The Intake Process by Linda Stewart
The therapeutic process begins not only with our first conversations – setting fees, scheduling, communicating the reason for seeking therapy – but also with our intake forms. My work with women and perinatal loss has brought up the need to give pause when organizing intake forms and forming assessment questions. I can recall a graduate school professor instructing that we should never overtly ask about abortion as part of personal history. Indeed, I have seen and have used intake forms that simply ask for the number of children and sometimes their ages. If you specialize in perinatal loss, including abortion, normalization can begin before a client ever discloses any such related grief or trauma. And that normalization can begin to occur with your intake form. We communicate something, however unintentionally, to our clients by what we ask, and by what we don’t ask. If we consider our forms from the perspective of new clients, we can provide a greater service by revising intake to support our client’s reproductive history before the first session begins.
My recommendation to those that may not specialize, but have found perinatal loss or trauma to be a part of some client histories and therapeutic work, is to use your intake form as a part of your therapy and therapeutic process. An individual’s reproductive history can be relevant to his or her therapy even if it is not the focus. By all means, please ask for number of children, and names and ages as well. [Side note: I have found for the most part that clients like to list ages anyway, and do so even if this is information that has not been requested. Clients often believe this to be, and I agree, helpful information.] But we can also learn from some medical professionals, and include number of pregnancies, miscarriages, stillbirths, abortion, and a place to identify infertility. The presence of these questions does not demand an answer, but provides normalization, diagnostic value, and validation that allow our client’s a voice for some very personal losses or decisions that are typically ignored or minimized.
Given statistics from the Alan Guttmacher Institute estimating that approximately 21% of pregnancies are aborted, the American Pregnancy Association providing that 10-25% of clinically confirmed pregnancies end in miscarriage, and the Center for Disease Control estimating stillbirths at 10.9%, it is unusual for me to come across clients that have NOT experienced some type of perinatal loss (either their own or someone’s they care about). Adoption placements are by far the least common with approximately 14,000 occurring annually[1]. As you know, perinatal losses are typically not the reason clients have reached out for therapy, but it when it does come up – often in an apologetic or minimizing way – the client anticipates that this will not be important to our sessions. However, if children, pregnancies, and any perinatal loss are referenced on the intake form, their experience or loss has just been normalized from the start. In other words, “If this is on the form, then I am not the only one – others mark these boxes.” Or, “If it’s on the intake form, it might be relevant. This therapist must want to know.”
This may appear to be invasive to some clients, and such an opinion should be respected and affirmed. If a male or female client remarks about these questions in a negative way, you might consider saying something like, “Please do not feel any pressure to answer. I am simply offering my clients the space and opportunity to disclose and also discuss a personal experience that is often ignored or overlooked outside of therapy.” Since assessment is not limited to the first session and initial paperwork, it can be revised as treatment moves forward. Something that a client does not disclose (for a variety of reasons) earlier in the therapeutic process is likely to be disclosed as trust is built and validation is experienced.
I interviewed some staff at a mental health hospital years ago, and they were surprised, as our conversation proceeded, to discover that although abortion and other pregnancy losses often present during their clients’ treatments, they had no related questions at all on their intake forms. Someone actually ran out of the room to grab an intake form and check. We all sat nodding, understanding the impact this can have on a man or woman struggling after an abortion or other type of pregnancy loss if no one were to ever ask whether or not this was a part of his or her story. If we don’t ask general personal history questions such as this, then we are perpetuating abortion and pregnancy related grief as disenfranchised grief.
As Greg has stated before, once something has been disclosed, it is not strictly up to us to determine whether that should then be the primary focus of treatment. Just because a male or female client marks that they have had or been a part of an abortion does not automatically mean that he or she is presenting with trauma related to this event. However, once the disclosure is made, we can professionally explore and assess how this affects the current course of therapy. It is possible that some may disclose, feel validated, have their experience normalized, and then be free to revisit the loss at a later time after other foundational work has taken place. The chances of this are less likely though if we do not model that it is an important part of personal history from the start. “Important part” does not mean necessary focus – but instead honors our client’s experiences by communicating that we are thinking about these as possible impacting events in a person’s story.
I admit that we might consider leaving children and pregnancies off of an intake so as to protect clients from the discomfort of having to even think about it. I am also aware of the pain that can result for someone who has lost a child. If our client’s oldest child died last year or 10 years ago they may ask themselves, “Do I put that I have 2 or 3 children?” And consider, “My only child is now gone, do I say that I have no children?” This happens as well, “I still mourn our oldest, but very few know that he even existed, how many children do I mark down?” Part of the beauty of therapy is that our clients experience the same difficulties in our office that they experience in every day living and interactions, but we have the chance to heighten these feelings and work with them in a way that can allow for exploration and emotionally corrective experiences[2].
Consider creating further opportunities for such therapy to occur, and include pregnancy questions in your intake. Then, don’t leave it there. Don’t breeze over this section as if it were a given address. Feel free to gently inquire, make mental notes, and leave the conversation (however it goes) open to further exploration any time that they wish, or that seems therapeutically relevant. You will be offering your clients (note: female AND male) a space to acknowledge such losses, and granting permission to grieve if they haven’t already.
And it is true to say that assessment continues and is revised as treatment moves forward. Something that a client does not disclose (for a variety of reasons) earlier in the therapeutic process is likely to be disclosed as trust is built and validation is experienced.
[1] Alan Guttmacher Institute
[2] Emotionally Focused Therapy model
The therapeutic process begins not only with our first conversations – setting fees, scheduling, communicating the reason for seeking therapy – but also with our intake forms. My work with women and perinatal loss has brought up the need to give pause when organizing intake forms and forming assessment questions. I can recall a graduate school professor instructing that we should never overtly ask about abortion as part of personal history. Indeed, I have seen and have used intake forms that simply ask for the number of children and sometimes their ages. If you specialize in perinatal loss, including abortion, normalization can begin before a client ever discloses any such related grief or trauma. And that normalization can begin to occur with your intake form. We communicate something, however unintentionally, to our clients by what we ask, and by what we don’t ask. If we consider our forms from the perspective of new clients, we can provide a greater service by revising intake to support our client’s reproductive history before the first session begins.
My recommendation to those that may not specialize, but have found perinatal loss or trauma to be a part of some client histories and therapeutic work, is to use your intake form as a part of your therapy and therapeutic process. An individual’s reproductive history can be relevant to his or her therapy even if it is not the focus. By all means, please ask for number of children, and names and ages as well. [Side note: I have found for the most part that clients like to list ages anyway, and do so even if this is information that has not been requested. Clients often believe this to be, and I agree, helpful information.] But we can also learn from some medical professionals, and include number of pregnancies, miscarriages, stillbirths, abortion, and a place to identify infertility. The presence of these questions does not demand an answer, but provides normalization, diagnostic value, and validation that allow our client’s a voice for some very personal losses or decisions that are typically ignored or minimized.
Given statistics from the Alan Guttmacher Institute estimating that approximately 21% of pregnancies are aborted, the American Pregnancy Association providing that 10-25% of clinically confirmed pregnancies end in miscarriage, and the Center for Disease Control estimating stillbirths at 10.9%, it is unusual for me to come across clients that have NOT experienced some type of perinatal loss (either their own or someone’s they care about). Adoption placements are by far the least common with approximately 14,000 occurring annually[1]. As you know, perinatal losses are typically not the reason clients have reached out for therapy, but it when it does come up – often in an apologetic or minimizing way – the client anticipates that this will not be important to our sessions. However, if children, pregnancies, and any perinatal loss are referenced on the intake form, their experience or loss has just been normalized from the start. In other words, “If this is on the form, then I am not the only one – others mark these boxes.” Or, “If it’s on the intake form, it might be relevant. This therapist must want to know.”
This may appear to be invasive to some clients, and such an opinion should be respected and affirmed. If a male or female client remarks about these questions in a negative way, you might consider saying something like, “Please do not feel any pressure to answer. I am simply offering my clients the space and opportunity to disclose and also discuss a personal experience that is often ignored or overlooked outside of therapy.” Since assessment is not limited to the first session and initial paperwork, it can be revised as treatment moves forward. Something that a client does not disclose (for a variety of reasons) earlier in the therapeutic process is likely to be disclosed as trust is built and validation is experienced.
I interviewed some staff at a mental health hospital years ago, and they were surprised, as our conversation proceeded, to discover that although abortion and other pregnancy losses often present during their clients’ treatments, they had no related questions at all on their intake forms. Someone actually ran out of the room to grab an intake form and check. We all sat nodding, understanding the impact this can have on a man or woman struggling after an abortion or other type of pregnancy loss if no one were to ever ask whether or not this was a part of his or her story. If we don’t ask general personal history questions such as this, then we are perpetuating abortion and pregnancy related grief as disenfranchised grief.
As Greg has stated before, once something has been disclosed, it is not strictly up to us to determine whether that should then be the primary focus of treatment. Just because a male or female client marks that they have had or been a part of an abortion does not automatically mean that he or she is presenting with trauma related to this event. However, once the disclosure is made, we can professionally explore and assess how this affects the current course of therapy. It is possible that some may disclose, feel validated, have their experience normalized, and then be free to revisit the loss at a later time after other foundational work has taken place. The chances of this are less likely though if we do not model that it is an important part of personal history from the start. “Important part” does not mean necessary focus – but instead honors our client’s experiences by communicating that we are thinking about these as possible impacting events in a person’s story.
I admit that we might consider leaving children and pregnancies off of an intake so as to protect clients from the discomfort of having to even think about it. I am also aware of the pain that can result for someone who has lost a child. If our client’s oldest child died last year or 10 years ago they may ask themselves, “Do I put that I have 2 or 3 children?” And consider, “My only child is now gone, do I say that I have no children?” This happens as well, “I still mourn our oldest, but very few know that he even existed, how many children do I mark down?” Part of the beauty of therapy is that our clients experience the same difficulties in our office that they experience in every day living and interactions, but we have the chance to heighten these feelings and work with them in a way that can allow for exploration and emotionally corrective experiences[2].
Consider creating further opportunities for such therapy to occur, and include pregnancy questions in your intake. Then, don’t leave it there. Don’t breeze over this section as if it were a given address. Feel free to gently inquire, make mental notes, and leave the conversation (however it goes) open to further exploration any time that they wish, or that seems therapeutically relevant. You will be offering your clients (note: female AND male) a space to acknowledge such losses, and granting permission to grieve if they haven’t already.
And it is true to say that assessment continues and is revised as treatment moves forward. Something that a client does not disclose (for a variety of reasons) earlier in the therapeutic process is likely to be disclosed as trust is built and validation is experienced.
[1] Alan Guttmacher Institute
[2] Emotionally Focused Therapy model