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Pointers on Doing Therapy

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An excerpt from Understanding Baffling Psychotherapy Clients

Many techniques can cause change. Mike Rutherford’s Equation for Change is explained as one scheme.

Indirect communication, homework assignments, and the example you are setting are also tools.

Discover Mike Rutherford’s Equation for Change.

You may have learned a specific set of techniques associated with the particular school of therapy that trained you. Having a foundation to build upon is an excellent thing. While I hope that this book increases your expertise in doing therapy, I will not advocate one school of therapy over another. Each offers valuable techniques. Instead, I would like to discuss what you might want to accomplish in therapy and how that affects the tools you use in your toolbox.

Employ Rutherford’s equation to create a compelling vision and first steps toward change.

The history taken at the first visit acquainted you with the client. It likely suggested some ideas about what should be accomplished. Let us look at some treatment goals and valuable tools.

The heart of therapy is helping the client change. The first visit highlighted the client’s dissatisfaction with the status quo. Now, it’s time to help the client imagine how different circumstances can be.

The initial interview focused on finding out what was wrong.

You looked for signs and symptoms of things being wrong. The client revealed mistakes, shortcomings, deficits, and problems. Efforts were made to mitigate the negative content by reviewing the client’s strengths and expressing your optimism that something can change.

On the second visit, reframe events positively. Stop asking why the client acted a certain way. Now ask them how they might create successful outcomes.

I am reminded of the behavioral shaping techniques experimenters used to get a bird to peck for seeds in the left direction. They ignore every movement the bird makes in the right direction, then drop grain each time the bird looks to the left. They shape the bird’s behavior by reinforcing the desired behavior and ignoring the negative. S. G. Friedman, PhD, explains this in “Shaping New Behaviors” in Good Bird Magazine, reprinted on https://www.behaviorworks.org/files/ articles/Shaping%20New%20Behaviors.pdf

In the first session, negative behaviors were identified; now, selectively reinforce the positive, hopeful behaviors and leave negative ones alone for now. In conversation with the client, your nod, smile, or short utterance, like “Yes” or “Uh-huh,” is reinforcing. Look for early, not-yet-significant signs that something is better, then comment on it. Ask the client what they learned from the first session or what is different.

Reframe their wrongdoings as missing the mark in the process of getting better with practice. Focus on incremental change by dividing a long-term goal into a series of more manageable short-term goals. Help them develop a growth mindset and give up having to defend themselves as a static being.

When you hear of their shortcomings, your heartfelt acceptance, grace, and mercy model what you want them to experience toward themselves.

When a child feels known and loved by their parents, it makes it easier to accept that they are okay and frees them up to focus on caring for others as they have been cared for. They are also more comfortable recognizing their mistakes because they have a sense of being fundamentally okay.

This initial focus on the self in therapy could feel to the client like you are encouraging self-centeredness. But self-love is not selfishness. Being genuinely able to accept their own humanity frees them to become less self-conscious and connect with others. For those who were not so lucky as children, learning to accept their own humanity lovingly requires first focusing on self-understanding.

Identify factors amenable to change.

Look for and point out evidence of your client’s value and resilience in the face of their situation. Encourage them to be curious about everyday life’s more changeable elements.

Where could they introduce some slight differences? Help them find a minor problem and develop a plan to change it. The idea is to show them that problems are not permanent.

Seek good circumstances in their current life to show them that, while some situations are bad, not everything in their life is going wrong.

They may think they have been singled out or are endlessly unlucky. While not minimizing how much their difficult circumstances have affected them, look for ways to normalize the parts of their situation they may have in common with others. For example, they did poorly on a difficult chemistry test, along with half their class. You might point out that they weren’t the only student who did poorly while at the same time underscoring that you share their concern about passing the course.

Look for examples of how they have connected with others and help them identify when others have responded positively.

This article from Positive Psychology covers using positive therapy in more detail and offers active listening and exercise techniques: “How to Practice Active Listening:16 Examples and Techniques” https://positivepsychology.com/active-listening-techniques/

Like the Alcoholics Anonymous (AA) sponsor, your own example can be a vision of what change looks like for the client.

You can also use yourself as an example to help your client develop a compelling vision of change. Just as a child learns from watching their parents’ behaviors, clients learn from observing yours.

Alcoholics Anonymous is a Twelve-Step program in which alcoholics meet anonymously to share their experience, strength, and hope to maintain their sobriety and live in recovery. In AA, alcoholics go to meetings where they see people in recovery and have regular contact with their sponsors, who are like mentors. They see how the sponsor can regulate their impulses and live in a way that makes their life manageable.

The alcoholic experiences the sponsor valuing them and sacrificing time and effort toward their well-being. When they relapse in their efforts toward sobriety, they experience the sponsor’s mercy and forgiveness. The sponsor’s tenacity in caring about them is a living statement of the belief that they, too, can recover. The sponsor’s life embodies the inspiring vision of things being different.

When I think about AA sponsors, I am reminded of what Father Jim Finley said in an interview with Gary Moon of the Martin Institute in discussing his book Christian Meditation: Experiencing the Presence of God:

We are most powerless in being powerless to be anything else other than infinitely loved by God. That it is coming to the realization that nothing we do or say can make God love us more and nothing we do or say can make God love us less. The sole measure is the measureless expanse of Himself given to us whole and complete in and as who we simply are as precious in our brokenness (Moon 2016).

I have seen AA sponsors show that same redemptive love to the people they sponsor. That modeling and caring are also redemptive in therapy.

But the sponsor does more than care. They also set limits, boundaries, expectations, and norms. The same is true in therapy. Remember that therapy does not begin until acting out ends. Then, the client internalizes the conflict and feels the urge to start the change process. As I have mentioned, clients learn frustration tolerance by being frustrated and tolerating it in digestible, age-appropriate amounts.

Different therapists use different techniques to bring about change.

Next, in Mike Rutherford’s equation for change, the first minor, successful steps are made. This is the how-to part. It is not enough to be dissatisfied and have hope; there needs to be a means to effect change.

Part of the how-to is helping the client examine what values they hold important. What do they see as the purpose of their life? Who and what have been important to them and have meaning? Reminding them of their core beliefs helps them build a base to make the first steps toward that interesting vision. They might draw on their spirituality and their parents’ and mentors’ teachings as sources of strength.

In the first step, you may educate and help the client build social skills. The client practices the new skills between sessions and returns to review how it went. These skills involve social learning and connecting with others as the client develops self-worth and confidence. You may teach mindfulness and affective containment techniques to help clients calm themselves. As the client undergoes trial and error, you respond with encouragement. Your support shows the client that failing is okay and part of the growth process.

Sometimes, you can carefully use humor to lighten the mood. For example, when a client tells me about a socially awkward moment, I might tell them how awkward I felt at a medical school prom in the early spring when I was wearing my cousin’s hand-me-down white dinner jacket and everyone else was still wearing black tuxedoes. I then point out that both the client and I lived to tell our tales.

Another aspect of helping clients with the first steps is helping them get out of their own way.

Cognitive-behavioral therapy techniques help clients when they make mistakes in their thinking. It helps them make better decisions. And that can lead to changed behaviors.

Psychodynamic insight-oriented therapy uses techniques to help the client discover the unconscious conflicts that create resistance to change and paralyze their drive activity. You may help the client see how the repetition compulsion works to repeat past conflicts in their present life. They look for examples in the present of the most recent repetition.

These are just two of many therapies that help clients take those first steps. Suppose you have determined that a medical problem is also impairing their ability to take the first steps. In that case, you will want to do what you need to help them get medication to treat that impairment. If you believe your client has a borderline personality disorder, remember that dialectical behavior therapy (DBT) has been proven to help.

Do what you can to control the treatment setting.

You may not have much control over the setting where you see your client. If possible, try to make it comfortable and warm. Your environment should reflect thoughtfulness, client consideration, and professionalism. You are trying to help your client feel emotionally safe.

Make some space between you and the client. Chairs should reflect equality. There should be privacy and quiet, but the client should know someone else is in the vicinity, like a symbolic monitor. A managed care company employee told me they looked at how old the magazines were in the waiting room to indicate quality care.

In treating trauma survivors, it is best not to wear cologne because the abuser might have worn that kind of cologne. It could trigger the client. Ask yourself if your clothing is appropriate. Evaluate the risks and benefits of wearing anything that shows your religious or political beliefs. Bumper stickers might also reveal something that puts off your client.

It is likely that some methods I am about to discuss do not fit your therapy situation. That’s okay. Take what is helpful.

Choose your words carefully and consider asking clients to repeat what they have just been told.

I have had clients come up to my wife and me in a store and tell my wife how I had changed their lives by telling them to dye their hair cobalt blue and how it made all the difference. I could not imagine what they thought I had said because I knew I had not told them to dye their hair cobalt blue. The lesson is to be careful about what you say and what you put up in your office. Clients may misunderstand you.

If my wife tells me to get milk on the way home from work, I have no particular feeling about it. Then I forget the milk. My wife is mad. I have no milk for breakfast. The next time my wife tells me to get milk, I have some emotion attached to it. It has what is called a limbic valence. In therapy, the situation’s urgency may lend some limbic valence to what the therapist says. However, I suspect it would surprise you to know that the client does not retain much of what you say.

If the client were a student listening to a lecture and not taking notes, you would not expect them to remember everything the lecturer said. The same is true in sessions. What if the lecturer prefaced their following remark with “This is going to be on the test”? Then your student is all ears.

So, there are times in your work with clients when you need to emphasize something important by repeating it or saying it in a way that lets the client know you believe it is important. If it is a direction related to a task, you might ask the client to repeat or write down what you just said. I’ve asked clients with attention deficit disorder or short-term memory difficulties to start a list of things they are going to need to remember to do after the session. Try not to overload your client’s short-term memory, as I do now with yours.

While teaching has its place in therapy, therapy more often consists of the therapist fostering the client’s efforts to do their own thinking about their situation with active listening, which might include occasionally restating elements of what the client just said in a way that clarifies it.

The client’s conclusions are sometimes more memorable than those the therapist introduces. They have taken the time to stop, think, and absorb what has been discussed before reaching their conclusion. Their revelation may represent insight into what was previously an unconscious dynamic, and they may be freed up from having to repeat the pattern.

Sometimes, you do not have time to wait for the client to draw a conclusion or identify a pattern because the therapy is so abbreviated. It may be the last of only a few visits. In that case, you need to weigh the risk of their intellectualizing or denying what you told them against their never having a chance to hear the interpretation at all.

Using active listening and positive communication, carefully choose your words and reframe things to help your client imagine how things could be better and justify their hope. You remind them about their support system of friends, family, and faith. You identify times when they succeeded in working with others and using their self-discipline. Discuss available support groups and other resources for people who lack a support system.

As mentioned earlier, if you must confront a mistake they have made, try to sandwich the criticism between two positive remarks. For example, you might first say that you know what an effort they have made to be on time despite their busy schedule. They were late the last two times, but you feel like they will renew their efforts to be on time.

If you find yourself needing to set a limit on your client, it is helpful to explain your reasoning and how your expectation is a vote of confidence in their ability to tolerate the frustration of respecting it. Setting limits helps clients build ego strength as they practice patience, frustration tolerance, and waiting.

If you determine that your client is a visual learner, ask them if they get the picture. If they are an auditory learner, ask them if your words are clear as a bell. Match your vocabulary to their primary mode of learning whenever possible.

When you ask an oppositional client to do something they are reluctant to do, introduce an element of choice. Pretend you are trying to get your two-year-old child to put on their socks. Do they want to put it on the left or right foot first? Does your client want to start with 25 mg or 50 mg of medication, and how long do they want to try it before they raise the dose? There are two choices slanted in their favor.

You may not think a client knows your thoughts, but your body language can give you away. You may be unwittingly reinforcing something. When you are dealing with a potential abuse history, make sure you don’t ask leading questions that suggest things to the client, and be careful with your body language.

Assigning homework can augment the treatment.

Sometimes, I have assigned homework tasks to clients. I may ask them to sit down with their parents or extended family members and review the family albums or pictures on their phones. I am trying to give them a way to be together and do something. But I also want to show them that they had some positive times together.

If I feel the client does not understand their parent’s life or struggles, I will ask them to sit down with the parent and have the parent help them complete a structured life sketch. I show them that each line includes the date, the year of the parent’s life, personal events, family life, health, and global events.

They have a line for each year of the parent’s life. Clients are often surprised by what they didn’t know about their parents. This exercise can be an icebreaker.

Using indirect communication may reduce resistance.

If you need to confront a client, you might use indirect communication. For example, I may know from what I have read about a college student that they get drunk in the downtown bars every Thursday night. I pick a brief article on binge drinking as part of my reading selection that I ordinarily use to test their memory and reading comprehension. It seems to the client that I use it for all clients, but it indirectly conveys information and may be a conversation starter.

My gastroenterologist friend treated alcoholics with cirrhosis of the liver in a general hospital. Just before he discharged them to their family doctor, he would have the nurse come into their hospital room and adjust the blinds to darken the room. When he came in, he would visit them briefly. Then, as he walked just a bit away from their bed, he would say he was calling their family doctor. In hushed tones, just loud enough for the patient to hear, he would pretend to tell the family doctor how bad their lab studies were and what their prognosis would be if they didn’t give up alcohol and get treatment for their alcoholism.

He had learned from his experience that patients listened more closely to what he was saying to someone else than they would if he put them in a position to defend themselves. He would later call the family doctor and say much the same thing.

Group therapy is beyond the scope of this book. If you want to learn more about groups, you might enjoy the chapter titled “Wilfred Bion’s Theories about Groups” in Search: A Guide to College and Life. I wrote this book with my wife (Roquemore 2020

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Discerning Clients’ Treatment Resistance

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This is an excerpt from Understanding Baffling Psychotherapy Clients.

Multiple elements go into a client’s resistance to change, including major mental illness, physical factors, medication effects, protective denial, lack of skills and knowledge, immaturity, passive-aggressiveness, and oppositional tendencies.

Multiple forces go into a client’s resistance to change.

Many of your clients might belong to the “worried well” and have skills and maturity. They are willing to look at themselves. These attributes make therapy easier. But as excited as clients are about changing, some things may stand in their way.

Imagine you are using your hand to prop up a pencil against a clipboard that is held at a sixty-degree angle. Your hand is just beneath the pencil, and the force of gravity holds the pencil against it. The force you exert upward against the pencil keeps it from sliding downward. Cohesive forces in the pencil keep it from falling apart. Air flows by the pencil. The sum of the forces on it is equal, causing it to stay put. It is stuck. The pencil appears to be inactive, yet many forces are at work. If we ascribe a motive to the pencil, we might say it is a lazy pencil that does not want to move. We might say that the forces on it conflict with one another. The pencil moves when you remove one of those forces by taking your hand away. It is no longer resistant to change.

Clients are aware of some behavioral determinants, but not others.

Multiple forces also affect people’s resistance to change. We describe behavior as “multi-determined.” Clients are unaware of some of these behavioral determinants.

Current research shows that our brains have billions of nerve cells. So, much activity goes on at the same time. We can’t be aware of all the multiple psychological processes in our brains, both waking and sleeping, that affect our behavior.

We cannot be sure what someone is thinking or why they feel what they do. This uncertainty is part of our challenge in trying to understand and help others.

The unconscious is not located in a specific part of the brain. The term refers to that part of the mind that is not accessible. Over the years, people have developed mental constructs to understand what is happening in the unconscious. We call these constructs “psychodynamics,” or “dynamics” for short. We try to understand the client’s dynamics by examining how one thought leads to another. When they repeat behaviors, we look for themes in the patterns. We examine how their view of us recreates past conflictual relationships.

Clients defend against recognizing their dynamics.

Understanding the unconscious dynamics allows us to help the client become aware of them, make better choices, and avoid repeating maladaptive behaviors. Removing resistance is like taking your hand away from the pencil and freeing it up to move. Freed from the effort needed to remain unaware, they develop a more accurate understanding of themselves.

And that leads to change.

The process of becoming aware of dynamics can make a client anxious. Developing an excellent client-therapist relationship is essential because the client needs to feel safe and have a caring, competent, and careful therapist they can talk freely to. Ideally, you will have helped the client develop techniques to deal with the anxiety and contain the generated affect.

“The process of psychotherapy is to strengthen the ego to be able to hear what one does not want to hear—the worst thing one could hear—what one’s defenses were erected to prevent” (Dill 2022).

Clients may feel they are paying a lot to see you and want to get into the heavy stuff right away. They may expect a quick fix. Let them know that you will work with them to develop the skills they need to cope with the resultant anxiety and difficult emotions. Explain the importance of developing skills and a

sense of safety before diving into the more challenging material.

Clients use different defense mechanisms to avoid the anxiety that comes with becoming aware. These defenses include some combination of denial, projection, displacement, regression, rationalization, reaction formation, repression, or sublimation.

Ryan Baily and Jose Pico discuss these and other defense mechanisms in StatPearls at https://www.ncbi.nlm.nih.gov/ books/NBK559106/ (Bailey and Pico 2025).

Resistance is not just a roadblock. It’s also the stuff of therapy and not just the roadblocks. If you have ever played the game Battleship, you know that if you accidentally set off a mine planted by your opponent, you also discover where their battleship is. You know they put their mines near their battleships to protect them. Similarly, when you encounter your client’s resistance, you know that something there is important.

Let’s look at how clients may resist treatment. They may have varying degrees of awareness of their resistance.

Reluctance to change may not be because of psychological resistance.

If your client does not understand what you are saying or misunderstands you, they may have a subtle hearing deficit. Hearing impairment is not always related to age. Hunters, service members, and rock concert fans are at risk. Clients may fill in the gap with assumptions based on what they expect you to say. Sometimes, they may look a little paranoid. Do you often have to repeat what you say?

English may be the client’s second language. When I am in another country and don’t quite understand what a salesclerk is saying, I smile and act like what I missed was not essential. Clients may also misread your behavior and manners.

When a client looks unmotivated, they may have a physical illness that makes them tired. Everything, including therapy, is more challenging when fatigued. Consider whether they may benefit from a workup for long-term COVID-19, anemia, hypothyroidism, diabetes, hepatitis, sleep apnea, mononucleosis, heart disease, poor nutrition, or low testosterone.

Marijuana can cause amotivational syndrome. Anergia (extreme persistent fatigue) can be a symptom of clinical depression and several other diseases. Apathy can be a symptom of several diseases, including neurological disease.

Robert van Reekum et al. have written an excellent article on apathy titled “Apathy: Why Care?” (Reekum 2005). Here is the link: https://psychiatryonline.org/doi/full/10.1176/jnp.17.1.7.

Sometimes, clients feel that if they talk, they risk being rejected by their family. Families may not approve of therapy or medications that affect the brain. They may feel threatened, knowing that secrets about abuse, addiction, infidelity, sexual abuse, or mental illness may come out. Family members may also believe that a client who needs therapy lacks faith in God.

Some people lack opportunities that would lead to a sense of personal agency. It seems life will not work out for them no matter what they do. Because they’re in pain, these clients may try therapy anyway. You may be the first person to believe in them, see their worth, or want to hear what they have to say. They may continue therapy, but it may be more because they like you than because they think they will succeed. They don’t want to let you down because it seems to matter to you how well they do.

Some people are reluctant to do therapy due to realistic, common-sense reasons. You may not know that the things they need to change are monumental and personally costly to change. If that client makes a change, they may be going against their family or culture. In another example, a woman may not want to realize her spouse is unfaithful because that would mean having to leave him and become a single parent.

Too little or too much medication hinders therapy.

If a client is too nervous, they may not do psychotherapy. Conversely, overmedicated clients may lack the motivation to do psychotherapy.

Some clients don’t recognize their maladaptive behaviors.

A client may see smoking or doing drugs as part of who they are and not a problem. They see the behaviors as ego-syntonic. Something that is ego-syntonic is thought to be consistent with the client’s fundamental view of themselves and their beliefs.

Clients may feel that your focus on change implies that they are not good enough as they are. In reality, you are showing them that you accept them as a person, encourage their self-acceptance, and help them change maladaptive ways of thinking and behaving. You want them to see those maladaptive parts of themselves as ego-dystonic, or not consistent with their identity. Your compassion shows them that you accept them as they are. For example, you accept the smoker but not the behavior of smoking.

Your client’s values may be different from yours, and your client may not have a concept of the value of therapy. Instead of being psychologically minded, maybe they have a superficial view of life. Because they see things concretely, they aren’t aware of the psychological process. They don’t consider personal growth an essential value. Clarifying these clients’ goals for treatment may help you see how and where to begin.

Different situations require different approaches to denial.

When a client sees maladaptive behaviors as part of themselves, this is just one form of denial. Denial is an unwillingness to accept reality and acknowledge what others can see as fact. It’s a defense mechanism against anxiety, but it also leads to resistance to change. If a client can’t conceptualize a problem as a problem, they don’t see it and can’t address it.

Their brain may have repressed something by pushing the anxiety-producing thought into their unconscious. The memory is not available to let them put a piece in the puzzle.

Imagine a half-ton pickup truck. How much manure can it haul? The answer is an infinity of manure, but only an average of three thousand pounds at a time. If you pile too much manure on it, it will break down from the load.

Sometimes, a person feels so bad about themselves, their life, and what they have done or not done that they already have three thousand pounds of emotional manure on their pickup truck. You may need to help them remove some of the more reachable emotional manure and reinforce the pickup truck before you consider breaking through their denial.

Prematurely breaking through their denial is like reminding a tightrope walker how high up they are.

When I was working in a senior intensive outpatient program, I met a woman who, as a child, had to wear worn-out, hand-me-down clothes to school. Her lifelong sense of shame manifested as an inability to protect herself from being used by others. When she entered treatment, confrontation was not part of her treatment.

Instead, she took part in group therapy several times weekly with other clients from her community. She discovered similarities with other group members and made strong connections. She witnessed them being cared about and accepted for who they were. In time, she came to feel accepted for herself. It was only then that her denial broke. Then she could see how shame had compromised her ability to set limits on others. Being accepted by others opened the way for her to accept the orphaned parts of herself.

On the other hand, my experiences in inpatient addiction treatment emphasized the need to break through denial more quickly because the denied behaviors were dangerous. These clients were in a supervised, safe setting with supportive staff, and intensive treatment was readily available. Staff carefully monitored the treatment effects. Clients were encouraged to see the big picture, remember their strengths, and be aware of their support network as they examined the consequences of their behaviors.e

Clients may not have developed the personal skill set to do therapy or initially see its value.

Ideally, children learn frustration tolerance by having to tolerate incrementally more difficult, age-appropriate frustration. If their parents do not provide them with opportunities to develop this tolerance, they may lack ego strength. People with ego strength can tolerate frustration, compromise, reflect on themselves, and see the big picture. These are the very skills clients need to do therapy successfully.

Clients who have a dim awareness of their skills gaps prefer to maintain the status quo and avoid taking on responsibilities they cannot manage. Instead, they expect others to change.

Beneath their voiced entitlement is an unrecognized feeling of inadequacy. By providing emotional support and using parent-like therapy techniques, you could gradually empower them by patiently helping them develop the ego strength they need to do the work in small steps.

Clients lacking self-reliance may be reluctant to accept responsibility for themselves.

Some people have a stronger aggressive drive than others. They have agency, take ownership of their therapy, and actively participate in the process. Other people are more passive and feel they are not the hero of their life story. They don’t want to be the alpha dog and prefer being taken care of. They want someone else to be responsible. Their situation growing up may not have supported their incremental growth toward self-reliance.

If you are feeling unusually maternal, ask yourself if the client is encouraging you to take care of them and do the work of therapy. They may think that doing the work themselves will risk you abandoning them, as they will no longer need you.

Passive-aggressive clients express their aggression by withholding progress.

When people are not comfortable expressing their aggression directly, they may express it passively by withholding, like a two-year-old child who withholds pooping in the toilet during toilet training. If a client consistently comes late, forgets their credit card, and requires you to pull teeth to get them to talk, they may be passive-aggressive. They may show subtle contempt by not bothering to bathe or change clothes. (Some depressed clients find activities of daily living to take too much effort. So make sure your client is not depressed.)

Do you feel irritated? Do they seem to get some pleasure from defeating you, the person they see as their opponent in the tug-of-war? Hearing them talk about how their boss or spouse is frustrated with them may make it clear that understanding the passive-aggressive behavior is central to the therapy.

Set limits on your passive-aggressive client so they can’t externalize their conflict by putting their feelings into behavior. When they can’t act out, they will internalize the conflict and make progress. When I worked in a prison setting, I noticed how depressed prisoners became when the acting out was limited and they realized their internal conflicts.

Clients become defensive if they believe you are telling them what to do or think.

Even when you listen carefully, ask open-ended questions, and pose your statements as ideas to consider, the client may feel you are telling them what to do. They resent it. Clients who had controlling parents may believe that you also think you know best and that you want to impose your opinion on them.

Victims of prejudice may expect you to act superior and discount their views. Their reflex opposition may reflect growing self-worth.

To avoid looking pretentious and authoritarian, I dress plainly in clothes that might have come off the rack at Walmart. My standard garb is an old, gray button-up sweater reminiscent of Mr. Rogers. It makes me look kind and nonthreatening. I want my clients to think it is going to be a “wonderful day in the neighborhood” and not a day at the office with a competitive male coworker or sexually abusive boss. I operate from a one-down position to be approachable and encourage emotional comfort.

In other settings, I might wear a suit because upscale clients would consider me unprofessional if I dressed otherwise and discount what I said.

I want my clients to feel safe. I speak softly, move slowly, and sit comfortably back in my chair. My responses to their comments are not rapid and may include a pause that shows I am carefully considering what they just said. I recognize that I might seem threatening, so my verbal and nonverbal behaviors anticipate that.

Oppositional behavior may have several explanations.

Occasionally, a client will loudly object to everything you say, including your recommendations. If they have a history of this exact behavior over time, consider whether they have oppositional defiant disorder (ODD). Clients with ODD tend to be grumpy, argumentative, and even spiteful at times.

Sometimes, clients who are manic can’t listen and are very sure of their own opinions.

Some people with schizophrenia are negativistic, and that negativism can look superficially like ODD.

While autistic clients vary widely, some have pathological demand avoidance, which results in them perceiving requests as a threat to their autonomy. Occasionally, autistic clients think your requests are illogical and should not be followed.

Don’t equate opposition or rigidity with invulnerability. Some rigid clients are fragile.

There is a group of people who come across as very rigid. Because they are so very inflexible, you may at first think they are solid. In fact, behind their rigid defenses, they are fragile. You need to treat them gently and work hard to avoid saying anything that could feel like a slight. They are easily narcissistically wounded. They are like peanut brittle. Brittle things are both rigid and fragile. They break easily.

Involuntary clients may have trouble changing due to serious mental illness.

Your voluntary outpatient client has made some effort to get up, dress, travel to your office, set aside time, and prepare to pay you. These behaviors suggest motivation to change and a desire for something to be different.

On the other hand, involuntary clients may lack the motivation and even partial insight that outpatient clients have. Some involuntary clients are, by definition, a potential danger to themselves or others. They may be psychotic, intoxicated, manic, profoundly depressed, suicidal, or unbearably anxious. Hopefully, medical interventions, medications, close observation, and support will make them more amenable to therapy at some point.

A discussion of serious mental illness (SMI) and inpatient treatment is beyond this book’s scope. Your first exposure to severe mental illness can be overwhelming. Harry Stack Sullivan said, “We are all more simply human than otherwise.”That is a good thing to remember as you see clients who are on the wrong side of the locked door.