Counseling Today, Cover Stories

Scaling client walls

By Laurie Meyers December 22, 2015

Every practitioner has been confronted by them — clients who show up for counseling (at least physically) but demonstrate little interest in actually being there, or clients who come in week after week but seemingly fail to make any progress. In some scenarios, these clients rarely speak. Or they talk about making changes but don’t take action. Or they talk about everything under the sun except what’s actually bothering them. You try to gently guide them; they drag their heels. What’s a Branding-Images_Client-Wallscounselor to do when faced with a client who is resistant?

Start by realizing that it isn’t useful to label a client as resistant, says W. Bryce Hagedorn, an addictions counselor in Orlando, Florida. The resistance, he says, comes from the client-counselor relationship — in particular, how a counselor approaches change.

“A big assumption that counselors make — particularly the longer they are in the field — is that they know what is best for clients,” says Hagedorn, a member of the American Counseling Association. “I don’t know that they would admit it, but the longer you are in the profession, the better you get, so you think you know how to achieve change. And we start to impose on clients.”

“We are trying to be agents for change, and we assume that [clients] are ready, willing and able,” he adds. “We design action-oriented change when they are
not ready.”

Hagedorn says it can be especially easy to fall into the trap of trying to impose change when working with clients who have substance abuse issues. Counselors often assume that people with substance abuse issues are in denial and thus need a “push,” Hagedorn says. On top of that, practitioners may feel the pressure of having a limited amount of time that insurance will pay for the client to complete treatment, he says.

“We need to get people [in treatment] from point A to point B, but when we push people toward B, people push back,” he explains. “It’s only natural. People don’t like change.”

Change is a process

Hagedorn, the former editor of the Journal of Addictions & Offender Counseling, says that earlier in his career, he was unquestionably guilty of pushing clients, often without quite realizing it. He was working with people struggling with substance and process addictions, both of which are often comorbid with other mental health issues.

“Just because clients are agreeing with you doesn’t mean they are going there with you,” he says. “There were plenty of times in the beginning [of his career] where, although the clients would agree with my ideas, they never tried them. I would design all of these activities and homework, but they just wouldn’t do them.”

Hagedorn eventually realized that although he was employing a more subtle form of pushing, he was still trying to move clients faster than they wanted to go. He reframed his approach by using the stages of change model developed by James Prochaska and Carlo DiClemente. The model focuses on specific strategies that are helpful to clients at each particular stage of change: precontemplation, contemplation, preparation, action, maintenance and termination.

“I was always using CBT [cognitive behavior therapy], and it’s really designed for people who are in the preparation or action stage [of change],” Hagedorn reflects. He eventually realized his activities weren’t working because the clients he was seeing were still contemplating change rather than preparing to take action or engaged in action toward change.

Hagedorn describes the thought process of clients who are in the contemplation stage as follows: “Since I am thinking about change, change is happening.” And that is valid to a certain degree, he says.

“For them just to come in [to counseling] each week, that can be a huge change for them,” he says. “We [counselors] tend not to honor that. If we can help them recognize what the next step would be, whether or not they are going to take it, that is significant.” Counselors must realize that ambivalence about change and relapse to past behaviors are normal and expected parts of all change processes, not just those related to addiction, Hagedorn says.

To encourage clients in their efforts at change without imposing his own ideas on them, Hagedorn started using motivational interviewing, a technique that incorporates principles from the stages of change model. Motivational interviewing also uses reflective listening, which demonstrates empathy and helps diffuse resistance, Hagedorn says.

As an example, with a female client considering leaving an abusive husband, Hagedorn says he might start with a statement such as “Tell me about what happened during the last altercation.” He then listens for specific details to reflect back and summarize so that the client will know he is listening.

“I’m listening both for words that use explicit feelings and for underlying meaning,” he elaborates. “She may say, ‘I just don’t know if I can do this anymore.’ So I can either say, ‘You don’t know if you can stay, or you don’t know what’s going to happen?’”

This approach communicates empathy while also eliciting information, Hagedorn says. He adds that the mistake many well-meaning counselors make is to instead listen to their “righting reflex” — the reflexive need to make everything “right” for clients.

“When someone comes in and talks about hurt, my righting reflex goes off — ‘I need to make this stop,’” he says. “That is not good because I am going to make a plan, and I start firing off questions: ‘What have you tried? Have you tried this? Why don’t you try that?’ I’m drilling her, and I freak her out. So she starts saying, ‘Well, it’s not always so bad …’”

Instead, Hagedorn likes to use the OARS method, which stands for open questions, affirmation, reflective listening and summary reflections. He says this technique often helps him implement change talk in clients.

“As they’re talking about what’s going on, I’m listening for them to say something that reflects that things aren’t all that they’re cracked up to be,” he explains. “Like [with the client in an abusive marriage], ‘Although I can predict the cycles [of violence], I realize my kids are seeing things that I don’t want them to see.’”

Hagedorn can then pick up on that observation and continue to strategically reflect. “I’m really hearing that there are two sides,” he might say. “On the one hand, you say there is predictability and stability, but on the other hand, you don’t want the kids to see what’s happening. Tell me more about that.”

Hagedorn also emphasizes the importance of counselors not taking any perceived resistance from clients personally. “When they push back, for me it’s a sign that I’m moving too quickly, not that I am doing something wrong,” he says. “I appreciate that as a sign of where we are in the therapy.”

To move past the point of taking resistance personally, Hagedorn said, he had to redefine what successful therapy looks like, and that often requires a great deal of patience. “People can get in a holding pattern. We all have things that we’ve been thinking about for years and haven’t done,” he points out.

Practitioners naturally prefer the action stage, and that can lead to frustration when clients are seemingly “stuck” in the contemplation stage. But as Hagedorn, an associate professor and coordinator in the Department of Child, Family and Community Sciences at the University of Central Florida, reminds his students, the stages of change model teaches that 80 percent of clients are in either the precontemplation or contemplation stage.

Hagedorn considers it a win if he can help clients move forward a stage or move them toward putting together a plan. If a client isn’t yet ready to transition to the next stage but has a good enough experience in counseling with Hagedorn that he or she is willing to come back when there is impetus to make a change, he also considers that a success.

Having said that, Hagedorn acknowledges that he doesn’t simply allow clients to circle around and around a problem with little apparent motivation to move forward. “I set treatment and session goals,” Hagedorn says. “I want to be moving toward something. If there have been a few weeks of no movement, maybe we need to reevaluate goals. Or maybe this stage of counseling is over.”

In such cases, Hagedorn might ask clients if they want to reduce the number of sessions or work on something else. If it becomes evident that certain clients really just want to complain, Hagedorn lets them know that he will still be there when they decide that it’s time to move past what is impeding them.

Solutions for students

ACA member John J. Murphy is an expert at working with a client population that is frequently perceived as resistant: high school students. Like Hagedorn, however, he doesn’t believe such labeling is useful.

“It blames the client for the impasse,” says Murphy, the author of Solution-Focused Counseling in Schools, published by ACA. “It kind of sets up an adversarial environment that I don’t think is really compatible with the way we know good counseling works.”

Calling clients resistant “kind of takes us [counselors] off the hook,” he continues. “It takes away our responsibility for finding a way to connect. They [clients] come to us in all sizes and shapes. Our talent is to tailor our approach to the person sitting across from us.”

Although he rejects the word resistant, Murphy, a former school psychologist who continues to work with students, teachers, parents and administrators, does think that school-age clients pose a unique challenge. “Students and young people rarely refer themselves for services, and that has major implications for how we approach them from the very start,” he explains. “We can’t approach them the same way [we would] someone who enters counseling in a voluntary way.”

Counselors working with young people should be aware that these clients are often in counseling at someone else’s request, Murphy says, and he advises acknowledging this with clients from the start. When applicable, Murphy tells clients that he knows it wasn’t necessarily their idea to be in counseling and understands that it’s not always pleasant to be a part of something when it’s not their choice. “No wonder you don’t like being here,” he might say to the client. “I don’t like doing things that someone who has control over me tells me to do when I don’t want to do them.”

Once Murphy validates school-age clients, he asks about their issues indirectly by inviting them to tell him why they think they were referred for counseling. “I will ask, ‘Do you know why you were asked to see me? Whose idea was it for you to come here? What do you think needs to change to get these people off your back?’” he says.

Murphy firmly believes such queries are helpful. He says the questions serve not only to put him squarely in the student’s corner but also allow him to learn more about the student’s perception of the situation and what he or she wants to get out of the sessions — even if it is just to get out of counseling altogether.

A student is generally referred to the school counselor’s office for behavioral or mental health counseling for one of two reasons: a specific event or ongoing, cumulative problems, says Murphy, a professor of psychology and counseling at the University of Central Arkansas. The event or crisis may take the form of a suicide attempt, a school suspension or getting into trouble with the law. Ongoing problems might include persistent conflict between the student and his or her parents, chronic lateness at school, refusal to do assigned work, disruptive behavior in class or harassment of other students. Other times, the problem may be more subtle, such as a formerly solid student whose academic performance starts to decline in one subject, then another and another, seemingly without explanation.

When faced with a student who seems disinterested in school or at home, it can be tempting to label him or her as apathetic, Murphy says. “That’s just a totalizing description,” he cautions. “It makes it seem like apathy runs from the tips of their toes to their head, and that’s not the way it works. Everyone is motivated by something. Our job [as counselors] is to find something that gives this person a heartbeat and energy.”

Murphy recounts working with a 17-year-old who was referred for counseling because of behavior issues that included not completing assignments. His grades put him at risk of not finishing high school. The school authorities and teachers said the student didn’t care about anything, but when Murphy asked him what he enjoyed doing in his spare time, he quickly learned that the young man had a passion for writing rap songs.

“I learn that this guy spends most of his evenings writing,” Murphy exclaims. “If you said that [a student spends all of his time writing] and they [the teachers] didn’t know anything else, they’d probably think that was great.” Many counselors or teachers might dismiss the student’s passion and talent after learning that the writing primarily involved rap songs, Murphy says, but that would demonstrate a lack of resourcefulness in connecting with a young person.

Murphy went on to ask the student if he had ever spoken with someone who recorded rap music. The young man said he knew someone who occasionally recorded for himself, but not professionally. Murphy then asked the student whether he would be interested in having his rap music recorded if he were to meet someone in the industry.

“He said, ‘Yes! Definitely!’ So now he’s energized,” Murphy continues. “[But] how does this become school related?”

Murphy asked the student if having a high school diploma might help him achieve his dream of getting his rap music recorded. The young man said he thought it would because people automatically assume that individuals who have graduated from high school are smarter. “Now, all of a sudden, school becomes a means to an end [for the young man],” Murphy says.

Murphy kept the focus narrow: You want to get your high school degree. What is one small step that you could take in school tomorrow that would move you toward your goal?

The techniques Murphy used are representative of solution-focused counseling, which he describes as a method of helping people change by building on their strengths and resources. These strengths and resources include elements such as special talents, interests, values, social and family support, heroes and influential people, and even a client’s own ideas about his or her problem and possible solutions. “I want to find out what they think might help turn things around,” Murphy emphasizes.

He also likes to focus on resiliency. “Everyone has overcome lots of things in their lives, [but] when we have a problem, it’s easy to forget that,” he asserts. “One of the core techniques [for developing resiliency] is building on the exceptions — a time when a problem could have occurred but did not.”

For example, with a student having problems with tardiness, Murphy would ask about a time when he or she wasn’t late. “What did you do differently? Who was around? What will it take for that to happen again?” he says.

The student might provide an answer as simple as her mother waking her up instead of her father. Often, Murphy says, he has no way of knowing if the answer the student identified truly made the difference in the outcome, but he’ll suggest that the student try it again to see if it resolves the problem.

“Solution-focused counseling changes a young person’s focus from, ‘How can I be more like other people’ to ‘How can I be more like myself during my better times?’” Murphy says. “I think it’s really important … when a young person realizes, ‘I already know what I need to do to be better. I just need to figure out how to do it more often or in different circumstances.’”

For instance, a student might recognize that he or she is a very good listener with friends but not with his or her parents, Murphy says. Based on the parents’ experience, they think their child isn’t a good listener at all, and that can become part of the young person’s self-perceived identity. But if the student can realize that he or she already possesses the skills needed to solve the problem, that is a huge step, Murphy says.

“It’s not going to be easy [to make that change],” he says, “but that is completely different than [thinking], ‘There is something missing in me. I am deficient.’”

Making a difference with mandated clients

Kerin Groves, a licensed professional counselor (LPC) with a private practice in Denton, Texas, counsels individuals who are typically very reluctant participants — mandated clients.

Most of her clients are referred through the court system for charges related to substance abuse or at the behest of child protective services. Groves evaluates these clients and, when needed, provides substance abuse or mental health treatment. But with many of the people she sees, her primary challenge is getting them to embrace counseling as a place where they can set and meet goals, which range from avoiding additional entanglements with the law to getting a child or spouse back to simply fulfilling their probation requirements.

Groves’ clients are often angry and defensive, and she has found that the best way to start is by acknowledging that fact and simply listening to what they have to say. These clients typically believe that no one is interested in their side of the story, Groves says, because they claim that all authority figures — from the police and judges to their lawyers, probation officers and child protective services — refuse to hear them out.

“So if they come into my office and I just say, ‘Tell me your version of what’s going on,’ they may talk for an hour and a half to tell me their perspective,” she says. “Even if it’s not based in reality, it’s something that’s almost magical. They will say, ‘You are the first person who has listened to me.’”

“That doesn’t mean I approve,” Groves continues, “but I’ve built up credit with them, let them know, ‘I understand the position you are in.’”

She says this is something that is important with all of her clients, but particularly with those who tend to be the most defensive and ashamed — mothers who have been referred to counseling by child protective services.

“In our culture, we see parenting as a very private matter,” observes Groves, a member of ACA. “Clients take it very personally. There is typically a lot of anger and denial — ‘The caseworker is picking on me.’ … [Being neglectful of or abusing your children is] hard to admit personally, and socially, it’s also taboo.”

It’s not unusual for parents mandated to counseling to claim that it’s no one’s business how they raise their children, she says. “I help them to recognize that they do have certain rights and privileges as parents and that authority figures only get involved when basic standards have been violated, such as the child has not been coming to school, is poorly groomed or can’t sleep because of all the chaos [from fighting or other disturbances] in the house,” Groves says. “There are standards as a society that we have set: We want [our children] to be clean, we want them to be well-fed. When you come up against those standards, then and only then will authority figures step in.”

However, in addition to helping parents understand the reality of their situation, Groves strives to build cooperation. The shame and embarrassment attached to child protection cases tend to work well as motivating factors because, generally, she says, the clients authentically want to change the situations they are in.

“I’ll say, ‘What I hear is that you really want to get your kids back because if you didn’t care, you wouldn’t have shown up for counseling. So let’s talk about what you need to do. What do you think you need to do?’ It’s different than me saying, ‘You need to do this, you need to do that,’” Groves emphasizes. “Most people, if they’re given a chance to relax and see that I’m not technically a part of the system — I’m not the judge or caseworker but someone who has been brought in to help them [the client] — they will come up with, ‘Well, I guess I need to get my boyfriend straightened out’ or ‘I need to stop drinking.’

“[I’ll say], ‘That’s great. I hope your boyfriend gets straightened out, but he’s not here right now. Let’s talk about what you can do.’”

Groves’ goal is to help her clients understand that they are the ones who need to take specific steps to change their circumstances. “If there is drug or alcohol abuse, they need to get treatment,” she says. “If there is a guy who is being abusive to the kids or abusive to the mom in front of the kids, the mom has to make some tough choices.”

Although her clients are often reluctant to come to counseling, it is typically fairly easy to get them to set goals, Groves says. “Most people will agree with, ‘I want to get authority figures out of my life’ [or] ‘I want to get caseworkers off my back.’ Those goals are not incompatible with counseling,” says Groves, who uses a combination of reality therapy, narrative therapy and motivational interviewing with her clients.

In addition, setting even basic goals can sometimes lead to big changes, Groves points out. “I have a client right now who was a very successful drug dealer who made a lot of money at a young age,” she says. “That worked out well for a while, but then he got caught distributing and is on probation.”

“When he [first] came in [to mandated counseling], he was pretty ticked off about it. He had been making $30K a month, and now he was just making minimum wage,” Groves recounts. “I had to spend a lot of time letting him vent about how unfair it was and just had to help him get to the point that this is where he is now. He has now come to the point that he says it’s nice to not have to look over his shoulder all the time. Because if you’re successful [at dealing drugs], someone else wants to take over or the police are looking for you.”

The man had already been on probation for three years before coming to Groves, so he had spent a good deal of time under scrutiny, getting clean and learning to toe the line, she says. During that time, he had started thinking about what was next in his life and was considering going to college.

“I think he had already been in preparation mode and had already decided that [going to school was] what he would choose because he didn’t want someone else to choose for him,” she says. “So we talked about ‘What are your skills? What are your strengths?’ He went back to college to study business because he recognized he was good at business. We turned that toward legal pursuits, and I think he’s going to be a great businessman.”

Groves also asked the client where he envisioned himself in 10-20 years. In thinking about his answer, the client said he had come to realize that if he hadn’t been caught selling drugs when he was, he likely wouldn’t be around because he would either be dead or in prison.

Groves acknowledges that some mandated clients never embrace the need for change. But she has worked with many others who upon being given tools to help them solve their problems were amazed at the difference it could make.

“I can’t tell you how many people have told me, ‘When I got into trouble, it was the worst day and the best day of my life, because I would never have changed if it weren’t for that,’” Groves says.

She doesn’t attribute those changes entirely to counseling, but she firmly believes that the mere act of giving a person a place to be heard and to regain some agency is powerful.

Creative cooperation

Clients have many reasons to be hesitant in therapy, particularly in the beginning, says private practitioner Suzanne Degges-White, an LPC. Feelings of anxiety, a lack of rapport with the counselor and a sense of shame for even needing counseling can all inhibit clients from opening up, she explains.

Because the therapeutic relationship is so crucial to the counseling process, a counselor cannot go forward without gaining the trust of the client, says Degges-White, a past president of the Association for Adult Development and Aging, a division of ACA. “Being asked to disclose and address topics that may be considered private can be anxiety provoking — scary, unsettling, too intimate for many of us,” she notes.

“Clients who choose to begin counseling are seldom intentionally resistant in such a way that they won’t work on an issue, [but] sometimes they need to know the support is in place if the topic gets too scary or shaky or anxiety provoking,” she says. “By finding a way to open up the relationship, you are going to be able to grow the comfort of the client and help the client feel that you and the process are trustworthy.”

“In straight talk therapy, there is so much ‘quiet’ in the room sometimes, with so much weight felt by the client to say what they ‘should’ be saying or to discuss issues they might not be ready to discuss or even that they don’t have the words to discuss,” Degges-White notes. “Sometimes providing a new method of communication and emotional expression can be exactly what is needed to get over the hurdle that has appeared in a session or a course of treatment.”

From her experience, injecting a dose of creativity into counseling often provides a mode of communication that feels less threatening to clients. For instance, asking clients to recreate their world in a sand tray may help them to more accurately evoke and articulate feelings than they could do with words, she says. Hiding a tiny figure under the sand with a larger figure standing on the mound can represent those things that the client is afraid to or not yet willing to say, she adds.

For example, Degges-White once had a female client in her 40s, and in the first sand tray world she created, she picked a tiny rabbit to represent herself, while her husband was represented by a tiger on a mountain. The client was dealing with being abused and feeling trapped.

“We did five different trays [over the course of the woman’s counseling]. In the end tray, she was an elephant — someone who moved slowly but was powerful and could pull trees down. Her husband was still a tiger, but not on a mountain, and she could handle him,” Degges-White recounts.

The woman was searching for the strength to know that she could live on her own if she wanted to, and she started to take steps toward independence, such as getting her own bank account. Although she was still not ready to leave the marriage because of her children, she had a need to feel like an individual. Once that happened, the client felt stronger and more assured. She and Degges-White went over the process of establishing a safety plan if needed, and the client was even able to have some needed discussions with her husband. The sand tray process had helped the woman overcome her lack of belief that she could, and should, express herself, and it also provided her with a different way of seeing herself, Degges-White says.

Other approaches can also be effective in overcoming clients’ hesitancy and unlocking their concerns, says Degges-White, who has found bibliotherapy to be particularly helpful. “It can be a wonderful way for clients to see their story in action without having to own it quite so personally,” she says. “Counselors can assign readings and movies for a client to read or watch and then ask them to journal afterward in order to process difficult feelings.”

Degges-White gives clients questions to answer when journaling or asks them to react to specific characters or events. For example, “What did it feel like for you when character X did that? Have you ever had a time when you wanted to do what character Y did? What did you think about the scene where the big event happened? What are some times in your life when you’ve had those same feelings?”

Degges-White, also a professor and chair of the Department of Counseling, Adult and Higher Education at Northern Illinois University, cautions that not all clients will be open to creative expression and suggests motivational interviewing as an alternative. But whatever approach a counselor takes, she thinks that normalizing the anxiety and reluctance a client may feel is extremely important.

Degges-White also believes it is useful for counselors to own their therapeutic limitations in the face of missing information. For example, she might tell a client, “It may be more challenging and it might take more time to reach the goals you’ve shared with me if we aren’t able to address all the aspects of the issue that have you stuck.”

At the same time, she says, it is important to let clients know that the counselor will accept them wherever they are in the process. She suggests saying something like, “However, I’m definitely glad you’re here, and I know that it took courage to show up today. So let’s begin where you feel comfortable beginning.”

 

 

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To contact the individuals interviewed for this article, email:

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

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