“No offense, but I don't need self-awareness,” said Michelle. “That's not what I'm paying you for.” After a brief pause for emphasis, she proceeded. “I am not telling you how to do your job, but I need tools!” she demanded forcefully with a pen and notepad in her hand.
Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.
Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.
While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.
She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).
“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.
I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.
One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.
With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).
***
Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.
I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.
File under: The Art of Psychotherapy, Musings and Reflections
Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.
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Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.
While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.
She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).
“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.
I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.
One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.
With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).
***
Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.
I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.
File under: The Art of Psychotherapy, Musings and Reflections