Improve rapport by allowing silences

Clients’ perceptions of rapport may be enhanced by silences. Therapists who are uncomfortable with silence should remind themselves that their client’s interpretation of the silence may be much more positive.

A client once asked me not to delay speaking once he finished a comment. He explained that his school report was always sent home in a sealed envelope. He would be forced to stand in silence while his father read the letter, not knowing whether the report was favourable or how his father would react. Three decades later, he experienced the same anxiety during silences in therapy. Agreeing that he was no longer a school child and that a considered response from me was likely to be better than a hasty response helped him overcome his anxiety about my silence.

Therapists may also be uncomfortable with silence in therapy. Time or results conscious therapists may feel that silence is not the best use of the limited time available in a session and may seek to pack as much into the discussion as possible. Other therapists may wonder whether silence means that their question or comment has confused, distressed or even offended the client. Rather than endure the silence, they may rephrase their question or seek to clarify or qualify their comment. Further silence may lead to further rephrasing.

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Beware of unofficial diagnoses & double meanings

Some terms used by therapists to describe clients have meanings which won’t be found in textbooks. Use of these terms is rarely of benefit to the client, although the term may say as much about the therapist as the client.

  • resistant to treatment
  • lacking motivation
  • poor historian
  • manipulative
  • demanding
  • somatising
  • chaotic
  • personality disordered

As diagnostic systems have developed, common place words have been redefined more narrowly & precisely for clinical use (eg: anxiety, depression).

As therapeutic professions have developed, there has been a less auspicious development: diagnostic labels have developed double meanings and common place words have been elevated to the level of diagnoses without the scientific scrutiny afforded official classifications.

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Know your client’s strengths

If you don’t know your client’s strengths, how can you capitalise upon them? Client factors account for 40% of the variance in outcomes and a wise therapist will play to their client’s strengths.

Clients are often defined solely in terms of their difficulties. “I’m seeing my obsessional woman this afternoon.” “When that guy with MS turns up, tell him I’m running late.” “Can someone attend to the broken leg in cubicle three?”

Modern medicine has come to be construed as an interaction between a physician and a disease rather than between a physician and an ill person striving to get well. (Scovern, 1999)

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Rules of thumb are dumb

Some rules of thumb are derived from experience, accurate or otherwise, (eg: the praecox effect) and some from hard research (eg: people with memory problems don’t admit to them), but all have a common flaw: even if true, they are both generalisations across a population and specific to the circumstances of their origin.

In an undergraduate lecture over twenty years ago, a senior Clinical Psychologist described the “praecox effect” (as in dementia praecox, or schizophrenia):

if, after having spoken to someone for half an hour, you have no idea what they’re on about, they’re schizophrenic

To an undergraduate struggling to cope with the complexities of psychology, psychiatry and mental health, any simple rule was welcome. Reading the literature on the high rate of psychotic diagnoses in immigrant populations, it didn’t take me too long to see the problems with this rule of thumb.

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Psychiatric Drugs Explained

A guide to psychotropic medication for therapists and their clients. This book lays out the pros & cons of mind-altering prescription drugs from a critical but balanced perspective.

Books considering psychotropic drugs tend to one of two extremes: either uncritical accounts of their effectiveness and the presumed biophysiology underpinning their action or highly critical “anti-psychiatry” polemics which damn the entire concept.

Psychiatric Drugs Explained, now in its third edition, manages to occupy the middle ground. Explicit details are given of the desired action of commonly used psychotropic drugs (with both UK and US names), but equal attention is given to their side effects and alternatives to their use (eg: in the management of sleep disorders).

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My client is crying

Trainees (and clients) need to know that crying is common in therapy. Experienced therapists need to remember that crying may be common in therapy, but that crying in front of a stranger is probably a rare experience for any given client: you may now be relaxed about the situation, but they aren’t!

Every trainee dreads this moment: your client is crying. You probably are unaccustomed to strangers crying in your presence. The fear is that their distress is your fault, that you weren’t sufficiently sensitive or supportive: now you have to manage the situation you’ve “caused”.

More experienced therapists will have seen literally hundreds of clients cry. You know that people in therapy will cry for a variety of reasons, usually unrelated to the therapist. Knowing how common crying is, you’ve evolved your own set of responses. You’ve probably forgotten how awkward you used to feel…and how awkward the client still feels.

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Closed questions can be supportive for clients

Judicious use of open & closed questions can empower clients. Restricting the range of responses when some are inappropriate or unavailable demands more of the therapist, but can be more supportive for the client.

One benefit of speaking slowly is that you get to think about how you frame your questions. The considered use of open & closed questions is a therapeutic skill often mentioned in workshops and textbooks but neglected in practice.

Open questions can be used for initial information gathering (“Tell me about your childhood”) and closed questions used to clarify the information given (“Were you abused as a child?”).

Closed questions restrict choice of response. They allow only a handful of responses (eg: yes or no) without stepping outwith the frame of the question (“I don’t feel comfortable talking about that”). Many clients are insufficiently assertive to sidestep the question and may feel pressured into premature disclosure of information (or lying) by closed questions.

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Overusing clients’ names can mask inattention

Use of a client’s name to foster engagement may mask flagging concentration and inattention. Using a client’s name sparingly permits more accurate judgement of attention to the conversation or task.

“…a person’s name is to that person the sweetest and most important sound in any language.” (Carnegie, 1936).

Whilst using client’s given names uninvited can backfire, a genuine (and successful) attempt to remember and recall someone’s name can pay dividends.

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Hypotheticals encourage proactive supervision

Using supervision to plan ahead for common and uncommon events has advantages for therapist and client. Both gain when the therapist has considered their range of responses ahead of time.

Ideally, clinical supervision is proactive. You discuss the progress of your cases and identify opportunities to be developed and pitfalls to be avoided. Inevitably, some supervision is reactive. You describe a problem or crisis and decide how such a situation can be avoided or better managed in future.

Reactive supervision can be dispiriting, even disempowering. The supervisor is given the role of dispenser of wisdom to the supplicant supervisee. A directive supervisor can leave you with the impression that you are still a novice (whatever your actual stage of training) with much to learn. Hopefully, we all still have much to learn, including our supervisors.

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Rehearse answers to common questions

Clients are likely to have questions about our services. Some may be asked, others may remain unspoken unless raised by the therapist.

No information sheet can answer every question our clients may have. Even if one did, some wouldn’t read it and others might be unable to either read or comprehend the text. You should therefore be ready to answer, and in some cases, pre-empt clients’ questions.

As a supervisor, I have asked my trainees to explain the difference between a psychologist and a psychiatrist before ever meeting a client. Most have managed a reasonable explanation. The learning point was not the quality of the explanation but the confidence with which it was delivered: everyone was caught off guard by the question and so came across as unsure, defensive, even shifty.

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