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Section 29
Pressure in the Therapeutic Relationship

Question 29 | Test | Table of Contents

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:

“I’ve 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 therapist’s 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.

Encouraging Clients to Be Difficult
“At about the time I decided to quit doing therapy and go into business, I noticed all my clients seemed to be difficult.” So spoke a burned-out professional.

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 Caroline’s neediness, or to anyone’s 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 him—his 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 can’t believe I’m paying this jerk, and he still doesn’t 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 therapist’s approval. As she becomes even more contrite, deferential, and clinging, the therapist withdraws further.

‘Why do these people find ME? Look at her—hanging 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 can’t 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.”

Feeling Threatened
Clients’ negative responses to therapy are not necessarily results of their resistance or tendency to be difficult. Often they are defending themselves against perceived attacks by clinicians who have been insensitive or clumsy in their interpretation or confrontation.

Contrast, for example, how two therapists might offer different responses to the following client statement:

Client: I’m not sure that I am ready to get into that yet.
Therapist A: I notice you seem very defensive when I probe in that area.
Therapist B: You’re not sure that you can trust me yet, and I can understand how you would prefer to wait until we get to know each other a little better.

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. I’m 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 (I’m too perceptive for him, and he just can’t handle it”). They test our patience (“She just doesn’t 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.

Making Excuses
Certain qualities predispose a therapist to encounter more than his or her fair share of difficult clients. Smith and Steindler believe that clinicians who are most vulnerable are those who have developed “therapeutic zeal”— “a kind of misguided conviction that they must provide treatment, literally, at all costs.”

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 therapist’s 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.”
• “When things don’t progress in therapy the way I believe they should, it’s because of my essential incompetence.”
• “My clients must cooperate with me at all times and love and appreciate everything I do for them.”
• “Therapy should flow smoothly and easily, and I should enjoy every minute of it.”

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 client’s 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 client’s 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: I’m sorry I missed my last appointment.

Perfectionistic Therapist: If only I could be more engaging and firmer in setting limits, this kind of thing wouldn’t happen to me.
Defensive Therapist: I’m obviously getting close to something that the client cannot handle.

Client: I really don’t appreciate what you just said.

Perfectionistic Therapist: Oops. I really blew that one. Why can’t I be more patient? I can’t seem to find the right way to get through.
Defensive Therapist: He’s just trying to distract me from the point I made. Boy, has he got a thin skin!

Client: I think one day I’ll just decide to kill myself.

Perfectionistic Therapist: After all this time I still haven’t been able to reach him. There must be something else I can do.
Defensive Therapist: Hey, that’s his choice. If that is what he decides to do, I can’t do much to prevent it.

Client: You’re a fraud. You just sit there each week pretending you know what you’re doing, but you don’t have any earthly idea how to help me.

Perfectionistic Therapist: Got me.
Defensive Therapist: It’s not MY job to fix his problem. He is just angry, because I’m so calm and composed when things get a little bumpy.

Client: I don’t know how I will survive when you go on vacation.

Perfectionistic Therapist: Maybe I shouldn’t be away so long. I seemed to have allowed too much dependency to develop, and now I’m cutting him off abruptly.
Defensive Therapist: He is just playing mind games with me. He will do just fine. And if he has a hard time with me away, it will be a good lesson for him not to become so dependent on me in the future.

Client: I’ve decided not to come back.

Perfectionistic Therapist: Where did I fail? I thought I did everything right. Yet, here is another one I lost because I just can’t adapt quickly enough. Maybe if I offered to lower my fee...
Defensive Therapist: It’s probably for the best. She is just not ready to change. Now, who can I put into that time slot?

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.

Centered 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 client’s 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.

- Kottler, J. A. (1992). When Therapists Sabotage Themselves. In Compassionate therapy: Working with difficult clients (pp. 52-59). San Francisco, CA: Jossey-Bass.

Cooperative Case Management Working with Challenging Client

- ISED Solutions. (2012). Cooperative Case Management Working with Challenging Clients. U.S. Department of Health & Human Services.

Personal Reflection Exercise #8
The preceding section contained information on when therapists hate the client. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Update
Exploring the Therapeutic Relationship
through the Reflective Practice
of Nurses in Acute Mental Health
Units: A Qualitative Study

- Tolosa-Merlos, D., Moreno-Poyato, A. R., González-Palau, F., Pérez-Toribio, A., Casanova-Garrigós, G., Delgado-Hito, P., & MiRTCIME.CAT Working Group (2023). Exploring the therapeutic relationship through the reflective practice of nurses in acute mental health units: A qualitative study. Journal of clinical nursing, 32(1-2), 253–263.

Peer-Reviewed Journal Article References:
Hiefner, A. R., & Woods, S. B. (2019). Implementing integrated behavioral health: Testing associations between shared clinical time and space and provider referrals. Families, Systems, & Health, 37(3), 206–211. 

Muran, J. C., & Eubanks, C. F. (2020). Introduction: Pressure in the therapeutic relationship. In J. C. Muran & C. F. Eubanks, Therapist performance under pressure: Negotiating emotion, difference, and rupture (pp. 3–12). American Psychological Association.

Muran, J. C., & Eubanks, C. F. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.

Ruiz, S., & Kubina, R. M., Jr. (2017). Impact of trial-based functional analysis on challenging behavior and training: A review of the literature. Behavior Analysis: Research and Practice, 17(4), 347–356.

QUESTION 29
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, what is an easy way out? To select and enter your answer go to Test.

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