The first visit with a mental health professional can be unsettling for the LEP. Not knowing what to expect, coupled with a potential language barrier, can create increased discomfort. As service providers, both you and your client (the mental health professional) will play a critical role in the first impression that your LEP will have.
Rapport building is a cornerstone of the therapeutic relationship. It starts immediately, from the time that the LEP first makes contact with the provider. If you recall the discussion on the Stages of Change, the client is now in the Action phase. However, that does not mean that confidence is firmly rooted in the process. A misstep at this critical point, could send the LEP back to a previous stage, including “I don’t have a problem. I can manage this on my own.”
Clinical training includes rapport building techniques to help break the ice and engage the client in the therapeutic process. The clinician will gauge the client’s presentation to mirror affect appropriately. If the client is smiling it would be appropriate to smile. If the client is quiet, looking down or crying, for example, the clinician would modify tone of voice and facial expressions accordingly. A key tool for clinicians is the manner in which they, themselves, present in the room. Remember SOLER?
- Sit squarely
- Open body posture
- Listen
- Eye contact
- Relaxed
Before commencing a session, clinicians are well served by taking a moment to center themselves and clear any distractions from entering into the session. The same would be true for interpreters.
Typically, a clinician will open the floor for the LEP to explain the reason for the visit (assuming participation is voluntary). “What brings you to therapy at this time?” Some clients are able to articulate the concerns they have more readily than others. The clinician might prompt the client to explain how this concern is manifesting itself in day-to-day life, in an effort to get a general sense of the impact that the client is feeling relative to symptoms. Some might be able to outline their symptoms, some may not. Either way, the clinician’s primary responsibility at this juncture is to ease the client’s mind, being sensitive to the current presentation. (In this example, I am assuming that participation is voluntary. If treatment is court-mandated or not voluntary, for other reasons, the rapport building phase may require different positioning by the clinician.)
Before proceeding into greater detail, the clinician will talk about the nature of the therapeutic alliance that will be formed with the client, most notably through the discussion of Informed Consent. Treatment is predicated on reviewing what are, essentially, the terms and conditions of the therapeutic relationship. A full understanding of those terms is required from the client before moving forward. In simpler terms, the client needs to know what to expect before getting started. Informed Consent is the framework on which treatment is built. Please note that if the client is a minor, this process will include the parents or authorized caregivers.
Key elements of Informed Consent include:
- Service to be Provided – mental health counseling
- Implications of Service – exploration of topics/experiences contributing to symptoms, including uncomfortable feelings that may arise in the course of treatment (risks & benefits)
- Anticipated Outcome – amelioration of symptoms
- Session Length
- Billing & Fees
- Scheduling & Cancellation Policy
- Voluntary Nature of Participation
- Medical Records – process by which information can be shared about treatment; taking into account HIPAA guidelines; review of authorization for release of information
- Confidentiality – overview of protected information & privacy practices, in addition to exceptions to confidentiality (outlined below)
- Suicide
- Homicide
- Grave Bodily Harm (Tarasoff Duty to Warn/Protect) GBH
- Child Abuse
- Elder Abuse
- Dependent Care Abuse
This is a particularly sensitive area, given the tenuous nature of the new relationship between clinician and client. If not delivered well, the client may have an adverse reaction. Here is an example of how this critical information might be delivered:
“In order for us to build a trusting relationship, everything that you share here is confidential. That means that I will not share what you tell me with anyone, unless you authorize me to do so (in writing). By law, though, there are certain exceptions to confidentiality which I discuss with all of my clients. They include: suicide – if I were ever concerned that you might be a danger to yourself; homicide and/or GBH – if I were ever concerned that you might be a danger to others; Child Abuse/Elder Abuse/Dependent Care Abuse – if, during the course of our discussions, there was reason to believe that some type of abuse had occurred or was occurring. As I mentioned, I share this with all my clients.” I have found that positioning it in these terms reduces the impact of these caveats to confidentiality.
Clinicians can develop their own Informed Consent documents and there are many online templates that can be used as guides. Documents are signed and dated by both clinician and client (if the client is a minor, parents must sign). I am including a link to an organization that has a representative sample of documents for different populations. Interpreters can use these templates as a guide, to get a broad overview of how Informed Consent may be discussed in the therapeutic setting. Please remember that these are not scripts and individual clinicians will have customized documents.
Please let me know if you have any questions or comments. My next post will focus on the Bio-Psycho-Social Assessment.
Kind regards –
Diane
Through My Mind's Eye 