Compliance

A client in the treatment program where I work has a particularly strong transference to me. I have no idea why, or what is coming up for her. I just know that she holds strong but very inaccurate beliefs about what I feel, think, and say about and to her.

It's a little unnerving to have someone reacting so strongly when you (1) don't know what is triggering it, and (2) have very little objective influence over the type or intensity of reactions. I suppose this is the nature of transference, however.

One aspect of the transference specifically stood out to me this week: the client told another staff member that I said she was not "complying with the program." This statement was interesting because I certainly did not say it...but bothersome because I would not say it.

"Compliance" (and all of its various derivatives) are words I have been conditioned to avoid because of their connotation. Compliance can mean cooperation, adherence to a plan, or conformity. However, unlike the other words I just used to define it, compliance tends to imply an expectation of obedience or yielding to authority. In fact, dictionary.reference.com adds: "especially in a weak or subservient way."

Obviously, it is a word that could be problematic if one is trying to empower clients! The medical world is consequently trying to move away from it, for example by talking about medication "adherence" rather than "compliance." In the Eating Disorder world, however, we still regularly refer to "meal plan compliance." In a population that often reports feeling powerless over their life circumstances, and has historically been disempowered by the treatment process, I find this a little problematic.

I don't know whether colleagues use this expression with clients. I do not. And I certainly never use the word "noncompliant" with clients! I think the word itself short-circuits meaningful exploration of the client's behavior, the difficulty of change, ambivalence, and the client's (legal and ethical) right to participate in decisions about treatment goals and interventions.

While it may seem like semantics, therapists (of all people) should understand the power of words - after all, we are in the business of "talk therapy." I try to choose my words carefully, and as in Jewel's song Life Uncommon, "let your words enslave no one...lend your voices only to sounds of freedom."

Ink

About 25% of people under age 50 have tatoos, and that number goes up when you look at younger segments of the population. It seems like it's almost a rite of passage these days to get "ink." While I don't actually have one, many of my friends and colleagues do. More conservative folks may get tattoos in areas they keep covered, but it's becoming more and more mainstream to have tattoos on places much harder to hide - hands, forearms, neck, ankles, feet (yes, I know feet can be hidden - but I wouldn't want to wear socks all summer!).

However, for better or worse, the corporate world - including healthcare - has not caught up with the times. Every company I've worked for has a policy barring visible tattoos. While enforcement of that policy seems to vary widely based on the agency and position, I can see how many clinicians in my age group might face tattoo-related difficulties at work.

When such difficulties arise, it may be tempting to abandon agency life for the freedom of private practice. However, regardless of the setting, it's important to consider the possible impact of tattoos on the treatment process.

The senior managers who establish tattoo policies are probably doing so based on their ideas about "professionalism" - along with other decisions about dress code, and the like. While a professional presentation is certainly important for therapists, I also think it's possible to appear professional with visible tattoos (if they are tasteful and unobtrusive). The bigger concern for me is how clients will interpret the tattoo.

Tattoos are a mode of expression, so we have to assume they will express something to clients - but much of their own individuality shapes their interpretation of the tattoo's "message." It would be a mistake to make assumptions about what that interpretation might be. When in doubt, and it seems that a visible tattoo is drawing a client's attention, I would say the best bet is to make it a manifest, rather than latent, part of the conversation - it's all grist for the mill, after all.

The tattoo may also shape the client's transference to the therapist. After all, a tattoo, as a form of self-expression, is the opposite of the "blank screen. It may influence what other relationships get layered over the therapeutic relationship, what associations are called up, and therefore significantly shape the content and context of therapy.

Whether or not transference becomes a factor, tattoos are inevitably a form of self-disclosure, and should be considered with the same care as other forms of self-disclosure. Will it help, hinder, or be neutral to the therapy? What would it be like for you to have the client interpret (and possibly misinterpret) it? What might it say about who you are, and how might that influence the client?

In all of these considerations, the population matters quite a lot. With some populations, a tattoo may make the therapist feel more accessible, and be a way of joining with clients. In other populations, it might lead to negative judgments of the therapist, or (with kids, for example) be seen as advocating a lifestyle key stakeholders (parents, funding sources, the board) don't support.

The bottom line is that, while you might not even think about your tattoo that often, if it's visible, you need to think about how that might impact your clinical work. If you're thinking about getting a tattoo, you might want to consider one you have the option of hiding if necessary (rather than wearing a band-aid all the time, as one of my colleagues had to do). If you're bent on a spot that you can't hide easily, consider the tattoo and it's message carefully - it will become part of your presentation as a professional!

Understanding Client Criticism: 5 Things to Consider

I've written in the past about challenges in giving and receiving feedback. I want to reflect more specifically today on feedback/criticism from clients. For most of us, our work is important to our identity, provides us with a sense of purpose, and (ideally) feelings of competency. It makes sense, then, that criticism of our work can feel threatening, and elicit a wide range of distressing emotions. Yet, how we respond to clients' criticism or anger toward us can significantly influence the quality of our treatment relationship.

Responding to criticism or anger from clients is not a simple or straightforward matter, however, because there are several variables at play.

1) First, it's important to regulate my own emotional reactions in the moment so that I can continue to function therapeutically and remain focused on the client's needs. I keep breathing and subtly relax my body in the session, keeping my own defenses from rising. Afterward, I may seek supervision or consultation to work through any emotional reactions that linger.

2) If a client is expressing criticism and anger, I have to assume that there has been some kind of empathic failure. I think it's important to hear the client's message and begin by demonstrating that I've heard them (using empathic reflection), validating their feeling, and considering the possible truth to what they're saying. This process begins to restore the empathic connection. It also requires sifting through what has been said (including excessive anger and hurtful words) to find the bottom-line message.

3) Sometimes the feedback is valid and there is some shift I can make in response, to better meet their needs. While it may be difficult, it's important to acknowledge when I've made a mistake (not to mention it's good modeling). Sometimes the feedback is accurate, but not something I can or am willing to shift. In these cases, I explain why I can't do what they're asking. For example, occasionally a client will become frustrated that I'm not "telling them what to do." I know that if I try to tell them what to do, however, I run the risk of telling them something that doesn't resonate with their own perspective, or something they're not ready to hear. Both of those possibilities would also be significant empathic failures. Since I value self-determination and think the process of clients coming to an answer themselves is often the real work of therapy, I can't in good conscience "tell them what to do." When I explain that, most clients respond with some version of: "I know you're right, but I still wish you could just give me the answers." I validate their frustration with the slowness and discomfort of the process - which is really the issue, rather than my withholding my expertise, as they originally suggested.

4) It's also important to consider the role of transference. Clients may be critical and angry not because of any mistake or misstep on my part, but because of their own transference. When I have listened for the bottom line message and genuinely don't believe it's consistent with what's actually been happening between us, I wonder whether the client's other relational experiences, anxieties, and patterns of interaction may be coming out in the transference. In these cases, the client's words/actions and my reactions are both sources of information about how the client experiences the world, and relates to important others. Once these patterns appear, good therapeutic work can be done by naming and exploring them together.

5) Another possibility when the feedback doesn't seem to match up with reality is that it is a defense mechanism. It may be that the work has come uncomfortably close to deeper issues, threatens to open painful issues, or is moving a client toward a change he or she feels unready to make. It is understandable that the client may subconsciously defend against these threats by reacting to me with anger, often employing displacement, projection, or projective identification. Responding to defense mechanisms is a very delicate matter, because "breaking through" defenses can seriously destabilize a client. I generally find it preferrable to gently lean into them, and back off if the defenses intensify. Whatever the issue is will resurface when the client is ready.

As you can see, there is a lot to think about and untangle when responding to a client's feedback - your own emotions, the possibility that you've made a mistake or had an empathic failure, whether or not the underlying request is clinically appropriate, and whether transference or defense mechanisms are contributing. There may even be other things that I'm missing. How do you think about and respond to feedback, including criticism and anger, from your client?

Attachment in Therapy

Underneath the theory and technique, the heart of therapy is the relationship - a special kind of relationship that is formed between therapist and client. The incredibly personal nature of what is shared in therapy gives the relationship a very intimate quality. As a result, clients tend to relate to the therapist in a way that reflects the patterns and expectations they bring to intimate relationships. 

We call it "transference" when the client layers a specific relationship from their past or present life onto the therapeutic relationship - for example, relating to the therapist as if she were the client's actual parent/partner/child, etc. However, even without this kind of transference, we are getting flavors of how the client feels about and relates to important other people. 

This process is both incredibly important and incredibly complicated for clients who have experienced relational traumas - when they have been hurt by those who were most supposed to love and protect them. Particularly when these traumas occur early in life, people may develop enduring patterns of "insecure attachment" - basically, relational templates that assume instability, unpredictability, and/or threat within close relationships. 

While there has been plenty written about attachment styles, I have been thinking more about how insecure attachment styles reveal themselves in therapy, and wanted to write a bit about the subject from this perspective. There are three kinds of insecure attachment, described in adults as preoccupied, dismissive, and unresolved:

1. Persons with a preoccupied attachment style are anxious about relationships, and cope with their anxiety by seeking reassurance. In romantic relationships, they may call often, ask if their partners love them or are mad at them, and so on. In therapy, they may need frequent reassurance that the therapist is "there," and will continue to be there. For example, one client of mine needs reassurance that each new adjunct service (case management, day treatment, etc) is not going to replace therapy, and is not an attempt to "get rid of her." Clients with this attachment style tend to find vacations and other cancellations or disruptions in treatment especially distressing and anxiety-provoking. They may also hold back what they consider to be the most unacceptable parts of themselves for an unusually long time, believing the therapist wouldn't continue working with them if they "really" knew them. As a result, continuity and unconditional positive regard in treatment can be immensely healing.
2. In contrast, people with dismissive attachment styles cope with their anxiety about relationships by dismissing the importance of relationships in general, and by minimizing the significance of particular relationships by leaving the other person before that person can leave them. These clients may be extraordinarily reluctant to engage in the therapeutic relationship. For example, I have one client with some risk issues who didn't want to schedule a follow-up appointment. She needs treatment, but I was sure that encouraging her to come would be the surest way to prevent that from happening. I waited two weeks, but she finally did call to request an appointment, and I am much more confident that she will come precisely because I stepped back and didn't try to pull her in. These clients may also be inclined to drop out without warning if things start to feel too intense. However, if they can hang in their through whatever is triggering the impulse to bolt, it's another potential for significant healing.
3. Finally, individuals with unresolved attachment styles are not consistent in a pattern of relating - they are (predictably) unpredictable. Sometimes preoccupied, sometimes dismissive, sometimes clinging while dismissing...you get the general idea. One client of mine copes with her fear of her partners leaving her by holding them hostage, or by leaving them first, depending on relative size and power. She abruptly dropped out of treatment with her last therapist when she sensed that the therapist was "tired" of her. The challenge for the therapist is to both be predictable in the face of unpredictability, and NOT realize the negative predictions (abandonment, rejection, or whatever).

As this last example suggests, I find it incredibly informative to ask about clients' past experiences with therapy, and how they ended. If someone seems to have dropped out just when they were getting to the heart of thing, I talk to them about relationship patterns, and how they may at some point feel like doing the same thing with me - but that they can make some real progress if they can stick with our relationship anyway. 

How do you assess for and understand the relational patterns that your clients bring to therapy? What have been the best and worst examples for you?