Q: I’m sometimes unable to form an alliance with “difficult” clients, and therapy fizzles out before it’s gotten started. How can I reach these hard sells?
A: As you’ve undoubtedly discovered, when we genuinely connect with clients, therapy usually goes smoothly and effectively, and the work is rewarding. We tend to ascribe our successes to our clinical skills and our clients’ motivation. Likewise, when things don’t go so well—when we sit with passive, sullen, unengaged, unforthcoming clients for session after session—we often think it’s because we lack the necessary skills, or the clients are unmotivated or resistant. We may even begin to resent such clients for putting up barriers against our best efforts to help them.
What stands in the way of connecting effectively? I’ve found that the major difficulty stems, paradoxically enough, from trying too hard! Many clients, even if they’re highly motivated to get into therapy, have only limited tolerance for emotional connection, interpersonal closeness, and sympathetic concern—actions that most therapists assume are central to the alliance and to therapy itself. The harder you try to reassure such clients and show how much you care, the more fearful, defensive, and withdrawn they become.
What’s happening here is a failure to match our self-presentation and efforts to connect with our clients’ emotional capacity to respond. To put it bluntly, our song hurts their ears, and the more they express their discomfort, the louder we sing. What we need to do instead is work on matching our personal style and way of connecting to theirs, making it easier for them to accept our attention and clinical focus.
Here are three guidelines that may help you form a solid alliance with your hard-to-reach clients.
1. Instead of assuming that withdrawn, distancing, sullen, un-forthcoming clients are being “resistant,” consider the possibility that emotional experience of any kind makes them uncomfortable and anxious. Or: it’s not about you.
Clients’ emotional distance may have nothing to do with your skills, but may reflect longstanding personal difficulties and family-of-origin issues. The emotional chilliness may be interesting in itself. Go with the flow! Engage your own curiosity about this dynamic without implicitly shaming clients for being “resistant” or “self-defeating.” Explore clients’ behavior with questions about its origins. Is the discomfort more related to issues of trust, feelings of vulnerability, rejection, or a need to be independent and in control? What does this say about their upbringing, previous relationships, or prior therapy? Your tone should be casual, respectful, and curious. “What’s it like to have nothing in particular to say?” you might ask. “Does this happen in other areas of your life?” “What impact does it have on you?”
2. Carefully observe clients’ reactions to your manner of relating and respond accordingly.
This may seem obvious. Aren’t we all on the alert for our clients’ emotional reactions to the ongoing process of therapy? But here I’m talking about looking for delicate, usually nonverbal, cues about the “temperature” of the session—largely an intuitive process.
Joseph was a young man referred because of his serious substance abuse, depression, and suicidal thinking. As we talked, he described a lifelong history of feeling that he’d had “difficulty fitting in,” along with tirades about the evils of “society”: people were “sheep,” who allowed themselves to be herded around by venal, self-serving politicians; people selfishly thought about meeting their own needs, with little concern for the greater good. My attempts to search for personal connections consistently met with argumentation. It was too painful for Joseph to acknowledge that his childhood with insensitive parents didn’t reflect the whole of society. I’d ask him in what way these “social” issues personally impacted or reflected his life, only to be assaulted with his criticism that my question proved his point—that I wasn’t concerned with the overall good of others, but was only selfishly interested in the individual. Whenever I spoke of my concern that just engaging in tit-for-tat dialogue made it difficult for me to help him, or said anything that indicated I cared for him, Joseph became visibly uncomfortable and responded with cynical and sarcastic remarks.
I used these reactions as a cue to search for a different way of relating, hoping to connect with a less defensive aspect of his character. Given his low tolerance for emotional experience, I turned down the heat on anything remotely emotional and changed my language from comments about “my concerns” and “his potential” to concrete remarks about keeping a “productive focus” and “meeting established goals”—less like therapy and more like a motivational business meeting.
I noted a reduction in tension and resistance almost immediately. The less effort I made to connect personally, the more Joseph relaxed and allowed connection. By going slower, we arrived faster. Eventually, Joseph became comfortable enough that I could gently confront him with the need to make a choice between “having fun”—engaging me in argumentative banter—or actually meeting his goals for therapy.
3. Closely monitor your clients’ anxiety level.
The best barometer of therapeutic responsiveness is clients’ anxiety level. Anxiety is like the tip of an iceberg. We may not know what lies below the surface, but sensitively monitoring clients’ discomfort will provide a guide for how to proceed. Alter your approach as needed to keep anxiety in an optimal range: too little and clients aren’t motivated; too much and they get overwhelmed and defensive.
Sue, a middle-aged woman with a long history of self-defeating behavior, suffered from severe depression and feelings of inadequacy. As a child, she’d been physically abused and devalued. My personality and training led me to maintain a more distant relationship, offering little of my personal self. Thus, when Sue would sink into helplessness and hopelessness, I’d explore, dispassionately, the related internal dynamics and conflicts. These explorations proved fruitless, and I noticed an increasing anxiety, frustration, and even confusion on her part. As I experimented by offering more personal reactions, I noted a reduction in anxiety and a deepening of rapport. Expressions of compassion for her suffering and admiration for her courage in addressing such difficult childhood experiences seemed to compensate for her inability to offer these feelings to herself. Unlike Joseph, who needed less therapeutic emotion, Sue needed more emotional connection than I’d been giving. She didn’t need to hide or guard herself: she needed to be understood explicitly and validated in a deeply emotional way.
In one therapy session, she reported a significant accomplishment, but was unable to experience any sense of pride or success in it. When I encouraged this well-deserved feeling, she became increasingly anxious. However, when I openly and warmly told her how proud I felt about her achievement, her discomfort immediately decreased. As I transitioned to a more affirming, explicitly validating, approach and “gave” this experience to Sue, she demonstrated steady improvement and increasing ability to experience healthy pride herself.
The more you develop a broad range of skills, comfort zones, and flexibility, the more you’ll be able to tailor your approach to the needs and styles of a variety of clients. You’ll be a master actor, able to adapt to a broad range of roles, rather than a character actor, who plays essentially the same part in every script.
Being an effective clinician means letting go of preconceived ideas about how to respond, and paying attention to your clients’ moment-to-moment needs. This attitude requires comfort with the unknown and faith in the therapeutic process. When you have no idea what to say until after the client has responded, you’ll know you’re getting the hang of it.
Steven Shapiro, Ph.D., is a clinical psychologist who specializes in personality disorders, adolescents and their families, parenting, and conflict resolution. He’s a senior faculty member of the Accelerated Experiential Dynamic Psychotherapy Institute in New York City.