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