Thursday, June 15, 2017

The Arc of Therapy: Beginnings (Part 1)

Sven Scheuermeier
[Episode 110] Today's episode of the Social Work Podcast is the first of a three-part series on the arc of therapy – the beginning, middle and end.  In today’s episode I’m going to talk about the beginning phase of therapy. I'll talk about some conceptual issues like what do people want when they come to treatment, and how should you be with clients? I’m also going to review some of the more concrete aspects of the beginning of treatment like biopsychosocial and DSM assessment, talking about confidentiality and billing. I want this episode to be interesting whether you’re a first year social work student or a 35 year veteran of the field.

I’d like to thank TheraNest for sponsoring this three episode series. TheraNest is simple and affordable practice management software. To start your free 21-day trial and save 20% on your first 3 months, sign up at

Download MP3 [46:28] is a practice management and therapy notes software used by thousands in mental health and social services. TheraNest includes an easy to use calendar for all your appointments and events. Enable voice, text message, and email reminders to reduce cancellations and no shows. Create invoices, superbills, accept payments including credit cards and submit insurance claims electronically. Enter case notes using one of our note templates (e.g., Progress Notes, Treatment Plans, Initial Assessments, Group Notes and Contact Notes) or create your own template. Best customer support in the business. Fast, friendly, and most importantly, helpful, we will stop at nothing to provide top-tier support. Save 20% on your first 3 months when you sign up at


Jonathan Singer: Today’s episode is the first of a three-part series on the arc of therapy – the beginning, middle and end.

I’d like to thank TheraNest for sponsoring these three episodes. TheraNest is simple and affordable practice management software that makes it easier for a solo practitioner or entire agency to get through the administrative part of being a therapist that, quite honestly, no one likes. TheraNest has geeky background stuff like HIPPA compliance and encrypted data transfer, AND cool front end stuff like a clean professional interface, intake assessments, progress notes, and top rated customer support. I thought TheraNest was the perfect sponsor for these episodes because only in fantasy land (or graduate school) can you talk about therapy without talking about paperwork.

While I’m giving shout outs, I want to thank a special group of people who have generously donated transcripts. One of the most frequently requested resource on the podcast is transcripts of the episodes. I want to give a big old Thank you to the following rockstars for generously donating transcripts:

  • Meredith Amshoff, a recent MSW graduate of Boston College, currently working with Catholic Relief Services in Kampala, Uganda.
  • Amy Smith, an early childhood special education paraprofessional
  • Raashida M. Edwards LMSW, Couples Therapist, Institute for Contemporary Psychotherapy in New York City.
  • Tierra Montgomery, a math student
  • and Kelsi Macklin from California. 

If you are interested in donating a transcript, please send me an email at

And before we begin the beginning I want to make it very clear that I’m not talking about therapy as a place. Sometimes we think about therapy and we imagine a sweet old private practice office with that chair that clients can curl up in and the art work that might be a projective test or just something that the therapist could afford in the early days before they had a waiting list. What I’m talking about over the next three episodes certainly fits that place. But I’m talking about therapy as a lens or approach to working with people that can happen anywhere. Some of the most profound therapy sessions I’ve had with my clients took place in a McDonalds on a hot summer day in Texas while eating a cold ice cream cone, or in the waiting room of dentists’s office with a client who had been suffering with rotten teeth for too long. In today’s episode I’m going to talk about some conceptual issues like what do people want when they come to treatment, and how should you be with clients? I’m also going to review some of the more concrete aspects of the beginning of treatment like biopsychosocial and DSM assessment, talking about confidentiality and billing. I’m mixing it up because I want this episode to be interesting whether you’re a first year social work student or a 35 year veteran of the field. And now, without further ado, on to the part of therapy that some people love and some people hate… Beginnings.


How does it all begin?
It is helpful to remember that the person or couple or family that is coming to see you would rather be doing almost anything else. They might be polite to you, or even excited to talk. But for most people, talking to a therapist is anxiety provoking, frustrating and some even see it as a form of combat. In the beginning it is helpful to be curious and remember that they have no reason to trust you. In episode 80 when I talked with Nancy Smyth about trauma informed care, she reminded us that lots of people who come to therapy have had some sort of experience or experiences that give them reason to distrust adults or mental health professionals. Communities of color have a long history of abuse and mistreatment by mental health professionals, so much so that we need to assume a level of cultural mistrust, particularly between white providers and clients of color.

So, given all this, before someone walks into your office – or you walk into their home – you have to assume that there was some sort of breaking point, one or more people either suggested or required (like a judge or a spouse) that the person to get help. Sociologist Bernice Pescosolido (I love saying that name) she came up with a theory of help-seeking called the Network Episode Model. Her research on adults and mental health treatment found that it takes entire communities to push folks into treatment. It is possible that someone made the appointment for them. There might have been a phone screening or intake, time passed – everything from a day to several weeks… The postmodern therapies like Solution-Focused and Narrative helped us to see that change is constant. We have to assume that some things changed between the when the client made the appointment and when they show up in your office (or you show up in their home). The change might have been something directly related to the presenting problem or reason for referral, or maybe not. But just like the relationship between the butterfly that flaps its wings and the tsunami that wreaks havoc on a shoreline halfway around the world, we should never discount the importance of the small stuff, especially if that small stuff is actually the big stuff, like people not trusting us or not wanting to be in therapy.

Agency referrals

Someone is already in the system and you’re getting another client on your caseload. Since the client is in-house, you’ll likely have access to their medical records and be eating lunch with their former therapist and might have even been staffing the case in weekly meetings. The challenge in this situation is to see the client with fresh eyes, even though there is all this information available.

Private practice

You might get a client from another therapist or primary care provider or mandated by a court order to get help. Really important to get release of information forms signed with all the right people in all the right places. If you’re referring a client to another therapist, you can’t follow up and say “Hey, did Domingo make an appointment with you?” Because… confidentiality.

At the very least you want to know: referral source, presenting problem, prior treatment history, and current goals.

What do people want when they come to therapy?

This is such a basic question, but it isn’t always easy to answer. Think about your own life for a moment. If you were to call up a therapist and make an appointment, what would you want to get out of treatment? Of course, it is likely that you don’t think you need to get therapy. So, more realistically, why would someone else want you to get therapy? If you did come for therapy what would you like to change? What thoughts, feelings or behaviors are getting in the way of you getting what you want in life?

This question of what people want out of therapy is really interesting. My dissertation research was on mothers who took their children for mental health services. I found something really interesting. And it was interesting enough to the four people on my committee that they gave me a Ph.D. Yeah, just like that. Super easy. What I found was that moms brought their kids to mental health services because they wanted one of two things: to know what the problem was, or to know how to solve it. One group of moms was looking for answers. They couldn’t figure out what the problem was. They knew something was wrong with their kid. Their teachers, their friends, their pastors, even their employers had said “something is wrong.” But they didn’t know what. And no one around them knew what. So, they were bringing their kid to the professionals to find out what was going on. It is important to emphasize that these moms had already done an exhaustive investigation into the problem before they got to therapy services. I’m highlighting this because therapists often think that they are the first stop in the help-seeking process. The truth is that they are only most recent. These moms wanted a thorough assessment and diagnosis. Now, I’m not using the term diagnosis to mean DSM diagnosis. I mean that they wanted the professional to let them know that a, b, and c were related and they were probably related to d, and that means e. For example, they wanted the therapist to say “the fidgeting, outbursts, and social ostracism you’ve seen at home and at school are related to his difficulty paying attention and hyperactivity. We think there are probably biological and environmental reasons why this is happening.” So that’s the thorough assessment. If you’ve been in the field for a while you might hear this as a general description of ADHD and are probably anticipating the next part of the conversation – the one where the psychiatrist recommends a psychostimulant and the therapist works with the kid on social skills training and time management, and works with the parents and teachers on being on the same page with structure, consequences and rewards. But that second part of the conversation about treatment jumps ahead a bit too soon. Remember, we’re talking about moms who don’t know what’s wrong and want to find out. They are not necessarily looking for the therapist to fix the problem. Why? Because they saw it as their job, as the moms, to fix the problem. Yes, they needed the professional to say what was wrong, but once they got that, it was their responsibility to fix the problem. For these moms, a 15 minute intake and three sessions of “let’s get to know each other” was the worst kind of services. They wanted 15 minutes of “let’s get to know each other” and a three session assessment.

Now the other group of moms came to services because they knew what the problem was but they didn’t know how to fix it or they had tried and couldn’t fixing it on their own. So, they might know that ADHD was the likely diagnosis for their kid who was fidgeting, having outbursts and experiencing social ostracism because they were the same way as a kid, or because they have another kid with the diagnosis, etc. But they don’t know how to fix the problem so they are coming to the professionals to do it. For these moms, 15 minutes of “let’s get to know each other” and a three session assessment was the WORST services. They wanted the 15 minute intake – someone to honor and respect their expertise as the mom and take them seriously when they said “here’s the problem, I need to know what you can do to fix it.”

Again, the moms had two different reasons for coming in. One was to find out the problem, the other was to fix a known problem. If you can get a handle on which one of these is the main focus for seeking treatment, then you’re further along than most folks.

So, a quick summary – most clients don’t want to come to therapy, and when they do you should know if they are looking to discover what the problem is or work on fixing it.

Biopsychosocial assessment

I talk about the basic biopsychosocialspiritual (BPSS) assessment in episode 2. For our purposes remember that the BPSS provides a context for why someone is seeking services. What’s going on with the person’s neurobiological functioning, physical health, family medical history or other medical treatment including medications? The psychological assessment includes things like understanding their personality style, attachment style, interpersonal relationships, any existing diagnoses. The socio cultural assessment looks at issues like cultural beliefs, community norms, external stressors. The spiritual assessment looks at several factors related to religion and spirituality. David Hodge, in his 2015 text, synthesizes several existing religious and spiritual assessment models into the acronym ICARING. When you do a spiritual assessment you want to find out: I - important: How Important is spirituality or religion? C - community: Is there participation in a religious or spiritual Community? A – assets and R – resources: Are there spiritual beliefs and practices that serve as assets and resources? I – influence: What is the Influence of spirituality and religion on the current situation? N – needs: Are there spiritual Needs that should be addressed? G – goals: Is incorporating spirituality into treatment one of the client's Goals? If so, how?  So, again, if you’re interested in learning more about the BPSS, check out episode 2.

In contrast to the BPSS which provides a context for the presenting problem, a diagnostic formulation places the problem in a category. The DSM is the most widely used system for categorizing mental health problems, but it’s not the only one. For a history of the first DSM up through DSM 4, check out the very first episode of the social work podcast. And for a scathing critique of DSM-5 you can check out my interview with Jeffery Lacasse in episode 101.

If you’re doing a DSM diagnostic interview, a great resource is the cultural formulation interview available for free on the website. Anyone doing a DSM diagnosis should use a cultural formulation. As part of the diagnostic interview, clinicians are expected to gather and summarize information in four areas:

  1. The first area is the cultural identity of the individual. This includes ways in which the person’s cultural, racial, and ethnic identity may “influence his/her relationship with others, access to resources, and developmental and current challenges” (APA, 2013, p. 750).
  2. The second area is cultural conceptualization of distress. This includes “cultural syndromes,” “idioms of distress,” and “explanations and perceived causes.”
  3. The third area is psychosocial stressors and cultural features of vulnerability and resilience. This is the part of the cultural formulation that covers the former Axis IV from DSM-IV – psychosocial stressors. 
  4. The fourth area is cultural features of the relationship between the individual and clinician. This asks the clinician to consider such issues as language barriers, cultural mistrust of professional services/providers, and how those cultural features may effect therapeutic alliance.

If you’re listening to me talk about the BPSS and the diagnostic interview and you’re starting to panic, take a deep breath. Your agency or practice probably has a standard intake form. If they don’t, practice management system like TheraNest there are intake assessment and diagnosis forms built into the software. You can modify these forms or create your own. When you’re done you can electronically sign and print to PDF or in hard copy.  TheraNest makes it easy find diagnostic codes and names with the click of a button.

It takes time and practice to learn how to do thorough assessments. New forms, new information… figuring out what is important takes time and makes new social workers and new employees slow. You’re thinking through all the options and this makes your thinking slow. So how do you speed up your thinking? This issue of fast and slow thinking was such a big deal that the guy who figured it out got a nobel prize.

Daniel Kahneman, the psychologist who won the Nobel prize for his work with Amos Tversky, talks about this experience of thinking fast and slow. Fast thinking, originally called System 1, is what experienced clinicians do all the time. After 5 minutes on the phone with a teacher, three minutes of being in a room with a kid, and two minutes of talking with the parent you’ve got a pretty good idea that the kid meets criteria for ADHD. Did you perform a thorough assessment in 10 minutes? No. But you have enough expertise to recognize a pattern based on minimal information. You go through a complex set of mental events and everything coalesces around this diagnosis of ADHD.

Fast thinking is great unless you can’t articulate why you came to the conclusion.  The conclusion is essential for documentation and conveying to judges and lawyers why you did what you did. Lawyers love cross-examining so-called expert witnesses who are unable to explain how they came to their conclusion.

If you’re supervising an intern, this “fast” thinking can be confusing or frustrating. Fast thinking can also be fascinating. It is what makes experienced therapists seem like magicians.

The flip side of fast thinking is what Kahneman called “slow” or “system 2” thinking. Beginner thinking is “slow.” Kahnemen doesn’t use this as a pejorative, although supervisors and interns often think of it that way. Thinking slow means being deliberate. If you don’t know what the information means you take time to sort it all out. Some of the tools used in slow thinking are algorithms, flow charts, logic models, and case formulations. Slow thinking often avoids the biases and errors of fast thinking. Fast thinking, on the other hand, forces a decision and moves things along when slow thinking might have us gather information and spend an inordinate amount of time sorting out what to do.

In an ideal world, fast and slow thinking work together for optimal decision-making. I would argue that if the supervisor is a fast thinker and the intern is a slow thinker that they can be a better team by talking through those differences. If you’re interested in learning more about Thinking Fast and Slow I highly recommend Kahnamen’s 2011 book of the same name. If you want some podcast episodes about Kahnamen’s work, just check out the Freakonomics podcast. It seems like about half of their episodes reference Kahnamen and Tversky.

Establishing rapport

Rapport isn’t something you establish once. Rapport ebbs and flows in therapy as it does in every relationship. The fancy phrase that we use in therapy is “Therapeutic alliance”. How strong is the alliance between the therapist and the client? Alliance turns out to be VERY IMPORTANT in client outcomes. I don’t care how good you are at identifying automatic thoughts, rooting out core beliefs, and dismantling the cognitive triad – if your client doesn’t like you you’re not going to make progress.

Therapeutic alliance is one of the common factors in psychotherapy. Common factors are thing that are present in all therapeutic relationships, regardless of the specific treatment approach. For example, a good CBT therapist and a good psychodynamic therapist will conceptualize client problems and approach treatment very differently, but both will have strong alliances with their clients.

Some of the other common factors are: agreeing on goals, collaboration, genuineness, positive regard, and expectations.   Now, you might be thinking to yourself “hmmmm… those sound an awful lot like the three conditions that Carl Roger said were necessary and sufficient to meet the needs of clients: empathy genuineness, and unconditional positive regard.” You’re right. Carl Rogers said that those three components were. As I talked about in episode 8 these three conditions are necessary, but in many cases not sufficient for people to get better.

Several years ago I worked with a woman in her mid-50s. She was recently unemployed, single, no children, and struggling with financial stressors and debilitating depressive symptoms including thoughts of suicide. There’s no doubt that I had to be empathic, genuine and have unconditional positive regard for this woman. She said that her peers looked upon her with pity – they were married. If divorced, at least they had children or grandchildren. If divorced and no children at least they had their careers. These were some of the things that fed into her depression. My validation that she was valuable and cared for was in and of itself therapeutic. It was necessary for treatment to work, but not sufficient. Medication helped with the depressive symptoms. I helped her think of her current situation as temporary. We framed it as a role transition, meaning she was depressed in part because she was grieving the loss of her previous role of partner and wife (and all the accompanying status and financial security that came along with that). I later found out that role transition is one of the big four issues that Interpersonal psychotherapy, which I talk about in episode 10, focuses on for treating women with depression.

Now, I bet you’re listening to this and saying to yourself, “wait a minute Jonathan, you were just talking about the common factors in therapy, and then you gave an example of how an empirically supported treatment was the thing that made the difference for your client.” Ok. Nice catch. Here’s the deal: The research on what makes psychotherapy work has found that when you compare treatments that work, the things that are most helpful are these common factors. The research does not say that any treatment will work.

Ok – now where was I? Oh yeah. Rapport. Hahaha. That’s right I was talking about building rapport and how that isn’t something that happens once and then you’re done.

One of the best ways to establish rapport is to find out what your client likes, what they are good at, things that make them feel good about themselves and that give you a chance to be impressed by them. We like it when others are genuinely interested and impressed by us. This effect is magnified when you’re sitting in the therapy room talking with someone who already knows some pretty embarrassing or shameful things about you, or is about to. So, small talk. But not just for the sake of small talk. For the sake of starting to build a therapeutic alliance. How do you know when you’ve established enough rapport to move out of small talk and into the next phase of treatment? Guy Diamond and Suzanne Levy, the co-developers of Attachment-Based Family Therapy, like to say that you know you’ve spent enough time on small talk when your client doesn’t have their guard up – when they start to answer questions unselfconsciously, freely, and spontaneously. Once this happens, you can feel more confident that they will be more honest and genuine with you. And, as I talked about in my digression a few minutes ago, honesty and genuineness are necessary components to effective treatment.
You need to review confidentiality, specifically what happens when someone mentions Harm to self, ongoing abuse of minors, older adults, or people with disabilities, and in states covered by threat to harm others. You want to make sure they understand billing and payments. You also want to screen for substance use, suicide risk, and risk for interpersonal violence.

Quick review:
Assume people don’t want to come to therapy, but they are here anyway. Your job is to build rapport, develop trust, and figure out why they are in therapy. It might be to figure out the problem, in which case a thorough biopsychosocialspiritual assessment and diagnosis is great. All assessments should be done through a cultural lens. If it is because they know what the problem is but don’t know how to solve it, then the focus should be on solutions.

Case conceptualization

One of the most important things to do in the beginning of therapy is to figure out what this is about. A term that people often use is “Case conceptualization.” Your conceptualization could be from a specific theoretical perspective such as CBT or psychodynamic. In episode 52 I spoke with Joe Walsh (the professor, not rock legend) about theories for clinical social work practice. He suggested that people have one or two dominant theoretical perspectives.

James Morrison, author of the very popular Guilford Press books, “DSM Made Easy” and “The First Interview” has a great example of how a single presenting problem can be understood from vastly different perspectives. Take the example of a married woman who drinks too much alcohol (Morrison, 2014, p. 3):

  • Dynamic. Her overbearing husband resembles her father, who also drinks.
  • Behavioral. She associates drinking with relief from the tensions induced by these relationships.
  • Social. Several girlfriends drink; drinking is accepted, even encouraged, in her social milieu.
  • Biological. We should also consider the genetic contribution toward alcohol misuse from her father.
Spiritual. Morrison doesn’t include this in his example, but Lori Holleran, whom I interviewed in episode 105, would say that understanding the spiritual aspect of problem drinking is key. A spiritual perspective might be that drinking has something to do with her struggles with who she is in this world.

Morrison correctly says that we should be able to see the issue from all of these perspectives simultaneously.

Ending the first session

We have to be prepared for the possibility that our first session might be our last. Research by Gibbons and colleagues looked at services use in community mental health clinics in 1993 and again in 2003. What they found was that the modal number of sessions that people attended was one. Now, the average number of sessions was higher because some people attended more than one. But most people only attended one session. The brief therapy approaches address this issue. One of the most valuable insights to come out of brief therapy is the idea that we can use time as a motivator. If you know you only have one session, you can think of your session as being the beginning middle AND end. We’ll talk more in depth about the middle and end in the next two episodes. But, suffice it to say that you should always think about the END of therapy in the beginning. What will let you and the client know they no longer need or want services? How will you measure change? What information will help you get to where you need to go, and what information will slow you down? What is your exit plan – i.e. what sorts of issues are present that cannot be addressed in your work but that would be important for someone else to address (hint: those are some of your referral sources).


Let’s imagine you’ve had an amazing first session with your client. They were anxious but your gentle and curious questions helped them to relax. You uncovered some important information about how they got here and what they were looking to get out of therapy. They curled up in that big chair of yours, or they really enjoyed their ice cream cone. The session ended with a commitment to come back for more sessions.

Now it is time to document. If you’re doing an intake it should be thorough, but it won’t be complete. You’ll learn things as you run through the course of therapy. Assessment is ongoing. When you learn new information or need to revise old information use your progress notes to document what you’ve learned and create addendums for your assessments. As I mentioned before, if you’re using a program like TheraNest, documentation might not be fun, but it is easy. It has intake forms, progress notes, and you can create your own customized forms. Submit electronic insurance claims, accept credit cards, create invoices and superbills. For an extra fee you can create a client portal to allow your clients to submit intakes forms and even schedule appointments online. Try TheraNest for free and receive 20% off your first 3 months when you sign up at

The second and third episodes in this series will cover the middle of therapy and the end of therapy. If you want more information about the episodes and research I’ve mentioned in this episode you can find links on the website at If you want to join the huge community of podcast listeners, please go to our Facebook page at or follow the Twitter account @socworkpodcast.

If you are interested in donating a transcript, please send me an email at

APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2017, June 15). #110 - The Arc of Therapy: Beginnings (Part 1) [Audio Podcast]. Social Work Podcast. Retrieved from

No comments: