When Clients Pose a Challenge in Treatment

Clients can pose any number of challenges. And it is easy--but not productive--to label clients as "resistant," or "lazy" or "unmotivated." The first step in figuring out what to do with clients who pose a challenge is to specify the problem. Therapists should ask themselves the following:

"What is the patient doing (or not doing) in session or between sessions?"

Or

"What is the client saying (or not saying) in session or between sessions?"

These questions help specify the problem(s). Perhaps, for example, "resistant" clients are skipping sessions, using substances between sessions, avoiding bringing up important problems, blaming others, focusing only on problem description instead of problem solving, criticizing the therapist, declaring that nothing can help, failing to do homework, displaying high degrees of emotionality, engaging in self-harm, making suicide attempts, or generally failing to progress.  The list could go on and on.

Having determined what the specific problems are, therapists next need to figure out whether the difficulties are due to clients' pathology, to therapist error, and/or to factors inherent in or external to treatment. The last includes the dose of treatment (perhaps more frequent sessions or a higher level of care is needed), medication (too much, too little, too ineffective, too little adherence, too many side effects), an undiagnosed organic problem, the format of treatment (individual versus group, couple, or family therapy), the absence of needed adjunctive treatment (medication or pastoral, nutritional, or vocational counseling, for example), or a toxic home or work environment.

Many times, though, challenges are related, at least in part, to therapist error. It is often difficult to identify these problems unless the therapist discusses the case and reviews a recording of a session with a colleague or supervisor.  Typical mistakes that therapists make include an erroneous diagnosis, an incorrect formulation of the disorder or incorrect conceptualization of the individual client, a faulty treatment plan, a weak or negative therapeutic relationship, an inadequate behaviorally-oriented goal list, inappropriate structure or pacing, too little focus on problem solving, incorrect implementation of techniques, and inappropriate assignment of homework.

Finally, challenges may also be related to clients' dysfunctional beliefs. Categories of typical therapy interfering beliefs include ideas of negative outcomes or negative meanings about engaging in treatment ("If I reveal myself to the therapist, she will hurt me," "If I let the therapist take control, it will mean I'm weak,"), experiencing negative emotion ("If I start to feel bad, I'll fall apart,")  , solving problems  ("If I even try to solve my problems, I'll fail,"), and getting better ("If I get better, I'll lose my therapist or have to go back to work").

Finally, therapists should examine and respond to their automatic thoughts when they experience a negative reaction toward clients. It is useful for therapists to expect that challenges should arise with many clients and that they shouldn't necessarily be able to help every client--though obviously, they should continue to educate themselves and seek consultation throughout their professional careers. 

Reference

Beck, J.S. (2005) Cognitive therapy for challenging problems: What to do when the basics don't work.

New York: Guilford Publications, Inc. 

Judith S. Beck, Ph.D., is Clinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania, and President of the Beck Institute for Cognitive Behavior Therapy in Philadelphia, a non-profit organization which offers resources and training, nationally and internationally, in CBT. www.beckinstitute.org

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.