My client is dead

Sooner or later, one of your clients will die. Waiting until it occurs to consider how this might affect you would be unwise.

Death of clients might be inevitable (f you work in palliative care), an acknowledged risk (if you work in psychiatric settings) or very rare. The cause of death may be deliberate action, accidental or ambiguous.

However hard you strive for “professional detachment”, the need to establish a rapport with your client means establishing a bond for which you may grieve when it is irrevocably lost. Inevitably, junior staff have more time to form such a bond, but have less experience to draw upon in dealing with the consequences.

Considering in advance how the death of a client might affect you will help you better manage both your feelings & responsibilities.

Expected deaths

Staff working with people whose conditions are terminal will be aware that death is likely. They may even be more aware than the client of when death will occur. Services dealing with inevitable death on a regular basis may have protocols for staff support and you should be made aware of these.

Whether or not there is official support available to staff, an established staff group is likely to have evolved its own coping mechanisms which may not be obvious to, or even shared with new and junior members, especially where the service has a low staff turnover or junior staff stay for only a short period.

Quizzing colleagues as to their coping strategies might not be the stuff of coffee room chats, but taking some private time (supervision or other 1:1 interactions) for such discussions is advisable. Be aware that there is no guarantee that even the most experienced staff have coping strategies which would work for you or that you would choose to use even if effective.

Therapists familiar with the dynamics of bereavement will be aware that, in the case of expected deaths, much of the work of grieving may be performed in advance. When a death occurs “on schedule”, those close to the deceased can be surprised by their quick acceptance: they have been preparing unconsciously for months.

When an expected death does not occur “on schedule”, the unconscious preparation & anticipatory grieving may be undone. The expectation becomes that the client will survive and the death may hit as hard as an unexpected death when it finally occurs.

Unexpected deaths

Sudden deaths may be a result of illness, accident or deliberate action. Sudden deaths are more likely to elicit feelings of anger & guilt in addition to the expected sadness.

People with chronic and terminal illnesses are still subject to the same risks and diseases as anyone else.

I was once shocked by the death of a client with a degenerative neurological disorder who suffered a fatal heart attack. This was not part of the profile of their disease and therefore seemed much more shocking. In retrospect, my client had all the markers of a high coronary risk, but the degenerative disorder seemed to override this in everyone’s eyes (including the client’s).

Accidental deaths may be related to treatment. Complications of a necessary operation or prescription of dangerous medication may kill a client and may have been accepted as a risk by the client. You and other colleagues may have held a different view and, however much you respect the client’s right to choose, there may be lingering resentment which might colour your professional interactions.

Distinguishing between an unfortunate outcome of a necessary treatment and the fatal outcome of poor practice can be hard, even for professional ethics boards. Where you harbour a grudge against the therapist responsible for the fatal intervention, you should ensure that you discuss this with senior colleagues: you may be being unfair or there may be a case of professional misconduct which should not go unaddressed.

Where the death appears to be a consequence of your action or inaction, this must again be addressed if you are to continue to practice to the best of your ability. If you were in error, this should be corrected. If you were not, you need to be sure of this to avoid self-doubt clouding future decisions. Discussing possible errors is difficult at the best of times, even without a death as a consequence, but you have a professional responsibility for good practice.

Death by design may be suicide or homicide. The killing of a client by another client would be the most complex scenario imaginable in terms of the implications for therapist and the service, but suicide is a risk in most mental health services and is arguably the cause of death for which you should be best prepared.

Suspicious deaths

Deaths which occur without witnesses may be not be fully explained or explainable. If a depressed client is hit by a car whilst walking drunkenly along the side of a road, was it suicide or accident? If a distracted, anxious client dies from a borderline overdose of a dangerous prescription medication, was it suicide or accident?

Where the true intentions of the dead person will never be known, there is room for doubt and self-blame on the part of the therapist, especially where contact was ongoing but even when the client had not been seen for months or years. Could I have anticipated and prevented this? The same question will occur to friends, relatives and perhaps even colleagues.

Many suicidal acts do not result in death, while impulsive suicidal gestures may be fatal. The true motivations of clients are known only to the client, whatever story they may offer if they survive, and possibly not even to them if they were intoxicated or otherwise out of control of themselves.

As noted above, it may be difficult or impossible to rule out the possibility that you could have averted a suicide. Regardless of the level of uncertainty, you are likely to harbour some feelings of anger or guilt (normal responses to an event outwith your control) which you should be able to address either with your supervisor, colleagues or some other reliable and confidential support.

Depending upon your involvement with the client and the nature of their death, you may be required to provide evidence to an inquest, a professional ethics hearing or even a criminal trial.

Your casenotes may be scrutinised or even removed. You should be aware of your employer’s and your profession’s standards regarding the retention of casenotes, as well as your duties of disclosure and confidentiality, following the death of a client.

Both legal and emotional support for staff affected by the death of a client tends to be poor. Ascertaining the levels of support available to you, and finding additional supports if necessary, should help you continue to practice effectively.

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

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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I have to breach confidentiality – part 1

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.

For UK therapists there are three occasions on which it is mandatory that confidentiality be overridden for the greater good: when the client is a risk to themselves, when the client is a risk to others and when there are children at risk; respectively, the therapist must inform the Responsible Medical Officer, the Police and the Social Services.

Particular services and professions may offer more specific guidance and place additional duties upon therapists, but it is likely that you will encounter at least one, if not all, of these eventualities.

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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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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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