Continual improvement in therapy is the exception, not the rule. Stalls and deterioration may indicate a problem with the client, therapist or both, but may also be a sign of progress onto dealing with greater difficulties masked by the initial problem.
The impression given by many textbooks is that improvement is gradual and continous. Clients progress smoothly from one treatment goal to the next until all issues have been resolved and they can be discharged from your caseload.
Many therapists experience a sinking feeling when a client who had been making progress reports no change (or worse, a deterioration) in mood or function (or both).
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Having too many goals can be as bad as having no goals. This is as true for therapists as for our clients, yet therapists may enter into a session with far too many goals to achieve in one sitting.
Trainees often struggle with first appointments, in which there is so much to do: establish a rapport, take a history, establish a diagnosis or formulation and agree a treatment plan. These would be the achievements of two, three or even more sessions but the impression given by many text books is that all of this must take place in the first session.
More experienced staff may feel the same pressures, but may also feel obliged by waiting lists and the need to demonstrate turnover to look for opportunities to discharge the case. Some may also feel that they must be on their guard against potential attempts at manipulation by the client.
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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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“Manipulative†clients may be reacting to overly controlling therapists. Before using such a destructive label, it is worth asking why someone would need to manipulate their therapist if they have agreed common goals.
“Manipulative†is one of a therapist’s most damning criticisms. While not as bad as “malingering†or “personality disorderedâ€, both of which have their place in formal diagnoses, the label has similar power to influence the client’s future treatment as it implies that there is something bad about the client’s behaviour or the client themselves.
“Manipulative†is defined as “tending to control or influence others cleverly or unscrupulouslyâ€. “Unscrupulously†is, in turn, defined as neither honestly nor fairly. The stereotypical manipulative client is one who misrepresents their symptoms to obtain extra medication for abuse or resale, or who exaggerates their symptoms or situation in order to obtain financial benefits they don’t deserve.
Some clients will be deemed “manipulative†when they give different accounts or responses to different professionals. I have observed therapists respond to a client sympathetically or supportively in the session, then speak critically or dismissively of the same client in supervision or at a multidisciplinary meeting.
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Writing only when you are speaking maintains normal eye contact. This serves to normalise the interaction, reassures the client that they have your attention and that you are writing what they are saying.
Writing while the other person is speaking reverses the normal pattern of eye contact.
Anyone who has had a medical appointment will know the unease associated with describing your symptoms to the top of your doctor’s head. They write feverishly while you speak, only meeting your gaze to ask a question, then dive back into their notes again as you begin your answer. All the while you’re asking yourself: what is it that they’re writing about me?
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A seventy year old sales manual is not an obvious first choice for a therapist’s bookshelf, but this is no ordinary sales manual. How to Win Friends & Influence People offers ways to make people like you, win people to your way of thinking & change people without giving offence or arousing resentment, achievements as useful to therapists and our clients as to salespeople.
Written in 1936 by Dale Carnegie, a public speaking coach, the book summarises twenty years of training courses and advice for salespeople and their managers. The language of the book is very much of its time, as are the examples Carnegie uses to illustrate his points (you will learn more about US presidents and 1930’s gangsters than you ever wanted to know!), but the core messages are timeless.
Carnegie argues that successful outcomes arise from positive relationships, much as Carl Rogers (father of counselling) believed that unconditional positive regard for the client was an essential part of effective therapy.
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