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.

You can always be misunderstood

There are two aims in any conversation: unambiguous expression of your own position and complete comprehension of the other person’s views. We should always remember that neither of these aims is a realistic goal.

A client told me of an ante-natal appointment at which her midwife said “So, your first child was deformed and your second child was killed: let’s hope it’s third time lucky, shall we?”

While it is difficult to imagine anyone not being offended by such insensitivity, it is equally hard to believe that the midwife was being intentionally cruel. If she thought at all about her comment, she may have imagined she was being warm & humorous: rapport-building.

While serving as a Member of the Finnish Parliament, communications researcher Osmo Wiio proposed his “laws of comunication”, including:

  • If communication can fail, it will
  • If communication cannot fail, it still most usually fails
  • If communication seems to succeed in the intended way, there’s a misunderstanding
  • If you are content with your message, communication certainly fails!

Clients are often mystified by someone’s negative reaction to what seemed, to them, to be a reasonable statement or request. In discussing such situations, we usually conclude that it is possible to misunderstand even the most clearly worded request and to be offended by even the most innocuous statement: what the speaker says may have little to do with what the listener hears.

Clients who are anxious or depressed may be less able to attend to either expression or comprehension with the same care & attention as their therapist. Therapists’ comments & questions, however clearly articulated, may still be misinterpreted because the client is not paying full attention or has information of which the therapist is unaware (but which the client may think the therapist knows).

Misunderstandings & unfortunate comments can be worked through given time and effort, but neither of these will be forthcoming from a therapist who thinks that their own communication is unambiguous.

The Golden Rule is universal

Treat others as you’d like to be treated is a universal principle. Therapists who avoid working with other faiths and cultures can be assured that there is common ground to work from.

Working with people with different beliefs can be challenging, especially for psychological therapists. By definition, every client holds some beliefs differing from the therapist’s but there is something particularly daunting about codified cultural and religious belief systems.

Clients will often seek out therapists of a similar culture or faith, fearing (sometimes correctly) that an ignorant or antagonistic therapist may question basic beliefs which they do not wish to examine.

Therapists may also shy away from clients of different cultures or faiths, fearing that a misunderstanding on their part may upset or offend the client, possibly even to the level of formal complaints. Such a lack of confidence does little for rapport.

Whilst therapists cannot know the details of every faith and culture they might encounter and should think carefully before attempting to work within frameworks they do not understand, there is one principle common to almost all belief systems: the Golden Rule;

do unto others as you would have them do unto you.

Religious Tolerance.org lists 21 world religions (including Christianity, Judaism, Islam, Hinduism & Sikhism) and a number of other philosophical systems which contain a version of the Golden Rule.

The site notes that most religions make some exception for non-believers, but the existence of this almost universal principle should reassure the uncertain that there can be common ground.

A wise therapist would not, of course, presume to believe that there can be complete agreement. The comedian Emo Phillips has illustrated the dangers of pursuing the search for common ground too far.

I was walking across a bridge one day, and I saw a man standing on the edge, about to jump off. So I ran over and said “Stop! don’t do it!” “Why shouldn’t I?” he said.

I said, “Well, there’s so much to live for!” He said, “Like what?”

I said, “Well…are you religious or atheist?” He said, “Religious.”

I said, “Me too! Are you christian or buddhist?” He said, “Christian.”

I said, “Me too! Are you catholic or protestant?” He said, “Protestant.” I said, “Me too! Are you episcopalian or baptist?”

He said, “Baptist!” I said,“Wow! Me too! Are you baptist church of god or baptist church of the lord?” He said, “Baptist church of god!”

I said, “Me too! Are you original baptist church of god, or are you reformed baptist church of god?” He said,“Reformed Baptist church of god!”

I said, “Me too! Are you reformed baptist church of god, reformation of 1879, or reformed baptist church of god, reformation of 1915?” He said, “Reformed baptist church of god, reformation of 1915!”

I said, “Die, heretic scum”, and pushed him off.

My client won’t do as I say

One of the major challenges to the therapeutic alliance arises when the client fails to follow the therapist’s advice. Therapists can often be heard to complain that clients reject their instructions (sorry, “advice”) out of hand:

Don’t they want to get better? Why won’t they do as they’re told?

When considering how you will respond to a client who is not following your advice, there are three questions you should ask yourself:

  • why should your clients do anything you say?
  • why should your client do what you’re saying now?
  • why wouldn’t clients follow your suggestions?

Why should clients do anything you say?

Take a moment to consider your role and relationship to your clients. Are you:

  • a taxi-driver: your client presents you with a destination to which you take them, requiring only that they behave themselves on the journey.
  • a tour guide: your client chooses a goal and you accompany them on their journey, using your knowledge of previous journeys to help you both negotiate any obstacles they may encounter, but relying on the client to keep up with you.
  • a travel agent: your client sets out their circumstances and wishes and you offer a set of options which they are free to pursue to whatever degree they choose. Which (if any) of the options the client chooses in no way reflects upon you.

How you see yourself will determine the degree of adherence to your advice that you expect from your clients. A “travel agent” may be disappointed that their recommendations are not followed, but has less invested in the process than a “taxi-driver”, who is likely to be frustrated by their passenger criticising their chosen route.

How the client sees your role will be a major influence on a successful outcome. You may see yourself as a “taxi-driver”, brimming over with “the Knowledge”", but your client may be looking for a travel agent.

Why should clients do what you’re saying now?

Therapists spend a long time training, both pre- and post-qualification. Most professions have requirements for continuous education in order to maintain registration. The average therapist is stuffed to the gills with basic science, clinical research, evidence-based practice guidelines and tips & techniques acquired by experience over the years.

The net result of all this knowledge can be a belief that there is a single best solution to a given problem. EMDR is superior to CBT in the treatment of PTSD. Exercise is preferable to rest in recovery from back injuries. Psychotherapy is preferable to medication in the management of anxiety. Examples abound in every discipline.

Alternatively there can be a belief on the part of the client that there is a single fix for their problem. Your carefully crafted multi-part, multi-level, even multidisciplinary intervention may seem too complex a response to a condition with a strong diagnostic label: one problem, one solution is more intuitive.

Consider your recommendations and your reasons for making them. Are you acting on the basis of peer-reviewed research, practice guidelines, experience of success with other apparently similar clients, or suggestions from a senior colleague? How convinced would you be by someone making recommendations to you on the same basis? Most importantly, how clear are you making your reasons to your client?

Most clients have little experience of therapy but have, by definition, a lifetime’s experience of being themselves. When a client says a certain technique won’t work for them, despite this technique having been of use to hundreds of clients before them, you have two options. You can expend a great deal of energy persuading and cajoling them to follow your advice. Alternatively, you could ask what makes them and their situation different from everyone else: maybe nothing, but maybe something and you won’t know which without asking.

Why wouldn’t clients follow your suggestions?

Fully half of all prescribed medication is unused. In the absence of authoritative figures, we can guesstimate that up to half of all therapeutic advice is not followed. Clients may leave the consulting room with no intention of following the advice they have been given or they may return to report that they have not performed their designated task.

There are many reasons why a client might not follow a therapists’s advice:

  • they don’t want it
  • they don’t understand it
  • they don’t believe they can do it
  • they don’t believe it will work
  • they fear it will make matters worse
  • they got a negative reaction when they first tried it
  • they couldn’t do it at the first attempt
  • they couldn’t do it consistently
  • they couldn’t do it at all

The time to address these issues is while the client is still in your room, not next week or next month when they return to report their “failure”. Although the last four points may only be confirmed (if at all) once the session is over, you and your client should have agreed how they will manage each possibility if it occurs.

[EMDR]: Eye Movement Desensitisation and Reprocessing
[PTSD]: Post Traumatic Stress Disorder
*[CBT]: Cognitive Behavioural Therapy

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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