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| Meeting the Challenge of "Hopeless" Clients |
| Feature Articles - Treatment Strategies or Protocols | ||||||||
| Monday, 31 March 2003 | ||||||||
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There are two main reasons why clients don't change when we want them to. First, change may not be as important to them as it is to us. Second, they may not believe that change is possible for them. Many clients are simply not interested in the kinds of changes we would like to see them make, while others desperately want to change, but they don't believe they can make it happen - and confusing hopelessness with disinterest can be a fatal mistake. Clients without hope, on the other hand, usually have an unrealistically low level of self-confidence. While outside pressure may have played a role in their decision to seek treatment, there is no need to convince them that they have a problem in need of attention. They are hurting so much that they are all but paralyzed by their pain. Rather than blaming others, those without hope have often accepted responsibility for their situation - even for the things that are beyond their control. Perhaps they even feel they deserved the physical, emotional, or sexual abuse they have suffered. Disinterested clients have an almost enviable ability to disconnect from their pain, and they are often unrealistically optimistic about their future. Clients without hope are unrealistically pessimistic about the future. They completely believe that a happy life is not possible for them. The disinterested client appears to be uncooperative because his or her agenda is different than ours. Clients without hope may agree completely with our goals, but may appear uncooperative because they do not really believe better things can happen for them. What is helpful to a "disinterested" client may make the situation worse for a "hopeless" client. For example, disinterested clients might benefit from your ability to help them connect with the more painful consequences of their actions - consequences that they do not realize are closely related to the problem behavior. Realizing that the problem behavior is directly connected to the painful consequences could motivate them to change. But "hopeless" clients are already in touch with - and often paralyzed by - their pain. To make things even more difficult for counselors, some hopeless clients exhibit a false bravado that makes them seem disinterested. Hope-inspiring reflections This article will focus on "hope-inspiring reflections," a technique especially helpful with clients who view themselves as hopeless. Such clients often make statements that preclude the possibility of change, such as "I never do anything right," or "I'll never be happy." Just the right type of reflection can acknowledge and validate the client's pain, while at the same time opening up, in the client's mind, the possibility for change. It's important not to devalue the hopeless client's pain. Well-intentioned suggestions that things aren't so bad could cause clients to feel they are not being heard - that somehow the depth of their despair has escaped you as their counselor. Therefore the reflection cannot be overly ambitious. It should allow for just a little bit more possibility than the client is currently feeling. For example, if a client says, "I never do anything right," you might reflect, "So you're feeling like you make a lot of mistakes." Although your reflection validates your client's point of view, it also opens up (very subtly) possibilities not in the client's statement. "Making a lot of mistakes" is a lot better than "never" doing anything right. The reflection leaves open the possibility of doing some things right at least some of the time. The phrase "So you're feeling like" opens up the possibility that while the client is feeling a certain way, feelings don't always square with the reality of the situation. If you're feeling one way today you can feel a different way tomorrow, but if you "never do anything right" - that possibility is not there for you. Using reflective listening There are at least five ways to open up possibilities by using reflective listening with hopeless clients. As we've just shown, allowing for exceptions to the problem is one of them. Introducing the idea that perceptions can differ from reality is another. Placing problems in the past - or solutions in the future - is another way. For example, if a client says, "I'll never be happy," you might reflect, "So far in your life, you haven't been as happy as you would like to be." Again, this validates the client's view, but subtly offers hope that the future could be different. Externalizing problems is another way to plant a seed of hope. Sometimes a diagnosis given by a professional could be seen by the client as a permanent disability. When clients see themselves as the problem, it can be very discouraging. When clients see the problem as separate from themselves, it can inspire hope. When a client suggests, "I'll always be a quitter," you might say, "The temptation to give up gets the best of you sometimes." This reflection acknowledges the client's view, but opens up an alternative view that does not make the problem the defining characteristic of the client. A fifth type of reflection acknowledges or encourages action on the part of the client. If a client says, "My jealousy always gets the best of me," you might say, "So you've been struggling with these feelings for most of your life." Once again, the client's view is validated, but the reflection acknowledges cause for hope ? the client is actively struggling against the problem, rather than passively accepting it. These reflections all evidence a very small movement away from hopelessness. But even that small movement can be a giant step forward for a hopeless client - the first step toward a whole new view of the situation. In the following example, the counselor uses all five types of hope-inspiring reflections. CLIENT: I'm a very depressed person. COUNSELOR: It seems like an overwhelming sadness gets the best of you sometimes. CLIENT: I'll always be depressed. It runs in my family. COUNSELOR: So you're feeling that change will be very difficult for you. CLIENT: Yes. I wonder if it's even possible. COUNSELOR: You've been struggling for a long time with some deeply sad feelings, even though you're not sure if you can win the fight. CLIENT: Right. It's really going to be an uphill battle. In this brief exchange, the counselor has used all five types of hope-inspiring reflections. While an untrained observer might think nothing of significance has taken place, there has been a small - but very important - improvement in this client's situation. The client has moved from thinking, "I'll always be depressed," to a much more hopeful place. The client has acknowledged the difficulty of the task at hand, but is willing to enter into the "uphill battle." Remember that truly hopeless clients need to feel heard. Don't go for the kinds of reflections that de-value or minimize their current pain. Acknowledge your clients' views of their situations, and use reflections that gently open the doors of possibility for change. Sidebar #1 Disinterested vs. Hopeless Clients "Disinterested Clients" "Hopeless clients" Unrealistically optimistic Unrealistically pessimistic Blame others Blame themselves Unrealistically high self-confidence Unrealistically low self-confidence Unrealistically high self-esteem Unrealistically low self-esteem Don't believe treatment is necessary Don't believe treatment can workSidebar #2 Five Types of Hope-Inspiring Reflections 1. Open up the possibility of exceptions to the problem. If the client uses words like "always" or "never," your reflection might include the phrase "most of the time" or "hardly ever." 2. Introduce the possibility that your clients' current perceptions may differ from the reality of their situations. Use reflections that include, "so you're feeling as if...," "It seems to you like...," and others that validate the client's current view, but also open the door to future changes in perception. 3. Put the problem in the past, or the solution in the future. When clients feel stuck, use reflections that put a time limit on their problems, or open up the possibility of a problem-free future. Your reflections might include phrases like, "So far...," and "Up until now... ." 4. Externalize the problem. Most people are reluctant to plan an attack on themselves. Once we help separate the problem from the client, the client is more likely to plan an attack on the problem. When clients label themselves as the problem, use reflections that identify the problem as separate from your client. 5. Acknowledge and encourage action. Clients who are actively resisting problem behavior are in a better position to change than those who passively accept their situation. Use reflections that acknowledge and encourage clients' efforts.Sidebar #3 Possible hope inspiring responses Client statement: "I'm a terrible mother." Possible hope inspiring reflection: "You're feeling like you're not as good a mom as you would like to be." Techniques used: perceptions differ from reality; acknowledging exceptions Alternate possibility for hope inspiring reflection: "You'd like to find ways to be a better mom than you have been lately." Techniques used: encouraging action; putting problem in the pastClient statement: "I never finish anything I start" or "I'll always be a quitter." Possible hope inspiring reflection: "Your perception is that you don't follow through on things as often or as well as you'd like to." Techniques used: perceptions differ from reality; encouraging action; acknowledging exceptions Alternate possibility for hope inspiring reflection: "The temptation to give up gets the best of you sometimes." Techniques used: externalization, acknowledging exceptionsClient statement: "I'll always be a fat pig." Possible hope inspiring reflection: "You feel like you've been struggling with a weight problem for a long time." Techniques used: perceptions differ from reality; encouraging action; externalization; putting problem in the past. Alternate possibility for hope inspiring reflection: "Your many attempts to lose weight have not been as successful as you might have liked." Techniques used: encouraging action, acknowledging exceptionsClient statement: "I'm too old to change." Possible hope inspiring reflection: "The way you see it, it's very difficult for people your age who are trying to change." Techniques used: perceptions differ from reality; acknowledging exceptions; encouraging action Alternate possibility for hope inspiring reflection: "Until now, you've always felt that changing is difficult as we get older." Techniques used: putting problem in the past, perceptions differ from realityClient statement: "My life is a mess." Possible hope inspiring reflection: "You're feeling as if there are a lot of problems in your life you'd like to address." Techniques used: perceptions differ from reality; encouraging action Alternate possibility for hope inspiring reflection: "So far your attempts to rearrange your life haven't met with much success." Techniques used: putting problem in the past, encouraging action, acknowledging exceptionsClient statement: "Nobody loves me." Possible hope inspiring reflection: "You're feeling like people don't care about you as much as you'd like them to." Techniques used: perceptions differ from reality; acknowledging exceptions Alternate possibility for hope inspiring reflection: "So far, you haven't been able to develop as many friendships as you would like." Techniques used: putting problem in the past, encouraging action, acknowledging exceptionsClient statement: "I'll never quit smoking." Possible hope inspiring reflection: "The way you're feeling now, quitting cigarettes is going to be very difficult for you." Techniques used: perceptions differ from reality; encouraging action; putting problem in past Alternate possibility for hope inspiring reflection: "Smoking cigarettes is a habit that you expect will be very difficult to break." Techniques used: externalization, encouraging actionClient statement: "I'm an addict, I was born that way." Possible hope inspiring reflection: "From your point of view, it's very difficult for some people to change, because of their genes." Techniques used: perceptions differ from reality; acknowledging exceptions Alternate possibility for hope inspiring reflection: "You're feeling as if your genes are making it more difficult for you to maintain a sober lifestyle." Techniques used: perceptions differ from reality, encouraging actionClient statement: "I wish I were dead." Possible hope inspiring reflection: "Sometimes you feel like life isn't worth the trouble." (These reflections assume that a suicide assessment has determined that there is no indication for additional precautions regarding possible suicide.) Techniques used: acknowledging exceptions Alternate possibility for hope inspiring reflection: "At this point in your life, you're struggling to find reasons to go on, or ways to make your life meaningful." Techniques used: putting problem in the past, encouraging action. Source: Solutions for the "Treatment-Resistant" Addicted Client (Roes, 2002) Nick Roes, PhD, CASAC, CJC, RAS, 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. Contact at Nick via e-mail at: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it Sources Consulted Miller, W.R., and Rollnick, S. (2002). Motivational Interviewing, Guilford Press: New York, NY. Roes, Nicholas A. (2002). Solutions for the "Treatment Resistant" Addicted Client, Haworth Press: Binghamton, NY. Clients referred to in this article as "disinterested" and "hopeless" are similar in profile to those referred to in Motivational Interviewing (Miller and Rollnick, 2002) as giving change "low importance" and having "low confidence" in their ability to change, respectively. "Disinterested" and "hopeless" are certainly not labels we would want to pin on any of our clients. We use the terms here to distinguish between two sets of common characteristics.             
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