BPS Research Digest 3rd anniversary

In celebration of three years of continuous publication, first as an email newsletter and now as a weblog, the British Psychological Society's Research Digest has published a special edition. >

The authors of seven psychology blogs have each provided an article detailing a psychology journal article from the last three years, one which inspired them or changed the way they think. >

The topics range from the academic to the pragmatic: from whether psychology is a coherent scientific discipline to whether police officers can detect attempts to deceive them. Will Meek's report on an investigation into maintaining happiness should be of particular interest to readers of this site.

Compensation cases and miraculous recoveries

Experience suggests that receiving compensation for physical or mental injury or distress is often followed by a significant improvement in the client's symptoms. Many therapists decline to take on clients with ongoing compensation cases and some question the honesty of clients who make such recoveries.

Therapists who decline such cases may simply be unwilling to become embroiled in a legal battle (or fearful that a litigious client may turn on them) but those who doubt the client may be failing an empathy test. A client claiming compensation has a great deal to fear from their therapist.

Clients seeking compensation for their injuries (physical or emotional) face a difficult dilemma: cases can take years (up to seven, in my experience) to come to court and any recovery in this time may be used by the defence lawyers to undermine their case, reducing any settlement.

Compensating irrecoverable injuries at a higher rate than recoverable conditions seems eminently fair. Clients who fear undermining their case through recovery may therefore seem grasping and greedy, but this view assumes that there will be a pay out, which is by no means certain.

From the client's perspective, they may have lost their livelihood, their home, even friends and family to the injury or the aftermath. They may be seeking recompense but they may also be seeking some form of acknowledgement of their loss by those responsible. The defence case generally rests upon denying liability and this lack of acknowledgement can put the client under immense strain.

Therapists work by encouraging clients to take a realistic view of their past, current and future circumstances. In doing so, they may ask many of the same questions as will be raised (more robustly) by the defence lawyers, making the therapist a more threatening figure than we might hope to be.

The client should also be aware that the therapist's notes and the therapist themselves may be called by the court, which has the power to override confidentiality. The client usually has no idea if this will happen and so may withhold information, especially information which they fear might put them in a bad light, to the detriment of therapy.

Once compensation has been awarded or a settlement has been reached, the client is likely to be more secure financially, which is usually a major relief: a disabled person may feel that they can now pay back those who have supported them over the years since their injury. Also, the client has a public, official acknowledgement of their hurt and loss, which should facilitate their own acceptance.

Most importantly, with no-one now working to undermine the client's case, they can now trust the supports and opportunities offered both within and outwith therapy. Given this, "miraculous" recoveries seem much less surprising or suspicious.

Therapists who argue that the client should await such a change in their circumstances before seeking therapy may be consigning people to months or years of stress, anxiety and depression. The work may be harder and the relationship and responsibilities more challenging, but the need is there.

Leave deduction to Sherlock Holmes

Deductions impress clients, but incorrect deductions can be disastrous. Deductive reasoning has its place in therapy, but only as a means of generating hypotheses on which you can work with clients.

A client who usually had bare arms arrived in a long-sleeved shirt on a hot day. When I noted the change, she showed me cuts on her wrists which had become infected. I asked her to consider getting the wounds treated and, at the end of the session, said how glad I was she'd decided to do so. She asked how I knew she'd made that decision and I pointed out that she'd rolled up her sleeves. She was impressed by my deductive abilities: I felt like Sherlock Holmes. I was an idiot.

Once her scars were revealed, my client no longer had anything to hide from me, but she could have rolled down her sleeves again just as soon as she left the room. By jumping to conclusions under the guise of "deduction", I could have damaged our rapport and possibly driven her away from seeking further assistance.

By a man's finger nails, by his coat-sleeve, by his boot, by his trouser knees, by the callosities of his forefinger and thumb, by his expression, by his shirt cuffs -- by each of these things a man's calling is plainly revealed. That all united should fail to enlighten the competent enquirer in any case is almost inconceivable. (A Study in Scarlet, Sir Arthur Conan Doyle)

The ability of Sherlock Holmes to deduce all manner of information by simple observation has been popularised (and caricatured) for more than a century. The creator of Sherlock Holmes was trained in the same observational tradition that produced Sigmund Freud. Freud's precise observations are admired even by those who reject his theories. The temptation to engage in Holmesian (or Freudian) deduction can prove hazardous for therapists (and their clients).

I have often read assessment letters wherein conclusions about beliefs and motivation are drawn from the client's appearance and manner. These deductions have not been confirmed by—or even discussed with—the client but will, at best, colour and, at worst, direct subsequent interventions, again possibly losing the client (whether figuratively or literally, if assessing suicidality)

Deductions can and should be drawn from careful observation and questioning. These deductions should be treated as hypotheses, to be tested and confirmed (or ruled out) through further discussion and exploration with the client. Sherlock Holmes was always correct in his deductions. He had the advantage of being a fictional character, but even he observed proper caution.

I have devised seven separate explanations, each of which would cover the facts as far as we know them. But which of these is correct can only be determined by the fresh information which we shall no doubt find waiting for us. (the Adventure of the Copper Beeches, Sir Arthur Conan Doyle)

One of the inspirations for Sherlock Holmes is believed to be Dr Joseph Bell, with whom Sir Arthur Conan Doyle studied medicine. Dr Bell was renowned for his amazing deductions, but his aim was not to impress his clients: he was aiming to engage the enthusiasm of his students for less glamorous, but ultimately more helpful, patterns of work.

In teaching the treatment of disease and accident, all careful teachers have first to show the student how to recognize accurately the case. The recognition depends in great measure on the accurate and rapid appreciation of small points in which the diseased differs from the healthy state. In fact, the student must be taught to observe. To interest him in this kind of work we teachers find it useful to show the student how much a trained use of the observation can discover in ordinary matters such as the previous history, nationality and occupation of a patient. (Dr Joseph Bell).

I have to breach confidentiality - part 2

Disclosures requiring that confidentiality be breached are rare. A little preparation should permit you to focus upon supporting your client through the process, preserving your therapeutic rapport.

In part one, we considered how to react when a breach of confidentiality seems necessary, how to prepare for such an eventuality and what to say to the client.

Now we will consider how to continue your involvement with your client once you have had to breach their confidentiality. We will also consider how to proceed when your decision to breach confidentiality is reached outwith the session, whether independently, directed by your supervisor or required by law (eg: by a court order).

Ending the session

The decision to override confidentiality will usually discontinue a therapy session, but probably not your involvement with the client.

You may be advised that your client is not detainable, not chargeable or that the child protection issue they have raised is already known. This decision is unlikely to occur before the scheduled end of the current session, so you should not assume that the client will be unavailable for their next appointment.

In theory, if you have been clear as to your obligations and the actions you must take, your rapport with your client should be unaffected: their disclosure will have been an informed choice and they will see you as doing your duty (which may have been a relief for them). This has usually been the case for me: the client has agreed with the breach of confidentiality and supported my action.

In practice, the client may still feel aggrieved, or may come to feel differently inbetween sessions, especially if the official response isn't a positive experience. Whatever your profession—psychologist or physiotherapist, counsellor or chiropractor—it would be advisable to devote some or even all of your next session to discussing the client's experiences since you last met.

Again in theory, you might expect feedback on your report from the relevant agency. In practice, the client may be your only source of information as to how your report was handled. If your client does not attend their next appointment, don't assume they don't wish to see you: they may well be detained in hospital or police custody. Check with the agency to which you made your report, but don't be surprised if they won't tell you: they too may have obligations to preserve the client's confidentiality.

If you are aware that your action will suspend or discontinue your involvement with the client, you should discuss how they may resume contact. As their mind will probably be on other things at this point, this discussion should be as simple and straightforward as possible, e.g. "when you get out of hospital, give me a call". You can follow this up with your usual discharge information letter: the discussion should address any feeling of abandonment, but the letter should ensure that your words of reassurance can be acted upon.

When the client is absent

It is possible that you may make the decision to breach confidentiality outwith the session, on reflection, if presented with additional information. If you are a physical therapist unacquainted with the client's mental health history, you might feel you need to consult a mental health specialist before making your call.

If you have prepared the ground, the client will know that you may be required to breach confidentiality and should also know that you are seeking advice as to whether this will be necessary. That you have disclosed their information should not then come as a surprise (or shock) to the client.

You may wish to advise the client of your decision, once reached. As the client is no longer in your presence, you should not be held responsible for their actions while you sought advice. However, it isn't hard to imagine that your call to advise the client might be construed as a warning by the police or social services. If you don't wish to be charged with obstructing the course of justice, seek the permission of the officer or social worker to whom you make your report before you contact the client.

If you have not prepared the ground for your disclosure, you may now regret it. If a client has disclosed information to you on the assumption that confidentiality is absolute, they may be disappointed, shocked or angered to discover that you have betrayed their confidence. True, they could react similarly in your presence, even if you have prepared the ground, but in this worst case scenario you may not be able to respond to their reaction for days or weeks, assuming that they ever attend another appointment with you.

Directed by supervisor

Trainees and junior staff may find themselves being directed to break confidentiality by a trainer or supervisor: a disclosure which did not seem significant to you may ring alarm bells for someone with more experience.

Again, your client should be aware that confidentiality is limited, but in this case you probably won't have been able to prepare the client for this specific disclosure. You should not be left to manage the disclosure and the client's reaction yourself: a good move might be for your supervisor to be present at the next meeting (if any) to explain their decision and take the brunt of any negative response.

If this sounds disempowering for you, consider that you're in a learning situation and that these circumstances are actually pretty rare: take the opportunity to watch a more experienced therapist handle such a situation before you have to deal with one alone!

Problems may arise if you disagree with your trainer or supervisor's decision. Most training contracts are written on the basis that your supervisor is ultimately responsible for your caseload: your clients are really theirs. You should hopefully be able to discuss any such disagreement with your supervisor but, if you do not have such a good working relationship, you may wish to clarify your exact responsibilities and rights regarding your clients: your training course, employer or professional body should be able to advise you.

Required by law

You should be aware that lawyers, courts and other agencies (e.g. police and social services) may request or require that you provide access to your casenotes. This is almost certain to breach the client's confidentiality, although the consequences will vary greatly from case to case.

Both your professional body and your employing organisation should have guidance as to your responsibilities in such cases but, ultimately, a court can insist that you hand over your notes or face charges yourself.

In such circumstances, you will usually have plenty of time to seek professional and even legal advice as to your position. Organisations' legal departments exist, in part, to guide staff in such circumstances, although it is as well to remember that their first responsibility is to your employer, not to you.

The important point here is to be aware that your casenotes may be requested by a court long after you have moved on to another job and that, if you are not contactable, a colleague may be required to manage matters in your stead. You should write your notes on the basis that they may one day be read out in court: if you wouldn't swear to it, think again before you write it.

Aim for reliability before availability

Reliability is more important than availability in the long run. Clients who know when you are not available can make informed choices regarding alternative sources of support.

I once worked with a client who rang her GPs so frequently and insistently that they established a rota for taking her calls. She bombarded every new therapist with telephone calls. I told her she could call me between 1030 and 1130 on Monday or Thursday and that if I was on another call, I'd call her as soon as I finished. She rang me twice the first week and two more times in the next six months. She also called her GPs and CPN less frequently.

Many therapists feel a duty to respond to client's crises. Who better to address a difficult situation: the therapist who has listened carefully to the client's life-story or the harassed junior medic who has never met them before? Shouldn't you always be available for your client?

There are few UK therapists who provide an emergency service. General Practitioners (family doctors) and out-of-hours co-operatives provide rapid response for clients in crisis. There is a plethora of helplines, staffed by volunteers and formally trained counsellors. Most other therapy services are not intended to have a crisis intervention role.

So how available to your clients should you be? That's a matter for discussion in your service and with your colleagues: your availability sets clients' expectations for others in your service, while the purpose or funding of your service may dictate or restrict your availability. Far more important than availability is reliability.

If your client believes that, by calling every 15 minutes, they may just catch you between sessions, they will call and call when they could have more immediate and more appropriate support from their GP or other emergency services. From a behavioural perspective, the client is on an "intermittent reinforcement schedule", where the occasional success maintains a behaviour despite repeated failures.

Being clear as to when you will be available gives the client the freedom to explore other options in the meantime. Most people manage most of the time without therapists. The easy availability of a therapist may discourage confiding in family or friends, potentially creating a new problem or at least exacerbating existing difficulties.

If your client knows that they can't speak to you until Tuesday, they may work out their own way of coping until then, which may preclude the need to speak with you or may at least give you both a foundation for further work. Being reliably available gives the client faith that waiting to speak with you will always pay off, a much more potent reinforcer than the intermittent reinforcement schedule.