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.

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!

Chris Allan is a Clinical Psychologist and Director of the Psychology Clinic at the University of Wollongong in New South Wales, Australia. His weblog In The Room addresses a range of therapeutic issues and the related literature.

Each post illustrates a problem encountered by therapists and offers insights into this problem, often with extensive quotes from relevant textbooks and journals. As a round up of “therapy tips & techniques you will find in your textbooks”, In the Room should be of use to any psychological therapist and is well worth a read by physical therapists also.

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.

Journals and other records kept by the client are a useful adjunct to most therapeutic approaches and an integral part of some, such as Cognitive Behavioural Therapy. Daily or hourly data points can be invaluable in establishing patterns and tracking progress.

Diary sheets may be handed out automatically at the beginning of therapy, in the expectation that clients will keep reliable records which can be used as the basis for therapy. Presenting clients who are already struggling to cope with another responsibility may not be the wisest move.

Anyone who has attempted to keep a daily journal (or blog regularly!) will know the difficulty of maintaining their resolve over the long term: the first week or two are reasonably easy, but week three or four is where most resolutions fail. Therapeutic records are no exception.

Before requiring a regular commitment from a client over & above their attendance at your appointments, it is worth considering:

• whether the data you are considering are necessary
• how much detail is required for the analysis
• how many data points are required

Rather than automatically requiring a diary or other recording outwith the session, ask yourself (and your client) whether the same information could be generated within the session. Clients who have struggled to carve the time for your appointment out of their schedule will appreciate you keeping your requests for extra time to a minimum.

Diary sheets are often standard forms copied from a book and require more information than may be necessary for your analysis, as well as more information than clients can comfortably record at the time. Look back over some old notes to see how often every column is completed reliably (if at all) on standard record forms. The less you require, the easier it will be to provide.

A client suffering migraine headaches drew a smiley face on each migraine-free day in her pocket diary. Flicking through the diary showed a clear increase in the number of smilies.

Most important is to consider whether the record keeping is part of the permanent change that your client wishes to make or is limited to their time in therapy. If the intention is that your client will keep a record indefinitely (e.g. a daily reflective journal), as much time should be devoted in session to establishing this habit as would be devoted to any other change in thinking or behaviour.

If the data is required for a specific part of therapy only, you should agree with the client that they will keep the record for only as long as necessary to collect the required data. If intended to track progress, a record kept for a couple of weeks at the start of therapy and reinstated near the end and again at followup may be more reliable than a supposedly continual record (which will probably lapse after three weeks or so).

Death of clients might be inevitable (f you work in palliative care), an acknowledged risk (if you work in psychiatric settings) or very rare. The cause of death may be deliberate action, accidental or ambiguous.

However hard you strive for “professional detachment”, the need to establish a rapport with your client means establishing a bond for which you may grieve when it is irrevocably lost. Inevitably, junior staff have more time to form such a bond, but have less experience to draw upon in dealing with the consequences.

Considering in advance how the death of a client might affect you will help you better manage both your feelings & responsibilities.

Expected deaths

Staff working with people whose conditions are terminal will be aware that death is likely. They may even be more aware than the client of when death will occur. Services dealing with inevitable death on a regular basis may have protocols for staff support and you should be made aware of these.

Whether or not there is official support available to staff, an established staff group is likely to have evolved its own coping mechanisms which may not be obvious to, or even shared with new and junior members, especially where the service has a low staff turnover or junior staff stay for only a short period.

Quizzing colleagues as to their coping strategies might not be the stuff of coffee room chats, but taking some private time (supervision or other 1:1 interactions) for such discussions is advisable. Be aware that there is no guarantee that even the most experienced staff have coping strategies which would work for you or that you would choose to use even if effective.

Therapists familiar with the dynamics of bereavement will be aware that, in the case of expected deaths, much of the work of grieving may be performed in advance. When a death occurs “on schedule”, those close to the deceased can be surprised by their quick acceptance: they have been preparing unconsciously for months.

When an expected death does not occur “on schedule”, the unconscious preparation & anticipatory grieving may be undone. The expectation becomes that the client will survive and the death may hit as hard as an unexpected death when it finally occurs.

Unexpected deaths

Sudden deaths may be a result of illness, accident or deliberate action. Sudden deaths are more likely to elicit feelings of anger & guilt in addition to the expected sadness.

People with chronic and terminal illnesses are still subject to the same risks and diseases as anyone else.

I was once shocked by the death of a client with a degenerative neurological disorder who suffered a fatal heart attack. This was not part of the profile of their disease and therefore seemed much more shocking. In retrospect, my client had all the markers of a high coronary risk, but the degenerative disorder seemed to override this in everyone’s eyes (including the client’s).

Accidental deaths may be related to treatment. Complications of a necessary operation or prescription of dangerous medication may kill a client and may have been accepted as a risk by the client. You and other colleagues may have held a different view and, however much you respect the client’s right to choose, there may be lingering resentment which might colour your professional interactions.

Distinguishing between an unfortunate outcome of a necessary treatment and the fatal outcome of poor practice can be hard, even for professional ethics boards. Where you harbour a grudge against the therapist responsible for the fatal intervention, you should ensure that you discuss this with senior colleagues: you may be being unfair or there may be a case of professional misconduct which should not go unaddressed.

Where the death appears to be a consequence of your action or inaction, this must again be addressed if you are to continue to practice to the best of your ability. If you were in error, this should be corrected. If you were not, you need to be sure of this to avoid self-doubt clouding future decisions. Discussing possible errors is difficult at the best of times, even without a death as a consequence, but you have a professional responsibility for good practice.

Death by design may be suicide or homicide. The killing of a client by another client would be the most complex scenario imaginable in terms of the implications for therapist and the service, but suicide is a risk in most mental health services and is arguably the cause of death for which you should be best prepared.

Suspicious deaths

Deaths which occur without witnesses may be not be fully explained or explainable. If a depressed client is hit by a car whilst walking drunkenly along the side of a road, was it suicide or accident? If a distracted, anxious client dies from a borderline overdose of a dangerous prescription medication, was it suicide or accident?

Where the true intentions of the dead person will never be known, there is room for doubt and self-blame on the part of the therapist, especially where contact was ongoing but even when the client had not been seen for months or years. Could I have anticipated and prevented this? The same question will occur to friends, relatives and perhaps even colleagues.

Many suicidal acts do not result in death, while impulsive suicidal gestures may be fatal. The true motivations of clients are known only to the client, whatever story they may offer if they survive, and possibly not even to them if they were intoxicated or otherwise out of control of themselves.

As noted above, it may be difficult or impossible to rule out the possibility that you could have averted a suicide. Regardless of the level of uncertainty, you are likely to harbour some feelings of anger or guilt (normal responses to an event outwith your control) which you should be able to address either with your supervisor, colleagues or some other reliable and confidential support.

Legal responsibilities

Depending upon your involvement with the client and the nature of their death, you may be required to provide evidence to an inquest, a professional ethics hearing or even a criminal trial.

Your casenotes may be scrutinised or even removed. You should be aware of your employer’s and your profession’s standards regarding the retention of casenotes, as well as your duties of disclosure and confidentiality, following the death of a client.

Both legal and emotional support for staff affected by the death of a client tends to be poor. Ascertaining the levels of support available to you, and finding additional supports if necessary, should help you continue to practice effectively.

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.

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.

Many clients, some famous and some not so famous, have written of their experiences in therapy. Therapists’ accounts of therapy tend to be confined to heavily anonymised snippets of conversation illustrating a particular point in therapy textbooks, or case studies in peer-reviewed journals which focus more upon the diagnosis & outcome than upon the process of intervention.

Dibs In Search Of Self is that rarest of books, an account by a therapist of every session (and the related consultations with teachers and family) of her contact with a small boy, the titular “Dibs”.

Virginia Axline is the author of Play Therapy, which outlines the application of a Rogerian, client-centred therapy approach to the psychological treatment of children. Play Therapy is heavily illustrated with the usual one paragraph snippets of conversations with clients (including Dibs), but this book describes, one chapter per session, the actions & discussions comprising each session and the therapist’s reflections on her client’s disclosures & her own actions (including her errors).

Dibs In Search Of Self is accessible to any reader and is a fascinating, moving book in its own right. It is, of course, required reading for anyone working with children. Moreover, as an insight into the mind of a therapist as a case progresses, it serves as an illustration not just of Play Therapy, but of sensitive & reflective practice with lessons for any therapist, regardless of their profession or client group. Oh, and it has a happy ending.

Reference

Axline, V (1964) Dibs: Personality Development in Play Therapy. Penguin Books Ltd

A client who I had advised on the control of panic attacks returned a year later to discuss another matter. At the end of the session, he told me that he had found a self-help book on panic attacks and “you know all that stuff you said? Well, it turns out you were right!”

Therapists may be perplexed or dismayed when clients prefer their own information sources to those of the therapist, especially when the other source is one which the therapist may consider disreputable. Therapists may be unaware of the range of resources available to and used by their clients, whilst clients may think their therapist is merely offering their own opinions.

Therapists usually derive their information from peer-reviewed research articles, professional journals, scholarly textbooks and teaching & training by eminent colleagues. This information is then implicitly or explicitly conveyed to clients in therapy sessions and associated handouts & leaflets.

Clients may have great difficulty accessing therapists’ information sources other than via their therapist. Even if aware that they exist, they may be barred from accessing professional journals or unable to afford necessary memberships or subscriptions. Textbooks are usually much more expensive than comparable self-help books, have opaque titles and tend to be jargon-heavy.

Clients usually derive their information from a wider array of sources, many of which may not be accorded much credibility by the therapists. Newspaper articles, magazine features, self-help books and groups & online discussion forums abound. Therapists who are unaware of these sources may be advised by helpful clients, although this assistance may not be welcomed by the therapists.

Secure in the knowledge that their information sources are of superior quality (which may well be a false assumption), therapists may be dismissive of clients’ newspaper-derived knowledge and online tales of others with similar difficulties. Clients may pick up on such condescension and react similarly to their therapist’s sources.

The science fiction writer Theodore Sturgeon, when told that 90% of science fiction had no literary merit, famously replied “90% of everything is crud”. There are many more newspapers than journals, more self help books than textbooks and more online forums than conferences: you can’t read them all, but if you don’t include some in your reading, your clients may keep the 10% that isn’t crud to themselves.

Professional codes of conduct require informed consent to treatment. Clients with cognitive damage or impaired communication pose a major problem for therapists and support workers. Informed consent may be beyond the capabilities of the client and may instead be granted by a relative or guardian.

When the client is obviously distressed, therapists and carers face a dilemma: should they continue with the intervention sanctioned by the guardian or should they suspend, even abandon their intervention?

Clients who lack the capacity for informed consent may still make smaller decisions relating to their care. Two important choices which can be made and communicated by all but the most disabled are a request for you to stop what you are currently doing and a request for you to end the session.

Before beginning work with a client whose communication is impaired or whose capacity is diminished, you should establish how they would convey a request for you to stop and a request for you to leave. If this is unclear or has yet to be established, either agree with the client how they would indicate such desires or consider a Clinical Psychology or Speech & Language Therapy referral.

There will be occasions on which an intervention must proceed regardless of the client’s wishes (as when the client is being treated under a Section of the Mental Health Act or similar legislation). For most therapists, these situations will be few and far between: medication may be required by a treatment order, but the same client may still have a choice as regards physiotherapy or dietetic advice.

Therapists should not assume that clients whose cognitive faculties and communication are unimpaired will be sufficiently assertive as to be able to say “stop” or “I want to leave”: many may have sought referral precisely because they lack such assertiveness.

Unassertive clients can be reassured that their telling you to “stop” or to “go away” is useful to you. No therapist wishes to force clients into discussions or actions for which they are unprepared, and some issues require a great deal of preparation. If you know your client will give you honest feedback—and your client knows they are permitted to do so—you can both relax.

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.