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.

Continue reading

Relaxation Techniques: A Practical Handbook

A compendium of relaxation techniques. This book supports the clinical practice of physical and psychological therapists seeking to explore the field of relaxation training or to tailor their approach to individual clients.

There are many different approaches to relaxation training. If this book doesn’t have them all, it certainly contains the vast majority.

First publshed in 1995 and now in its third edition, the book covers the physiology underlying tension and stress together with physical and cognitive approaches to relaxation. Each chapter expands on one approach, detailing the theory (if any) behind the approach, then offering scripts, variations on the main approach and benefits and pitfalls of the approach.

Continue reading

Using clients’ given names uninvited can backfire

Uninvited use of a client’s given name can impede rapport in a number of ways. Moving from a position of formality to informality and intimacy is easier than backtracking.

A therapist’s first encounter with a client usually requires the use of their name, if only to ensure that you haven’t picked up the wrong person. The usual practice is to use either the client’s full name (as given on their referral letter or case file) or their title and family (last) name. Some therapists attempt to establish an air of informality by using the client’s given (first) name, but this is a risky practice for a number of reasons. In decreasing order of seriousness:

The client’s given name is first and most commonly used by their parents and siblings. Being called (without invitation) by one’s given name can throw the client into a child role with the therapist as parent (especially if the therapist then goes on to introduce themselves by their title and family name). Depending upon the client’s experience of childhood, this might be reassuring or anxiety provoking. It is definitely disempowering and may be seen as patronising.

Continue reading

Slow speech makes for clear communication

Speaking more slowly can improve communication between therapist and client. Slow speech is more comprehensible and more considered.

Anxiety is characterised by rapid speech. Therapists, especially trainees, may be anxious in sessions, but may also feel the need to speak more quickly in order to pack more into the time available. This can backfire by making the therapist seem anxious.

Following rapid speech demands greater attention. When listening, we are attempting to make sense of what is being said. The more time we have to consider what is being said, the more likely we are to understand what we are hearing.

Clients are by definition functioning less than optimally. Anxiety, depression, pain, fatigue and medication effects can impair concentration and therefore affect clients’ ability to follow and make sense of what we are saying.

Continue reading

Practicing Therapy

A collection of exercises for developing therapists. The insights to be derived from this book should improve the practice of any therapist.

Somewhere there’s a book that all the experienced therapists know about and it’s not about how to do therapy, it’s about how to do therapy better. It’s got all the secret little extra tricks they know about that aren’t in any of the models and that they forget to tell you about in class. And they won’t ever tell you where that book is – you just have to figure it out.

As Margaret Rambo admits in the introduction, Practicing Therapy doesn’t contain many secret tricks, but it is a book about how to do any therapy better.

Continue reading

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).

Continue reading

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.

Continue reading

DoctorQ on PocketDoctor.co.uk

A useful list of questions to ask your family doctor. These questions cover most eventualities in family medicine, but are also useful pointers to the information other therapists should be able to provide their clients.

The average GP consultation leaves little time for questions. 5-10 minutes is the norm, most of which will be spent on information gathering and diagnosis.

Patients may have questions which they are reluctant to ask their GP. They may have decided not to take up more than their fair share of the GP’s time. They may have thought of their question a few hours or days after the appointment. In either case, they may hesitate to bother a busy GP again with the same matter.

Phil Hammond, a former GP who writes for the satirical magazine Private Eye and has presented a number of popular medical TV programmes, has written a list of helpful questions covering many of the situations which might occur in a medical consultation.

Continue reading

Manipulative therapists get manipulative clients

“Manipulative” clients may be reacting to overly controlling therapists. Before using such a destructive label, it is worth asking why someone would need to manipulate their therapist if they have agreed common goals.

“Manipulative” is one of a therapist’s most damning criticisms. While not as bad as “malingering” or “personality disordered”, both of which have their place in formal diagnoses, the label has similar power to influence the client’s future treatment as it implies that there is something bad about the client’s behaviour or the client themselves.

“Manipulative” is defined as “tending to control or influence others cleverly or unscrupulously”. “Unscrupulously” is, in turn, defined as neither honestly nor fairly. The stereotypical manipulative client is one who misrepresents their symptoms to obtain extra medication for abuse or resale, or who exaggerates their symptoms or situation in order to obtain financial benefits they don’t deserve.

Some clients will be deemed “manipulative” when they give different accounts or responses to different professionals. I have observed therapists respond to a client sympathetically or supportively in the session, then speak critically or dismissively of the same client in supervision or at a multidisciplinary meeting.

Continue reading

Writing when you speak preserves eye contact

Writing only when you are speaking maintains normal eye contact. This serves to normalise the interaction, reassures the client that they have your attention and that you are writing what they are saying.

Writing while the other person is speaking reverses the normal pattern of eye contact.

Anyone who has had a medical appointment will know the unease associated with describing your symptoms to the top of your doctor’s head. They write feverishly while you speak, only meeting your gaze to ask a question, then dive back into their notes again as you begin your answer. All the while you’re asking yourself: what is it that they’re writing about me?

Continue reading