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!

You will upset your clients

Apparently innocuous comments can upset your clients. You can’t avoid triggering issues unknown to you, but you can be ready to respond if they are brought to light.

One participant in a relaxation class became increasingly agitated as the relaxation script was read to the group. She then burst into tears and fled the room. The script used a “relaxing image” of walking deeper into a cool, leafy forest: no one knew that the client had been attacked in just such a location.

Many therapists live in fear of distressing their clients by “saying the wrong thing”. Forethought and attentive listening can permit you to avoid many problems, but there will inevitably be a time when you trigger issues of which you were unaware.

Some might argue that the visual imagery offered in the relaxation script was inoffensive and the client’s traumatic associations with such an image were rare and could not be foreseen, but this argument doesn’t wash.

A few moment’s consideration reminds us that “one man’s meat is another man’s poison”: what you find rewarding might be a disincentive for me; what you find relaxing I may find dull or irritating. Assuming that an image I find relaxing will relax you also is a procedural blunder on my part, even without the traumatic associations.

If participants in the group had been invited to think of somewhere they found safe and relaxing, the client’s distress could (probably) have been avoided. The undisclosed issue would remain, however, and might still be brought to light.

Without knowing all the details of a client’s history, a therapist’s passing comment may trigger insecurities or traumatic memories which are rare, if not unique in the general population (e.g. memories of a former husband’s extra-marital affair triggered by a reference to Winnie the Pooh: husband and lover referred to each other by names from the book).

Psychological therapists ought to be alert for apparently unjustified distress and changes of mood. Physical therapists’ attention will often be elsewhere and initial signs of distress may be missed. Whenever and however the client’s distress comes to light, it is the response to this distress which should be the primary issue.

Few therapists would deliberately make crass and offensive comments, but it is inevitable that you will triggers hidden issues at some point. You should be prepared to respond appropriately and sensitively when it happens, rather than worrying about whether it will happen.

Prevent panic: keep your room cool

Prevent clients from panicking by keeping your room cool. Overheating clients can misinterpret a rise in room temperature as the onset of a panic attack.

Panic occurs when benign physical sensations are interpreted as threatening, leading to a surge of adrenaline which exacerbates the sensations and the perceived threat (eg: a cramped chest muscle causes anxiety and tension, increasing the pain from the muscle and increasing the worry that a heart attack is occurring).

Anxious clients entering a hot consulting room can misinterpret the rise in temperature as a rise in their own anxiety levels. Fearing that they will lose control in front of you, they will produce more adrenaline, further raising their body temperature and beginning the vicious circle of a panic attack.

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I have to breach confidentiality – part 2

Disclosures requiring that confidentiality be breached are rare. A little preparation should permit you to focus upon supporting your client through the process, preserving your therapeutic rapport.

In part one, we considered how to react when a breach of confidentiality seems necessary, how to prepare for such an eventuality and what to say to the client.

Now we will consider how to continue your involvement with your client once you have had to breach their confidentiality. We will also consider how to proceed when your decision to breach confidentiality is reached outwith the session, whether independently, directed by your supervisor or required by law (eg: by a court order).

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I have to breach confidentiality – part 1

Disclosures requiring that confidentiality be breached are rare. A little preparation should permit you to focus upon supporting your client through the process, preserving your therapeutic rapport.

For UK therapists there are three occasions on which it is mandatory that confidentiality be overridden for the greater good: when the client is a risk to themselves, when the client is a risk to others and when there are children at risk; respectively, the therapist must inform the Responsible Medical Officer, the Police and the Social Services.

Particular services and professions may offer more specific guidance and place additional duties upon therapists, but it is likely that you will encounter at least one, if not all, of these eventualities.

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Claim your chair with your notepad

Use your notepad to claim your chair before the client enters the room. If you can sit where you need to be, there will be no unease to be misinterpreted by the client.

A prison inmate advised me that I was sitting in the “wrong place”. I wasn’t sure what he meant. He explained that I had naively given him the chair nearest the panic button. Although he had no plans to attack me or hold me to ransom, he was concerned that I might make the same error with some of his less forgiving peers.

There are many reasons why a therapist might wish to occupy a given seat in the consulting room: security (proximity to the panic button and/or the door), easy access to equipment (phone, instruments or tests), presentation (if taping the session) or simply a different view. One GP’s room I used had a skeleton in the corner! I always made sure my clients were facing away from this, particularly in discussions of bereavement and chronic illness.

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Be ready for clients’ companions

Be prepared to deal with the companions clients may bring to therapy. Dealing gracefully and helpfully with them can’t hurt your relationship with the client.

With the obvious exception of Marital Therapy and Child & Family Therapy, models of therapy tend to assume a 1:1 interaction between a therapist and a client.

In practice, most clients are accompanied, at least to their initial interview, by a parent, partner or friend (sometimes all three). Service information leaflets often neglect to advise clients whether their companion can join them in the consulting room, creating the potential for an awkward first interaction with the therapist: “can my Mum / husband / friend come in with us?”

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My client is crying

Trainees (and clients) need to know that crying is common in therapy. Experienced therapists need to remember that crying may be common in therapy, but that crying in front of a stranger is probably a rare experience for any given client: you may now be relaxed about the situation, but they aren’t!

Every trainee dreads this moment: your client is crying. You probably are unaccustomed to strangers crying in your presence. The fear is that their distress is your fault, that you weren’t sufficiently sensitive or supportive: now you have to manage the situation you’ve “caused”.

More experienced therapists will have seen literally hundreds of clients cry. You know that people in therapy will cry for a variety of reasons, usually unrelated to the therapist. Knowing how common crying is, you’ve evolved your own set of responses. You’ve probably forgotten how awkward you used to feel…and how awkward the client still feels.

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Hypotheticals encourage proactive supervision

Using supervision to plan ahead for common and uncommon events has advantages for therapist and client. Both gain when the therapist has considered their range of responses ahead of time.

Ideally, clinical supervision is proactive. You discuss the progress of your cases and identify opportunities to be developed and pitfalls to be avoided. Inevitably, some supervision is reactive. You describe a problem or crisis and decide how such a situation can be avoided or better managed in future.

Reactive supervision can be dispiriting, even disempowering. The supervisor is given the role of dispenser of wisdom to the supplicant supervisee. A directive supervisor can leave you with the impression that you are still a novice (whatever your actual stage of training) with much to learn. Hopefully, we all still have much to learn, including our supervisors.

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Rehearse answers to common questions

Clients are likely to have questions about our services. Some may be asked, others may remain unspoken unless raised by the therapist.

No information sheet can answer every question our clients may have. Even if one did, some wouldn’t read it and others might be unable to either read or comprehend the text. You should therefore be ready to answer, and in some cases, pre-empt clients’ questions.

As a supervisor, I have asked my trainees to explain the difference between a psychologist and a psychiatrist before ever meeting a client. Most have managed a reasonable explanation. The learning point was not the quality of the explanation but the confidence with which it was delivered: everyone was caught off guard by the question and so came across as unsure, defensive, even shifty.

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