Book Reviews

Those Troublesome Clients

Psychotherapy with "Impossible" Cases: The Efficient Treatment of Therapy Veterans
by Barry L. Duncan, Mark A. Hubble, Scott D. Miller.
W. W. Norton. ISBN: 0393702464.

Every therapist has experienced the frustration of dealing with difficult clients. Nothing seems to work. Both client and therapist despair. Often such troubling clients are labelled "resistant" or "personality disorders." Frequently a series of therapists become worn out by these "impossible" clients. They become "veterans" of the therapy business, thus the sub-title of this book.

The authors say neither the clients nor the therapists are to blame for the therapeutic impasse. They came to this conclusion, and their suggestions for resolving the impasse, after a five year project. They studied their own treatment failures, and learned three "conceptually simple, yet pragmatically difficult, lessons:

(1) all theoretical models have limited applicability;
(2) the therapeutic relationship is more valuable than expert interventions;
(3) what clients know, think, feel, and want has far more relevance to problem resolution than our favored academic conceptualizations."

The authors blame neither clients nor therapists for impossible cases. Rather, they see the culprit as "the assumptions, attitudes, and actions inherent to psychotherapy." Among these is the *expectation of impossibility*. Thus labelling often predicts a poor therapeutic outcome.

Two experiments (one from 1968 and one from 1973) are cited as evidence of

(a) how strongly influenced therapists can be by authoritative labelling of clients by respected clinicians, and

(b) how robust expectations can be, even in the face of contrary evidence.

The latter was the infamous Rosenhan experiment in which normal confederates pretended to be mentally ill. Despite weeks of non-psychotic behavior while hospitalized, the diagnosis of these pretend patients remained unchanged. The psychiatrists in charge, unable to change their expectations, twisted the pretend patients' histories and normal behavior to fit the original label of "schizophrenic."

What the authors suggest as a solution to impossibilty is implicitly an indictment of current attitudes. They offer the following guidelines so clients can retain or rebuild their dignity:

  1. The client is the hero in the 'drama' of therapy.
  2. Therapy is not done *to* a client.
  3. Interventions are not the "deal" in therapy.
  4. The therapist suggests, the client chooses.

Two therapy practices which help to create veterans are "doing more of the same" and "theory countertransference" (TC). As an antidote to doing more of the same, the authors suggest that jaded therapists adopt a "beginner's mind". The implication is that for the beginner, each case is new.

TC means forcing the client's story and symptoms into the therapist's favorite of the 400 or so competing theories of therapy.

But the authors caution, "because theories are abstractions, their usefulness is not guaranteed. When the therapy goes well, there is a natural tendency to say that the theory is affirmed. Nonetheless, when the therapy falters, often the theory is upheld at the expense of the client." (And let us not forget that "theories of therapy are principally theories of psychopathology.")

Then, of course, the client's dignity is impugned. An additional source of humiliation of a client is to dismiss him or her as unmotivated. "An unproductive and futile therapy can come about by mistaking or overlooking what the client wants to accomplish, misapprehending the client's readiness for change, or pursuing personal motivation."

The proposed solution is to practice "client-directed" therapy. That this could be considered news makes this reviewer shudder as to what appears to be going on in many therapy offices. Clearly few therapists are aware, although all should be, of the importance of "understanding the client's subjective experience and phenomenological representation of the presenting problem, and placing that experience above any theoretical predilection."

It is puzzling that Duncan et al. do not question the training of therapists. After all, if practitioners are so liable to push their pet theories onto clients, to pejoratively label, and to be boxed in by negative expectations, surely there is something missing in their schooling. Or does this apply only to psychologists? Social workers in training *are* taught about the importance of belief systems. Surely all trainee therapists should be made aware of these issues.

Near the end of the book the authors confess that their strategic therapy eyes were opened by the kind of clients they formerly dismissed as "therapist killers." They were forced to recognize their clients' inner strengths "and the contribution of a real collaboration."

They quote from another of their books: "Contrary to therapist desires for and marketing hype about "treatments of choice," prescriptive approaches for specific problems are based more in myth than empirical verification."

Homage is paid by the authors to predecessors such as Carl Rogers. There is a welcome tribute to the clients who taught the authors the lessons of how to deal with impossibility, and transcripts of sessions which bring the concepts alive. An abundance of references in the text both substantiates the authors' claims and yields a treasure trove to be mined at leisure.