Work with, not around, chaotic clients

Therapists can either work on, or work around, the chaos in client’s lives. Identifying clients, rather than their circumstances, as chaotic risks disempowering the client.

“Chaotic” seems to be one of the mildest “unofficial diagnoses” a therapist can apply to a client: it seems more descriptive than derogatory. “Chaotic” is defined as being “in a state of complete confusion or disorder”. This would be an accurate description of the circumstances of a large number of mental health clients, especially those who come to the attention of psychiatric services.

The stereotypical “chaotic” client would be someone who misses appointments, over- or under-uses prescription medication, has disrupted and disorganised home and work routines and struggles to achieve any consistency or reliability in their interactions. This state of affairs would usually have been at least part of their reason for seeking therapy.

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Setting homework has negative implications

Setting “homework” for clients implies that no relevant work would otherwise occur between sessions. When clients fail to do their homework but achieve positive change anyway, the focus may fall on the former rather than the latter.

Physical therapies often entail a certain amount of work on the part of the client inbetween sessions with the therapist: daily exercises may be set, weekly diet sheets may be provided, medications may be prescribed.

Psychological therapies may also require work inbetween sessions. The notion that therapeutic change occurs only within sessions, in the presence of the therapist, is disproved by the evidence: the greatest portion of therapeutic change is attributable to factors entirely outwith therapy.

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Demanding clients make legitimate requests

“Demanding” clients are often making legitimate requests. Therapists applying such a label should consider whether it is the client’s requests or the service’s lack of resources which is unrealistic.

“Demanding” is a label often applied to clients by therapists, although rarely within earshot of clients. The label influences the responsiveness of the service to the client’s stated needs by implying that their requests for assistance are in some way inappropriate or excessive.

The stereotypical demanding client is therefore one who places undue demands upon the service, seeking longer or more regular contact with their therapist than is usual or seeking access to medications and other resources which would drain the budget of the service.

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Helpful patients are not hateful patients

Therapists should encourage and support, not dread, “helpful patients”. Internet or other research by the client can indicate active involvement in treatment.

In 1978 JE Groves described four categories of “hateful” patient, ie: the patients most physicians dread:

  • dependent clingers
  • entitled demanders
  • manipulative help-rejecters
  • self destructive deniers

To this list a fifth category appears to have been added: “helpful” patients, who search the internet for details of their condition and treatment and provide these to their therapist. Comments from colleagues (in person and via blogs), as well as cartoons and the popular press, suggest that these folks inspire almost as much dread (or, at least, derision) as the other four stereotypes.

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Beware of unofficial diagnoses & double meanings

Some terms used by therapists to describe clients have meanings which won’t be found in textbooks. Use of these terms is rarely of benefit to the client, although the term may say as much about the therapist as the client.

  • resistant to treatment
  • lacking motivation
  • poor historian
  • manipulative
  • demanding
  • somatising
  • chaotic
  • personality disordered

As diagnostic systems have developed, common place words have been redefined more narrowly & precisely for clinical use (eg: anxiety, depression).

As therapeutic professions have developed, there has been a less auspicious development: diagnostic labels have developed double meanings and common place words have been elevated to the level of diagnoses without the scientific scrutiny afforded official classifications.

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