Monday, August 22, 2011

Difficult Clients

We all have them: clients who push our buttons. We can't hold it against them...after all, they wouldn't need us if they didn't have problems! But it can be a challenge to sit with them session after session, maintaining empathy and keeping our own negative reactions from interfering in the work.

Therapists sometimes call our reactions to clients "countertransference." Originally, it referred narrowly to the therapist's reaction to the client's transference. While countertransference of this sort definitely does occur, it seems unfair not to acknowledge our own contribution to the reactions we have. Thus, countertransference often refers to the therapist's reactions more broadly, both those naturally arising from the client's presentation, and those arising from our own history, personality, and unresolved issues.

It follows, then, that therapists all tend to have negative reactions to certain "types" of clients, while reactions to other client types is more idiosyncratic. Several of the personality disorders seem to trigger an almost visceral reaction in the therapist - and not just the much-maligned "borderlines," who often trigger negative reactions by virtue of the intensity of their own distress, and their episodic complete rejection/devaluation of the therapist (none of us like to feel despair, or incompetence). Clients with narcissistic personality disorder may also devalue the therapist, and may  be hard to empathize with if they aren't empathic toward others. Those with antisocial personality disorder may "feel" dangerous, like predators, while those with dependent and histrionic personality disorders may feel suffocating, demanding, or flooding with the intensity of their distress.

Another category of "difficult client" is the "help-seeking help-rejector" - the one who expresses a desperate wish for symptom relief, but then shoots down any treatment recommendations that are offered. The therapist may be left feeling inadequate or helpless, and may start to feel exasperated.

Our own make-up can also shape our vulnerability to certain client "types." It may get under our skin that a client is confrontational, or passive. Perhaps he or she reminds you of your mother/father/boss/ex, or has presenting problems are too close to something you've struggled with in the past. Hopefully you know what triggers a negative reaction in you, so that you can be vigilant against allowing these feelings to "leak out." I know that I struggle to be accepting of narcissism, so I am extra-careful to not act on my impulse to burst a narcissistic client's bubble.

Supervision or consultation is the best bet when a client brings out a negative reaction in you. Especially in agencies where it's not possible to refer out the clients who might not be a good therapeutic match, a good supervisor can help you sort out your own "stuff" from what the client is bringing, perhaps think differently about him/her, and respond in the best possible way. Other forms of self-care are also important: reducing vulnerability by getting enough sleep, a healthy diet, exercise, recreation, and social support, and recognizing when seeing a therapist yourself might be helpful.

What clients do you find most challenging? What do you do to maintain equilibrium?

1 comment:

  1. What often seems missing in discussions of "difficult clients," is that client viewpoint is utterly absent. Clients will see therapists as domineering, delusional, misdirected or simply unhelpful. Or the therapist represents himself with powers he really doesn't possess. Or therapy is oversold, creating the fantasy that it can create impossible transformation. Client feedback is ridiculed and deflected. First do no harm? I'd say, first establish basic human respect.