What to do When Clients Get in Their Own Way
Curt and Katie chat about what therapy interfering behaviors (TIBs) are and how to address them in therapy. We explore the balance between reducing barriers for clients while also holding them accountable for their behavior. We also talk about how to identify if it is the therapist or the client engaging in a TIB.
It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.
Click here to scroll to the podcast transcript.
In this episode we talk about how to deal with therapy interfering behaviors:
- What therapy interfering behaviors (TIBs) are and how TIBs show up in the therapy room.
“When we look at therapy interfering behaviors, I think there’s acknowledgement that these can happen both from the client and the therapist.” – Katie Vernoy
- How to address TIBs in therapy (we may disagree a little here).
- The balance between reducing barriers for clients and holding them accountable.
- If you should still have session when a client shows up late.
- Using appropriate self-disclosure to address TIBs.
- Should you fire clients for TIBs?
“Sometimes these clients have these moments, and it makes them very unlikable in the moment but getting through these moments are things that helps to make the real relationship of therapy continue to grow and develop, which makes these clients more likeable.” – Curt Widhalm
- When therapists engage in TIBs.
- How to evaluate if it’s a client TIB or therapist TIB.
- Managing imposter syndrome when a client becomes hostile because the therapist cannot provide what the client wants.
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Resources for Modern Therapists mentioned in this Podcast Episode:
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Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
Consultation services with Curt Widhalm or Katie Vernoy:
Connect with the Modern Therapist Community:
Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Curt Widhalm 0:00
This episode is sponsored by SimplePractice.
Katie Vernoy 0:02
Running a private practice is rewarding, but it can also be demanding. SimplePractice changes that. This practice management solution helps you focus on what’s most important your clients. By simplifying the business side of private practice like billing, scheduling, and even marketing.
Curt Widhalm 0:18
Stick around for a special offer at the end of this episode.
Katie Vernoy 0:23
This podcast is also sponsored by RevKey
Curt Widhalm 0:25
RevKey is a Google Ads digital ads management and consulting firm that works primarily with therapists. Digital advertising is all they do, and they know their stuff. When you work with RevKey they help the right patients find you ensuring a higher return on your investment in digital advertising. RevKey offers flexible month to month plans and never locks customers into long term contracts.
Katie Vernoy 0:49
Listen at the end of the episode for more information on RevKey.
You’re listening to The Modern Therapist’s Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 1:10
Welcome back modern therapists. This is The Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is the podcast for therapists about all things therapist related: what we do with our clients, the things that we do outside of the therapy room, things that we do inside the therapy room. I don’t know I’m back to not introducing podcast well.
Katie Vernoy 1:34
This is a podcast interfering behavior.
Curt Widhalm 1:38
On that note, Katie, do you know what you call an Interrupting cow?
Katie Vernoy 1:42
Curt Widhalm 1:43
Moo! All right, Dad jokes aside. After our episode on firing your clients, ethically, we got a review on Apple from Apple user, vinyldash. And I’m going to paraphrase quite a bit of this here. But this is a review that we’re actually going to have two episodes of response. So we do appreciate all of the feedback that we get from our modern therapist community here. And we do look at a lot of them. So please give us ratings and reviews. Let us know what we’re doing well, what you’d like to see us cover. You can do this on any of the review sites or on our social media; join our Facebook group, The Modern Therapist group. But there is a lot here that came from this review. In response to that episode on firing our clients. Apparently, we miss some opportunities for some nuance, and especially in the case of firing our clients. The only issues that we discussed were when therapists feel unsafe or threatened. True, yes. And maybe we could have done a better job of titling that episode to something about therapists safety and firing clients there. Going back to this review as a private practice therapist far more common scenario when considering premature termination comes from what they call in DBT, therapy interfering behaviors or just repeated boundary violations. And after addressing them in session and attempting to help client gain awareness about these behaviors outside of the therapy relationship. These are far more nuanced situations that don’t make this reviewer feel unsafe, but do ultimately make it sometimes impossible to continue seeing the client when the clients are often already struggling with abandonment issues. And this user would like us to maybe address that a little bit more. We’re going to have this episode and next week’s episode cover some of the nuance here because we try to keep our episodes here about 30 minutes, it doesn’t always allow for us within a single episode to get into a lot of the nuance here, Katie and I were talking about how there’s kind of two different things here. One is talking about therapy, interfering behaviors and managing them. The other is maybe some other non threatening situations where it might be right to terminate with clients. And that’s going to be for next week here. So therapy interfering behaviors, Katie, I think it might help our audience here to know a little bit about how this shows up in the therapeutic relationship. This is something that we know comes from the DBT worlds but whether you’re a DBT practitioner or not, this happens across a variety of practices.
Katie Vernoy 4:42
When we look at therapy interfering behaviors, I think there’s acknowledgement that these can happen both from the client and the therapist. And so I want to make sure that we put that front and center because I think oftentimes, clients get blamed for interfering in therapy and I think therapists can contribute and we’ll get into that more later. But looking at some of the therapy interfering behaviors that I think are most difficult, and maybe we can just start with the logistical ones up front, are coming late to session, missing sessions, last minute cancellations, no shows, not paying, maybe trying to reach out to therapists repeatedly in between sessions kind of crossing those boundaries. But I think the the logistical ones, rather than the clinical ones, I think are ones where people can really get in trouble. Where if you’re looking at a business model, if you have clients that are consistently not paying or late canceling or, you know, or even canceling right on that, you know, whether it’s 24 or 48 hour mark, and you’re not able to fill those session times, I think, from a business standpoint, the no brainer is just fire him right, like just these clients need to go. But I think that there are clinical reasons not to and I think there’s also actually business reasons not to as well. But how often do you experience these types of therapy interfering behaviors, because I think the argument that a lot of people make is that if you set up your practice properly, and you have appropriate boundaries, you don’t see these as often. But I actually think that they’re clinical. And I think that some practices will always see them, at least at the beginning. To a certain extent.
Curt Widhalm 6:16
I think that I run into them a lot less now than I did earlier in my career. And part of that is having structured my business with some of the things that we’ve talked about on the podcast before. Having a client credit card on file sure makes it to wear them forgetting their checkbook doesn’t become a therapy interfering behavior, it’s pushing a couple of buttons that allows for me to charge those cards in the first place. Having automated appointment reminders, sure, makes no showing for sessions a lot easier. But probably the most important thing that I’ve learned is addressing stuff with clients as soon as possible.
Katie Vernoy 6:57
Curt Widhalm 6:57
And this is something where I don’t consider myself a DBT therapist, but the more that I read about DBT, the more that I recognize that I do use a lot of DBT principles in my practice. And I think one of the main things that I do with my clients, and I have a practice that mostly works with adolescents, so this also includes therapy interfering behaviors from their parents is not letting a lot of these feelings swell up, and being able to address it right away in the next session. Or if I am getting a lot of frequent contact in between sessions, you know, those clients where you see their phone number pop up, yet again, you get that little feeling in your stomach, where it’s like…
Katie Vernoy 7:42
Curt Widhalm 7:43
Dealing directly in the therapeutic relationship with clients about how these boundaries end up being crossed, and how it’s something that interplays within our relationship, and is likely interplaying within the relationship those clients are having in other places in their lives, is something where providing that direct feedback to them with the goal of continuing therapy successfully. When you were talking about that there’s a lot of therapists who are really quick to, you know, wanting to get rid of these kinds of clients is, this is really coming from the empathic place of I want this and us to work together. And here’s the impact that this is having, not only on your progress, but on our relationship towards that progress, that really sets a foundation of we’re addressing these behaviors, we’re addressing them again, and we’re addressing them again, that helps to bring this insight up for clients that I do see them start to have more of a understanding of the impact of what they’re doing, not just for themselves in kind of saving themselves out of their own anxiety plays, but also within the context of the relationships of the people around them.
Katie Vernoy 9:01
I love those interventions. And I also think they’re challenging because oftentimes it means putting a little bit more of you in the room, and it’s working in the transference, so to speak, how you’re treating me is probably how you’re treating others. And let’s let’s work it out between us. And I think that works really well. But it does make an assumption that there’s something that they’re doing that is consistent across their life. And that may be true, and I think we need to assess that. But I think I actually start further back, which is trying to understand why it’s happening. You know, I go from a place of someone’s not doing some overt or covert behavior to try to interfere with therapy, but that there may be logistical issues. You know, the first thing I do is I ask them, is this the time for therapy? Do we need to make a different schedule? Do we need to move this around? Is there something that’s keeping you from wanting to come to therapy. You know, it’s looking at what what is their experience? And is there something in their life that’s getting in the way of therapy and not just like, Hey, this is how they treat everyone. They’re always late. They always are inconsistent and over inconsiderate, but actually like, did we just schedule it a bad time? And part of your clinical issue is that you want to please me, so you don’t feel comfortable asking for a different time. So you’re always running late? Is it the way that I start therapy annoys you? And so you’re you’re hesitant to come in? I mean, I feel like to me, and maybe this isn’t that different than what you were saying. But I feel like, oftentimes, the assumption is that this is a resistance or a therapy interfering behavior, which I guess it is interfering with therapy, but it may actually be logistical and practical, and just like, Hey, I realize that I’m exhausted at nine in the morning, and I’m going to sleep through my alarm, and I can’t do it. So we need to schedule it after two, you know, it’s not that I don’t want to see you, it’s that I’ve made a commitment I can’t keep,
Curt Widhalm 11:01
I think, and maybe where I’m shying away from this a little bit is for some clients, you might be asking for an insight that they don’t necessarily have the capability of being able to look at themselves yet.
Katie Vernoy 11:17
Curt Widhalm 11:17
I work very much in the present, the relational aspects of things, and for me with those particular kinds of clients, and as this review is pointing out, being able to talk about the impact that somebody’s behavior has, in real time on the person that that behavior is having is the very DBT intervention of modeling emotions and thoughts and being vulnerable about what’s happening, you know, everybody’s favorite DBT intervention, DEAR MAN, of being able to describe what that impact is, and being able to model how that’s happening. And sometimes I’ll even go so far as to say, here’s, here’s, DEAR MAN in practice, here’s me describing what your impact is on me. And here’s me expressing what that impact does for me, and once again, asking you to look at how these actions in the collective of them has that and you know, reaffirming, are you really committed to changing these kinds of behaviors, knowing that these behaviors have an impact. This way, it’s not getting a lot into the why it’s not getting into, you know, the potential of being able to externalize the responsibility onto anything else, traffic, trauma, anxiety, whatever else it is. But looking at the personal responsibility, that’s still part of the behavior in real time as it impacts with somebody, ideally, you as the therapist, if you’re following what I’m describing here, in a way that is managed, you know, maybe with a slight annoyance, yeah, I’m annoyed when you don’t show up when you say that you’re going to show up. That helps a real relationship to develop. So that way these clients have the ability to work through these therapy interfering behaviors, and outside of the room, relationship interfering behaviors, that allows for that insight that you’re talking about to start to develop and be able to be expressed more effectively.
Katie Vernoy 13:28
So I agree that’s a great intervention. I don’t think that that’s a bad intervention. I think that it’s a wonderful intervention. I think the addition and it sounds like you’re saying that maybe this is not a good addition, is actually trying to see if there’s anything that’s happening on the therapist side of the street coming as a human and saying, Hey, is there a way that we can make this better? Because Is this the right time for you to show up? Is this is there something there because to me, going from the this is your behavior, and you’re doing it wrong, doesn’t acknowledge that there are real life situations that can get in the way of people doing stuff that when those things are resolved, and when they are actually talked about and it’s acceptable to be a human and have some of these things happen And it’s not like, Hey, this is this is a problem behavior, you need to fix it. But it’s like, Hey, this is what I’m seeing. I’m trying to understand it. What do you understand about it? What do I understand about it? What can we do about it? It’s not saying, Hey, stop it, which is, I think can with the power differential, I think can happen. And I think people can feel very turned off by that.
Curt Widhalm 14:33
Oh, to clarify, I’m not saying what you’re doing is wrong. What I’m saying is this behavior has this impact.
Katie Vernoy 14:40
Curt Widhalm 14:40
And by virtue of being able to bring it up in this way, what we’re doing is we’re coming to the place that you’re describing, which is coming to a joint solution on how to make things work together. And ideally, if a client is able to follow that same sort of process of being able to say when You do this, it impacts me this way. That is therapeutic growth in very much the same way that we’ve just modeled and is something that we would hope to be able to create the space for them to have that real relationship with you as the therapist there.
Katie Vernoy 15:14
So the big difference then from something that you might do interpersonally is that you just start from a place of this is therapeutic material, and we need to address it?
Curt Widhalm 15:23
Katie Vernoy 15:24
Instead of Hey, what’s going on?
Curt Widhalm 15:26
Right, because especially with these kinds of clients, we’re exhibiting these kinds of therapy interfering behaviors all over the place. There’s never a bad time to enforce limits, unless it’s way too late. And those limits are the things that we hope that people read in our informed consent, the things that everybody is agreeing to, at the beginning of the first session, when you know, here’s all of our practice policies that they’re just kind of glossing over, because what they’re there for is I want to be healed, I want to be out of this feeling that they’re just kind of Yeah, yeah. Now, let me tell you about, it’s important to come back to what those limits are, as those limits are being tested, and repeatedly being tested, that leads us as clinicians to feel like, are we actually providing this client with good therapy?
Katie Vernoy 16:17
Some of this It sounds like might be stylistic. And I think it probably depends on the clients that you’re seeing, and that kind of stuff, how you approach it, I think, I think we’re saying very similar things. I think the nuance here is, for me, I start from the relationship and trying to understand what’s happened to you from for it sounds like for you, you start within the relationship and, and holding a boundary. And that doesn’t suggest I’m not also holding the boundary. It’s just I think we there’s not one right way to get to the conversation of Hey, this behavior is interfering with therapy, it may also be interfering with the rest of your life. And how do we make you more successful here, as well as how do we extrapolate that out to your life.
Curt Widhalm 17:02
And I think the approach that I’m taking here is that I’m wanting to keep the client engaged in the process of what is happening, and not bypassing what’s happening in the moment and immediately jumping out to other places that this could possibly be happening. And if there is a therapist pleasing aspect of clients in these situations, you can get to kind of this bypass or this ignoring of other places that this is happening for those clients, you know, oh, no, I don’t see this happening in other places, even when it totally is that they’re just trying to be like, you know, I’m a good client, you know, this is the only place that it’s coming up where we might, you know, be chasing a rabbit down one path that needs to go several different paths. I don’t know if that metaphor works, but it…
Katie Vernoy 17:56
I think it’s understandable. But yeah, I mean, I think it’s some of this is so unique to each client, though, it really depends on what they’re working on, and what the therapy interfering behavior is, I think.
Curt Widhalm 18:08
Within this, and you brought up earlier about some of the logistical aspects of this comes with the way that we might choose to run our sessions. Now for you, if a client’s running late to a session, do you set limits on like, well, if you’re not here by 20 minutes, and we’re canceling the session, and I’m just going to charge you anyway.
Katie Vernoy 18:28
Sometimes it depends on the client, I have clients that have chronic illnesses, and different things that may interfere with their ability to come right on time, or those types of things. And so those are discussed and addressed. But I don’t necessarily say if you’re not available by this time, I’m going to close the session out like I’m not going to, I’m not going to do a 30 minute session, if you show up 20 minutes late, I don’t say that, for me the flexibility of enforcing the time limit, and charging them for the session, kind of whether they show or not, I think that lives, but I think the tardiness is more enforced interpersonally and if someone’s 20 minutes late, or 30 minutes late, and they’re like, hey, should I still come? I say no. But if if they come into a session at the 15-20 minute mark, or they tell me Hey, I’m going to be there in five minutes, I will honor the session. I think for me there’s a humanity that I add that maybe others see as not having great boundaries. But for me that that I understand that people have unique experiences and my timeliness is pretty good overall, my attendance rates pretty good overall, I kind of go from the place of I understand and value that you’re doing your bus and if you’re not showing up on time or you’re not showing up consistently, that’s something we need to talk about. So that’s how I manage it. How do you manage it?
Curt Widhalm 19:54
If the client is 48 minutes late to session, we have a two minute session. And I say that because I mean, if they’re paying for a 15 minute session, and I’ve got that 15 minutes blocked out for them, but if they show up, it gives us the opportunity, even in those two minutes to begin to address what is happening and what the impact is.
Katie Vernoy 20:18
Curt Widhalm 20:19
And you’ll see this in a variety of situations, I’m going to change a bunch of details about a client here so that way, I can keep this anonymous. I had a client several years ago, that would always have digestive issues. The minute before the sessions were to begin in our office, this client would show up to the office, the little call light in my office would go on appropriately, about eight or nine minutes before the session, but it would be as soon as I would come out, hey, I gotta go the bathroom. And it would oftentimes be 30-40 minutes in the bathroom, that when this client would eventually come back, the discussion would be, what are you getting out of the therapy, because, you know, what we’ve agreed upon. And the treatment plan that we set out together was to be able to look at the way that your behaviors are kind of procrastinating. And it sure seems like this is happening here. And what I’m hearing from you that therapy is not being successful, I look at moments like these. And it feels like you’re trying to blame me for therapy not working. But we’re missing 40 minutes out of the session. This is where it took several months of having conversations like these. A number of times when this client was upset because I was charging them for the agreed upon hour and, you know, having these 2-5-10 minute sessions that address these behaviors, this client terminated with me for a while and came back 18 months, two years later, and said that that was an opportunity that they saw that they were having this kind of avoidant behavior with a number of other places in their lives. But it took somebody consistently pointing that out to them, for them to now come back to therapy and want to actually start addressing it. So clients like these can seem highly motivated, even in the midst of their therapy interfering behaviors going on. But setting up this foundation, and really being able to not go beyond your own limits as far as what you’re emotionally, having happen with the clients managing your own countertransference. But appropriately, self disclosing can set these clients up for a lot longer process of being able to come to the realizations that they had hoped that they would get in the first place. And this is where a lot of my clients come to eventually say something to me as far as this is what makes your therapy very real. You’re very honest about what you’re doing. And about the impacts that things are happening. You’re not just kind of setting up some rules and not explaining why.
Katie Vernoy 23:16
I think that’s the important point is explaining why the rules are there and having that transparency, because I think if it feels punitive, if it feels dehumanized, you didn’t show up until two minutes. So we’ll do the two minutes and I’m charging you for the whole time. I think that doesn’t necessarily resonate with some folks. And so I think if it’s like you’re describing, you’re actually talking about it within the relationship. I think that is so critical, because so many of the clients that I’ve had come to me have talked about feeling like their therapist didn’t care about them. They were very punitive toward them, or they didn’t see them. And I think for me that that element of being able to hold both pieces, the strong boundaries and infrastructure, as well as the caring human connection. I think that’s what’s most important to me.
Curt Widhalm 24:07
And this comes back to the idea of we can’t infantilized or treat our clients like they’re inherently weak, that having a real relationship, even if it’s a chaotic real relationship is something that does provide the space for growth for these kinds of clients and ultimately allows for the growth of the clients to be able to carry the same kind of principles through other places in their life, and being able to consistently show up and have that acceptance of our own limits. Being able to describe the acceptance of our own limits, and really being able to model it even when it’s initially in bringing it up with clients like this drives our own anxiety through the roof because it’s not an easy transition of going from a therapist. Who’s expecting clients show up and just immediately start doing the work to being able to address things immediately, because we’re trying to keep that professionalism in place. But I think being able to have that honest relationship to appropriately self disclose, when you know, when we hear about this appropriately, self disclosing for the client’s benefit, where I don’t talk about things is, I don’t talk about them not showing up is having impact on my money, I don’t want them to take the message that they’re just you know, in my life, because they’re paying me. Part of that is maintaining the boundary of you reserve some time, that time, cost this amount of money that time was reserved for you, and I’m holding that boundary with you.
Katie Vernoy 25:48
Curt Widhalm 25:49
I don’t, you know, put this in sort of this punitive. Well, you did this. So I’m doing this, it’s more in that nuanced. I had this experience of your behavior. And it left me with this impact. It is radically self accepting my own reactions to that. I don’t go so far as to being like, and I want to punish you for this.
Katie Vernoy 26:13
But I think oftentimes, folks will see consequences of their behavior as punishment. That’s why how it is presented, how the boundaries are presented are important. I’m looking at the time and I want to shift to some other stuff, because I think we’re, we’ve we’ve covered I think, the logistical elements except when do we fire clients for these types of boundary crossings of coming late, missing sessions, last minute cancellations, or not paying?
Curt Widhalm 26:41
I typically don’t. I find that all of these behaviors are in Yalom’s words, grist for the mill of psychotherapy, that these are all processable, being able to continue to talk about it, you know, if it’s logistical things like, okay, scheduling is something that it’s hard for clients to get to our office during rush hour, we’ll work towards appropriate accommodations. I don’t make promises of let me move seven other clients so that way you can get your ideal time. It’s let’s look at my calendar and see if there is a more appropriate time that you can fit in. That is, again, it’s bringing together these principles of I have limits too.
Katie Vernoy 27:28
Yeah, I think you finish there, I start there, I think we have a similar way to handle it. But I actually there are times when I think that it may be appropriate to terminate with clients. One is if they truly are not paying the credit card on file is expired, and they’re not getting back to you at a certain point you don’t want to be keeping that client. I think if clients are consistently missing, you know, last minute cancellations, and you’re seeing them very infrequently. I think there’s a time at which that becomes clinically irresponsible to have them on your caseload. I think if you’re able to keep the conversation going, that’s one thing. But I think if it’s something where you’re absolutely not doing any treatment with them, because they come in once a month, you’re discussing therapy interfering behaviors with them, they go all right. All right. All right, and then they don’t come back for three or four weeks. I think it’s I think at some point, you know, you do have a responsibility both to yourself and to your client to not pretend that’s therapy. So shifting gears, there are these logistical reasons that I think we’ve talked about pretty well. But there’s also some clinical reasons that are called therapy interfering behaviors, whether it’s not trying out interventions, not participating, not speaking a lot, asking or demanding more than a therapist can offer, or even being disrespectful or hostile or critical to the therapist. And I would refer people for that part, potentially back to the episode on how to fire clients ethically, although I think there’s ways to keep those clients. Or not expressing your emotions effectively as another one just to add that in. But when I’m thinking about this, for me, I go to this conversation that we’ve had about resistance. And some of this I feel like is blaming clients for therapist failures.
Curt Widhalm 29:13
Katie Vernoy 29:15
If a client is not trying out an intervention that a therapist think is the right intervention, or they’re not engaging in the conversation in the therapy room, or they’re asking for more than the therapist can offer. And I think the assessment of what that means, potentially the client is saying, I don’t agree, I don’t I’m not signed on for this treatment plan. You’re not helping me to have an engaging conversation here. And I want more than what you’re offering to me because I don’t feel like I’m getting better. Now. Obviously, the assessment is the most important part of that. But I think if therapists go to my clients are interfering with their own behavior because they’re not trying what I want them to do when they’re not talking to me and they’re not and they’re asking me for more I think the therapist needs to do a self evaluation, are you actually aligned with what the client wants to work with? And what they want to work on?
Curt Widhalm 30:09
And you gave a couple of answers even within your question there. One is, if this is not the treatment plan I agreed to, then you’ve done the wrong treatment plan as the therapist. And that’s where you need to go back to. Part of this is going to be dictated by the theory that you’re working from, that a lot of times what I’ll see is especially like kids with anxiety, that don’t want to use anxiety management techniques, and I’ll hear parents, you know, come into the beginning or the end of the session and be like, my kid’s still anxious. Okay, let’s shift treatment theories, let’s go from working CBT with a kid to family systems to see how parents are reinforcing some of the anxiety relief seeking behaviors that running to mom or dad to appease some of the anxiety rather than having mom and dad reinforce, now’s the time to use those anxiety techniques to be able to clinically address this in a way kind of is going to really depend on the context of whichever client but it takes the step back on the therapist part to really evaluate is the working alliance there, do we agree on what the problem is and how we’re going to get there, because that’s going to set up your treatment plan. And your treatment plan is going to be something that the client clinically, ethically should be involved with, if they have any capacity to start working on it. And that is going to be the vast majority of clients. So this is part of where really being the therapist is being able to have that wide variety of different ways to approach this, as you described.
Katie Vernoy 31:55
The other element is potentially my framework, which is the client as the expert of their own experience. And so if I were to suggest a specific intervention, they come back the next week, they haven’t tried it, or they didn’t do the homework or whatever it is they didn’t do it, my approach will potentially be the same regardless if I think it’s therapy interfering, or I had a, you know, an misalignment on the treatment planning. But it’s: what happened? What made it so that you chose not to do that? And how do we either figure out how you do it, which is, hey, you interfered with therapy because you didn’t do what I told you to do. And we all agreed that you were going to do it and it’s great. Or it’s how did I What did I miss? What’s not feeling right for you? What are the steps, maybe were three steps forward, and we need to take five steps back to identify the behavior ahead of it that’s getting in the way of you being ready for this, that or the feelings or emotions or whatever the perception ahead of it that’s that you’re not ready for this. To me, I feel like when clients consistently are coming in week after week, not having done the work, so to speak. My instinct is not that’s a therapy interfering behavior. My instinct is that it’s me, I’ll address it similarly. But I think for me, it’s sometimes I hear clinicians getting very upset because their clients aren’t doing what they think they should be doing. And I’m always cautious to assume that therapy interfering behaviors on the clients part.
Curt Widhalm 33:32
It’s worth evaluating. Why can’t it be both? That..
Katie Vernoy 33:37
Curt Widhalm 33:38
…is, and this is, again, working radically within what’s happening in real time in that relationship with clients is being able to explore both with clients. That, hey, you’re here to work on these things. We’ve agreed to this plan. Is this a plan that we need to reevaluate so that way you can be successful? Sometimes, yeah, where I often see this coming up is kids who are drug into therapy by their parents, and the kids don’t really want to be in therapy. But then it’s being able to shift what therapeutic goals are to something that does speak to the kids. It’s being able to frame it in a way these are, you know, the therapists responsibility ends of things. But I’ve worked with plenty of kids who don’t agree that the problem is what the same problem is that their parents bring them in with. And again, this comes with some of the experience, particular to my practice the intake session, I make sure that parents are involved in the first several minutes of the session to be able to say, all right, describe what you want for your kid here. And you know, after a few minutes of laying out kind of what the problem is, what the limits of confidentiality are all those you know, wonderful first session things. And I send mom and dad back out to the waiting room, I’ll turn to the kid and be like, Alright, I heard mom and dad story, what’s up with them, and kids almost universally are like, Alright, see, now I get to describe what my part of the problem is. It’s it’s a symbolic shift over to the client in that situation to give them more control over the therapy process. So that way, it’s meeting the client where they’re at, not where somebody else wants them to be. And this is where clients will talk about, you know, my therapist forced me into this thing I didn’t want to do. But you can set your client and therefore yourself up for more success by really focusing on that therapeutic alliance upfront to make sure that you’re working towards the thing that you both agree that you need to be working on.
Katie Vernoy 35:46
Well, and I think, to me, a critical distinction is desired outcome and intervention. Because I think, and this is just a nuance to kind of explain it to the audience, I know that you agree with this. But we agree to work toward an outcome, I don’t know, except for more specific types of treatment, like EMDR, DBT, that kind of stuff that people are agreeing on specific interventions. I think that those things, by nature need to be fluid, unless there’s an evidence based practice that suggests a specific structure for the therapy. And so to me, and maybe this comes back to motivational interviewing, and how do we get the person ready to go and make sure that it’s their decision to make a change, or maybe it goes to really understanding the client as a human and being present for them while they figure out, you know, their particular method of healing. I also think that there’s things that we can’t know, deeply in our souls, and maybe not even intuitively because many of us didn’t learn these things in grad school, but the different cultural methods of healing and being able to align those I think, if we are caught in our own, this is what I think my clients should do. I think we’re going to experience more of these types of therapy interfering behaviors versus coming from a place of collaboration and connection when we when we run up against these things.
Curt Widhalm 37:13
Absolutely. You’re right. I was ready to fight you when you said that. You knew that I would agree with it. But…
Katie Vernoy 37:20
I know you all too well. So the final one is this kind of disrespectful, hostile, critical of the therapist, or demanding more than the therapist can offer. And I think that’s similar to what we were talking about with safety. But we talked to in that regard, we were talking about how to fire the client in that episode, which will obviously link to in the show notes. But I think that there’s also, how do you actually deal with that if you’re wanting to keep the client in the session, if a client is being hostile towards you, like absolutely hostile?
Curt Widhalm 37:49
I think that a lot of times, this is where those kinds of behaviors first bring up a lot of that imposter syndrome for a lot of therapists have like, oh, they’re seeing through what I can’t do. And, again, this comes with experience, it comes with supervision, consultation, your own therapy, of being okay with where your limits are, sometimes clients are going to ask for more than what you can provide. And it’s okay to be honest of this is, you know, something that you as a client, you’re asking for something that I can’t do. And there might be feelings, there might be continued hostility about that. Now, this is honestly mostly where I would suggest that you talk about this as far as clinical techniques. I want EMDR, I want brain spinning. I sorry, I can’t do that. That’s not part of my training, that helps to, again, model an appropriate reaction, don’t take it necessarily, personally, but it’s being able to first recognize your own feelings that are coming up in these situations helps to more successfully navigate this. Clients are going to have bad days from time to time, they’re going to project stuff onto you that you’re going to be the target of whatever just happened in the car. Again, number of teenagers that show up in my office just upset of whatever the conversation was in between school and my office ends up being something that gets kind of pushed at me. So the first steps of it is, is there still a place to make therapy work? Sometimes these clients have these moments, and it makes them very unlikable in the moment but getting through these moments are things that helps to make the real relationship of therapy continue to grow and develop, which makes these clients more likeable. But it’s being able to know your own reactions, know your own limits within what’s coming up as appropriately, setting the right kinds of boundaries. Doesn’t help me when you talk with me like this. And if it doesn’t help me, it’s not helping us.
Katie Vernoy 40:03
Yeah, I think there’s I mean, I always go back to, is the client hostile towards me? or angry at me because of a clinical misstep or an interpersonal misstep? I always want to have that assessment be the first thing that I do. And sometimes it’s like, absolutely not, I was fine. This is, you know, whether we call it transference or therapy interfering, or whatever, you know, then then I’m okay, you know, my side of the street is clean over here, let me figure out what’s going on for them and help them to process it, and not necessarily give them the same experience someone outside would give them because most people would walk out of the room or snap back or whatever. But give them an understanding of what that experience is and what they’re putting out. So I see that there have been times when clients are pissed at me because I made a mistake. And so I think, recognizing that there are times that I’m going to have to come back and say, Hey, I missed something there. Let’s talk that through. And most of the time, not always, but most of the time, the client and I are able to come to a better understanding and improves communication. And it’s also modeling, apology and repair, as well as providing them with an opportunity to figure out what do I do when I’ve blown up at somebody, and then the relationship continues, which I think is really powerful. So to me, I feel like there’s, there’s a lot that as therapists were being asked to do, that potentially no one in their life would put up with, for our clients. And so to me, it’s it’s sorting out how do we walk through them in a way that allows for healing to happen, while then still taking care of ourselves. So when I’ve got a client that’s hostile towards me, whether I’ve done something or not, I’m gonna be calling colleagues to consult or at least to vent or whatever, so that I can get myself back in the right place. If I’ve got clients who are consistently making my schedule a mess, I might consult again and say, Hey, you know, what boundaries am I missing? How can I get this back under control? Or what are the things that are coming up for me that I keep helping this client move their appointment all over the week? You know, whatever it is. But I think the doing of these things of having these hard conversations of giving this feedback that most people won’t give our clients, I think is hard enough. But it is we did sign up for it. Maybe not every client maybe not every situation, but we did sign up for this.
Curt Widhalm 42:37
We would love to hear more from you. You can talk about the episode in our Facebook group: Modern Therapists Group, let us know on social media or leave us a rating and review but we’d love to hear about how you handle therapy interfering behaviors from your clients. And you can check out our show notes at mtsgpodcast.com. And also check out the now entirely virtual Therapy Reimagined 2021 Conference, we’ve had to make some adjustments. We’re looking at the COVID numbers and decided that we’d love to hang out with you. We don’t want to hang out with the Delta variant. So join us online you can get your virtual tickets over at therapyreimaginedconference.com. And until next time I’m Curt Widhalm with Katie Vernoy.
Katie Vernoy 43:27
Thanks again to our sponsor SimplePractice.
Curt Widhalm 43:29
SimplePractice is the leading private practice management platform for private practitioners everywhere. More than 100,000 professionals use SimplePractice to power telehealth sessions, schedule appointments, file insurance claims, market, their practice and so much more. All on one HIPAA compliant platform.
Katie Vernoy 43:48
Get your first two months of SimplePractice for the price of one when you sign up for an account today. This is collusive offer is valid for new customers only. Please note that we are a paid affiliate for SimplePractice so we’ll have a little bit of money in our pocket. If you sign up at this link: simplepractice.com/therapyreimagined . And that’s where you can learn more.
Curt Widhalm 44:09
This episode is also sponsored by RevKey
Katie Vernoy 44:13
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Curt Widhalm 44:36
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Katie Vernoy 44:53
You can find more at revkey.com and make sure to mention that you’re a Modern Therapist’s Survival Guide listener.
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