Most clients have abnormal daily routines

We base our assumptions about normality on our own experience and risk mistaking the norms of our immediate social circle (or movies and TV) for demographic reality.

I was asked to help stroke ward staff manage a patient who took his bed very early in the evening and woke correspondingly early in the morning. Most hospital patients have difficulty being woken at 6am: this gentleman was up at 4am. The concern was that the stroke had damaged his body clock. In fact, he was a farmer, following his normal sleep routine of sixty-eight years!

Most people work 9–5, apart from farmers, students, factory workers, children, supermarket staff, retirees, taxi drivers, cleaners, restauranteurs, post office workers…

Working 9–5, Monday to Friday is a pretty middle-class, professional schedule … and maybe not even that: hospital nurses, medics and other staff (e.g. radiographers) work shifts and anyone employed by an international company may be required to keep the hours of their colleagues in another time zone.

An “abnormal” daily schedule — in the eyes of their therapist — can reduce the chances of a client engaging in therapy. Continually offering a single mother an appointment at the time school ends turns therapy into one more stressor. Therapy may even have to take a break during the school holidays.

Sleep or meal times at odd hours — long distance lorry drivers may be eating their dinner at “breakfast time” — can make a diet sheet or sleep diary difficult to interpret and may, if not fully understood, lead to impractical advice being offered.

Sleep and work routines may form as much of a culture as race, nationality or ethnicity. There are people who have worked night shifts for decades: counselling disruption of their longstanding routines could be as “culturally insensitive” as challenging any taboo about food, dress or physical contact.

Making the daily routine an initial interview question can help maintain awareness that your “normal” day may not be your client’s (or your colleagues’). You may not know your client’s schedule when you offer the first appointment, but there’s little excuse for not knowing when to offer the second.

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.

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.

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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Setting homework has negative implications

Setting “homework” for clients implies that no relevant work would otherwise occur between sessions. When clients fail to do their homework but achieve positive change anyway, the focus may fall on the former rather than the latter.

Physical therapies often entail a certain amount of work on the part of the client inbetween sessions with the therapist: daily exercises may be set, weekly diet sheets may be provided, medications may be prescribed.

Psychological therapies may also require work inbetween sessions. The notion that therapeutic change occurs only within sessions, in the presence of the therapist, is disproved by the evidence: the greatest portion of therapeutic change is attributable to factors entirely outwith therapy.

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Helpful patients are not hateful patients

Therapists should encourage and support, not dread, “helpful patients”. Internet or other research by the client can indicate active involvement in treatment.

In 1978 JE Groves described four categories of “hateful” patient, ie: the patients most physicians dread:

  • dependent clingers
  • entitled demanders
  • manipulative help-rejecters
  • self destructive deniers

To this list a fifth category appears to have been added: “helpful” patients, who search the internet for details of their condition and treatment and provide these to their therapist. Comments from colleagues (in person and via blogs), as well as cartoons and the popular press, suggest that these folks inspire almost as much dread (or, at least, derision) as the other four stereotypes.

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To see ourselves as clients see us

Therapists should be aware that clients may see them in a very different light. They should also be aware that these impressions are a matter of perspective and there may be fewer real differences than either therapist or client imagines.

Robert Burns wrote

Wad that God the giftie gie us
To see ourselves as others see us

In principle we all have such a gift (except perhaps people with autism, but that’s another discussion). In practice, this gift tends to be underused, especially in the consulting room.

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The Road to Recovery is not smooth

Continual improvement in therapy is the exception, not the rule. Stalls and deterioration may indicate a problem with the client, therapist or both, but may also be a sign of progress onto dealing with greater difficulties masked by the initial problem.

The impression given by many textbooks is that improvement is gradual and continous. Clients progress smoothly from one treatment goal to the next until all issues have been resolved and they can be discharged from your caseload.

Many therapists experience a sinking feeling when a client who had been making progress reports no change (or worse, a deterioration) in mood or function (or both).

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Change occurs outwith therapy

Therapeutic change is due more to factors outwith therapy than any one aspect of therapy. Factors outwith the session are at least as important as our rapport with our clients…and much more important than our years of experience or the technique we’re using.

The myth of therapy is that it is done by therapists to patients and that the outcome is a measure of the therapist or of the technique employed, not of the client (unless, of course, the client is “resistant” or “non-compliant”, in which case the outcome is very definitely attributed to them!).

The myth of therapy is perpetuated by research focusing upon the outcome of a given intervention on a given condition, where the therapist is merely a vessel for delivery of the treatment and the client is an interchangeable recipent of said treatment.

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