Disclaimer: This article was created to guide mental health practitioners in dealing with client’s characteristics that act as barriers to successful therapeutic outcomes. This article is free of judgment and discriminatory intentions.
As therapists, our primary mission is to guide our clients into achieving treatment goals, and the only way to attain this is through “progress”. When we do not see progress, we automatically take things personally. We fear that we are not doing a good job with our client. From this fear, doubt and frustration start to creep in, and this can detrimentally lead to burnout.
While various factors lead to a therapist’s burnout, a common one includes the (unintentional) difficulties that the clients bring to the session. Nonetheless, after you read this blog, perform a self-check. Separate your personal bias from your client and question whether the problem is with you or with your client. Assess for countertransference, over-reactions, and any emotional judgments about the situation you are going through with your client.
5 TYPES OF DIFFICULT CLIENTS:
1. SUICIDAL CLIENTS:
There is an undeniable taboo about this topic due to differences in cultural/religious beliefs and societal/moral norms. Moreover, in the therapist role, the suicidality talk causes great stress, for every conversation about suicide risk must be taken seriously. As therapists, we have legal, ethical, and moral obligations that we must obey. Therefore, failing to assess suicidality in our clients can be a lethal error. This phenomenon can induce significant stress and tension to us clinicians.
WHAT TO DO: According to research, talking to clients about suicide does NOT increase the risk for suicide; in fact, asking about suicidal thoughts can actually decrease the overall weight and severity of the thoughts. That being said, it is safe for you to let go of the stigma surrounding this topic. If your client is at risk of suicidality, you must conduct a risk assessment in every session and document it. You must create a safety plan and contract with your client. Continue to address this topic until your client stops showing signs of any foreseeable harm.
2. NON-COMPLIANT OR SELF-SABOTAGING CLIENTS:
These clients are known for being “resistant to treatment”. There are a couple of patterns you should keep in mind to spot on such occurrences efficiently. Many times, clients that are non-compliant or self-sabotaging seem to be the perfect client in session, but once they walk outside the door, they go back to their maladaptive habits as they fail to apply the principles discussed in therapy. Alternatively, these are the clients that are constantly “running late” and “needing to reschedule”. They are also known for avoiding deep (relevant) topics. Another important particularity of this group of clients is that their defense mechanisms are sturdy and almost shatterproof. They are experts at intellectualizing, rationalizing, changing topics, and surfing through the sessions.
WHAT TO DO: As therapists, we feel responsible for the client’s lack of progress. We end up overworking ourselves, which often leads to burnout and frustration. When indeed, this is the time to put the breaks on and practice “patience, unconditional positive regard, and acceptance”. You have to meet your client at baseline and step up at the client’s rate. If you are pushing while your client is pulling, or vice versa, you are not moving (Physics 101). Whatever opposite force you expel on your client, will fuel their resistance and leave you drained. What helps is to take a step back; walk behind your client, not in front. Imagine you are their shadow, instead of the light that guides the session. Keep up with them; follow their lead. That way, the resistance will no longer be an existing factor in the room. Once the resistance dissolves, you and your client will face the core issue. Perhaps the problem is not what it looks like on the surface, but there is a hidden meaning that your client feels the need to cover up (consciously or subconsciously) with the mask of resistance. Allow your client to lead the way. Remember, your client’s behavior in session is who they are or have been for a long time, you cannot expect that to change that in a few sessions. The “real work” will take off once your client decides.
3. INACTIVE, UNINVOLVED CLIENTS:
These clients are also resistant to treatment but have a particular characteristic: They are going to therapy against their will. Many times, clients that are inactive or uninvolved in their treatment are involuntary clients or court-order clients. There is no doubt your client does not want to be in session, and that can make the session hostile and unpleasant.
WHAT TO DO: Get ready to deal with (awkward) silence in these sessions; remind yourself -silence is not a monster. Let your client think and feel, and get in the present moment with them. If the silence starts to “get loud” simply address it with your client. “I wonder what your thoughts are when you are silent”, “How do you feel when we have silent moments like this?”. It is going to take a lot of work to get this client to talk, but eventually, they do so. Be aware of the signs and determine what could be a topic worth exploring. Even if at the start, their topic of choice does not seem to be related to the treatment goals, you will find that the pieces of puzzle eventually fit together. Keep in mind that research supports Motivational Interviewing as an ideal approach for involuntary clients.
4. COMPLEX DIAGNOSES:
Some complex mental diagnoses to treat include psychosis, chronic depression, chronic suicidality, personality disorders, Dissociative Identity Disorder (DID), long/chronic history of addiction, pedophilia. Other complex diagnoses include those that are not aligned with our expertise, and this is part of the focal challenge here. When we are presented with a client that deviates from the most typical/familiar diagnoses, we have to put much more work into preparing the sessions and achieving the treatment goals. This experience can become stressful and overwhelming for professionals.
WHAT TO DO: Work hard, but honor your limits. We are not know-it-alls, and it is healthy to come to terms with that. There are going to be diagnoses or conditions that go beyond our professional competences. To best approach these situations, you must consult with your supervisor and colleagues, do the necessary research, and establish a plan of action. However, please consider that you cannot cure the incurable. If you cannot foresee a positive prognosis with this client, know that it is appropriate to refer your client to another therapist or a higher level of care.
5. CLIENTS THAT LACK BOUNDARIES:
These are the clients that call you between sessions, send you a message in the middle of the night, or search you up on social media. They do not have bad intentions; still their inappropriate actions elicit tension and apprehension.
WHAT TO DO: First, do a self-assessment and consult with colleagues. Consider the possibility that you have failed to establish and sustain clear ethical boundaries from the beginning of the sessions. Afterwards, explore the behavior with your client. “Where is this dependency and curiosity coming from?” “What could be alternative courses of action your client can take to avoid this behavior?” Finally, be assertive about your ethical obligations as a therapist and kindly tell your client what they are.