Check you have the right client

Check you have the right person before you begin your session. There is scope for confusion in busy clinics, but mistakes can occur even in otherwise empty waiting rooms.

There was only one person in the waiting area. I said her name and she followed me into my room. After 10 minutes or so, it became clear she wasn’t my client: she was in a lot of pain and had been awaiting a GP; when I walked into the waiting room, she hadn’t listened to the name I called. She missed her actual appointment and I missed my actual client.

Outside of addiction services, therapy clients rarely have anything to gain by posing as someone else. When dealing with people who are distracted by pain, hallucinations or medication, however, there is potential for confusion.

Most therapists are accessed via reception staff. Depending upon the layout of the facility, receptionists may be able to point out your client in the waiting area (or at least confirm that your client has arrived). In a busy outpatient clinic or GP surgery, this may not be possible.

Calling a client’s name in a busy waiting room may get you someone with a similar name awaiting another therapist. Explaining your role and name dropping the referrer may be enough to alert the client that they are in the wrong session, but clients are frequently referred without adequate consultation or by locums or other staff whose names they don’t know.

First time clients may have psyched themselves up to speak to a stranger about their most intimate concerns Even if not in pain or on medication, they may not be listening for much other than their cue to reel off their story. Details such as the wrong GP or profession may pass them by.

Clients with multiple appointments or a history of referrals may be numb to the whole process. They no longer attend to therapists’ names or professions: they just follow the latest person to call their name and do what they’re told, however unusual it may seem.

Short of requesting photo ID, there’s no foolproof way to prevent identity confusion, but the potential can be minimised by requesting that the client provide a piece of personal information: “can you just tell me your correct address?” or “can you just confirm your date of birth?”. Don’t give the information in the question: “is your date of birth 29.10.64?” can be answered with a nod that proves nothing.

The aim is to request a single piece of fairly specific data, the provision of which both confirms the clients’ identity and passes control of the conversation back to you, so that the client doesn’t launch into their story before you’ve been able to explain consent or confidentiality.

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.

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

Overusing clients’ names can mask inattention

Use of a client’s name to foster engagement may mask flagging concentration and inattention. Using a client’s name sparingly permits more accurate judgement of attention to the conversation or task.

“…a person’s name is to that person the sweetest and most important sound in any language.” (Carnegie, 1936).

Whilst using client’s given names uninvited can backfire, a genuine (and successful) attempt to remember and recall someone’s name can pay dividends.

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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.

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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.

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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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Disclosure is promoted by permission not to speak

Giving clients permission not to speak encourages disclosure. Explicitly granting the freedom to subvert our power frees the client to tell us what they need.

The first time is to check out the therapist, the second is to tell you the real problem.

I was given this advice in training and for years it seemed to be true. Now, in my practice at least, it is the exception rather than the rule.

The balance of power in therapy lies with the therapist. We decide when, where and for how long is each appointment. We set the boundaries and grant exceptions. The client must work within our framework.

Clients can exercise control by withholding information or themselves. Failure to attend is the ultimate means of regaining control of therapy. More subtly, the client can, without overtly challenging the therapist, keep back important facts for as long as they choose.

Full disclosure can occur in the first appointment if the client has permission to withhold. I tell clients “if there are any questions you don’t feel comfortable answering, that’s OK”. It is now rare for clients to surprise me in the second appointment (unless I forget my line).

The underlying process may be that, having been given permission to withhold, the client can now exercise control by disobeying you…and telling all. This appears manipulative but this accusation would be genuine only if the permission to withhold were false, given only to manoeuvre the client rather than arising from a genuine respect for their privacy.