Difficult Client Or Difficult Psychotherapist?

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Clients with whom psychotherapists find it difficult to communicate can be divided into two groups - some with chronic mental illness, others with personality disorders. Of course, these clients have the most pronounced disorders, as a rule, long-term ones, the prognosis for which is very doubtful. The communication style of such people looks defiant: they are practically unable to establish and maintain healthy relationships with others. Usually these clients gravitate towards one of two poles - they are passive, apathetic, or they are prone to aggressiveness, impulsiveness, vindictiveness, manipulative behavior. As a rule, such people have behaved in this way for a long time and are determined to follow the same course.

Many authors believe that difficult clients do not exist, there are only difficult psychotherapists. To test this claim, a special study was conducted to find out the opinion of prominent American clinicians on this matter. All psychotherapists interviewed agreed on which clients should be considered the most difficult. Certain diagnostic categories naturally emerged: borderline, paranoid, antisocial personalities and with somatic manifestations. Narcissistic disorders are also included in this list, as clients with these disorders are prone to acts of violence, including against themselves. More often than others, people with alcohol and drug addiction, chronic mental illness, clients who belong to pathological family systems, and hospital patients, known as "gomers" (Get Out of My Emergency Room - Get Out of My Emergency Room - Get Out of My Emergency Room - As a rule, elderly people who lack attention are united by their irreversible mental changes, the presence of complex symptoms, inability to cope with normal adult roles and the lack of a place to go after discharge from the hospital).

In a factor analysis of possible internal reactions of psychotherapists to the behavior of difficult clients, the researchers found that against the background of the problem population, clients suffering from depression and suicidal tendencies evoke the strongest feelings. Clinicians found it much more difficult to deal with clients with severe depression and intense conflicting feelings than with hospitalized borderline or schizophrenic patients. On the one hand, the therapist has a strong desire to save the client's life, to help him cope with despair. On the other hand, he feels frustration, fear and his own powerlessness. Similar feelings are evoked by other clients belonging to the category of difficult, who are not so much resisting as it is simply difficult to work with them, in particular, we are talking about victims or perpetrators of incest, as well as victims of torture.

It should be recognized that almost all diagnostic categories of clients serve as a source of unique problems and cause particular difficulties for psychotherapists, difficulties in communicating with a client in the process of psychotherapy depend little on their symptoms: the main role is played by the way they respond to their problems. Not all drug addicts or persons suffering from obsessive-compulsive disorders or chronic depression present special difficulties for the therapist. In fact, the greatest satisfaction can be obtained from working with those who suffer from severe pathology.

Often, clinicians prefer to work with clients who suffer from the most severe disorders, not only to increase their authority or in a bout of masochism, but mainly because such clients need their help more than others. Psychotherapists with experience of this work are of the opinion that the nature of the disorder does not necessarily cause problems, whether it is a case of patients with schizophrenia, rapists, borderline personalities or substance abusers, the unique way of manifestation of symptoms in each case and the client's response to the produced interference.

Any attempt to present a client with a tendency to resist change as difficult raises at least two problems. First, such a concept reflects the views on the resistance of the therapist himself and may not take into account the importance of environmental factors. Secondly, then it is necessary to recognize the dichotomism of such a construct: the client can be either difficult or not difficult.

Most of us understand that the point is not at all whether the client is difficult or not, but in the number and severity of problems that arise in the course of therapy. Therefore, it is necessary to take into account not only the unique personal characteristics of the client (which may predetermine his intractability), but also take into account a number of other issues. Who, besides the direct participants, sabotages therapy? What caused the aggravation of relations with the client? What is it about the client's environment and circumstances that contribute to the difficulties?

The ability to diagnose reliably becomes even more problematic because the process itself is highly subjective. If we ask 10 different psychotherapists to evaluate the condition of the same client, we are unlikely to hear two identical opinions. As an illustration, imagine a new visitor walks into your office and asks something like the following question: "Can I get information about your qualifications and training before I sign with you?"

While you are pondering your answer to the client's question, let's see how other psychotherapists interpret this dating initiation.

- A familiar case. It won't be easy with him.

- Not a bad question to start with. I, too, would not entrust my life to a specialist about whom I have no idea.

“Apparently, he feels a need from the very beginning to establish who is in charge here. I should watch this carefully.

- Probably, in an unfamiliar environment, he feels uncomfortable and tries to buy time to get used to it.

- As long as he focuses on me, he does not need to talk about his own problems.

- It is curious that he started with this question. I would like to know why?

Any of these options for assessing the situation may be correct. It is possible that working with such a client will not be easy, but it is equally likely that his question is fully justified and dictated by the circumstances. Based on many other features of this case - non-verbal, contextual signals, reasons for referral to therapy, the psychotherapist makes a number of conclusions: that this client belongs to the category of difficult ones (psychotherapists A, C or D), that the client's question is quite adequate (psychotherapists B or D) or that a final decision should be postponed until further evidence is available (psychotherapist E). Probably, it is the last option that is preferable, since the psychotherapist maintains a neutral position and carefully observes what is happening; this option is also the most difficult, because the decision has yet to be made.

During the first meeting with clients, we ourselves are often worried - we try to make a favorable impression, try to find out the essence of what is happening, make a decision about what kind of help a given client needs and whether we can provide it. Internal tension is aggravated by the fact that the client checks us to decide whether he turned to for help there. He wants to know what the therapist thinks is his problem and has the therapist had to deal with similar situations before? What is the estimated duration of psychotherapy? What, in fact, will this psychotherapy consist of? The main difficulty is to try to get a complete and, if possible, objective idea of what is behind this or that client's behavior without giving out your excitement and anxiety.

Some psychotherapists find almost all of their clients difficult; others do not agree with this or do not think at all on this topic. Psychoanalysts tend to look for signs of resistance in each client, considering this a normal, completely natural phenomenon, and are willing to patiently wait until resistance finally appears. In contrast, problem-solving therapists believe that resistance was introduced by frustrated clinicians who are unable to give the client what he wants. In any case, one should distinguish between reluctant and difficult clients.

Resistance to change may actually be natural as the client breaks up with old habits and replaces them with new, more effective ways of functioning. Difficult clients tend to resist in particularly subtle ways. Consequently, we are talking about a certain range of manifestation of resistance to the therapeutic process, that is, the whole point is in the severity of the inherent behavior of this client to the detriment of himself, as well as in the degree of frustration of the psychotherapist.

You can doubt how to correctly assess the client's question in the previous example - whether it is natural and logical, whether it reflects excitement, is it a sign of intractability, or is somewhere in the middle, but hardly anyone will have doubts about the question asked another client: “What gives you the right to get into someone else’s life? Have you been taught to ask stupid questions at university, or are you naturally curious?"

In this case, most psychotherapists from A to E (as well as all the other letters of the alphabet) would agree that this client is undoubtedly in the difficult category. Regardless of the reason for her hostility, whether it be a deep wound or simply hypersensitivity, this client would surely cause a lot of trouble even for the most patient clinician.

What makes the client difficult

I would like to emphasize once again that some authors insist that there are no difficult clients, but only difficult psychotherapists. Thus, Lazarus and Fay consider resistance to be fabrications of those clinicians who do not take responsibility for the failure of therapy. When criticizing psychotherapists who tend to blame their clients for all the failures, there is a danger of going to the other extreme. Of course, both members of the therapeutic alliance are equally responsible for the failure of therapy.

Of course, psychotherapists are capable of mistakes and wrong judgments. Indeed, our therapeutic style, professional experience and personal characteristics greatly influence the outcome of psychotherapy. It is also hard to deny that there are “difficult” psychotherapists who are so rigid that they cannot help some of their clients and accuse them of lack of flexibility. However, there are also clients whose behavioral characteristics will greatly complicate the work of any clinician, regardless of his level of competence. Based on the conclusions reached by numerous researchers, as well as from his own experience with clinicians, Kottler identified several types of clients that are considered the most difficult. Their distinctive features are described in the next post.

If we carefully analyze the distinctive features of those clients whom psychotherapists find the most difficult, it turns out that the main thing is the need to pay increased attention to them. Regardless of the specific diagnosis (paranoid state, narcissism, or borderline state), first impression (stubbornness, manipulativeness, tendency to complain), as well as regardless of their behavior (rejection of help, unwillingness to cooperate, tendency to take unnecessary risks), difficult clients claim something more than the usual attention from the psychotherapist, in any case, the main problem for psychotherapists is the need to spend additional time and effort on such clients.

Another important feature of difficult clients that psychotherapists note is their tendency to control the therapeutic relationship. The client's resistance is often explained by the fact that, against the background of despair, he is trying to regain self-confidence, for which he seeks to take control of the course of therapy and the psychotherapist himself. This is a common occurrence. A truly difficult client, however, is one who shows resistance not only in the context of a certain situation, but is predisposed to it by character. Such a person reacts to a threat (which he sees in everything) with an attempt to dominate all interpersonal relationships that develop throughout his life.

The third distinguishing feature of difficult clients from ordinary ones is the nature of their psychological defense mechanisms. People with higher-order defenses, such as suppression, intellectualization, and rationalization, are much easier to communicate than those who employ the relatively primitive defenses described by Kernberg, such as splitting, that is, the real dissociation of unacceptable impulses inherent in borderline individuals. Such mechanisms effectively protect the client from internal conflicts, but they also have side effects, in particular, they reduce the client's flexibility and adaptability.

The fourth characteristic of difficult clients is their tendency to externalize problems. These people are at war with all of humanity. They feel so bad that they are ready to take revenge for all the wrongs inflicted on them in the past. “Instead of admitting that there is a problem in himself, and, consequently, the possibility of solving it, such a person ascribes the problem to the outside world. It is “other people” who do not love him, interfere with his life, cause his worries and worries, usurp his rights.”Therefore, all forces are rushed to restore justice, tell everyone and everyone about the blatant lawlessness and protect themselves from imaginary attacks, attacking the closest people.

It can be concluded that most psychotherapists have similar ideas about the most difficult clients. These clients demand more from us than we can or are willing to give. They are constantly fighting with us, trying to force us to fulfill their whims. They stubbornly disagree with our vision of their problems. And if they nevertheless admit some of their shortcomings, they refuse to follow our recommendations for overcoming them.

Continued

Colson, D. B. and others. An anatomy of countertransference: staff reactions to difficult psychiatric hospital patients. Hospital and Community Psychiatry. 1986

Jeffrey A. Kottler. The compleat therapist. Compassionate therapy: Working with difficult clients. San Francisco: Jossey-Bass. 1991 (lyricist)

Kernberg, O. F. Severe Personality Disorders: Psychotherapeutic Strategies 1984

Lazarus, A. A. & Fay, A. Resistance or rationalization? A cognitive behavioral perspective. In P. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches. 1982

Steiger, W. A. Managing difficult patients. Psychosomatics. 1967

Wong, N. Perspectives on the difficult patient. Bulletin of the Menninger Clinic. 1983