Katharina Anger, Ph.D.; Juliet Hawkins, M.A.
Sometimes our most brilliantly constructed therapeutic interventions seem to go nowhere: that is, in spite of the obvious merit of the intervention, the client appears reluctant, or worse, unwilling to try it. Often therapists will then try to convince their client of the validity of their suggestion. And in some cases, frustrated therapists may even refer to the client (either directly or in discussions with other professionals) as resistant. Few therapists are trained in how to deliver an intervention with an eye to maximizing the likelihood that it will be received well. Instead, lacking viable alternatives, clinicians are left to argue with their client or nod their head in resignation.
This paper will focus on the context of interventions rather than on any particular intervention. Specifically we will expand the work of Richard Fisch and John Weakland who have addressed the issue of how interventions are delivered within the context of a brief therapy approach (Fisch, Weakland, & Segal, 1982; Watzlawick, Weakland, & Fisch, 1974; Fisch & Schlanger, 1999). Although we subscribe to a brief therapy approach in our work, we intend here to explore a more general application of some of their ideas about how to more successfully deliver interventions to other therapeutic arenas regardless of the theoretical orientation or the specifics of any particular intervention.
Assuming that the interventions being proposed are clinically sound, the way in which a therapist couches an intervention can be as important as the content of the intervention itself. It is our experience that when therapists pay more attention to the factors surrounding the intervention, it can turn out to be more successful. Simply having a good idea is often not be enough to convince a client to follow the suggestion. The therapist needs to present the intervention in such a way that the client sees for him/herself that it is a good idea and worth considering. In our work, we sometimes refer to the process of figuring out the best way to present an idea as the sales strategy.
One of the most important factors in creating a good sales strategy is the clients positionthat is, the values, beliefs and attitudes that shape the way a person views himself, his relationships, and the rest of the world. Client position also comes into play in how a person views the problem that s/he brings into therapy. We have found that making use of their position is key in helping clients see the usefulness in cooperating with a clinically sound intervention. Even though the client is asking for help, it can be difficult for her to let go of a familiar way of looking at a situation and/or doing things: a way that is often deeply entrenched in her value system. Therefore, it will require great skill on the therapists part to encourage the client to do something differently.
To identify the clients position, the therapist needs to listen carefully to the way in which clients describe their problem. Their explanation as to why the problem is occurring or the meaning of the problem can give us clues as to what their position is. For example, the position of a mother of a child with Mild Mental Retardation and behavior problems who describes her child as unable to behave better is very different from that of another mother with a similar child who describes him as being obstinate and unwilling to behave. With the first mother, a therapist would be wise to step gingerly and to suggest interventions as ways of compensating for disability. The second mother is more likely to respond to an approach that talks about limit-setting, consequences, and teaching her child a lesson (assuming, of course, that our assessment does not find that her expectations are unreasonable). The first mother would most assuredly balk at such a harsh approach, feeling that the clinician does not understand her childs difficulties. By including the clients position, the same basic intervention can be delivered in two distinct ways, depending on to which approach the parent is more likely to respond.
There are times when more than one person may be involved in a situation and each of them may have different or even competing positions. For example, a 34-year-old woman, diagnosed with Mild Mental Retardation and Intermittent Explosive Disorder, was referred by her twin brother (also her legal guardian) for psychotherapy to address her impulsive and self-destructive behavior. Clara reportedly had a boyfriend who she allowed to treat her badly, putting up with his verbal abuses and occasionally taking her money. The brother wanted someone to speak to Clara about breaking off this relationship and being more compliant with family members. In addition, he was terrified about allowing Clara, who had only recently moved in with him following living more freely with her mother, to go out by herself for fear that she would meet up with her boyfriend or place herself in some other danger. When Clara began therapy, she talked about feeling isolated, lonely, and closed in, particularly in comparison to how it had been with her mother. She complained about being treated like a child by her family. She admitted that her boyfriends behavior was less than exemplary, but without him she would have no one to talk to. Claras position was that she needed a social life, and that her brother was preventing her from doing so by putting all these restrictions on her. It seemed obvious to Clara that her brothers restrictions forced her to sneak around in order to have any social life. Her brothers position was that Clara was impulsive and did not know how to handle herself without supervision. It was obvious to him that Clara needed to drop this destructive boyfriend and needed to be closely supervised by the family to protect her. Clearly the positions of Clara and her brother were very different. In order to get Clara to do anything differently, any interventions directed to her would have to be couched in terms of facilitating her freedom and independence. In contrast, if the therapist were working with Claras brother, the intervention would have to be structured in terms of assuring Claras health and safety, as well as motivating Clara to get rid of her boyfriend.
In adapting to the clients position, it becomes clear that arguing with a client is counterproductive. An example of this occurred in the case of a 72-year-old woman with Mild Mental Retardation and a Paranoid Personality Disorder. Ruth often got into conflicts with her co-workers, and, according to the staff at the day program, she was often the instigator of these conflicts. As a result, they referred her to therapy to help her stop needling people. Ruth, however, had no interest in seeing herself as causing these problems. Her position was that these people were bothering her, stressing her out, and that she was worried about how this stress was affecting her health (e.g., high blood pressure). Confronting Ruth with her responsibility in initiating fights proved to be useless. Instead, the therapist shifted gears, stopped challenging Ruths position that people were bothering her, and chose to focus on her concerns about maintaining good health. By not arguing with Ruth, the therapist was able to gain her cooperation in working on changing some of the ways in which she was dealing with others as a way of avoiding being stressed out and possibly raising her blood pressure.
In addition to utilizing the clients position and not arguing, there are other strategies that therapists can use to maximize the effectiveness of therapeutic interventions. For example, it is often useful for a therapist to take a one-down position in relation to the client. In doing so, the therapist avoids the role of expert and may instead foster a collaborate attitude which acknowledges the client as expert in defining and understanding their problem. Empowering clients in this way increases their optimism. Assuming a one-down position can be as simple as asking questions about things the client or their family is already doing to try to fix the problem. Similarly, clinicians should give the client credit for therapeutic success and take on blame themselves for any failures or setbacks. A mother who was unable to implement well enough a suggestion for how to better manage her ADD son will feel much relieved to hear the therapist apologize for moving too fast or for not being clear enough, and will be more likely to return than if she feels accused. The task of resolving a problem can be daunting. Being concerned about being blamed or disappointing a therapist if things do not go well is an additional, unnecessary burden.
Making use of the clients position, maintaining a therapeutic one-down attitude, giving credit, and avoiding arguing have proven particularly helpful in situations where there is a therapeutic impasse. Addressing the clients concerns, beliefs, and values helps them to feel understood and increases the chance that they will be cooperative. In these ways, therapists can maximize the effectiveness of therapeutic interventions.
Fisch, R., & Schlanger, K. (1999). Brief Therapy with Intimidating Cases: Changing the Unchangeable. San Francisco: Jossey-Bass.
Fisch, R., Weakland, J., & Segal, L. (1982). The Tactics of Change: Doing Therapy Briefly. San Francisco: Jossey-Bass.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of Problem Formation and Problem Resolution. New York: Norton.
For further information:
Katharina Anger, Ph.D.
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New City, NY 10956