Types of difficult clients in therapy
As a therapist, you want to help your clients move forward to meet their treatment goals using specific tools and processes to help them in many areas of their lives. Therapy sessions involve working towards identifying problems, expressing feelings, working through and reprocessing painful emotions and memories, changing behaviors, improving relationships, and many more issues. Therapy can be hard work with a "perfect" client. But what happens when you have a difficult client? This article will discuss several types of difficult clients in therapy and suggestions on how to deal with them.
How do the different types of difficult clients in therapy affect a clinician?
The different types of difficult clients in therapy can present challenges for even the most experienced and skilled therapists. Not only can these challenging situations derail the progress in treatment, but they can also affect how the therapist feels and responds to the client.
When providers work with different types of difficult clients in therapy, they might:
- Question or doubt their abilities as a therapist
- Dread sessions with a particular client
- Increasingly dislike their role as a therapist
- Cancel sessions
- Feel burnt out
- Be overly cautious in sessions
- Feel nervous or avoid addressing certain issues with a client due to fear of how the client might respond
- Feel intimidated or scared of certain ethical, legal, or liability risks
Many therapists experience these types of responses when working with various types of difficult clients in therapy. In a counseling practice, you will most likely run across many clients who present challenges to you. Learning about some likely challenging types of difficult clients in therapy can help you to better understand and prepare for how to respond.
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Unmotivated clients
Some clients come to therapy with no desire or motivation to work on therapy goals or to even be in the session. Many times, clients lack motivation when they did not initiate the therapy. They may have a court-mandated treatment or perhaps a family member that pushed them to go to therapy. Sometimes another healthcare provider may request or require them to have therapy.
What to expect in sessions
Communication of their lack of desire to be there: They will let you know, one way or another, that they do not want to be in session with you. They might boldly state “I”m only here to make my wife happy but there’s nothing wrong with me. I don’t need therapy.” Or, they might display non-verbal expressions such as eye-rolling, crossing their arms, or blank stares at you.
Provide vague answers: When you ask questions in the assessment or in session, they will give very vague and non-committal responses. You might hear a lot of “I don’t know” or “I don’t care about that” types of comments.
Change of topic: They change the topic that the therapist initiates to something of more interest to them.
How to respond in session
Let them guide the session: Pushing your therapy agenda will strengthen their resistance to being there. Use the therapy time to reflect upon their desired topic of conversation. Actively engaging the unmotivated client in their preferred discussion can increase the rapport and trust factor in the relationship.
Re-evaluate treatment goals: When you recognize that you have an unmotivated client, work with the client in session to assess treatment goals. Ask them how they would like to use this time and what goals you can work on together.
Self-sabotaging clients
When you work with a client who self-sabotages, they will likely appear to have made some progress in treatment but then return to maladaptive patterns in their life. They may have a substance abuse relapse, engage in self-harming behaviors, return to an unhealthy relationship, or other patterns that existed prior to coming to therapy.
What to expect in sessions
Not completing homework: Clients who sabotage their treatment progress may stop following through on homework assignments. Quite often the client will minimize or justify the lack of follow-through in homework.
Cognitive dissonance: In the session, they may say one thing but their actions in session or outside of the session contradict it.
Cancel sessions, come late, or leave early: In an attempt to avoid their fears or face the self-sabotage in session, these clients tend to limit or miss their sessions. They may make a great excuse or just not contact you at all.
How to respond in session
Several different treatment techniques or interventions may help the client work through the reasons behind the self-sabotage:
Motivational interviewing: Can help to resolve ambivalence
Acceptance and Commitment Therapy (ACT): Can help to change the client’s relationship with unproductive thoughts and to eventually release them
Self-compassion work: Can help the client to find insight into their pattern of self-sabotage while working on forgiving and accepting themselves
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Hostile clients
Working with a hostile client can feel very scary and lead to anxiety and self-doubt for the therapist.
What to expect in sessions
Verbal aggression: A hostile client may yell and scream at you, another staff member, or another participant in the session. They may raise their voice in session when discussing an upsetting situation.
Physical aggression: Some clients may escalate their behaviors to show physical aggression. They may destroy office furnishings, throw things, or even try to physically harm the therapist or someone else in the office.
Threats to harm: Hostile clients may threaten you or someone else in the office. They may make threats in person, over the phone, or even virtually.
How to respond in session
Remain calm: As difficult as it may feel, you should do your best to remain calm during any hostile situation with a client. Showing your client that you feel scared, anxious, or angry can escalate the client’s behavior to a more dangerous situation.
Show empathy: If possible, demonstrate your empathy towards the client's emotional response. It might help to de-escalate the situation and allow the opportunity to explore the episode therapeutically in session.
Set boundaries: Carefully set boundaries and limits with the client regarding how they may treat you (or others).
End the session: If the client does not adhere to the established boundaries and continues to engage in hostile behavior, end the session. You do not have any obligation to expose yourself to abuse and dangerous behaviors. If necessary, call 911.
Discharge with a referral: If you feel scared or uncomfortable with any client you have the freedom to discharge the client with referrals to other providers. Make sure to document carefully the reasons for the discharge and the referrals provided.
As a therapist, you will likely meet with various types of difficult clients in therapy. Difficult clients can lead to high levels of stress and burnout for practitioners. Engaging in self-care, seeking consultation, and engaging in therapy for yourself can help you to cope with the effects of difficult clients and burn-out in general. It can also help to design your schedule so that you have time to debrief after a session with the different types of difficult clients in therapy.
Tools like TheraPlatform can help clinicians organize and manage their notes and client treatment goals. TheraPlatform, an all-in-one EHR, practice management and teletherapy tool was built for therapists to help them save time on admin tasks. They offer a 30-day-trial with no credit card required and the ability to cancel at any time.
More resources
- Therapy activities
- Building your private practice through patient engagement
- Identifying your ideal private practice client
- The Ultimate Teletherapy E-book
- The Ultimate Billing Guide for Therapists
- Therapy resources and worksheets
