Set limits on diaries & records

Set clear limits on diary-keeping and other journals. By asking for the minimum amount of information necessary, you increase the chances of obtaining reliable data.

Journals and other records kept by the client are a useful adjunct to most therapeutic approaches and an integral part of some, such as Cognitive Behavioural Therapy. Daily or hourly data points can be invaluable in establishing patterns and tracking progress.

Diary sheets may be handed out automatically at the beginning of therapy, in the expectation that clients will keep reliable records which can be used as the basis for therapy. Presenting clients who are already struggling to cope with another responsibility may not be the wisest move.

Anyone who has attempted to keep a daily journal (or blog regularly!) will know the difficulty of maintaining their resolve over the long term: the first week or two are reasonably easy, but week three or four is where most resolutions fail. Therapeutic records are no exception.

Before requiring a regular commitment from a client over & above their attendance at your appointments, it is worth considering:

  • whether the data you are considering are necessary
  • how much detail is required for the analysis
  • how many data points are required

Rather than automatically requiring a diary or other recording outwith the session, ask yourself (and your client) whether the same information could be generated within the session. Clients who have struggled to carve the time for your appointment out of their schedule will appreciate you keeping your requests for extra time to a minimum.

Diary sheets are often standard forms copied from a book and require more information than may be necessary for your analysis, as well as more information than clients can comfortably record at the time. Look back over some old notes to see how often every column is completed reliably (if at all) on standard record forms. The less you require, the easier it will be to provide.

A client suffering migraine headaches drew a smiley face on each migraine-free day in her pocket diary. Flicking through the diary showed a clear increase in the number of smilies.

Most important is to consider whether the record keeping is part of the permanent change that your client wishes to make or is limited to their time in therapy. If the intention is that your client will keep a record indefinitely (e.g. a daily reflective journal), as much time should be devoted in session to establishing this habit as would be devoted to any other change in thinking or behaviour.

If the data is required for a specific part of therapy only, you should agree with the client that they will keep the record for only as long as necessary to collect the required data. If intended to track progress, a record kept for a couple of weeks at the start of therapy and reinstated near the end and again at followup may be more reliable than a supposedly continual record (which will probably lapse after three weeks or so).

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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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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Think before you act for your client

Stop and think before you take action on behalf of your client. You may be depriving them of the opportunity to help themselves (with appropriate support).

Therapists are people who want to help. People of equivalent qualifications in other fields are usually paid more and have better conditions: we don’t do it for the money, but because we want to make a difference.

Trainees want to help. Faced with overwhelming distress or disability, you want to make a difference but have only a limited repertoire of knowledge to draw upon. You may (mistakenly) feel that you must compensate for your shortcomings and so attempt to offer more practical help where possible.

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Leave contracts out of the first session

Many therapists set explicit goals and use treatment contracts with their clients. Goal setting provides a focus for therapy: contracts indicate that both parties have agreed to the terms of the therapy (or should: the contract you use does bind the therapist as well as the client, doesn’t it?)

Some therapists aim to conclude this business by the end of the first session. While this gives a nice structure to therapy (1st session: agree goals, 2nd session: work toward goals), this may not be the best way forward.

Setting goals and signing a treatment contract is a big step for a client. Although clients may have been awaiting their first appointment for weeks, months, even years, the assessment process may bring to light new information and perspectives which could alter their aims significantly…given time to think things through.

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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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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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Remove the miraculous from the Miracle Question

The Miracle Question can elicit negative responses from some clients. These negative reactions can be avoided by rephrasing the question without the miraculous element.

The Miracle Question is used by Solution-Oriented Therapists to elicit the conditions which would lead the client to consider their problem solved:

Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?

The client’s answer generally contains the seeds of their own solution and can be used to set treatment goals and propose strategies. Used properly, the Miracle Question can be a powerful therapeutic technique, but it has several liabilities inherent in the phrasing of the question.

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What is your one aim for any session?

Having too many goals can be as bad as having no goals. This is as true for therapists as for our clients, yet therapists may enter into a session with far too many goals to achieve in one sitting.

Trainees often struggle with first appointments, in which there is so much to do: establish a rapport, take a history, establish a diagnosis or formulation and agree a treatment plan. These would be the achievements of two, three or even more sessions but the impression given by many text books is that all of this must take place in the first session.

More experienced staff may feel the same pressures, but may also feel obliged by waiting lists and the need to demonstrate turnover to look for opportunities to discharge the case. Some may also feel that they must be on their guard against potential attempts at manipulation by the client.

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How will you know you’re a better therapist?

Solution-Oriented therapists ask clients how they will know when they are better. Therapists often wish to be better in their role, but few ask the Miracle Question of themselves.

Solution-Oriented therapists often ask clients the Miracle Question:

Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? (de Shazer, 1988)

Stressed therapists might be asked a similar question:

Suppose that tonight, while you are asleep, there is a miracle and you become a better therapist. How will you know that this has happened? What will you notice has changed about the way you’re working?

I’ve asked this question many times, of my self and of others. The answers tend to be much the same.

  • Every intervention I make in therapy will work
  • My clients will never try to manipulate me
  • I will always be available for my clients whenever they want me
  • Nothing I say will ever upset my clients
  • All my clients will get better all the time
  • My clients will be grateful for the help I’ve given them
  • My clients will co-operate with my therapeutic strategies
  • If I see a problem, I will be able to address it and solve it
  • I will always know what to do in any situation arising in therapy
  • I will not feel frustrated, angry or anxious during therapy sessions

If our clients gave such unrealistic answers, we would renegotiate more practical, achievable goals. How will you know when you’re a better therapist?