There are those times in our practice when clients challenge us, some actually so perturbing that they elicit visceral responses we would rather deny. One such category of problem children are those folks who complain consistently about not feeling at all better. Despite their dissatisfaction, we will see noticeable changes in their systems and sense palpable changes in their tissue. We, therefore, reasonably expect that these changes will have created sufficient movement that clients will begin reporting real progress. Yet, for some this never occurs.

This disconnect between our perceptions and that of our clients always proves exasperating and frequently we are left confused and wondering what we did wrong. Inevitably, this confusion leads to conflicts, many of which we cannot resolve.

The Client’s Tale

From day one, she was highly resistant, yet oddly tenacious, in her resolve to trudge forward. The explanation for this inconsistency puzzled me and despite our continuing efforts, remained obstructed. As our sessions progressed, each one began with a nearly verbatim reaffirmation that she noticed no change either during the previous session or in the intervening time. She reported consistently no decrease in her discomfort, no noticeable improvement in movement, balance, ease, or range of motion (ROM). Each cueing, somatic exploration, visualization exercise, or suggestion for lifestyle modification was met with a passive acceptance that felt more defeatist than participatory. An oddly sincere desire to try whatever was suggested coexisted inexplicably with her stoic fatalism; the reasons for her overriding belief that change was in fact not viable lurking just beyond my grasp.

This kind of somatic schizophrenia (a metaphor only and not a suggestion that the client was actually psychotic) proved a source of considerable emotional confusion for me. As you might expect, I asked her why she continued to come back each week when she stated unrelentingly that nothing had changed. Her answer only deepened my confusion. She simply repeated that she needed the work and kept hoping that she would get better. Such bracing in structure and affect, the stubborn determination to “tough it out” while at the same time arguing at every stage should perhaps have told me I was out of my depth. Yet, I was young and doggedly determined to meet her head-on.

Every week she flashed me that same defiant look, that same prideful tone. “I feel nothing,” she reiterated triumphantly, her manner evoking a certain smugness, a red badge of discouragement, if you will. An odd metaphor, but, since I never could fathom the exact nature of what we were playing out, all I have is metaphor and speculation.

Things really heated up as soon as we began doing more direct neck work. Many of my readers are perhaps familiar with the type of deep neck and intra-oral work taught by many neuromuscular therapists or variations of that work done in various structural integration protocols. Such individuals may well anticipate what occurred. For those whose neck and head work are less intensely specific, there may be some confusion as to the intense response we describe below. However, since we are at this point more interested in the progress of our story than specific theory or technique, we will look at the emotional aspects of this work.

In my experience, this area more than any other, including the pelvic floor, deep abdominal regions, and the tissue around the breast, is the most potentially charged of any territory. Here is where we meet the world, where we take in sustenance and air, where we speak our heart and express ourselves. Work in the anterior neck region, for instance, can trigger respiratory anxiety if the client has a history of asthma, has ever choked on food or any other foreign substance, or been choked. Consequently, an individual may interpret even the gentlest entry into the oral or nasal passages as a violation, even when he has readily agreed to the work and processed its ramifications with his practitioner. Therefore, manipulation in this region generates the highest likelihood of triggering fear and anger responses. Not unexpectedly, even when we remain hypervigilant in our work in this territory, the possibilities of trauma activation may sneak up on us. This short, but I think necessary, discussion leads us back to the client under consideration.

I proceeded patiently through the surface and deeper lateral and posterior neck structures of this client. Highly rigid and not overly responsive, there were no real surprises at this point. Some delicately executed anterior neck work nothing new. The client remained still and quiet. Then came the first internal exploration of the mouth. It proceeded slowly, but soon it became clear something was very wrong. It started as a slight tremor of the jaw, one that would not go away. Slowly, the tremor intensified. Soon the client realized she was both reacting and unable to restrain the trembling of her mandible. Suddenly, she became extremely agitated. She sat straight up and started yelling, “Get out. Get out.” She was so incredibly angry and unwilling to allow me to see her break down that she continued quite literally screaming until I left. A bit shaken, I went upstairs and within less than two minutes she was fully dressed and literally bolting for the front door. She neither looked at me nor did she speak. She ran to her car, got in quickly, loudly slammed the door, and sped off. Of course, I never saw her again nor did I ever attempt to contact her despite my understandable curiosity as to the aftermath of her panicked departure. What a shocking, yet amazing, experience for us both.

The Practitioner’s Tale

One of the many things that helped me reframe this messy encounter was to remind myself that the therapeutic experience is not a real interaction; rather it is a complex, artificial relationship having nothing to do with our normal social intercourse, yet one loaded with intricate leakings and projections that may show up at any turn. Another strategy that has slowly taken hold in my overly defended psyche is the daily practice of letting go. By this, I mean the challenge of detaching from my clients’ failures and successes while reminding myself constantly how small a part I actually play in their progress and recovery. The most important aspect of this process of release is the requisite discipline of preparing to end the therapeutic process and then say good-bye. We forget all too often, in our desire to help and feel special, the challenges the client faces when she realizes that the therapy is concluding. We must therefore understand that how we say good-bye to clients who are dissatisfied is even more important (and certainly much more difficult) than how we say good-bye to our happy clients who are ready to move on, or at the very least, take an extended hiatus from us so they can more successfully integrate the work we have done.

This language may have a certain Eastern flavor that is not part of everyone’s reality, so, to reframe my point, the less invested we are in our client’s process, the more we can help them. Another way of saying this is that we must be compassionate without trying to take care of our clients. Having as deep an understanding as possible of the ways we wish to rescue, to play a paternal role, or to work out our unresolved emotional issues with our clients will help protect them from us and at the same time show us where we need to heal ourselves in order to better help others heal themselves. An extraordinary teacher of mine suggested recently to me that we all need to learn how to bind up and contain any emotional frequency that may inadvertently create a sense of vulnerability or lack of emotional safety in our clients as they project onto us during their complex bonding and healing process. Again, while this language (emotional vibrational frequencies) may seem esoteric, the notion that we all project and countertransfer as we interact goes without saying. Therefore, the better we understand and regulate this subconscious mechanism, the more safe and secure our clients will feel. This, after all, seems to me the most important aspect of the therapeutic process, having much more to do with facilitating integration and transformation than mere technique or intellectual expertise.

A Reader’s Tale

I wish to end with a few suggestions for those who may recognize themselves in the above tale, or who might wish to know how to deal with similar challenging clients in the future.

Realistic selectivity

Be very selective about taking on complex clients with long-term chronic or emotional injuries, as, despite your skill set, you might fall into a series of traps, particularly if the problem client experiences immediate and strong change. Beware of the amazing first session. It usually leads to subsequent disappointments, yet always feels wonderfully seductive.

Know your limits

Set realistic goals and expectations with clients about a normal range of change and spell out as clearly as possible what you mean by noticeable change. Failure to clearly explain both the limits of your technique and realistic expectations for the work are two of the most common reasons for subsequent anger, confusion, and conflict between the client and his therapist.

Know their limits

Do not overload them with information because you feel the need to “really help them,” or ask more of them then they are able to give. In other words, meet them, work with them, and most importantly accept them in the present moment.

It’s all about them

Remember that this is their time and not yours. Each time you decide to speak, ask yourself if what you are about to say is more about you than about them. If so, practice silence and stillness. For many of us, this is really hard and, if so, that is all the more reason to devote focused attention to it.

Review: beginning of  session

Include time in your session for processing the previous week’s progress and allow clients appropriate time to report what they felt during the week. Note any improvement, no matter how slight, and point it out without overemphasis. Remember that people in pain often function by dissociating and rarely have very good self-monitoring mechanisms in place. Teaching them better awareness skills is very important and should be a part of every treatment session. Be wary of those who have been to many therapists, especially others in your area of expertise, and complain at length about never having experienced any real change. The problem here will surely lie with the client rather than all those therapists.

Review: end of session

Take time at the end of each session to review any perceived progress, no matter how small. Give simple instructions for homework or awareness exercises designed to help reinforce what has been addressed during the session.

Progress review limits

Have a built-in time frame for a comprehensive review of the sessions’ progress. This might occur at the third or fourth session. This review process is critical and will help the client express his concerns about how the therapy is progressing. If the client is truly unhappy at this stage, you must be prepared to end therapy after this session or even before actually doing any further work. Be ready to do this as cleanly and honestly as possible.

Saying good-bye

Handle your closure session with as much sensitivity and lack of defensiveness as possible. This may be quite difficult, as the client may become aggressive and very critical (even nastily personal) at this stage for a number of not-so-obvious reasons.

Transference

Understand clearly that their anger, when it comes, is seldom really about you and the inherently artificial therapeutic process. Look at it in a larger context as some projection of frustration or dissatisfaction with others either in the client’s past or present. Parental projections are ubiquitous in all therapeutic relationships.

Countertransference

Be on the lookout for what you project onto your client. Failure to do this may create emotionally charged issues that undermine safety in the room.

So, complain to me

Encourage your clients to feel really free to complain. This may be the only time in their day that someone focuses their full attention on them and gives them permission to vent. This really builds trust and shifts focus to where it always belongs—on them.

Good closure

End your sessions as well as you can and try to learn each time you do so. By not saying good-bye properly, you will have in some way failed in your role as their therapist, and this we all should wish to avoid at all costs.

 Raymond J. Bishop, Jr, PhD, lived and worked in Atlanta, Georgia, prior to his death December 5, 2008. He blended his music and Rolfing—his two intellectual passions—in wonderfully expressive and illustrative ways. We’re sad to let you know this feature is his final article we had waiting in the wings to publish. For more information on his legacy, visit his site www.idarolfsbrahms.com.