Enhancing Outcomes For Reluctant Clients With Challenging Issues: A Research Update

Defining a reluctant client when it comes to psychotherapy can be difficult because the majority of clients seek therapy when they have known issues and are ready to make changes to improve their lives. According to the Journal of Psychology and Clinical Psychiatry a reluctant client is defined as a person who is unwilling or hesitant to participate fully in the helping process because they are reluctant to change (Ucar, 2017). A client may be hesitant to fully commit to treatment because they have been mandated to attend therapy by the court for alcohol or drug misuse, child abuse, and violence, which are often stigmatized. Other clients may have been coerced by a loved one or spouse to go to therapy to keep the family intact. Whatever the reason, it is important to learn skills that foster an environment that will help the client to become invested in their therapy.

Counseling Techniques That Help

When working with reluctant clients it can be difficult for a treatment provider to establish an effective therapeutic relationship, but there are some well-researched techniques that help to establish an effective and trusting relationship. Two of the most successful techniques are presupposition and neurolinguistics. According to Joshua Uebergang, who teaches communication techniques, neurolinguistics looks at how an individual’s thoughts, feelings, and actions produce the results they get right now. Presupposition gives the therapist the foundation to understand how someone perceives the world and presents an opportunity for changing behaviors (Uebergang, 2015). Counseling Today suggests that using these techniques for managing resistant clients works because they help therapists to understand the client’s world and to reframe the behavior for what it is and not as resistance (Shallcross, 2010).

According to Saul Singer, a marriage and family therapist who teaches continuing education classes on this topic, these methods get patients both involved and invested in their therapy. Clients who do not want to be in therapy often participate until they have received the outcome they want, which is to be out of therapy. If a client is receiving treatment solely because it is court-ordered, they may not be working on goals that will help them in the long run. When therapists use presupposition and neurolinguistics to communicate with clients, they gain their trust, and can begin to peel back the layers of their issues. People in court-mandated treatment often believe it is a waste of time and may resent the time spent in a counseling session that interferes with their normal daily routine (Lipack, 2012).

Communication is an important aspect of working with reluctant clients. It is important to ask open-ended questions, affirm and support, listen reflectively, summarize, and elicit self-motivational statements (Shallcross, 2010). The use of neurolinguistics and presupposition revolves around how therapists ask questions and make statements. For example, asking a question that says, “when you do this…” instead of “if you do this….” makes the subject seem more tangible in the client’s mind.

These techniques can also help therapists understand the hierarchy of client’s needs. Often, clients have multiple issues, and it can be difficult to discover the most important or urgent issue for a client. One excellent technique for therapists to use in such a situation is the miracle question. The miracle question, created in 1988 by Steve de Shazer, one of the pioneers of solution-focused therapy, is a creative way to devise good therapeutic goals (Tyrrell, n.d.). The miracle question basically asks people to imagine, however fantastical it may be in their particular circumstances, that their life has already dramatically changed for the better. This allows the therapist to help the client to become more open and enables them both to discover what is really important to the client.

Research Uncovers the Myth: Experience Does Not Equal Effectiveness

Today, we see more and more reluctant people entering treatment for substance misuse and mental health concerns. The use of neurolinguistics, presupposition, and various communication skills are invaluable tools. Specific techniques can also get clients to trust their therapists, understand that they have some things that need to be worked on, and to invest in themselves on working towards set goals. Current research is providing new evidence to support what it really takes to be an effective therapist or treatment provider with positive treatment outcomes. Interestingly, research shows no significant relationship between years of experience in being a therapist and “expertise, interpersonal skills, ability to form therapeutic alliances, or client outcomes (e.g., Goldberg et al., 2016; Hersoug, Hoglend, Monsen, & Havik, 2001; Lafferty et al., 1989; Truax & Carkhuff, 1976; Tracey, Wampold, Lichtenberg, & Goodyear, 2014; Witteman, Weiss, & Metzmacher, 2012)” (Miller & Moyers, as cited in Effective Psychotherapists, 2021, p. 127).

Possible reasons for this include the fact that therapists seldom receive immediate feedback about the success of their interventions or treatments. They also work alone with their clients, unlike surgeons who work in the presence of colleagues and support staff and receive feedback almost immediately. A 2015 study found that therapist characteristics such as gender, caseload, age, years of experience, and other demographics were not significant predictors of client-reported outcomes. The evidence supported the amount of time spent improving therapeutic skills and in reviewing therapy recordings as the two highest predictors of positive outcomes (Chow et al., 2015). Barriers to effective outcomes often include systemic and policy barriers that can also contribute to the lack of improvement in a therapist’s skills over time  (Miller & Moyers, 2021). So, what steps can therapists take to increase their expertise and client outcomes? According to the evidence, a therapist can do the following activities:

1. • Engage in “deliberate practice.” Deliberate practice is the process of developing and engaging in activities to improve skills and receiving feedback from trustworthy and dependable sources. The feedback loop between a teacher or supervisor and a therapist allows the therapist to make changes in treatments and interpersonal skills, learn new skills, and improve them over time (Miller et al., 2020; Miller & Moyers, 2021).
   • Develop “Interpersonal Micro skills.” Some of these include fine-tuning skills of reflective listening and accurate empathy guided by both client responses and regular supervisor review using techniques of generating reflective statements, improving vocal inflections, and recording therapy sessions for later review with the permission of clients (Miller & Moyers, 2021).
   • Monitor client outcomes. Follow-up calls to clients, simple evaluations, and client ratings of therapists can provide valuable information about the skills and expertise of therapists and enable feedback to inform them of the need for additional skill development (Miller & Moyers, 2021).

Is It Really That Simple?

Obviously, the process is more complex than just following three suggestions and attending professional development and education after initial clinical training. Careful selection of training opportunities can support the strengthening of interpersonal micro skills and deliberate practice. Passive workshops or classroom instruction are not as effective as experiential learning for improving the skills that research indicates are the most effective in producing positive outcomes. Techniques such as being observed and receiving feedback, role-play, and other hands-on methods have been shown to be more beneficial than other teaching methods (Miller & Moyers, 2021). Furthermore, these types of trainings need to start early in the training process for counselors and psychotherapists and the importance of the need for continued experiential training, supervision, and coaching throughout their careers must be stressed to those entering the behavioral health field. This creates the understanding that ongoing efforts in skills development is key to client outcomes.

This research update was inspired by a new book by Theresa Moyers and William Miller that was published in January 2021, Effective Psychotherapists: Clinical Skills That Improve Client Outcomes.  The volume was written to answer questions about what makes some therapists more effective than others. The authors accomplish their mission by reviewing current clinical research literature to stress the importance of continuing the right kind of education and skills training starting immediately after initial counselor education has been completed. It is a worthy addition to the library of any behavioral health provider.

For additional information, resources, podcasts, and training on this and other behavioral health topics check out the CASAT OnDemand:

• Learning Labs – Deep dive curated resources for a variety of behavioral health topics
• Resources & Downloads – Downloadable materials and links related to behavioral health
• CASAT Conversations – A podcast resource for exploring topics of interest to behavioral health providers
• CASAT Learning – CASAT Learning is our new and improved registration and training platform where you can access self-paced online courses, as well as register for live webinars and in-person classes.

Special Note: This Catalyst blog post was developed by the Center for the Application of Substance Abuse Technologies (CASAT) at the University of Nevada, Reno. Feel free to use this information. A link to our site and attribution is appreciated. Suggested citation: CASAT OnDemand. (2018, July 25). Enhancing Outcomes for Reluctant Clients With Challenging Issues. CASAT OnDemand. https://casatondemand.org/2018/07/25/enhancing-outcomes-for-reluctant-clients-w-challenging-issues/

Ready to Learn More?

Enhancing Outcomes for Clients with Challenging or Unique Issues: LIVE WEBINAR

April 17, 2023 | 9:00 am to 12:15 pm PST
April 18, 2023 | 9:00 am to 12:15 pm PST 

This workshop was developed from five decades of clinical practice and research on solution-focused and solution-oriented therapies, supplemented with addendums from neurolinguistic studies, strategic interventions, and client-need driven clinical processes. Effective with clients mandated or coerced into treatment; low resource and vulnerable high-risk clients and families; SUD and co-occurring disorders; client-families with histories of referrals to child protective services or juvenile justice; couples’ work and structural family therapy; and clients from diverse cultural and socio-economic backgrounds. Clinical processes include methods to accomplish a collaborative therapeutic alliance, foster cooperation, build hope, set meaningful goals, define authentic change, and enhance outcomes. It is not a rigid practice model but rather a culturally sensitive, adaptive, and collaborative approach that combines the experience and strengths of the client with the skills of the clinician. Based on the book, Brief Therapy for Clients with Challenging or Unique Issues: A Clinician’s Guide to Enhancing Outcomes, in publication with Routledge/A Taylor and Francis Group, for release Summer 2023.

Presented by: Saul Singer, LMFT, LCADC

Registration required: https://www.casatlearning.org/calendar-view/unique-issues

References and Recommended Reading

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.

Di Bartolomeo, A. A., Shukla, S., Westra, H. A., Shekarak Ghashghaei, N., & Olson, D. A. (2021). Rolling with resistance: A client language analysis of deliberate practice in continuing education for psychotherapists. Counselling and Psychotherapy Research, 21(2), 433-441.

Ibebunjo, E. (2021). Examining Therapist Experience with Resistant Clients.

Interview with Saul Singer, MFT, LCADC. Continuing education instructor at CASAT, interview date (February 5, 2018).

Kadur, J., Lüdemann, J., & Andreas, S. (2020). Effects of the therapist’s statements on the patient’s outcome and the therapeutic alliance: A systematic review. Clinical psychology & psychotherapy, 27(2), 168-178.

Lipack, J. (2012, July 11). When People Are Mandated to Treatment. Retrieved from https://www.goodtherapy.org/blog/mandated-substance-abuse-treatment-0711124

Miller, S. D., Chow, D., Wampold, B. E., Hubble, M. A., Del Re, A. C., Maeschalck, C., & Bargmann, S. (2020). To be or not to be (an expert)? Revisiting the role of deliberate practice in improving performance. High Ability Studies, 31(1), 5-15.

Miller, W. R., & Moyers, T. B. (2021). Effective Psychotherapists. Guilford Publications.

O’Neill, R., Gilea, B., & Fellenger, S. (2020). Motivational interviewing for caregivers of LGBT youth. Journal of LGBT Youth, 17(3), 315-330.

Ryland, S., Johnson, L. N., & Bernards, J. C. (2021). Honoring Protective Responses: Reframing Resistance in Therapy Using Polyvagal Theory. Contemporary Family Therapy, 1-9.

Shallcross, L. (2010). Success stories with challenging clients. Counseling Today. Retrieved from http://ct.counseling.org/2010/10/success-stories-with-challenging-clients/

Shallcross, L. (2010, February 14). Managing Resistant Clients. Counseling Today. doi:http://ct.counseling.org/2010/02/managing-resistant-clients/

Tyrrell, M. (n.d.). How to Use the Miracle Question With Your Therapy Clients: 3 Examples. Retrieved from https://www.unk.com/blog/miracle-question-examples/

Uebergang, J. (2015, February 03). Neuro-Linguistic Programming Presuppositions – 12 Rules to Change Your Reality. Retrieved from https://www.towerofpower.com.au/nlp-presuppositions

Ucar, S. (2017). Reluctance and Resistance: Challenges to Change İn Psychotherapy. Journal of Psychology and Clinical Psychiatry,7(6). Retrieved from http://medcraveonline.com/JPCPY/JPCPY-07-00464.pdf

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