December 1st, 2012

Getting your bearings with difficult clients

Valuing instead of evaluating your work

I was in graduate school when I happened upon a flier for a literary panel discussion featuring some lions of the literary world – among them, novelist Kurt Vonnegut (one of my absolute favorites). At the end of the talk, I sat in the auditorium and listened as the moderator invited people with questions to approach microphones set up in the aisles.

An awkward-looking English department grad student walked up to the microphone.

“I have a question for you, Mr. Vonnegut,” he stammered, clearly nervous. “I’ve admired your writing for years and I also want to write satirical novels like yours,” he said. The poor guy was embarrassing himself. No one could write like Vonnegut – especially satire. “I was wondering if you might have any advice for me as I move forward.”

I felt a wave of condescension for my long-haired friend – this collie of a creative writing student who pushed his glasses up on his nose while waiting for Vonnegut’s reply.

I wished for a power outage. Maybe someone would faint. Perhaps a fire alarm would rip the room and relieve this guy of further humiliation.

Kurt Vonnegut sat forward slowly. He was thin and looked like he might break if he came forward too quickly to the microphone sitting on the table in front of him.

He smiled, but only a bit. He knew something very “deep” that we could all benefit from.

“You will fail,” he said – and that was it. He sat back and waited for the moderator to move things along.

I watched the wreck that was the aspiring writer turn and head back up the aisle toward his seat in the auditorium’s oblivion section. I couldn’t have agreed with Vonnegut any more. That guy would fail.

Truth be told, as a therapist (and in other domains) I’ve failed pretty much daily since then. Some failures have been big, some small, but truth be told, we all fail in our clinical work, particularly with our most challenging clients – the ones who no show, blame us, violate boundaries, berate and deflate us. Here’s a core question: Are you willing to fail with such clients AND continue forward in the direction of your values as a clinician?

We are trained to pursue goals in our work. Sound practice calls for it, managed care mandates it. Ask yourself though – How much can you actually control the outcomes in your work? How often have you gripped the idea of a particular outcome with a client only to end up stymied, frustrated, if not hopelessly dejected? So while we need goals, is it possible for us to clench them too tightly at times? It can be easy to lose touch with the reasons for opening yourself up to possibilities and change with our most difficult clients. We clutch things we’re afraid of losing or we ready ourselves to strike back at perceived threats. The theme is rigidity and tension, a closing up that, at least temporarily, cuts us off from progress.

In the language of the Acceptance and Commitment Therapy (or “ACT”) approach “values” refer to the most central things we do in an ongoing way that set the direction for our lives. They are not the “goals” that we are so focused on in our professional endeavors (such as symptom reduction or a client obtaining a job or renovating a relationship). Values can be thought of as an internal “compass” giving you a heading, a direction, not an end point.

Imagine the following scene: You’re sitting at the head table in a large ballroom. The room is filled with well-dressed folks who have gathered to hear toasts in your honor. Speakers, people you know and respect as professionals, colleagues and friends, are rising one by one to the podium to give their thoughts on the impact of your work. You catch your reflection in the fine silver set before you and note that you are a “tad” more advanced in age than your present self. Let go of critique and modesty. What would you most want others to have noticed about your actions as a clinician across sessions, across clients, across the span of your career?

Now, imagine yourself sitting with the most “difficult” client you’ve ever worked with. Render this person vividly in your imagination. Imagine it is your fantasy termination session. What would you be thinking, feeling, saying and doing? It is an ideal termination session, so what would you be doing?

Notice what emerged for you. If they were things such as “compassionate presence,” “perseverance,” or “conveyed hopefulness,” then you connected with your values as a clinician. And these are distinct from outcomes such as “resolution of unresolved shame” or “remission of depression.” They are moments you can hold versus objects you’re tempted to grab at (and ultimately can’t control). Think back to times when you were working from any of these values – when your interventions flowed in that particular direction. What was your sense of the passage of time? How self-conscious were you? Were you connected to your work, or were you tripped up and ensnared? How effective were you?

I think this is what Vonnegut was trying to convey that day in the auditorium – that we need to hold ourselves a bit loosely, though pursuing our endeavors passionately. Either that or he was just being a wiseass.

Mitch Abblett, Ph.D. is the clinical director of the Manville School at Judge Baker Children’s Center in Boston. He is also a consultant, trainer and author of “The Heat of the Moment in Treatment: Mindful Management of Difficult Clients” (W.W. Norton and Co., to be released in Spring 2013).

By Mitch Abblett Ph.D.

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