The Therapeutic Paradox of Self-Invalidation

If validation is one of the core skills for fostering a therapeutic alliance, it may be even more important for clients who grew up in an invalidating environment, may have little prior experience of validation, and habitually invalidate themselves. However, it's also important to consider and plan for how a particular client is likely to experience and react to validation. Some respond positively: validation improves rapport, diffuses pain, and over time helps clients become better able to self-validate and self-regulate. Others find validation itself to be distressing.

While such a reaction may seem counterintuitive, it makes sense in the context of the client's experience. For someone who has been chronically invalidated, the experience of validation is foreign and uncomfortable. The client may feel thrown off balance by the unexpected response.

At a more complex level, a client who habitually self-invalidates may find validation itself...invalidating. This presents quite the therapeutic paradox: I can validate my client's experience, which invalidates their self-invalidation of that experience; or I can validate the self-invalidation, which invalidates the experience.

Both of these options are likely to dysregulate the client. Perhaps this is why clients with Borderline Personality Disorder are so often labeled "difficult clients." However, that's also invalidating of the genuine and understandable distress these clients experience living inside this paradox day in and day out.

The challenge for therapists is to find a way to lessen a client's suffering by gradually lessening the internal dissonance of self-invalidation - which happens in part through the experience of validation. How, then, can we make validation less invalidating?

I believe the answer is that validation itself must be dialectical. We need to name and reflect both the client's initial internal experience, and their self-invalidation of this experience. In this way, by simultaneously validating the experience of invalidation, and the experience that is invalidated, the client may finally be able to experience genuine validation.

The Sweet Spot

When it comes to how long clients stay in treatment, there seems to be a "sweet spot." When clients discharge prematurely, they are at greater risk for relapse, either because there are more residual/unresolved/partially-resolved symptoms, or because progress/changes made in treatment are still new and therefore harder to sustain (or both reasons). These risks seem relatively obvious - widely accepted among practitioners, and cited in textbook discussions on termination.

Less widely known/discussed are the risks of clients staying too long in treatment. There seems to be a window during which clients are ready for discharge, and able to sustain progress without treatment at the current level of care. Symptoms have resolved sufficiently, and their developmental momentum is in the direction of health and recovery (helping them continue forward movement after treatment ends). However, if they linger too long in treatment, the momentum shifts - the treatment may stagnate, or even regress. Symptoms may reemerge and motivation may flag. Discharging a client with this kind of momentum - away from, rather than toward, health and recovery - also poses a greater risk of relapse...perhaps even more so than clients who discharge too early.

While it is easy to describe this "sweet spot," in practice, it can be deceptively hard to hit. There are several factors that make it challenging to gauge a client's readiness for discharge:

1. Uncertainty about whether symptoms are resolved "enough" (given that there is probably no person on earth who is truly free from all mental health symptoms!) - clinicians may find themselves second-guessing whether the client is actually free of "clinically significant distress," or whether residual symptoms are harbingers of a coming relapse.
2. The client's own anxiety about discharge - often, clients doubt their own ability to maintain changes without the support of treatment, and the idea of discharge may send them into a tailspin. Clinicians may be reluctant to discharge a client if s/he is uncertain about wanting discharge, and/or the client's anxiety may be contagious and make the clinician also doubt his/her readiness.
3. Attachment - the client's attachment to us, and our attachment to them, may make both parties reluctant to discharge due to anticipated grief.
4. Agency culture - Some clinics operate on the principle that clients should receive as much treatment as insurance companies will authorize. And while insurance companies do their best not to authorize more treatment than the client genuinely needs, it's not a perfect system (after all, all they have to go on is what clinicians tell them!). Accrediting bodies (which are different than payors!) require that clinical decisions be made based on clinical presentation and not on insurance. While it may be...profitable...to keep clients in treatment as long as possible, it's not good for clients, and it's not ethical practice. We all need to be in the habit of using our clinical judgment rather than being guided by insurance.

How do you think about readiness for discharge? How do you find the "sweet spot," and what makes it difficult?

Escaping the Waiting Place

In his guide to life, "Oh, The Places You'll Go," the sage Dr. Seuss warns readers about:

"a most useless place. The Waiting Place...for people just waiting. Waiting for a train to go, or a bus to come, or a plane to go, or the mail to come, or the rain to go, or the phone to ring, or the snow to snow, or waiting around for a Yes or a No, or waiting for their hair to grow. Everyone is just waiting. Waiting for the fish to bite, or waiting for wind to fly a kite, or waiting around for Friday night, or waiting, perhaps, for their Uncle Jake, or a pot to boil, or a Better Break,
or a string of pearls, or a pair of pants, or a wig with curls, or Another Chance. Everyone is just waiting."

 

Most of us can probably relate. I think most people find themselves, at various points in our lives, feel like we have to put everything else on hold while we're waiting for...whatever it is we're waiting for. We wait to grow up, to go to college, to finish college, to get the perfect job, to buy the perfect house, to find a spouse, to have a family, for our kids to walk, start school, finish school...etc. We can spend most of our lives waiting for some future point to really live!

The same pattern can play out in therapy. All too often, clients say they "aren't ready" to change their behavior, or talk about/work on something sensitive, or take whatever risk they need to take to reach their life goals. They want to wait - until it stops hurting, or they stop having distorted thoughts, or completely resolve the last little bit of ambivalence, or stop feeling depressed (angry, anxious, whatever), or "get over" their grief, or forgive someone, etc., etc., etc.

Dr. Seuss does not happen to offer any sage advice on escaping the Waiting Place (he writes only: "Somehow you'll escape all that waiting and staying. You'll find the bright places where Boom Bands are playing"). However, barring a boom band showing up in our offices, therapists are challenged to find creative ways to help our clients break out of their "waiting."

I think it starts with psychoeducation. At its heart, waiting is the result of inaccurate or distorted thoughts or beliefs about the nature of feelings, thoughts, and actions. For example, people often operate on the assumption that feelings are an accurate basis for, or inevitable determinant of behavior. Based on this assumption, people who are depressed often say that they'll get up, shower, get dressed, socialize, etc, once they "feel better." However, research suggests that people begin to "feel better" once they start getting up, showering, socializing, etc. (an approach called Behavioral Activation). Identifying, and providing education to counter, the inaccurate assumptions impeding the client from taking necessary action is an important first step.

Even with this foundation, clients may still be stuck in the Waiting Place. Here's the hang up: we judge the veracity of new information based on how it fits with our experience. Without taking action, clients have no new information to test out the accuracy of what we want them to believe. But, they don't want to take action until they believe the new information. We have a few options in this sort of stalemate. We can continue trying to "talk them into" believing the new information. We can facilitate "vicarious learning" by pointing to others whose experiences provide support for the new information. Or, we can encourage clients to test it themselves in a small experiment. Instead of committing to sustained effort or change, they can just try it for a limited time or in a limited frequency, and self-monitor for any changes in how they feel (the experiment should be long enough to provide accurate information, however!). Finally, we can reach for any past experiences the client may have had that provide supporting evidence.

What other strategies do you have for helping clients (or yourself) escape the Waiting Place?

The Chicken and Egg of Comorbidity

Which came first, the chicken or the egg? This perennial, unanswerable question seems to have a parallel in therapy: what do you treat first? When a client comes in with multiple issues (as so many of them do), where do we start?

A professor in graduate school would quip: "Partialize and Prioritize." In other words, try to break problems down into manageable sections, and take them one at a time. But which one first? I've heard different schools of thought: either start with a relatively easy, achievable goal to increase self-efficacy and help people feel like therapy is helping (particularly if you don't yet have a rapport with them), or start with the most urgent concern. However, there are certainly other factors that influence this decision - for example, an insurance company that recently told my colleague they'd pay for a client to receive treatment for one problem, but not for another.

DBT actually offers a sequence of "primary behavioral targets," starting with risk issues (suicide, self-harm), then "therapy-interfering behaviors," then behaviors that interfere with quality of life (dysfunctional behaviors of all kinds, including substance abuse, impulsivity, and poor judgment), then increasing coping/life skills, then decreasing other symptoms.

I tend to agree that you have to start with imminent risk, and anything that is impeding or preventing treatment. I tend to include substance use in the latter category if people can't address emotional issues because they are under the influence and pretty much numb. However, with multiple problems, all of which are somewhat risky, I try to figure out whether one problems seems to be driving others, and start there.

However, like the metaphorical chicken and egg, it's rarely easy or clear to determine causality. Sometimes one problem emerged first (depression, and then an eating disorder, for example), but people often aren't aware of a sequence. Starting with whatever feels more important to the client is a good alternative (or even primary) strategy. Then, if another problem begins to prevent further progress on the top-priority issue, it becomes clear how they're related, and how to begin untangling them. For example, a client entering treatment for an eating disorder, who is totally unmotivated to change their behavior (and unresponsive to motivational interviewing) because depression has sapped all motivation about anything. Unless we treat the depression, we're unlikely to get far with anything else.

How do you "partialize and prioritize"? How do you make decisions about what to focus on when clients present with comorbid problems?

Magic Numbers

When it comes to age, our society is full of "magic numbers" - ages at which something changes with our rights, privileges or opportunities. I bet we all remember turning 16 (driving), and 21 (drinking). My aunt just celebrated 65, which comes with eligibility for Medicare, closely followed by social security retirement benefits. However, while we feel more excitement about some of these landmarks, they don't carry the same societal "magic" as age 18.

Sure, we look forward to getting to vote. Some people look forward to 18 because they can join the military, or legally smoke. No one really looks forward to becoming eligible for jury duty. But, all of these rights come at the age of 18 because that is the age we are considered "adults." The magic age of "majority."

While most of us hopefully realize that becoming an adult is a process rather than an occasion, the legal significance of the magic age 18 also has significance in the treatment context. I'm reflecting on this topic this week because I have a client in the intensive outpatient program who turns 18 this week. Since we are an "adult" program, we already structure it with the expectation that people are coming volutarily and responsible for their own choices. Whether she is 17 or 18 will not change our direct interventions or treatment plan. However, it will change a few things - namely that she, rather than her parents, will have to (get to) sign the legal paperwork, including consenting to treatment, and choosing to whom information can be released.

Her mother is concerned that she will not sign a release to allow us to speak with her parents. That will be up to her, of course, and I can imagine a kid who is developmentally trying to individuate from her family (and ambivalent about treatment) enjoying being able to exclude her parents from her treatment, but I hope she doesn't. I think family support can be vital in recovery, and secrecy tends to work against recovery. The parents still have some bargaining chips, of course - while the magic number says she is an adult, she is still financially dependent on her parents, and hopes to go to college in the fall. I doubt she will want to jeopardize that!

How do you think about and deal with the transition from minor to adult in your clinical work?

Another Ethical Quagmire

Another ethical dilemma has arisen for me this week, in the context of the partial hospital program where I work. Specifically, a current client's cousin may be referred from our inpatient unit to the PHP. My client is understandably reluctant to have a family member present in treatment with her (beyond the standard meetings with immediate family, which don't include the rest of the group, and still leave the majority of treatment separate from family). However, management does not consider that sufficient reason not to accept the cousin.

I have serious misgivings about the idea of attempting to treat clients who are related to each other in the same group program. I've had to stop and think about it more to try to articulate my reasons. My initial reaction was that it should be obvious we can't accept the cousin - an assumption I made because it has been the policy at all the other places I've worked that relatives cannot be in group treatment together, nor can they be seen by the same outpatient providers. Since it is apparently not as obvious as I thought, here are what I consider the relevant issues:

1) Dual Relationships
Obviously, family members have an existing relationship with one another outside of treatment. By accepting them both into the same treatment program, we are putting both in the uncomfortable position of having a dual relationship - family member and group member. Dual relationships are discouraged by professional codes of ethics because they raise the possibility of other ethical issues. Some of those are discussed below, but here I'll focus on boundaries.

Specifically, it can be very hard for clients and clinicians to sort out where one role stops and another begins. What interactions between two related clients are coming out of their relationship as group members, and which coming out of their family relationship? Can there even be group member interactions between them that aren't in some way informed by the family relationship? Nobody can set aside all the things they already know or believe about a person, and limit their interactions to only what they've learned or experienced in the treatment setting. The chances that one will reveal too much about the other, or make judgments and assumptions on the basis of past interactions, is high. On the flip side, it can be hard to leave treatment at treatment, and not have group interactions influence outside interactions. It's hard to compartmentalize, and easy to forget how one knows something.

2) Confidentiality
While both relatives may agree up front to keep things disclosed in treatment confidential...they may not actually do so. There is more temptation to tell other family members what a relative disclosed in treatment, versus what strangers shared. There is also the very real possibility that something from treatment will later be used as ammunition in the heat of an argument. Both are likely aware of this possibility, and may self-censor as a result.

Staff may also (inadvertently) struggle with confidentiality. Just as it may be hard for related clients to separate what they know from outside treatment, and what they know from inside treatment, it can be hard for clinicians to remember what they learned from one client, what they learned from the other client, what the clients said in private, and what they said in group.

3) Conflict of Interest
This may be the most concerning aspect of this dilemma for me. The primary "interest" - priority/responsibility - of the clinician is the client's welfare. Whenever there are multiple clients (e.g., group, couples or family therapy), there is potential for a conflict of interests - something that's good for one might be bad for another. The clinician faces a definite conflict - internally and externally - whenever faced with that kind of choice.

The most often cited example occurs in family therapy when the clinician has to file a report of possible child abuse/neglect. While the clinician notifies the whole family of her legal obligations at the beginning of treatment, it still usually causes problems when a report actually has to be filed. The decision is made easier, however, by clear legal standards (i.e., mandated reporting) and the general ethical guideline to advocate for the most vulnerable/least powerful person's interests.

Assuming no clear power differential between our potential related clients, a conflict of interests between the two would be much harder to resolve. Imagine, for example, they have an argument, and both declare: "If she continues treatment, I'm dropping out!" Assuming neither budges from this position, even after a cooling-off period and talking with staff and peers, the treatment team is faced with quite the dilemma: there are two medically and psychiatrically compromised individuals who want treatment...but not if the other one is present. We might choose the more medically unstable, or the least ready for discharge, but the other one might reasonably claim that we did not fulfill our obligation to her. We might decide to discharge both, to avoid any claim of discrimination against one, but we'd have to find some way to ensure adequate aftercare for both. Yes, it would be quite the quagmire.

There is also the question of whether a conflict of interests already exists if we accept one and not the other. My contention is that our primary responsibility is to the client who has already been admitted to our program. The other is on an inpatient unit within the same agency, so some may say that we have a responsibility to her as well. However, I disagree - the inpatient team is responsible for her treatment, and arranging reasonable aftercare. If she can't come to us, that means they need to find a way for her to go elsewhere, or access a different level of care (IOP vs. partial, perhaps), or have more frequent outpatient appointments and monitoring until her relative discharges and she can start our program. There are solutions. Our responsibility is to ensure the best possible treatment for the client we already have.

It seems clear to me that dual relationships, possible breaches of confidentiality (and self-censorship out of fear of such a breach), and conflicts of interest would interfere with the quality of treatment for both. Instead of providing good treatment to one, we're providing treatment to both that is only ok...at best. That is not ethically sound, damages our reputation in the community, and could influence our reimbursement by insurance...and that's not even considering the cost to the individual clients in unresolved symptoms and ongoing struggle. But, again, this is just my opinion.

The 80/20 Rule: An End to Perfectionism's "Grade Inflation"

I learned an interesting idea this week, in relation to perfectionism: the 80/20 rule, also called the Pareto Principle. Basically, this principle states that 20% of our total effort produces 80% of our end results.

The 80/20 rule applies to many areas of life. For example, 80% of a business's profits come from 20% of its customers, 80% of crimes are committeed by 20% of criminals, and 80% of health care costs come from 20% of patients.

All that is well and good, but I'm more interested in how it applies at the individual level: 20% of the time and energy we spend on any activity produces 80% of the end result. That means the other 80% of the time and energy we put in only adds 20% (max) to the end result. Continuing to work on something trying to get it to 100% perfection is an inefficient use of our resources - namely, the time and energy that could be put to better use on another activity.

For example, let's say I'm cleaning the kitchen. I could spend 1 hour on it (20%) and have it reasonably clean (80%). Or I could try to get it 100% clean, spend 4 more hours on it, and still fall short of my goal (because it's impossible to get anything 100% clean!). Instead, I could use those 4 hours to do laundry, go to the grocery store, get dinner in the oven, and write a blog post - none of which would get done if I put all my time and energy into the kitchen.

Striving for perfection, then, is inherently imperfect, because it is inefficient, and often prevents people from being able to do at least some of the things that are important to them. And that's to say nothing of the feelings of frustration and inadequacy that inevitably occur because perfection is just not possible.

100% may be possible on a math test or the SAT's, but it's not possible in real life, and striving for perfection actual prevents us from achieving our full potential, because we're wasting our resources. If we allow 80% to be good enough, we will be happier and more productive. It's time to end the (metaphorical) grade inflation, and return to the days when 80% was a darn good result!

If you have any examples of how the 80/20 rule might apply to your life, please share!

Perfectionism: Mastery Gone Awry

Last week, I wrote about mastery - the feeling of competence or achievement that can be such a vital part of mental health. However, sometimes our desire for mastery goes awry, turning into perfectionism - compulsive efforts to reach impossibly high standards, while viewing anything short of perfection as failure. Perfectionism can involve standards we have for ourselves, standards we have for other people, or standards we believe others have for us.

While it's normal, and sometimes even helpful, to have high standards, these standards veer into perfectionism when they are excessive (i.e., unreachable), arbitrary, unnecessary, and rigid. High standards enhance functioning and help us be/do our best. Perfectionism, on the other hand, tends to interfere with performance and functioning in many areas of life. In fact, perfectionists are often paralyzed by their perfectionism: they either spend an inordinate amount of time on one task or activity trying to get it just right, or they don't even start a task or activity because they know they can't meet their own standards. Perfectionism takes a toll on relationships and self-esteem. It can produce anger and sadness, and is clinically linked to depression, OCD, other anxiety disorders, body dysmorphic disorder, and eating disorders.

The dysfunctions associated with perfectionism fall into two main categories: behaviors designed to help the person meet their excessively high standards, and behaviors aimed at avoiding situations that involve perfectionistic standards. The first category includes things like checking, repeating, correcting, organizing, etc. The second category includes difficulty making decisions, procrastination, and giving up too quickly. These behaviors are a burden for the perfectionist, and a source of annoyance to those around him/her.

Behind these behaviors lie a host of distorted thoughts, including filtering out positive feedback (to hone in on negative), black-and-white thinking (if I'm not perfect, I'm a failure), mind reading, comparisons, and lots and lots of "shoulds." Therefore, a major focus of intervention with perfectionists is correcting distorted thought patterns (using such CBT strategies as examining the evidence, identifying alternative (more realistic/helpful) thoughts, considering advantages/disadvantages of the thoughts, and hypothesis testing. Changing the thoughts will shift some of the perfectionistic behaviors, but these also may be addressed more directly through exposure exercises, where the person does the opposite of the perfectionistic behavior, and rides out the resulting anxiety until it lessens. This has to be repeated several times to create lasting change.

Basically, at its core, perfectionism reflects the fear that we're not "ok" - lovable, competent, acceptable, worthy, etc. These core beliefs take longer to change that thoughts or behaviors, but with the benefit of significantly improving quality of life. It really boils down to this: being perfect isn't worth it!

How do you see perfectionism's effects on people, and how do you help perfectionistic clients? Have you ever had a client who was perfectionistic about therapy itself?

(Based in part on When Perfect Isn't Good Enough)

On Their Own Terms (Or, It Takes Two to Terminate)

A few days ago, in my post on Good Goodbyes, I wrote about my ideal termination process from a clinical perspective. However, as I sit here waiting for my clients to come in for scheduled termination sessions (after notifying them last week that this would be our last session together), I am reminded that what I consider a "good" goodbye clinically may NOT be what my clients want. And while they may not have much say over whether or not I leave, they do have some say in how they take their leave from me: it takes two to terminate.

Some clients will come in for a final visit. They may studiously avoid speaking of endings, and instead try to divert conversation onto other, less sensitive subjects. However, some will talk about goodbyes, this one and others, and express their feelings about it. They may be able to review the work they've done, and the progress they've made. They may express anxiety about whomever the next provider will be - sometimes I get the sense that it is change rather than endings or goodbyes that causes the most discomfort during termination. They may try to drag the session out as long as it will go, to delay the inevitable. But, eventually the end comes, and we bid each other farewell - some over their shoulders as they rush out the door, others with a handshake or hug or wave.

I like the closure of saying goodbye. But, a lot of people really HATE goodbyes. Confronting their feelings about the loss, sitting with those feelings, isn't something that they want to do. So, when it comes to a planned termination, clients who hate goodbyes may just not come. They prefer to say goodbye on their own terms, by not saying it at all. Avoidance at its finest. I find this kind of non-goodbye deeply dissatisfying because it lacks closure...but I understand the impulse, because I'd just as soon not make a fuss of saying goodbye to my colleagues.

Another possible response to planned termination is regression - the client may revert to symptoms or behaviors they experienced earlier in treatment. When this happens, it can leave you feeling discouraged about the work...but it helps to know that it's normal, and time limited: the progress is still there, and will reemerge after this ending has passed.

It's been suggested to me that therapists can predict and plan for how each client is likely to respond to termination by seeing how they respond to other separations during treatment, such as the therapist's vacations or sick leave. However, not enough of my clients have been with me through this kind of break, so I can't tell whether a pattern would appear. Are there other things you've learned or noticed about how clients handle termination on their own terms?

The Many Reasons Clients No-Show

I wrote about the financial side of "no-shows" in a previous post, but the clinical aspects of no-shows also deserve attention.

My clients have complicated lives. Most are low-income, many are single mothers, some work multiple jobs, have court obligation, or complex medical conditions. I understand how they might get overwhelmed and forget an appointment here and there. Buses and childcare can be unpredictable, money might run low toward the end of the month, and if the phone is shut off, there's no reminder phone call. All legitimate explanations for a missed appointment.

I wouldn't be doing my due diligence, however, if I didn't at least consider the possibility that there's more to it. No-shows can have clinical significance on at least two levels.

First, they may be diagnostically significant. Does the person often forget to do things, in spite of reminders? If so, common causes for memory impairment must be considered, including attentional deficits, cognitive disorganization, or even dementia. If they remember but can't work up the motivation to come in, or even call, that's also informative - avolition is a symptom of mood and thought disorders. Or perhaps they both remember and are motivated to come to their appointment, but 1) oversleep (sedation from meds? staying up late, or even day/night reversal? a new infant, or graveyard shift?), 2) can't find their keys, miss the bus or get off at the wrong stop, get sidetracked on an errand...... (overall disorganization, issues with attention, poor time management, or impulsivity?), 3) had to handle a crisis at work, with the kids, with their health or their aging parents (an isolated incidence, or a pattern, perhaps related to low self-worth, co-dependency, or even narcissism?). I could continue, but you get the idea - sometimes the functional impairments causing someone to seek treatment interfere with their ability to seek treatment. In these cases, managing symptoms well enough to make it to appointments could very well be a treatment goal.

However, even when someone no-shows for perfectly legitimate situational or diagnostic reasons, there's still a deeper clinical level that should be considered - the potential meaning of the missed session in the context of the work between therapist and client. Does the no-show happen right after the client allowed him- or herself to be particularly vulnerable? After the therapist confronted something, or assigned homework? Around a particular date (the first of the month, a holiday, etc)? Or even, predictably, every other session? The client may be - knowingly, or more likely unknowingly - either reverting to avoidance, expressing their ambivalence or resistance, or making a protest.

I'm not suggesting that there is always some deeper meaning to a no-show (sometimes the cigar is really just a cigar). But, sometimes there is something else going on, and if so, the no-show is an opening to address it. If you don't, at best it's a missed opportunity, and at worst, the no-shows will continue until the issue they represent is resolved.

What do you see as the clinical significance of no-shows? How do you address these clinical issues when no-shows happen?

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?