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Common Mistakes with Therapeutic Plateaus

Another form of stuck clinical relationships involves the client who keeps making self-destructive choices, ones the therapist is on record as having repeatedly warned against. One therapist in a workshop I led talked about her long-term therapy with a woman who kept bringing new men home from AA groups, living with them for a time, and then feeling used and abandoned when they didn’t need her any longer. I don’t know how many sessions the client spent talking about this pattern and agreeing about how harmful this behavior was for her. She’d always conclude that she wasn’t going to do it anymore, and then, bingo, a few weeks later, there’d be a new sad sack living at her house. Another classic scenario is the woman who continually returns to an abusive husband or boyfriend in the hope that, this time, his apology indicates real change, or the married man who’s had a series of affairs and resists talking to his wife about his unhappiness in the marriage because he doesn’t want to deal with the fallout of those conversations.

The big challenge for these clinical relationships isn’t that the client is behaving in a self-defeating way—it’s the client’s life, after all—but that these individuals cling to therapy, desperately asking for help but declining to take the responsibility to extricate themselves from toxic situations.

In my own clinical experience, Cindy stands out. She enjoyed therapy and had inherited enough money to work or not as she pleased. She’d made strides in her single parenting—the kids were now raised—but continued to allow herself to be used by one man after another. Each time, she worked in therapy to extricate herself from the relationship, but whenever a new questionable character came along, she was impervious to my fervent attempts to get her to pay attention to the multiple red flags whipping in the wind. I’m not talking about subtle signals here: one man asked her for a good-sized loan after three dates, another offered to pay her younger daughter’s college tuition (never having met the girl) and then asked for a “bridge loan,” and yet another flirted openly with Cindy’s adult daughter. When I’d ask if she saw a familiar pattern, she’d reply, “Well, I have a different sense this time. I’m stronger, and this man is really not like the others.”

These are our Dr. Phil cases, when we want to ask, perhaps with a snarky, self-satisfied smirk, “So how’s that working out for you?” Except we’re not on TV. We’re caught up in an ongoing clinical relationship, and it’s important that we not make the following common mistakes:

Acting as if the client’s decisions reflect our competence. This is the central mistake behind most lapses in the therapist’s craft when working with challenging clients. The truth, of course, is that we’re responsible only for how we conduct ourselves in the therapy room, not for how our clients behave in their own lives. But it’s hard to hold on to our boundaries when we see clients drive their cars over cliff after cliff while begging us for driving tips.

Acting like disapproving parents. Schooled in avoiding direct advice, most therapists ask screwdriver-like questions such as, “What was going on in your mind when you invited another man to move in with you after meeting him just twice?” The client gets the underlying drift: The therapist thinks I’m an idiot.

Assigning pejorative clinical interpretations. When therapists lose their boundaries, feel overresponsible, and don’t really know what to do, they often default to poking at the function of the symptom with questions like “Why do you think you need men to treat you so badly?” When the client denies needing to be abused, the therapist doubles down: “If you don’t like it, then why do you think you keep putting yourself in this situation?” The client then translates this statement as You’re even more messed up than either us thought before.

Threatening to end therapy. Usually we fire the client in indirect ways like “I don’t see how this therapy is really helping you.” I know of one frustrated therapist, however, who said outright that she couldn’t work with a client as long as the client chose to stay in an abusive marriage. In another case, the frustrated therapist waited until a husband, following another marital argument in the session, blurted out, “We’re not getting anywhere in this therapy.” The therapist saw an opening and said, “If you don’t think the therapy is helping, then maybe we shouldn’t keep meeting. Why don’t you think about whether you want to continue and call me back if you want to schedule an appointment?”

Coming on too strong. In a number of my couples cases, one spouse’s individual therapist seemed to have taken such a hard position in favor of divorce that the client was too ashamed to continue therapy and attempt to reconcile the marriage. In reality, it’s unlikely that the individual therapist likes to promote divorce. Instead, I imagine that the therapist was sick of seeing no movement, but lacked a more skillful way of dealing with the impasse.

Listening too closely to the negativity of our consultation group. It often happens that a consultation group feels it’s listened too long to your stories about an impossible client and wants to put both you and the client out of misery. I remember a case consultation when a colleague leaned in toward me, lowered her voice, and said, “Maybe you should ask your client what she gets out of being so unhappy? What’s in it for her?” The problem here wasn’t her advice; it was the negative energy behind it that I inadvertently absorbed. Having consulted yet again on this particular client’s case, I probably should have carried a big sign with me when I walked into our next therapy session—Warning: Lurch Risk Ahead.

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