Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.
Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback
Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).
Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.
Empathy and Emotional Validation
Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:
- “Of course you feel angry about being here.”
- “I don’t blame you for feeling pissed about having to see me.”
- “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
- “It pretty much sucks to have a judge require you to meet with me.”
- “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”
Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:
Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.
Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.
Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).
Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.
Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.
Client: (Softening) Yeah. I do love my daughter.
The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.
Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.
“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”
Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.