Tag Archives: resistant clients

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.”

 

 

****

 

To contact the individuals interviewed for this article, email:

 

****

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

Letters to the editor: ct@counseling.org

Connecting with clients

By Laurie Meyers August 18, 2014

Modern counseling models and techniques are as varied and diverse as the counselors and clients who use them. Most counselors have a particular theory, method or school of thought that they embrace, whether it is cognitive behavior therapy, solution-focused therapy, strength-based, holistic health, person-centered, Adlerian or other. Yet all of these approaches and techniques Therapeutic-alliance_brandinghave at least one thing in common — their potential effectiveness is likely to be squelched unless the counselor is successful in building a strong therapeutic alliance with the client.

The crucial nature of the therapeutic alliance is not a new idea. In 1957, Carl Rogers wrote an article in the Journal of Consulting Psychology outlining the factors he considered necessary for achieving constructive personality change through therapy. Four of the six items directly addressed the client-therapist relationship. Rogers asserted that the therapist must:

  • Be genuinely engaged in the therapeutic relationship
  • Have unconditional positive regard for the client
  • Feel empathy for the client 
  • Clearly communicate these attitudes 

In the decades since Rogers’ article was published, many other studies have explored the therapeutic alliance. In 2001, a comprehensive research summary published in the journal Psychotherapy found that a strong therapeutic alliance was more closely correlated with positive client outcomes than any specific treatment interventions.

So, what constitutes a therapeutic alliance?

“Most scholars who write about the therapeutic alliance describe it as a relational factor in counseling that includes three dimensions: goal consensus between counselor and client, collaboration on counseling-related tasks and emotional bonding,” explains American Counseling Association member John Sommers-Flanagan. “The best ways to form and strengthen the alliance are specific counselor behaviors that contribute to those three ‘alliance’ dimensions. Focusing on these dimensions helps grow the therapeutic relationship.”

“For example, goal consensus or agreement involves listening closely to the client’s distress and hopes and then being able to articulate that distress and hope back to your client,” says Sommers-Flanagan, an author and associate professor in the Department of Counselor Education at the University of Montana. “This can happen from any theoretical orientation. For a cognitive behavioral therapist, it could include collaboratively generating a problem list. For a more existentially oriented counselor, it could involve asking the client ‘What do you want?’ and then gently exploring the many nuanced dimensions of how your client answers that question.”

“Collaboration on counseling-related tasks can involve nearly any task that is clearly described and that clients understand as related to their problems or goals,” he continues. “This could involve everything from taking a social history to implementing a progressive muscle relaxation procedure.”

“Emotional bonding between counselor and client is different for every unique counselor and client,” Sommers-Flanagan says. “It might involve compassionate or empathic listening or humor, or just sitting together while the client experiences strong emotions, or giving positive and supportive feedback to clients.”

The power of relationship

Although it may be next to impossible to find a counselor who doesn’t agree that bonding with clients is important, becoming overly reliant on technique and method still poses a common temptation for many professionals.

“Counselors are in love with their techniques and interventions,” ACA member Jeffrey Kottler says ruefully. “We hungrily buy books and attend workshops hoping for the next latest and greatest breakthrough.”

Kottler appreciates what research into evidence-based practices and promising theories can contribute to the counseling profession’s body of knowledge. At the same time, he contends that specific techniques aren’t nearly as important to the therapeutic process as some practitioners might think.

“I can recall few instances, either from research studies or my own practice, in which clients reported that it was some singular technique or intervention that was most helpful to them,” says Kottler, a prolific author, researcher and professor of counseling at California State University, Fullerton. “Instead, they so often say that they felt heard and understood and valued by their counselor. They talk a lot about the power of the relationship.”

“[Obviously] in many cases, clients need a lot more than feeling understood or enjoying the benefits of being in a respectful, facilitative alliance,” he adds. “Yet without the foundation of a constructive relationship, anything else that we do isn’t going to work very well or last very long.”

After all, one key to effectively addressing a client’s issues is to first understand those issues within the context of the client.

“It’s critical for the counselor to learn the client’s worldview in order to enhance cooperation in the counseling process,” says ACA member Jeffrey Guterman. When counselors diagnose the problem and launch into a prescribed method of treatment without first discussing the client’s concerns and goals, they are likely to be met with resistance, explains Guterman, a licensed mental health counselor (LMHC) in Fort Lauderdale, Florida, and the author of Mastering the Art of Solution-Focused Counseling, published by ACA.

It is also difficult to accomplish true change unless the counselor is listening to what the client wants, not what other people think the client needs, says Guterman.

He recalls one client in particular. “I had a case of a 71-year-old man with alcohol abuse who was persistently resisting efforts by several mental health professionals, relatives and friends to get him to go to Alcoholics Anonymous (AA). He had a long history of alcoholism, but all along he insisted he didn’t believe in a higher power. Other professionals said to him, ‘It doesn’t have to be religious; it could be spiritual.’”

Rather than dismissing the man’s objections to AA, Guterman took the time to listen and attempt to understand where he was coming from. The client had previously tried treatment programs that followed the AA model, Guterman says, but he always ended up drinking again. “When he was referred to me, I assessed that he was an atheist and that this was the defining worldview in his life,” Guterman notes. “That was the main barrier to his entering into treatment.”

Guterman referred the client to a program that took a secular approach to treatment rather than asking those in recovery to focus on a higher power. The man felt validated and listened to by Guterman and willingly accepted the referral into treatment.

Guterman says it is not uncommon for people wrestling with alcohol or drug abuse to reject the idea of addiction and thus be unwilling to consider abstinence. Some clients come to treatment seeking only to control their drinking, he says, and under the AA model, these individuals would be considered in denial. Although it might be best for people who struggle with alcohol abuse not to drink at all, Guterman says, if a client isn’t ready to consider that option, he believes it is better for a counselor to address what goal the client is ready to work on, such as controlling alcohol intake. Otherwise, the client may drop out of treatment altogether, which means he or she isn’t getting any help at all. But if a counselor meets the client where he or she is, there is always the possibility of change, Guterman says.

Giving clients room

“It’s a difficult lesson to learn — to allow space for the client to take the session where he or she wants it to go and at the pace he or she feels comfortable with,” says ACA member Olga Gonithellis, an LMHC in New York City. “This requires therapists to challenge their automatic tendency to want to direct the session and [instead] approach certain topics only when the client has opened the door.”

Allowing the client space while simultaneously trying to establish communication, and ultimately an alliance, sometimes requires a bit of creativity and a lot of patience on the part of the counselor, Gonithellis notes.

“An adolescent girl came to see me after her psychiatric hospitalization for suicidal ideation,” she recalls. “For the first three to four sessions, she refused to talk about the incident, made minimal eye contact and played with her cell phone during the session while repeatedly stating that she didn’t need therapy.” 

Initially, Gonithellis alternated between giving the girl space to be silent and validating her emotions, but the client remained distant.

“The next time she came in, I had brought some magazines, glue and scissors,” Gonithellis says. “I told her, ‘I know you don’t want to talk, and I’m OK with that. But instead of just sitting here in silence for the next 45 minutes, maybe we can go through these magazines together and cut out pictures that we like and create a collage. Is this OK with you?’ and she nodded yes. Her affect and energy level changed drastically as she became more present and animated. We spent the session being verbally silent, yet speaking through our selection of images.”

In the next session, the girl made more eye contact and seemed more comfortable. In subsequent sessions, she continued to grow more relaxed and less guarded. “It seems like presenting her with another way of connecting was meaningful and symbolic of being willing to meet her halfway,” Gonithellis says.

For Clayton Martin, meeting clients halfway was a little more complicated, requiring him to stare down hostility and, in some cases, even household implements. Martin, an ACA member, started his career by providing in-home counseling as part of a Medicaid-funded community health program in Fort Lauderdale. His clients were troubled youths who were in counseling only at the insistence of a parent or other authority figure. And these adolescents definitely did not want Martin in their homes. 

“I’ve had young people come at me with a fireplace poker the minute I set foot in the house,” he recounts. “I’ve had children display extreme resistance. I’ve been the eighth counselor to come into the home … where the seven counselors that preceded me just wagged a finger at this kid or were completely out of touch with [the client’s] worldview and just tried to enforce discipline.”

Rather than being intimidated, Martin sought to understand what was behind each client’s bravado and anger. “The first step when you walk into the home and this kid is demonstrating extreme resistance, cussing you out, coming after you or just ignoring you is to just roll with it,” he says. “Accept it, don’t show any fear and don’t show any anger.”

Martin tried to look at the situation from the adolescents’ point of view. “They may have been set up to distrust authority figures or helpers. Instead of letting myself get thrown off by a violent reaction, [I would] accept what they were doing as a natural and understandable personal safeguard,” he says.

When it comes to adolescents, Martin says, counselors cannot fake a sense of acceptance or a willingness to understand their stories. Adolescents know when they are being lied to, he says. “Insincerity is blood in the water to the youth client. They know when someone is being genuine, and they know when someone is not being genuine,” Martin notes.

Retreating into the role of the authority figure or trotting out scripted “advice” is a sure way to lose (or never gain) the trust of these clients, Martin says. “But if you can just stand there and let them blow themselves out like a hurricane, showing no fear, showing acceptance of how they feel, eventually [most of them] will come around,” he says. “They’ll see that you’re not there to wag a finger at them, that you are not going to treat them with kid gloves or from a certain distance because you are frightened of them, and they’ll open up.”

Validation, acceptance and empowerment

Another critical part of getting young clients to open up is making them feel heard and understood, Martin says. “The next part of this process for me is to validate their story. [I’ll say something] like, ‘Hey, it’s obvious that you don’t like me being here. I can’t say I blame you. If some strange guy were to walk into my house who my mom had made show up because I’m not acting right, I wouldn’t want him there either. I’m just wondering whether you can tell me a little bit about some of the counselors you might have seen in the past or the things that led up to your mom thinking I needed to be here.’”  

Validation and acceptance are necessary parts of any therapeutic intervention, regardless of the client population, notes Gonithellis. “Allow room for feedback [and] keep checking in every so often,” she urges. “By making space for clients to give feedback about the counseling process, the therapist shows acceptance of the client’s sincere feelings, good or bad. Simply asking a question such as ‘How are we doing?’ or ‘Are these sessions helpful?’ gives clients the chance to express themselves, while conveying the message that their reactions, positive or negative, will be heard and respected.”

Lauren Ostrowski, a licensed professional counselor and ACA member in Pottstown, Pennsylvania, concurs. “Meet the client where they are,” she says. “This is true even if this means spending five minutes on topics that are important to the client that may not be directly related to the reasons they are coming into counseling.”

Allowing clients to stray from an ordained course to touch on these tangential — yet personally important — matters can help clients feel that the counselor sees them as more than just a set of symptoms or a diagnosis, Ostrowski says. In addition, these tangents often reveal important information about the client and empower them in session, which can further cement the therapeutic alliance, she says.

Enthusiasm for the work can be a boon to the counselor-client relationship as well. “I love working with the troubled youth clientele,” Martin says. “I love working with the kids who are going to come at you with a fireplace poker and cuss you out magnificently on the first session because … if you have good chemistry with these guys and the appropriate background and a fire for working with that clientele, you can do some amazing things with them.”

Hitting roadblocks

But sometimes, despite attempts to offer respect, validation and space, client and counselor still don’t click. Is it time to throw in the towel when both the client and counselor are frustrated?

Not necessarily, says Guterman, who reiterates the importance of first learning the client’s point of view. In such situations, he recommends that counselors again ask themselves if they have made their best effort at thoroughly understanding the client’s worldview.

If that’s not the problem, Guterman suggests evaluating the pace of the counseling sessions’ progress. “Are you pacing with the client? All clients are different, and some clients prefer to go slow,” he says. “You [the counselor] may be solution focused, but if you go too fast, the client who is very problem focused may think that the problem is being stolen away from them.”

Even counselors who have absorbed a client’s worldview may forget that it is the client who ultimately is in charge. The client will define the goals that he or she would like to achieve.

“Let the client determine what is most important,” Ostrowski advises. “Sometimes what seems small to a counselor may be the most crucial element of what is happening in a client’s life right now.”

It may also be helpful, both for strengthening the therapeutic alliance and for therapeutic progress, to shift the perspective periodically, Ostrowski says. Although the client is most likely coming in for counseling because he or she is unhappy or wants to change something, most clients can think of something in their lives that is going well, she says. “Allow for some positive discussion,” Ostrowski suggests. “Thinking of something that is going well … can provide a springboard for discussing strengths that can help with parts of their life that they would like to change.”

Another approach that can benefit the therapeutic alliance is subtly reminding clients that counselors are human too, with lives and interests that extend outside the office, Ostrowski says. For example, briefly talking about a movie that a client has seen recently can be a nonthreatening way to build or strengthen rapport, she notes. Some counselors might balk at engaging in these brief personal interludes, but Ostrowski believes they are helpful in connecting with clients. “Is there really any harm in spending less than a minute to discuss how loud the Fourth of July fireworks were this year?” she asks.

In cases in which a lack of therapeutic alliance exists, it is always tempting to look at the client as the source of the problem, but counselors should also look in the mirror, Guterman says. “We always tell our clients the only one you can change is yourself. This applies to us counselors too,” he asserts. “If we’re not connecting with our clients, what can we do differently?”

Extreme resistance

Guterman acknowledges, however, that it is particularly difficult to connect with clients who have been mandated to counseling. These clients, typically ordered into therapy by the courts because they have a history of being abusive parents or spouses, or because they have problems with anger or substance abuse, simply do not want to be there.

Similar to the approach Martin took with his angry adolescent clients, Guterman finds it best in such cases to get straight to the point. “Usually, the best thing is to join with the client and say, ‘Yeah, I can understand that you don’t want to be here. I wouldn’t either. But since you are here, what do you want to work on?’ … Enhancing cooperation rather than creating resistance is important,” Guterman emphasizes.

Another part of enhancing client cooperation, and thus strengthening the therapeutic alliance, is for counselors to demonstrate knowledge of and respect for diversity and multiculturalism. Possessing an understanding and appreciation of the client’s culture can play an important role in the approach a counselor takes.

For instance, abusive parents who get sent to court-mandated counseling might think there is nothing wrong with hitting their children. This could be because the parents come from a background or culture in which hitting is an acceptable form of punishment or discipline. Regardless of the parents’ reasoning, a counselor is not likely to be able to change that mindset.

“If you say hitting is never necessary, you’re going to get shut down,” Guterman says. “So you ask, ‘What is your goal?’ And often they will say, ‘To get these people off my back.’’

Guterman then summarizes the reality of the situation: If they hit their children again, their children will be taken away from them. This creates an impetus for the parents to let Guterman teach them other ways of disciplining their children.

In certain cases, however, counselors might find that they cannot make the unwilling client willing, despite applying all their skills.

“I’ve been in situations where I’ve exhausted my tool kit,” Martin acknowledges. “The next thing I will do is go to the parent and say, ‘They’re [the child is] not ready for counseling. Maybe they’re ready for a different sort of intervention — a wilderness program or something like that — but they’re not ready for counseling now.’”

Martin then would give the parents his card and invite them to call him if the situation changed. “I make sure that the client is there when I say to them directly, ‘If you change your mind and get to a place where you feel like we can do some work together, please give me a call,’” Martin says.

On occasion, the parents still didn’t want Martin to stop the counseling sessions with their child, so Martin kept going back and doing whatever he could.

“I had a kid who fought with me and ignored me for a year,” he recounts. “We had two conversations that led to some sort of therapeutic benefit, and at a point when he was really acting up and fighting a lot in school, I took this kid on a tour of an alternative school [for troubled children], and that turned out to be therapeutic. He decided he did not want to stay on track to go to the alternative school and made some adjustments to his behavior. Ultimately, that’s what got him out of therapy, because that’s what got him to stop getting into trouble.”

“So,” Martin says, “even if what we would consider counseling wasn’t effective, I was able to do something that produced a positive result for the guy.”

Constantly hitting walls while trying to connect with clients was tough, admits Martin, who eventually left his position as an in-home counselor and is now working with youth at a substance abuse center. But he doesn’t think his efforts were in vain.

“In some way, shape or form, I feel like I’ve connected with everybody, even the folks who have terminated on me or have found therapy to be unsuccessful on the whole,” he says.

Martin credits one of his first mentors with helping him understand that. “I came to her with a difficult case and asked, ‘What do you do with the person who won’t work, with the person who resists everything?’” Martin remembers. “And she said, ‘You accept what they’re doing and accept where they are on their personal journey, and you plant a seed and hope that it opens up later.’”

A spirit of excitement

Martin believes there is something — however small — that he can connect to on some level with every client, and that’s what motivates him to keep coming back.

“With everyone I counsel, no matter how much they despise me or how much they resist, I try to bring a spirit of excitement to the relationship,” he says. “[A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them.”

“I just try to convey that element of acceptance, of excitement,” Martin says. “So no matter what behavior they are manifesting, there is something really worthwhile [about them]. … Like that kid I fought with for a year. He was strong. That kid held on to a poker face for a year and didn’t flinch. And that made him interesting to me. I wanted to know how else that toughness manifested itself. 

“And sometimes we’d have conversations about it [the client’s toughness] that would put half a smile on his face. I’d like to think that he looked back on those conversations later and thought, ‘Hey, maybe that guy was on to something and I can use this thing that I’ve got for a different purpose.’”

At the same time, Martin cautions that a counselor’s interest in and excitement about clients has to be sincere, particularly with those who don’t want to be in counseling in the first place. “If you fake it, they will smell it, and they will hate you more than ever,” Martin says.

At the end of the day, a counselor’s authentic desire and determination to connect may be at the heart of the therapeutic alliance.

“Maybe I am young and naïve, but I think that you can really find something intriguing, redeemable or enjoyable about any client,” Martin asserts. “If you dig hard enough, you’re going to find something about the kid that’s going to make you want to come back the next week. And once they sense that about you, it’s a game changer like no other.”

****

Jeffrey Kottler and Richard Balkin will be giving a keynote on “The Power of Relationships in Counseling — and the Counselor’s Life” at the ACA Conference & Expo in Orlando, Florida, in March.

****

To contact the individuals interviewed for this article, email:

 

****

 

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

Letters to the editor: ct@counseling.org

****

No, I didn’t! Denial revisited

By Michael Hubbard July 7, 2014

denialGiven that I thought I’d cultivated my listening skills, it was uncharacteristic of me to so abruptly interrupt a patient who felt compelled to plead his court case of a criminal charge in group therapy. We in group, of course, were experiencing the very common occurrence of denial.

As part of a program in a largely forensic mental institution, our clinicians are primarily working with individuals convicted of some offense and admitted under the “guilty except for insanity” (GEI) determination. More specifically, my team’s sex offender treatment program works with those who have a sex offense conviction in their history and/or have been sexually assaultive or otherwise sexually inappropriate in the hospital.

Yet to take it out of the forensic arena, most counselors will have any number of client cases in which some form of denial may also play a central role. We see denial and so-called “resistance” in couples counseling, in family counseling and when working with any age and circumstance. We witness denial in issues of death and dying or with clients and families dealing with serious or terminal illness. And what counselor working in the drug and alcohol, gambling and other addictions field wouldn’t agree that denial is a hallmark in that client population? Ultimately, whatever level of denial we experience may be perceived as resistance and a barrier to treatment.

 

There are all kinds

While there are multiple types and levels of denial, most are ultimately rooted in avoiding or mitigating responsibility and accountability, generally more along the lines of minimizing or redefining behavior. Yet I have worked with some clients who engage in denial of facts, especially in the initial sessions. This is the classic denial of their offense or some other behavior. It’s also the very common default or impulsive defense mechanism among many of us, especially at a young age (“No, I didn’t break that window”).

In the case of the patient I interrupted, he not only denied the offense (a rape charge), he also denied any transgression in his entire life. Further, he was more focused on pleading his case with the group members and clinicians than on his treatment.

More common, however, are all the other types of denial. Many sex offenders with whom I have worked will engage in denial of impact or harm (“I only fondled her”), even if they admit to their offense. I see this often in cases of attempted rape, wherein the prevailing, and mistaken, attitude is often that there is less trauma if there was no penetration.

Yet we see that same perspective in other forms of rationalization (“Children are resilient; he’ll forget it”), in couples and family disagreements (“It’s always drama with her, so we don’t take her threats of suicide seriously”) and with other situations. Those who work with grief and bereavement will very likely identify with the upset client whose friends, family members or other acquaintances deliver minimizing and rather dismissive statements such as “time to move on,” “don’t dwell on it,” “get over it” and, of course, the trite “time will heal.”

Denial of intent is another common excuse (“It got out of control”). In my work, I’m often subjected to a curious phrase regarding date rape: “There we were … and it just happened,” thus jettisoning the fantasizing, the grooming and all the other behaviors that led up to a life-altering result.

Denial of responsibility, which is related to denial of intent, does not necessarily deny behavior, but is more along the lines of shifting blame. An example most of us have heard, particularly in working with children, is “He started it first.” In a more bizarre example, however, I had a client who was talking about a college female who was raped. His comment was, “Well, it happened in a fraternity. She should have known what was going to happen because that’s what happens at frat houses.”

There are many other types of denial, of course, including a minimizing form — denial of frequency (“It only happened once”) — and denial of fantasy (“I only fantasize about my girlfriend in a healthy way”). That fantasy example was voiced by a hypersexual patient who had molested many young boys over the years. He was engaging in impression management to impart an image of his engaging only in appropriate fantasies.

 

Do I really need this?

One important form of denial affects almost all counselors and other clinicians: denial of treatment need. Many clients with whom I’ve worked say, “I’ve learned my lesson. I’ll never do that again.” While they may genuinely believe that, what they’re overlooking is that they may not have examined the circumstances that led to their offenses, their triggers and risk factors and, thus, what interventions to use. Yet this type of denial isn’t the sole property of those who have engaged in some form of criminal activity.

Many counselors in various settings deal with individuals who have been “coerced” into making appointments. It may be someone with gambling, alcohol or other addictions forced into treatment by families, friends or even a workplace supervisor. It may be someone who had a “dirty” urinalysis at work and was suspended until he or she engaged in some mandatory employee assistance program (EAP) sessions. Few of these individuals show up feeling the need for treatment, especially if it was not their choice.

Often, resistant clients show up in family counseling. These may be teenagers or others with behavioral issues, or a spouse with relationship problems, depression, sexual dysfunction or other presentations. Many of these clients feel that they don’t need counseling, or even if they agree to the need, they are embarrassed to be seeking mental health counseling. Stigma exacerbates a natural tendency to deny.

Many of the individuals pushed into counseling may feel that the problem is with their partner, their parents or with other relatives or friends. Even among those who admit to some level of treatment need or recognize a problem, many prefer to participate in the multibillion-dollar self-help industry of books and videos. Yet is that so very different from those who deny a disease or who think that they can lose weight or otherwise regain some level of health on their own through use of a book or video? The question remains whether an individual who feels confident in self-healing is still engaging in a form of denial. Perhaps so, but with placebo or other effect in place, does it matter if the outcomes are positive?

It may be important to explore why denial occurs in our clients, but a key question is whether denial is a deal killer in treatment. It may seem, for instance, that working with an offender who denies his or her crime is a barrier, but there are many who would disagree with that premise.

 

Does it matter?

In the world of sex offender treatment, most community-based and residential programs in the United States consider taking responsibility for offenses a key component of treatment. That would be defined as a disclosure or admission at least approximating police and victim reports, even if the offender minimizes or engages in other forms of denial. Use of polygraphs is also a common practice. In fact, it is generally a condition of parole.

By comparison, no Canadian sex offender programs require full admission of guilt, and one report indicates that only approximately 26 percent of Canadian community-based programs require any offense disclosure at all (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2010). That may seem counterintuitive. After all, how can one deal with any situation — whether offense-related or not — if the client denies its occurrence? The answer may rest in what we as clinicians are seeking, both in mining for information helpful in therapy and as an outcome.

But does it matter? While it would seem logical that issues are difficult to address if denied, in the sex offender world at least, data are indicating very little correlation between denial and recidivism. Some, in fact, would point out that denial is an indicator that the offender is well aware, and ashamed, that the act was inappropriate or deviant, in addition to being illegal. In such cases, perhaps our clinical attention is distracted by their denial and should be emphasized elsewhere (e.g., social skills, healthy relationships, etc.).

For those clinicians who believe that client denial does matter, some point to other contributing factors to denial, including the milieu. For instance, in group therapy, it’s reasonable to believe that initial denial would be both common and understandable, particularly with an individual newly introduced to the group. Safety and trust must generally be established. It’s the rare client who is willing to share his or her failures in front of strangers.

Yet one source of help is when the newer clients in group realize that there are others in the same boat, that they’re not alone and that there is support. While this is one of the many advantages of group therapy, a step-up approach with motivational interviewing and alliance-building in individual sessions may be required.

Even in smaller situations such as couples counseling, the sharing may be difficult at first. Yet there are also other dynamics involved in couples and family counseling, such as clients seeking support for “their side,” the fight over “right and wrong,” couples utilizing other techniques (e.g., manipulation) and the perceived or actual issues (even if they aren’t obvious to the clients).

 

Who’s responsible?

It’s far too easy for many of us to say that a client is “in denial” or “resistant.” As stated earlier, many U.S.-based sex offender programs require accountability, including reasonable admission of offenses, with the implication that treatment could be withheld if the offender refuses or resists.

Whether or not it matters may be determined on an individual basis. If it is deemed important, and if there is resistance, might this not be a responsivity issue? And if so, should we not be responsible ourselves as the clinicians?

Our program here is on a risk/needs/responsivity model. Simply put, higher-risk patients receive more intense treatment than those assessed at lower risk. Patient needs, including dynamic risk factors, are addressed as important factors in treatment. Responsivity is an indication of the patient’s response to and/or acceptance and digestion of the treatment approach, as well as a measure of the clinician’s ability to provide the service that will be most accepted.

So while we may feel justified in indicating that a patient’s intransigence is a barrier to treatment, are we not responsible on some level for treatment failure if we are not experiencing a response? And if we assume that responsibility, is it not our task to continue the search for treatment to which the patient may respond? Can we achieve a measurable outcome even in the face of denial? Obviously, some programs believe so. But how?

In a forensic setting, we’re seeking risk mitigation — simply put, to achieve a goal of returning the patient to the community without that individual committing another offense. But can risk mitigation be achieved even if the patient refuses to take responsibility for his offenses? Perhaps so if we’re able to work with the patient to discuss all the circumstances and other factors surrounding the offense. I call this the “backdoor approach.”

For instance, if a patient is willing to discuss what was going on in his or her life prior to, during and even after an offense — even without admitting to an offense — we may be able to identify and point out behavioral patterns and/or circumstances that would be considered potentially contributory to an offense. For example, while not necessarily an excuse for offending, if the patient states that he or she was on methamphetamine or other substances, a risk factor emerges.

I have had patients indicate that their offenses occurred after a break-up or during a rough period in a relationship. Regardless of whether one believes that watching pornography is pre-offense behavior, many have indicated that they turned more and more to porn after a break-up or during a period of no sexual activity, and sought other outlets. Alcohol and drug use has been cited as one of the more common outlets.

Of course, in our setting in a mental institution, there are also contributory situations of a patient going off medication or otherwise decompensating, leading to offense-related behavior. Stress and other situations can be explored, patterns noted and, thus, risk factors identified. Even in cases in which the offense is denied, the patient is often able to see what situations set up as being more risk-related scenarios — and thus their vulnerabilities. Risk mitigation can then be effected on some level by addressing the vulnerabilities through appropriate interventions.

This same approach would be viable in couples counseling, family counseling and other similar forms of counseling. In short, we can examine environmental and other issues that trigger emotions, thoughts and consequential behavior in our clients. This approach relates to a form of mindfulness in which clients can step away and look at external influences, perhaps setting aside blame and personalized issues in the process.

 

Ethical issues

While considering the reasons for denial, and strategies to achieve some outcome, the topic is not without some ethical issues. The preamble of the 2014 ACA Code of Ethics reads in part:

“These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

autonomy, or fostering the right to control the direction of one’s life;

nonmaleficence, or avoiding actions that cause harm;

beneficence, or working for the good of the individual and society by promoting mental health and well-being;

justice, or treating individuals equitably and fostering fairness and equality;

fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships; and

veracity, or dealing truthfully with individuals with whom counselors come into professional contact.”

In attempts to deal with denial, are there iatrogenic factors present in our demand for disclosure that would constitute maleficence? And where do we stand, and how would we know, if the person indeed did not commit an offense? If, in our cases, a denier passes a polygraph, does that carry any weight, notwithstanding admissibility (or not) in court, police reports or other materials?

Would it be ethical to “treat” someone for something they did not do; or do we treat based upon all the other findings, regardless of the client’s adamant stance? Are we out of our scope of practice if drawn into the legal questions? We must be mindful of these ACA ethics standards:

 

B.1.b. Respect for Privacy

Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

 

B.1.c. Respect for Confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

 

B.2.e. Minimal Disclosure

To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

 

These questions may all lead to what boundaries we draw regarding working with denial. It is likely an easier decision when there is no denial of fact, but rather the more often expected “lesser” denials. Yet, as in all cases, we must consider potential iatrogenic effects. When we consider how very much we detest denial in our society, and yet forgive confession, it behooves us to explore our goal as counselors when denial is a key factor.

We might want to examine whether our goal is an outcome we can achieve by other means, or whether we are so outraged at the “lies” that we become committed to “breaking” someone.

 

****

Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

 

For related reading, see Hubbard’s article from the April 2014 issue of Counseling Today: Sex offender therapy: A battle on multiple fronts

 

Managing resistant clients

By Lynne Shallcross February 14, 2010

You can’t change anyone else; you can only change yourself. Many counselors have used this common bit of wisdom to help clients overcome problems, but it’s crucial that counselors internalize that idea themselves, says Clifton Mitchell, a professor and coordinator of the community agency concentration in the counseling program at East Tennessee State University.

“We tell our clients things like, ’You can’t change other people; you can only change yourself.’ Then we go into a session trying to change our clients. This is hypocritical,” says Mitchell, the author of Effective Techniques for Dealing With Highly Resistant Clients, which is in its second edition. “I teach, ’You can’t change your clients. You can only change how you interact with your clients and hope that change results. That’s all you get.’”

Counseling-theoriesThe concept of counselors focusing exclusively on their interactions with clients and letting change happen on its own is key to the successful management of resistance and the pivotal point of effective therapy, says Mitchell. For 10 years, the American Counseling Association member has studied and presented seminars on dealing with resistance in therapy. “Although most therapists have been trained extensively in theoretical approaches, few have had extensive training in dealing with resistance,” he says.

Conventional thought defines resistance as something that comes from within the client. In other words, says Mitchell, “If you’re not buying what I’m selling, you’re resistant. Those definitions have existed for years in the mental health literature. The problem with that is it makes it difficult to do something about it.”

But times and definitions of resistance have changed, he says, removing the blame for resistance from the client and putting the responsibility squarely on the shoulders of counselors. Modern definitions come from social interaction theory, Mitchell says, and indicate that resistance doesn’t exist until a counselor and client have a conversation; resistance is borne out of the interaction style. “This says if what you’re doing with the client is not working, then do something else because your interaction is creating resistance,” he says. “The beauty of viewing resistance from a social interaction theory is we’re empowering ourselves to do something about it.” Mitchell defines resistance as something “created when the method of influence is mismatched with the client’s current propensity to accept the manner in which the influence is delivered.”

When counselors label a client’s behavior as resistant, typically, one of two things has occurred, Mitchell says. “Either we do not have a technique to manage what is going on in the interaction at the moment, or we do not understand enough about the client’s world to understand why they are responding the way they are. So, we label them as resistant as a result of our inability and lack of therapeutic skills. There is always a reason the client is responding the way they are. Our job is to understand the client’s world to the degree that we see their behavior for what it is and not as resistance.”

Another shift in thinking that can benefit counselors? Accept that resistance isn’t always inappropriate, says Robert Wubbolding, director of training for the William Glasser Institute and director of the Center for Reality Therapy in Cincinnati. “It is a client’s best attempt to meet their needs, especially their need for power or accomplishment,” says Wubbolding, an ACA member and professor emeritus at Xavier University. “Resistance is a universal behavior chosen by most people at various times. Sales resistance is helpful for the purpose of practicing thrift and saving money.”

Clients are sometimes resistant because the counselor is asking them to deal with an undesired agenda, Wubbolding says. “Resistance means we’re working on the wrong problem a problem that the client doesn’t care to work on. Counselors need to connect with the client in order to find the right problem. I suggest connecting on the basis of clients’ perceived locus of control. Many clients resist because counselors focus too quickly on the clients’ feelings, behaviors or sense of responsibility. If a client resists because they feel everyone else has the problem, then focusing on the client presents a miscommunication.”

A dose of reality

Wubbolding uses a reality therapy approach to reduce resistance. “The counselor needs to help (clients) see that their resistance is not to their advantage,” he says. “As a teacher and practitioner of reality therapy, I suggest that the counselor begin by asking clients what other people in their environment are doing to them, how they oppress them, reject them, make unreasonable demands on them and control them. It is important for counselors to connect with clients on the basis of the client’s reality rather than putting emphasis on the counselor’s agenda. In other words, the counselor may want the client to make better choices, but without connecting with the client’s perceptions in the beginning of the counseling process, the counselor might facilitate more resistance rather than less.”

“Then,” Wubbolding continues, “the counselor can help clients explore what they’ve done to get people off their back and to do what they want them to do. The key here is questions focusing on self-evaluation such as, ’Have your efforts been successful?’ Clearly, they have not been successful, so when clients decide that what they’ve been doing is not working for them, they are more inclined to make alternative choices. Thus, self-evaluation is key in dealing with resistance.” Wubbolding offers the example of a teenager who is flunking out of school, taking drugs and being rebellious toward school personnel and his parents. “Connecting with this individual on the basis of perceived victimhood and external control is often effective and serves as a basis for asking crucial questions: Have you tried to tell these people to leave you alone? How have you tried? Is what you’re doing to get them off your back working? Is there any chance that telling them one more time is going to do the trick?”

“It seems to me,” Wubbolding might tell this resistant client, “that you have two choices” to continue down your current path or to choose a different path. “You can continue to do what’s not working, or you could try something different. One road maintains the misery you (currently) have and will probably make it worse. The other road will more than likely help you if you’re willing to give it a try.”

“After connecting with the clients’ perceptions, their sense of external control or sense of being controlled,” Wubbolding says, “the counselor can proceed to inquire as to whose behavior the client can control, what choices are available and whether making a change is either possible or desirous.”

A two-way street

Newer definitions of resistance empower counselors to exert more control and influence over the situation, Mitchell says, but these definitions also place great responsibility on practitioners to keep things moving forward. “If you feel your client is resisting you, you also must be resisting your client,” Mitchell says. “Resistance goes two ways. The challenge is having to find more creative and different ways to interact.”

It’s a task worth tackling, Mitchell contends, because the degree to which a counselor effectively manages resistance can determine whether therapy is successful. “Therapeutic outcomes are determined by how well we manage the places in therapy where ’stuckness’ appears to occur,” he says.

The counselor-client relationship is key to helping the client move forward, Wubbolding says. “Clients are less resistant if they feel connected with the counselor. If counseling is to be successful, the client must be willing to discuss the issue, examine it and make plans. If clients will not disclose their inner wants, actions, feelings and thinking, change is very difficult. But in the context of a safe, trusting relationship, they are more likely to disclose such information. After clients lower their defenses, they can then more freely discuss their inner thoughts and feelings. After this occurs, the counselor can help them conduct a more fearless self-evaluation.”

Also important, Mitchell says, is having a mutually agreed-upon goal. It’s all too easy for counselors to put themselves in situations where they have a goal in mind for the client, but the client either isn’t aware of or doesn’t agree with that goal. If the client-counselor relationship is key to good outcomes, Mitchell says, a mutually agreed-upon goal is the key to a good client-counselor relationship.

Mitchell admits that receiving “I don’t know” answers from clients can be frustrating and make counselors feel as though they aren’t getting anywhere in session. But he advises counselors not to grow discouraged or to waste time fighting the client’s response.

Responding, “Oh, yes, you know the answer,” will only create resistance and force the client into a defensive position, Mitchell says. “The safest way to respond to an ’I don’t know’ response is to accept it, embrace it and empathize with it,” he says. “If you do that, you will decrease the defensiveness that comes with fighting it.”

If a counselor empathizes with the client and agrees that the problem is difficult to figure out, the counselor is indicating that he or she is joining the client in the attempt to find a solution, Mitchell says. Too often, he adds, counselors make the mistake of treating an “I don’t know” answer as a barrier rather than an opportunity to work with the client. “Use it as a doorway into the struggle,” he says. “Most people don’t realize it’s a great place to get to.” Assuming the role of “expert” can also get counselors into trouble with resistant clients, Mitchell says. When a counselor gives ideas or suggestions related to a client’s problems and starts hearing “Yes, but …” answers, it’s time for the counselor to vacate the expert seat, he says. “You need to stay in a naïve, puzzled, unknowing, curious position. You need to not have knowledge; you need the client explaining to you. We want them talking, not us talking. If you’re not buying what I’m selling, I need to quit selling.” Encouraging clients to analyze their situation and explain it to the counselor is important, Mitchell says, because in the process, they might discover insight for improving the situation.

Mitchell also exhorts counselors to do the unexpected. “Typical responses beget typical answers, and typical reactions keep clients stuck in their situation,” he says. “Resistance is fueled by the commonplace. The client is likely expecting the same type of response from you and already has a rebuttal waiting. If socially typical responses were effective, we would not need therapists. Why do the unexpected? It disrupts patterns of thinking and responding a key to creating change.”

Perhaps the best way for counselors to avoid resistance with clients is to allow change to happen on its own, Mitchell says. If a counselor enters the therapeutic relationship and pushes the client to change before that person is ready, resistance will be the likely result, he says. Instead, he advises counselors to simply listen to the client and focus on not creating resistance and not fostering defensiveness. Then, step back and let change happen, he says. “If you go in there and make not creating resistance your first priority and let the change come as a second priority, with highly resistant clients, you’re more likely to get change.”

Quick tips

Counseling Today asked Mitchell and Wubbolding to weigh in with their best recommendations for managing resistance in the counseling relationship.

  • “Stay out of the ’expert’ position,” Mitchell says. “The more resistant the client, the less knowledge you should profess to know. The more motivated the client, the more knowledge you can express.”
  • “Don’t collude with clients’ excuses,” Wubbolding says. “Don’t buy into and encourage feelings of victimhood and powerlessness. Discussion of these perceptions are useful in the beginning of the counseling session, but the counselor needs to move beyond them and lead the client beyond them. There is a French saying, Qui s’excuse s’accuse. Whoever excuses, accuses. Facilitating feelings of powerlessness only communicates to clients that they are powerless. This is a disservice to them.” Empathize, but don’t sympathize, he says. “Try to see the client’s point of view without communicating a sense of victimhood.”
  • “When you encounter resistance, slow the pace,” Mitchell says. “Trying to go too fast is a perfect way to increase resistance. Only take baby steps with resistant clients.”
  • “Don’t argue,” Wubbolding says. “This creates more resistance.”
  • “Focus on details. The devil is in the details, and so are all solutions,” Mitchell says. “Details create options. If you do not have enough options, you do not have enough details about what is occurring in the client’s situation. All therapeutic breakthroughs come from addressing and processing a detail in the client’s life that no one has ever discussed and processed before.”
  • Leave blame out of it, Wubbolding says. “Don’t blame the client, and don’t blame the people they think are creating their problems.”
  • “Always treat the resistance with respect,” Mitchell says. “The client has a reason for what they just said, (so) respect it.”
  • “Seek emotionally compelling reasons for change,” Mitchell says. “Do not waste time trying to create change through logic. If people changed because of logic, nobody would smoke or drink and everyone would have an exercise program and get eight hours of sleep. When people make major changes in their life, they don’t do it because of logic. They do it because they have an emotionally compelling reason.”
  • “Stay out of an excessive questioning mode of responding with resistant clients,” Mitchell says. “Questions are micro-confrontations with resistant clients that invite unproductive answers. Excessive questioning is the primary means by which therapists get sucked into the client’s ’stuckness.’ Learn to dialogue without questions.”

Ultimately, all therapy comes down to the successful management of resistance, Mitchell says. “Most therapists approach clients from the perspective of creating change. They would benefit themselves greatly if they would approach clients from the perspective of not creating resistance and let change occur as a natural result of the client exploring his or her own world.”

 

****

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org. Letters to the editor: ct@counseling.org.