Read your clients’ information sources

Be aware of clients’ information sources in addition to your own. Newspapers, magazines and online forums vary widely in quality, but may contain information of use to you and your other clients.

A client who I had advised on the control of panic attacks returned a year later to discuss another matter. At the end of the session, he told me that he had found a self-help book on panic attacks and “you know all that stuff you said? Well, it turns out you were right!”

Therapists may be perplexed or dismayed when clients prefer their own information sources to those of the therapist, especially when the other source is one which the therapist may consider disreputable. Therapists may be unaware of the range of resources available to and used by their clients, whilst clients may think their therapist is merely offering their own opinions.

Therapists usually derive their information from peer-reviewed research articles, professional journals, scholarly textbooks and teaching & training by eminent colleagues. This information is then implicitly or explicitly conveyed to clients in therapy sessions and associated handouts & leaflets.

Clients may have great difficulty accessing therapists’ information sources other than via their therapist. Even if aware that they exist, they may be barred from accessing professional journals or unable to afford necessary memberships or subscriptions. Textbooks are usually much more expensive than comparable self-help books, have opaque titles and tend to be jargon-heavy.

Clients usually derive their information from a wider array of sources, many of which may not be accorded much credibility by the therapists. Newspaper articles, magazine features, self-help books and groups & online discussion forums abound. Therapists who are unaware of these sources may be advised by helpful clients, although this assistance may not be welcomed by the therapists.

Secure in the knowledge that their information sources are of superior quality (which may well be a false assumption), therapists may be dismissive of clients’ newspaper-derived knowledge and online tales of others with similar difficulties. Clients may pick up on such condescension and react similarly to their therapist’s sources.

The science fiction writer Theodore Sturgeon, when told that 90% of science fiction had no literary merit, famously replied “90% of everything is crud”. There are many more newspapers than journals, more self help books than textbooks and more online forums than conferences: you can’t read them all, but if you don’t include some in your reading, your clients may keep the 10% that isn’t crud to themselves.

Ensure that your client can say stop

Ensure that your client can tell you to stop or to go away. All but the most severely disabled clients should be able communicate these instructions and should be encouraged to do so.

Professional codes of conduct require informed consent to treatment. Clients with cognitive damage or impaired communication pose a major problem for therapists and support workers. Informed consent may be beyond the capabilities of the client and may instead be granted by a relative or guardian.

When the client is obviously distressed, therapists and carers face a dilemma: should they continue with the intervention sanctioned by the guardian or should they suspend, even abandon their intervention?

Clients who lack the capacity for informed consent may still make smaller decisions relating to their care. Two important choices which can be made and communicated by all but the most disabled are a request for you to stop what you are currently doing and a request for you to end the session.

Before beginning work with a client whose communication is impaired or whose capacity is diminished, you should establish how they would convey a request for you to stop and a request for you to leave. If this is unclear or has yet to be established, either agree with the client how they would indicate such desires or consider a Clinical Psychology or Speech & Language Therapy referral.

There will be occasions on which an intervention must proceed regardless of the client’s wishes (as when the client is being treated under a Section of the Mental Health Act or similar legislation). For most therapists, these situations will be few and far between: medication may be required by a treatment order, but the same client may still have a choice as regards physiotherapy or dietetic advice.

Therapists should not assume that clients whose cognitive faculties and communication are unimpaired will be sufficiently assertive as to be able to say “stop” or “I want to leave”: many may have sought referral precisely because they lack such assertiveness.

Unassertive clients can be reassured that their telling you to “stop” or to “go away” is useful to you. No therapist wishes to force clients into discussions or actions for which they are unprepared, and some issues require a great deal of preparation. If you know your client will give you honest feedback—and your client knows they are permitted to do so—you can both relax.

My client won’t do as I say

One of the major challenges to the therapeutic alliance arises when the client fails to follow the therapist’s advice. Therapists can often be heard to complain that clients reject their instructions (sorry, “advice”) out of hand:

Don’t they want to get better? Why won’t they do as they’re told?

When considering how you will respond to a client who is not following your advice, there are three questions you should ask yourself:

  • why should your clients do anything you say?
  • why should your client do what you’re saying now?
  • why wouldn’t clients follow your suggestions?

Why should clients do anything you say?

Take a moment to consider your role and relationship to your clients. Are you:

  • a taxi-driver: your client presents you with a destination to which you take them, requiring only that they behave themselves on the journey.
  • a tour guide: your client chooses a goal and you accompany them on their journey, using your knowledge of previous journeys to help you both negotiate any obstacles they may encounter, but relying on the client to keep up with you.
  • a travel agent: your client sets out their circumstances and wishes and you offer a set of options which they are free to pursue to whatever degree they choose. Which (if any) of the options the client chooses in no way reflects upon you.

How you see yourself will determine the degree of adherence to your advice that you expect from your clients. A “travel agent” may be disappointed that their recommendations are not followed, but has less invested in the process than a “taxi-driver”, who is likely to be frustrated by their passenger criticising their chosen route.

How the client sees your role will be a major influence on a successful outcome. You may see yourself as a “taxi-driver”, brimming over with “the Knowledge”", but your client may be looking for a travel agent.

Why should clients do what you’re saying now?

Therapists spend a long time training, both pre- and post-qualification. Most professions have requirements for continuous education in order to maintain registration. The average therapist is stuffed to the gills with basic science, clinical research, evidence-based practice guidelines and tips & techniques acquired by experience over the years.

The net result of all this knowledge can be a belief that there is a single best solution to a given problem. EMDR is superior to CBT in the treatment of PTSD. Exercise is preferable to rest in recovery from back injuries. Psychotherapy is preferable to medication in the management of anxiety. Examples abound in every discipline.

Alternatively there can be a belief on the part of the client that there is a single fix for their problem. Your carefully crafted multi-part, multi-level, even multidisciplinary intervention may seem too complex a response to a condition with a strong diagnostic label: one problem, one solution is more intuitive.

Consider your recommendations and your reasons for making them. Are you acting on the basis of peer-reviewed research, practice guidelines, experience of success with other apparently similar clients, or suggestions from a senior colleague? How convinced would you be by someone making recommendations to you on the same basis? Most importantly, how clear are you making your reasons to your client?

Most clients have little experience of therapy but have, by definition, a lifetime’s experience of being themselves. When a client says a certain technique won’t work for them, despite this technique having been of use to hundreds of clients before them, you have two options. You can expend a great deal of energy persuading and cajoling them to follow your advice. Alternatively, you could ask what makes them and their situation different from everyone else: maybe nothing, but maybe something and you won’t know which without asking.

Why wouldn’t clients follow your suggestions?

Fully half of all prescribed medication is unused. In the absence of authoritative figures, we can guesstimate that up to half of all therapeutic advice is not followed. Clients may leave the consulting room with no intention of following the advice they have been given or they may return to report that they have not performed their designated task.

There are many reasons why a client might not follow a therapists’s advice:

  • they don’t want it
  • they don’t understand it
  • they don’t believe they can do it
  • they don’t believe it will work
  • they fear it will make matters worse
  • they got a negative reaction when they first tried it
  • they couldn’t do it at the first attempt
  • they couldn’t do it consistently
  • they couldn’t do it at all

The time to address these issues is while the client is still in your room, not next week or next month when they return to report their “failure”. Although the last four points may only be confirmed (if at all) once the session is over, you and your client should have agreed how they will manage each possibility if it occurs.

[EMDR]: Eye Movement Desensitisation and Reprocessing
[PTSD]: Post Traumatic Stress Disorder
*[CBT]: Cognitive Behavioural Therapy

Have stuck clients keep a prospective diary

Ask clients stuck awaiting change to keep a prospective diary. An explicit account of life after the hoped-for change can help clients unstick themselves and start changing now.

Some clients (and some therapists) get stuck awaiting a single change which will solve all their problems at a stroke. “Once I’m rehoused…”, “Once I get my compensation…”, “Once you start taking your medication consistently…”.

A key feature of these hoped-for changes is that they are usually external to the person holding out for them: the client holds out for change at the Housing department or law court, the therapist holds out for change in the client. The implicit message is “it’s not my fault nothing is happening yet”.

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Prevent panic: keep your room cool

Prevent clients from panicking by keeping your room cool. Overheating clients can misinterpret a rise in room temperature as the onset of a panic attack.

Panic occurs when benign physical sensations are interpreted as threatening, leading to a surge of adrenaline which exacerbates the sensations and the perceived threat (eg: a cramped chest muscle causes anxiety and tension, increasing the pain from the muscle and increasing the worry that a heart attack is occurring).

Anxious clients entering a hot consulting room can misinterpret the rise in temperature as a rise in their own anxiety levels. Fearing that they will lose control in front of you, they will produce more adrenaline, further raising their body temperature and beginning the vicious circle of a panic attack.

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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.

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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.

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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).

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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?

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