Therapy Without Force: A Treatment Model for Severe

Psychiatric ProblemsStruggling to Be a Non-Coercive Therapist

Presented by : Dr. Daniel MacklerLicensed Clinical Social Worker | LCSW.

•In the midst of a system laced with coercive mores, how can a therapist behave non-coercively, and thus therapeutically?

•In the general sense, the best way to behave non-coercively is to be a more effective therapist—and, lacking that, to be able to connect the client with systems, agencies, groups, literature, clinicians, and peers who offer something that is effective. It is our job to struggle to understand where the client is coming from—and to understand his real needs. Psychosis and depression and anxiety and rage are symptoms of a deeper need. So are suicidality and homicidality. We therapists have a responsibility—a true responsibility—to uncover and empathize with our clients’ deeper needs, and

•then to help them find resolution.

•The facile empathy of “loving clients back to health” is not curative in and of itself, and I have seen too many cases in which the therapist’s empathy evaporates when the client becomes “imminently” suicidal or floridly psychotic. Likewise, often such clients accept no surface empathy, either because it threatens their boundaries or because they know—through bitter experience—that it will do them no good. Thus our job is to go deeper—both with our clients and with ourselves.

•Our job is to learn to know ourselves to our depths. When therapists have not done their own deeper work, which is all too common, their psyches cannot help but pressure them to turn away psychologically from clients who share deeper and more painful material—especially the metaphorical material labeled as psychosis. And when the mental health field as a whole has not done its deeper work, and bases its standards on more shallow or unscientific or flimsy or denial-laden theories, it rushes to coerce, to medicate, and ultimately to subdue those whose symptoms and very existences offer challenge.

•Our job as therapists is to do our inner homework. When we do this we become less frightened of our clients and particularly of their symptoms. We instead gain a framework to understand where they are coming from, and if we lack that, which at times is not unreasonable, at least we have a framework for developing the ability to understand. Working with clients diagnosed with psychotic disorders may provide no better challenge for the therapist to go deeper within himself and to study his own comparable sides. This can be terrifying—and sometimes psychosis-provoking for the therapist himself—but what better way to derive true empathy for clients? There is a reason that so many of the most compassionate advocates for those diagnosed with psychotic disorders are psychiatric survivors themselves. And clients are by no means foolish when they say they would prefer to work therapeutically with someone who has been in their shoes. Don’t

we all ultimately wish for this?

•But there are times when a given client will be too much for even an experienced, compassionate, anti-coercion therapist. Perhaps the two make a poor therapeutic fit. Perhaps a particular therapist is excellent for one client but kicks up too much anxiety or other negative feelings in another. Or perhaps a given client needs more structure than a given therapist can provide. Or perhaps a client who is tapering off psychiatric drugs experiences so much upwelling rage or psychosis—the result of pre-existing problems or simply the biological reactions to drug withdrawal—that the therapeutic relationship becomes unworkable.

•This can be particularly difficult for the therapist (not to mention for the client), not only because of the emotional intensity of the interactions but also because most dedicated, non-coercive therapists hate “giving up,” having long since prided themselves on

being able to work with the “toughest clients”.

•Personally, my model in these cases is to “give up”—and end the therapeutic relationship—but to do so without being coercive to the client. The key here is to do so as gently as possible, with as much warning as possible. My non-coercive model, as I have come to develop it, involves three stages, as follows:

•But again, this does not make the work of the therapist any easier. The challenge remains great. Life pressures the therapist to seek out better colleagues, better supervision, better referral networks, better peer support, better therapy, and better self-therapy. Doing therapy with people experiencing deep distress pressures the therapist—in a healthy, non-coercive way—to be more honest, more self-revealing, less rigid, less conventionally boundaried in the clinical sense, more compassionate, more self-questioning, more involved, more creative, and simply more real. If the therapist wants to go home at the end of the day and not think about his work till the next day, then he is in the wrong profession—or working with the wrong client population.

•Stage One•The primary stage involves letting my clients know, ideally from the

first therapy session—before the working relationship has even begun in earnest—the nature of my therapeutic limits. Each therapist has his own. Sometimes these can be left to assumption, but I find that with clients who are experiencing high degrees of emotional distress, it is therapeutically wiser to leave less to assumption. This helps set a clear foundation for the frame and boundaries of the therapy.

•I tell clients what types of behavior I can tolerate in therapy and what types I cannot. For instance, I can tolerate a fair degree of yelling and screaming and insults and rage directed toward me—and I try to use this for therapeutic benefit—but I can only tolerate so much, and with so much volume. I work out of my apartment, and I have neighbors: I cannot risk them calling the police on me, or having the landlord revoke my lease. Also, I cannot tolerate client violence toward me—or threats of violence. As such I let them know upfront that that is a therapeutic deal-breaker

•Similarly, I have my own emotional limits: I can tolerate hearing about a significant degree of conflict from my clients—relayed words about their suicidality, rage, anger, paranoia, violence, etc.—but only to a degree. I have learned that sometimes I reach my limit and can tolerate no more—especially if a client is making no headway in curbing his behavior. When I find myself nearing my limits with a client—or even getting blips on my radar screen that I might be nearing my limits—I let the client know.

•In this first stage I also discuss with the client his feelings about therapy. In some cases, if I feel it might become relevant later on—which it often does—I ask him about his point of view regarding such subject matters such as coercion, force, boundaries, suicidality, psychiatric hospitalization, psychiatric medication, and confidentiality. I try to provide a safe environment in which to discuss these topics to whatever degree both he and I feel it helpful. I feel that this to be vital in providing a client with real, mutually agreed upon informed consent—which to me is a prime ingredient in basic respect.

•Likewise, I invite clients to ask me any questions they might have about my perspective on these topics—or any subject they feel is important, however uncomfortable—and I make it my business to be frank and honest. Also, I tell clients that they can feel free to give me fictional scenarios on various subjects (such as suicidality or homicidality) and ask how I might behave if such a scenario were to happen. Also, I welcome clients to re-open the discussion at any point in the therapy. If I don’t know his opinion on these subject matters early on and he doesn’t know mine, we risk forming our therapy relationship on very shaky ground—one that risks collapsing in ugly ways down the road. Having an open, flexible dialogue on these often taboo subjects can go a long way toward building appropriate and realistic therapeutic trust—which can prove invaluable not just for the therapy itself, but for the client’s whole life.

•Stage Two•If, at some point in the therapy, I find that I am becoming too

overwhelmed or uncomfortable by the client’s actions or behavior to be able to function effectively as his therapist, I share this openly with the client. In this second stage, I let him know that the agreed-upon frame in which we are operating may not be enough to tolerate what he is experiencing. I remind the client of my previously stated limits as a therapist, in order to build continuity with that foundation.

•Sometimes clients, despite our initial discussions, have the erroneous belief that they can say or do whatever they want in session—that the therapeutic environment is a place where they can totally be themselves, with no consequences whatsoever. Although the degree of consequences can vary with different therapists, it is our job to communicate our limits as clearly and consistently as possible. Otherwise we risk blindsiding clients with consequences that can seem arbitrary, unexpected, and unfair. On the other hand, effective communication of our limits can actually prove to be therapeutic in and of itself, not just because it places the onus of responsibility on the client, but because it reminds the client that the entire world operates within limits. All actions have consequences, and therapy can be an optimal place to explore this reality.

•Meanwhile, to return to the particulars of the second stage, if I am becoming overwhelmed by a client, I use my anxiety and apprehensions—after I have analyzed them within myself and feel confident that they are well-founded and not overly laced with my own denial—as an attempted wake-up call for the client. Here therapy offers him an opportunity to study his life and see if he can make changes that involve adopting, or considering adopting, a healthier lifestyle, or at the least a healthier perspective. Sometimes this works.

•Other times it does not. In some cases I have been accused by clients of trying to coerce them into changing—to make me happy and to keep the therapy alive. In a sense this might appear to be true—which might seem contradictory to the point of this paper—but I view it differently. From my perspective when a client takes steps that break the agreed-upon therapeutic frame it is he who bears the primary responsibility. He is making a choice, be it conscious or unconscious, through his action, and it is actually he who is abandoning the therapy: breaking the therapeutic contract, as it were. So in a sense he is coercing me to change the stated and mutually agreed upon frame of the therapy—a frame which I think is quite liberal and therapeutically reasonable. My resistance to changing the frame is less a coercion of him than a reflection of his coercion of it.

•But like all things that are complicated in therapy, sometimes there are counterintuitive solutions, and that is where I feel the onus is on me to be creative. Sometimes a client who is challenging the frame of the therapy needs to come more often. Often in the second stage I offer the client the opportunity to come and see me more often—and sometimes this goes a long way to quelling anxiety—his and mine! Other times I suggest that the client expand his support network beyond the therapy relationship. (I will address this more in the next stage.) Sometimes the pressure on the one-on-one therapy relationship is simply too great—and when the client builds a broader, more holistic support system, the tension in the therapy can abate significantly.

Stage Three•The third stage of my non-coercive model happens when a

client is simply unable or unwilling to operate respectfully within the stated frame of the therapy. Here I feel I cannot continue the relationship as it has been going. I do not force him to do anything, and instead use the only option at my disposal: I pull back, all the while making it clear that this is what he is forcing me to do, against my desire. I do not hospitalize, call police, call case managers, punish, pressure medication, or suggest medication.

•Instead I simply let him know that he, through his actions, has damaged our relationship to the degree that I have no choice but to withdraw from it. But in the same way that I counsel people to avoid abrupt withdrawal from psychiatric drugs, I myself avoid, if at all possible, abruptly withdrawing from a therapeutic relationship—in order to avoid abandoning him. I give as many warnings as I can, I state the reasons for my actions as clearly as possible, and in some cases I discuss with the client the possibility of postponing therapy for a period of time—a week, two weeks, even a month if necessary—to give him a chance to see if he can be more reasonable in working toward keeping alive his relationship with me.

•If I do postpone the therapy I offer him as many other alternatives as possible so that he might find ways to help himself in the meantime. Some of the alternatives might include: referrals to other therapists, referrals to group therapy, referrals to day programs, referrals to activity groups, referrals to peer support services, referrals to case managers or direct support services, referrals to Twelve Step Programs (such as AA, Narcotics Anonymous, Gamblers Anonymous, Al-Anon, even Double Trouble), and referrals to substance abuse programs. Often, before pulling away, however, I offer clients conjoint meetings in therapy with other important figures in their lives—people from their personal and professional support network—in order to discuss these potential changes and explore ways of finding clients more appropriate levels of assistance.

•My goal during this third stage, and the previous stage as well, is to help the client feel respected—and to minimize the damage not just to our therapeutic alliance, but to the work we have accomplished thus far. Often I have heard clients tell of a wonderful relationship they had with a past therapist being called into question by the therapist’s poor handling of a crisis or therapeutic “termination.” Sometimes clients suffer for years over these mishandled endings—and consequently lose great degrees of trust and faith in humanity. As such, I strive to be as respectful to clients on the last day of therapy as on the first—and all the more so if the therapy relationship is ending under less than ideal circumstances.

•And sometimes things do not go ideally. Sometimes the client can take the therapist’s withdrawal from the relationship as an attack on his sense of self. This is most pronounced when the client has placed strongly idealized parental-like expectations onto the therapist. Sometimes clients, especially when they themselves are in the throes of extreme emotional distress, have a difficult time understanding the anxiety and conflicts they can induce in a therapist, and can even feel betrayed and undermined when they discover that their therapist is not an ideally parental “god,” but instead all-too-human.

•The betrayal they feel from the therapist can translate to them as a form of therapeutic coercion. Perhaps the client, especially the client who feels the therapy is his primary lifeline, says, “Your commitment is to help me, and at my moment of greatest need you are rejecting me because I'm not behaving in the way you want! You’re forcing me to change my way of behaving to suit you—and I don’t like being

coerced to change! You lied to me”!

•What then is the therapist to do? This, of course, is complex, because sometimes the client in this situation has so little empathy for the position of the therapist that it is difficult for the therapist to reach him in a way that he finds satisfying or understandable. Here I simply do my best and try to be as honest and forthright as possible, though I have never found this to be easy. I let him know that the primary rejection of the therapy has come from him—though I acknowledge that perhaps a different therapist might have handled the situation more effectively, and if I am sorry then I let him know. (Often I am very sorry.) But at the same time I do not shy away from the reality that through his decisions he is actually rejecting himself, and in many cases is following the model of much of his own traumatic history of rejection.

•I encourage him—and at times even plead with him—to look more closely at his actions and thoughts and behavior and history so that he might better understand why I am pulling away. I often point out that I am rarely the first person in his life to pull away from him under such circumstances. (Often he agrees.) Usually I am just one in a long string of failed interpersonal relationships—and that I have no desire to participate in repeating this pattern of his. I tell him that as much as I might like to save him from himself, doing this is neither my ability nor my responsibility. I let him know that it is not a therapist’s job to carry the full psychic burden of the therapy—or even the majority of the burden—even if the client thinks that that is what he is paying for. The therapist’s ultimate job is to help place the locus of control back in the center of the client. The responsibility for the client’s salvation—assuming the client is an adult—is his, and if he cannot do it, especially after I have given the relationship my best, then he must face his own consequences.

•Although the client in this situation might feel that I am pressuring him to begin taking psychiatric drugs—especially if he has heard that message repeatedly throughout his life—that is not my stand: my stand is the client has to take more responsibility to be more mature. This might involve coming to therapy more often or more on time, getting better sleep, eating better, exercising more, paying bills more regularly, avoiding prostitutes or anonymous sex, watching less TV, avoiding fighting or arguing with others, being more respectful to his neighbors or friends, making new friends, going to more support groups, meditating more, seeking out spiritual outlets, doing fewer drugs, drinking less alcohol and caffeine, managing his budget better, and often simply doing more therapeutic work and self-reflecting outside of the therapy session.

•It is worth noting that my withdrawal from clients is quite uncommon, and I only use it as an option of last resort. But it is an option, and it is not coercive, because unlike coercion it is neither intrusive nor undermining of autonomy. Instead, as horrible and painful as therapeutic withdrawal can be, it provokes autonomy. And ultimately, whether the client uses this provocation toward autonomy to his benefit or not—now or in ten years’ time—is up to him. But it is not the therapist’s job to force him to become autonomous. It is only the therapist’s job to respect him.

References•

Hall, Will (2007). Harm Reduction Guide to Coming Off Psychiatric Drugs. Published by The Icarus Project and Freedom Center, but see also: http://theicarusproject.net/HarmReductionGuideComingOffPsychDrugs

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Harrow, M. and T. Jobe (2007). Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. The Journal of Nervous and Mental Disease. 195(5): 406-14.

Hornstein, G. (2009). Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness. New York: Rodale.

Jackson, Grace (2009). Drug-Induced Dementia: A Perfect Crime. Bloomington, IN: AuthorHouse.

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