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The Pointless Games We Play With “Difficult” Clients

The Pointless Games We Play With “Difficult” Clients

By Mitch Abblett, PhD, author of From Anger to Action

Tug-of-war is a silly game; all of that straining in order to move a rope a matter of yards. If you’ve ever played it, the whole thing seems pointless, and yet it is so easily and regularly played in our daily social lives. Husbands with wives, parents with children, coworkers and confidantes—no one, not even experienced therapists writing blogs, is above such game playing. One person feels an unmet need and pulls at an important other to meet it. The other misreads or rejects the person’s pulling and gives a yank themselves. It is universal.

In my clinical work with at-risk kids and teens, adult psychiatric inpatients, and many outpatient clients suffering the effects of trauma, I’ve learned to ask an important question: Of what am I absolutely certain about this client? What are the thoughts I’m gripping tightly about this person that pass the “nod” test—that if I heard a colleague say this about my client, I would nod emphatically in agreement without really thinking about it? On many occasions, I’ve written statements in progress notes such as “unmotivated for change,” or “help-rejecting,” “manipulative,” or “oppositional or noncompliant to interventions.” Outside the clinical realm, we—the trained therapists—might look at clients struggling with their behavior and call them “borderline,” or “lazy,” or even a “lost cause.”

We must ask ourselves, what will be the likely ripple effects of gripping these thoughts with such certainty. Are we taking a mere passing thought and creating a monster? A self-fulfilling prophecy?  Conflict and negative feelings are natural to relationships. It is what is done with those feelings that predicts what will eventually happen.

Neuroscience has identified the role of “mirror neurons” in the brain during any human interaction. These brain cells, according to neuroscientists such as Daniel Glasser at University of College London, prime our systems for similar reactions—a tendency to mimic the observed person’s emotions and behavior. These specialized brain cells may be the biological seat of the skills of attunement which are the stock and trade of psychotherapists. 

In therapy, what happens in the moment between therapists and clients—the tit-for-tat of emotional and behavioral reactions—is very important in the eventual trajectory of the work. Work from parallel fields (such as John Gottman’s study of couples, and Glasser’s examination of mirror neurons) suggests the benefits of therapist attention to the process of their in-session interactions with clients. 

Despite our professional intentions, the pain carved across a client’s face sparks emotion and behavior in us as observers. Anxiety can pull (especially for us empathy-prone folk) for anxiety. Look anyone in the eyes and try not to communicate anything—an impossibility. While our training may have us hold our inner experience in check, our brains have a mind of their own—we communicate glimpses of our inner landscape to clients regardless of our efforts. Instead of avoiding this neuroscientific fact, we might benefit from embracing it, and learning to harness skills for authentic exchange to move clients toward lasting change in the context of a healing connection.

Research from dozens of studies has consistently shown “therapeutic alliance” to be a robust predictor of outcome in therapy. Studies have also shown that ruptures in the alliance—breaks in the therapeutic bond as a result of errors and (to use Gottman’s term) missed “bidding” between therapist and client—are predictive of poor treatment outcomes. When therapists push their change agendas without the consent and agreement of clients, and when they fail to attend to clients’ experience, rupture occurs and tug-of-war interactions become more likely. 

Therapists who give up games and learn to “dance” in attunement with clients are perhaps more likely to generate progress in treatment. This may be especially true of therapy with “difficult” clients whose behavior hits clinicians’ buttons—those who are violent and abusive, substance users, clients suffering from significant mood disturbance, trauma victims, and those diagnosed with personality disorders or with highly maladaptive social behavior. These clients seem to slap therapists with the rope. These people pull for negative reactions. And as soon as therapists get caught in assuming “intent” on the part of clients for their rope-pulling, a-tugging they both will go.

What is needed is proactive recognition of the patterns of interaction. Most importantly, resolution of difficult client-clinician patterns requires a moving toward the pattern in some way. What are the scripts I’ve learned about how to experience and express emotion that may be interfering with my work with a particular client? What thoughts might stand a loosening of grip? How might I mindfully allow my inevitable experience of negatively toned thought and emotion during sessions instead of shoving such reactions away? How might I communicate engagement and commitment to the agreed upon goals of treatment despite the client’s behavior and my negative reactions? When might be the best juncture for proactive intervention—a process intervention? An authentic acknowledgement of error perhaps? Maybe a limit that needs to be set, or a strategic bit of self-disclosure, or bit of shared humor (remember, mirror neurons and the development of alliance through shared affect)? Might there be a role for any of these in your efforts to drop the rope with “difficult” clients?

Human action becomes vital and vehement when what is basic to us—the “stuff” we experience as core to our survival (whether literally true or not)—is threatened. Our brains seem to know little difference between fear bred from bullets and ill-timed therapist “interpretations.” If we miss the cues, fail to attend to clients’ bids for connection, and if we react instead of responding, we will tug-of-war needlessly with our clients. Let’s make a pledge to strike terms such as “oppositional,” “manipulative,” or “unmotivated” from our session notes. Let’s instead look to the mutuality of clinical work. It’s where the data says the action of change is.

Person with their fist in the air and back is facing the coverMitch Abblett, PhD, is a clinical psychologist with a private psychotherapy and consulting practice in Wellesley, MA. Prior to this, he served as executive director of The Institute for Meditation and Psychotherapy, and, for over a decade, he was clinical director of the Manville School, a Harvard-affiliated therapeutic day school program in Boston, MA. Learn more at www.drmitchabblett.com.