Empower Your Practice

Journal for Practice Managers

How to Deal with Difficult Clients in Therapy (Or To Avoid Them!)

In each private practice there are patients who require special attention from the clinician. The behavior of such patients complicates the work, hinders the development of group norms. And the patient himself is not able to use the potential of psychotherapy to solve his own problems.

In the UK, one adult in three visits psychotherapists, 15% of women receive medical treatment compared to 9% of men. This is a large army of people with various kinds of disorders you have to deal with every weekday.

This article will enlighten you on how to build a solid therapeutic relationship with such clients to help them and save your own mental health at work.

Medesk helps to automate record keeping and recreate an individual approach to each patient, paying maximum attention to him.

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Moreover, you’ll learn a lot about:

  • General principles of communication with challenging clients
  • 4 Types of difficult clients you may run into
  • FAQ by your colleagues

10 Principles of Communication with a Challenging Client

These tips will help you no matter what your patient’s diagnosis is.

#1. Listen carefully, and you will understand what is behind the aggression

Behind every aggression there is a real pain and suffering. It is necessary to understand the feelings of the patient and his behaviour by means of his voice, intonation, and gestures, not by his words. Try hard to hear the main idea in the stream of sentences, separating the aggressive form from the content, otherwise your own emotions will prevent you from adequately perceiving the situation at the present moment.

Listen to WHAT he says, not HOW he says it.

#2. Do not give in to provocations

An aggressive patient expects you to respond to his provocation by engaging in a verbal altercation. Remember that you are stronger in medical matters, and by entering into an exchange of verbal shots, you will become equal with the patient and his core issues.

An aggressive patient

There are no winners in a verbal duel, because the problem will not be solved. Don’t forget to set boundaries between a client and yourself.

#3. Do not repeat rude words after the patient

Rephrase what was said without changing the essence, and answer the essence of the problem. The more emotional the patient, the more calmly you should react. Stay polite and correct, but be sure to continue to show interest in the patient's well-being.

Cold correctness infuriates the aggressor as well as retaliatory rudeness.

#4. Don't take it personally

The aggression of patients in most cases is not directed at you, but at the situation. "You've got it all mixed up!" means that "My tests didn't come on time, and I'm not interested in who is to blame for this, but since I'm talking to you, then you should listen to me and correct the situation.”

The doctor acts as a lightning rod, not a target of aggression.

Don‘t fall into the countertransference. Remember, when the therapist experiences a feeling of anxiety during the therapy session, when he is afraid of the thoughts caused by the therapeutic process, then his desire to avoid anxiety and its psychodynamic roots force him to adopt protective attitudes.

#5. Address the patient by name

If the patient does not reply, call him by his name. The majority of people will stop when you mention their name, and you will be able to voice your answer.

Remember that for a person the sound of his name is the sweetest and most adorable sound in human speech.

#6. Express sympathy and understanding

It is necessary to express regret about the current situation, but without particulars. Do not separate yourself from the institution in which you work, or from colleagues, even if there is their fault. You always have a reasonable alternative to discuss it during your intervention session.

I understand your feelings, and it's really unpleasant. I'm sorry that this misunderstanding happened.

#7. Agree and apologize

It is better to accept the patient's dissatisfaction straight away if it is justified. If it is unreasonable, then agree with the reservation of the essence of the situation without referring to the person. An imaginary consent and an imaginary admission of guilt immediately extinguish the conflict and allow you to move on to solving the issue.

Be taller and better than the aggressor inside your own therapy room.

#8. Take a break if necessary and if possible

If you feel that emotions are overwhelming, then leave the battlefield to recover. This should be done under a plausible pretext and for a short time, especially when a client feels overtensed.

Excuse me, I need to check the information on this issue. I'll be back with you in a minute.

#9. Suggest a plan of action

After you have listened to the patient and understood what his problem is, state your suggestions clearly and unambiguously. Be absolutely sure that your treatment plan is feasible.

#10. Finish your solution proposal with a closed question

Are you satisfied with this option?

This creates the illusion of a choice in which the patient has no choice but to confirm yours.

4 Types of Difficult Clients You May Run Into

Several studies have focused on the essence of therapy and the specialist-client relationship. Dr. Fred Hanna in his book “Therapy with Difficult Clients: Using the Precursors Model to Awaken Change“ thinks that family and close relatives of a patient have a huge potential to help resistant clients if they come to therapy together.

But is this method really workable if we are talking about patients with personality disorders, resistant patients, or “visitors“?

Let's take a closer look at these types of patients.

#1. Clients with personality disorders

According to our analysis of Quora, Google and Reddit, most therapists agree on the fact that treating disorders is the hardest task for them.

The main feature of personality disorders is the presence of maladaptive features of the psyche - such patients are not able to adjust to changing conditions, do not know how to get along with others. Previously, these disorders were called psychopathy, but over time, experts have adopted the Western point of view – psychopathy is still a separate mental disorder. There are several types of personality disorders, sometimes there are mixed types of the disease. Treatment should be carried out only by experienced specialists, but the main problem with this disorder is that most patients do not recognize their mental problems.

In the electronic patient card at Medesk, it is possible to view all the services rendered during the treatment at the clinic. It allows the attending physician to get acquainted with the patient's medical history, view all appointments and reports that were written by other doctors, as well as compare the results of current and previous analyses of the patient.

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The treatment of such clients is nearly always a long-term process even if a person is willing to communicate. When it comes to self-sabotaging clients, the likelihood of a doctor's burnout is extremely high.

So, if you feel ready to work with these people, learn to be patient, especially in the initial phase of the therapy.

#2. Treatment-resistant clients

They seem to care about the process of therapy, not its result. These patients go to psychologists and psychotherapists often and with pleasure. And they often go to seminars, trainings, but they do not want to work on themselves, because they are under the illusion that they are always working on themselves.

They regularly use these endless trips to therapists, seminars, and trainings as a shield from facing their real issues.

These clients go without passes, strive for something, "grow", and yet if the therapist starts giving homework, asking about the results of a previous session, or doing something the client dislikes, he will easily change this specialist to another one.

What to do with the treatment-resistant clients?

Try to get to the true values of them, what really drives them, often asking the questions "Why? What do you need it for?"

#3. Clients with mental health disabilities

The duty of a specialist is to treat this type of patient, so this may seem strange. So, what’s the catch?

Depression or anxiety is no doubt a huge bottleneck in the life of an average person. However, disability insurance benefits can cover any disadvantages.

What does it mean?

To qualify for and receive benefits, people with disabilities see a specialist. Many of them lack motivation to get better because it would mean a loss of the appropriate lifestyle. This is a very common example of a secondary gain, meaning the choice between "being healthy" and "staying sick."

When you are sick, you fully receive the care of family and friends, and deservedly, they are healthy, and you are sick. You have the right to talk to them for hours about your problems, about yourself, about your illness, and all your demands seem to be legitimate.

Working with secondary benefits in psychotherapy is the most critical condition for really serious psychological changes. They are unlikely to happen while it is there. In these conditions, it remains either to find it, realize it and decide what to do, otherwise just wait for the receipt or receipt template of this benefit to become meaningless. If the client has a serious intention to change his worldview, the awareness of secondary benefits and the search for new behaviours outside the disease becomes the main focus of work.

#4. Visitors

People who come to a psychologist for help do not always want to get it. Visitors usually do not have a specific request for consultation.

Visiting clients are also different in their goals and behaviour:

  • The client was sent by someone, or he was forced to go to a psychologist by relatives, friends who wanted him to change, or the court ordered him to undergo therapy. There is no motivation and impulse for therapy and change. Often, such clients can observe an absent look, short phrases, closed poses, unwillingness to open up.
  • A client who came out of curiosity to see what would happen during therapy and, therefore, he does not have a request as such either. Often, these clients ask a lot of questions that don't relate to the essence of the statement; they talk animatedly, jumping from topic to topic, often ignoring the limits of the specialist.
  • Clients looking for a loved one in the person of a psychologist. They also don't need psychotherapy and changes. Most likely they need someone to listen to them, as well as support. There are several options for the development of the session: either they will not give you a word to say, or they will start asking for personal details of the psychologist's life, violating his boundaries, and they can offer their service, which you did not ask for. Or they will pay more for the consultation than they should. Then suddenly, they will call at night and start talking about what happened. They will be very surprised that the psychologist does not want to.
  • Psychologists are sometimes called upon to provide certificates for court, school, guardianship, or employment purposes to work. Such people don't need therapy either.

What to do with visitors?

Alternatively, during the conversation, you can find a personal request, interest, establish trust in yourself and translate the visitor into a customer-buyer. Otherwise, it remains only to say goodbye to the visitors and no friendly gatherings, i.e. to keep its borders and take care of itself.

FAQ by Your Colleagues

Throughout this section, we have compiled the top 5 frequently asked questions about dealing with difficult clients, according to social media, and attempted to answer them briefly. We know how busy psychologists can be, so see the table below:

FAQ concerning difficult patients

Final Thoughts

The more difficult the clients are, the more they need your help and treatment.

In some cases, interaction with the patients can result in mental discomfort and even emotional burnout for the doctor. But knowing the characteristics of the patient's psychotype helps the psychologist to better understand his needs, expectations, fears and emotional reactions. This allows you to optimally organize the process of interaction with patients, use certain tools of influence. You can make it easier by automating part of your work with the help of modern EHR systems.

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