Jan 21, 2010 12:00 AM

Therapy Without Force:  A Treatment Model for Severe Psychiatric Problems

by Daniel Mackler, LCSW  (www.iraresoul.com)

Introduction

The standards of care of the modern mental health system all but insist that a therapist use force in working with clients diagnosed with severe psychiatric problems—especially those labeled with schizophrenia or bipolar disorder.  The mental health practitioner is taught to be skeptical of their judgment, their self-control, and thus their wishes.  Hand-in-hand with this skepticism comes the therapeutic model that says that “we know what is best for them” and that all of our decisions and our expertise, whether they like it or not, are “for their own good.”

But is this always the case?

When we trump a person’s right to make autonomous decisions we send him the message that he is incompetent.  We teach him not to trust himself.  We teach him that his experience is a pathology rather than an opportunity for self-study and growth.  We teach him that his “symptoms” or “defenses” are a problem rather than a window into a world of deeper meaning and history.  We teach him that life’s answers are outside of him, that the truth is not within him, and that his best bet is not to look within for guidance.  How is this so different from the message that “mental illness” is a genetic, biological aberration and that the only hope for salvation is psychiatric drugs for life?

Although I do not wish to deny that many people credit the forced treatment they experienced as helpful, in that way that many people credit medication as being lifesavers, how much more might they have credited truly respectful and non-coercive caring that produced the same or even better results?

In this paper I will explore the various facets of coercive treatment for people with severe emotional problems, and explore how to be an optimally non-coercive therapist.

Types of Coercion

1)  Forced Medication

The first and perhaps most common type of coercion faced by consumers labeled with severe psychiatric disorders is forced medication.  (Here I also include other forms of forced biological treatment, such as forced electroconvulsive therapy.)  This can take many forms—both overt and covert.  The overt forms include forcing someone to take antipsychotics in order to get or keep his housing or other benefits, forcing someone to take antipsychotics in order to continue his participation in a work or mental health program (or in therapy itself), forcing someone to take antipsychotics in order to be granted release from a mental hospital, forcing someone to take medications, including injectible antipsychotics, under threat of being re-hospitalized (e.g. Involuntary Outpatient Commitment), and, in a hospital setting, physically restraining someone and injecting him against his will.

Although these forms of overt coercion vary in their intensity, they all share a common thread of denying a client his right of choice.  Likewise, the coercion in these “treatments” squelch his self-respect and undermine his sense of self in a way that is metaphorically comparable to the bodily side effects of the drugs themselves.

Likewise, any therapist who participates in overtly forcing a person to take medication deals a crippling blow to the therapeutic alliance—if there was one to begin with.  Similarly, any family member or friend who uses force to pressure someone to take medication strikes a blow at the foundation of trust in the relationship.  If someone wishes to take psychiatric drugs on his or her own, and has fully informed consent about the drugs’ potential risks versus benefits, then it is his business to decide his own course of action.  But if he (or she) wishes to avoid medications, then that too is his full right as a human being.  It is no one else’s right to question him.

Meanwhile, covert forms of forced medication are, in many cases, similarly pernicious.  A primary one involves the therapist pressuring the client to take antipsychotics in order to keep in the therapist’s good graces.  Many people underestimate, or outright ignore, the psychological intensity of this.  Clients, especially those who are vulnerable, lonely, isolated, and desperate for connection—which is not uncommon in people diagnosed with severe mental problems—may be so attached to their therapist that they will do almost anything to win his favor.  Rejection by their therapist may be unthinkable to them—even provoking suicidal feelings in some—especially if they have a repeated history of abandonment by parental-like figures.  This affords the therapist massive power to throw around his weight in the most subtle of ways—and apply coercive force simply with a withheld smile or a grumbled reply.

Another covert type of force involves the use of societal stigma—and unscientifically-based social mores.  A person labeled with a psychotic disorder who refuses medication can meet all types of emotional resistance from friends, family members, peers, and even the television and newspaper.  Together they can form a covert wall of force, psychologically pressuring the client to “do the right thing,” “face reality,” and “take your meds.”  When the therapist gives any credence to these social norms—and does not overtly challenge the inappropriateness of those who preach its message—he subtly joins the norm himself.  For this reason I am hesitant to support family therapies that place pro-medication family members on equal therapeutic footing with anti-medication consumers.  So much coercive damage can be done to a client in the name of “respecting alternate points of view.”  Isn’t it more appropriate for the therapist to side first and foremost with the client, and to respect his autonomy and boundaries no matter what?

2) Forced withdrawal from medication

This is the flip side of the previous form of coercion.  In this scenario the seemingly “progressive” therapist uses the power of his role to pressure the client to stop taking his medications.  Perhaps the therapist is even skilled and experienced at helping clients withdraw—and has successfully guided many through the process.  His skill, however, is tainted if the decision to withdraw or taper does not come solely from the client.  The therapist’s job is to present the potential pros and cons of medication—assuming, that is, that the client is interested in hearing them—and then to back off and let the client decide for himself.

I recently heard a story of a Scientologist who pressured a “resistant” mental health consumer to withdraw from her psychiatric medication.  Although the woman had no intention of withdrawing, the coercion caused her to feel undermined, and thus emotionally damaged, as a person.  And she did not even have a close relationship with the Scientologist!  How much worse is it, then, when a trusted therapist uses the nurtured intimacy of the therapy hour to meet his own treatment ideals?

3) Forced Hospitalization

I consider forced hospitalization to be downright vicious, if only for the iatrogenic damages—damages caused by the treatment—of hospitalization itself.  Although some credit hospitalization as a life-safer, too often I have seen clients choose to enter the hospital entirely on their own, free of coercion, and come out far less centered and happy than before they even went in.  And how much worse is it when they are hospitalized against their will?  The wealth of psychiatric survivor literature on this subject is enough to tell that tale.

So often a therapeutic relationship cannot stand the violation inherent in the therapist forcibly hospitalizing the client.  It is a basic attack on the person’s freedom, on par with getting someone unfairly arrested, or, in the words of so many clients, metaphorical for being raped.  (And that doesn’t even address the subject of the number of consumers who actually do get raped or physically assaulted during involuntary mental hospitalizations.)

On the flip side, many outpatient therapists lack the skill, training, or insight—or collegial support—to know how to remain therapeutic in the face of a “psychotic” or “acting out” client.  But I argue that limitations in the ability of the therapist do not excuse the use of coercion.  Ideally, the therapist’s limitations should place pressure on the therapist to find ways to become more therapeutic (a subject I will address later in the paper), though of course many therapists and many therapeutic systems fall short of the ideal.  Instead they adopt treatment models based on coercion—or simply refuse to work with clients who are “too severely disturbed.”  Likewise, other treatment providers stigmatize, criticize, or marginalize therapists who have the skills they lack.  This stigmatization is convenient:  it is much easier to pathologize the competence of a fellow clinician than to study and outgrow one’s own professional limitations.  Denial, projection, and rationalization are by no means limited to one side of the couch.

4) Forced Therapy

All too often people are mandated to therapy.  Mandates are an overt form of coercion, because choice has been removed from the equation.  Although some people do benefit from mandated therapy, in the few beneficial cases I have observed the benefit came only once the client’s motivation for therapy eclipsed the intensity of the mandate, thus, in essence, negating it.  Early in my therapeutic career I worked in various outpatient therapy clinics in New York City and was forced, as part of my job duties, to work with mandated clients, some of whom were deemed “psychotic.”  These clients were mandated to work with me by a variety of sources, including mental health programs, psychiatrists, family members (who threatened to kick the client out of the house if he didn’t go to therapy), parole or probation officers (who threatened prison and demanded attendance records), housing programs (who threatened to kick the clients onto the street if they didn’t attend “therapeutic treatment”), and sometimes even by my own clinic itself, which would refuse to allow the client access to his psychiatrist (that is, psychopharmacologist) until he concurrently attended therapy. 

This mandate almost assuredly rendered the therapy untherapeutic from the start, and incidentally, such clients, despite the mandate, generally had a much lower show-rate for sessions than my non-mandated clients.  And should I be surprised?  I myself personally hate being mandated to do anything, especially if I’m supposed to talk about my most personal issues with a complete stranger who is in the power position.  (I was mandated to two sessions of psychotherapy at age thirteen and I still resent that therapist, twenty-five years later.)

Meanwhile, the way I helped mandated clients find value in the therapy was that I told them that the only goal I felt that was reasonable for the therapy was to help them get their mandate revoked, and I devoted all my energy to this end.  I wrote letters for them—which I let them edit—detailing why they did not “need” therapy and why revoking the mandate would be the most therapeutic course.  I told my mandated clients that I believed that if there were any hope of them getting anything useful out of the therapy it could only come from their choosing to attend on their own volition.  Many appreciated this—and many, with my full support, dropped out of therapy the day their mandate was revoked.  I invariably considered this a success, though I admit to having felt a much greater sense of satisfaction when they continued to come to therapy voluntarily following the revocation of the mandate.  That was where the real therapy began.

In this vein, I am generally hesitant to work with children, as so many are initially resistant to coming to therapy.  Children lack the ability to give consent to be able to vote, to be able to drink alcohol, to have sex, to serve in the military, to be able to choose where they live, and in most cases to work.  Thus I also question if children, in most cases, also lack the psychological ability to give consent to come to therapy.  Are they not often, at some subliminal level—and sometimes a not-so-subliminal level—being coerced to come to therapy by someone, somehow?

At this point, being in private practice, I refuse to work with mandated clients.  I only agree to work with people who come by choice—and not based on fear of even the most minimal external punishment.  By agreeing to work with mandated clients I have come to realize that I cannot avoid being part of the coercive power structure.  And my self-esteem cannot tolerate that.

5) Force used to prevent suicide (and harm to others)

This type of force is particularly complex.  The standards of care of the mental health field insist that we therapists do all within our power to prevent our clients from committing suicide.  Our licenses and our jobs rest on our commitment to stop clients from harming themselves (and others), at all costs.  In some cases we have the “right” and even “responsibility” to pressure them to take medication or be locked up in the hospital.  In other cases we have the “right” and “responsibility” to break therapeutic confidentiality and call their friends and family members and other treatment providers—who in turn might hospitalize them or have them arrested—even if we never got a signed release of information.  We have the “right” and “responsibility” to call the police on them, to get them dragged away in handcuffs and straightjackets, to have their freedoms stripped away, and to treat them as objects—objects to save—not subjects.  And we do this in the name of love and caring and therapeutic insight and professionalism.

Although at times our interventions might be loving and caring, at other times they are not—and are instead a chance for the therapist to act out his power.  I personally wish to avoid using this power at all costs.  In my ten years of being a therapist, and working with countless suicidal people, I have not yet hospitalized one—or broken his or her confidentiality.  (And I have never had a client commit suicide—for which I am thankful.)  Instead I deal with his or her suicidality—and struggle to find ways to try to alleviate it.  I also begin with the basic assumption, which I often share with the client, that a person coming to therapy does not fully want to kill himself, because if he was so fully committed to killing himself he wouldn’t come to talk about it.  He would simply do it.  In this regard, I discuss his options, and place the onus of responsibility on him, which in and of itself can help to alleviate suicidality.

Although the practical reality of this is rarely so easy as the last half-paragraph might suggest, it is not impossible.  It just requires creativity—and perhaps most of all it requires that the therapist be able to tolerate a huge amount of anxiety and uncertainty.  Many therapists cannot or do not wish to do this, and in many cases I can understand why—because I often do not feel up to the task myself.  The pressure on a therapist can be intolerable, not just because it is terrifying to ponder one’s emotional reaction to a client potentially murdering himself, but also terrifying to consider the legal and professional ramifications for a therapist who did not take forcible action to prevent it.  For that reason I at times have serious doubts about the ultimate legitimacy of the whole mental health field.  How can a therapist be expected to work therapeutically in a field that requires that when the going gets rough he become a coercive agent of the state?

Similarly, therapists are pressured to prevent clients from harming others.  We are expected in many cases to use coercive force, which risks placing us in a double bind.  Clients come to us vulnerable and desperate for help, and we do as we are taught in encouraging them to be open and honest about their actions, thoughts, and motives, yet at times we might be expected to hospitalize them or even indirectly have them arrested (such as through breaking confidentiality in warning a potential victim of theirs) if they become too honest and admit to certain unsavory thoughts or illegal actions.  And if we don’t practice coercion, however subtle or justified this coercion might appear, and they do harm or kill someone else, then we may be held culpable—both by the state, the licensing boards, and our own ambivalent consciences.  This can be hell on a therapist—and pressure those of us who eschew coercion to become therapeutic supermen and superwomen who push the envelope of the standards of care, racing therapeutically against time and ancient trauma to “undo” violent impulses.  But might not this pressured race—which a client much surely sense, if only unconsciously—also be a form of coercion?

I understand and respect that therapists have to follow the laws of their state to prevent clients from harming others, and I am not arguing that we disregard these laws, but I do ask this:  where do we draw the line in warning victims?  And what constitutes a real danger to others, much less an imminent danger to others?  And most importantly, I ask this:  what else might we do to prevent a client harming others?  This whole subject matter, which I have only dealt with minimally, is rife with complexity and frustration, and leads into the next subsection.

Struggling to Be a Non-Coercive Therapist

In the midst of a system laced with coercive mores, how can a therapist behave non-coercively, and thus therapeutically?

In the general sense, the best way to behave non-coercively is to be a more effective therapist—and, lacking that, to be able to connect the client with systems, agencies, groups, literature, clinicians, and peers who offer something that is effective.  It is our job to struggle to understand where the client is coming from—and to understand his real needs.  Psychosis and depression and anxiety and rage are symptoms of a deeper need.  So are suicidality and homicidality.  We therapists have a responsibility—a true responsibility—to uncover and empathize with our clients’ deeper needs, and then to help them find resolution.

The facile empathy of “loving clients back to health” is not curative in and of itself, and I have seen too many cases in which the therapist’s empathy evaporates when the client becomes “imminently” suicidal or floridly psychotic.  Likewise, often such clients accept no surface empathy, either because it threatens their boundaries or because they know—through bitter experience—that it will do them no good.  Thus our job is to go deeper—both with our clients and with ourselves.

Our job is to learn to know ourselves to our depths.  When therapists have not done their own deeper work, which is all too common, their psyches cannot help but pressure them to turn away psychologically from clients who share deeper and more painful material—especially the metaphorical material labeled as psychosis.  And when the mental health field as a whole has not done its deeper work, and bases its standards on more shallow or unscientific or flimsy or denial-laden theories, it rushes to coerce, to medicate, and ultimately to subdue those whose symptoms and very existences offer challenge.

Our job as therapists is to do our inner homework.  When we do this we become less frightened of our clients and particularly of their symptoms.  We instead gain a framework to understand where they are coming from, and if we lack that, which at times is not unreasonable, at least we have a framework for developing the ability to understand.  Working with clients diagnosed with psychotic disorders may provide no better challenge for the therapist to go deeper within himself and to study his own comparable sides.  This can be terrifying—and sometimes psychosis-provoking for the therapist himself—but what better way to derive true empathy for clients?  There is a reason that so many of the most compassionate advocates for those diagnosed with psychotic disorders are psychiatric survivors themselves.  And clients are by no means foolish when they say they would prefer to work therapeutically with someone who has been in their shoes.  Don’t we all ultimately wish for this?

But again, this does not make the work of the therapist any easier.  The challenge remains great.  Life pressures the therapist to seek out better colleagues, better supervision, better referral networks, better peer support, better therapy, and better self-therapy.  Doing therapy with people experiencing deep distress pressures the therapist—in a healthy, non-coercive way—to be more honest, more self-revealing, less rigid, less conventionally boundaried in the clinical sense, more compassionate, more self-questioning, more involved, more creative, and simply more real.  If the therapist wants to go home at the end of the day and not think about his work till the next day, then he is in the wrong profession—or working with the wrong client population.

But there are times when a given client will be too much for even an experienced, compassionate, anti-coercion therapist.  Perhaps the two make a poor therapeutic fit.  Perhaps a particular therapist is excellent for one client but kicks up too much anxiety or other negative feelings in another.  Or perhaps a given client needs more structure than a given therapist can provide.  Or perhaps a client who is tapering off psychiatric drugs experiences so much upwelling rage or psychosis—the result of pre-existing problems or simply the biological reactions to drug withdrawal—that the therapeutic relationship becomes unworkable.

This can be particularly difficult for the therapist (not to mention for the client), not only because of the emotional intensity of the interactions but also because most dedicated, non-coercive therapists hate “giving up,” having long since prided themselves on being able to work with the “toughest clients.”

Personally, my model in these cases is to “give up”—and end the therapeutic relationship—but to do so without being coercive to the client.  The key here is to do so as gently as possible, with as much warning as possible. My non-coercive model, as I have come to develop it, involves three stages, as follows:

Stage 1

The primary stage involves letting my clients know, ideally from the first therapy session—before the working relationship has even begun in earnest—the nature of my therapeutic limits.  Each therapist has his own.  Sometimes these can be left to assumption, but I find that with clients who are experiencing high degrees of emotional distress, it is therapeutically wiser to leave less to assumption.  This helps set a clear foundation for the frame and boundaries of the therapy.

I tell clients what types of behavior I can tolerate in therapy and what types I cannot.  For instance, I can tolerate a fair degree of yelling and screaming and insults and rage directed toward me—and I try to use this for therapeutic benefit—but I can only tolerate so much, and with so much volume.  I work out of my apartment, and I have neighbors:  I cannot risk them calling the police on me, or having the landlord revoke my lease.  Also, I cannot tolerate client violence toward me—or threats of violence.  As such I let them know upfront that that is a therapeutic deal-breaker. 

Similarly, I have my own emotional limits:  I can tolerate hearing about a significant degree of conflict from my clients—relayed words about their suicidality, rage, anger, paranoia, violence, etc.—but only to a degree.  I have learned that sometimes I reach my limit and can tolerate no more—especially if a client is making no headway in curbing his behavior.  When I find myself nearing my limits with a client—or even getting blips on my radar screen that I might be nearing my limits—I let the client know.

In this first stage I also discuss with the client his feelings about therapy.  In some cases, if I feel it might become relevant later on—which it often does—I ask him about his point of view regarding such subject matters such as coercion, force, boundaries, suicidality, psychiatric hospitalization, psychiatric medication, and confidentiality.  I try to provide a safe environment in which to discuss these topics to whatever degree both he and I feel it helpful.  I feel that this to be vital in providing a client with real, mutually agreed upon informed consent—which to me is a prime ingredient in basic respect.

Likewise, I invite clients to ask me any questions they might have about my perspective on these topics—or any subject they feel is important, however uncomfortable—and I make it my business to be frank and honest. Also, I tell clients that they can feel free to give me fictional scenarios on various subjects (such as suicidality or homicidality) and ask how I might behave if such a scenario were to happen.  Also, I welcome clients to re-open the discussion at any point in the therapy.  If I don’t know his opinion on these subject matters early on and he doesn’t know mine, we risk forming our therapy relationship on very shaky ground—one that risks collapsing in ugly ways down the road.  Having an open, flexible dialogue on these often taboo subjects can go a long way toward building appropriate and realistic therapeutic trust—which can prove invaluable not just for the therapy itself, but for the client’s whole life.

Stage 2

If, at some point in the therapy, I find that I am becoming too overwhelmed or uncomfortable by the client’s actions or behavior to be able to function effectively as his therapist, I share this openly with the client.  In this second stage, I let him know that the agreed-upon frame in which we are operating may not be enough to tolerate what he is experiencing.  I remind the client of my previously stated limits as a therapist, in order to build continuity with that foundation.

Sometimes clients, despite our initial discussions, have the erroneous belief that they can say or do whatever they want in session—that the therapeutic environment is a place where they can totally be themselves, with no consequences whatsoever.  Although the degree of consequences can vary with different therapists, it is our job to communicate our limits as clearly and consistently as possible.  Otherwise we risk blindsiding clients with consequences that can seem arbitrary, unexpected, and unfair.  On the other hand, effective communication of our limits can actually prove to be therapeutic in and of itself, not just because it places the onus of responsibility on the client, but because it reminds the client that the entire world operates within limits.  All actions have consequences, and therapy can be an optimal place to explore this reality.

Meanwhile, to return to the particulars of the second stage, if I am becoming overwhelmed by a client, I use my anxiety and apprehensions—after I have analyzed them within myself and feel confident that they are well-founded and not overly laced with my own denial—as an attempted wake-up call for the client.  Here therapy offers him an opportunity to study his life and see if he can make changes that involve adopting, or considering adopting, a healthier lifestyle, or at the least a healthier perspective.  Sometimes this works.

Other times it does not.  In some cases I have been accused by clients of trying to coerce them into changing—to make me happy and to keep the therapy alive.  In a sense this might appear to be true—which might seem contradictory to the point of this paper—but I view it differently.  From my perspective when a client takes steps that break the agreed-upon therapeutic frame it is he who bears the primary responsibility.  He is making a choice, be it conscious or unconscious, through his action, and it is actually he who is abandoning the therapy:  breaking the therapeutic contract, as it were.  So in a sense he is coercing me to change the stated and mutually agreed upon frame of the therapy—a frame which I think is quite liberal and therapeutically reasonable.  My resistance to changing the frame is less a coercion of him than a reflection of his coercion of it.

But like all things that are complicated in therapy, sometimes there are counterintuitive solutions, and that is where I feel the onus is on me to be creative.  Sometimes a client who is challenging the frame of the therapy needs to come more often.  Often in the second stage I offer the client the opportunity to come and see me more often—and sometimes this goes a long way to quelling anxiety—his and mine!  Other times I suggest that the client expand his support network beyond the therapy relationship.  (I will address this more in the next stage.)  Sometimes the pressure on the one-on-one therapy relationship is simply too great—and when the client builds a broader, more holistic support system, the tension in the therapy can abate significantly.

Stage 3

The third stage of my non-coercive model happens when a client is simply unable or unwilling to operate respectfully within the stated frame of the therapy.  Here I feel I cannot continue the relationship as it has been going.  I do not force him to do anything, and instead use the only option at my disposal:  I pull back, all the while making it clear that this is what he is forcing me to do, against my desire.  I do not hospitalize, call police, call case managers, punish, pressure medication, or suggest medication.

Instead I simply let him know that he, through his actions, has damaged our relationship to the degree that I have no choice but to withdraw from it.  But in the same way that I counsel people to avoid abrupt withdrawal from psychiatric drugs, I myself avoid, if at all possible, abruptly withdrawing from a therapeutic relationship—in order to avoid abandoning him.  I give as many warnings as I can, I state the reasons for my actions as clearly as possible, and in some cases I discuss with the client the possibility of postponing therapy for a period of time—a week, two weeks, even a month if necessary—to give him a chance to see if he can be more reasonable in working toward keeping alive his relationship with me.
 
If I do postpone the therapy I offer him as many other alternatives as possible so that he might find ways to help himself in the meantime.  Some of the alternatives might include:  referrals to other therapists, referrals to group therapy, referrals to day programs, referrals to activity groups, referrals to peer support services, referrals to case managers or direct support services, referrals to Twelve Step Programs (such as AA, Narcotics Anonymous, Gamblers Anonymous, Al-Anon, even Double Trouble), and referrals to substance abuse programs.  Often, before pulling away, however, I offer clients conjoint meetings in therapy with other important figures in their lives—people from their personal and professional support network—in order to discuss these potential changes and explore ways of finding clients more appropriate levels of assistance.

My goal during this third stage, and the previous stage as well, is to help the client feel respected—and to minimize the damage not just to our therapeutic alliance, but to the work we have accomplished thus far.  Often I have heard clients tell of a wonderful relationship they had with a past therapist being called into question by the therapist’s poor handling of a crisis or therapeutic “termination.”  Sometimes clients suffer for years over these mishandled endings—and consequently lose great degrees of trust and faith in humanity.  As such, I strive to be as respectful to clients on the last day of therapy as on the first—and all the more so if the therapy relationship is ending under less than ideal circumstances.

And sometimes things do not go ideally.  Sometimes the client can take the therapist’s withdrawal from the relationship as an attack on his sense of self.  This is most pronounced when the client has placed strongly idealized parental-like expectations onto the therapist.  Sometimes clients, especially when they themselves are in the throes of extreme emotional distress, have a difficult time understanding the anxiety and conflicts they can induce in a therapist, and can even feel betrayed and undermined when they discover that their therapist is not an ideally parental “god,” but instead all-too-human.

The betrayal they feel from the therapist can translate to them as a form of therapeutic coercion.  Perhaps the client, especially the client who feels the therapy is his primary lifeline, says, “Your commitment is to help me, and at my moment of greatest need you are rejecting me because I’m not behaving in the way you want!  You’re forcing me to change my way of behaving to suit you—and I don’t like being coerced to change!  You lied to me!”

When then is the therapist to do?  This, of course, is complex, because sometimes the client in this situation has so little empathy for the position of the therapist that it is difficult for the therapist to reach him in a way that he finds satisfying or understandable.  Here I simply do my best and try to be as honest and forthright as possible, though I have never found this to be easy.  I let him know that the primary rejection of the therapy has come from him—though I acknowledge that perhaps a different therapist might have handled the situation more effectively, and if I am sorry then I let him know.  (Often I am very sorry.)  But at the same time I do not shy away from the reality that through his decisions he is actually rejecting himself, and in many cases is following the model of much of his own traumatic history of rejection.

I encourage him—and at times even plead with him—to look more closely at his actions and thoughts and behavior and history so that he might better understand why I am pulling away.  I often point out that I am rarely the first person in his life to pull away from him under such circumstances.  (Often he agrees.)  Usually I am just one in a long string of failed interpersonal relationships—and that I have no desire to participate in repeating this pattern of his.  I tell him that as much as I might like to save him from himself, doing this is neither my ability nor my responsibility.  I let him know that it is not a therapist’s job to carry the full psychic burden of the therapy—or even the majority of the burden—even if the client thinks that that is what he is paying for.  The therapist’s ultimate job is to help place the locus of control back in the center of the client.  The responsibility for the client’s salvation—assuming the client is an adult—is his, and if he cannot do it, especially after I have given the relationship my best, then he must face his own consequences.

Although the client in this situation might feel that I am pressuring him to begin taking psychiatric drugs—especially if he has heard that message repeatedly throughout his life—that is not my stand:  my stand is the client has to take more responsibility to be more mature.  This might involve coming to therapy more often or more on time, getting better sleep, eating better, exercising more, paying bills more regularly, avoiding prostitutes or anonymous sex, watching less TV, avoiding fighting or arguing with others, being more respectful to his neighbors or friends, making new friends, going to more support groups, meditating more, seeking out spiritual outlets, doing fewer drugs, drinking less alcohol and caffeine, managing his budget better, and often simply doing more therapeutic work and self-reflecting outside of the therapy session.

It is worth noting that my withdrawal from clients is quite uncommon, and I only use it as an option of last resort.  But it is an option, and it is not coercive, because unlike coercion it is neither intrusive nor undermining of autonomy.  Instead, as horrible and painful as therapeutic withdrawal can be, it provokes autonomy.  And ultimately, whether the client uses this provocation toward autonomy to his benefit or not—now or in ten years’ time—is up to him.  But it is not the therapist’s job to force him to become autonomous.  It is only the therapist’s job to respect him.

References

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Harrow, M. and T. Jobe (2007).  Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. The Journal of Nervous and Mental Disease.  195(5): 406-14.

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