The Client as Expert

Mar 07, 2017

“I see the world down there and think, ‘They can have it.’ I have no luck in this world, I have not fitted well with it, and it has answered and repaid my aversion abundantly. But it has not killed me. I still live, I have defied it and held my ground, and if I have not become a successful manufacturer or boxer or movie star, I have become the thing that as a boy of twelve I set myself to be – a poet. And I have learned, among other things, that if one desires nothing of the world and simply observes it quietly and attentively, the world has much to offer of which the world’s successful darlings know nothing.”

Herman Hesse
author of Steppenwolf, Demian, and The Glass
Bead Game

The Client as Expert

TISA Description of the Problem: In order to help our clients, it is necessary that at times we allow them to be our guides. Ultimately no one knows the everyday problems, nuances, and difficulties of our clients better than the people who live them. The most powerful therapeutic bonds occur between clinicians and clients who share in the rich pool of their combined wisdom. The following imminently practical tip provided by Barry Lachman, M.D., MPH provides an avenue for tapping this creative pool.

Tip: Two problems of apparently opposite valence can arise from a single miscommunication between the client and the clinician: 1) a client may think that we do not really understand their lives and their problems or 2) a client may mistakenly overestimate how much we really do understand or know about their current situation. Either misperception can be counter-therapeutic. To short-circuit this potential problem I have found the following approach useful:

“Mrs. Jones I am very reliant on you to help me understand exactly what is going on. So each time we meet I will be tapping your experience to help me understand better what plans to suggest. If you think about it, I hear about your problems for about 15 minutes in a day. You live with these problems the other 23 hours and 45 minutes of that day. And then I only see you once every two weeks. Obviously you are the expert here on what is happening and I have some real expertise on solving problems, together we can make a great team.”

TISA Follow-up: I really like the above tip from Barry. It helps set the stage for a collaborative relationship. I find this type of approach useful in many different aspects of clinical work from psychotherapy to improving medication interest. For instance when doing homework assignments in CBT, if the client seems to be having problems completing the work, a nonjudgmental comment can be useful for transforming a roadblock, such as, “Jim it looks like it has been a little difficult to complete the work. It can be hard to get this type of work done. Share with me a bit what are some of the difficulties for you in getting the homework completed, only you know what’s going on at home and perhaps we’ve chosen some assignments that are too inconvenient or perhaps we will both decide that this approach is not a particularly useful one for you.”

Likewise, when patients have trouble with taking medications as prescribed, there are often very good reasons related to the timing of the medication and other extenuating circumstances as home. Only the patient is the expert here, and this is also true with side-effects. In this light I often find it useful to make comments such as, “When it comes to side-effects, Mr. Jones, you are obviously the expert here. You are taking the medication not me, and I am entirely dependent upon your input as to what it is like for you to take this medication from the improvements it brings to its possible side effects. So please feel free to let me know what is going on and always be sure to share any concerns or worries you may have about side-effects. We will make a great team that way. And I have really good feelings that this medication may help you a lot.”

Tip provided by:

Barry Lachman , M.D., MPH
Parkland Community Health Plan
Dallas, Texas