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One therapist, a veteran of two decades in the trenches, was heard to say to her colleagues who had been commiserating about their caseloads over coffee:
Ive cut my practice down to five clients. And I hate them all.
Everybody laughed uproariously.
However, embarrassed some of us are about our genuine feelings, it is a reality of professional practice that we hate some of our clients. They do not pay us enough to put up with the obstacles they run us through, the games they play with our heads, the obstructive, vindictive, manipulative ploys that we inadvertently find ourselves caught up in. I suppose, if we thought about it, we would have to be crazy not to dislike someone who places additional and unnecessary burdens on our lives and who evokes fear, aversion, guilt, and inadequacy in us because of his or her ability and interest in being dependent, self-destructive, and controlling.
This perspective on difficult clients views them more as a function of the therapists frustration tolerance than of their own behavior. Even Freud was said to have become so irritated on occasion with his more resistant clients that he would kick the couch they were lying on.
When we reach the limits of what we know or can do, when we feel confused or blocked by a situation that is beyond our understanding or abilities, an easy way out is to blame the client. Looked at structurally, difficult clients are not problems in themselves but are more often problems for others, especially the therapist. It is, therefore, crucial when we attempt to unravel the dynamics of what is going on with an especially challenging case that we look first to ourselves and to what we may be doing to make clients difficult.
Ethics - Encouraging
Clients to Be Difficult
It is true that therapists who feel depleted, who have lost their passion and excitement for their work, and who are tired, bored, and indifferent to what they are doing are going to encounter more clients who appear uncooperative and resistant than are those practitioners who truly love doing therapy. The depleted therapist views certain behaviors as annoying while the energized practitioner sees them as challenging. The former calls uncooperative clients a pain in the ass whereas the latter resonates with their pain. The burned-out clinician is impatient, frustrated, and overly demanding that clients do exactly what he expects. Any deviations from the program are labeled resistant and are dealt with accordingly.
Often the depleted therapist is actually the one who helps launch the client in a career of being difficult. Caroline walks in feeling hurt, rejected, and abused by her ex-husband. She longs for understanding, even attention from someone, especially a man. She is needy and vulnerable, and this condition becomes immediately evident as she attempts to engage her therapist in some personal interaction. She desperately wants him to see her as a person, not as an object, a client who is just paying money for his time.
The therapist is exquisitely sensitive to Carolines neediness, or to anyones for that matter. He is making child support payments that are more than he can afford. He is seeing many more clients than he feels comfortable with, but he needs the extra money. Everyone seems to want a piece of himhis ex-wife, his children, and the thirty-some clients whom he has begun to fantasize as leeches clinging to his body, draining his life blood. And then Caroline walks in.
The therapist puts on a mask of compassion, pretending to care. His disdain and revulsion for this dependent woman, another leech, inadvertently seep through. Caroline can sense that he does not like her; she has vast experience reading men who act as though they care about her but only tolerate her presence.
And here is another one. I cant believe Im paying this jerk, and he still doesnt have the courtesy to be considerate. Look at him, trying not to yawn. This is humiliating. Who the hell does he think he is?
Caroline tries harder to win her therapists approval. As she becomes even more contrite, deferential, and clinging, the therapist withdraws further.
Why do these people find ME? Look at herhanging on every word I say. I suppose I should confront this dependency stuff, or she will never let go.
He does so. Caroline explodes. For the first time in her life, she tells somebody, a male somebody, to go screw himself. She storms out of the office in tears.
The therapist shakes his head. He cant wait to tell a colleague about this latest wacko. He wonders why they always end up on his doorstep.
Two years pass before Caroline builds the confidence to see another therapist. This time it is a woman. But before Caroline even begins, she lets the new therapist know her terms and expectations. The therapist sighs to herself: Another difficult client.
Contrast, for example, how two therapists might offer different responses to the following client statement:
Im not sure that I am ready to get into that yet.
Provocative intervention. Although we cannot necessarily conclude that one response is more effective than the other, it seems clear that the more provocative intervention of Therapist A is likely to spark entrenched resistance in the client. As so often occurs, we become the catalyst for creating monsters of our clients by not respecting their pace or needs at a given moment in time. We may feel as though we are only trying to be helpful, but the clients feel that we are trying to nail them to the wall. The only possible responses a client can make to such a perceived attack are a strategic withdrawal, an unrestrained retreat, or a vehement counterattack.
In the strategic withdrawal, clients tell themselves that therapy is apparently not a very safe place. They begin to feel that any vulnerability they expose will be exploited, any weakness they show will be jumped on. They fail to see that we are only trying to identify their self-defeating behaviors and increase their awareness of their dysfunctional patterns. Instead, they devise ways to get through the sessions without sustaining too much damage. They throw up a smoke screen to cover their retreat, using rambling, distractions, overcompliance, anything to buy enough time to bow out without getting shot in the back.
An unrestrained retreat is a considerably more direct response to perceived attack: Goodbye. Im not coming back. But I will be sure to call you when I am ready. The message is clear that therapy does not feel safe to the client, and it is time to leave the scene.
The vehement counterattack may actually be the healthiest response of all, even if the therapist must expend considerable trouble to neutralize it. The client feels hurt, rejected, and belittled; like most wounded creatures, he or she is a formidable foe when cornered. Either as a reflex action or a deliberate choice to do battle, the wounded client begins a war of attrition. He or she has now determined that we are, indeed, like other sadistic authorities who have wielded unrestrained power in the past. But since we are being paid to be helpful, we are certainly fair game from whom the client will exact retribution. Payback is a bitch.
Difficult clients threaten us in ways we would prefer to ignore and avoid. They challenge our expertise (Im too perceptive for him, and he just cant handle it). They test our patience (She just doesnt seem to have the motivation it takes to get anything out of therapy). They threaten our very sense of competence as professionals (Who is HE to talk about being a fraud?). It is for these very reasons that we prefer to keep potential failures at a distance, disown them whenever possible, and blame the client as being difficult whenever we feel threatened.
Ethics - Making
This idealism, unrealistic expectations, and search for perfectionism lead the therapist to experience much disappointment. Clients are not sufficiently grateful for all the effort that has been expended on them. They fail to live up to the therapists expectations for where they should be. Further, the therapist feels disappointed in his or her own performance when a client is not cooperating: I must be doing something wrong. If only I were more skilled/intelligent/creative, surely I could solve this problem.
His analysis of resistance in therapy led Ellis to believe that the most difficult client of all is the therapist, especially when he or she stubbornly holds onto beliefs such as the following:
I must be successful with all my clients all the time.
These internal assumptions operate in those therapists who are most prone to the deleterious effects of working with difficult clients. Such clinicians assume too much responsibility for therapy outcomes, believing they are at fault when the clients problems are not resolved positively. One successful defense against the temptation to accept responsibility for negative results is to take the opposite tack: blame the client for being difficult.
Therapists excuses. Therapists generally make two types of excuses to account for the clients obstructiveness: one is the tendency for the therapist to be a perfectionist and to blame herself when therapy does not proceed according to plan. The second is to be defensive and disown any responsibility for negative outcomes. These extreme points of view are shown below by a description of the internal dialogue of the Perfectionistic Therapist and the Defensive Therapist in response to several difficult client behaviors.
Client: Im sorry I missed my last appointment.
Client: I really dont appreciate what you just said.
Client: I think one day Ill just decide to kill myself.
Client: Youre a fraud. You just sit there each week pretending you know what youre
doing, but you dont have any earthly idea how to help me.
Client: I dont know how I will survive when you go on vacation.
Client: Ive decided not to come back.
At the heart of any answers we might formulate in response to the client statements listed above are our own inclinations toward being perfectionistic or defensive. Our core issues remain ever-sensitive to the buttons that are triggered by work in sessions every day. The more difficult and challenging the client, the more we must resort to our own self-protective defenses.
between these two perspectives is a position that allows us to be realistic about
what we can and cannot do. On the one hand, it is important not to fall victim
to the clients attempts to draw us into a dysfunctional system; maintaining
emotional distance is helpful in this regard, as is having reasonable expectations
for our clients and ourselves. Yet, hiding behind a thick mask of clinical detachment
is ultimately not useful, either. It makes us appear withholding and cold to people
who so strongly crave a little caring and cuts us off from our personal issues
that are ignited by therapeutic interactions. If we are not willing to admit the
extent to which we are affected by certain kinds of clients and incidents, we
can never attempt to loosen their stranglehold.
Cooperative Case Management Working with Challenging Client
- ISED Solutions. (2012). Cooperative Case Management Working with Challenging Clients. U.S. Department of Health & Human Services.
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