Working with Difficult Clients

Noticing and Identifying Difficult Client Behaviors

As a BHA/P, you will work with people who are struggling with problem behaviors and relationships. Sometimes, these problems may make it challenging for you and the client to work together effectively. Some issues that may make it difficult to work with a client include:

Note: If you suspect that the client is abusing or neglecting a child or vulnerable adult, report it as soon as possible. See Chapter B-5: Mandatory Reporting and Duty to Warn.

BHA/Ps are most effective at helping their clients when they have empathy towards their clients. Empathy is the ability to understand and share the feelings of another person. Empathy also includes understanding why our clients behave the way they do.

To be an effective behavioral health provider, it is important to realize that the difficult behaviors your clients have in treatment also probably make their lives challenging and unhappy for them outside of treatment. It is your job to try to understand and work with difficult people while maintaining safe and professional boundaries. Remember that:

  • Difficult client behaviors often develop because of the client’s past experiences. For example, clients who have a history of being abused may have a lot of trouble controlling their anger towards others. Although they may be challenging to work with, you should keep in mind that this behavior developed because of life events that were not their fault—and at this point, the behavior may feel out of their control.
  • Difficult clients may expect that you will not want to work with them. They may have experienced professionals becoming angry with them, avoiding them, or pushing them away. For this reason, it is especially important to have empathy, keep calm, be consistent, and keep yourself from responding to them in negative way.
  • Your client’s difficult behavior is not about you. If your difficult client has just met you and is yelling at you about how unfair it is that she was court-referred for counseling, try to remain calm and remember that you did nothing wrong. She would probably be yelling at any person in your role. Also, remember that the behavior you are seeing is part of what is causing her problems in her life—the problems she has come to you for help with.

It is not your job to listen to abusive language or put yourself in harm’s way. If a client is behaving in a way that makes you feel unsafe, you should calmly end the interaction. Ask for help from a coworker, your supervisor, or local law enforcement if you need to. Also, always document these encounters and follow up with your supervisor about any incident that made you feel uncomfortable or unsafe so that you can make a plan for how to move forward with the client.

Angry or Defensive Clients

Angry behaviors can be the result of several different mental health and substance abuse problems. For example, anger can be the result of:

People who are not seeking treatment voluntarily will also sometimes be angry or defensive towards their treatment provider. They may believe they are being treated unfairly, or they may blame others for their problems. They may believe they do not have a problem when it is clear to others that their behavior is causing problems in their lives.

Use these strategies when you are working with people who are angry or defensive:

  • Remember your basic listening skills. Listen carefully and try to understand the client’s perspective.
  • Once you’ve made it clear that you understand the client’s perspective, ask him questions about how his life problem has impacted him in different ways. For example, you can ask a client who was arrested for a DUI, “How has this experience affected your family? How has it affected your work? How has it affected your stress level?” This strategy helps you remain understanding while also promoting the client’s internal motivation to change.
  • As your session is ending, be sure to make it clear that your client is welcome back. For example, you can say, “I really appreciate you talking with me today about what’s bothering you, and I look forward to seeing you next time.”
  • Don’t argue with the client. This will increase anger for both you and the client. Instead, use de-escalation techniques.

When an angry client is having a difficult time calming down and staying in control of his behavior, there are some specific de-escalation techniques you can use:

  • Allow plenty of physical space between you and your client.
  • Don’t touch your client.
  • Remain at your client’s eye level. If he is sitting, you sit, too. If he stands, you stand.
  • Don’t point or shake your finger at your client.
  • Don’t smile or laugh in response to your client's behaviors. An angry client might believe that you are making fun of him if you smile.
  • Keep your voice low and calm.
  • When you are talking with the client, be respectful.
  • Use active listening. Reflect back what your client is saying. Ask if you are getting it right: “So, you are feeling very frustrated by all of these problems--is that right?”
  • Empower your client by offering choices: “I can help you fill out a patient complaint form, or I can go and get my manager for you to speak with.”
  • If de-escalation strategies are not working or if you feel unsafe at any time, end the interaction. One way to end the conversation is to say, "I can see you're upset right now. Why don't we end our session now, and I'll contact you tomorrow to reschedule." However, if you feel unsafe at any time, focus your attention on getting to a place where you feel safe. Contact your supervisor as soon as possible.

Inappropriate Client Behavior

Some clients may not understand or follow social rules for how to interact appropriately with a counselor in a professional setting. Some examples of inappropriate client behavior:

  • Your client calling you repeatedly at home.
  • Your client asking a lot of personal questions about you.
  • Your client making sexual comments or sexual advances towards you.

Pay attention to your feelings when working with clients. You may recognize that your client is pushing boundaries or behaving inappropriately because you start to feel uncomfortable or the interaction starts to feel unprofessional. Try to identify (in your mind) the problem behavior that is occurring so that you can think through how to respond. Then, think about how to set a boundary so that the client understands the need to change the behavior. Setting boundaries is an important skill for dealing with difficult client behaviors.

Remember the followingtips for setting boundaries:

  • Regularly review your values and have a high level of self-respect. These are foundational to your ability to set and maintain boundaries.
  • Stay calm.
  • Be firm, but kind.
  • Try to avoid becoming angry or blaming.
  • State the boundary clearly: “I’m glad you see me as a resource, but I don’t take calls from clients at home. Could you give me a call tomorrow at work?” or “I’m sorry, but I don’t talk about my personal life during sessions with clients. We need to use our time to focus on the reasons you are here.”
  • For a client making sexual statements or advances, you need to make your boundary firm and clear. “I’m not comfortable with what you are saying. I need you to understand that I’m working with you as a professional, and it is not okay to talk to me that way.” If you feel unsafe, end the session, but make it clear that you or one of your colleagues will follow up with the client later about next steps for treatment. Also, it is always important to talk with your supervisor about any sexually inappropriate client behavior so that you can decide how to safely manage the behavior moving forward.
  • Consult your supervisor if you are having trouble establishing or maintaining boundaries with your clients.

It can be especially challenging to have empathy for clients who are pushing your boundaries. Remember that many individuals with histories of neglect or abuse will have a difficult time knowing how to relate to others. They may be needier or more dependent than other people. They also may have learned that the only way to get attention from other people is by pushing others or behaving dramatically. What feels to you like irritating or challenging behavior may be the result of a traumatic life history that has failed to teach your client appropriate ways of interacting with others. When you set clear, firm boundaries with your client, you are also teaching and modeling for your client new, more effective ways of interacting with others.

Clients Who Perpetrated Sexual Abuse, Sexual Assault, or Violence Against Others

Some clients have a history of having perpetrated (or committed) sexual abuse, sexual assault, or violence against other people. Clients with a history of being perpetrators can be especially challenging for BHA/Ps to work with for a few reasons:

  • You may struggle to maintain empathy for perpetrators of crimes against others.
  • In small communities, you may know or have knowledge of the victims of the crime.
  • You may have your own personal history of being the victim of crime.
  • You may have strong personal beliefs about protecting victims or holding perpetrators accountable.

All of these factors may result in BHA/Ps experiencing negative feelings or reactions towards clients who have perpetrated crimes against others.

When you are working with perpetrators of crimes, it is very important to remember that it is not your job to pass judgment on clients. We do not determine guilt or assign punishment. Instead, we need to help our clients identify, accept responsibility for, and change their negative behaviors. To do that, we have to work towards understanding them and their actions.

Remember: understanding a person or situation is not the same as excusing a behavior. A client who perpetrates crimes against others may have a history of experiencing difficult life circumstances. Working to understand how these circumstances have impacted your client’s behavior is not the same thing as excusing that behavior. Many behavioral health providers are advocates for victims and have strong personal beliefs against violent crime and sexual abuse—but at the same time, they recognize that helping perpetrators to change is one important way to help communities remain safe.

Always talk with your supervisor if your negative reactions to a client are making it difficult to work with him effectively. Although you should strive to maintain empathy for all clients who come to you for help, there may be certain situations when you cannot work effectively with a client. Instead of pushing a client away with negative reactions, seek supervision early and make a plan for how your organization can meet that client’s needs.

Personality Disorder Diagnoses

Some clients with difficult behaviors will be diagnosed with apersonality disorder. A personality disorder refers to a problematic pattern of thinking and behavior that lasts throughout a client’s adult life and has a negative impact on all areas of her life, especially her relationships. Not every client with difficult behaviors has a personality disorder. However, some clients may come to you with a personality disorder diagnosis in their record, and this should alert you to be ready to address challenging behaviors if they occur. There are several types of personality disorders; only the two most commonly diagnosed disorders are discussed in more detail here. For additional information on other personality disorders, consult with your supervisor or refer to the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Antisocial Personality Disorder is a pattern of violating boundaries and disregarding the rights of other people. Individuals with Antisocial Personality Disorder may:

  • Perpetrate criminal behavior against others. For this reason, they may become involved in treatment because they are court-ordered to participate.
  • Have a difficult time taking responsibility for their behavior, and they may blame others for the things that happen to them.
  • Not feel much or any empathy for victims or other people.
  • Engage in a lot of unsafe or risk-taking behavior, including substance abuse.
  • Challenge authority figures, including mental health treatment providers.
  • Have been diagnosed with Conduct Disorder as children.

Borderline Personality is a pattern of unstable emotions, relationships and self-image. Individuals with Borderline Personality Disorder may:

  • Have episodes of intense anger or irritability.
  • Change quickly between feeling positively and negatively about other people in their life.
  • Have a lot of past relationships that ended with anger and negativity (“burning bridges” with others).
  • Become dependent on their behavioral health provider, calling frequently or making statements like “you are the only one who can understand me.”
  • Exhibit impulsive behavior in response to feeling intense emotions, including repeated self-harm behavior, high-risk sexual activity, or substance abuse.

When you are working with a client who has a personality disorder, it is very important to remember that these problems very often develop as a result of negative life experiences. For example, research shows that Antisocial Personality Disorder in adults is associated with childhood histories of neglect. Also, research has demonstrated that adults with Borderline Personality Disorder are more likely to have experienced sexual abuse in childhood. Empathy for clients with personality disorders is an important first step towards being able to work with them effectively.

Additionally, BHA/Ps should remember the following tips for working with clients who have personality disorders:

  • Set clear boundaries from the start. For example, explain how often the client will be seen, how they should contact you between appointments, and how they can access emergency care.
  • Be consistent.
  • Do not avoid or push away your client.
  • Explain to the client that you are providing them care as part of a team, which includes your supervisor.
  • Consult with your supervisor frequently for support and guidance.

Creating a Safe Environment

When you are working with a client who is at risk of emotional or violent outbursts or inappropriate sexual behavior, talk with your supervisor about how to ensure your safety during and in between sessions. Some approaches that you and your supervisor may use include:

  • Know and follow your organization’s policies and procedures for provider safety.
  • Meet with your client when another person is in the building.
  • Alert other staff in your clinic before you meet with the client.
  • Position your chair between your client and the door.
  • Keep your phone within reach.
  • In high risk situations, you and your supervisor may decide to contact your local VPSO ahead of time to let them know you may call for assistance (while being careful to secure your client’s identity and protected health information).

These strategies, while not guaranteeing safety, can reduce the risk of harm to you or other staff members. Additionally, difficult clients who observe that you are working as part of a team to provide them care may be less likely to push boundaries or exhibit unsafe behavior than if they perceive you to be working independently or alone.