To Assume Something About a Patient Is Awfully Wrong
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Mandated Clients
Running head: MANDATED CLIENTS/MANDATED THERAPISTS
Mandated Clients/Mandated Therapists
Anthony Nguyen, Shawne Ortiz, Geetanjali Sharma, and Kristen Vega
Our Lady of the Lake University
Mandated Clients/Mandated Therapists
To assume something about a patient is awfully wrong
-Milton Erickson
Most therapeutic models are based on the assumption that the process of therapy will be a voluntary endeavor in which both the client and therapist will engage in a therapeutic relationship through mutual consent. While clients often seek mental health services because they feel the need to, many may also be referred involuntarily to mental health professionals for treatment. Tohn and Oshlang (1996) have defined “mandated” clients as individuals who are sent or brought by someone else for treatment including various sources such as, courts, protective service agencies, employers, employment assistant programs, schools, parents, and significant others. Clients mandated for therapy may indicate the insistence of others (probation officer, parent, spouse, school counselor) as their reason for coming to therapy, present themselves as not needing help, or demonstrate little willingness to establish a relationship with the therapist (Egan, 1998). This could present hurdles early on in the therapeutic process making it exasperating both for the therapist and the client. For the purpose of this paper, we will use the term mandated client solely when describing a referral from the legal system under threat of legal consequences if they do not complete treatment.
Clients are frequently referred to mental health professionals for treatment through the criminal justice system since therapy may be viewed as a feasible and economic alternative to imprisonment (Berg & Shafer, 2004). However, clients mandated into therapy may view the process of therapy as being forced upon them with the therapist representing yet another part of the legal system. On the other hand, therapists may anticipate certain attitudes in mandated clients and label them as resistant, unmotivated, uncooperative, involuntary, defiant, reluctant, difficult, or noncompliant (Berg & Shafer, 2004; de Shazer, 1984; Dolan, 1985; Egan, 1998; Lipchik, 2002, Selekman, 1993; Tohn & Oshlang, 1996).
Although clients may be frequently blamed for their noncompliance and subsequent failure in therapy, Dolan (1985) suggested that resistance reflects on the therapeutic relationship and the extent to which the therapist, and not the client, has been unsuccessful in communicating and achieving trust through the therapeutic process. Further, de Shazer (1984) found that the concept of resistance in therapy is unhelpful and handicapping for therapists since it alienates the clients by assuming they do not want to change. Instead, de Shazer and his colleagues recommend that clients are almost always motivated for change and have adequate abilities to bring about positive changes in their lives. The apparent resistance should be viewed as the client’s way of cooperating in therapy since it lets the therapist know what is not working for the clients (Berg & Shafer, 2004; de Shazer, 1984; de Shazer et al., 1986; Dejong & Berg, 2002; Lipchick, 2002; Selekman, 1993).
Most current literature focuses on clinical work with voluntary clients; therefore, guidelines for working effectively with mandated or involuntary clients are limited (Ivanoff, Blythe, & Tripodi, 1994). We will provide an overview of our theoretical orientation, prevalent perceptions of mandated clients, and the application of solution focused brief therapy with mandated clients using an illustrative case study of a 17 year old male client court ordered to seek therapy for anger management at our training facility.
Overview of Solution Focused Therapy
Developed by Steve de Shazer and his colleagues at the Brief Family Therapy Center, Milwaukee in the late 1970’s and early 1980’s, Solution Focused Therapy (SFT) has emerged as an effective and popular model of brief therapy today. SFT is one of the more recent therapeutic approaches to emerge in the field of counseling psychology. The theoretical underpinnings of SFT are based on the philosophy of Milton Erickson and Jay Haley and share many commonalities with the work of Paul Watzlawick, John Weakland, and their colleagues at the Mental Research Institute (MRI) at Palo Alto, California (Watzlawick, Weakland, & Fisch, 1974; Weakland, Fisch, Watzlawick, & Bodin, 1974). When compared to prevalent models of therapy, SFT takes a different approach to understanding the formation of problems and their subsequent resolution. Solution focused therapists perceive problems as a by product of human interactions that occur between people and not due to any inherent deficits situated within individuals (de Shazer et al., 1986). Therefore, SFT does not subscribe to the disease model that focuses on diagnoses and pathologizing clients. Instead, clients are considered adept at solving their problems at all times since they are viewed as having unique attributes, strengths, values, resources, positive qualities, and abilities essential for successful resolution of problems. The focus on strengths, resources, and solutions instead of client’s problem and pathology in SFT differentiates it from traditional therapies. This is liberating for the therapists because it allows them to take a not-knowing, non-expert stance, while still remaining curious and interested in exploring client strengths and past successful handling of problems in order to help clients resolve their own problems (DeJong & Berg, 2002; Hoffman, 1990). In focusing on clients as experts of their lives, solution focused therapists reinstate the idea that clients hold the key to solving their problems. The therapists act as agents of change by assisting the clients in constructing their own solutions to the identified problem. This frequently entails changing interactions in the context of the situation in which the problem occurs, the perceptions and interpretations associated with the interactions or situation which comprise the problem, or co-construction of alternate, problem-free futures which are acceptable to the clients (de Shazer et al., 1986).
Solution focused therapists engage in solution talk by exploring and building on what is going well in the clients’ lives and this begins as early as the first session. Solution focused therapists believe that it is not necessary to know minute details of the complaints in order to start exploring possible solutions with clients; therefore, sessions are not focused on gathering a detailed past history of complaints and hypothesizing about or explaining why the problem occurs (de Shazer et al., 1986; DeJong & Berg, 2002). The goal of SFT is to utilize the clients’ language to find out what is going well and to continue doing what works. However, this does not imply that the clients cannot talk about their problems since they must engage in solution building. Clients are asked to identify and describe the problem in order to provide information on their perceptions of the problem and how they will know that the problem that brought them to therapy has been resolved (de Shazer et al., 1986; O’ Hanlon, 1993).
Goals established in SFT are well defined and concrete since well defined goals provide a tangible way to measure the usefulness of therapy for clients and also enable them to anticipate positive change (de Shazer et al., 1986). Asking clients, “How do you think I can be helpful to you today?” allows the therapist to begin focusing on what the clients want from therapy. Goals, frequently set in the first session, are small, behavioral, achievable, and described as presence rather than absence of something (DeJong & Berg, 2002). One of the ways well formed goals are established in SFT is by asking the Miracle Question:
Now, I want to ask you a strange question. Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem which brought you here is solved. However, because you are sleeping, you don’t know that the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved? (de Shazer, 1988, p. 5)
Dejong and Berg (2002) believe that asking clients the miracle question enables them to think about unlimited possibilities, changes the course of the conversation from problem talk to solution talk, and evokes hopefulness about the future. Given that initial responses to the miracle question can be vague or grandiose, therapists may need to follow up with several related questions that help clients describe their more satisfying and problem-free futures in terms that also embody characteristics of well formed goals according to SFT, such as, “What else will you be doing that is different?” or “Who else will notice and how or when will they know that a miracle has happened?”
Frequently, even before clients come to therapy, they are able to successfully resolve or deal with at least some aspect of the problem. They may also describe occasions when the problem-free futures elicited through the miracle question are already happening. Solution focused therapists ask exception questions to elicit when the problem does not occur and how the clients were able to get the exceptions to happen (de Shazer, 1986; DeJong & Berg, 2002). Small instances, such as, getting out of bed to make it to the appointment in a client who is depressed or a couple is able to agree on what they want to work on when they are having marital problems, may be considered as exceptions to the problems since only a small change is required to have a rippling effect that reverberates through the entire system (de Shazer, 1986).
Scaling questions are frequently used with great versatility in SFT in order to make abstract concepts like goals, aspirations, perceptions, confidence, motivation, and commitment more concrete, and therefore, more attainable for clients. Scaling questions invite clients to put their observations, impressions, and predictions on a scale of 0 to 10 (DeJong & Berg, 2002). For example, a client may be asked, “On a scale of 0 to 10, where 0 means that you are not at all confident and 10 means that you are absolutely confident, how confident are you that your probation officer will let you off probation early?” and “On that same scale, what will the probation officer see you doing when you are at 8 or 9?” Scaling questions may be used early in therapy to negotiate goals and later, to assess progress in therapy or terminate successfully. For example, “On a scale of 0 to 10 where 0 means you are not able to control your anger and 10 means you are successful in controlling the anger, where are you on that scale now, where do you want to be, and where will you be when therapy can end?”
Prevalent Perceptions of Mandated Clients
Individuals who voluntarily seek counseling services typically arrive at their own conclusion to initiate the therapeutic relationship (Abu Baker, 1999). In other words, these clients are not mandated by the legal system or referred by an outside agency. However, the number of mandated cases in the United States has drastically increased since the 1980s. It was during that time that policymakers sought alternative ways to treat substance abusers, in hopes of reducing costs and excess numbers in correctional facilities. This increase in referrals has prompted clinicians to investigate this population, in hopes of identifying how to work effectively with these individuals (Polcin, 2001). Most therapists are trained to work with clients who willingly refer themselves to counseling. As a result, Boyd-Franklin and Garcia-Preto (1994) stated that therapists face unique challenges when working with mandated clients and alluded to the idea of possibly requiring a different approach with this population. Furthermore, Boyd-Franklin and Garcia-Preto supported the notion that appropriate clinical training would be necessary to ensure clinicians could work with these clients effectively.
One challenge faced by therapists working with mandated clients is staying motivated and engaged during the session, particularly if they get the sense that the client is not working collaboratively with them (Rooney, 1992). Furthermore, if therapists continuously encounter similar responses from other mandated clients, they may be hesitant to start a therapeutic relationship with these individuals because they perceive them as resistant. Moreover, some therapists take these challenges personally, which could lead to an impasse. It is important for clinicians to realize that some mandated clients appear withdrawn as a result of feeling humiliated or ashamed they were forced to seek treatment, not in response to the therapists themselves. Practitioners can usually facilitate progress if they are capable of reframing these responses as normal ones given the circumstance (Rooney, 1992), but other dilemmas sometimes transpire.
Under most theoretical approaches, self-referred clients are responsible for choosing their goals for treatment. Even if therapists take a directive stance, they still value the client’s input and worldview. Therapists want to find out what clients want to accomplish in therapy, as well as what they will be doing differently when their goals are met (Beck, 1995). However, the goal setting process may be different in the case of mandated clients. Romig and Gruenke (1991) reported that the referring party often defines the goals of therapy and these clients are cognizant that most therapists are required to provide feedback before they can terminate services. Hence, these individuals may not be eager to participate in therapy sessions. As a result, some therapists choose to take an indirect approach with these clients, in order to come across as less threatening and to gain better awareness of their worldview (Romig & Gruenke, 1991).