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Helping Difficult Clients to Stick to Therapy

Posted Sep 14 2008 4:17am

Here is a nice little paper by Denise Ben Porath (full text available) on securing commitment to treatment with more complex and difficult clients such as those suffering borderline personality disorder. This is a great article in that it provides lots of examples of therapist-client dialogue.

She outlines a number of commitment strategies designed to enhance the client’s engagement in therapy. These techniques are not for use when a client is clearly engaging but more when a client is motivated both to change but is maybe frightened of what this will mean for them. This client often presents as stuck and conflicted, for example the client who turns up for therapy but is resistant or will not work once they get there.

The Devil’s Advocate is a technique to engage the client in arguing for change. The therapist takes up the no change position and argues the benefits of not engaging and not changing. Using this technique requires some forethought as positive reframes for the status quo and not engaging need to be thought of. Ben-Porath provides a nice vignette of this.

Therapist: It must be hard for you to have hope in a system that hasn’t been able to help you for the past 13 years.

Client: Yeah, I mean I am like. what’s the point.

Therapist: Yes, what is the point? You have seen therapist after therapist for 13 years. Why bother with treatment at this point?”

Client: I don’t know

Therapist: I mean really therapy can be expensive, it takes time why not just be at home watching television or doing something else.

Client: Because I can’t keep living like this!

Therapist: Living like what?

Client: Being miserable. My options are to be miserable or try to figure out how not to be so miserable which would you choose? Maybe this time therapy will help me be less miserable.

When done well it enables the side of the client that wants change to be strengthened. To some degree it is a variation on a cost-benefit analysis of engaging in therapy with the therapist providing the costs.

Another technique she writes about is the door in the face technique. The therapist starts by making a large and probably unreasonable request of the client given their current situation. When this is refused they then ask for a smaller and more reasonable request.


Most of us may use this technique with a suicidal client. We may first ask they guarantee not to kill themselves. If this is refused then we may ask for a guarantee to stay alive until the next session. It is opposite of the foot in the door technique of asking for something small from the client and then expanding on this. Another example from Ben-Porath.

Client: Wait a minute you are trying to tell me that I need to stop cutting myselfand throwing up to get a boyfriend? I had a boyfriend and we were inlove and he knew what I did.

Therapist: Well perhaps relationships are not an area of difficulty for you. It seems

that you are able to get involved in intimate relationships. So why bother

coming to treatment? [Devil’s advocate]

Client: Well I can get involved, but I can’t stay involved. We’re not together


Therapist: What happened?

Client: He was verbally abusive. He was always putting me down telling me I

was fat and stupid and calling me “mental.”

Therapist: Not a very nice guy, huh?

Client: Hardly.

Therapist: See that is the difference. I am going to help you find a nice guy thatyou can fall in love with. There are plenty of guys out there who areabusive, dismissive, and hostile that you could fall in love with. Itsounds like you may have met a few of them. But we are looking for adifferent kind of guy, one who doesn’t berate or humiliate you. But thattype of guy is hard to find when you berate your own body. So whatdo you say, can you get on board with this idea of working on givingup self-harming behaviors if it means finding this new and improvedguy?

Client: What do I have to do?

Therapist: Let’s start by you contracting with me not to binge, purge, or cut whilein treatment [door-in-the-face].

Client: I’m not going to agree to that!

Therapist: Why not?

Client: Because I doubt if I can do it. I have been doing these things for years.

Therapist: Okay, fair enough, what about agreeing to learn and subsequentlytry some new behaviors when you feel the urge to engage in theseelf-destructive behaviors. Would you be willing to commit to that?

Client: Yeah I could do that.

Therapist: Okay, so let’s start there.

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