Notice Obstacles in the Treatment of Baffling Clients

It might be a mistake to assume clients see therapy like you do. Differences lead to delays in treatment, erratic or surprising progress, and possibly the need to set limits.

Clients differ in when they need treatment.

My patient was a frail woman in her late sixties who was frightened to be in a big hospital in a big city far from her farm. Her chart noted that she had been having auditory hallucinations and frequently talked to the trees. I asked her husband how long it had been going on. He told me she had been talking to the trees for four years. I asked him what led him to bring her in for treatment. He said that she had stopped cooking a week earlier.

That was a lesson in how what is clinical to one person is not to another. You may hear your client tell you about a horrible situation, such as domestic abuse, and assume they would not have tolerated it for long. Clients may be embarrassed to tell you how long it has been happening.

Adults may take longer to notice children with attention deficit disorder without hyperactivity than they would children with hyperactivity. Children without the hyperactivity can stay in their chairs and not aggravate teachers or parents. Their inattentiveness can be dismissed as laziness or a lack of motivation. They are no trouble. If they are doing well in school, no one notices that they must study twice as hard.

Fear and stigma can delay treatment.

When I was a kid, I was afraid of what the doctor would do to me. Now I fear what he will tell me is wrong. Clients may delay treatment when they fear what they may discover. They may delay because of costs or because they don’t understand the significance of their symptoms. Sometimes, they delay because they’re in denial or want to avoid stigma.

I have seen clients whose parents had mental illnesses that were improperly treated. The children delayed seeking treatment because they were skeptical about what a profession that failed their parents could do for them.

As I have mentioned, different cultures may regard seeking treatment as a sign of a lack of religious faith.

Misinformation can be an obstacle in treatment. In 1982, I had a client in a rural area who had to lock herself in her home’s bathroom to avoid her neighbors trying to perform an exorcism to remove a demon. The neighbors believed she had a demon as a result of seeing a psychiatrist. They had bought into the idea that educated people are not God-fearing and that the secret nature of our meetings hid a kind of brainwashing with sinful intent.

My wife and I allowed the neighbors’ church to baptize members in our creek. But when we moved away, one of those neighbors told my wife, “We don’t need your kind around here.”

The rooster on our farm had a bad habit of getting into my neighbor’s henhouse. She would call me and insist that I come and get him. Unfortunately, he was too fast for me to catch during the daytime, so I had to wait until he roosted at night. I can’t help but think that part of our outcast status was due to her still being upset about our rooster getting into her henhouse.

Clients dump revelations on their way out the door.

Time limitations can impede treatment. Before letting your client go out the door at the end of the session, quickly ask yourself if you have forgotten to do or ask something that will later come back and bite you. Make sure you have considered PODS. Could your client be psychotic, organic (like a brain tumor that is primarily a physical cause of illness), drug-affected/depressed, or suicidal? Is there some important information you have not gathered? Is that weapon still secure, as you were told earlier?

The last few minutes of the session can have special meaning. Sometimes, a client who wants to reveal something but does not want to deal with it will wait until they are holding onto the door to leave. Then they say, “By the way, I found out my husband has a second family. See you next week.”

A client may see the end of the session as a signal that you believe you have helped them enough. It can feel like a mini termination. It is evidence that you don’t recognize how much they are hurting. You are setting a limit on them and challenging their special neediness. You might see it as a vote of confidence that they can wait until their next visit to continue the work. Some clients, however, see it as you throwing them over for the next client. A client may be reminded of how their parents passed them over for a younger sibling.

Ideally, the end of the session might come with a synthesis of what your client has been saying, framed positively and reflecting your understanding. The end of the session is crowded with tasks, like reviewing directions, making an appointment, and maybe writing a prescription. Try to allow enough time for these tasks by paying attention to the clock. Make time to write your note. It bears repeating that if you don’t write it down and document it, you have no evidence that it happened if you go to court.

Sometimes, clients will surprise you with what they can do.

Remember the waiting list effect, where the client starts feeling better just knowing they will see someone. Then there is the placebo effect, when someone feels better taking a sugar pill because they expect it to work. Don’t demean these effects. The client needs every advantage possible.

You may have noticed that some clients who see novices do better than expected despite their severe illness because the novice did not know the client was not supposed to get that much better. Their collective hope inspired the client to make changes.

I had a revelation while studying neurological literature for my psychiatry board exams. I realized that I have attention deficit hyperactivity disorder. All those years, I thought it was as hard for everybody else as it was for me. I went to school during the Vietnam War era, and I had a low draft number. Failing out of medical school and getting killed in Vietnam was a palpable fear that kept me motivated. Oddly, I owe my career to the Vietnam War and to not knowing that finishing medical school was supposed to be almost unachievable for me.

Client progress may not be linear.

A client told me it might seem like she was going in circles with her growth. She said that, in fact, she was going around in spirals. She was still repeating behaviors but could now see them better from above.

In school, your grades reflected your progress. As a therapist, you might seek confirmation of your abilities by looking at your client’s progress. They are not the same. Check yourself to be sure you are not unconsciously pressuring your client to get well. Sometimes, your clients may show no overt signs of improvement, but they may be gaining insight, as my client described it, in spirals. On other occasions, you are planting seeds that take time to bloom.

Clients may also regress to regroup after an unusual stressor. Consider discussing your treatment and diagnosis with a supervisor or colleague when you feel your client is not progressing.

Remember, you may be a client’s transitional object.

Your client benefits from you being a steady, consistent, dependable, separate person, just like a child can count on the teddy bear they use as a transitional object in their efforts to relate to a “non-me.” When you feel that a client is kicking you around, remember that the teddy bear, though loved, is also dragged through the dirt. It is about persisting in being there for the client.

Some clients are adept at splitting care systems.

Some character-disordered clients can disrupt systems in a way that reflects their own dynamics.

Nursing staff used to come to me to explain that a particularly manipulative, impulsive patient would be too much for the staff to deal with and set limits on. Staff memories of her last hospitalization were widely different from each other, but all could agree that her stay had been disruptive to the therapeutic community.

I went to my director, explained what the nursing staff had told me, and asked if we could refuse the woman’s admission. He put a limit on me and told me that he expected me to admit her, treat her, and help the staff. I returned to the staff and told them that I expected them to handle her and set limits on her. They returned to the patient and said they would admit her, but they expected her to control herself and abide by the limits. My boss realized the limits had to be set at all three levels.

Overdoing may be a defense.

Sometimes, clients with a parent who is a failure will resolve to not be like their parent. Because they have internalized part of that parent, they naturally worry about being just like them. They have a deep fear of falling apart and not functioning, like their parent who fell apart.

This fear makes objective success and accomplishment, as well as reassurance, very important. The client may be tired of having to be so aggressive and unconsciously wishes to be passive. They may want to stop and relax. But they fear that passive wish because it feels like if they give in to it, they can never get back on the treadmill and will become their parent.

Sometimes, regression in the service of the ego is a necessary part of progress. In that situation, the client momentarily uses older coping techniques when under tremendous stress because it takes less effort. They need all their energy to regroup. Clients who must overdo it struggle to accept healthy regression.

People who overdo it also have trouble taking vacations. You may remember that going on vacation rates as a thirteen-point stress on the Social Readjustment Rating Scale, often called the Holmes and Rahe Stress Scale. Saul McLeod explains the Social Readjustment Rating Scale in Simply Psychology at this link: https://www.simplypsychology.org/ srrs.html

Other times, overdoing it is a way of avoiding feelings. One client became depressed some months after losing her son. She had stayed busy and run away from the despair until she broke her leg and literally could not keep running.