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.

Check you have the right client

Check you have the right person before you begin your session. There is scope for confusion in busy clinics, but mistakes can occur even in otherwise empty waiting rooms.

There was only one person in the waiting area. I said her name and she followed me into my room. After 10 minutes or so, it became clear she wasn’t my client: she was in a lot of pain and had been awaiting a GP; when I walked into the waiting room, she hadn’t listened to the name I called. She missed her actual appointment and I missed my actual client.

Outside of addiction services, therapy clients rarely have anything to gain by posing as someone else. When dealing with people who are distracted by pain, hallucinations or medication, however, there is potential for confusion.

Most therapists are accessed via reception staff. Depending upon the layout of the facility, receptionists may be able to point out your client in the waiting area (or at least confirm that your client has arrived). In a busy outpatient clinic or GP surgery, this may not be possible.

Calling a client’s name in a busy waiting room may get you someone with a similar name awaiting another therapist. Explaining your role and name dropping the referrer may be enough to alert the client that they are in the wrong session, but clients are frequently referred without adequate consultation or by locums or other staff whose names they don’t know.

First time clients may have psyched themselves up to speak to a stranger about their most intimate concerns Even if not in pain or on medication, they may not be listening for much other than their cue to reel off their story. Details such as the wrong GP or profession may pass them by.

Clients with multiple appointments or a history of referrals may be numb to the whole process. They no longer attend to therapists’ names or professions: they just follow the latest person to call their name and do what they’re told, however unusual it may seem.

Short of requesting photo ID, there’s no foolproof way to prevent identity confusion, but the potential can be minimised by requesting that the client provide a piece of personal information: “can you just tell me your correct address?” or “can you just confirm your date of birth?”. Don’t give the information in the question: “is your date of birth 29.10.64?” can be answered with a nod that proves nothing.

The aim is to request a single piece of fairly specific data, the provision of which both confirms the clients’ identity and passes control of the conversation back to you, so that the client doesn’t launch into their story before you’ve been able to explain consent or confidentiality.

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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Tell clients confidentiality has limits

Therapists often assure clients that the information they provide is confidential. Confidential is defined as “intended to be kept secret”. Whether the information will be kept as secret as the client (or therapist) imagines depends upon the therapist and the service.

Confidentiality in the strictest sense implies that only the therapist will be privy to the information provided by the client. In practice this level of confidentiality is impossible to offer, as therapists have professional and legal obligations to uphold.

Most professions and services require that clients give informed consent to all assessments and treatments, which includes basic information gathering. Clients must therefore understand the limits upon the confidentiality you can offer before beginning to discuss their case. Clients who provide information which necessitates breaking confidentiality may feel betrayed by their therapist if not first advised of their therapist’s obligations.

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