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Editor's Note By Rich Simon

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When the Tough Get Therapy

As therapists, many of us practice in two different worlds. In the first, we see polite, well-behaved, articulate clients with solid values—often middle-class professionals like ourselves. They engage fully in therapy, talk cogently about their problems, listen attentively to our responses, make reasonably good-faith efforts to follow our suggestions, and sooner or later get better. No wonder we genuinely like these people! If it didn’t smack of countertransference and ethical compromise, we might actually enjoy hanging out with them socially. How could we not? They so beautifully reinforce in us the notion that we’re really damned good therapists!

Then there’s the other, darker world, populated by clients who almost never follow the rules for good-client deportment. They yell at us, manipulate us, go broodingly silent on us, have uncontrollable emotional breakdowns in session, disappear for weeks at a time, ignore our advice, and later blame us when their lives don’t improve. The normal rules of genteel reciprocity, so willingly respected by our “nice” clients, are routinely trashed by these “tough customers.” Oddly, they don’t seem to care whether they reinforce our good opinions of ourselves and our clinical expertise.

These clients raise the clinical temperature far above our usual lukewarm comfort zone, and with sweat metaphorically pouring down our faces, we often respond to our own ineffectiveness and sense of incompetence via the good, old-fashioned expedient of professional name-calling: the problem isn’t us, it’s them—they’re borderline, narcissistic, resistant, impossible, hopeless.

This response isn’t useful to us or to these poor souls, who stand among the most wounded of the people we see, the clients most needing our help. You might even say that if psychotherapy aspires to be more than just soothing ministrations to the worried well, these difficult people are perhaps the most deserving of good therapy and a major justification for our profession in the first place.

But treating these toughies requires something more from us than business as usual. We can’t afford to cruise along on “therapeutic instinct,” hoping we’ll never be genuinely tested. The clients of this second, more challenging world require us to exert ourselves in ways that are often uncomfortable. After all, we aren’t used to feeling unbalanced and vulnerable in sessions, to having so many of our own deep issues triggered. With these clients, we need to learn not only to tolerate our own discomfort, but to fine-tune our awareness of what’s happening, moment to moment, in both them and us. We need to join them fully in grappling with their demons. This isn’t the same kind of work as spending an hour talking quietly with an appreciative client who’d never dream of exploding in therapy or stalking you.

Working with these challenging clients is, of course, what the craft of therapy is all about. The effective therapist can’t make headway with such clients simply through empathy, niceness, and a desire to make them feel better. While this may be the hardest work you’ll ever do, the contributors in this issue make the case that, if you give it the time, attention, and attitude it deserves, it can be the most rewarding.

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1 Comment

  • Comment Link Sunday, 07 July 2013 21:30 posted by Robert Hennelly

    Your recent articles on resistance provided many helpful insights into a very complex and multi-layered phenomenon. However, I was disappointed that Clifton Mitchell [“Is Resistance Dead”] was dismissive of psychodynamic perspectives. He cites classical Freudian theory from 100 years ago without acknowledging the rich contribution to understanding resistance made by later developments in psychodynamic theory found, for example, in object relations theory and self psychology. What Mr. Mitchell did by ignoring the development of psychodynamic theory over the past century is tantamount to suggesting that learning theory did not develop beyond Pavlov’s dogs or Watson’s experiments with mice in his basement laboratory at the University of Chicago more than a century ago. William Dougherty [“When Therapy Is Going Nowhere”] offered valuable guidance on how to resolve resistance issues, or how to avoid them altogether. At the same time, a discussion of the differences between resistance and defenses, as well as the interplay between them, would have made his advice on resistance even more helpful. Such a discussion would invariably lead to the recognition that resistance, like defenses, is often employed to avoid emotional pain or unthinkable thoughts that a client may find overwhelming. Because there are competing theories of personality, all of which are supported by research and all of which have different psychotherapy modalities, it seems that a comprehensive approach that draws from different schools of psychotherapy would provide the best guidance for dealing effectively with complex issues like resistance.
    R. Kevin Hennelly, MA, MS, JD is a psychotherapist in Santa Fe, NM who specializes in treating co-occurring and attachment-related disorders.