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Section 12
Therapy Resistance

Question 12 | Test | Table of Contents

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.

Keep Your Sense of Humor
It is funny, as well as tragic, the extent to which some people will go to get attention. What makes clients difficult is how inventive and creative they are in their attempts to control relationships. They live by another set of rules. 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 minute’s work. The doctor then countered that if it would make her feel any better, he would leave the needle in longer.

Do Not Retaliate
Therapy is lost once we have been sucked so far into the trap that we begin entertaining fantasies of how to get even with the client. It is the difficult client’s job to try to upset our equilibrium. It is only business, nothing personal.

It is our job to find a way to absorb or rebuff direct attacks in such a way that we don’t 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.

Define Rules and Roles
Clearly spell out what you are willing to do and not willing to do. Explain the consequences of going outside the boundaries. Enforce the rules calmly and consistently. Do not make exceptions.

Stay Flexible
Although the external boundaries of therapy are fairly sturdy, it is important internally to remain loose. Difficult clients are unpredictable. They come at us from directions that we do not expect. As long as we remind ourselves anything can happen at any time, we are prepared to go with the flow, to counter with a response in an ever-changing situation.

Be Pragmatic
We get into trouble with any client when we persist in continuing with a treatment strategy that is not working. The more difficult the client, the more quickly things will deteriorate if we do not adapt our methods to fit the unique requirements of a given situation.

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.

Use Self-Disclosure Effectively
One of the most useful tools at our disposal is our own reactions to a client’s behavior. This is especially true with those who have trouble trusting people to begin with; the last thing in the world they need is a shell of a person hiding behind a professional role. The therapist’s genuine reactions, when conveyed sensitively and compassionately, can often be turning points for the alliance.

Confront, Confront, Confront
Certain people have discovered the secret for how to irritate the hell out of others and get away with it. They can be obnoxious or insensitive or manipulative or controlling without disastrous consequences to themselves. They know that other people may not like them very much, but the successfully obnoxious client has learned to stop just short of sparking violent retribution.

Our job, then, is to be one of the few people in the client’s 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 don’t like what you are doing, but I realize I need it.”

Be Patient
Seligman reminds us that the most essential rule for treating difficult clients is to remember that therapy can sometimes take a long time. Trust is built only gradually. Because difficult clients struggle with trust issues more than most people, we must often exercise extreme patience until a therapeutic alliance is firmly established.

Decode the Meaning of the Resistance
All forms of resistance are communicating some message to us: “I hurt,” “I’m scared,” or perhaps “I enjoy the power I feel in controlling others.” Once we have figured out the meaning underlying a client’s behavior, we can then find a way to deal with it. Ideally, helping clients to understand what they are doing and what helps them to change their self-defeating behavior.

Be Compassionate
Keep in mind that all the preparation and training in the world will not equip us with every tool we need to handle problematic people. “With difficult patients, more often than not, we have to rely on intuition, on belief, and on professional dedication.”

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.

When All Else Fails
“I am a pretty good therapist, and I have been doing this for a number of years. I have done everything I can think of. I am flat out of ideas. You are probably going to be like this for the rest of your life, unless you can come up with something that you think would be helpful.”

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 client’s 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.

Framo’s 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.

Is 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.

Personal Reflection Exercise #2
The preceding section contained information on rules of engagement. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Update
Understanding Client Engagement
in Digital Mental Health Interventions:
An Investigation of the eTherapy
Attitudes and Process Questionnaire

- Clough, B., Yousif, C., Miles, S., Stillerova, S., Ganapathy, A., & Casey, L. (2022). Understanding client engagement in digital mental health interventions: An investigation of the eTherapy Attitudes and Process Questionnaire. Journal of clinical psychology, 78(9), 1785–1805.

Peer-Reviewed Journal Article References:
Jordan, L. S., Anderson, L. A., & Hall, J. N. (2021). Sowing the seeds: Sociocultural resistance in the psychological sciences. Cultural Diversity and Ethnic Minority Psychology.

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.

QUESTION 12
What are some “rules for engagement” with resistant clients? To select and enter your answer go to Test.

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