Ensure that your client can say stop

Ensure that your client can tell you to stop or to go away. All but the most severely disabled clients should be able communicate these instructions and should be encouraged to do so.

Professional codes of conduct require informed consent to treatment. Clients with cognitive damage or impaired communication pose a major problem for therapists and support workers. Informed consent may be beyond the capabilities of the client and may instead be granted by a relative or guardian.

When the client is obviously distressed, therapists and carers face a dilemma: should they continue with the intervention sanctioned by the guardian or should they suspend, even abandon their intervention?

Clients who lack the capacity for informed consent may still make smaller decisions relating to their care. Two important choices which can be made and communicated by all but the most disabled are a request for you to stop what you are currently doing and a request for you to end the session.

Before beginning work with a client whose communication is impaired or whose capacity is diminished, you should establish how they would convey a request for you to stop and a request for you to leave. If this is unclear or has yet to be established, either agree with the client how they would indicate such desires or consider a Clinical Psychology or Speech & Language Therapy referral.

There will be occasions on which an intervention must proceed regardless of the client’s wishes (as when the client is being treated under a Section of the Mental Health Act or similar legislation). For most therapists, these situations will be few and far between: medication may be required by a treatment order, but the same client may still have a choice as regards physiotherapy or dietetic advice.

Therapists should not assume that clients whose cognitive faculties and communication are unimpaired will be sufficiently assertive as to be able to say “stop” or “I want to leave”: many may have sought referral precisely because they lack such assertiveness.

Unassertive clients can be reassured that their telling you to “stop” or to “go away” is useful to you. No therapist wishes to force clients into discussions or actions for which they are unprepared, and some issues require a great deal of preparation. If you know your client will give you honest feedback—and your client knows they are permitted to do so—you can both relax.

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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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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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.

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How to Win Friends & Influence People

A seventy year old sales manual is not an obvious first choice for a therapist’s bookshelf, but this is no ordinary sales manual. How to Win Friends & Influence People offers ways to make people like you, win people to your way of thinking & change people without giving offence or arousing resentment, achievements as useful to therapists and our clients as to salespeople.

Written in 1936 by Dale Carnegie, a public speaking coach, the book summarises twenty years of training courses and advice for salespeople and their managers. The language of the book is very much of its time, as are the examples Carnegie uses to illustrate his points (you will learn more about US presidents and 1930’s gangsters than you ever wanted to know!), but the core messages are timeless.

Carnegie argues that successful outcomes arise from positive relationships, much as Carl Rogers (father of counselling) believed that unconditional positive regard for the client was an essential part of effective therapy.

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