What to Do When a Client Isn’t Engaged in Therapy

By Stephanie Catella, PsyD

Lack of engagement in treatment can take many forms. It may show up as not completing homework in between sessions, ambivalence in setting or working toward treatment goals, being unresponsive to your questions, or a desire to stay topical and avoid the deeper emotional content and contexts. While these are common difficulties in therapy, if they aren’t addressed, they can result in attrition and failure to make progress and heal, leaving clients just as stuck as when they began therapy. At worst, when a client’s lack of engagement in therapy isn’t addressed, they can lose hope in the therapeutic process.

What you can do about it:

1. Assess how strong your rapport is with the client. Reflect on it in between sessions and notice what adjectives you’d use if a colleague asked you to describe your rapport. Then, ask the client about their experience in therapy with you so far.

2. Show empathy, and with warmth, kindly point out the ways in which their behavior is ambivalent and its impact. For example, using a statement like “I notice that you often voice a desire to _______ (state their therapy goal), and when we get closer to identifying how you can address it, _______ (state the barriers you observe). This is a natural response to enacting change. Let’s explore it together to help you get unstuck.”

3. Gently and directly help your client explore what’s beneath the resistance. One way to guide clients in this direction is to ask, “When I ask about _____ (the area in which you’ve observed resistance), what thoughts pop up?” After the client responds, then ask, “And what happens in your body when I ask about _____ (the area in which you’ve observed resistance)?” If your client is unresponsive or can’t recall these answers, ask them what thoughts and physical sensations they have in this moment. The answers often resemble each other.

Stephanie Catella, PsyD, is a clinical psychologist with expertise in transdiagnostic cognitive behavioral therapy (CBT) for trauma, anxiety, and building emotional intelligence. After completing fellowships at the San Francisco VA and the University of California, San Francisco; she codirected the Berkeley Cognitive Behavioral Therapy clinic with Matthew McKay. In addition to her private practice, she authored an FDA-cleared prescription digital therapeutic for fibromyalgia, and serves as an advisor to HealthTech companies.