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Fun indeed! If we might distill the essence of what experts have been saying about the most important operating principles when working with difficult clients, most of them would have to do with fun. This is the first of several rules of engagement.
Your Sense of Humor
It sometimes helps us to keep things in perspective when we realize the absurdity of what we are witnessing: a client who is trying to bait us by testing what she can get away with, another who saves the best stuff for the last five minutes of every session, or still another who weeps uncontrollably every time we get close to something important.
In a survey of how therapists cope with stress induced by working with difficult clients, one of the most adaptive strategies relied on was optimistic perseverance tempered by an appreciation for humor. Siegel tells the story of an obnoxious patient who was giving her doctor a particularly hard time over the cost of every procedure he suggested.
When he recommended a cortisone injection in her knee to relieve arthritic pain, she asked how much that would cost. As a courtesy, he replied that he would charge her half his usual fee of $10, to which she became outraged that he would charge so much for less than a minutes work. The doctor then countered that if it would make her feel any better, he would leave the needle in longer.
It is our job to find a way to absorb or rebuff direct attacks in such a way that we dont suffer emotional injury and the client learns that such conduct is unacceptable, and ultimately self-destructive.
When the situation calls for firmness, it is important that we enforce necessary limits without losing our compassion and without becoming punitive. Favored ways that we are prone to retaliate when we feel hurt or angry include withdrawal, emotional spankings inflicted under the guise of confrontation, ridicule masked as dry wit, or more direct forms of aggression: calling the client names or even firing him in anger.
Rules and Roles
Take inventory of everything that has already been tried with the client and has not worked: Do not do any of those things any more. Do something else. Again. And again. Until you find the right combination of factors that make a difference.
Sometimes the therapeutic alliance itself will provide sufficient leverage to keep the client in line. Other times you will need to keep matters more behaviorally focused or more cognitively centered or more affectively oriented. Eventually, with sufficient time and patience, we usually find the key to eliciting greater cooperation.
Our job, then, is to be one of the few people in the clients world from whom she will tolerate honest confrontation without running away. If we are to be helpful at all, we must have license to tell clients they are out of line without fear that they will flee. This practice works only when clients are sure that we are confronting them with love and concern rather than anger and hostility. The ones who do leave are not good candidates for change to begin with; if they stick around, they are saying by their behavior, I dont like what you are doing, but I realize I need it.
the Meaning of the Resistance
It is interesting that the quote above is not from a therapist but from a dentist who is describing what is necessary to handle unpleasant patients. Yet, in whatever setting a helper practices, he will encounter rude and demanding consumers who require even more than the usual dose of kindness, compassion, and understanding in order to feel cared for.
All Else Fails
After this startling speech, LoPiccolo then demonstrates what he believes is a crucial skill for clinicians: to let go when there is nothing else that can be done. There comes a time, after we have tried everything we can think of and consulted every resource that is available, that we have no choice (other than to drive ourselves crazy with feelings of inadequacy) but to put the ball back in the clients court: OK, you win. Collect your prize. You get to stay the way you are. So now what do you want to do next?
Framo notes that when he was young and idealistic, he zealously took on the challenge of any case who walked in the door; he reluctantly admits now that there are some clients, and some families, who are so difficult to work with that they defy treatment by almost any expert on earth. Their feelings of entitlement can drive even the most experienced and patient practitioner to lash out in frustration.
Framos best advice when encountering such cases is to give up the fantasy of omnipotence, the belief that you can reach anyone all the time. There are some people whom no therapist alive can help. And there are some who are simply beyond what you can do.
I find this to be wonderful advice indeed! The only problem is that I have an awful time following it. My fear is that if I regularly accept my limitations and give up my sense of omnipotence, I also sacrifice a potent weapon that has, on occasion, served my work well.
My stubborn reluctance to give up, to let go of seemingly hopeless cases, has on (admittedly) rare occasions produced miraculous results. Granted, the success rate is probably one in a hundred, and that means ninety-nine times I feel thwarted and frustrated. Yet, I think it is a price worth paying to help that one client who seemed so hopeless.
this a neurotic flaw in me? Most definitely. Would I enjoy my work more and stretch
out my career if I eased up a bit? I am working on it. But in the meantime, until
I can let go of hopeless cases, I am stretching myself in ways I never could imagine,
challenging myself to discover new ways to work with difficult clients.
Peer-Reviewed Journal Article References:
Schwartz, R. A., Chambless, D. L., Milrod, B., & Barber, J. P. (2021). Patient, therapist, and relational antecedents of hostile resistance in cognitive–behavioral therapy for panic disorder: A qualitative investigation. Psychotherapy, 58(2), 230–241.
Urmanche, A. A., Oliveira, J. T., Gonçalves, M. M., Eubanks, C. F., & Muran, J. C. (2019). Ambivalence, resistance, and alliance ruptures in psychotherapy: It’s complicated. Psychoanalytic Psychology, 36(2), 139–147.
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