Toward a Taxonomy of
Unwillingness: Initial Steps in Engaging the Unwilling Client
David Willshire
Thomas Embling Hospital
(Forensicare), Melbourne, Australia
Stanley L. Brodsky
Department
of Psychology, University of Alabama, U.S.A.
Abstract: One of
the most difficult tasks facing the clinician in the forensic setting is to
engage meaningfully with clients who have been mandated to attend therapy. This
paper contends that unwillingness to engage in treatment is a complex,
multi-dimensional construct. Three major impediments to therapy are identified:
little motivation, contextual factors that inhibit treatment involvement, and
the use of techniques that do not translate to treatment of forensic patients.
Beyond the organisational challenges of modifying the context in which
unwilling clients find themselves, therapists can work personally on motivation
and treatment techniques in engaging such clients. A number of preferred
therapeutic strategies are suggested.
(The authors are indebted to
Michelle Barnett for her assistance in preparation of this manuscript.)
Engaging the Unwilling Client
Clients who are coerced into
therapy are present both in outpatient clinics, in which family members may be
the coercers, and forensic settings, in which courts or other institutional
pressures may require psychological treatment. Despite the substantial numbers
of such unwilling clients, few efforts have been made to develop conceptual
frames of reference for these clients. Therapists typically have viewed
unwillingness to enter treatment as a unitary concept, in which clients fall
somewhere along a single dimension that ranges from highly willing and eager to
highly unwilling to engage in treatment. Our initial task in this paper is to
challenge that assumption of the single dimension. Our position is quite to the
contrary; we maintain a working assumption that client unwillingness is a
complex, multidimensional construct, best understood by factoring in
motivational, contextual and technical elements. To begin with, motivational
contexts address the events that lead to the coercion of the clients into
therapy.
How the Clients Get to Us
Clients may be directed to attend
the outpatient clinic by partners, family members, or employers, or by a court,
by a parole board or by a community corrections officer. Other coerced clients
may be sentenced or remanded prisoners or may be forensic mental health
inpatients - either sentenced or awaiting trial. One additional category is the
severely mentally impaired forensic patient. In general, unwilling clients may
be coerced or mandated into undertaking therapy or may be in a setting in which
others, such as a forensic mental health team, conclude that the client would
benefit from having therapy, usually for a designated issue such as anger
management, sex offending, or drug and alcohol issues.
In such contexts, the therapist
may, or may not, be an agent of the mandating body, a process that Brodsky
(1973, 1981) has described as being a system professional versus being a system
challenger. When confronted with milieu demands to provide what has been called
armtwist psychotherapy, the treaters have a choice;
they can accept the implicit values of the setting or detach themselves to some
extent from contributing to the coercive process. One needs
to be clear, whichever position one takes, about what might further be called
"metacoercion" in which the therapist is
coerced to be involved with the mandating body (eg reporting non-attendance,
providing a nonconfidential evaluative summary
report).
Three Major Impediments to Therapy
The three major impediments to
therapy for unwilling clients are:
1. Little motivation;
2. Contextual factors that
inhibit treatment involvement; and
3. Treatment techniques with
ordinary patients do not necessarily translate to treatment of forensic
patients
1. Little Motivation:
(a) Problem Definition:
Clients often do not experience
the problem for which they were referred as being a problem for them. They
believe that the behaviour that concerns others is quite reasonable and that
the law has been unfair and punitive. An example is persons who use violence
instrumentally to get what they want. Their violent behaviour is not mediated
by anger and is adaptive, in that it generally serves to get them what they
want. The behaviour may be normative in the environment in which they live
(e.g., in prison) and within their subculture outside prison. Their problem is
that they have been caught. Clients who become angry and then behave
aggressively or violently may also enjoy their anger and the sense of energy
and power that it gives them, and believe that it is a useful and legitimate
way to manage their lives.
Denial often is a component of
low motivation. Persons charged with sex offences may deny that they committed
the offence (Jackson & Thomas-Peter, 1994; Kennedy & Grubin, 1992) or claim no recollection of it - what Happel and Auffrey (1995) call
"the dance of denial" (p. 5). If they do admit the offence, they may
lack any sense of remorse other than for the fact that they were caught (Happel & Auffrey, 1995;
Kennedy & Grubin, 1992), or may actually blame
the victim (Kennedy & Grubin, 1992).
Some offenders are preoccupied
with the perceived injustice of their situation. Thus, they may engage in an attributional transformation in which they see themselves
as victims of an unjust system, or, equally commonly, condemn the police and
express resentment toward the specific authority figures responsible for their
custody and control. They may find it hard to address their feelings of
vulnerability needed to own up to misdeeds and begin to undertake therapeutic
work (Marshall, 1994). Their strong narcissistic traits may lead to the belief
that society's norms are antiquated, unnatural or unfair when it comes to
sexual expression, aggression, or property ownership.
(b) Negative Expectations
Clients may be fearful or
ignorant about the process of therapy and their role in it. They may feel
pessimistic that therapy can do any good or they may feel powerless and
hopeless, asserting I can't change or I've tried everything or I did a course
in anger management and it made no difference. A few clients fear that they are
hopelessly disturbed and unredeemable. Others do not believe that the possible
benefits of therapy outweigh the time and effort involved (Garfield, 1994).
For some clients, therapy
represents a recapitulation of previous aversive experiences. They often have
had previous experience in the criminal justice system - having been caught,
charged and judged, and then directed to report regularly to a community
corrections officer - and may well fear being judged negatively by the
clinician and further condemned for their actions. Many negative views about
therapy and therapists are based on clients' past experiences of therapy. They
report that the therapist has been overly judgmental and moralistic, not
listened to or understood them, and so on. This view may have been reinforced
by a history of seeing therapists since childhood, with few positive outcomes,
and by having undertaken various courses of change or treatment in prison with
no apparent effect.
The recalcitrant client may
believe that there would be negative consequences to changing. For example,
using assertion rather than aggression might mean being seen as diminishing
masculine worth and may be contrary to what is needed to survive in prison or
within their social network (Winn, 1996). For a small number of inmates, there
may be some secondary gain in maintaining the behaviours - they like to be seen
as peculiar and disturbed and do not wish this peculiarity to be modified.
(c) Power and Control Issues
The inherent power imbalance in
the client-therapist relationship is intensified in the forensic setting
(Brodsky, 1998). The therapist knows much about the client from file notes,
reports and records whereas most clients are likely to have little more than a
stereotyped view of what a therapist is, based on
minimal first hand experiences or on what they have seen on movies and
television.
Clients may fear that therapy
will be controlling, and that the therapist will try to dominate them. As a
consequence they often fight against what they perceive as an imposition on
their freedom in a setting in which they have few other sources of
self-efficacy and mastery than the maintenance of the private self (Whiteside,
1998). As an illustration, one client seen in an outpatient forensic mental
health service asserted that "I'm the only one who can change me, and I'm
not gonna!"
(d) Cognitive and Personality Factors
Long-standing, intractable problems,
rigid and inflexible coping styles or interpersonal difficulties may lessen
amenability to treatment. Therapy may represent a potent threat to self-esteem,
implying that clients are inadequate. They may fear a lowering of status by
being in therapy and by being seen as disturbed or crazy by others.
The client may well have characterological difficulties in establishing trust or in
forming collaborative relationships, especially with those perceived to be in
authority. This difficulty may stem from being a victim of past abuse with a
consequent difficulty in trusting people, sometimes reinforced by prison
culture in which you have to be careful to whom you tell what. Many forensic
clients have disturbed backgrounds in which basic trust has never been
developed or has been violated. To allow oneself to change requires an element
of trust, and it is risky to do so whilst living in a hostile environment such
as prison or in mixing with peers for whom being distrustful and distant is a
way of life.
In contrast to the problems of
diminished emotions and distrust, some more disturbed clients believe that they
have done bad things and that they should continue to suffer for these
transgressions. They may be concerned that therapy may take away the bad feelings
deservedly experienced. Other clients may experience great shame or
embarrassment about their offence, and may fear that the therapist will be
authoritarian, judgmental, moralistic, or disgusted. Demoralisation due to
prolonged incarceration itself may so impair working on self that the
demoralisation becomes the priority problem needing treatment.
(e) Other
Cultural issues may preclude
compliance. For instance, people from certain cultures are more fearful of
authority than others or may come from regimes where they have experienced
abuse or even torture at the hands of the authorities. Other cultures promote a
macho mentality that may become a prominent impediment. Family, partners or
friends may also sabotage therapy, through their own needs and self-serving
concerns that are murky and ill understood.
2. Contextual Factors That
Inhibit Client Involvement
(a) Who is the Client? Whose Goals? Who Pays?
The therapeutic relationship in
the forensic setting is typically not a dyad but a triad, involving the
therapist, the client and society, as represented by the criminal justice
system or by the treating team. The goals of treatment may have been set by the
court or releasing authorities rather than by the client. The client is not
paying for the sessions, and hence may have little sense of ownership,
investment, or of getting value for money (Brodsky, 1998).
(b) Coercion
Institutional coercion is part of
much therapy in the forensic setting; clients are typically mandated to attend
therapy rather than having freely chosen it for their own benefit. Thus, when
Monahan (1980) asked whether therapy serves the interests of the individual
offender, the institution, or of society, mandated treatment nudges us toward
the latter answer. After all, confidentiality is not absolute in any setting,
but it is especially compromised by the security demands and treatment
objectives of the forensic setting. Finally, it should be noted that the
clients who have criminal charges pending may be reluctant to discuss issues
for fear of confidentiality being breached. There may also be other related
offences for which they have not been charged that can deter open involvement
in treatment.
3. Treatment Techniques with
Ordinary Patients Do Not Necessarily Translate to Treatment of Forensic
Patients
Person-centred, cognitive,
psychodynamic, and behavioural principles do not fully apply in the forensic
setting. In this section, we address the constraints on treatment techniques
and the preferred modalities of treatment. Respect and empathy do cut across
all theoretical dimensions. Unless the therapist can be moderately respectful
and empathic, there is little hope that the client will develop these same
attributes.
(a) Therapy Should Not Be Client Centred
In traditional counselling
arrangements, the client rather than the therapist tends to set the goals of
therapy and to decide the treatment priorities. The therapist often concurs
with the client's views if they disagree on priorities or the client will go
elsewhere. In forensic work, however, the client's personal goals may well be
to convince the therapist that the crime was not as severe as indicated, or
that the victim provoked the situation, or that they do not remember what
happened. Hence, in the forensic setting, the therapist will often set the
goals, frequently guided by the wishes of the court or releasing authorities,
and must remain vigilant in not colluding with problematic and unspoken goals
of the client. (Salter, 1988).
(b) The Therapist is Not Nonjudgmental
The traditional therapist strives
to be non-judgmental and not tell clients what to do or what values to hold.
These therapists endeavour to side with their clients and see the world from
their point of view. In the forensic setting, however, therapists assume much
responsibility for their clients' goals, and also make an implicit statement
about values. The clients need to learn that the therapist does not believe
that violence or child sexual abuse is acceptable, or that it is not acceptable
to slap one's wife even if an open hand is used, as one client asserted. At the
same time, effective therapists avoid being hardnosed in conveying such
opinions; often an indirect method may invite the client to enquire further
about the therapist's view. A more direct confrontation is likely to lead to
resistance.
(c) Behavioural Limits Are Set.
Therapists need to set limits on
behaviour regarding attendance, participation, degree of involvement, and
completion of homework. Rules of therapy are set early and clearly.
Confidentiality is not only explicitly limited, but may be breached more often
than in other settings.
(d) Unconditional Neutral Regard Rather than Unconditional Positive
Regard
In the forensic setting, the Rogerian notion of unconditional positive regard (UPR) is
not appropriate. Although some therapists aspire to show UPR for the person but
not for the behaviour, this therapeutic posture is difficult. Many therapists
in forensic settings do have substantial personal reservations or judgements
about their clients, and the disparity between such aspirations and realities
leaks through to impair therapy. Unconditional Neutral Regard is perhaps a more
reasonable and attainable goal, not unlike the Buddhist notion of acceptance
with equanimity.
(e) Trust is Neither Assumed Nor Given
The offender may proclaim,
"I didn't do it" and may often be quite persuasive; after all,
subsequent evidence does exonerate a few convicted offenders. In the forensic arena,
therapists need to retain a healthy scepticism and use their knowledge and
experience to question what has been put to them. For instance, if violent or
sex offenders claim a lack of memory for what happened, the naive clinician
might be persuaded that the client, especially if older, has a memory deficit.
A more experienced clinician will realise that denial is common in offenders.
(f) Insight May Not Be Necessary:
Insight alone is insufficient for
change and looking for why a particular offence occurred can be a waste of
time. Rather than "why did I offend?" the question is usually better
framed as "how do I not offend from now on?" In sex-offender
treatment, for instance, Salter (1988) notes that more effective treatments have
been developed, based not on principles derived from
the insight-oriented therapies but on those derived from the addictive
therapies.
(g) Don't Ask Questions
Questioning may remind the client
of past interactions with interrogators such as police, the judiciary and
correctional staff. Brodsky and Lichtenstein (1999) see therapists asking
questions as detrimental to the therapeutic process; it tends to promote
defensive responding in clients and it tends to shape therapists' actions into
stereotypical patterns. It is not unusual for therapists to have their
therapeutic repertoire consist primarily of questions. Making statements rather
than asking questions frees the therapist and client up from a question and
answer type of therapy to one that involves meaningful, directive feedback and
instruction.
(h) High Levels of Activity and Structure by the Therapist
Compulsive exploration of the
client's past and on their feelings should be avoided, as this approach is
largely ineffective (see, for example, Orlinsky, Grawe, and Parks, 1994). Rather, therapy that requires the
active involvement of the client is to be preferred, such as rational emotive
behaviour therapy (REBT), cognitive behavioural therapy (CBT), and
interpersonal process methods. If the clients are unmotivated, engaging them in
activity can set the ball rolling. For instance, in working with
anger-management issues, the therapist may ask the client to stand up and throw
mock punches, while the therapist demonstrates different responses. In a group,
in an activity akin to musical chairs, people have to rotate seats or
disclosures, or participation, when their allocated number is called out. Such
structure makes it extremely hard for people to not participate. Therapists
need to adopt a posture of being directive without being controlling; being
overly directive may elicit a strong reaction from the client against being
dominated. Otherwise, the therapist is likely to become locked into a control
struggle with the client.
(i) Continuity with the Research Literature on
Treatment Effectiveness
Much of therapy is drawn on the
immediate clinical judgement or past experience of the treater. A major
component of the scientist-practitioner model is to go beyond clinical
knowledge and look toward a synthesis of research findings with therapeutic
practices. Thus, three principles are noted that have emerged from the research
literature.
- Keep the patient for 3 sessions
or until a working therapeutic relationship is established (Brodsky, 1998).
Experience and data alike indicate it takes at least three sessions to engage
the client and to do a good longitudinal assessment. Similarly, the client is
assessing the therapist and will likewise require at least that long to decide
if it is possible to benefit from working together.
- Refuse to tolerate passive and
uninvolved patient behaviours. People need to participate actively in their own
therapy if change is to occur. It may help to explain one's role as being like
a coach who will be helping them to lift their game; this may engage the client
who is expecting a controlling and authoritarian approach
- In the forensic hospital
setting, a time to meet may be proposed or a choice between two options given.
With clients who do not wish to meet, therapists may continue to assert the
need to meet, ignoring excuses or agreeing that the reason they have given for
not wanting to meet actually constitutes a good reason to meet.
(j) A Case Illustration
William was a sex-offender on two
years parole who had to make a 300 km (190 mile) round
trip from his home to the outpatient clinic each time he attended. He presented
for his second session saying with a nonchalant grin that he had not done the
suggested homework and in fact had not even given it a second thought. The
therapist noted that William was welcome to continue attending every week for
the next two years without doing any work at all. The therapist would continue
to be paid and could sit there and drink coffee for an hour while William did
nothing constructive. On the other hand, if William did engage, and did some
work in sessions, then it might be that scheduling of sessions could switch
from weekly to fortnightly, and that it might even be possible to finish before
the two years was up. A noticeable change in William's involvement in therapy
occurred and he became an active participant in dealing with the issues that
faced him.
Concluding Perspectives
Therapists need to manage their
own distress at what forensic clients may have done; these reactions tend to
interfere with effective therapy. In this managing of personal reactions, or the counter-transference in traditional
psychodynamic terms, one learns to observe sensations or feelings without reacting
to them. With some clients, the therapist needs to be able to weather emotional
storms for prolonged periods of time before successful engagement can occur.
After six years of working with one especially demanding and difficult client,
the therapist was told that he was the only one who had managed to
"withstand the test of time" and that perhaps it was time to begin
some therapy.
Even subtle therapist hostility
can be detected by clients who are sensitive to these reactions. At times, the
clinician needs to be able to listen without interruption and without providing
advice or instruction, without taking the moral high ground. It is suggested
that therapists avoid responding to clients in the likely, predictable or
conventional way (Kopp, 1977). Some forensic clients have extensive histories
of seeing therapists and may actually be quite experienced in therapy tactics.
On a previous hospitalisation one
client had refused food to the point that he needed to be fed through a
nasogastric tube. He met with the therapist but elected to not speak. The
therapist chose to not talk either. After about 50 minutes the client asked, in
a plaintive voice, if he could go to the toilet. The therapist agreed and the
client left the room. In the subsequent sessions, the client actively and
verbally engaged in therapy.
The judicious use of humour can
be an effective way of circumventing a client's defences. By putting forward
playfully exaggerated scenarios therapists can challenge the client's ways of
thinking about a situation. It can assist clients to decatastrophise
their problems in a context that allows them to see the absurdity of troubling
situations. The therapist wants the client to think differently; humour
involves taking a different view of a topic. It transcends the serious and can
permit bold confrontation in a benign, non-hostile way. It is difficult for
most people to react angrily back to good humour.
A few clients work hard to
demonstrate that the therapist is incompetent and it can indeed be hard at times
to not feel incompetent when working with difficult clients. One approach,
articulated by van Bilsen (1991), is based on the TV
detective Columbo, played by the actor Peter Falk,
and involves the therapist taking on a slightly bumbling and ineffectual
manner, professing a poor memory and taking lots of notes. This Columbo approach can be powerful in disarming critical or
resistant clients and their fantasies of the therapist being a powerful and
controlling entity.
Summary
We have looked at a number of
potential factors that impede engagement with unwilling clients. Traditional
counselling techniques do not work well with such clients. While we cannot
modify much about the context in which unwilling clients find themselves, we
can work on motivation and techniques. Sometimes it is just not possible to
engage successfully with a client, and therapists have to know when it is time
to withdraw. The client ultimately does have the ability to say no and accept
the consequences of this decision.
REFERENCES
Brodsky, S. L. (1998). Psychotherapy
with reluctant and involuntary clients. In G. P. Koocher,
J. C. Norcross, & S. S. Hill III (Eds.), Psychologists' Desk Reference (pp.
306-310). New York: Oxford University Press.
Brodsky, S.L. and Lichtenstein,
B. (1999). Don't
ask questions: A psychotherapeutic strategy for treatment of involuntary
clients. American Journal of Psychotherapy, 53, 215-220.
Garfield, S. L. (1994). Research
on client variables in psychotherapy. In A. E. Bergin & S. L.
Garfield (Eds.), Handbook of psychotherapy and behavior
change (4th ed., pp. 190-228). New York: John Wiley & Sons, Inc.
Happel, R. M.
& Auffrey, J. J. (1995). Sex offender assessment:
Interrupting the dance of denial. American Journal of Forensic Psychology, 13,
5-22.
Jackson, C. & Thomas-Peter,
B. A. (1994). Denial
in sex offenders: Workers' perceptions. Criminal Behaviour and Mental Health,
4, 21-32.
Kennedy, H. G. & Grubin, D. H. (1992). Patterns of denial in sex
offenders. Psychological Medicine, 22, 191-196.
Kopp, S (1977). If you meet the Buddha on the road,
kill him!. London: Sheldon Press.
Marshall, W. L. (1994).Treatment effects
on denial and minimization in incarcerated sex offenders. Behaviour Research
and Therapy, 32, 559-564.
Miller, W. R. and Rollnick,
S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: The Guilford Press
Monahan, J.(editor) (1980)
Who is the client? The ethics of psychological intervention
in the criminal justice system. Washington, D.C :
American Psychological Association
Orlinsky, D.E., Grawe, K, and Parks, B.K. (1994) Process and outcome in
psychotherapy -- Noch einmal. In A. E. Bergin & S. L.
Garfield (Eds.), Handbook of psychotherapy and behavior
change (4th ed., pp. 190-228). New York: John Wiley & Sons, Inc.
Salter, A.C. (1988). Treating child
sex offenders and victims: A practical guide. Newbury Park: Sage
van Bilsen,
H.P.J.G. (1991). Motivational interviewing: Perspectives from the Netherlands,
with particular emphasis on heroin-dependent clients. In W.R.
Miller and S. Rollnick. (pp. 214-224).
Motivational interviewing: Preparing people to change addictive behavior. New York: The Guilford Press
Whiteside, R. G. (1998). The art of using and
losing control: Adjusting the therapeutic stance. Philadelphia: Brunner/Mazel, Inc.
Winn, M. E. (1996). The strategic
and systemic management of denial in the cognitive/behavioral
treatment of sexual offenders. Sexual Abuse: Journal of Research and
Treatment, 8, 25-36.
This article was first published in Psychiatry, Psychology and Law,
Volume 8, Number 2, 2001 pp. 154-160
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