My job is extremely satisfying when a client is able to work through problems efficiently and establish a new level of happiness. To have a client identify a problem and take the necessary steps to resolve the situation gives me a true feeling of gratification. Unfortunately, however, life in therapy isn't always happiness, red wine and lingerie models. More often than not clients have obstacles that prevent them from living the best life possible. These barriers are usually a combination of both internal and external forces that are working against them. An empathic voice is my modus operandi, but sometimes clients need a stronger approach to facilitate change.
The late Dr. Albert Ellis was by far the best at confronting clients. His approach was later stolen by hacks such as Dr. Laura and Dr. Phil. While sometimes labeled as vulgar and harsh, Ellis was a shrewd clinician who made it clear that he was attacking a client's thoughts and behaviors, not the person. This is a subtle but important difference. If he thought you were acting like a douchebag he told you so. But he made it a point to say that isolated thoughts and actions do not define you as a person. This helped to mobilize clients to not label themselves or have their self-esteem be compromised.
Therapist Rule: Confronting a client is most effective within a solid therapeutic relationship that is built on trust and respect for both therapist and client.
Consider my work with Craig, a mid-30's man not unlike the completely fabricated Marc. Craig had been trying for months to get out of an unsatisfying relationship with a long-term girlfriend. This is an extremely common problem seen in the therapy room and one that many of us can relate to. Whether this need to hold onto a partner is due to stability/comfort, a fear of the unknown, a fear of being alone, a concern that we will regret breaking things off, or countless other reasons, many clients struggle when attempting to break free from a relationship that is not meeting their needs.
Craig and I worked on this issue for many months with no change. We used Freudian interpretations, self-esteem building exercises, simple pros and cons checklists to decide if the relationship was worth abandoning (according to the list, it was), and every other intervention under the sun. We even role-played the break-up conversation (note: let the record show that I hate being a woman). We were both getting annoyed with the lack of results and it must have shown on my face.
"Dr. Rob are you angry with me?"
Back in the late 90's a professor said to me, "Rob, you are an extremely attractive man. In addition, when a client asks you about a personal feeling and you choose to answer, take a moment and consider what your emotion actually is rather than giving a knee-jerk response based on what you think the client might want to hear. Therapy is a reflective process and modeling this for your clients will help them take a step back and look at themselves more closely."
"Thank you, Dr. Johnson. I've been working out."
I remembered her words of wisdom and put it into practice with Craig. I considered his question for a few moments.
"No. I'm not angry per se. However I am frustrated with our lack progress on this issue."
"So you're not angry, you're frustrated with me?"
"No that's not exactly right. I'm frustrated with what is happening here. I think part of me is frustrated with you for not taking the action that we both agree is good for you. Part of me is frustrated with myself for not getting you to that point of action. And still another part of me is frustrated with the sad reality that things don't always work with the efficiency that we want."
"That just sounds like therapy-speech. I think you're angry with me."
Again, pause. "I really don't see it that way, but as I conceded I am bothered by your lack of action. I think your fear is holding you back from getting out of this relationship and moving on."
"So you think I'm a pussy, is that it?"
"Is that what we're calling your lack of progress? If so then yes I think you are acting like a pussy. But the fact that you are introducing such a strong term makes me think that you yourself believe that you're a pussy."
"But I'm not!"
"Then stop acting like one and be a fucking man and get out of this relationship. You're miserable and quite frankly I can't fathom how she can't be miserable as well! In fact this whole conversation is making me miserable."
"You're right. Screw her!"
"Good for you. Take care of business!"
"Yeah, take care of business. I should kill that whore!"
"Yeah you should...wait, what?"
"Nothing nothing. Just a figure of speech."
I scrutinized Craig very closely with squinted eyes. "Craig, if you say that is a figure of speech, you better mean that. I'm not screwing around here."
Craig laughed. "Dr. Rob, I swear. I'm just pumped."
"Fine, be pumped. But if you hurt anyone I won't even visit your sorry ass in prison."
I would love to say that Craig came back the next week a single man but it didn't quite work out that way. He was still in the relationship for a few more weeks but it did finally end at his behest. When it was over I asked him what prompted him to take action.
"Well the heated discussion we had helped I think," he said. "I was so excited to break things off, but the feeling didn't last. Over the next few days though I continued to think about it and something sort of clicked. Like 'I'm not being fair to anyone here, not me, not my girlfriend, and I'm certainly wasting my money in therapy if I don't make a change.'"
"Well I'm glad something finally worked. Congratulations on making that change. How do you feel?"
"I miss her a little bit but not as much as I had expected. I'm pretty happy overall."
The lessons here are multiple:
1) Do not kill anyone, especially someone with whom you are about to break-up. 2) Unhealthy relationships take a long time to end. Far too long for my tastes. 3) I can be a bad-ass when necessary. Well, if by "bad-ass" I mean slightly confrontational. 4) A little tough love can go a long way.