Even though Seattle-area private practitioner Kirk Honda, PsyD, had been a psychotherapist for 15 years, it only took a hostile client a few minutes to make him question his own competence.
He was working with two parents and their daughter, when the father started attacking Honda, making hostile comments about his abilities as a therapist. The daughter soon joined in. "Within 15 minutes, they had completely torn apart my self-esteem," says Honda, who chairs the couple and family therapy program at Antioch University in Seattle. "I started having a mini anxiety attack. I started to sweat. I couldn't think straight. I almost ran out of the office."
Although the mother stepped in to defend Honda and they eventually repaired their therapeutic relationship, the experience left him shaken. He's not alone. Psychologists sometimes face clients who have personality disorders that prompt them to lash out, for example. Other clients may just be rude. Some — whether they're in court-mandated treatment or pushed into therapy by spouses or parents — just don't want to be in therapy. Challenging clients aren't just a problem for clinical and counseling psychologists, either. Forensic psychologists, such as those working as postdivorce parenting coordinators, can also face hostility.
Responding the wrong way — whether by pushing back at the client or withdrawing — can derail the client's progress, say Honda and others. But, they add, there are ways to use uncomfortable interactions to actually improve treatment.
How can psychologists respond effectively to challenging clients? Here's advice from practitioners who have eased stressful encounters with their clients:
Calm yourself. When faced with a challenging client or situation, you don't want to escalate the situation by reacting to it in kind, says Honda. Instead of fighting back, be aware of your emotional and physical state, such as a racing heart, surging adrenaline, confusion and dread, he says. When the father and daughter started yelling at him, for example, Honda put his head in his hands and asked them to stop talking for a few minutes so he could calm down. Without that time out, he says, "I knew I wasn't going to be able to be constructive."
Mindfulness meditation can help psychologists prepare for the anxiety, frustration and anger that challenging clients provoke, says psychologist Mitch Abblett, PhD, executive director of the Institute for Meditation and Psychotherapy in Boston. Through daily practice of mindfulness, clinicians can learn to notice sensations arising in the body and thoughts arising in the mind without judgment. They can also keep in mind the core values that undergird therapy. "If you connect with those values, it can pull you through some of these charged moments," says Abblett.
Express empathy. Don't argue or make excuses, says Honda. Instead, validate the client's feelings by saying, "You're angry with me because …." and asking "Am I hearing you right?" And even if it doesn't feel fair, says Honda, apologize, telling the client you're sorry that something you did has made them angry or that they feel you're not competent to provide the services they need. "That can not only help de-escalate the situation, but can also further the ultimate goal of providing therapy," he says.
But keep in mind that expressing empathy has to be done right or challenging clients may see it as phony, says Stanley L. Brodsky, PhD, a professor emeritus of psychology at the University of Alabama in Tuscaloosa, who also has a private practice. "Difficult, suspicious clients may be put off by expressions of empathy," he says. "One has to earn the right to be empathic with such clients and to avoid clichéd expressions."
Compassion for the client should also be accompanied by consequences, adds Abblett. "This is not a rainbows-and-unicorns passive approach," he says. Acknowledge the emotion that is driving the client's behavior, then emphasize that it's not acceptable for him or her to make threats or swear, refuse to pay for services or simply not show up, he says.
Reframe resistance. "Some clients say they really want to change, then fight every inch of the way to make sure they don't," says Fred J. Hanna, PhD, who directs the counselor education and supervision program at Adler University in Chicago and is also a faculty associate at Johns Hopkins University. But don't resist resistance, says Hanna. "When the client is resisting the therapist and the therapist starts getting irritated with the client, then you have two people resisting each other," he says. "That's not therapy; that's called war." Instead, suggests Hanna, praise the client's resistance. "I say, 'If you worked as hard to make your life better as you do to make sure nothing changes, you could be extraordinarily successful,'" he says. If a client curses at him, Hanna expresses his admiration for the client standing up for him- or herself. Doing so, he says, helps clients see that their therapists understand them.
At least rudeness gives you something to work with, adds Brodsky. Say a client attacks the way a psychologist looks. Don't react negatively, Brodsky says. Instead, encourage the client to say more about why you're so unattractive. "Once you do that, you're actually talking," says Brodsky. Plus, if clients are rude with therapists, they're often rude with others in their lives. "It lets you explore what they've done to put off other people," says Brodsky.
Cultivate patience. Psychologists should strive to be patient not only with challenging clients, but also with themselves, says Sarah A. Schnitker, PhD, an associate professor of psychology at Fuller Theological Seminary in Pasadena, California. Her research has uncovered two strategies that can help psychologists cultivate more patience. One is loving-kindness meditation, in which practitioners direct well wishes to themselves, friends and family, even their enemies. The other strategy is re-appraisal, or thinking about situations in new ways. If a client is frustrating you, remember the bigger picture — that therapy is helping to bear the burden of another person's pain, says Schnitker. "You might think, 'This is helping to test me as a clinician' or 'This is helping me develop patience, a virtue I can use in my own life.'"
Seek support from your peers. Psychologists can feel a lot of shame when they're having trouble with clients, says Honda. "A big reason for that is because people don't talk enough about their difficulties," he says. "They think they're the only ones." Sharing tales of challenging clients with other mental health professionals — while respecting confidentiality — can not only help end that isolation but also lead to constructive suggestions about how to deal with such challenges.
It can also be helpful to get a second opinion by consulting on specific cases with colleagues who are "outside the fray," says Matthew J. Sullivan, PhD, a private practitioner in Palo Alto, California. "You can touch base with them when you're feeling rattled or insecure about something you've done," he says. Even a quick phone call with a colleague can help.
Consider terminating the relationship. Clients who think a psychologist is terrible at his or her job have every right to question credentials, challenge therapeutic decisions or even decide to end the relationship, says Honda. Sometimes, he says, "it just isn't a good match."
It's also OK for a psychologist to end the relationship, says Abblett. "I talk about how it seems like we're not on the same page about our expectations of the work and our mutual responsibilities," he says. Abblett outlines what he believes his own responsibilities are toward a client, then asks the client if he's meeting them. He then tells the client what he needs from him or her. "If that can't happen, we may need to talk about a referral to someone else," says Abblett.
We’re all familiar with the spike in cortisol levels we feel when faced with agitated patients in the emergency department. That’s not only because of our hard-wired fight-or-flight response but also because we know that these patients are high-risk to themselves, us, and our ED staff. Agitation or agitated delirium is not a diagnosis but rather a cardinal presentation. Pathology, such as psychiatric, medical, traumatic, and toxicological diagnoses, is lurking beneath; it is imperative that we safely and rapidly calm these patients so we can assess and manage their underlying diagnoses. Here is a five-step approach to managing agitated patients.
Explore This IssueACEP Now: Vol 37 – No 11 – November 2018It is helpful to categorize the level of agitation to better target sedation. The mildly agitated patient is able to converse and is cooperative without being disruptive, while the moderately agitated patient is disruptive to your emergency department without imminent danger to themselves or your ED staff. However, the severely agitated patient is imminently dangerous to all. This last category includes patients with excited delirium syndrome, a true emergency with a very high mortality rate. Excited delirium syndrome has several distinctive features that include unusual superhuman strength, imperviousness to pain, severe metabolic acidosis, inability to maintain attention, and hyperthermia.1
Step 2a: Nonpharmacologic De-escalation for Mildly or Moderately Agitated Patients
Verbal de-escalation is often effective in the mildly to moderately agitated patient, but it requires a calm and deliberate approach.2 Some key elements of effective de-escalation include environmental awareness and self-awareness, such as delegating one person to speak to the agitated patient, ensuring a quiet room, modulating your own emotional and physiologic responses to remain calm, avoiding clenched fists, and having your hands visible.
The SAVE mnemonic outlines scripted responses that may be helpful when faced with a violent patient:3
- Support: “Let’s work together…”
- Acknowledge: “I see this has been hard for you.”
- Validate: “I’d probably be reacting the same way if I was in your shoes.”
- Emotion naming: “You seem upset.”
Step 2b: “Code White” for Moderately and Severely Agitated Patients
Consideration should be given to calling a “code white” for the patient who is an immediate physical threat to you or your staff. A common pitfall is to call a code white as a threat to an uncooperative patient, which can inadvertently increase agitation. Consider calling a concealed code white, directly to security, rather than using an overhead page for the moderately agitated patient who is not posing an imminent danger.
Step 3: Safe and Effective Physical Restraints
There is ongoing debate as to whether physical restraints should be used at all in the management of the agitated patient in the emergency department. If you are going to use physical restraints, the goal should be to use them only as a last resort as a bridge to chemical restraint, which should take no longer than five to 15 minutes with appropriate dosing.4 Prolonged use of physical restraints may result in active resistance of restraints, which may lead to electrolyte abnormalities or dysrhythmias and put the patient at further risk for rhabdomyolysis.