Navigating the complexities of client-therapist relationships can be challenging, but it is critical for successful treatment outcomes. Understanding how to effectively engage with clients who exhibit resistance, hostility, or demanding behaviors is a skill that therapists must learn to foster a productive therapeutic environment.
In this Q&A, Spencer MacDonald, Newport Healthcare’s Executive Clinical Director, sheds light on these important dynamics and highlights a few of the most common types of difficult clients in therapy. With extensive experience in working with diverse clients and training clinical teams, Spencer offers valuable strategies and approaches that can empower therapists to build trust and collaboration, ultimately promoting positive change in their clients’ lives.
He broke down approaches to working with four types of challenging clients—resistant, hostile, demanding, and withdrawn.
Resistant Clients
How would you describe a resistant client?
A resistant client is either reluctant or unwilling to change their behavior. This resistance may be overt—clearly stating their reluctance to engage—or it may manifest subtly through disruptive actions, refusal to adhere to guidelines, or making excuses to avoid therapy sessions and groups.
What are some strategies for working with a resistant client?
Developing trust with a client is the best antidote for resistance. We create trust by simply becoming interested and curious about them. It’s essential that we avoid rushing to challenge the client or argue with them about why they’re resistant to change. This can make them feel attacked, increasing their resistance.
What is the best therapeutic approach to use with resistant clients?
For younger clients, using modalities that rely less on talking can be helpful, such as art therapy, music therapy, sand tray therapy, etc. For older adolescents and young adults, Motivational Interviewing (MI) is a powerful modality for addressing resistance in therapy. It’s the gold standard treatment approach for helping people make positive change in their life. MI supports clients to tap into their deeply held values and beliefs, to guide them in making choices about which behaviors are ultimately more beneficial to their growth and well-being.
Instead of confronting resistance directly, MI therapists accept and explore it. This helps clients feel understood and less defensive, allowing them to express their concerns about making changes. Success in using MI boils down to three things:
- Collaboration—developing a partnership with the therapist, care staff, and relevant team members
- Evocation—the team’s belief in the client to grow and change, if they want to
- Autonomy—the client’s ability to make choices for themselves
I like to approach these situations the same way I would a puzzle. I’m energized by the challenge, and it leads me to consider different ways to problem-solve why a client may not be improving in care.
Spencer MacDonald, Executive Clinical Director
Hostile Clients
What is a hostile client, and what interventions are helpful with these clients?
A hostile client is typically one who tries to intimidate staff and other clients through their language or behavior. MI is useful with these clients, too. We can use MI to show them that we understand their frustrations, and also to explore the reasons behind their hostile behavior. Depending on the age of the client, sometimes it’s helpful to enlist the support of caregivers to set boundaries with the client and clarify the potential consequences of failing to complete treatment.
It’s important for staff to find a balance between addressing the client’s behavior with compassion and understanding and letting them know that their behavior is inappropriate. Here are some techniques that are helpful in working with a hostile client:
- Give them enough space to not feel threatened
- Keep your voice measured and calm
- In group treatment settings, give the client space away from other clients until they’re able to calm down
If the client can identify their hostility as a problem, it makes it much easier to work collaboratively with them to develop a treatment plan.
Demanding Clients
What are some traits of a demanding client?
Demanding clients make frequent and/or unreasonable requests of their therapist or care team. For example, a client may expect certain results right away, have unrealistic expectations about the therapeutic process, or insist they won’t improve unless they are using a specific therapy model.
In each of these instances, their intentions may be good, but their focus on a specific need can distract them from using their time more effectively. In other cases, demanding behavior may be meant to distract from engagement in therapy, reflecting the client’s ambivalence toward being in treatment.
What are some best practices for working with a demanding client?
For those who are well-intentioned, spending time with the client and listening to their concerns can help them refocus their attention. Other times, you can prompt them to consider whether their concerns are worth dedicating so much time to, given that they may be slowing down their treatment trajectory.
For those who are intentionally disrupting their treatment with their demands, engaging them with treatment goals that are meaningful to them, such as improving communication and boundaries with their family members, can dramatically reduce the negative behavior.
Withdrawn Clients
What are some challenges in working with a client who is withdrawn?
Withdrawn clients can be challenging, but it’s usually less a behavioral issue and more often a response to debilitating mental health symptoms, like hopelessness and low self-worth. Acknowledging the client’s strengths can be helpful—for instance, you can acknowledge their resilience for managing their acute symptoms as long as they have.
Withdrawn clients can also be exceptionally hard on themselves, so supporting them to assign appropriate responsibility for their experiences and symptoms can reduce thought distortions that propagate their low self-worth. This may include helping them to better understand the impact of complex trauma, such as prolonged exposure to unhealthy family figures and environments.
3 Keys to Working with a Difficult Client
What are the most important things to remember when working with a difficult client?
First, practice empathy. There’s a good chance these negative behaviors are the reason the person sought treatment in the first place. I like to approach these situations the same way I would a puzzle. I’m energized by the challenge, and it leads me to consider different ways to problem-solve why a client may not be improving in care.
Second, be aware of your own reactions and triggers. If you’re labeling a client as difficult based primarily on the emotional reaction they evoke in you, your chances of working with them effectively are greatly reduced. In fact, you could inadvertently do more harm.
Finally, reframe difficult situations as opportunities to connect. A skilled therapist or therapeutic team will be able to identify the underlying reasons for a client’s behaviors, and respond in an authentic way that increases trust and connection. By collaborating with clients and recognizing their concerns and their autonomy, you give them the space to access their own innate desire for growth and improvement.