Toward a Taxonomy of Unwillingness: Initial Steps in Engaging the Unwilling Client
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.
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).
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.
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.
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.
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This article was first published in Psychiatry, Psychology and Law, Volume 8, Number 2, 2001 pp. 154-160