Many of us in the addictions field have argued about which approach is best. Like children in a school yard, we are very protective of our territory — our chosen school of thought, and sometimes openly hostile to others. But many studies show that widely varied models and techniques have similar positive results (Hubble, Duncan, & Miller, 1999). So when our preferred methods are not working as well as we would like, a willingness to break our own rules of client engagement may help.

When we begin to view our clients as “resistant” to our efforts to help, we may have settled into a pattern that is perpetuating the status quo rather than promoting change. This may sound obvious, but when we want our clients to do something different, we might try doing something different ourselves.

Techniques that you are not currently using may be more likely to break a logjam, because they interrupt the pattern of your usual relationship with the client. Overuse of any technique will likely decrease its effectiveness, as it becomes an expected part of your therapeutic routine.

The following suggestions are adapted from Solutions for the “Treatment Resis-tant” Addicted Client (Haworth Press, 2002). They are designed to make your therapeutic messages more memorable, and to interrupt a less-than-successful pattern of relating to your clients.

Paradoxical intervention? “No problem!”
One of the most difficult skills for counselors to master is overriding what the authors of Motivational Interviewing call the “righting reflex” (Miller & Rollnick, 2002). When we present the arguments for change to clients who are ambivalent, we are most likely to evoke their arguments for the opposite side of their ambivalence. In other words, the harder we try to talk our clients into something, the more likely they are to argue with us. And each time they hear themselves talk about the “wrong” side of their ambivalence, they become less likely to change and more committed to the status quo.

Paradoxical interventions are designed to surprise clients, in that they are often contrary to what the client is expecting. Though they seem to break the rules of common sense — and do occasionally backfire — some strategies are appropriate when you reach a therapeutic stalemate.

It is sometimes helpful to clients for the counselor to play devil’s advocate, and argue for the “wrong” side of the client’s ambivalence. This type of “reverse psychology” is designed to evoke “change talk” — statements of problem recognition, intention to change, and optimism (Miller & Rollnick, 2002). When counselors take over the arguments in favor of change, it leaves only the counterarguments (or “yes/buts”) available to the client (Cade & O’Hanlon, 1993).
Sometimes therapists will advise their clients to continue or even increase the symptoms they are trying to ameliorate so that clients who feel no control over their symptoms can take control. The conscious decision to intentionally increase problematic behavior is also called escalation or symptom prescription.

The following case study illustrates the successful application of this technique.

Case study: “Learning to lie”
“Shirley,” who was working in group therapy to overcome her dishonesty, had agreed to a homework assignment in a previous group that she at first thought was a joke: Tell one extra lie a day. She had explained that she “just couldn’t help herself,” and “lied for no good reason, just out of habit.” Shirley often felt embarrassed when caught in her lies and said she wanted to change, but wasn’t sure if she could break the habit, since she lied “without thinking.”
She agreed to the assignment of telling one “extra” lie a day, as an experiment.

GROUP LEADER: So how did you do with your homework?

SHIRLEY: Terrible.

GROUP LEADER: Maybe it wasn’t such a good assignment.

SHIRLEY: (smiling) Yes, it was. That was just my one extra lie for today!

GROUP LEADER: So you got something out of the assignment?

SHIRLEY: Yes. A lot. To be honest, at first I thought this was the stupidest idea I ever heard — even after you explained what you were hoping might happen. I do lie a lot without even knowing it. But telling that extra lie, I had to really plan it. This made me more conscious of my lying, doing this extra lie on purpose. And I felt more stupid lying, even though some of my automatic lies are about just as stupid things.

GROUP LEADER: What else did you learn?

SHIRLEY: By telling that extra lie, I learned that I can control my lying. If I really had no control over my lying, I wouldn’t be able to lie on purpose like that. And if I can have control to lie more, I can have control to lie less.

This assignment of symptom prescription succeeded in heightening the client’s awareness of a behavior she wanted to change, and it helped her gain self confidence that the change was within her power to accomplish. The group leader did not look upon the symptom prescription as an attempt to “trick” the client into changing. The group leader took care to explain the reasons for trying this paradoxical intervention, what might be accomplished, and left it up to the client to decide if it was worth a try as an experiment. Though the client was skeptical about taking on the assignment, it was done with her informed consent and agreement.

Another type of symptom prescription may be helpful to anxious clients who are distracted by thoughts of something bad happening. Suggesting that the client try to bring on the feared event or condition may be helpful in either of two ways: 1) the client will be unable to bring on the feared event or condition, and so be less anxious and distracted by the prospect, or 2) the client will succeed in bringing on the feared event or condition, and it will be over with; the client will have experience dealing with the feared event or condition, and realize that it wasn’t really as bad as feared.

My all-time favorite example of this type of symptom prescription is offered by Dr. David Burns in The Feeling Good Handbook (1990). He tells of his success asking clients concerned about their sanity to “go crazy.” If a client is highly anxious about keeping it together, Dr. Burns might say, “I know you’ve been afraid of cracking up for many years. This would be as good a time as any to go ahead and get it over with. After all, you are with a psychiatrist. Why don’t you go ahead and do it? Please try your hardest to lose control and crack up (p. 229).”

Dr. Burns writes that he might even demonstrate bizarre behavior for the client, by standing on his desk and singing. He reports that most often clients laugh and feel relieved, realizing that if they can’t crack up on purpose when they’re trying to, there’s not too much chance that they’ll crack up by accident, and their anxiety about the matter is lessened.

Paradoxical pattern intervention
Some pattern intervention tasks that qualify as paradoxical are surprising to the client, or out of the ordinary for a therapeutic setting. Sometimes simply suggesting a rearrangement of the sequence of events surrounding the problem can be helpful. For example, if a client has a pattern of not notifying his spouse when he’s coming home late, drinking with his friends, returning home and acting obnoxiously, and profusely apologizing the next day to his wife, the counselor might suggest to the client that he apologize to his wife before going out drinking.

Utilization: Spinning straw into gold
Every once in a while a client comes along whose view of the problem is precisely the same as ours. But not very often. Utilization involves use of each individual client’s unique set of resources and ideas, and being flexible enough to connect in a different way with each client. The idea is to take full advantage of clients’ strengths, their innate capacity to grow, and helpful events in the clients lives outside therapy, as well as things most counselors would consider “negatives.”

Some personality characteristics that counselors would like to change may be important to the client; they may be characteristics that clients feel make them who they are. When we respect this, the client is more likely to cooperate with us.

Challenging clients are often described as stubborn, defiant, angry, untrusting, passive, manipulative, disinterested, or uncaring. But the flip side of each of these characteristics is a quality many of us admire.

For example, if we consider the attributes of stubbornness and perseverance, our choice of words may depend as much on the intended goal of the person we are considering as what the person is actually doing. If we think it is a good goal, we may be more likely to call the attribute perseverance; if we disagree, stubbornness.

If your client seems stubborn, consider whether the behavior of “sticking to one’s guns” being displayed can be used to the client’s benefit. Likewise, if a client seems manipulative or defiant, have your client consider the possibility of using this independence and strong will as part of the solution. If you view your client as passive, consider whether a serene acceptance of things as they are might be part of a better future for the client.
The following case study demonstrates this technique.

Case study: “She ruined my life!”
“Shelby,” a 19-year-old in residential treatment, had been complaining in several consecutive groups about a girl who “ruined her life” in eighth grade. The group members seemed tired of hearing about this, after three weeks of trying to get Shelby to stop blaming all her misfortune on her childhood nemesis, Brittany, and accept responsibility for her current situation. But Shelby acted like a broken record.

Shelby had seen herself as a member of the most popular and elite of the eighth grade crowd. She had unselfishly taken Brittany under her wing when Brittany moved into town and helped her feel like a part of her clique. But according to Shelby, Brittany was very jealous of her. She made up lies about her that the other girls believed, and stole all her friends. Since Brittany was from a relatively wealthy family, she reinforced her position as Shelby’s replacement by buying expensive gifts for the other girls in the clique, and taking all of them, except for Shelby, on outings. According to Shelby, Brittany mocked and abused her every chance she got. Brittany was so afraid that Shelby would some day regain her place as leader of the group that she never passed up an opportunity to put Shelby down. Shelby eventually became a very angry young woman, and withdrew almost completely from the social scene to hang out with the “bad” kids.

GROUP LEADER: It sounds like this girl really hated you.

SHELBY: She did.

GROUP LEADER: And do you think she realizes how what she did to you has affected your entire life?

SHELBY: I doubt it. I hope she doesn’t know, because I wouldn’t want to give her the satisfaction.

GROUP LEADER: It sounds like you’d really like to pay her back for all she’s done to you. Are you still in touch with her?

SHELBY: No. I heard she moved.

GROUP LEADER: What did you used to do that used to upset her the most?

SHELBY: Mostly she upset me. The only times I think I got back at her were when I pretended not to be upset.

GROUP LEADER: So making believe she didn’t affect you got under her skin?

SHELBY: Yeah, but then that would make her try even harder, until I couldn’t take it any more. Then I usually ran away and cried.

GROUP LEADER: Maybe it would help for us to come up with a way to REALLY pay her back. Even though she’d never even know about it.

SHELBY: What do you mean?

GROUP LEADER: Well, it seems like the only times you got to her, even a little bit, is when you pretended she didn’t matter. I was just thinking if it would pay her back if she really didn’t matter. Even though you’re not in touch, she sounds like the kind of person who would be rooting against you. She’d want you to be a broken-down druggie loser. She’d wish for you to mess up in the program.

SHELBY: Yeah, she would. I hate her so much.

GROUP LEADER: Well, if the only times you got to her were when she thought she couldn’t get to you, I was thinking about how much it would really bother her if you really got things together, and didn’t even have to pretend that she didn’t matter. If you could make it so she didn’t matter for real, and you weren’t even pretending. Just imagine how mad that would make her.

The group leader is trying to utilize Shelby’s negative feelings about Brittany to motivate her to create a better life for herself. It’s hard to imagine that a person who would refuse to get her life together for her own benefit would be willing to do it to spite someone they used to know in eighth grade. But the above group session did seem to turn the focus away from complaints about Brittany, and at least temporarily motivate Shelby to consider things within her control that might improve her situation.

But which personality traits should be utilize and which should we target for extinction? The most respectful course of action is to take your direction from the client. If and when clients ask for our help in changing something, we might work for the transformation or extinction of the characteristic they are concerned about. If, on the other hand, the client has decided the characteristic is not one the client wants to change, the respectful thing to do would be to utilize the characteristic to help make changes the client does want.

“I give up!”
Surrender is often seen as a necessary First Step for clients, but knowing when to throw in the towel is also important for counselors. When we try too hard we can undermine our clients’ sense of self-efficacy, and push them into a passive role.

If you find yourself more upset at a lack of progress than your client, you may be trying too hard to be helpful. In some cases, the harder we work, the less our clients do. When some clients get the feeling that we are accepting all the responsibility for continuing progress, they feel relieved of any responsibility for their own situations.

Other times, we may be trying too hard to explore sensitive issues, like sexual or physical abuse, that our client is not ready to talk about, and we may be viewing the resistance we helped create as a treatment impasse. In these situations, it may be better to avoid a sense of urgency, go slow, and establish a firm foundation for change.

Still other times, your client may simply be at a plateau, or a natural resting place where clients need a rest from changing to consolidate their recent progress. Review past accomplishments and bring up the possibility that now may be a good time to stop and consolidate their recent gains. Validate the accomplishments and recognize the maintenance of changes as a real accomplishment.

Forget about it!
Sometimes it’s helpful to forget about the problem altogether. Instead of a focus on stopping the problem, focus instead on starting something else. According to many practitioners and researchers, addressing the problem may even be the problem. Their models hold that the way a problem started is no longer important. The reason it’s still a problem is only because of the way the client is trying to solve it. The goal of therapy in this case is not to get your client to do something to try and solve the problem, but to get them to give up on the attempted solution that is maintaining their problem (Fisch & Schlanger, 1999).

Self-disclosure: “Thanks for sharing!”
Discussion of self-disclosure often conjures up frightening scenarios of violated boundaries. When new counselors ask, “what things should I disclose about myself to clients,” the most common answer is “nothing.” Besides our name, rank, and serial number, is there anything else we can ethically tell clients about ourselves?

Some practitioners and treatment programs have very strict rules regarding self-disclosure. Avoiding inappropriate relationships is, of course, the highest priority, and a cornerstone of every ethical code for counselors. That said, not all personal information that counselors share with clients violates the sanctity of the client/counselor relationship. Properly timed and appropriate self-disclosure can sometimes move a stuck client, especially when used by counselors who do not generally share anything personal.

Of course, any self-disclosure on the part of counselors must have a client-benefiting reason behind it. Self-disclosure should be viewed as a possible tool for meeting client needs, and not your own.

One client-benefiting reason is to help the client be comfortable with your level of training and experience. Self-disclosure may also allow you and your client to examine a process that is not working (Littrell, 1998). By honestly sharing your own feelings about your perceived lack of progress with the client, you might provide your client the opportunity to get “unstuck.”

Self-disclosures similar to the one below have had varied results, but sometimes succeeded by a) eliciting the client’s previously unknown theory of change, b) discovering that the client is seeing and can identify more progress than the counselor, or c) eliciting client suggestions for improving the client/counselor relationship.Example: “I’m feeling very inadequate as your counselor, and it worries me because if I’m not optimistic about your situation, I’m afraid this will rub off on you. I’m wondering if I can be doing anything differently than I have been, to be more helpful to you. I feel very badly about not being very helpful so far, and I need to know your thoughts on what I can do to improve our relationship.”

Such a disclosure might encourage clients to share their ideas more often than do periodic requests to review progress. You might review with your client the tools you have been using unsuccessfully in treatment, and ask for the client’s opinions on what has and hasn’t been helpful so far.

Other client-benefiting reasons for self-disclosure include modeling, normalizing, or validating one possibility for appropriate behavior, feelings, or perspectives. With clients who are really down on themselves, self-disclosures about mistakes you have made, similar to ones clients are concerned about, can sometimes be helpful. Clients may also benefit from self-disclosures they perceive as expressions of empathy (Hubble, Duncan, & Miller, 1999). Finally, your self-disclosure might encourage your clients to share their theories of change and become partners in the therapeutic process.

Techniques that you are not currently using may be more likely to break a logjam, because they interrupt your usual pattern of relating. Next time you’re working really hard to get your clients to change what they do, consider the possibility of changing what you do. Rules were made to be broken.

Nick Roes, PhD, has written hundreds of articles and several books, most recently Solutions for the “Treatment-Resistant” Addicted Client (Haworth Press, 2002). He is Executive Director of New Hope Manor, a regular presenter at international conferences, and leads staff trainings for professionals nationwide. His Web Site is www.NickRoes.com and he can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Burns, D.D. (1989), Feeling Good Handbook. New York: Plume/Penguin Books.
Cade, B. & O’Hanlon, W.H. (1993). A Brief Guide to Brief Therapy. New York: W. W. Norton & Co.
Fisch, R. & Schlanger, K. (1999). Brief Therapy With Intimidating Cases. San Francisco: Jossey-Bass Publishers.
Hubble, M.A., Duncan, B.L., Miller, S.D. (1999). The Heart and Soul of Change, Washington, D.C.: American Psychological Association.
Littrell, J.M. (1998) Brief Counseling in Action. New York: W. W. Norton & Co.
Miller, W.R. & Rollnick, S. (2002). Motivational Inter-viewing. New York: Guilford Press.
Roes, N.A. (2002). Solutions for the “Treatment Resistant” Addicted Client. Binghamton, N.Y.: Haworth Press.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2003, v.4, n.4, pp. 46-51.

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