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.

Always ask when you don’t understand

Asking when you don’t understand benefits you and your clients. Pretending to understand can discourage disclosure and support poor decision making.

When I began working with people with learning disabilities, I was told “don’t pretend that you’ve understood what someone says to you”. This seemed fairly obvious advice until I was in the embarrassing situation of having to say “I’m sorry: I didn’t catch that” for the third time in five minutes.

Whether faced with a speech impediment or bombarded with abbreviations & unknown references, it is tempting to nod in agreement and try to move on. In either case, the principle is the same: by attempting to avoid embarrassment now, you’re preparing the ground for future, potentially much more serious, problems.

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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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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.

Closed questions can be supportive for clients

Judicious use of open & closed questions can empower clients. Restricting the range of responses when some are inappropriate or unavailable demands more of the therapist, but can be more supportive for the client.

One benefit of speaking slowly is that you get to think about how you frame your questions. The considered use of open & closed questions is a therapeutic skill often mentioned in workshops and textbooks but neglected in practice.

Open questions can be used for initial information gathering (“Tell me about your childhood”) and closed questions used to clarify the information given (“Were you abused as a child?”).

Closed questions restrict choice of response. They allow only a handful of responses (eg: yes or no) without stepping outwith the frame of the question (“I don’t feel comfortable talking about that”). Many clients are insufficiently assertive to sidestep the question and may feel pressured into premature disclosure of information (or lying) by closed questions.

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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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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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