Mandated patients often throw some challenging remarks to their
therapists. Let me share some ways to field these remarks and
keep the therapy session moving forward. Now, have you ever heard
any of the following?
That's your opinion.
You learned everything in books.
You're too young.
Are you an alcoholic?
You're just here to make money.
When patients say,
"That's your opinion," they seem to be expressing
hostility and defiance. They are trying to take the focus off
themselves and put it onto the therapist. A quick way to put the
focus back onto the patient is to say, "Tell me your
opinion," and then begin a discussion based on the patient's
answer. The success of this kind of exploration heavily depends
on how verbally skilled the patient is. A patient with poor
verbal skills might not be able to express his opinion, and this
inability could be felt as an embarrassment and could jeopardize
the therapeutic relationship. If the patient has good verbal
skills, then you can continue the therapeutic/teaching process.
Another way to
respond to this type of patient is to ask, "What is my
opinion based on?" The answer, of course, is that your
opinion is based on your knowledge and work experience. If the
patient is able to answer thusly, then they themselves have proven
the validity of your opinion. If they cannot or will not answer
your question and you have to answer it yourself, it still gives
you an opportunity to diffuse their anger. You can tell the
patient that from what you have learned and from what you have
seen in other patients in similar situations, this is the way
If the patient is
able to recognize that your opinion is based on knowledge and job
experience, then they can conclude that maybe you actually know
what you are talking about. They can choose to listen to you,
because now they know that you are not trying to control them or
berate them. You are only trying to provide them with information
and alternatives that will help them get whatever it is they want
in life: job, marriage, keeping their kids, staying out of jail,
and so on.
What about the
patient who devalues your help by saying, "You learned
everything in books." If you have had several years of
specialized education, this remark can seem to pierce through to
an uncomfortable truth. The fact is, however, therapists have
not learned everything from books. You can answer the
patient by explaining that a lot of book-learning was necessary
in order for you to get a job in counselling. There are certain
educational requirements with which you had to comply. Since you
enjoy helping people, you did what was necessary and got your
education. This neutralizes the patient's attempt to project
their own feelings of inferiority onto you. The patient possibly
secretly envies your career.
There is another
possible dynamic underlying the "You learned everything in
books" response. The patient is looking for assurance that
you can really help. They have some doubts about your emotional
ability to digest all the sadness and horrors of their life. Can
you take it? Their suspicion is that you have led a sheltered
life. You can tell them that, although you have learned a lot
from books, you have had your share of disappointments in life
and you know what it's like to feel bad. This is just enough
self-disclosure to humanize yourself and to let them know that
you have integrated book knowledge with the everyday struggles of
Next we come to the
patient who says, "You're too young." For students and
beginning professionals who work with patients older than
themselves, this observation might seem like an indisputable
truth. The patient, however, wants to feel confident of the young
professional's capability. The worst thing you can do is to get
defensive: this will only make you appear unqualified to do your
You can tell the
patient that you work under supervision and that you are a part of
a treatment team. You can tell them that all treatment plans and
decisions are approved by your supervisor. This should assure the
patient that any errors will be caught immediately. In order to
counteract any prejudice against youth, you can also add that all
counsellors, regardless of their age, are required to participate
in clinical supervision. Some patients, however, will not like
the fact that their case is being discussed with others. You may
have to re-explain how confidentiality is interconnected with the
agency's team approach.
If the patient
persists and wants an older, more experienced therapist, here is
a strategy to consider. Ask the patient to give you a two-week
trial. If they are still unhappy with you after two weeks
(assuming that the patient has sessions more than once per week),
you will then agree to ask your supervisor about the possibility
of transferring their case. Most likely, you will be able to
prove yourself within two weeks. You will have established a good
relationship with the patient, and the therapeutic work will be
proceeding forward. If the patient continues to complain, the
complaints will probably be unfounded and obviously intended to
undermine the therapy.
"Are you an
alcoholic?" If you work with alcoholics and drug addicts,
you will recognize this as a trick question. No matter whether
you answer yes or no, you might find yourself trapped. If you
answer no, that you are not an alcoholic, the patient can then
conclude that you cannot help because you cannot possibly
understand what it is like to be addicted. If you answer yes,
that you are an alcoholic, the patient can then conclude that you
cannot help because you have too many character flaws of your own.
are probably expressing deep insecurity. They really do not care
if you are an alcoholic or not. That is not the issue, even
though that is the question they ask. They are not challenging
your qualifications. They want to know if your life has been
dragged through the same muck as theirs. If you answer this
question with sensitive self-disclosure, it could be turned
against you with unexpected aggression. You will probably make
this mistake only once! Insecurity and aggression can be a
To keep the session
moving, you can politely say that you prefer not to answer
questions about your private life. Patients have a right to know
your educational and work experience qualifications, and to know
your theoretical approach. Any use of self-disclosure beyond that
needs to be done cautiously and for the purpose of promoting the
therapeutic process. Working with profoundly insecure patients
requires an unfolding process of trust and respect.
are not looking to identify with you. They are looking for some
opening in your life where they can debase you. If they insist
that they need to know if you are an alcoholic in order to trust
you, then you can recommend that they attend A.A. meetings (which
they surely are not currently attending). Explain to them that
A.A. is the place where they can find other alcoholics who have
had many of their same experiences.
"Are you an alcoholic," also comes in various guises.
It can be worded as, "Do you ever get drunk," "Do
you go to bars," "What do you do for fun," and so
on. The word fun usually translates as intoxication.
Whatever the guise, the patient is searching for negative material
on you. If you decide to self-disclose to a hostile patient,
remember that the patient is not bound by confidentiality. You,
the therapist or counsellor, must keep patient information
confidential. But the patient can repeat, quote or misquote
anything you say.
encounter the patient who says, "You're just here to make
money." This is insulting. The easiest way to respond is
to make a joke out of it. When a patient throws this one at me,
I just agree and say with a spark of humor, "Yeah, that's why
I became a social worker--to get rich." In group therapy
sessions, this response gets a good laugh from the other patients.
They all know that we do not make much money. The matter is
settled without further fuss, and the session moves on to more
This essay is not
meant to be advisory or instructive. I have only been sharing
techniques that I have learned over the years. What works for me
might not work for you. Therapists have different personalities
and will develop different styles. Good luck in fielding whatever
challenges your patients deliver.
above descriptions of hostile attitudes and remarks are probably
more common to the court-mandated and prison populations.
Professionals who work with voluntary and motivated patients, or
who work in private practices, might find the content of this
essay to be extreme in comparison with their own experiences.]
[NOTE: For other
essays on similar topics, see Kindness of Strangers (written
02/06/06), Meet Me Halfway (written 03/06/03).]
Until we meet