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.

You will upset your clients

Apparently innocuous comments can upset your clients. You can’t avoid triggering issues unknown to you, but you can be ready to respond if they are brought to light.

One participant in a relaxation class became increasingly agitated as the relaxation script was read to the group. She then burst into tears and fled the room. The script used a “relaxing image” of walking deeper into a cool, leafy forest: no one knew that the client had been attacked in just such a location.

Many therapists live in fear of distressing their clients by “saying the wrong thing”. Forethought and attentive listening can permit you to avoid many problems, but there will inevitably be a time when you trigger issues of which you were unaware.

Some might argue that the visual imagery offered in the relaxation script was inoffensive and the client’s traumatic associations with such an image were rare and could not be foreseen, but this argument doesn’t wash.

A few moment’s consideration reminds us that “one man’s meat is another man’s poison”: what you find rewarding might be a disincentive for me; what you find relaxing I may find dull or irritating. Assuming that an image I find relaxing will relax you also is a procedural blunder on my part, even without the traumatic associations.

If participants in the group had been invited to think of somewhere they found safe and relaxing, the client’s distress could (probably) have been avoided. The undisclosed issue would remain, however, and might still be brought to light.

Without knowing all the details of a client’s history, a therapist’s passing comment may trigger insecurities or traumatic memories which are rare, if not unique in the general population (e.g. memories of a former husband’s extra-marital affair triggered by a reference to Winnie the Pooh: husband and lover referred to each other by names from the book).

Psychological therapists ought to be alert for apparently unjustified distress and changes of mood. Physical therapists’ attention will often be elsewhere and initial signs of distress may be missed. Whenever and however the client’s distress comes to light, it is the response to this distress which should be the primary issue.

Few therapists would deliberately make crass and offensive comments, but it is inevitable that you will triggers hidden issues at some point. You should be prepared to respond appropriately and sensitively when it happens, rather than worrying about whether it will happen.

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.

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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Work with, not around, chaotic clients

Therapists can either work on, or work around, the chaos in client’s lives. Identifying clients, rather than their circumstances, as chaotic risks disempowering the client.

“Chaotic” seems to be one of the mildest “unofficial diagnoses” a therapist can apply to a client: it seems more descriptive than derogatory. “Chaotic” is defined as being “in a state of complete confusion or disorder”. This would be an accurate description of the circumstances of a large number of mental health clients, especially those who come to the attention of psychiatric services.

The stereotypical “chaotic” client would be someone who misses appointments, over- or under-uses prescription medication, has disrupted and disorganised home and work routines and struggles to achieve any consistency or reliability in their interactions. This state of affairs would usually have been at least part of their reason for seeking therapy.

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Give clients your full name and title

Introduce yourself with your full name and professional title. Clients can then decide how to address you as rapport builds, especially if you provide a reminder of your name (ie: a readable ID badge).

One client called me “doc” for most of our first meeting, until I felt compelled to advise him that I did not have a doctorate. He replied that he called every therapist “doc” as there were far too many of us for him to remember all our names.

In the first stage of a consultation, clients are bombarded with information, amongst which is the name and / or title of their therapist. People who are anxious or in pain usually have poor concentration and therefore poor memory, so the chances of a client remembering your original introduction are small.

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Demanding clients make legitimate requests

“Demanding” clients are often making legitimate requests. Therapists applying such a label should consider whether it is the client’s requests or the service’s lack of resources which is unrealistic.

“Demanding” is a label often applied to clients by therapists, although rarely within earshot of clients. The label influences the responsiveness of the service to the client’s stated needs by implying that their requests for assistance are in some way inappropriate or excessive.

The stereotypical demanding client is therefore one who places undue demands upon the service, seeking longer or more regular contact with their therapist than is usual or seeking access to medications and other resources which would drain the budget of the service.

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Tell clients confidentiality has limits

Therapists often assure clients that the information they provide is confidential. Confidential is defined as “intended to be kept secret”. Whether the information will be kept as secret as the client (or therapist) imagines depends upon the therapist and the service.

Confidentiality in the strictest sense implies that only the therapist will be privy to the information provided by the client. In practice this level of confidentiality is impossible to offer, as therapists have professional and legal obligations to uphold.

Most professions and services require that clients give informed consent to all assessments and treatments, which includes basic information gathering. Clients must therefore understand the limits upon the confidentiality you can offer before beginning to discuss their case. Clients who provide information which necessitates breaking confidentiality may feel betrayed by their therapist if not first advised of their therapist’s obligations.

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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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