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

Aim for reliability before availability

Reliability is more important than availability in the long run. Clients who know when you are not available can make informed choices regarding alternative sources of support.

I once worked with a client who rang her GPs so frequently and insistently that they established a rota for taking her calls. She bombarded every new therapist with telephone calls. I told her she could call me between 1030 and 1130 on Monday or Thursday and that if I was on another call, I’d call her as soon as I finished. She rang me twice the first week and two more times in the next six months. She also called her GPs and CPN less frequently.

Many therapists feel a duty to respond to client’s crises. Who better to address a difficult situation: the therapist who has listened carefully to the client’s life-story or the harassed junior medic who has never met them before? Shouldn’t you always be available for your client?

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Check your client can read and write

Checking that your client can read & write assists both you and them. Attempting to use questionnaires, journals or bibliotherapy with someone hiding their illiteracy could end your intervention before it has begun.

Literacy isn’t essential in therapy: psychological therapies aren’t called “talking cures” for nothing and physical therapies usually require little in the way of reading or writing. Clients who cannot write can keep pictorial records or use voice recorders (now built into many mobile phones) to keep notes of thoughts or actions. Much of the literature therapists would wish to hand out to clients could, with a little effort, be offered as graphics or video & audio recordings.

The difficulty for most therapists will be in identifying clients whose illiteracy may be one of their most closely guarded and shameful secrets. Ticking the boxes on your questionnaire need not mean that the questions have been read. Phrases like “your writing is too small” or “I’ve left my glasses at home” may mean exactly what they say, or may be well-practiced cover-up routines. Allocating an illiterate person to bibliotherapy can be a waste of their time and yours.

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Think before you act for your client

Stop and think before you take action on behalf of your client. You may be depriving them of the opportunity to help themselves (with appropriate support).

Therapists are people who want to help. People of equivalent qualifications in other fields are usually paid more and have better conditions: we don’t do it for the money, but because we want to make a difference.

Trainees want to help. Faced with overwhelming distress or disability, you want to make a difference but have only a limited repertoire of knowledge to draw upon. You may (mistakenly) feel that you must compensate for your shortcomings and so attempt to offer more practical help where possible.

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