Most clients have abnormal daily routines

We base our assumptions about normality on our own experience and risk mistaking the norms of our immediate social circle (or movies and TV) for demographic reality.

I was asked to help stroke ward staff manage a patient who took his bed very early in the evening and woke correspondingly early in the morning. Most hospital patients have difficulty being woken at 6am: this gentleman was up at 4am. The concern was that the stroke had damaged his body clock. In fact, he was a farmer, following his normal sleep routine of sixty-eight years!

Most people work 9–5, apart from farmers, students, factory workers, children, supermarket staff, retirees, taxi drivers, cleaners, restauranteurs, post office workers…

Working 9–5, Monday to Friday is a pretty middle-class, professional schedule … and maybe not even that: hospital nurses, medics and other staff (e.g. radiographers) work shifts and anyone employed by an international company may be required to keep the hours of their colleagues in another time zone.

An “abnormal” daily schedule — in the eyes of their therapist — can reduce the chances of a client engaging in therapy. Continually offering a single mother an appointment at the time school ends turns therapy into one more stressor. Therapy may even have to take a break during the school holidays.

Sleep or meal times at odd hours — long distance lorry drivers may be eating their dinner at “breakfast time” — can make a diet sheet or sleep diary difficult to interpret and may, if not fully understood, lead to impractical advice being offered.

Sleep and work routines may form as much of a culture as race, nationality or ethnicity. There are people who have worked night shifts for decades: counselling disruption of their longstanding routines could be as “culturally insensitive” as challenging any taboo about food, dress or physical contact.

Making the daily routine an initial interview question can help maintain awareness that your “normal” day may not be your client’s (or your colleagues’). You may not know your client’s schedule when you offer the first appointment, but there’s little excuse for not knowing when to offer the second.

Be on time for your clients

Be on time for your appointments & consultations. Punctuality conveys professionalism, respect and allows you to address & manage possible resistance on the part of the client.

There’s a Catch–22 type joke (at least, I thought it was a joke) about clients’ attendance at appointments:

If they’re early, they’re anxious; if they’re on time, they’re obsessional; if they’re late, they’re resistant.

Therapists, by contrast, seem only to have two modes: on time (rare) and late (mostly). Lateness on the part of therapists is usually due to an excessive workload and so is likely to be forgiven—or at least tolerated—by NHS clients. The implicit message, that the therapist’s time is more valuable than the client’s, doesn’t make for a good start to a session, however.

In an over-subscribed service, punctuality is difficult to ensure. Many medical services don’t even try, overbooking clinics on the principle that there will be non-attendances. The aim is to ensure that the clinician never has to wait for a patient, but this almost guarantees that the patient will face a lengthy wait.

Punctuality has no downside. Lateness may imply importance and high demand, but punctuality conveys professionalism, courtesy and credibility: who would accept time management advice from someone who arrived late?

Ten minutes in a busy clinic can be a very short time: scribbling casenotes, fielding phone calls and requests from colleagues, scanning files and letters prior to your next appointment.

Ten minutes in a waiting room is a long time, especially if you have arrived early in order to ensure that you are on time, if you are anxious or in pain, or if you have psyched yourself up for the appointment. A punctual therapist will get a calmer, less anxious client.

Therapists who book appointments back to back (or overbook clinics) to compensate for non-attendance are replacing one problem with another. Punctuality ensures that persistently late clients are obvious to the therapist, not just their receptionist, permitting contributory issues to be addressed. Tackling client lateness when you are habitually late would be a challenge for even the most blatant hypocrite!

The Golden Rule is universal

Treat others as you’d like to be treated is a universal principle. Therapists who avoid working with other faiths and cultures can be assured that there is common ground to work from.

Working with people with different beliefs can be challenging, especially for psychological therapists. By definition, every client holds some beliefs differing from the therapist’s but there is something particularly daunting about codified cultural and religious belief systems.

Clients will often seek out therapists of a similar culture or faith, fearing (sometimes correctly) that an ignorant or antagonistic therapist may question basic beliefs which they do not wish to examine.

Therapists may also shy away from clients of different cultures or faiths, fearing that a misunderstanding on their part may upset or offend the client, possibly even to the level of formal complaints. Such a lack of confidence does little for rapport.

Whilst therapists cannot know the details of every faith and culture they might encounter and should think carefully before attempting to work within frameworks they do not understand, there is one principle common to almost all belief systems: the Golden Rule;

do unto others as you would have them do unto you.

Religious Tolerance.org lists 21 world religions (including Christianity, Judaism, Islam, Hinduism & Sikhism) and a number of other philosophical systems which contain a version of the Golden Rule.

The site notes that most religions make some exception for non-believers, but the existence of this almost universal principle should reassure the uncertain that there can be common ground.

A wise therapist would not, of course, presume to believe that there can be complete agreement. The comedian Emo Phillips has illustrated the dangers of pursuing the search for common ground too far.

I was walking across a bridge one day, and I saw a man standing on the edge, about to jump off. So I ran over and said “Stop! don’t do it!” “Why shouldn’t I?” he said.

I said, “Well, there’s so much to live for!” He said, “Like what?”

I said, “Well…are you religious or atheist?” He said, “Religious.”

I said, “Me too! Are you christian or buddhist?” He said, “Christian.”

I said, “Me too! Are you catholic or protestant?” He said, “Protestant.” I said, “Me too! Are you episcopalian or baptist?”

He said, “Baptist!” I said,“Wow! Me too! Are you baptist church of god or baptist church of the lord?” He said, “Baptist church of god!”

I said, “Me too! Are you original baptist church of god, or are you reformed baptist church of god?” He said,“Reformed Baptist church of god!”

I said, “Me too! Are you reformed baptist church of god, reformation of 1879, or reformed baptist church of god, reformation of 1915?” He said, “Reformed baptist church of god, reformation of 1915!”

I said, “Die, heretic scum”, and pushed him off.

Demon Haunted World

An accessible argument in favour of the scientific method. The book provides tools for discriminating science from pseudoscience and knowledge from speculation.

The late Carl Sagan was a strong proponent of science and the scientific method. The Demon Haunted World (subtitle: Science as a Candle in the Dark) revises a number of his magazine articles into a larger argument.

Sagan’s central thesis is that we should take nothing for granted. We should acknowledge that what we “know” is a collection of theories which have not yet been disproved, but which should continue to be tested in order that, if they fail, they can be replaced by more complete theories. There is no place for ego or privileged beliefs in Sagan’s world.

The highlight of the book is the twelfth chapter, entitled “The Fine Art of Baloney Detection”. The earlier chapters cover phenomena ranging from crop circles to demons, faith healing to alien abduction. In each case Sagan highlights the personal and cultural biases which permitted or permit these memes to thrive.

“The Fine Art of Baloney Detection” lays out a series of tools for sceptical thinking. Sagan advises us not to get overly attached to an idea, but to examine why we like it and to ask ourselves if we can find reasons for rejecting it (because if we don’t, others will: in our case, our clients!).

The chapter ends with a list of fallacies of logic and rhetoric for us to avoid. These include arguments from authority (“trust me, I’m a doctor”?) and considering only the two extremes on a continuum of intermediate possibilities (biological or psychological?).

The Demon Haunted World is an interesting read for scientist and lay person. Chapter 12 is highly recommended to both therapists, clients and anyone hoping to make sense of the “evidence base”.

Reference

Sagan C (1997) The Demon Haunted World: Science as a Candle in the Dark. Headline: London.

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.

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