Always ask when you don’t understand

Asking when you don’t understand benefits you and your clients. Pretending to understand can discourage disclosure and support poor decision making.

When I began working with people with learning disabilities, I was told “don’t pretend that you’ve understood what someone says to you”. This seemed fairly obvious advice until I was in the embarrassing situation of having to say “I’m sorry: I didn’t catch that” for the third time in five minutes.

Whether faced with a speech impediment or bombarded with abbreviations & unknown references, it is tempting to nod in agreement and try to move on. In either case, the principle is the same: by attempting to avoid embarrassment now, you’re preparing the ground for future, potentially much more serious, problems.

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Check your client can read and write

Checking that your client can read & write assists both you and them. Attempting to use questionnaires, journals or bibliotherapy with someone hiding their illiteracy could end your intervention before it has begun.

Literacy isn’t essential in therapy: psychological therapies aren’t called “talking cures” for nothing and physical therapies usually require little in the way of reading or writing. Clients who cannot write can keep pictorial records or use voice recorders (now built into many mobile phones) to keep notes of thoughts or actions. Much of the literature therapists would wish to hand out to clients could, with a little effort, be offered as graphics or video & audio recordings.

The difficulty for most therapists will be in identifying clients whose illiteracy may be one of their most closely guarded and shameful secrets. Ticking the boxes on your questionnaire need not mean that the questions have been read. Phrases like “your writing is too small” or “I’ve left my glasses at home” may mean exactly what they say, or may be well-practiced cover-up routines. Allocating an illiterate person to bibliotherapy can be a waste of their time and yours.

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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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Use your casenotes as a Foley file

Making notes of information incidental to the case enhances interactions. The more personal details you retain, the more intimate the interaction and the greater the sense of personal attention.

Compare & contrast the following:

Last time you said you were going on holiday with your husband and daughter but you were worried about the journey: how well did it go?

Two weeks ago you said you were going to Greece with David & Sally but you were worried about the flight: how well did it go?

Item one says: I was listening. Item two says: I was really paying attention.

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BPS Research Digest

A newsletter-cum-blog from the British Psychological Society. Summarising a dozen psychology journal articles each month in accessible prose, the Digest is a good light read and a useful pointer to the full articles.

Unlike the American Psychological Association, the British Psychology Society does not make the members’ monthly journal available online, but does offer the BPS Research Digest: a round up of interesting and thought-provoking recent research.

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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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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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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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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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Claim your chair with your notepad

Use your notepad to claim your chair before the client enters the room. If you can sit where you need to be, there will be no unease to be misinterpreted by the client.

A prison inmate advised me that I was sitting in the “wrong place”. I wasn’t sure what he meant. He explained that I had naively given him the chair nearest the panic button. Although he had no plans to attack me or hold me to ransom, he was concerned that I might make the same error with some of his less forgiving peers.

There are many reasons why a therapist might wish to occupy a given seat in the consulting room: security (proximity to the panic button and/or the door), easy access to equipment (phone, instruments or tests), presentation (if taping the session) or simply a different view. One GP’s room I used had a skeleton in the corner! I always made sure my clients were facing away from this, particularly in discussions of bereavement and chronic illness.

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