I have always thought of myself as the kind of psychologist who offers a safe space for a patient to walk in, unload all that is bothering them out onto my carpet, and leave without a thought for me to clean up. Sometimes they continue to carry pieces with them, but with each additional session, we are able to get to the core of the issue together.

I am sure all of us would love to have a caseload of clients who come in on time, ready to work on their issues, make progress at a steady pace, and pay on time (preferably in cash!). Unfortunately, this is, for most of us, not a fact of life.

Therapy is much more challenging with coerced, reluctant, or difficult clients. These are typically clients who are not necessarily ready to make a change in their life, but have been forced to do so by the court system, the child welfare system, or their spouse or significant other. We deal with Axis II patients, angry parents who are in the middle of a divorce, and patients who will not pay.

When a client like this enters our offices, we find ourselves cautious, perhaps even afraid or avoidant of approaching issues for fear of the client’s reaction. And to top it off, there are also ethical, legal, clinical, and risk-management choices when making decisions about how to work with difficult clients. But difficult patients need access to therapy too. This article will include advice on how to work with challenging clients and tips for taking care of yourself while doing so.

1. Determine the Client’s Stage of Readiness

If we look at the stages that Prochaska and Norcross (2001) suggest occur in therapy, we could put difficult clients into the precontemplation stage; these clients likely do not have any intention of changing in the foreseeable future.

Therefore, the therapy needs to be less about making change with the client and more about moving them to the contemplation level of Prochaska and Norcross’s (2001) six stages of readiness for change.

2. Give the Client Choices

Note any therapeutic possibilities to the patient.

Describe the choices of direction the therapy might take.

This gives the client the chance to make an informed decision, and engages them in the process. Make sure to give directed feedback in the here and now so that the client learns about their dynamics.

3. Establish a Set of Rules

Work with the client initially to establish a set of rules as part of the treatment plan.

Do you mind if they yell, or are your walls thin and neighbors sensitive? Talk about this with the client, and then write it down. “I will not raise my voice, and if I do, my therapist will remind me once to lower my voice, and if I do not comply, may end the session.”

There is to be no physical violence in your office at any time. The client can take a “time-out” of the session and leave to walk around outside if they feel themselves getting angry, but should come back in prior to the end of session for closure.

4. Focus on Client Strengths

Focus on the strengths the client already has, because identifying and increasing these strengths will decrease depression and increase attachment and optimism.

5. Don’t Ask “Why”

Try not to ask questions that start with “Why?”

Have you ever been bombarded by an acquaintance at a party with a plethora of questions, most of which start with “Why”? It automatically puts one on the defensive, and the next thing you know, you’re faking a sudden flu and trying to get out of that party as fast as you can.

Imagine how it feels to the patient who enters your office not of their own volition. They have to meet with a stranger when they do not particularly want to, tell this stranger all the reasons why they are supposed to be in this office, and answer what must feel like a barrage of questions that are not pertinent to their presenting problem. This type of therapy would lead the client to be automatically defensive, and this creates a rift in the therapy from the beginning.

Brodsky (2011) suggests that instead of asking questions, therapists make statements based on knowledge. A therapist usually knows how the client is feeling, or what brought them to therapy (with this population) and saying so can shortcut frustration. Articulate observations and transactions. A therapist can put what they are observing in the session into words, or what they observe about the emotional quality of the exchanges between themselves and the client.

6. Pay Attention to Patient Behavior

Remember that the microcosm is the macrocosm. How they behave with you in the therapy room is likely how they work among the general population in their every-day lives.

This means you do not necessarily have to focus specifically on the outside presenting problem, but can focus on the here and now of the relationship, and determine what those interactions say about the patient. “Jimmy, I notice that you tend to talk very quickly and raise your voice when I talk about your boss, and this makes me feel as if you are angry about what is happening in the session or with me. Do you get this type of feedback from other people in your life? Is this something you have felt before?”

By recognizing that there are challenges within the therapeutic relationship, and, yes, using some neutral self-disclosure, the client may begin to shift their thoughts to how they get along with others, and if it is similar.

7. Provide Alternative Constructs

Help the client to develop less limited constructs within their lives. They may have adjustment difficulties, such as behavioral conflicts or law-breaking behaviors, for which they have no other response.

Providing them with other constructs that are effective, such as assertiveness versus anger, gives the client more options. The client does not feel as defensive when this is occurring because you are not trying to take away their problem behavior, but rather providing them with additional ways to deal with life challenges.

8. Be Aware of Client Questions

Pay attention when a client starts asking a lot of questions, as it may be they are attempting to move attention and focus away from their own behaviors, or it may be diagnostic in that the client has a general inability to focus or maintains an overall pattern of avoidance.

Causal questions, questions about when they will get better, and self-serving questions all may be attempts by the client to shift responsibility onto you, the system, or others.

9. Be Aware of Your Own Beliefs During Treatment

Be aware of what emotional and individual beliefs you bring to treatment.

These beliefs may become self-fulfilling, and the treatment may fail. Your individual belief system may be setting the client up, and difficult clients can tell if your empathy is phony from a mile away.

10. Practice Self-Care

Finally, practice self-care in order to ensure that you return to work each day invigorated and ready to do your best work.

Having a strong social network is a very positive way to protect yourself. People to consult with, people with whom you can seek supervision, engaging in hobbies, reading, gardening, and exercising are all ways to ensure you are able to separate your work life from your home life.

In Conclusion

Listening respectfully to your client, ensuring informed consent, and involving the clients in all aspects of their treatment planning will go a long way toward building rapport and turning that difficult client into someone with whom you are able to make great strides.

One final thing to remember: regardless of how good of a therapist we believe we are, we will not be able to help everyone who walks into our office. It is okay to refer out to someone whom we believe will be a better match. Doing so will ensure your sanity and keep you practicing within your area of expertise.

 

References:
Brodsky, S. (2011). Therapy with Coerced and Reluctant Clients. American Psychological Association: Washington, DC.
Prochaska, J.O. & Norcross, J.C. (2001). Stages of Change. Psychotherapy, 38(4), 443-448.

 

 

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Michelle Yep-Martin, PsyD

Dr. Michelle Yep-Martin is a psychologist and Approved Provider and Supervisor for the assessment and treatment of sexual offenders. She currently works with the State of Alaska Department of Corrections providing group and individual services to male and female sexual offenders.She also works with the Department of Juvenile Justice working with juveniles who have been adjudicated of sexual offenses.Dr. Yep-Martin works in the community and with incarcerated offenders, in conjunction with probation officers and other community resources, providing management and treatment.She has published Female Sexual Offenders: Current Treatment, Relational Aspects of Offense Styles, and the Effect of Therapeutic Alliance.Dr. Yep-Martin is a consultant for Saybrook University, and is an expert witness for the Alaska State Court System.She also works with those who are not adjudicated, working with depression, anxiety, obesity, couples and families.