been seeing for a while Pose a non-directive question How has your week been? How have you been feeling since our last session? Ask a Specific Question Last week we talked about X. Have you given that any more thought Collaboratively set an agenda (most common in CBT or other structured therapies) Today I’ll like to review X and discuss Y. What else would you like to make sure we get to? Hybrid Approaches are Also Common Today I’d like to review X and discuss Y. Before we jump to that, I’d like to check in on how things have ben going and see if there is anything else we might need to add to the agenda.

Maintaining a Focused Discussion Achieving therapeutic goals set in the first session after intake requires keeping a focus to discussion Two basic approaches to therapy depending on what type you are doing Focus specifically on particular presenting problem(s) – other material is distraction Scan conversation for information that helps identify relevant themes (e. g. , someone who is depressed and doesn’t know why might repeatedly be unassertive or have cognitive distortions)

Concluding the Session It is your responsibility to manage time and avoid cutting patient off abruptly The patient did not keep rambling on so that you never got to the material you need to – You LET the patient ramble on so you never got to the material you needed to If a patient repeatedly raises important topics right at the end of session it is important to address this and make sure it is not reinforced with additional session time At the end you should summarize, review homework assignment (if any), and possibly preview the next session

Supervision Most of you have no experience doing psychotherapy and are getting about 50 hours of lecture on it. Many of your supervisors have 1000 s of hours of experience delivering psychotherapy, several 3 and 4 credit courses in it, annual CE training it, and have read 100 s if not 1000 s of books and articles about psychotherapy You just started doing this, so if you are very confident about what you’re doing, you’re over-confident It is important to admit ignorance or uncertainty about how to proceed or things in session that did not go well If you only talk about what went well in session and never ask for input, your supervisor will suspect that you are not able to accurately self assess (Dunning-Kruger) You should be prepared for supervision with a summary of what happened in session both observable and also your impressions about things. You should also have a list of goals for supervision. “The patient seemed to wander, I’d like to figure out how to manage the session more effectively. ” “The patient didn’t seem to understand my explanation of problem solving. I wondered if you had ideas about how I might do it differently. ” “I kept feeling the need to give the patient advice and solve the problem. I need to hold back and let him do the work. “

Progress Notes Vs. Psychotherapy Notes Progress notes are required for psychotherapy Psychotherapy notes refer to notes you take for yourself about the content of what is discussed and your interpretation of that material if any Progress notes document start times/stop times, diagnoses & symptoms, functional status, treatment plan, progress to date, treatment modalities and frequencies. In other words they describe what happened and was observed in the session with almost no reference to content