We’ve all had the high-maintenance client that is constantly in crisis, hijacks the session, and even demands time outside of the session. These clients routinely have what I call a COW: Crisis of Week. Every week, it’s either the same COW or a different COW! How can we help clients deal with chronic COWs, without derailing the rest of treatment?
Here are my favorite strategies for clients with COW problems:
1. Allocate either the first ten minutes or last ten minutes of each session for COW time.
2. Adopt a skill focus in your sessions. As each COW comes in, use the COW as a learning opportunity to teach new skills.
3. Have your client email a detailed description of their COW. Tell them you will reply to their email within twenty-four hours.
4. Assign a Diary Card for your clients to track their thoughts, emotions, reactions, triggers, and so forth. Then, when they show up in session with their COW, the COW has already been spelled out on paper.
5. Use session time to help dissect the COW with a chain analysis: Prompting Event > Interpretations and Distortions > Emotions and Sensations > Action Urges > Behavior > Consequences and Vulnerabilities. In particular, explain how the aftermath of their behavior is what makes them vulnerable to yet another prompting event—in other words, their reaction to the trigger (and not the trigger itself) is what sets them up for another rodeo.
6. Schedule a five-minute phone conversation once per week (more times if necessary). This will be a BRIEF check-in to simply remind the client of what skills they can be using, NOT a full-blown session. Having a scheduled time for the check-in will actually reduce (not increase) the frequency and intensity of the phone calls.
Kirby Reutter, PhD, is a bilingual licensed psychologist, licensed mental health counselor, and internationally certified substance abuse counselor. Reutter has widely presented his unique approaches to psychotherapy throughout the nation, including one TEDx talk and three trainings for the US military. In addition, Reutter has conducted international research on spiritual coping, the results of which have been published by three different sources and personally presented at the Massachusetts Institute of Technology in 2015. Reutter was named a New England Scholar in 2002, as well as Northcentral University’s Alumni of the Year in 2018 for his work with trauma treatment, including survivors of human trafficking. Reutter currently contracts with the US Department of Homeland Security.