This article explores five ways in which mental health clinicians may inadvertently build resistance in clients, lowering their capacity to effectively engage.
Jump to section:
Introduction
Mental health clinicians, often without realising it, build resistance in clients – lowering their capacity to effectively engage. This often happens through protocols and habits that communicate something different to what the clinician is asking or intends to convey (Rosengren, 2009). In this article, we explore five ways clinicians may inadvertently build resistance in clients: the assessment trap; the expert trap; the premature focus trap; the labelling trap; and blaming/chatting.
The assessment trap
Therapists are trained to get a history from the client straight away. Most agencies and institutions have specific assessments they need the practitioner to complete during the first session. The resultant question-and-answer hour may not be representative of the types of sessions which will follow, but the client does not know that. What the client experiences is the clinician taking the lead, asking all the questions, and expecting them to give short answers which get the assessment form filled in, rather than the elaborated responses (born of more open questions) that are more conducive to fostering the therapeutic alliance.
Of course, if there is any possibility that the client is suicidal or there is any imminent emergency, the clinician needs to have a complete enough picture to ensure the proper care and safety of the client. But the form-filling protocols of the typical assessment session steer the client into a passive, one-down role. Think about it: do you as a clinician really need to know everything about the client before you can even have a conversation? When closed (assessment) questions come thick and fast, the client has no opportunity to talk him/herself into change (Miller & Rollnick, 2013). This assessment trap leads into another: the expert trap.
The expert trap
Once the client has been squeezed into a passive role, it is only a tiny baby step, process-wise, from there to the clinician becoming the “expert.” The short-answer questions, fired one after the other, communicate “I’m in control here.” When someone takes over a process (as the acknowledged professional), asking all the questions and writing down the answers, most clients (logically) expect to be told in due course what the solution is, what they need to do (Miller & Rollnick, 2013).
That’s a fair enough expectation for someone who presents with, say, a sprained arm, sore throat, or cut finger; Western general practitioner systems are predicated on the notion of “information in, answer out” and the patient expects at the end of the questions to be given a prescription, a sling, or a plaster – or at least instructions on how to treat the problem. Personal change, however, is not amenable to passively being “done to” and such role-taking as expert-patient is not expected to achieve real conversation about change, let alone change itself.
Premature focus trap
Let’s face it: as mental health professionals, we do have expertise. In fact, when clients come in and start talking about their problems, we often can see beneath the presenting issues to those that are inevitably at the core of the problem. But it is a swift ride to power struggles, discord, and disengagement if we prematurely attempt to get clients to focus on concerns we may hold for them, while ignoring their “take” on the problem. Rather, we must engage with clients from their starting point. Our concerns are probably related to how they see the problem and, as they engage and disclose, the connection is likely to become relevant to them as well (Westra, 2012; Rosengren, 2009; Miller & Rollnick, 2013).
An example of avoiding this trap occurred in a Northern Territory clinic, in Australia. The client presented with generalised anxiety disorder and was particularly anxious over the potential removal of her daughter from her care. The therapist, an alcohol and drug specialist, wanted to address the question of the woman’s substance abuse, but restrained herself, focusing with the client on the custody question. As a trusting therapeutic alliance grew, the woman gradually ventured the reason for the daughter’s imminent removal from her care: the drinking. Having been listened to respectfully and made a partner in the problem-solving process, the woman came on board with how she might change her drinking habits in order to keep custody of her daughter. Change talk was elicited, and gradually a plan was formulated by the therapist and the woman together. In this case, the therapist also avoided the labelling trap, which we discuss below.
The labelling trap
One strand of premature focus is when the practitioner “needs” to name the “diagnosis” to the client, thus labelling him or her. It is hard enough for many clients to front up for mental health help; they feel further stigmatised or “boxed in” by labels. Some writers claim that it is a way that the clinician retains control; others contend that it is at least a judgmental communication (Miller & Rollnick, 2013). Either way, it can build resistance and move the client toward disengagement.
Ultimately, if the client is a fully participating partner in the process and is moving toward changing that which is harming their life, the appropriate therapeutic conversation – one preserving client respect and autonomy – finds no need to resort to labels; the disharmony thereby engendered hinders progress (this does not mean that you need to discourage clients who self-label in recognition of what they are dealing with. For example, “I really have a phobia about flying” or “I want to get rid of my PTSD”) (Westra, 2012).
Stuck on side issues: Blaming and chatting
Similarly to labelling, it is neither helpful nor necessary in most therapies to be concerned with affixing blame. Clients are sometimes quite active in trying to apportion it (to anyone else but themselves, or alternatively, taking too much responsibility for how things turned out). The engagement-promoting intervention here runs something like, “I can see why you hold your parents responsible for the high anxiety you feel most of the time, but this process is a no-fault one. It is about seeing what can help you to feel better, not ascribing blame for why you feel so anxious.”
Off-topic chatting, apart from a few exchanges to build rapport at the beginning of sessions, also does not help the client move toward engagement with the considered change. Rather, when the primary focus is on the client’s goals and concerns, he or she can move forward toward reducing or eliminating the anxiety or other problems (framework for traps adapted from Miller & Rollnick, 2013).
Key takeaways
- The initial assessment can push the client into a passive role, where the clinician’s lead in questioning creates an environment unrepresentative of future therapy. This can result in a clinician-client dynamic that is more aligned with filling out a form rather than fostering a therapeutic alliance.
- The portrayal of the clinician as the sole expert or authority in the relationship can create an unhelpful dynamic where the client is expected to passively receive solutions. Personal change is not amenable to passively being “done to” and such role-taking is not expected to achieve real conversation about change, let alone change itself.
- Clinicians need to be cautious of prematurely focusing on underlying issues that they perceive, rather than engaging clients from their starting point. Ignoring the client’s perspective on the problem can lead to discord and disengagement.
- Assigning labels or diagnoses can lead to resistance and disengagement. Clients can feel stigmatised or “boxed in” by these labels, hindering the therapeutic process. An emphasis on respect and autonomy without the need for labels is encouraged.
- Focusing on blaming others for a client’s situation or engaging in off-topic conversation doesn’t promote engagement or forward progress in therapy. Rather, clinicians should aim to focus on the client’s goals and concerns.
References
- Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change, Third edition. New York: Guilford Press.
- Rosengren, D.A. (2009). Building motivational interviewing skills: A practitioner workbook. New York: Guilford Press.
- Westra, H.A. (2012). Motivational interviewing in the treatment of anxiety. New York: Guilford Press