It’s a sunny day in April. The dogwood tree outside my office building has exploded into blossom. I’ve cracked open a window, and robins chirp outside. One of them, orange breasted, scuttles along the ledge, pausing inches from the chair my next client will soon occupy. I hear footsteps in the hall: a sharp, abrupt series of clacks. My chest tightens. Camilla has arrived.
A white, middle-aged, legal assistant I’ve seen for three sessions, she has spread her purse, shawl, and shopping bag across the couch in my waiting room. As I open the door to greet her, she tears a page from one of the magazines I leave out for clients and slips it into her purse. Then she rises, gathers her things, and slices past me into my office. Her irritability isn’t visible to the naked eye, but I can sense it crackling around her. Closing the door behind us, I glimpse the robin careening away from the window. Lucky, I think. What I wouldn’t do to fly away like that right now!
“Aren’t you going to ask me how I am?” Camilla says after a long silence.
“How are you?” I take her literally, making my first mistake of the session.
“I’m miserable, thank you,” she sneers. “Same as last week. My ex still hasn’t paid me the rent he owes. What a lowlife! I’ll never find peace till I get that money.”
“How is that to depend on him for your peace?”
“Jesus!” Camilla snaps. “Are you even listening to me? I told you. I’m miserable.”
“Are there feelings that go with ‘miserable?’” I press.
“Why?” She draws out the vowel sound into one long syllable as she incrementally raises her voice. “When I tell you my feelings, you ask what feelings go with my feelings. It’s annoying!”
“Well, ‘miserable’ is more of an interpretation than a feeling,” I say, committing my second mistake of the session. Now, I’m in a debate about semantics. “Could we pay attention to what’s going on in your body right now?” But it’s too late; she’s on a roll.
“What are your feelings about this? What are your feelings about that? I could make a recording of you asking that over and over and have therapy by myself. Why do I pay for this nonsense?”
“You feel strongly—.”
“I feel miserable!” she interrupts. “Do you need a hearing aid?”
Camilla grew up with a father who, like me, was a therapist—which may explain, at least in part, her antagonism toward me. Despite being a mental health professional, her father had failed to recognize his own bipolar diagnosis. He got excited about inventing new gadgets and trying to patent them, and when nobody paid him millions for his creations, he sank into weeklong depressive episodes. Since his death, Camilla has struggled with explosive romantic relationships.
The hot, prickly sensation I’ve come to recognize as anger moves through my torso, neck, and arms. I know Camilla’s contempt protects her from being vulnerable. A strong, vicious offense is a powerful defense against being disappointed, hurt, neglected, invalidated, rejected, and betrayed. I have plenty of theories about why she and other antagonistic clients undermine my attempts to support them, but my theories aren’t always enough to keep me mentally sharp and flexible in a way that translates into helpful clinical interventions.
“Have you noticed we seem to get into these power struggles in our sessions?” I ask.
“I say it like it is,” Camilla says. “That’s just who I am. I hate bullshit. And when we started therapy, you said you welcomed my feedback.”
“I did, and I also said our first few sessions would be trial therapy,” I remind her, making my final, and worst, mistake of our session.
“What’s your point?” She stares out the window.
“I’m unsure about whether I’m the right therapist for you or if I can offer you what you need,” I say. “I’m wondering if maybe a different therapist might be a better fit.”
“Basically, you’re getting rid of me.” There is a catch in Camilla’s throat, but she’s also smiling broadly. Was she expecting this? Is she sad or happy? Her eyes narrow. “That’s fine, I get it. We gave it our best shot, and it didn’t work out. Yup, let’s go with a referral. Who do you recommend?”
Keeping it Intrapsychic
I’ve always gravitated toward theoretical frameworks that fit my personality. I suspect many therapists do. When we’re good at something, it makes sense that we try to do what we’re good at more often. When we don’t do something well, we naturally do it less, and as a result, continue to find it challenging. This becomes a loop, reinforcing both our strengths and our weaknesses. Most clinical approaches I’ve studied—from integrative psychodynamic therapies to emotion and attachment-based approaches—amplify the clinical and interpersonal skills I’m already naturally good at, like being attuned and empathetic, following another’s lead, prioritizing feelings, and aspiring to be clients’ “true other”—a term used in Accelerated Experiential Dynamic Psychotherapy for moments when a clinician is there for a client in some powerful, emotionally corrective way.
I inadvertently honed many of these skills in my own high-conflict, walk-on-eggshells-or-get-blasted-to-smithereens family of origin. But even if my early home environment had been more peaceful than it was, I might still have ended up becoming a conflict-avoidant adult. Attributing conflict avoidance solely to early trauma oversimplifies it. In fact, you could argue—and many have—that conflict avoidance is a sociobiological side-effect of being human.
We all want to be liked.
“You can’t be a therapist and a conflict seeker,” says integrative trauma specialist Janina Fisher, who uses Sensorimotor Psychotherapy, EMDR, Internal Family Systems, and other modalities with trauma survivors. “If you enjoy conflict, you generally choose a different field. Most therapists try to avoid empathic failure, and to do that, you have to be conflict averse. I look at it as an adaptive skill—except when it’s not.”
The “when it’s not” part of conflict avoidance has been an ongoing issue for me with antagonistic clients. As I’ve looked for effective ways of working with people who taunt, demean, and pick fights, I’ve noticed that many methodologies offered today—and even historically—fall into one of two camps: either anxiety-regulating or anxiety-welcoming. The anxiety-regulating camp is my happy place, clinically and in my nonwork-related life. Here, the therapeutic alliance is cultivated gently, with a focus on relational attunement, tracking somatic cues, facilitating emotion, and minimizing clients’ discomfort.
In the anxiety-welcoming camp, though these elements are considered important, the emphasis is placed on calling out clients’ defenses—even if that means temporarily increasing their anxiety. This is done to strengthen the therapeutic alliance through honesty, to increase awareness of ingrained defenses, to clear a path for emotion to arise, and to empower clients by resisting the temptation to rescue them. Once clients recognize their defenses and feel the suffering they cause, they can risk abandoning them in favor of healthier alternatives.
Both camps have a lot to offer therapists, even though anxiety regulators have accused anxiety welcomers of being harsh jerks better suited to trial lawyering than therapy, and anxiety welcomers have criticized anxiety regulators as being touchy-feely rescuers.
Steve Shapiro, a psychologist with 16 years of experience treating involuntarily committed clients in an emergency psychiatric hospital, thinks these therapeutic camps present a false dichotomy. Currently a certified International Experiential Dynamic Therapy Association teacher, he trains mental health professionals internationally using an active and focused method of therapy known as Intensive Short-Term Dynamic Psychotherapy (ISTDP). In his view, being skilled at regulating and welcoming anxiety increases the therapist’s range of options with different clients—or with the same client at different times.
Most clinicians have experienced the if-all-you-have-is-a-hammer-everything-looks-like-a-nail phenomenon at some point in their training—a result of clinging to a false sense of security based on the faulty belief that a single approach can simplify the complex task of psychotherapy. A solely anxiety-regulating therapist might overuse supportive interventions such as, “Wow, no wonder you do that; you had it so tough,” missing opportunities to invite stuck or unmotivated clients to stretch out of their comfort zones. A rigidly anxiety-welcoming therapist might alienate overwhelmed or anxious clients by challenging them before fostering a therapeutic alliance, saying things like, “Do you see you’re taking a helpless position?”
Although ISTDP is sometimes viewed as confrontational, Shapiro believes you can be a compassionate therapist who prioritizes anxiety regulation, like Fisher, while challenging a client to get uncomfortable—a strategy he dubs “highlight and invite.” Just as you won’t reach your fitness goals without breaking a sweat and breathing heavily, you won’t reach your emotional goals without experiencing some amount of anxiety. Growth means you’re entering a zone of uncertainty.
“If you’re being kind to your friend who’s harming themselves by withholding honest feedback,” Shapiro says, “who does that serve? Them or you? Whose anxiety are you managing? I hear therapists say, ‘I’m not challenging or interrupting my client right now even if what they’re doing affects me negatively because I’m gaining their trust.’ But if someone started cutting themselves or waving a knife in session, how long would you wait to say or do something about it? Would you wait to develop a more trusting alliance before intervening? Or do you build the alliance by calling out the elephant in the room, even when it’s hard?
“In psychotherapy, trust is built through clinical competence where the therapist is grounded, effective, flexible, attuned to emotional cues, and aware of disguised communication—not from a positive and superficial connection that ignores the harsh realities we sidestep in polite society. When therapists are courageous enough to address destructive defenses directly, clients typically have a dual reaction: their unhealthy side feels angry, while their healthy side is relieved. After all, if we as therapists don’t address the elephant in the room, who will?”
Shapiro helps trainees understand and operationalize specific principles for working with clients whose interpersonal survival strategies draw others into rescuing dynamics or power struggles. One principle, keeping the conflict intrapsychic, is a key tenet of the work. Keeping clients’ conflict intrapsychic means the uncomfortable, mixed, conflicted emotions they’re avoiding with defenses like antagonism are maintained as the focus of treatment. Rather than getting sidetracked into red-herring arguments or debates, a therapist highlights the clients’ current defense—inviting them to notice how antagonism is something they do, rather than a fixed, immutable way they are. It has a function—and a cost.
For certain clients, unconsciously creating interpersonal strife may be a reliable way to avoid painful feelings that accompany internal conflicts. By outsourcing half their conflict onto another person, they’re momentarily less torn, which reduces their emotional distress. Helping clients see how this strategy robs them of half their complexity, stokes fights, and isolates them from others can be a first step to regaining wholeness. Through this lens, clients no longer seem quite so antagonistic: they’re using a coherent protective strategy—one with tragic consequences.
Firefighters get trained to do what’s unnatural for them. As therapists, we need to be able to do what’s unnatural for us, too.
“In moments when a client devalues us,” Shapiro says, “it’s easy to take it personally. I’m always reminding myself, ‘Oh, now they’re starting to devalue. That means the heat got turned up, their anxiety got triggered, and here’s a defensive reaction.’ When I remember that, it’s not personal: it’s emotional physics. This keeps me grounded, at least on a good day. To avoid taking things personally, we need to accept our reactions to clients’ behaviors while consulting a sound theoretical map that helps us understand what’s happening clinically. Taking a client’s antagonism personally usually leads us to say some version of ‘Listen, therapy is a collaboration, and I’m wondering if I’m the right therapist for you.’”
We’re chatting about this issue on a Zoom call. Although Shapiro sits against a backdrop of books that span the length of my screen, he looks as if he’d be just as comfortable climbing mountains as doing therapy. Is he someone with special powers, I wonder, a wizard who’d magically listened in on the day of my ill-fated session with Camilla? Or is the statement I’m wondering if I’m the right therapist for you a universal copout for conflict-avoidant therapists, sort of like a lover in a fizzling-out relationship saying, “It’s not you, it’s me”?
“As soon as we respond like this,” Shapiro explains, “it means the client’s defense did its job well. The antagonism was effective. It kept us at a distance. The client took a step back and we took two steps back. You can avoid this pitfall by keeping the client’s conflict intrapsychic. You might say, ‘Do you notice this devaluing mechanism clicking in right now?’ I wouldn’t ask, ‘Do you notice you’re devaluing me?’ I’d emphasize it’s a mechanism. ‘You learned to do it to protect yourself. It’s not you; in fact, it keeps the real you hidden.’
“Then I might say, ‘Let’s think this through. If you keep using this devaluing mechanism, how will you get the help you want from me? I hear a lot of criticism, but I’m wondering if this devaluation takes you away from feelings arising toward me and our therapy?’
“Of course, I wouldn’t say all that at once, but I’d highlight the conflict between the client and themselves, rather than between them and me. That’s what secure attachment is. It’s good parenting. Rather than saying, ‘How dare you talk to me that way, go to your room!’ we say, ‘You seem upset right now. What’s going on?’ The therapist avoids an interpersonal struggle.”
Sitting at my desk, I wonder how my session with Camilla might have unfolded differently if I’d translated one or two of these principles into my work with her the day she’d exclaimed, “Why do I pay for this nonsense?”
“Do you notice this mechanism of devaluing me and the work we’re doing?” I imagine myself saying. “Could we see what happened inside you before it kicked in?”
I know a single intervention is never a magic bullet. Camilla probably would not have exclaimed, “Wow! I finally see the function of my antagonism and the toll it takes on my relationships.” But at least I would have taken a step toward her, rather than away from her.
Doing What’s Unnatural
Both Fisher and Shapiro agree: if you’re not properly trained, or don’t feel competent working with people who present with a particular cluster of symptoms or personality traits, you’re ethically bound to refer them to someone who can provide appropriate treatment.
“But I do wonder how you develop a sustainable practice referring out the hard cases,” Shapiro says. “It’s like a dentist saying, ‘This client needs an extraction; I only do cleanings.’ I find some therapists focus on defiance as the problem and underestimate or misconstrue compliance—which is also a serious barrier to connection. Like, when a client says, ‘You’re so smart. I’ve never had such great therapy. You saved my life. I’m blown away by your brilliance.’ It’s easy to assume these statements bode well for treatment, which isn’t always the case. We’re used to seeing antagonism as a problem because it’s so unpleasant. And yet compliant people also defend against connection by hiding their true self. They’re being inauthentic—superficial, pleasing, entertaining, even flirtatious. Compliance is just as destructive as defiance—maybe more so because it’s less visible. Yet people rarely say to compliant clients, ‘I can’t work with you, let’s find you a different therapist who’s a better fit.’”
Early in my career, I mistook sessions with compliant clients as the “good” ones because I hadn’t yet recognized compliance as the smiley face I painted on my own pain. Soft spoken and quick to apologize, I used to sit on the edge of my seat, eager to help, always trying to say something gentle or kind. It wasn’t until I’d worked on processing my own traumas that I began resisting the pull toward compliance and feeling what I truly felt—anger, fear, love—and inviting clients to feel more of what they truly felt with me in session.
“My field is trauma,” Fisher notes. “There’s a high proportion of trauma clients who find therapists with a soft, gentle approach triggering. Some clients come from an environment, culture, class, or socioeconomic group where conflict is normal, and gentleness feels fake to them. Also, many people who’ve been abused distrust niceness because it played a role in their abuse. Even if you’re a conflict-avoidant therapist—which I most certainly am—it’s crucial to learn how to handle conflict, confront clients about certain things, and set limits.”
Fisher didn’t have to wait long in her career to learn this lesson. When she began her internship training on an inpatient unit in a Massachusetts hospital, her first client—an 80-year-old woman with multiple health issues—fired her within 20 minutes of meeting her. “The woman appeared quite disheveled,” Fisher recounts. “Some of her clothing was on backward. It looked like she hadn’t washed her hair in weeks. I said, ‘We’re going to help you take better care of yourself,’ and it hit a nerve. She found what I said offensive—maybe because I’d made an assumption about what she wanted before really listening to her. ‘What are you suggesting?’ she yelled, pointing at me angrily. ‘You don’t know me. Who the hell do you think you are? I want a different therapist!’
“There I was, a psychology intern on my first day with my first client, and I’d failed. I found a stairwell, sat on the top step, and cried. I was devastated. At some point, the head nurse opened the door and said, ‘What’s wrong?’ I told her I’d been fired by a client, and she said, ‘Good for you! You hit a hot button, so you did something right.’ That helped me think about things differently. A client becoming antagonistic doesn’t mean we’ve failed as therapists. Sometimes it means we’ve touched on something sensitive and important.”
Fisher’s story reminds me of a simple but empowering principle I’ve heard teachers and trainers share across modalities and camps: a therapist’s intervention is never just what they say or do—a single arrow that moves from therapist to client. It’s a feedback loop between therapist and client: two arrows. It includes the client’s response. Effective therapy explores both arrows, especially hot buttons we touch that set clients off. The challenge for therapists is maintaining a curious and exploratory stance. We get attached to our theories, sometimes forgetting that every one of our thoughts and responses represents a hypothesis that a client may confirm or deny. When we ask, “What was it about what I just said that triggered a reaction in you?” we’re entering into a collaborative exploration of unknown territory.
“Anxiety-regulating ways of doing therapy focus on bypassing defenses with empathy or inviting clients to set defenses aside,” Shapiro says. “And it would be great if softer techniques always worked. But with many clients, they don’t. We need to be able to challenge clients’ defenses, and that’s hard. It’s unnatural. Think about a surgeon. Medical students often faint when they first cut a body open because most people aren’t inclined to cut other people open. It’s the same with firefighters. When a building is burning, our instinct is to run away from the flames, not into them. Surgeons and firefighters get trained to do what’s unnatural for them. As therapists, we need to be able to do what’s unnatural for us, too. A surgeon has special permission to cut someone open. A firefighter has special permission to enter a burning house. As therapists, we have special permission to address clients’ antagonism and their other entrenched defenses to help them meet their goals, even if this means going somewhere that’s normally off limits. But without training, practice, and a map guiding us, we get lost.”
In my case, when a client like Camilla becomes antagonistic, I take it personally, think I’ve failed as a therapist, or get mad at the client for being difficult. I’ve always known my clients’ antagonism frightens me, but what I haven’t always been aware of is that my own antagonism frightens me even more. I’ve explored this in clinical supervision and individual therapy. In high-conflict moments in session, I intellectualize, repress my feelings, or become cloyingly empathetic. My frustration with clients gets masked and hidden.
Staying connected to what’s happening inside me while remaining curious about my antagonistic client’s internal experience does indeed feel like the psychotherapeutic equivalent of entering a burning building—or maybe even two burning buildings at once. My instinct is to run as fast as I can in the opposite direction.
Unlike with surgeons or firefighters, our tools as therapists are personal because we are the tools. Consequently, examining our relationship to anger and conflict is often vulnerable and anxiety provoking. It’s tempting to ignore it by focusing exclusively on the client’s contribution. This is easy to do with clients who provide plenty of provocative material to focus on.
You’re More Messed up Than I Am
Although I’ve only ever connected with Janina Fisher on a screen, her benevolence is palpable. She has an easy laugh. Her abundant, curly hair frames sparkling eyes and round, pink cheeks. I realize that the reason it’s hard to imagine her being confrontational is because she reminds me of a fairy godmother. Developing a tolerance for conflict has taken her more than 20 years, she confesses, and she’s always learning new tricks. One of them has to do with accessing more of her own intensity and energy in situations where clients are combative.
“For me, saying ‘You may not speak to me that way in my office’ is too confrontational,” she admits, “but I can say, ‘Oh, you’re fucking pissed off, aren’t you?’ When I match a client’s energy, or use their language, I’m not just connecting with them: I’m communicating ‘I won’t fight with you, but I won’t let you squash me like a bug, either.’”
Shapiro does something similar. He shares a story of an adolescent client who sat down in his consulting room and proceeded to argue with everything he said.
“Welcome,” Shapiro had begun. “Because I don’t know you yet, I’d like to ask you some questions about your history, then we can talk about why you’re here.”
“I was born, my life sucks, and people are assholes,” the young man had answered. “I’m here because my parents are paying you to fix me.”
“Well, is there anything you’d like to get from being here?” Shapiro had asked.
“Sure—I’d like to get this over with. Therapy is a joke.”
At first, Shapiro had responded calmly to his client’s provocative statements—focusing on validating his ambivalence about working together, avoiding getting drawn into the content of accusations, and directly highlighting what he saw happening between them.
“Do you notice the combativeness you’re engaging in with me?” he’d asked.
“Wow, you think this is combative? You therapists are chumps,” the client had said. As the session progressed, he’d grown even more oppositional.
“What would you do if I took your books off the shelf and threw them across the room?” the client had asked at one point. “Would you whine about my behavioral problems to my parents?”
“Well, how would you react if I expressed my frustration here by pounding my fists on this desk?” Having been an angry, rebellious teenager himself, Shapiro could relate to his client even as he confronted him.
His adolescent client’s smug demeanor changed into annoyance.
“You can’t do that,” he’d said. “You’re the therapist.”
“Wait—you act out, but I have to take it?” Shapiro had asked. “How does that work?”
“You’re the professional,” the client had insisted. “You’re the adult.”
They’d continued like that for a while, the client arguing with Shapiro, Shapiro arguing back, and then, at one point, the client had stopped and stared, his face registering disbelief.
“You know what?” he’d said, dumbfounded. “I think you’re more messed up than I am!”
And then they’d both laughed.
“It was the first moment of genuine authenticity we’d had in our session,” Shapiro says. “I’d surprised his unconscious, and it paved the way for a discussion about what was getting enacted between us. Other therapists he’d worked with—and there were quite a few—had doubled down on their standard approaches. I’d stayed professional, but instead of tamping down my anger toward his defensiveness and antagonism, I brought it into the room in an intervention that connected us. I confronted his acting out defenses by joining with them, which helped keep my client’s conflict internal.”
I Don’t Hate My Client
Recently, a colleague told me a story about a therapist she’d known who’d tried gentle approaches with an antagonistic client, to no avail. One day, the therapist calmly said, “I’m experiencing something interesting I’d like to share with you because I think it might be helpful. It’s almost like I want to pick you up and throw you out the window. Have you ever felt anything like this, or gotten feedback from people who’ve felt this way toward you?” The client was stunned, but then admitted she’d been feeling the same impulse toward the therapist.
When I first heard this story, it was like hearing about a Sasquatch sighting. I’m awed by the possibility that real-life therapists can pull off something this delicate and have it lead to a positive outcome. Part of being conflict avoidant means you worry about all the different ways being direct will end in disaster. But in calm moments, I can see how saying It’s almost like I want to pick you up and throw you out the window might create an opening to explore aggression a client outsources onto others through projective identification.
Sometimes, Shapiro guides his supervisees to connect with their anger toward clients and express it in supervision with him, no holds barred. Usually, it takes a few tries. When a supervisee succeeds, yelling at an imagined client, “Shut the hell up! I’m sick and tired of hearing you go on and on. I can’t get a word in edgewise!” Shapiro will say, “Good! Very good!” Then he’ll invite them to do what many therapists find infinitely more challenging. “Now, express that same sentiment in clinical language that helps the client.”
With someone who interrupts or argues, that might translate into, “Do you notice how you’re talking over me and your own feelings right now?” And then keeping the conflict internal: “How will you get the help you came for if I don’t have an equal voice in here?”
Shapiro recalls times when he’d deny his own reactions toward antagonistic clients, even when they were undeniable.
“You look like you’re getting frustrated and hate me right now,” a highly antagonistic client had said to him once after 30 minutes of harshly devaluing him in session. “Is that true? Are you frustrated with me?”
“No,” Shapiro had answered.
Now, he advocates responding in an authentic manner that’s specific, but without an agenda. “I don’t hate you, but I’m finding these barriers that block me out very frustrating because I’d like to help you reach your goals. Of course, my desire isn’t important here, as this is your therapy and your life. Ultimately, you’ll be the one to decide how much you’re interested in getting the help you came for.”
Detaching from the outcome of the client’s therapy doesn’t mean you don’t care—it means you respect the client’s autonomy. Before sessions with his most difficult clients, Shapiro reminds himself, mantra-style: “I don’t hate my client; I hate their defenses. I don’t hate my client; I hate their defenses.”
Channeling our anger into interventions in clinically useful ways requires us to do and say things we may not be good at, if we avoid conflict, or if we’ve spent most of our careers being gentle. But we can grow as therapists by experiencing—and befriending—our own anger, seeing it as energy and information. We can expand our toolkit of interventions and invite clients to recognize and explore how antagonism distances them from us and their own internal conflicts. If we unintentionally communicate that we need to sidestep healthy anger—or any feeling, for that matter—what are we modeling? Are we giving clients the message that for relationships to work, certain things must be avoided?
Like everything unnatural—whether we’re therapists, surgeons, or firefighters—doing what’s needed in critical moments to help another person takes all kinds of courage, commitment, and practice.
MAIN PHOTO © ISTOCK / AARONAMAT | SECOND PHOTO © ISTOCK / MARTIN-DM
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