As a fresh graduate or trainee in psychotherapeutic practice, chances are that you have often struggled with the following questions:
Should I tell my client about his/her diagnosis?
What if they freak out after hearing it?
Should I just say “have patience and I’m doing what’s best for you” and keep the findings to myself?
Should I discuss the treatment plan with my client?
Will my client understand the nitty-gritties of the treatment plan?
Do I need to keep having fresh discussions about the illness and the treatment with my client from time to time or in the beginning is enough?
Well, let me tell you these are perfectly valid and “normal” questions. As someone who has been practicing as a Clinical Psychologist and Psychotherapist for almost 13 years, I have experimented with both “not-telling” and “telling” approaches and have myself struggled with similar questions from time to time because EVERY client is different.
So I’ll tell you what you need to do to keep your communication as a clinician, transparent, effective and profitable towards the desired therapeutic outcomes with your client.
Get down from the pedestal. A psychotherapeutic relationship is deeper and more “intimate” than a typical doctor-patient relationship so to gain the trust of your client and build rapport you will have to adopt an “equal-footing” stance. Your client is sitting in front of you hoping you’ll show them a way – not just hand them a prescription of pills. To ensure that they develop the courage to walk on the path you guide them to, they need to trust you. That’s why you need to take them into confidence. Adrienne A Gardner, PhD, an independent practitioner from Greater Atlanta Area, Georgia says, “It’s important to establish and maintain a relationship of honesty and integrity with the client from the very beginning. Take time to explain the process of therapy and incorporate them into it so that they take ownership for their successes and failures in order to achieve their goals while in therapy and beyond.”
Get a hold on your own anxiety. It’s quite commonplace to feel anxious about opening up with a client because sometimes you are not sure whether you’ll be able to articulate what you want to say; you wonder how the client will react; you also wonder if they will get angry or disappointed and not come back. All these doubts require that you remind yourself that this communication is not about YOU but it’s about what is best for the client and for their recovery. If a client does walk away, as a seasoned clinician, you must not take it personally or feel offended. Use it as an opportunity to use a modified approach next time if you can spot certain loopholes.
Jenai Hicks, a registered Mental Health Counselor intern from Florida, seems to have found a way out of this anxiety. She says. “To decrease the possibility of panicking, I seek to normalize the experience by explaining how clinical symptoms are simply common human emotional and mental experiences that have become too intense, severe or exaggerated. I also may use appropriate self-disclosure or share stories about people in my life or even use stories from TV and movies to show how common it is for people to have mental health concerns.”
Let the patient/client be your guide. How much you’ll reveal to the client about their diagnosis and at what stage of your communication, should be decided majorly by taking into account patient characteristics. Attributes such as educational qualification, social status, IQ and EQ levels are all factors that should guide you pretty accurately. Gail Katz is an information specialist in the mental health sector in Bethesda, Maryland and she avers, “Stating this from a client’s point of view: Let them set the pace for disclosure. Some patients may not be helped by knowing anything about their diagnosis or “label.” That information could actually cause a setback. In describing how they feel and observing their behavior over time, they’re giving you the knowledge you need to help them out. I don’t think it’s possible, for example, to know what’s going on for sure until you’ve had several appointments, unless it’s a straight and simple situational issue. Most aren’t.”
Be cautious with the diagnostic label. While sharing and educating the client is important, you must exercise extreme caution while revealing the diagnostic label because people hear these diagnoses thrown around all the time with half-baked information and that leads to a lot of apprehension and stigma. So if you start off by saying that they have “borderline personality disorder”, “bipolar disorder” or even “depression”, you may trigger all those ill-informed misconceptions and then your exercise in communication will end up being counterproductive.
Deborah Brown, licensed professional counsellor from Philadelphia, shared with us, “the treatment plan is theirs to develop, the diagnosis is mine. As we know, diagnosis is an art and some would say it is quite subjective. After working with them to identify treatment goals, they are typically clear on the path ahead. That path is theirs, and I will serve only as a guide. The diagnosis may become clear over time, and shared only when there is sufficient evidence to support that conclusion. The diagnosis is my conclusion drawn from their story, and cannot become a negative label that becomes part of their obstacle. Diagnosis serves only as a source of light shed upon the person’s path that may help them along.” On the same lines, Marvin Evans, a licensed clinical professional counsellor (LCPC) from Chicago states that “I don’t share a diagnosis unless the client asks. Then I explain it’s the nomenclature of the profession and the diagnosis should not be interpreted as another “label” for them to wear. Then we talk about what it means to them to have a name for what appears to be the problem. Interesting stuff often emerges.”
All said and done, sharing is always better. I personally have always found that, no matter what your pace is, or how you decide to dole out the information, DO IT. Use your clinical judgement to determine how much your client can take and when, and then make them your collaborative partner in the treatment process. Here’s some more on what professionals all over the world had to say about this.
“The clinician’s relationship with his/her patient/client is built on effective communication, and these interactions often involve information-sharing about diagnosis and therapy options. The patient has the right to a written treatment plan that should be created together with the therapist. The clinician who can communicate “unwanted news” in a direct and compassionate way, will not only help the patient cope, but will also strengthen the therapeutic relationship, so that it endures and extends the healing process.” – Dr M. Rizwan Khan, Clinical Psychologist, Jacksonville, Florida
“I reveal everything, more or less. I work a lot with people with Borderline Personality Disorder, and they have often been told that they “can’t be fixed” and “it’s all in their heads” not only by laypeople, but by professionals as well. I tell them what their diagnosis means, what the symptoms were that led me to that diagnosis, and what we can do together to move forward. Their treatment goal is based on *their* goals, not mine, often in quotes, such as “I want to get my life back” or “I want to stop sabotaging relationships”, and then objectives are quantifiable and specific, such as “will develop effective communication skills from DBT enough to form two supportive friendships in the next [treatment period].” – Jennifer Liles, Licensed Clinical Social Worker, Kansas City, Missouri
Finally, I think Sandra Hammond, a grief counsellor from Denver sums it up perfectly when she says, “I think the answer like most answers in this industry. is… “it depends”. I believe a better question is not about the client as much as it is about the professional. Is it a part of our chosen career field to be authentic what our purpose of diagnoses is? Is it a part of our professional ethics to be clear on our therapeutic orientation and expertise to evaluate the perspective of which a person’s complaints and/or stories are understood as symptoms then are compared to a set of life-changing (commonly life-limiting) criteria? I think before answering these questions more needs to be known about the environment and the purpose that requires clinical language instead of assuming that it is mandatory.”
Well, now you know, making your client an active participant in the therapeutic journey seems to be the general consensus on the way to go among the best professionals all over the world. What I’d like to tell you is, that yes, you’ll make some mistakes along the way. You may reveal a little more than required sometimes and trigger the patient; you may overcompensate by holding back too much and risking a disconnect with the next one; all this will happen, but every time it happens, trust your instinct as a competent therapist, admit to yourself where you slipped up, and then take steps to repair the therapeutic relationship. It won’t be the end of the world!
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