difficult clients involves much more than adopting a particular set of attitudes
or establishing an effective alliance; it requires intervening, sometimes quite
forcefully, to stop a clients self-defeating patterns and to help channel
energies in more constructive directions. The particular nature of these action
strategies, whether variations of providing structure, using cognitive interventions,
setting limits, or employing paradoxical techniques, is probably less important
than the practitioners willingness to equip himself with a variety of therapeutic
options he can draw on as the situation requires.
section is not meant to be a comprehensive compilation of all the action-oriented
interventions that are at the therapists disposal as much as a sampling
of the most common possibilities. So often with difficult clients we are unable
to apply standard strategies that have proved effective before; we
are usually required to modify and adapt interventions to the unique requirements
of a case.
Ethics - Balancing
Your Power with Cognitive Interventions
At the heart of most forms of resistance
is some underlying thought disorder in which the client distorts reality and applies
erroneous, illogical, irrational, or self-contradictory reasoning processes. This
conception of client difficulty falls within the province of cognitive therapists
but most practitioners also find it helpful to hone in on what clients are thinking
and processing that leads them to interpret and respond to the world the way they
Once clients, even very difficult clients, are helped to realize
that their absolutist thinking is a gross distortion of reality, that the shoulds,
musts, and other dogmatic demands that are part of their vocabulary
are actually setting them up for failure, the stage is set for considering alternative
ways to look at their situation.
greater patience and repetition is needed to reach clients with severe disturbances
and thought disorders, they can often be led to understand that the following
statements apply to them. As you read through the following list, ask yourself
how you might accomplish a balance in the power dynamic with one of your resistant
clients when approaching them with these ideas:
You are the one creating
the obstacles to getting what you want; it is not being done to you by others.
Just because you are not progressing as fast as you would like does not mean you
will not eventually reach your goals.
Pain and discomfort accompany
any growth; there is no sense in complaining about it because that will not make
it go away.
Setbacks are an inevitable part of life and simply signal
that you need time to gather your momentum.
Just because you are struggling
in these few areas of your life does not make you a complete loser and failure.
You have the capacity to stop making things difficult for yourself and others
when you decide to think differently about your situation and your life.
Ethics - Cognitive
methods In spite of claims by Ellis and others who argue that cognitive
methods are successful in countering the resistant behavior of borderline personalities
and even psychotic individuals, I would suggest that these methods are probably
even more helpful when we use them with ourselves. One of the hallmarks of the
cognitive therapist is supposed to be that he practices what he preaches. As almost
any therapeutic impasse involves some contribution by the clinician, it is often
necessary for us to challenge our own belief system to understand what is occurring.
There are thus parallel processes operating simultaneously: on the one hand we
are identifying those counterproductive beliefs that the client is using to sabotage
progress; on the other we are confronting ourselves to let go our own irrational
demands. These usually take the form of unrealistic expectations we hold for our
own behavior or for that of the client, standards of perfection that can never
Psychodynamic Perspective on Therapeutic Boundaires:
Creative Clinical Possibilities
- Bridges, N. A. (1999). Psychodynamic perspective on therapeutic boundaries: Creative clinical possibilities. J Psychother Pract Res., 8(4). p. 292-300. The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #9
The preceding section contained information on practical
strategies for resolving impasses. Write three case study examples regarding how
you might use the content of this section of the Manual in your practice.
Ethics CEU QUESTION
23 What is an example of a forceful cognitive intervention to use with
a clients self-defeating patterns, if used correctly will not violate the
balance of power? To select and enter your answer go to Ethics CE Test.
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