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.

To label the client, rather than their behaviour and circumstances, as “chaotic” implies that this is a stable trait. This could well affect decisions regarding referral and management, steering the client towards disempowering options.

  • A chaotic client may be more likely to be steered towards depot injections rather than self-administered medication.
  • A chaotic client may be less likely to be referred to a high-demand service due to suspicions that the appointment(s) will not be kept.
  • A chaotic client may have strict contracts or other conditions imposed in order to prevent waste of therapist’s time.

Caring therapists may be tempted to pitch in, possibly stepping outwith their professional roles to ensure attendance, etc. Overworked therapists may be tempted to cut their losses, abandoning interventions or referring on to more flexible (but possibly less appropriate) services.

It is easy to forget that mental health problems and/or poor social circumstances impair client’s entire life including their ability to engage with services. Chaotic behaviour should be treated as a problem in its own right, with appropriate formulation and intervention for each individual. Interventions without knowledge of causation (or worse, assumptions as to causation) are unlikely to be either effective or constructive.

If you are tempted to label a client (rather than their circumstances or behaviour) as chaotic, ask yourself:

  • am I satisfied that the expectations of my service regarding engagement are reasonable for people with the problems we address?
  • do I know that the client has the resources and support to permit anyone else to meet the reasonable expectations of my service?
  • am I convinced that the client’s present confusion and disorganisation is a stable trait?

2 thoughts on “Work with, not around, chaotic clients

  1. Very interesting blog. I am a doctoral student in clinical psychology who just happened to run across your website. It’s nice to think more experienced therapists are out there offering snippets of wisdom.

  2. This is so true. I know of many counsellors who would rather refer than to help. Partly due to that ethics professor who scared them by overstating the risks, and partly due to how easy it is to refer than to help. In anycase, a proper intake session can indicate which counsellor should see the client.

    Carpe Diem Online Counselling

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