Wave of Consciousness, "A Voice of Sanity in a World of Conflict"

That's Your Opinion

by Natalia J. Garland, M.S.W.

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?

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 things are.

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 living.

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 job.

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.

These patients 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 destructive combination.

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.

Such individuals 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 whether or not 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.

The question, "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.

Finally, we 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 productive discussion.

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.

[REMINDER: the 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.] (Written 08/02/04)

[NOTE: For other essays on similar topics, see Kindness of Strangers (written 02/06/06), Meet Me Halfway (written 03/06/03).]