By Rich Simon As a young therapist in a residential treatment center during the late ‘70s, I once worked with a 15-year-old delinquent boy—incarcerated for some offense that would seem comparatively minor today—and his tumultuous family. When the boy was ten, his father (divorced from his mother and living in a different state) changed genders—a fact he first “announced” to his young son, who had come to visit, by suddenly putting on a dress and high heels soon after picking up the boy at the airport.
It was a moment that the boy had secretly replayed over and over again in head. But on the surface, he was a tough, abrasive kid who tangled regularly with his rigidly authoritarian stepfather while his mom looked on helplessly until both decided to kick the boy out. Eventually, all three ended up in my office for what seemed like an eternity of increasingly hopeless sessions.
Any one of the issues in the boy’s background—rejection by not one, but two fathers, sexual identity, trauma, his mother’s remarriage and implicit betrayal of him, the deep shame and fear he hid beneath a veneer of aggression—would have been more than enough for me. All I can remember now about those stressful hours—besides the boy’s palpable rage, the mother’s teary-eyed confusion, the stepfather’s disgust with me for not being tougher on his stepson—was the overwhelming sense that I was completely out of my depth and sinking fast. Eventually, the family dropped out of treatment and, along with the shamed feeling that I had failed them, I have to admit I also felt undeniable relief.
For all I knew at the time, I was the only therapist who had ever had such an experience. We inhabit a field that thrives on hearing about thrilling new treatment models and therapeutic geniuses who never met a disorder they couldn’t cure, a client whose life they couldn’t transform. But we don’t even know how to talk about the more realistic scenario in the practices of most clinicians, the cases that don’t really pan out quite the way we had hoped, not to mention those terrible cases that even years afterward have the power to make us cringe.
Fortunately, at this stage in the development of our field, it’s become clear that there are certain types of clients that severely challenge most of us, and demand exceptional skill and knowledge. In our webcast series, Tough Customers: Treating Clients with Challenging Issues, we’ve asked experts in treating borderline, narcissistic, attachment-disordered, and self-destructive clients to share the practical lessons they’ve learned about working more effectively with these troubled treatment populations. Rather than keeping our failures to ourselves or just stewing in our sense of frustration, incompetence, and anger, this series offers a nuts-and-bolts look at more effective strategies for handling our most challenging cases. I think it will open up new possibilities for you in helping the clients who haunt you long after their sessions are over.
Treating Clients with Challenging Issues
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