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Published in: The Psychotherapy Networker, March/April, 2005, pp. 23-25.

Column: "In Consultation"

Turning Refuseniks into Customers

Therapy with involuntary clients

by Steve Andreas

Q: I've had very limited success treating court-referred clients. They're often hostile and have little use for me. What do you recommend that I do differently?   

A: If you see court-referred clients, you know that they're usually furious about being coerced into therapy, appear to despise you, and totally resist any of your efforts to engage them. And it's worse when they put on a smiley face to appear cooperative! In couples therapy, often one partner is there under some kind of duress and behaves in much the same way. So how can you "hook" these clients and actually help them?

Clients who are in therapy only because they have to be create a difficult dual relationship in which the therapist is both helper and jailer. Virginia Satir often said that when someone offers you a communication, verbal or nonverbal, particularly one that puts you in a difficult position, you always have the choice either to accept their frame of reference, to redefine it in a way that's more useful to you, or to do both at the same time. This third possibility is the most elegant--both accepting the frame of coercion, and redefining your relationship inside that frame, so that you can do some work.

How to do this is another question. Unfortunately, there are no clear-cut, ready-made, clinical recipes for turning therapy refuseniks into eager customers. It takes some planning to devise imaginative and creative approaches, along with a willingness to go out on a limb and conduct therapy in ways that your old, classically trained supervisor might not entirely approve of.

For example, some years ago, the parents of a crack addict forcibly kidnapped him from a crack house in New York, brought him home to Denver, and physically dragged him in to one of my star students, Bob Levin, hoping to cure his addiction. This was one unwilling client! After listening briefly to the parents as they explained the situation, with their son sullenly sneering in a corner, he asked the parents to go out into the waiting room.

When Bob and the crack-addicted son were alone, Bob said, "Look, it's pretty obvious to me that you have no interest in giving up crack. And, frankly, I have absolutely no interest in trying to get you to do something you don't want to do. That would be very, very frustrating and difficult for both of us, and a complete waste of our time. On the other hand, your parents are paying me to see you, and I like to give full value for my time. Since we both have to spend some time together, I wonder if there might be some changes that you'd like to make, so that we could make good use of our time together?" Bob then outlined a plan that would seem to be a druggie's dream. "For instance," he said, "would you like to know how to tell when someone is trying to burn you on a drug deal? Would you like to be able to spot narcs before they spot you? How about learning more moves for getting it on with the chicks?"

Those possibilities, and some others, were quite interesting to this young man. Over the next several sessions, Bob proceeded to teach a wide range of perceptual and behavioral skills and deal with some of his client's internal conflicts that came up in the course of their sessions. Besides resolving some old history that often brought up bad feelings, the client came to realize that much of his life was devoted to opposing his parents' wishes, rather than discovering what he wanted--and that he was just as trapped by this as he would have been if he always did what they proposed. He learned how to attend to peripheral vision and notice subtle, nonverbal signals from others that indicated their internal state, and how to establish rapport with people by imagining, literally, stepping into their posture and movement, and feeling their expressions on his own face. As a result of learning how to better connect with and read other people, he became much more perceptive, thoughtful, and able to respond flexibly and creatively to a wide range of situations with much more self-awareness and self-confidence. Learning how to be alert and centered during a drug deal generalized widely to other contexts, giving him a sense of poise and resourcefulness that many would envy.

Then he stopped coming, and the parents reported, quite upset, that he'd returned to the crack house in New York. Bob did his best to calm them, suggesting that they at least wait a few weeks to see what happened before doing anything. A couple of weeks later, the son phoned Bob to say that he'd left the crackhouse and returned to Denver because, as he put it, "I don't want to hang around those weird people anymore. And I want to meet with you again, and explore what I'm going to do with my life now."

Bob first entered the coercion frame by saying "we both have to spend some time together," and then allied himself with the son by eliciting and responding to his goals and motivations. In the process of ostensibly helping the son be a more effective drug buyer, he was actually teaching him how to be a more thoughtful, congruent, and self-aware human being. Bob thus made it possible for the two of them to work together on the young man's issues, completely sidestepping the parents' coercion. Yet the work they did together in pursuit of the son's goals also resulted in what the parents wanted. By establishing a voluntary frame of cooperation within the frame of coercion, they escaped it and all the pitfalls it harbored.

Another colleague, John Enright, once worked with juvenile offenders who were given the choice of jail or going to six hours of counseling. Understandably, most of them preferred the counseling to jail, but they had zero motivation to do any serious work. After some frustrating weeks, John looked up the statute to see how the "six hours of counseling" were described, and he found that there was no specification of how long each individual session had to be, only that all together they had to add up to six hours.

From then on, when he saw offenders, he'd first clearly explain the kind of counseling he did and how that might help them solve any difficulties they felt they had, whether or not they were related to their problems with the law. Then he told them that since the statute didn't specify the length of the session, if at any time he decided they weren't participating sincerely, he'd end the session after 10 minutes. If that were to continue, the offender would have to come in 36 times. This simple arithmetic motivated many of his clients right away, while others tested him a few times to see if he really meant it. Once it was clear that John would indeed end a session after 10 minutes if they weren't contributing, they actually got down to the business of seriously discussing issues of importance to them and working on changing their lives.

In this case, John amplified and utilized the coercion while establishing a cooperative frame inside the coercion frame.

At another time, John was conducting group therapy in a mental hospital, where all involuntary clients were required to attend group-therapy sessions. Their general attitude to both him and therapy ranged from bored disinterest to active hostility. How could he change the situation so they'd become voluntary clients? One day, after several frustrating sessions, he drew a chalk line across the middle of the meeting-room floor. Then he explained that he wanted to try a very different kind of session, and that all those who wanted to participate could move to his side of the line. Those who didn't want to participate could stay on the other side of the line and observe. He also said they could change sides whenever they wanted to. This ploy didn't seem to work at first: most of the patients remained on the other side of the line. But, for the first time, he noticed that they all were looking at him with curiosity and interest, wondering what he'd do next.

Their show of curiosity emboldened him to go even farther. So the next day, he tried a variation on what he'd done with the chalk line. After everyone was sitting in the usual circle, he asked those who were interested in participating to move their chairs one foot forward and those who weren't interested in participating to move their chairs one foot back. Group members could move their chairs forward or back at any time, to publicly indicate their interest level. Working only with those who had moved their chairs forward was much more interesting and rewarding than before. Having signaled their consent to the therapeutic process nonverbally, many actually joined the discussion, began talking about what they were feeling and thinking, and started really getting into the therapy. Periodically patients in the back row spoke up or snorted in derision, whereupon John thanked them for their contribution, and asked them to move their chair forward, since they were participating. If someone in the inner circle didn't participate for a while, John pointed this out and asked them to move their chairs back until they again wanted to join in.

Rather than struggle with the fact that they were all there involuntarily, John made an opportunity within that coercion for them to make an unambiguous voluntary commitment to participate, or not. That tiny, one-foot commitment made by each person made a huge difference in the quality of the interaction, and the sessions became quite lively and useful.

This frame can be applied directly to couples therapy, providing immediate and unambiguous information about who the "customer" is, and who's only a complainant or bystander. This works best after some normalizing frames that bypass judgment--for instance, explaining that when couples come in, often one partner is hurting more and is more desperate for some kind of change, while the other may think everything is fine, if only their partner wouldn't complain so much. After one of them identifies himself or herself as being less interested in therapy, it can be useful to say, "Okay, since you're not interested in couples therapy, I assume it's completely all right with you to just observe, and I'll work with him to reach his goals, and whatever he decides to do as a result of that will be okay with you." This usually results in a significant change in perspective, and often an increased willingness to participate.

Whoever our clients are, and whatever the circumstances by which they end up in our offices, we have to remember that therapy is always "voluntary," or it's not therapy at all, unless perhaps your name is Milton Erickson! People can't be forced to change their minds, even if we think it's for their own benefit. But by respecting their frame of reference while using a little imagination in redefining it, we can glide between a rock and a hard place--between the forces that would try to coerce clients into change and their natural, even praiseworthy, resistance to coercion--and find our way home to what really matters to them, which is the only place in which we can do productive work.

 

For NLP Books by Steve Andreas, see Heart of the Mind, Transforming Your Self, Virginia Satir: Patterns of Her Magic, >&Six Blind Elephants Vol I & II.

 


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