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Despite the number of patients that gain great healing and change through in person or online therapy, many choose to leave it, with about 1 in every 5 clients dropping out of therapy. A reluctance to seek treatment in the first place, a history of unskilled or abusive therapists, distrust or anxiety surrounding the therapist and therapy overall, trauma, or their mental health diagnosis can all add up to a wary patient who doesn’t want to be there and is unwilling to open up. So how can therapists build a strong therapist client relationship or therapeutic alliance? It starts with fostering healthy therapeutic alliances, identifying potential pitfalls or ruptures to that therapist-patient relationship, and quickly repairing and resolving those issues so that clients feel safe, heard, and ready to progress for a more positive treatment outcome.
Beyond diagnosis and external factors (such as court-mandated psychotherapy, or the urging of a partner to seek mental health treatment), the therapist themselves can greatly affect how a client feels about them, and therefore their therapeutic relationship. For example, clients might have their own idea of how a therapist should dress. Observe body language and look for clues like boredom, judgment, disapproval, apathy, or discomfort. Other than the counselling environment, therapists who may appear as if they are silently judging their clients are more likely to inadvertently cause their clients to clam up. This might not be the best way to start a therapy session.
Therapeutic environments can have an impact on how comfortable a client feels in that space. A room has thin walls, a room that’s too hot or cold, uncomfortable seating, loud and distracting noises, or odd scents might make a client feel unsafe or unwelcome. Then there’s also the good old-fashioned mismatch: not all therapists are a great match for their clients, and vice versa. Therapists need not share the same perspectives as their clients, but when both have extremely different worldviews in politics, religious beliefs, and core values, it can make it that much harder to work with patients effectively.
Clients need the ability to share honestly and communicate openly with therapists about their experiences and behaviors, including feelings of guilt, shame, anger, and sadness. Though it takes time to build trust, building the therapist client relationship or therapeutic alliance immediately, over time, and for the long haul is crucial to supporting the patient and their needs.
Help clients feel comfortable from the very first session. Share how the therapeutic process could unfold, ways to help, and explain how initial sessions may differ from sessions later on. If you foresee barriers like different types of traumas, asking them for intimate details isn’t going to yield much trust later on. Instead, make addressing discomfort around psychotherapy the first issue to tackle and listen to how the client actually feels about therapy.
See what the client’s cultural, religious, or other norms and values are. Their views about their own experiences may affect their ability to open up and talk about how they feel. Men who were brought up to believe masculinity means not showing emotion will likely have a more difficult time expressing themselves. Someone who is exploring their sexual orientatio or gender identity may need a different method to open up compared to a heterosexual woman who grew up in a conservative Christian family or a liberal aetheist who grew up acclimated to therapy. Therapists should try out different methods for different therapy-client relationships, taking into account a client’s cultural background, spiritual beliefs, socioeconomic status, attachment style, therapy preferences, sexual orientiation, gender identity, race, and so on. Meet them at their level and encourage them to continue to open up so they know it’s safe to do so. Tailor the structure and environment of each session to help suit your client’s needs.
On the other hand, clients who aren’t ready or willing to talk about specific subjects aren’t “difficult,” per se, but they may still be grappling on how to share on those subjects. Think of ways to bolster safety and support in session. Interpersonal relationships are built over time. It’s normal for the first few sessions with a client to only offer a few disclosures. Investing in these early interactions allows for the client to warm up to you, get used to therapy, and come to trust you so that they can begin opening up authentically and delving into deeper issues.
Client goals vary, but it can help to talk out what their goals are for therapy. When therapists and clients agree on and collaborate together on patient goals, outcomes are enhanced. Those that don’t want to be there can still learn something and enjoy the benefits of therapy. Talk to your clients about what they hope to get from therapy so you can help set realistic expectations and use those goals as guides in how far they’re progressing for a more positive therapeutic outcome. For example, if a client is dealing with PTSD or childhood trauma, let them know this is something you two can discuss further when they’re ready. Encourage them to keep tackling these hard issues without insisting that they do. Let them know you might need to ask more than a couple of questions – and know that sometimes you’ll need to ask them more questions, ask different types of questions, or offer up the same question in a different way for them to understand.
The same goes for methodology. If that same trauma client is resistant to general talk therapy, they may be more receptive to specific cognitive behavioral therapy methods that pinpoint where and how they feel wrong. When therapists ask questions or suggest ideas in an empathetic manner, it can open up the patient to admit they’re resistant to treatment for varying reasons. If the therapist can break down the idea or task in a way that feels more comfortable for the patient, it can break open how the client actually feels or why they’re resistant to change.
Even if it’s taking a while for the therapist or counselor client relationship to build into something stronger, remember that judgment over their actions will not help. Keep your own feelings in check if you find yourself disapproving of something they’ve said or done. And avoid making them feel rejected. Clients are opening up about their most intimate moments – make them feel listened to and heard! Don’t set off those vulnerable feelings into a tailspin by rejecting their premise, shutting down ideas, dismissing values, or interrupting. Be empathetic and warm, following their lead in therapy session. Pay attention to your facial expressions, posture, tone of voice, and eye contact (or lack thereof).
Likewise, manage your own emotions. Your own anxiety or fears about being unable to help them could rub off on them and erode the trust you’ve worked so hard to build. Work on ways to build yourself up so that you can keep the focus on the client. Come prepared to sessions with questions, have your research done, and plan conversations ahead to help you stay on task. Be self-aware enough to know if transference is occurring during sessions, meaning, if a client has an issue you have also dealt with or are dealing with, hold back from making the session about you, offering advice in a pinpointed way, or admonishing the client.
Most of all, don’t take client interactions personally. You are there to help with their emotional baggage, not your own. If a client isn’t talking, it’s not necessarily about you. If a client is particularly difficult for you, consider talking to fellow peers, your supervisor, or other therapists about the issue.
Finding what works best per client takes time and effort. Strengthening the therapeutic relationship may require a variety of strategies, but patience, great listening skills, empathy, and a solid plan of action will help therapists overcome many of the obstacles they face when dealing with more challenging clients.
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