You can always be misunderstood

There are two aims in any conversation: unambiguous expression of your own position and complete comprehension of the other person's views. We should always remember that neither of these aims is a realistic goal.

A client told me of an ante-natal appointment at which her midwife said "So, your first child was deformed and your second child was killed: let's hope it's third time lucky, shall we?"

While it is difficult to imagine anyone not being offended by such insensitivity, it is equally hard to believe that the midwife was being intentionally cruel. If she thought at all about her comment, she may have imagined she was being warm & humorous: rapport-building.

While serving as a Member of the Finnish Parliament, communications researcher Osmo Wiio proposed his "laws of comunication", including:

• If communication can fail, it will
• If communication cannot fail, it still most usually fails
• If communication seems to succeed in the intended way, there's a misunderstanding
• If you are content with your message, communication certainly fails!

Clients are often mystified by someone's negative reaction to what seemed, to them, to be a reasonable statement or request. In discussing such situations, we usually conclude that it is possible to misunderstand even the most clearly worded request and to be offended by even the most innocuous statement: what the speaker says may have little to do with what the listener hears.

Clients who are anxious or depressed may be less able to attend to either expression or comprehension with the same care & attention as their therapist. Therapists' comments & questions, however clearly articulated, may still be misinterpreted because the client is not paying full attention or has information of which the therapist is unaware (but which the client may think the therapist knows).

Misunderstandings & unfortunate comments can be worked through given time and effort, but neither of these will be forthcoming from a therapist who thinks that their own communication is unambiguous.

Be on time for your clients

Be on time for your appointments & consultations. Punctuality conveys professionalism, respect and allows you to address & manage possible resistance on the part of the client.

There's a Catch-22 type joke (at least, I thought it was a joke) about clients' attendance at appointments:

If they're early, they're anxious; if they're on time, they're obsessional; if they're late, they're resistant.

Therapists, by contrast, seem only to have two modes: on time (rare) and late (mostly). Lateness on the part of therapists is usually due to an excessive workload and so is likely to be forgiven—or at least tolerated—by NHS clients. The implicit message, that the therapist's time is more valuable than the client's, doesn't make for a good start to a session, however.

In an over-subscribed service, punctuality is difficult to ensure. Many medical services don't even try, overbooking clinics on the principle that there will be non-attendances. The aim is to ensure that the clinician never has to wait for a patient, but this almost guarantees that the patient will face a lengthy wait.

Punctuality has no downside. Lateness may imply importance and high demand, but punctuality conveys professionalism, courtesy and credibility: who would accept time management advice from someone who arrived late?

Ten minutes in a busy clinic can be a very short time: scribbling casenotes, fielding phone calls and requests from colleagues, scanning files and letters prior to your next appointment.

Ten minutes in a waiting room is a long time, especially if you have arrived early in order to ensure that you are on time, if you are anxious or in pain, or if you have psyched yourself up for the appointment. A punctual therapist will get a calmer, less anxious client.

Therapists who book appointments back to back (or overbook clinics) to compensate for non-attendance are replacing one problem with another. Punctuality ensures that persistently late clients are obvious to the therapist, not just their receptionist, permitting contributory issues to be addressed. Tackling client lateness when you are habitually late would be a challenge for even the most blatant hypocrite!

In the Room

A blog focussing upon cognitive behavioural & psychodynamic techniques & issues "in the room" rather than case or theoretical discussions.

Chris Allan is a Clinical Psychologist and Director of the Psychology Clinic at the University of Wollongong in New South Wales, Australia. His weblog In The Room addresses a range of therapeutic issues and the related literature.

Each post illustrates a problem encountered by therapists and offers insights into this problem, often with extensive quotes from relevant textbooks and journals. As a round up of "therapy tips & techniques you will find in your textbooks", In the Room should be of use to any psychological therapist and is well worth a read by physical therapists also.

The Golden Rule is universal

Treat others as you'd like to be treated is a universal principle. Therapists who avoid working with other faiths and cultures can be assured that there is common ground to work from.

Working with people with different beliefs can be challenging, especially for psychological therapists. By definition, every client holds some beliefs differing from the therapist's but there is something particularly daunting about codified cultural and religious belief systems.

Clients will often seek out therapists of a similar culture or faith, fearing (sometimes correctly) that an ignorant or antagonistic therapist may question basic beliefs which they do not wish to examine.

Therapists may also shy away from clients of different cultures or faiths, fearing that a misunderstanding on their part may upset or offend the client, possibly even to the level of formal complaints. Such a lack of confidence does little for rapport.

Whilst therapists cannot know the details of every faith and culture they might encounter and should think carefully before attempting to work within frameworks they do not understand, there is one principle common to almost all belief systems: the Golden Rule;

do unto others as you would have them do unto you.

Religious Tolerance.org lists 21 world religions (including Christianity, Judaism, Islam, Hinduism & Sikhism) and a number of other philosophical systems which contain a version of the Golden Rule.

The site notes that most religions make some exception for non-believers, but the existence of this almost universal principle should reassure the uncertain that there can be common ground.

A wise therapist would not, of course, presume to believe that there can be complete agreement. The comedian Emo Phillips has illustrated the dangers of pursuing the search for common ground too far.

I was walking across a bridge one day, and I saw a man standing on the edge, about to jump off. So I ran over and said "Stop! don't do it!" "Why shouldn't I?" he said.

I said, "Well, there's so much to live for!" He said, "Like what?"

I said, "Well...are you religious or atheist?" He said, "Religious."

I said, "Me too! Are you christian or buddhist?" He said, "Christian."

I said, "Me too! Are you catholic or protestant?" He said, "Protestant." I said, "Me too! Are you episcopalian or baptist?"

He said, "Baptist!" I said,"Wow! Me too! Are you baptist church of god or baptist church of the lord?" He said, "Baptist church of god!"

I said, "Me too! Are you original baptist church of god, or are you reformed baptist church of god?" He said,"Reformed Baptist church of god!"

I said, "Me too! Are you reformed baptist church of god, reformation of 1879, or reformed baptist church of god, reformation of 1915?" He said, "Reformed baptist church of god, reformation of 1915!"

I said, "Die, heretic scum", and pushed him off.

Set limits on diaries & records

Set clear limits on diary-keeping and other journals. By asking for the minimum amount of information necessary, you increase the chances of obtaining reliable data.

Journals and other records kept by the client are a useful adjunct to most therapeutic approaches and an integral part of some, such as Cognitive Behavioural Therapy. Daily or hourly data points can be invaluable in establishing patterns and tracking progress.

Diary sheets may be handed out automatically at the beginning of therapy, in the expectation that clients will keep reliable records which can be used as the basis for therapy. Presenting clients who are already struggling to cope with another responsibility may not be the wisest move.

Anyone who has attempted to keep a daily journal (or blog regularly!) will know the difficulty of maintaining their resolve over the long term: the first week or two are reasonably easy, but week three or four is where most resolutions fail. Therapeutic records are no exception.

Before requiring a regular commitment from a client over & above their attendance at your appointments, it is worth considering:

• whether the data you are considering are necessary
• how much detail is required for the analysis
• how many data points are required

Rather than automatically requiring a diary or other recording outwith the session, ask yourself (and your client) whether the same information could be generated within the session. Clients who have struggled to carve the time for your appointment out of their schedule will appreciate you keeping your requests for extra time to a minimum.

Diary sheets are often standard forms copied from a book and require more information than may be necessary for your analysis, as well as more information than clients can comfortably record at the time. Look back over some old notes to see how often every column is completed reliably (if at all) on standard record forms. The less you require, the easier it will be to provide.

A client suffering migraine headaches drew a smiley face on each migraine-free day in her pocket diary. Flicking through the diary showed a clear increase in the number of smilies.

Most important is to consider whether the record keeping is part of the permanent change that your client wishes to make or is limited to their time in therapy. If the intention is that your client will keep a record indefinitely (e.g. a daily reflective journal), as much time should be devoted in session to establishing this habit as would be devoted to any other change in thinking or behaviour.

If the data is required for a specific part of therapy only, you should agree with the client that they will keep the record for only as long as necessary to collect the required data. If intended to track progress, a record kept for a couple of weeks at the start of therapy and reinstated near the end and again at followup may be more reliable than a supposedly continual record (which will probably lapse after three weeks or so).