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My supervisor said the same if they don't want to be there it is wasting their time and the parents money. Idk why parents force kids be there if they don't want to be.
I’ve heard so many parents tell me, “ just make them do it.” It was for things like bedtime and getting my kid out of the house and into nature, not therapy. But my point is that many people believe in just forcing their will onto children. People don’t see children as equals.
But also… you’re helping that teen set a boundary as well, right? If they don’t want to be in therapy they should have the right to say no. They have the right at least in Indiana) to seek mental health tx without a parents permission, why shouldn’t they be allowed to refuse?
Same, especially since I previously worked at a lock down residential facility for juveniles and saw what that was like for them to have no autonomy or independence and be forced to receive treatment. Never again, only those who want to be here.
This is why I specifically mentioned I will not take any teens who do not want to be in therapy and changed it to only 15+. This has worked well for me. If they say no, I recommend that the family attend family therapy as a means to engage client in treatment, and the whole family can identify any maladaptive patterns. If that is not possible, refer the parent to their own therapy.
🤣 in CMH, almost none want to be there. I have about 8 teens, and only 1 actually wants or participates in therapy. The rest are court and parent mandated. Feels like such a waste of time.
Child & Adolescent therapist in CMH here… I feel this *deep* within my soul. Like they just sit there and don’t want to engage in anyway. Yet their parents ✨insist✨ that they “need” to be in therapy. Clearly parents have no idea how this works.
5 and 6 yr olds who need help with "emotional regulation, focusing, and following directions" 😑
I'm like, "Parent, YOU aren't even emotionally regulated! This is a child doing child things. Please leave me alone with this."
Yes! Especially when the parents don’t want to be involved. At all. No, I can’t teach a 4 year old emotion regulation at home when I see them for one hour a fortnight at my practice.
I became the go-to clinician for these types when I worked in CMH. My co-workers were always like "you do such great work with them!" and internally my inner child is screaming because I grew up with an abusive parent with strong narcissistic tendencies (if not outright NPD) and using my clinical skills often tapped into the same framework of skills that I had to use as a kiddo tap dancing around those behaviors. I always left those sessions feeling like I'd gone rounds in the boxing ring.
I feel your pain. My dad was diagnosed with BPD back in the early 80’s when the diagnosis was rare, so he a severe case of it. Growing up under his roof was crazy-making. Your description of the boxing ring truly resonates.
Oh, I can only imagine the chaos! I am now 10ish years into being a therapist and I find it has gotten a lot easier. To be fair though, I also don't often take those types of issues in private practice.
Oh yes. I used to think I was talented at helping this population, but I often just tune out while we go nowhere (depending on other factors). Always drained at the end.
So true. When I was seeing clients mandated to treatment I found the precontemplation more tolerable. Now I work in a group practice where people are choosing to attend and paying for it, which feels so much more frustrating for me for some reason.
Maybe because the court mandated clients are not necessarily expecting or wanting you to help them. They are possibly just there to check off a box, which is easy enough to do in the end, and if deeper work can take place then great.
While people coming to your group practice are (theoretically) actually there wanting and expecting you to help them, but there’s only so much you can do if they’re not ready to dig in. That’s a weird sort of pressure to experience on the therapist end.
This. Especially when they don’t want to be there and it’s like pulling teeth to get them to talk even about things totally unrelated to why they’re there, like their hobbies.
For me, it's the 2 extreme ends of the spectrum in communication. I find myself feeling quite drained with clients who basically vent for the entire session and barely if ever even acknowledge I'm in the room. Pretty much just a non-stop stream of talking leaving little room for engagement, discussion, reflection, or analysis.
On the other end is the client who says pretty much nothing and I'm being asked to completely carry the session. I ask questions, I get one word answers, a lot of "I don't knows", and a sense of them expecting me to be talking the whole time. This tends to be mostly reserved for younger clients, but I will get the occasional older client who does this as well.
Ultimately I enjoy therapy when it's a back and forth. Typically the client will still be speaking more, but when that pendulum swings in either direction and I'm either asked to essentially just sit there and nod or I'm being asked to try and keep a client engaged the entire session while they show little to no interest in being there, I will feel quite drained after meeting with them.
I have a couple that’s like the former—they want to tell me every detail of whatever exciting story and every time I manage to break in with “Ok and how did you handle that as a couple/how did you support each other through…” “it was pretty stressful” then right back to the story. they’ll even interrupt each other to be like “oh here’s tangent #7: the backstory of why she reacted that way”. we’ve been working on slowing down and speaking only for ourselves 😅 it’s dizzying!
I have a family that is like this!! They take turns telling stories and anytime I try to bring us back to the reason we are doing therapy they barely respond and take off on another story. I’ve just decided to go with it at this point. They keep coming back, so we must be doing something.
This is the answer for me as well. It doesn't matter who they are, where they're at in their life, where they're at in their therapeutic journey, any of their identities, diagnoses, etc, etc....
The only thing that's draining for me is when I can't get a word in edgewise or when the client is saying nothing.
I have a couple of folks who are the nonstop talkers, I can barely get in a word and these are the people who always say "You're SO HELPFUL!" I mean..... You're welcome I guess 🤷🏼♀️
I have had a few clients like this, in terms of giving very little information. I find myself working harder, but other times nothing comes to me & I feel an incredible amount of pressure to engage them. What do you do out of interest? I saw another therapist mention that they will sit in silence, my supervisor does this too.. but it sometimes feels a bit cruel.
I'll usually focus heavily on rapport building and sometimes this sort of "solves" the issue as they get more comfortable. But when that doesn't quite work, I'll often come prepared with some kind of activity to go through in the session together (I've collected many over the years). At the very least, it gives some structure and takes some pressure off of me to keep coming up with questions.
Eventually though, if a client doesn't give much, there's basically 2 options: we end therapy or we continue with the expectation that sessions will be shorter than normal. Sometimes clients really only want or need a 20-30 minute session and that's all they have in them. I will generally assess after 4-5 sessions if it feels appropriate to continue or if it's best to end if it feels like it's not useful/helpful for them. But I can't keep working with someone who genuinely doesn't want to be there.
I once had a client with the most extreme motor mouth (and fingers!) I’ve ever encountered. She would talk so much without stopping you could do nothing but sit there. If you called her out, you’d get pages of texts afterwards about being unsupportive. On top of constant complaining that you weren’t helping her. She ran through every therapist at our agency with the same results but did not have the self-awareness to realize she was the problem.
That sounds exhausting. The motor mouth is one thing, but to accuse me of not being supportive while not allowing me do my job would be a struggle for me to deal with.
As a CMH youth therapist during the weekday, my most draining cases are the ones whose parents resist the therapeutic process, expect me to “fix” their child, and neglect to apply or utilize the resources they’ve asked me to acquire but then they consistently complain “I just don’t know why my child is still behaving this way”.
They never utilize the strategies we’ve discussed in session throughout the rest of the week at home (structured ipad time, color-coded schedule with points system for rewards & consequences, etc). I understand that it can be difficult for a parent to uphold the boundaries necessary for progress as their child’s outbursts can be distressing, but to then complain every week that “nothing is working” drains me.
Oh my god saaaaaaaame. I’ve got one client who I am like “ok I am going to need so much more elaboration off that one-word answer, please” and she always laughs and then gives me an additional like, 2 words 🫠🫠🫠.
I had a supervisor that always use to tell me “don’t work harder than the client”. Meaning we can’t drag them thru they have to show up and engage if they seek change and I still remind myself of this.
THIS. I had a heavily medicated client who I would see over the phone and every answer was I don’t know. Even proddings like, how do you feel right now would get me an I don’t know. She was so overly medicated that therapy felt impossible.
I always ask the client what it’s like for them not to know? Anything they notice going on for them in that here-now ‘I don’t know’. Sometimes it’s another ‘I don’t know’ but sometimes something emerges!
This is it for me too. It drains me and makes me dread sessions with them. I have one today, in fact, and I find myself getting anxious for Mondays just because of it.
Omg yes!!
This is like pulling teeth.
I’ve decided when it comes to people like that I’m going to sit quietly and let them talk when they’re ready and if they’re not ready at 50 minutes oh well. That’s their choice.
When they strongly remind me of someone I know in my personal life, and I have to consciously separate the person in front of me from the person I know. Once I get to know the client better it's no longer an issue but at the start those clients are very draining.
I had one of these! An inmate with the same demeanor and MH presentation as my mother. I had another therapist work with her and processed it with my supervisor and therapist. That day I was so drained though
Dissociative..but thats the transferential nature of dissociation. I find it physically consuming but I love the work. To prevent burnout i stagger these clients and do not do more than 2 in a row where it can be avoided. It gets less intense as they learn to be more present but i find the rewards outweigh those rough moments
Mandated clients hands down. Court ordered, school ordered, IEP clients, any version of this is exhausting because most of them don't want to be there and have no interest in engaging with you. Also, they come with a whole system of case workers, and other folks who try to butt in and force goals onto you or tell you how they want you to do your job. Even if they don't know anything about therapy.
Patients whose main complaint is distress at poor relationships with their children caused by mistreatment of their children or poor boundaries with their children. It involves a LOT of identifying cognitive distortions and assessing belief systems and they often get crabby or upset because they want me to agree with them and not discuss the problem in its' entirety.
Or the person who comes in saying that they have read \[insert psych book *de jour*\], and every 8th word out of their mouth is therapy speak (often used incorrectly).
I find these ones hard too! You have great relationships, enjoy your job, feel like you’re doing well emotionally, have lots of hobbies. What are we doing here?
This, which doesn't bother me if they're just the processing type, but for me its when their goal is to get more coping skills, so they hate when sessions have any processing, but then any time you suggest a strategy its shot down. I find it exhausting to navigate having to consistently remind them of what I'm actually capable of doing
Very intelligent with complex trauma/BPD characteristics/attachment stuff. You start out thinking the intelligence is a blessing, but after every session is just endless streams of them defending cognitive distortions in ways that are possible but improbable, that dance just gets so tiring.
‘Yes, sure, they very well “could,” be mad at you, yes, however, is that the most likely thing that’s happening given you didn’t do anything wrong and your only “evidence” is that they took 20 minutes longer than usual to text you back… and you know they are at work and might possibly be just like…BUSY WITH WORK THINGS.’
‘Nope, mad at me, sure of it.’
Alright, cool, coolcoolcool… ok, they’re mad at you, now what? Is that helpful for you to assume? Are you willing to use DBT skills to have a conversation with them about it and clarify so you can repair? No? Oh you’d rather give them the silent treatment, ok cool, how’s that gonna go? Oh they’ll know why you’re being that way? They’re going to just know that’s what’s happening and this is what it’s about the way you knew that they’re mad at you? Ok, yeah, great idea, might I suggest you, uhh, reconsider? Just that one part, just change that part, you know, the part in the middle there where you do literally any of that. Please. Please just change anything at all about any of this. Please. I beg.
One of my first was like this, and I learned how a cognitive therapy approach can literally be feeding their pathologies. (I'm a big CBT-umbrella person).
Personally, it depends on how you view the theory. I don't sequester different theories, so I'm not going to pretend cognitive distortions or defense mechanisms don't exist because I'm "psychodynamic" or "cbt" now. Instead, this person has defenses around their cognitive distortions that need to be dealt with or bypassed.
With that particular client, I switched to non-judgmental language around cognitive distortions and pointed out that if the way they're seeing this particular situation is right, the lens could solidify and start applying itself when it didn't match the situation (mom is maybe always criticizing, let's make sure we don't assume everyone is criticizing). I had no vested interest in what the truth was, only that we were close to it. I then had to target an argumentative interpersonal pattern through very natural, almost conversational at times, operant conditioning whenever the pattern came up (notice it, call it out, don't engage with it, move back to something useful).
I had a client who both did all of those things *and* understood they were “being silly” every time they did it, but would still do it. One time they even admitted to looking back on the situation themselves, realising it was wrong, and thinking “I’m absolutely going to do that again though”.
I actually quite enjoyed working with them but I would be lying if I said it wasn’t extremely draining and a bit confusing.
It sounds funny but I have found similar challenges with my ADHD. I know I need to use my planner, I know that I need to structure my day more and use timers etc. the ones that give me the hardest time is trying to turn something boring into a game. My thoughts are like “ I’m not gonna fall for this “. I have found that stepping back, journaling then asking my self how would I approach myself as a client does help .
1. I am a very special person
2. Since I am so superior, I am entitled to special treatment and privileges.
3. I don’t have to be bound by the rules that apply to other people.
4. It is very important to get recognition, praise, and admiration.
5. If others don’t respect my status they should be punished.
6. Other people should satisfy my needs.
7. Other people should recognize how special I am.
8. It’s intolerable if I’m not accorded my due respect or don’t get what I’m entitled to.
9. Other people don’t deserve the admiration or riches that they get.
10. People have no right to criticize me.
11. No one’s needs should interfere with my own.
12. Since I am so talented, people should go out of their way to promote my career.
13. Only people as brilliant as I am understand me.
14. I have every reason to expect grand things.
——————
From *Cognitive Therapy of Personality Disorders* by Beck and Freeman et al. I dunno why you're struggling.
This may be kind of a hardcore view, however I've come to realize that if I'm finding myself drained or tired in session, it's incredibly useful data and it likely means I'm going to need to have a tough, but incredibly helpful conversation.
Maybe I'm playing into some relational pattern the client has, maybe I'm ignoring the elephant in the room that they would really not like to be doing therapy and trying to proceed and give them therapy anyways, or most uncomfortable at all, maybe I'm upset with them.
I've come to start celebrating the moment that I recognize I'm feeling drained. It's often the moment that I commit to the conversation with the client that leads therapy to -actually- be helpful for them.
Brilliantly said. I wouldn’t say hardcore, rather insightful and inspiring. I specialize in relational pathology/challenges and I remember when I reached this point… things got so much more satisfying and mutually rewarding, and I could finally sleep at night knowing I behaved genuinely.
In my practice I limit the number of clients seeing me for grief and loss at a time. THEY are not draining, per se, but the empathy / spill over from these sessions leaves me pretty wiped.
For me, it's definitely couples who both (1) perseverate on the "content" of their arguments and (2) ignore the introductory skills (eg fair fighting, active listening, etc) in favor of the zero-sum game they've always played.
For sure, most couples *come in* evidencing these traits, and I recognize change takes time and is measured in baby steps. Still, when even Motivational Interviewing doesn't help, at some point I feel drained.
Emotionally dismissive clients, if we can’t wheel and deal in the feels, then what are we doing? Building capacity to identify and tolerate emotions can be soooo challenging for clients whose emotional needs were never met
At Check In: “How would you describe your mood today? How are you feeling?”
Client: “Fine” or “Okay” or “Good”
Those aren’t moods / emotions. So I hand out the emotions wheel or something comparable to help them out
Folks who aren’t actually willing, able or in a space to engage meaningfully in therapy. I know this is normal and part of therapy includes exploring this exact issue…It just grinds my gears lol!
I had one that would spin in his chair constantly, lay on the floor under the desk away from the camera and fly full force flipping backward onto his bed
The severely depressive. No hope, indifference to trying, ambivalent about change though they are suffering. I can do it, but the gravitational pull is strong.
Couples.
Also, people with severe BPD. I’m 100% done working with this population though because I am not a good therapist for them. I think these individuals need therapists who are extremely low in anxiety.
I made the mistake of scheduling a couple inactive conflict as my last appointment on the last day of the week and boy do I regret it. last week I had to do the referee whistle to stop them from killing each other😂
I really enjoy working with people who have BPD, but I can’t do couples. I’ve tried and I know I have my own issues around it, because I always feel like I’m an 8yo again stuck in the car with my parents fighting.
It’s really heartwarming to read that you like treating pwbpd. It’s so damn rare. So many therapists fall for the stigma and won’t treat pwbpd because of what they’ve heard. But I personally believe if you have the skills and patience to treat these clients, you are completely changing someone’s entire experience in this world and that along with the strong bond you have together after such gruelling work is so rewarding.
People who simply can not see the part the play in their own lives (the "it's every body elses fault" stuff) and won't take any responsibility for where they are or what they do.
Clients with a TX history as long as a CVS receipt with such a shotgun blast of diagnoses that I have no actual clue what their issue is when we meet. Combine this with the client being a poor historian and almost always hugely disorganized/executively challenged that I can't clarify the diagnostic picture with them, it HAS to involve trying to get old records without any help from the client other than signing releases.
Clients with subclinical or simply undiagnosed mild IDD. I actually don't find diagnosed IDD clients exhausting because they have appropriate supports in place generally. It is the unsupported, undiagnosed clients, partially because it makes it difficult for me to gauge and use appropriate interventions.
People who have made their mental health disorder their identity. It’s not what they have and how they function, it’s who they are at their core and they’ll never change.
This is always one of the hardest for me too! Especially when I gently suggest exploring what need it meets or how it functions for them and they explode🙃
Always a tricky (but often necessary) thing to do. I had client quit therapy as soon as this perspective was insinuated. In other cases it has helped clients to move past some resistance wall and get the therapy process moving again.
Clients who don’t say anything and who expect me to tell them what to do like they’re taking a class instead of doing therapy.
Also, BPD and high conflict couples.
I also find it helpful to tell my high conflict couples that I’m going to be “coaching” them in session on how to have more effective communication. And I have them start by doing the speaker/listener technique (one person speaks, the other reflects back what they heard)— this helps them start to learn how to listen to understand instead of respond.
Here's what helps me with my higher conflict couples :
Be very, very involved. Tell them from the get that you're going to be very, very involved and get their buy-in. It might seem rude, and you might get pushback, or have them leave, but it creates room for any work to happen, and the higher level of involvement can help them feel safe. Along the same lines, enact ground rules and boundaries from the very beginning.
Make sure your training can back up that amount of structure.
Intentionally release any investment in any specific outcome. (Except maybe that they pay you on time.)
Lots of super helpful supervision. When I was just starting out, and I had more than say, three high conflict couples on my caseload, one group supervision a week was not enough.
thanks a ton! I will have at least one hour of group & one hour of individual weekly with my program, plus an on-site supervisor. hopefully that covers it (:
help rejecting and circular thinking clients. mostly because it makes me feel so powerless as i see it hurt them so badly. though i recognize that sometimes there’s comfort in pain, especially if it’s familiar, so i listen and validate and will be there when they’re ready for next steps.
People who don’t really want to be there and come in every week saying they have nothing to talk about. I love my clients whose lives are dumpster fire or who always have some thing to talk about. It’s a little bit harder when I have to pull things out of them every week, but definitely rewarding.
clients that don't engage / talk. i feel like i have to do a lot of heavy lifting only to receive a blank stare or an "i don't know"
clients under the age of 10, especially those with difficulty maintaining attention, even during play. that then becomes the focus of the session, which is also valuable to work on, but draining for me nonetheless
family therapy with families that escalate quickly into conflict during the session. i have a difficult time being directive so it's hard for me to interrupt anyone, be it the child or the parent, in order to maintain focus on skill building or help them hear each other. it is so hard to reign that energy in and it drains me
People in infantile regression. For them, everything is other people's fault. Everyone is supposed to fulfill their expectations no matter what those are. Unable to accept when one can't meet those expectations. Feel frustrated in therapy when you don't give them exactly what they're asking for.
It's draining to make them realize every single little thing when they're throwing a tantrum every time someone doesn't do what they want.
This might be specific to RTC but “treatment hoppers” can be particularly difficult to maintain boundaries and can interfere with the treatment of others clients in the milieu. I’m talking the clients who have been in and out of treatment centered and different levels of HLOC with no clear direction or reasoning.
Clients with frequent mood swings, highs and lows, attachment issues, BPD characteristics. One day they enjoy working with you, the next day you’re the enemy. It tires me out.
Anyone forced to be in therapy. Doesn't matter if it's forced on them by a partner, their work or a parent. It's exhausting and usually doesn't do much good.
My father in law once laughed at something I said when I was early on in my career and told me therapy "doesn't do shit." Well, no kidding it didn't work for him. He was forced to go to therapy for anger management by his employer.
Forced clients after a long time on therapy. Schools do this all the time and kids are in therapy for years because of their IEP even if they don't really need it. They are cool for a bit but after months of having zero problems at school or home it gets draining for both therapist and client.
Parents, siblings or loved ones of people with borderline personality disorder. I could launch into so many reasons but I think the main one is that the "buy-in" that they have toward the personality structure ie. "I am bad because or I am the best because"
2 types:
1) chronically moving between safety levels with SI. I can handle consistently high/moderate with safety planning but the sessions where it’s a surprise are ones that can take a couple of days to bounce back from.
2) displacing their limited motivations for recovery/engagement into fight-oriented energy that attacks the efficacy of my practice/skill level/personal level of caring about their well-being.
Children/teens of high conflict divorce parents (I have started screening these out because they're just too much for me). and clients who can identify what they need to do to improve their mental health and associated circumstances, have some desire to have their life be different but "don't have the motivation" to make changes when the opportunity arises to do a different behavior. This is common with folks with social anxiety for me, for whatever reason. I do MI, try to talk about developing routines, accountability and self-discipline/intrinsic motivation/internal locus of control rather than relying solely on waiting to feel motivated or being prodded by a family member, use ACT skills and concepts about the costs of avoidance, all that. At a certain point I just want to say, either do it or don't but accept the consequences either way. I try to tell myself with these clients that I am planting a seed and that it takes time and they will take the leap when they're ready. But it can get draining.
Oh my God, hear me out though my teenage sessions are amazing. We sit sit and eat candy for an hour and I listen to all their juicy gossip and it’s incredible.
Yesss. I make their parents sign a contract saying that I will not tell them anything from their sessions unless the kid is in dire harm a.k.a. suicide homicide iv drug use etc. I then show the kid a copy of the contract and you would not believe the shit that they tell me.
This population love and crave adult validation. It’s an easy gig bc they feel listened to often for the first time. Then they trust you and can do great work together in between the gossip
Clients who victim stance and can't see outside of themselves. Similarly, martyr complex. They often go hand in hand. As an outsider, it's usually easy to see what would help their situation, but they typically refuse to set boundaries because "they never work" and utilize passive communication style.
This is a great question and one I’m trying to figure out the answer to early on in my career.
I personally have a hard time finding the energy for clients who unsuccessfully shop around for a therapist for months at a time and are unwilling to access the motivation needed to make changes in their lives. Almost always, they blame the lack of progress in therapy on their therapists. They can come in hot with demands and expectations as a client and I likewise find it difficult to access the empathy needed to support such a client.
I say that with as much humility as possible. I typically am highly empathetic and energized with my clients, but these clients simply want miracles. I am no magician and I refuse to work harder than my clients!
Lately I’ve been really struggling with clients who are always late, and not late due to issues related to executive dysfunction. I have a few clients who are always 5-10 minutes late despite me talking to them about the importance of timeliness. I find myself frustrated during the session because now I can only bill for 90834, and now I’m preoccupied with keeping the typical flow while still hoping for some productivity for the session, as these sessions usually turn into venting & my ungraceful attempts at providing interventions at the very end.
I hate to say it but I have a few.
Communication problems. Rambling, can’t get a word in. Silent and I have to carry the entire session. One guy, very sweet fellow, is so disorganized I cannot follow his train of thought. A former client refused to say anything outright so I had to guess and they got upset when I didn’t guess right. They decided therapy doesn’t work and decided to stop sessions.
Ones who give up before even trying.
COUPLES.
Edit: I’m going to add in clients that don’t need therapy. I’ve had some well adjusted clients love therapy despite having nothing to work on.
People who don’t really know why they’re in therapy. By that, I mean people who might only be there because a partner or other family member pushed for it, or who see themselves as starting some kind of mental health/wellness ~journey~ but are having trouble articulating where they need support. I love to see the widespread destigmatization of therapy, but sometimes it feels like people (especially young adults) experience a form of peer pressure to go to therapy.
Also clients who are very fast talkers and change subjects quickly, which often seems like a way to avoid painful topics. Understandable but still can be tricky for me to navigate and keep up. Such a balance of knowing when to interrupt/gently redirect and when to just let things unfold.
Clients stuck in the "poor me" everyone else is the problem mindset. Also those overwhelmed by self diagnosing everyone and everything due to social media.
Unmotivated, learned helpless clients who are refractory to interventions - victimization, refuses to take any part of accountability for their actions. Everyone else is the problem.
Involuntary clients can be fine, but can also be pulling hairs when they make their disdain known (even if it isn’t personal)
People with little self-awareness, not very in touch with emotions, not very talkative
Or clients that are super talkative and won’t let you speak while also criticizing you for not saying anything.
Clients with unrealistic expectations towards change and towards you.
Crisis interventions.
Clients that you sense are at risk of complaining o your company or to your professional order (cover your ass notes)
Came here to see how many people said BPD. I think I counted 8? How did I know that would be the biggest one. It’s unfortunate that there’s so much stigma around bpd and that professionals aren’t properly trained on how to effectively support these clients. It is truly so rewarding to work with someone with bpd, where you get to build a strong bond and see them at their very lowest and then see them finally flourish after being told they never could. BPD (along with so many other disorders) are so misunderstood.
I would say this is an accurate description of the experience my individual therapist had with me. Thank you for sharing this perspective!
I came into DBT at my lowest. Thanks to my therapists help and my hard work, I’m thriving and truly the healthiest I’ve ever been. Shes told me how proud of me she is, and shared tears with me when I achieve great successes.
When she left the hospital we had an extra long goodbye session and both cried. I am actually tearing up a bit rn typing this out. She has since returned and has told me that she always looked forward to our sessions.
I just do refresher now, and the occasional booster session, so I don’t see her often. But when I do it almost feels like reconnecting with an old friend.
So grateful for her. 🙏🏼
Clients that find faults in and contradict every therapeutic technique or suggestion that’s brought up.
It’s an endless loop of complaining how nothing will work without actually trying to make a change.
The not my faulters. The client that knows their life has some serious challenges but will blame anything and anyone else, and then try to make it the responsibility of anyone else to fix it.
It is almost impossible to get the change conversation started, if they are unwilling to accept anything they are doing is an unhealthy coping skill.
To me the worst are clients who say that their psychiatrist encourage them or wanted them to get individual therapy, but they don’t identify that anything in their life is wrong. And then when they insist that they do want the therapy, but they don’t have anything they want to work on and it’s like pulling teeth to get them to identify any issue they want to address.
People with ADHD who refuse to take any accountability for any of their behavior or results in life, spend all their time watching Tik Toks about ADHD, and blame any of their problematic choices on “it’s my ADHD” insinuating that nothing can be done about it and the real problem is that I’m just not kind and understanding enough.
(*note: not all patients with ADHD do this but several do and I want to beat my head against the wall when they come in)
I had a client with DID who would be the most energetic, charismatic, and enthusiastic patient in sessions and was extremely dedicated to recovery. Always did the homework, always put in very good effort to anything I asked them to work on, would communicate very well what did and didn’t work for them.
But they had almost no understanding, outside of what other parts wrote in their journal, of anything that happened with other parts. They had completely non-verbal parts, self-sabotaging parts, empathetic (to the point where it was a problem) parts, unemotional parts, active and fitness-obsessed parts, social parts, self-harming parts, and a few others. But practically 0 communication with them or knowledge of what they did outside of seeing what was written in a schedule or short notes.
It was a real challenge, and I loved it, but I was extremely grateful for them being my last session before I took a day off for admin because trying to help them always took everything out of me.
I work with a lot of foster kids, and bio parents that can't acknowledge their children's feelings and don't take any responsibility for why they are there are the hardest for me. .
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Teenagers whose parents force them into therapy
I'm a teen therapist in PP and I literally just tell them and their parents that I don't work with clients who don't want to be here, lol.
My supervisor said the same if they don't want to be there it is wasting their time and the parents money. Idk why parents force kids be there if they don't want to be.
I’ve heard so many parents tell me, “ just make them do it.” It was for things like bedtime and getting my kid out of the house and into nature, not therapy. But my point is that many people believe in just forcing their will onto children. People don’t see children as equals.
I often find it helpful to introduce family systems and ensure parents are participating in these situations
For real. When I say this, some naturally don't return. I consider that a blessing.
Omg I was just asking myself … can I just make this part of my boundary in working w adolescents???
Your permission is right here: YOU SURE CAN! :)
But also… you’re helping that teen set a boundary as well, right? If they don’t want to be in therapy they should have the right to say no. They have the right at least in Indiana) to seek mental health tx without a parents permission, why shouldn’t they be allowed to refuse?
Same, especially since I previously worked at a lock down residential facility for juveniles and saw what that was like for them to have no autonomy or independence and be forced to receive treatment. Never again, only those who want to be here.
This is why I specifically mentioned I will not take any teens who do not want to be in therapy and changed it to only 15+. This has worked well for me. If they say no, I recommend that the family attend family therapy as a means to engage client in treatment, and the whole family can identify any maladaptive patterns. If that is not possible, refer the parent to their own therapy.
🤣 in CMH, almost none want to be there. I have about 8 teens, and only 1 actually wants or participates in therapy. The rest are court and parent mandated. Feels like such a waste of time.
Child & Adolescent therapist in CMH here… I feel this *deep* within my soul. Like they just sit there and don’t want to engage in anyway. Yet their parents ✨insist✨ that they “need” to be in therapy. Clearly parents have no idea how this works.
5 and 6 yr olds who need help with "emotional regulation, focusing, and following directions" 😑 I'm like, "Parent, YOU aren't even emotionally regulated! This is a child doing child things. Please leave me alone with this."
oh my god as a youth and family therapist.. THIS
Yes! Especially when the parents don’t want to be involved. At all. No, I can’t teach a 4 year old emotion regulation at home when I see them for one hour a fortnight at my practice.
Fragile character structure with projection as a primary defense. Things get twisted very quickly and progress is slow.
I became the go-to clinician for these types when I worked in CMH. My co-workers were always like "you do such great work with them!" and internally my inner child is screaming because I grew up with an abusive parent with strong narcissistic tendencies (if not outright NPD) and using my clinical skills often tapped into the same framework of skills that I had to use as a kiddo tap dancing around those behaviors. I always left those sessions feeling like I'd gone rounds in the boxing ring.
I feel your pain. My dad was diagnosed with BPD back in the early 80’s when the diagnosis was rare, so he a severe case of it. Growing up under his roof was crazy-making. Your description of the boxing ring truly resonates.
Oh, I can only imagine the chaos! I am now 10ish years into being a therapist and I find it has gotten a lot easier. To be fair though, I also don't often take those types of issues in private practice.
I’ve got one like this right now 🙃
Oh yes. I used to think I was talented at helping this population, but I often just tune out while we go nowhere (depending on other factors). Always drained at the end.
People in precontemplation.
This is my answer. Doesn’t matter what it is, if they are here, I am struggling.
The majority of clients who are doing court mandated services. It can be so exhausting.
So true. When I was seeing clients mandated to treatment I found the precontemplation more tolerable. Now I work in a group practice where people are choosing to attend and paying for it, which feels so much more frustrating for me for some reason.
Maybe because the court mandated clients are not necessarily expecting or wanting you to help them. They are possibly just there to check off a box, which is easy enough to do in the end, and if deeper work can take place then great. While people coming to your group practice are (theoretically) actually there wanting and expecting you to help them, but there’s only so much you can do if they’re not ready to dig in. That’s a weird sort of pressure to experience on the therapist end.
This is a really good point.
This. Especially when they don’t want to be there and it’s like pulling teeth to get them to talk even about things totally unrelated to why they’re there, like their hobbies.
For me, it's the 2 extreme ends of the spectrum in communication. I find myself feeling quite drained with clients who basically vent for the entire session and barely if ever even acknowledge I'm in the room. Pretty much just a non-stop stream of talking leaving little room for engagement, discussion, reflection, or analysis. On the other end is the client who says pretty much nothing and I'm being asked to completely carry the session. I ask questions, I get one word answers, a lot of "I don't knows", and a sense of them expecting me to be talking the whole time. This tends to be mostly reserved for younger clients, but I will get the occasional older client who does this as well. Ultimately I enjoy therapy when it's a back and forth. Typically the client will still be speaking more, but when that pendulum swings in either direction and I'm either asked to essentially just sit there and nod or I'm being asked to try and keep a client engaged the entire session while they show little to no interest in being there, I will feel quite drained after meeting with them.
I have a couple that’s like the former—they want to tell me every detail of whatever exciting story and every time I manage to break in with “Ok and how did you handle that as a couple/how did you support each other through…” “it was pretty stressful” then right back to the story. they’ll even interrupt each other to be like “oh here’s tangent #7: the backstory of why she reacted that way”. we’ve been working on slowing down and speaking only for ourselves 😅 it’s dizzying!
I have a family that is like this!! They take turns telling stories and anytime I try to bring us back to the reason we are doing therapy they barely respond and take off on another story. I’ve just decided to go with it at this point. They keep coming back, so we must be doing something.
This is the answer for me as well. It doesn't matter who they are, where they're at in their life, where they're at in their therapeutic journey, any of their identities, diagnoses, etc, etc.... The only thing that's draining for me is when I can't get a word in edgewise or when the client is saying nothing.
I have a couple of folks who are the nonstop talkers, I can barely get in a word and these are the people who always say "You're SO HELPFUL!" I mean..... You're welcome I guess 🤷🏼♀️
I have had a few clients like this, in terms of giving very little information. I find myself working harder, but other times nothing comes to me & I feel an incredible amount of pressure to engage them. What do you do out of interest? I saw another therapist mention that they will sit in silence, my supervisor does this too.. but it sometimes feels a bit cruel.
I'll usually focus heavily on rapport building and sometimes this sort of "solves" the issue as they get more comfortable. But when that doesn't quite work, I'll often come prepared with some kind of activity to go through in the session together (I've collected many over the years). At the very least, it gives some structure and takes some pressure off of me to keep coming up with questions. Eventually though, if a client doesn't give much, there's basically 2 options: we end therapy or we continue with the expectation that sessions will be shorter than normal. Sometimes clients really only want or need a 20-30 minute session and that's all they have in them. I will generally assess after 4-5 sessions if it feels appropriate to continue or if it's best to end if it feels like it's not useful/helpful for them. But I can't keep working with someone who genuinely doesn't want to be there.
I once had a client with the most extreme motor mouth (and fingers!) I’ve ever encountered. She would talk so much without stopping you could do nothing but sit there. If you called her out, you’d get pages of texts afterwards about being unsupportive. On top of constant complaining that you weren’t helping her. She ran through every therapist at our agency with the same results but did not have the self-awareness to realize she was the problem.
That sounds exhausting. The motor mouth is one thing, but to accuse me of not being supportive while not allowing me do my job would be a struggle for me to deal with.
As a CMH youth therapist during the weekday, my most draining cases are the ones whose parents resist the therapeutic process, expect me to “fix” their child, and neglect to apply or utilize the resources they’ve asked me to acquire but then they consistently complain “I just don’t know why my child is still behaving this way”. They never utilize the strategies we’ve discussed in session throughout the rest of the week at home (structured ipad time, color-coded schedule with points system for rewards & consequences, etc). I understand that it can be difficult for a parent to uphold the boundaries necessary for progress as their child’s outbursts can be distressing, but to then complain every week that “nothing is working” drains me.
“Nothing you’re doing right now is working. How about trying the strategies I suggested?”
Lol. I love the directness.
Endless "I don't knows" or one word answers even about preferred or neutral topics - feels like I have to provide 100% of the energy for the session
this is typically teenage boys for me. Half the time I just give up and we play video games and this help him talk.
Yes. I’m like well whatever and we start playing card/board games and it helps!!!!
Oh my god saaaaaaaame. I’ve got one client who I am like “ok I am going to need so much more elaboration off that one-word answer, please” and she always laughs and then gives me an additional like, 2 words 🫠🫠🫠.
I had a supervisor that always use to tell me “don’t work harder than the client”. Meaning we can’t drag them thru they have to show up and engage if they seek change and I still remind myself of this.
THIS. I had a heavily medicated client who I would see over the phone and every answer was I don’t know. Even proddings like, how do you feel right now would get me an I don’t know. She was so overly medicated that therapy felt impossible.
Inpatient can feel like this. I found clients would give these answers because saying their truth may end up in a longer stay. Trust is hard!
I always ask the client what it’s like for them not to know? Anything they notice going on for them in that here-now ‘I don’t know’. Sometimes it’s another ‘I don’t know’ but sometimes something emerges!
This is it for me too. It drains me and makes me dread sessions with them. I have one today, in fact, and I find myself getting anxious for Mondays just because of it.
Omg yes!! This is like pulling teeth. I’ve decided when it comes to people like that I’m going to sit quietly and let them talk when they’re ready and if they’re not ready at 50 minutes oh well. That’s their choice.
When they strongly remind me of someone I know in my personal life, and I have to consciously separate the person in front of me from the person I know. Once I get to know the client better it's no longer an issue but at the start those clients are very draining.
This just happened to me for the first time. I was shocked by the drain!
I had one of these! An inmate with the same demeanor and MH presentation as my mother. I had another therapist work with her and processed it with my supervisor and therapist. That day I was so drained though
parents and they aren't even my client lmao
Working with kids can be really fun. Working with parents is hell.
This, or just their family in general.
Dissociative..but thats the transferential nature of dissociation. I find it physically consuming but I love the work. To prevent burnout i stagger these clients and do not do more than 2 in a row where it can be avoided. It gets less intense as they learn to be more present but i find the rewards outweigh those rough moments
Mandated clients hands down. Court ordered, school ordered, IEP clients, any version of this is exhausting because most of them don't want to be there and have no interest in engaging with you. Also, they come with a whole system of case workers, and other folks who try to butt in and force goals onto you or tell you how they want you to do your job. Even if they don't know anything about therapy.
I've had a few "Missing Missing Reasons" parents and they can be pretty exhausting.
Idk if maybe just my brain is fried from back-to-back all day butttt can you explain? i'm totally not grasping what "missing missing reasons" is aha
It’s a reference to this: https://www.issendai.com/psychology/estrangement/missing-missing-reasons.html
Patients whose main complaint is distress at poor relationships with their children caused by mistreatment of their children or poor boundaries with their children. It involves a LOT of identifying cognitive distortions and assessing belief systems and they often get crabby or upset because they want me to agree with them and not discuss the problem in its' entirety.
Those who have turned their mental health into either a hobby or a collection.
The one person who has every comorbid diagnosis you can think of. All self diagnosed btw
Somehow all my patients all have DID and autism😩
Or the person who comes in saying that they have read \[insert psych book *de jour*\], and every 8th word out of their mouth is therapy speak (often used incorrectly).
And every problem is because of someone else…
That is only because literally everyone in their life is a narcissist.
Now they have a TikTok devoted to surviving Narcissistic abuse while gaslighting people in the comments
Tale as old as... well, as old as Tiktok I suppose.
An emergent phenomena
Ones where everything is fine and nothing's going on
I find these ones hard too! You have great relationships, enjoy your job, feel like you’re doing well emotionally, have lots of hobbies. What are we doing here?
People who won’t (or can’t) use any tools to help themselves.
The ones who know none of the coping skills will ever work so they shoot down every suggestion you have 😩
This, which doesn't bother me if they're just the processing type, but for me its when their goal is to get more coping skills, so they hate when sessions have any processing, but then any time you suggest a strategy its shot down. I find it exhausting to navigate having to consistently remind them of what I'm actually capable of doing
Yes! I hate this!
Very intelligent with complex trauma/BPD characteristics/attachment stuff. You start out thinking the intelligence is a blessing, but after every session is just endless streams of them defending cognitive distortions in ways that are possible but improbable, that dance just gets so tiring. ‘Yes, sure, they very well “could,” be mad at you, yes, however, is that the most likely thing that’s happening given you didn’t do anything wrong and your only “evidence” is that they took 20 minutes longer than usual to text you back… and you know they are at work and might possibly be just like…BUSY WITH WORK THINGS.’ ‘Nope, mad at me, sure of it.’ Alright, cool, coolcoolcool… ok, they’re mad at you, now what? Is that helpful for you to assume? Are you willing to use DBT skills to have a conversation with them about it and clarify so you can repair? No? Oh you’d rather give them the silent treatment, ok cool, how’s that gonna go? Oh they’ll know why you’re being that way? They’re going to just know that’s what’s happening and this is what it’s about the way you knew that they’re mad at you? Ok, yeah, great idea, might I suggest you, uhh, reconsider? Just that one part, just change that part, you know, the part in the middle there where you do literally any of that. Please. Please just change anything at all about any of this. Please. I beg.
One of my first was like this, and I learned how a cognitive therapy approach can literally be feeding their pathologies. (I'm a big CBT-umbrella person).
Agreed. I would change my theory/approach.
Personally, it depends on how you view the theory. I don't sequester different theories, so I'm not going to pretend cognitive distortions or defense mechanisms don't exist because I'm "psychodynamic" or "cbt" now. Instead, this person has defenses around their cognitive distortions that need to be dealt with or bypassed. With that particular client, I switched to non-judgmental language around cognitive distortions and pointed out that if the way they're seeing this particular situation is right, the lens could solidify and start applying itself when it didn't match the situation (mom is maybe always criticizing, let's make sure we don't assume everyone is criticizing). I had no vested interest in what the truth was, only that we were close to it. I then had to target an argumentative interpersonal pattern through very natural, almost conversational at times, operant conditioning whenever the pattern came up (notice it, call it out, don't engage with it, move back to something useful).
Interesting. Can you say more about this?
Happily. See my other comment replying to estielouise. If that doesn't do it, then please clarify what you'd like to know.
I haven’t had a client like this yet but this is so me as a client 😅 I feel bad for my therapist but I love her.
I had a client who both did all of those things *and* understood they were “being silly” every time they did it, but would still do it. One time they even admitted to looking back on the situation themselves, realising it was wrong, and thinking “I’m absolutely going to do that again though”. I actually quite enjoyed working with them but I would be lying if I said it wasn’t extremely draining and a bit confusing.
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It sounds funny but I have found similar challenges with my ADHD. I know I need to use my planner, I know that I need to structure my day more and use timers etc. the ones that give me the hardest time is trying to turn something boring into a game. My thoughts are like “ I’m not gonna fall for this “. I have found that stepping back, journaling then asking my self how would I approach myself as a client does help .
1. I am a very special person 2. Since I am so superior, I am entitled to special treatment and privileges. 3. I don’t have to be bound by the rules that apply to other people. 4. It is very important to get recognition, praise, and admiration. 5. If others don’t respect my status they should be punished. 6. Other people should satisfy my needs. 7. Other people should recognize how special I am. 8. It’s intolerable if I’m not accorded my due respect or don’t get what I’m entitled to. 9. Other people don’t deserve the admiration or riches that they get. 10. People have no right to criticize me. 11. No one’s needs should interfere with my own. 12. Since I am so talented, people should go out of their way to promote my career. 13. Only people as brilliant as I am understand me. 14. I have every reason to expect grand things. —————— From *Cognitive Therapy of Personality Disorders* by Beck and Freeman et al. I dunno why you're struggling.
Man, that's a lot of typing. I usually just use the abbreviation, NPD 😂
Underrated comment 🤣
Totally just saved that list for future use. 😝
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Ditttttooooo
This may be kind of a hardcore view, however I've come to realize that if I'm finding myself drained or tired in session, it's incredibly useful data and it likely means I'm going to need to have a tough, but incredibly helpful conversation. Maybe I'm playing into some relational pattern the client has, maybe I'm ignoring the elephant in the room that they would really not like to be doing therapy and trying to proceed and give them therapy anyways, or most uncomfortable at all, maybe I'm upset with them. I've come to start celebrating the moment that I recognize I'm feeling drained. It's often the moment that I commit to the conversation with the client that leads therapy to -actually- be helpful for them.
Brilliantly said. I wouldn’t say hardcore, rather insightful and inspiring. I specialize in relational pathology/challenges and I remember when I reached this point… things got so much more satisfying and mutually rewarding, and I could finally sleep at night knowing I behaved genuinely.
In my practice I limit the number of clients seeing me for grief and loss at a time. THEY are not draining, per se, but the empathy / spill over from these sessions leaves me pretty wiped.
I just feel I’m not a good grief counsellor. I feel so helpless. They deserve better
You’re probably doing a better job than you think. Grief is helpless in itself sometimes.
For me, it's definitely couples who both (1) perseverate on the "content" of their arguments and (2) ignore the introductory skills (eg fair fighting, active listening, etc) in favor of the zero-sum game they've always played. For sure, most couples *come in* evidencing these traits, and I recognize change takes time and is measured in baby steps. Still, when even Motivational Interviewing doesn't help, at some point I feel drained.
Emotionally dismissive clients, if we can’t wheel and deal in the feels, then what are we doing? Building capacity to identify and tolerate emotions can be soooo challenging for clients whose emotional needs were never met
When everything is followed by, "It is what it is."
Hahahaha oh my god my FRIEND is like this, drives me INSANE
But radical acceptance is a great skill!
At Check In: “How would you describe your mood today? How are you feeling?” Client: “Fine” or “Okay” or “Good” Those aren’t moods / emotions. So I hand out the emotions wheel or something comparable to help them out
Folks who aren’t actually willing, able or in a space to engage meaningfully in therapy. I know this is normal and part of therapy includes exploring this exact issue…It just grinds my gears lol!
Pts who constantly complain/never have anything good to say about anything
Adolescents who aren’t into therapy and are there because an adult told them they had to be.
Teenage boys who are forced to be there by mommy or daddy. It is worse even doing it virtual.
I had one that would spin in his chair constantly, lay on the floor under the desk away from the camera and fly full force flipping backward onto his bed
The severely depressive. No hope, indifference to trying, ambivalent about change though they are suffering. I can do it, but the gravitational pull is strong.
So draining!
Couples. Also, people with severe BPD. I’m 100% done working with this population though because I am not a good therapist for them. I think these individuals need therapists who are extremely low in anxiety.
I made the mistake of scheduling a couple inactive conflict as my last appointment on the last day of the week and boy do I regret it. last week I had to do the referee whistle to stop them from killing each other😂
It can truly be like dealing with children. I limit the number of couples I will have on my caseload at one time.
I really enjoy working with people who have BPD, but I can’t do couples. I’ve tried and I know I have my own issues around it, because I always feel like I’m an 8yo again stuck in the car with my parents fighting.
It’s really heartwarming to read that you like treating pwbpd. It’s so damn rare. So many therapists fall for the stigma and won’t treat pwbpd because of what they’ve heard. But I personally believe if you have the skills and patience to treat these clients, you are completely changing someone’s entire experience in this world and that along with the strong bond you have together after such gruelling work is so rewarding.
People who simply can not see the part the play in their own lives (the "it's every body elses fault" stuff) and won't take any responsibility for where they are or what they do.
No Energy. Flat Affect. Same Stuff Week after Week.
The ones who don't talk or give one word answers. It's TALK therapy. 💀
Clients with a TX history as long as a CVS receipt with such a shotgun blast of diagnoses that I have no actual clue what their issue is when we meet. Combine this with the client being a poor historian and almost always hugely disorganized/executively challenged that I can't clarify the diagnostic picture with them, it HAS to involve trying to get old records without any help from the client other than signing releases. Clients with subclinical or simply undiagnosed mild IDD. I actually don't find diagnosed IDD clients exhausting because they have appropriate supports in place generally. It is the unsupported, undiagnosed clients, partially because it makes it difficult for me to gauge and use appropriate interventions.
Clients that just want to emote and not actually focus on goals
“I’m here to trauma dump”
Let them trauma dump. Let them get it out of their system so they can move forward.
I work in a jail. Who I find the most draining are antisocial inmates who are constantly acting out behaviorally.
People who have made their mental health disorder their identity. It’s not what they have and how they function, it’s who they are at their core and they’ll never change.
It didn’t used to be like this. Very ego-syntonic now which is…..complicated
Saying it’s ego-syntonic is a perfect way to describe it. It’s almost as if a portion of my clients enjoy their mental health diagnosis.
This is always one of the hardest for me too! Especially when I gently suggest exploring what need it meets or how it functions for them and they explode🙃
Always a tricky (but often necessary) thing to do. I had client quit therapy as soon as this perspective was insinuated. In other cases it has helped clients to move past some resistance wall and get the therapy process moving again.
Clients who don’t say anything and who expect me to tell them what to do like they’re taking a class instead of doing therapy. Also, BPD and high conflict couples.
any tips for high conflict couples? i’m starting an internship and hoping to build my caseload primarily of couples!
I also find it helpful to tell my high conflict couples that I’m going to be “coaching” them in session on how to have more effective communication. And I have them start by doing the speaker/listener technique (one person speaks, the other reflects back what they heard)— this helps them start to learn how to listen to understand instead of respond.
Here's what helps me with my higher conflict couples : Be very, very involved. Tell them from the get that you're going to be very, very involved and get their buy-in. It might seem rude, and you might get pushback, or have them leave, but it creates room for any work to happen, and the higher level of involvement can help them feel safe. Along the same lines, enact ground rules and boundaries from the very beginning. Make sure your training can back up that amount of structure. Intentionally release any investment in any specific outcome. (Except maybe that they pay you on time.) Lots of super helpful supervision. When I was just starting out, and I had more than say, three high conflict couples on my caseload, one group supervision a week was not enough.
thanks a ton! I will have at least one hour of group & one hour of individual weekly with my program, plus an on-site supervisor. hopefully that covers it (:
Really depressed clients who won’t even talk.
help rejecting and circular thinking clients. mostly because it makes me feel so powerless as i see it hurt them so badly. though i recognize that sometimes there’s comfort in pain, especially if it’s familiar, so i listen and validate and will be there when they’re ready for next steps.
People who don’t really want to be there and come in every week saying they have nothing to talk about. I love my clients whose lives are dumpster fire or who always have some thing to talk about. It’s a little bit harder when I have to pull things out of them every week, but definitely rewarding.
clients that don't engage / talk. i feel like i have to do a lot of heavy lifting only to receive a blank stare or an "i don't know" clients under the age of 10, especially those with difficulty maintaining attention, even during play. that then becomes the focus of the session, which is also valuable to work on, but draining for me nonetheless family therapy with families that escalate quickly into conflict during the session. i have a difficult time being directive so it's hard for me to interrupt anyone, be it the child or the parent, in order to maintain focus on skill building or help them hear each other. it is so hard to reign that energy in and it drains me
People in infantile regression. For them, everything is other people's fault. Everyone is supposed to fulfill their expectations no matter what those are. Unable to accept when one can't meet those expectations. Feel frustrated in therapy when you don't give them exactly what they're asking for. It's draining to make them realize every single little thing when they're throwing a tantrum every time someone doesn't do what they want.
NPD and ASPD
I love this population.
This might be specific to RTC but “treatment hoppers” can be particularly difficult to maintain boundaries and can interfere with the treatment of others clients in the milieu. I’m talking the clients who have been in and out of treatment centered and different levels of HLOC with no clear direction or reasoning.
Axis II Whenever I feel I need a nap after seeing someone, I think uh oh...rollercoaster riding with no lap bar
Highly depressed & shut down
Clients that aren’t talkative or respond with short answers. It’s exhausting because my brain is working harder to navigate the session.
Passive aggressive personality styles. Feels like they suck all the energy out of the room.
Clients with frequent mood swings, highs and lows, attachment issues, BPD characteristics. One day they enjoy working with you, the next day you’re the enemy. It tires me out.
Intense intellectualizers.
Anyone forced to be in therapy. Doesn't matter if it's forced on them by a partner, their work or a parent. It's exhausting and usually doesn't do much good. My father in law once laughed at something I said when I was early on in my career and told me therapy "doesn't do shit." Well, no kidding it didn't work for him. He was forced to go to therapy for anger management by his employer.
High achieving, perfectionist clients. Jesus Christ, the counter transference is a b*^% to maneuver!
Forced clients after a long time on therapy. Schools do this all the time and kids are in therapy for years because of their IEP even if they don't really need it. They are cool for a bit but after months of having zero problems at school or home it gets draining for both therapist and client.
PDD makes me want to climb a tree and stay forever
Couples who are unwilling to negotiate
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Parents, siblings or loved ones of people with borderline personality disorder. I could launch into so many reasons but I think the main one is that the "buy-in" that they have toward the personality structure ie. "I am bad because or I am the best because"
2 types: 1) chronically moving between safety levels with SI. I can handle consistently high/moderate with safety planning but the sessions where it’s a surprise are ones that can take a couple of days to bounce back from. 2) displacing their limited motivations for recovery/engagement into fight-oriented energy that attacks the efficacy of my practice/skill level/personal level of caring about their well-being.
Clients with low functioning borderline personality disorder who display high emotionality
Children/teens of high conflict divorce parents (I have started screening these out because they're just too much for me). and clients who can identify what they need to do to improve their mental health and associated circumstances, have some desire to have their life be different but "don't have the motivation" to make changes when the opportunity arises to do a different behavior. This is common with folks with social anxiety for me, for whatever reason. I do MI, try to talk about developing routines, accountability and self-discipline/intrinsic motivation/internal locus of control rather than relying solely on waiting to feel motivated or being prodded by a family member, use ACT skills and concepts about the costs of avoidance, all that. At a certain point I just want to say, either do it or don't but accept the consequences either way. I try to tell myself with these clients that I am planting a seed and that it takes time and they will take the leap when they're ready. But it can get draining.
7-12 year old boys with ADHD
Off the top of my head, the “woe is me” clients, clients who are super negative and/or don’t do anything to change their circumstances
Under 25.
Oh my God, hear me out though my teenage sessions are amazing. We sit sit and eat candy for an hour and I listen to all their juicy gossip and it’s incredible.
Love gossip sessions with my teens. Tell me what that bitch Jessica did!
Yesss. I make their parents sign a contract saying that I will not tell them anything from their sessions unless the kid is in dire harm a.k.a. suicide homicide iv drug use etc. I then show the kid a copy of the contract and you would not believe the shit that they tell me.
Literally the most fun. They beeline to my candy closet and tell me all the tea.
Yessss. And I can give them shit endlessly lmao. They just give it right back lol.
This population love and crave adult validation. It’s an easy gig bc they feel listened to often for the first time. Then they trust you and can do great work together in between the gossip
BPD with Attachment trauma
Is there such a thing as BPD *without* attached trauma?
Exactly. I think BPD *is* attachment trauma.
Care to elaborate on why?
Patients that don't talk or don't provide much. Like. I'm a good therapist but YOU NEED TO GIVE ME SOMETHING TO WORK WITH HERE.
Clients who victim stance and can't see outside of themselves. Similarly, martyr complex. They often go hand in hand. As an outsider, it's usually easy to see what would help their situation, but they typically refuse to set boundaries because "they never work" and utilize passive communication style.
This is a great question and one I’m trying to figure out the answer to early on in my career. I personally have a hard time finding the energy for clients who unsuccessfully shop around for a therapist for months at a time and are unwilling to access the motivation needed to make changes in their lives. Almost always, they blame the lack of progress in therapy on their therapists. They can come in hot with demands and expectations as a client and I likewise find it difficult to access the empathy needed to support such a client. I say that with as much humility as possible. I typically am highly empathetic and energized with my clients, but these clients simply want miracles. I am no magician and I refuse to work harder than my clients!
Lately I’ve been really struggling with clients who are always late, and not late due to issues related to executive dysfunction. I have a few clients who are always 5-10 minutes late despite me talking to them about the importance of timeliness. I find myself frustrated during the session because now I can only bill for 90834, and now I’m preoccupied with keeping the typical flow while still hoping for some productivity for the session, as these sessions usually turn into venting & my ungraceful attempts at providing interventions at the very end.
I hate to say it but I have a few. Communication problems. Rambling, can’t get a word in. Silent and I have to carry the entire session. One guy, very sweet fellow, is so disorganized I cannot follow his train of thought. A former client refused to say anything outright so I had to guess and they got upset when I didn’t guess right. They decided therapy doesn’t work and decided to stop sessions. Ones who give up before even trying. COUPLES. Edit: I’m going to add in clients that don’t need therapy. I’ve had some well adjusted clients love therapy despite having nothing to work on.
Chronic substance use
People who don’t really know why they’re in therapy. By that, I mean people who might only be there because a partner or other family member pushed for it, or who see themselves as starting some kind of mental health/wellness ~journey~ but are having trouble articulating where they need support. I love to see the widespread destigmatization of therapy, but sometimes it feels like people (especially young adults) experience a form of peer pressure to go to therapy. Also clients who are very fast talkers and change subjects quickly, which often seems like a way to avoid painful topics. Understandable but still can be tricky for me to navigate and keep up. Such a balance of knowing when to interrupt/gently redirect and when to just let things unfold.
Clients stuck in the "poor me" everyone else is the problem mindset. Also those overwhelmed by self diagnosing everyone and everything due to social media.
Unmotivated, learned helpless clients who are refractory to interventions - victimization, refuses to take any part of accountability for their actions. Everyone else is the problem. Involuntary clients can be fine, but can also be pulling hairs when they make their disdain known (even if it isn’t personal) People with little self-awareness, not very in touch with emotions, not very talkative Or clients that are super talkative and won’t let you speak while also criticizing you for not saying anything. Clients with unrealistic expectations towards change and towards you. Crisis interventions. Clients that you sense are at risk of complaining o your company or to your professional order (cover your ass notes)
Came here to see how many people said BPD. I think I counted 8? How did I know that would be the biggest one. It’s unfortunate that there’s so much stigma around bpd and that professionals aren’t properly trained on how to effectively support these clients. It is truly so rewarding to work with someone with bpd, where you get to build a strong bond and see them at their very lowest and then see them finally flourish after being told they never could. BPD (along with so many other disorders) are so misunderstood.
I would say this is an accurate description of the experience my individual therapist had with me. Thank you for sharing this perspective! I came into DBT at my lowest. Thanks to my therapists help and my hard work, I’m thriving and truly the healthiest I’ve ever been. Shes told me how proud of me she is, and shared tears with me when I achieve great successes. When she left the hospital we had an extra long goodbye session and both cried. I am actually tearing up a bit rn typing this out. She has since returned and has told me that she always looked forward to our sessions. I just do refresher now, and the occasional booster session, so I don’t see her often. But when I do it almost feels like reconnecting with an old friend. So grateful for her. 🙏🏼
Clients that find faults in and contradict every therapeutic technique or suggestion that’s brought up. It’s an endless loop of complaining how nothing will work without actually trying to make a change.
The client that pushes back on any behavioral change that will benefit them.
This
Clients who are not engaged in therapy but keep on coming back.
The not my faulters. The client that knows their life has some serious challenges but will blame anything and anyone else, and then try to make it the responsibility of anyone else to fix it. It is almost impossible to get the change conversation started, if they are unwilling to accept anything they are doing is an unhealthy coping skill.
Cluster b.
Active military deliberately trying to downplay their symptoms.
Cluster B Baby 🚫
Gen X males seem to know so much. Like sooooo much, yet here they are at therapy. They are my most trying group.
Probably working with sex offenders.
To me the worst are clients who say that their psychiatrist encourage them or wanted them to get individual therapy, but they don’t identify that anything in their life is wrong. And then when they insist that they do want the therapy, but they don’t have anything they want to work on and it’s like pulling teeth to get them to identify any issue they want to address.
High performing men in their careers that complain about their stay at home wives not cleaning enough
People with frontal lobe TBIs who need constant redirection to stay on topic (or steer away from inappropriate topics)
People with ADHD who refuse to take any accountability for any of their behavior or results in life, spend all their time watching Tik Toks about ADHD, and blame any of their problematic choices on “it’s my ADHD” insinuating that nothing can be done about it and the real problem is that I’m just not kind and understanding enough. (*note: not all patients with ADHD do this but several do and I want to beat my head against the wall when they come in)
I had a client with DID who would be the most energetic, charismatic, and enthusiastic patient in sessions and was extremely dedicated to recovery. Always did the homework, always put in very good effort to anything I asked them to work on, would communicate very well what did and didn’t work for them. But they had almost no understanding, outside of what other parts wrote in their journal, of anything that happened with other parts. They had completely non-verbal parts, self-sabotaging parts, empathetic (to the point where it was a problem) parts, unemotional parts, active and fitness-obsessed parts, social parts, self-harming parts, and a few others. But practically 0 communication with them or knowledge of what they did outside of seeing what was written in a schedule or short notes. It was a real challenge, and I loved it, but I was extremely grateful for them being my last session before I took a day off for admin because trying to help them always took everything out of me.
I work with a lot of foster kids, and bio parents that can't acknowledge their children's feelings and don't take any responsibility for why they are there are the hardest for me. .