Have stuck clients keep a prospective diary

Ask clients stuck awaiting change to keep a prospective diary. An explicit account of life after the hoped-for change can help clients unstick themselves and start changing now.

Some clients (and some therapists) get stuck awaiting a single change which will solve all their problems at a stroke. “Once I’m rehoused…”, “Once I get my compensation…”, “Once you start taking your medication consistently…”.

A key feature of these hoped-for changes is that they are usually external to the person holding out for them: the client holds out for change at the Housing department or law court, the therapist holds out for change in the client. The implicit message is “it’s not my fault nothing is happening yet”.

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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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Leave contracts out of the first session

Many therapists set explicit goals and use treatment contracts with their clients. Goal setting provides a focus for therapy: contracts indicate that both parties have agreed to the terms of the therapy (or should: the contract you use does bind the therapist as well as the client, doesn’t it?)

Some therapists aim to conclude this business by the end of the first session. While this gives a nice structure to therapy (1st session: agree goals, 2nd session: work toward goals), this may not be the best way forward.

Setting goals and signing a treatment contract is a big step for a client. Although clients may have been awaiting their first appointment for weeks, months, even years, the assessment process may bring to light new information and perspectives which could alter their aims significantly…given time to think things through.

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Remove the miraculous from the Miracle Question

The Miracle Question can elicit negative responses from some clients. These negative reactions can be avoided by rephrasing the question without the miraculous element.

The Miracle Question is used by Solution-Oriented Therapists to elicit the conditions which would lead the client to consider their problem solved:

Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?

The client’s answer generally contains the seeds of their own solution and can be used to set treatment goals and propose strategies. Used properly, the Miracle Question can be a powerful therapeutic technique, but it has several liabilities inherent in the phrasing of the question.

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What is your one aim for any session?

Having too many goals can be as bad as having no goals. This is as true for therapists as for our clients, yet therapists may enter into a session with far too many goals to achieve in one sitting.

Trainees often struggle with first appointments, in which there is so much to do: establish a rapport, take a history, establish a diagnosis or formulation and agree a treatment plan. These would be the achievements of two, three or even more sessions but the impression given by many text books is that all of this must take place in the first session.

More experienced staff may feel the same pressures, but may also feel obliged by waiting lists and the need to demonstrate turnover to look for opportunities to discharge the case. Some may also feel that they must be on their guard against potential attempts at manipulation by the client.

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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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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 will you know you’re a better therapist?

Solution-Oriented therapists ask clients how they will know when they are better. Therapists often wish to be better in their role, but few ask the Miracle Question of themselves.

Solution-Oriented therapists often ask clients the Miracle Question:

Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? (de Shazer, 1988)

Stressed therapists might be asked a similar question:

Suppose that tonight, while you are asleep, there is a miracle and you become a better therapist. How will you know that this has happened? What will you notice has changed about the way you’re working?

I’ve asked this question many times, of my self and of others. The answers tend to be much the same.

  • Every intervention I make in therapy will work
  • My clients will never try to manipulate me
  • I will always be available for my clients whenever they want me
  • Nothing I say will ever upset my clients
  • All my clients will get better all the time
  • My clients will be grateful for the help I’ve given them
  • My clients will co-operate with my therapeutic strategies
  • If I see a problem, I will be able to address it and solve it
  • I will always know what to do in any situation arising in therapy
  • I will not feel frustrated, angry or anxious during therapy sessions

If our clients gave such unrealistic answers, we would renegotiate more practical, achievable goals. How will you know when you’re a better therapist?