The involuntary client may be referred to you by the legal system with the idea that either:
For the uncooperative client, one way of making the experience really punishing is to be nondirective and withhold information about what the therapist wants. This is not a good idea.
One reason to be mysterious:
Being clear about what is wanted runs the risk of giving the client something specific to resist. Thus, sometimes the therapist will remain vague out of that fear, rather than out of a belief in nondirection. In this case, there arises a kind of mutual insanity, in which the therapist won't tell the client what is needed for the client to benefit from therapy, and the client, sensing the withholding, resists the therapist. Then the therapist can say the client is resistant.
Creating cooperation with the visitor:
On the other hand, telling specifically what is wanted can promote a positive and healthy relationship, in a case where the client really would like a change, but does not know how to use psychotherapy. If the client still resists, then the therapist can explore in a more straight-forward way what that resistance is about. It may be there are some assumptions about hidden agendas and the like, and the therapist can dispel those, pointing out there is really nothing the therapist can do to the client against the client's will.
Who is the customer?
You may both benefit from carefully thinking about who is the customer here and what is wanted. It may be, for example, that the real customer is some outside agency which is referring the client. You may not be expected to help with psychotherapy so much as perform some other task. For example, you may be asked to make predictions about whether this person is likely to do some dangerous or antisocial act. In this case, you need to be clear that you are not a therapist, you are a behavior prediction expert. It may well be that being an expert and being a therapist are contradictory roles, in that people tend to take more passive positions vis-a-vis experts, which is the opposite of what we hope a patient in psychotherapy will do.
Another possibility is that you are expected to help a patient interact with other social agencies. For example, you may find you would be best serving the customer if you helped the client get community home nursing assistance. So let's be wondering what is our actual role in this setting, and don't assume you are to act as a therapist.
Stay pleasant: In any case, make sure the interactions you have with the involuntary client are always pleasant to that person. Confrontation and challenging the patient are not indicated with a visitor; it is necessary that you treat the person with a certain amount of respect so as to make the relationship pleasant for both of you.
One way to do this is to look for things you approve of about that person. If you cannot find anything you genuinely approve of, refer! Don't make yourself and the client miserable by trying to work in an atmosphere of mutual dislike.
Joining: the therapist empathizes with the feeling of being forced to come to therapy. There is a story of a young girl who wet the bed. After the parents had enlisted their whole church congregation to pray for her, to no avail, they punished her by dragging her to the "crazy doctor." They asked Milton Erickson, the therapist, to cure her of the bed wetting. Erickson, having previously enlisted their oath and promise that they would utterly cooperate no matter how shocking his behavior, acted outraged and indignant and sent the parents out. He turned to the young patient, saying "Who the hell do those people think they are, trying to order me to cure you. I'll do what I want to do! They can't order me around!"
While you may not have the histrionic quality or acting skills necessary to pull that off, you can join with the client and empathize about the forced nature of the relationship. You can emphasize how you also don't like being ordered into a relationship, and think it entirely normal and understandable the client will resist.
Substituting: In the Erickson case referred to above, he suggested they work on something more interesting to him, and involved her in other activities which indirectly treated the bed wetting. With the involuntary client, find something else the client does want to work on and demonstrate the usefulness of psychotherapy in that area. If you can help your client in the "safer" area, the client may allow you to help in more sensitive areas.
You might try to ask what the very least thing is that you could accomplish in counseling. Give the client some time to think about how therapy might benefit her/him. You may want to tell one or two stories about how people did benefit from therapy.
Restraint from change: Some clients will discuss the problem but with no real effort to change. In this case, the therapist may be tempted to encourage or confront the client. In alcoholism treatment centers, this is called "confronting the denial." It is not fun, and I don't recommend it, except in the context of a family confrontation meeting. In individual work, it is much better for the therapist to look at this as an opportunity to learn flexibility. The therapist avoids the beartrap of encouraging the client to change by pointing out how the symptomatic behavior actually indirectly benefits the person (or social agency) who complains the most about the problem. For example, a teenager who won't work and hangs around home is defined as sacrificing a normal desire to get dough, date chicks, and have fun, so that his mother will not be bored at home. What a noble sacrifice!
Of course, unless you can see some genuine reasons why the client, from her/his point of view, should not change, you ought not to do this intervention. In other words, you can only do this if you mean it, to some extent. Otherwise, it will sound phony and manipulative and the fact that you are lying and trying to fool the client will leak out. When I restrain a patient from change, I really mean it. Strangely enough, when I do that, the client relaxes and since I am in charge of resistance, will offer less.
Family therapy: Whoever is complaining the most about the problem is the most likely to actually change some behavior around the problem. I have seldom met teenagers who think they need to be more responsible and hang around with a better class of people. Since those are the parents' issues, I like to work more with the parents.
The biggest beartrap in family therapy is to take sides. The therapist must remain above blaming and keep attention on how everyone will have to adjust to the problem being gone.
In family therapy, it will be useful to emphasize language patterns which externalize the problem. What that means is that instead of Johnnie "being a bedwetter" (a verb suggesting he is identified as that), we talk about Johnnie being under the influence of this problem (from Michael White). We also use circular questions which presuppose the family will have challenges in adjusting to Johnnie's success.
Often we can profitably use the notion of "who is the customer here?" to formulate our interventions. If the referred patient is actually a visitor, we can ask that person not to change, while we work with the person in the system who is more concerned and agitated about the problem. In this case, the patient is actually doing the customer a favor, since it gives the customer a chance to practice new ways of handling the problem. If the patient were to suddenly reform, it would be a disservice, since the customer wouldn't have anyone to practice on. Then you should give the customer behavior-change homework.
It is helpful to ask what is known as "circular questions" or encouraging the family members to say things about each other that they wouldn't ordinarily say. Examples would be, "Who do you think will be the most helpful to you in solving the problem? Who will be the least helpful? What do you think your mother will say when I ask her how serious the problems are? Who is most upset over the problems you are in? Who is least upset?" This type of questioning seems to lead to interesting information and change of emotional tone in the family.
Network therapy: include in the initial session everyone who might have information about the reason for the referral. It is especially important to invite, for example, the probation officer or a representative of the court. This is a complainant with a great deal of information which then can help motivate the patient to work, if for no other reason than to get the court or probation officer off his/her back.
After a review of all the actual behaviors which bring the patient to therapy, the therapist can clarify the expectations, arrange for whatever reports are necessary, agree on the schedule for the reports, and dismiss the complainant. After that, the other members of the network and the patient begin to discuss how to meet the requirements to get the patient out of trouble.
Other people who can be included in sessions would include employers, work supervisors, roommates, friends, and other important persons who aren't related by blood or marriage to the patient. Clearly, the more people you can enlist in therapy, the better the chances of finding someone with a key to unlock this dilemma.
A specific technique I like is to use post-it notes and write suggestions of how to help the client on them. I put the suggestions on a wall where all can see them. Everyone should call out suggestions; after you have twenty or more, ask the network members to silently go to the wall and arrange all those suggestions into logical groups or categories.
Now have the network name each category, and develop a set of priorities for the categories. Since we can't work on all at once, figure out which one seems to be the most central. Work on it first, generating more ideas of how to do that. Then move out to other categories and other specific issues.
Metered therapy: This pattern helps motivate the client either out of financial interests or out of inconvenience factors. The therapist must get a statement from the court as to how many visits are required. The court will probably want you to suggest a number.
I suggest 12 sessions, for example. You can use any number, and adapt the math. The model remains the same whether you use 12 sessions, or 50. But you must have a specific number of sessions.
I can explain to the client that 12 sessions is 600 minutes of therapy. When he has completed that, I will write a statement that he has come for therapy and attended the required time.
Today he will get 50 minutes of credit, since he has showed up. On each session after this one, he will be given credit for time during which he is showing good client behavior. I define that in very clear behavioral terms. If he does not show good client behavior, he will be warned. After three warnings, if he still does not show good client behavior, the session is ended and the amount of time spent during that session (say, 10 minutes) is credited to him (leaving 540 minutes to finish). If he is required to pay, then I charge him the full fee, since I had set aside the whole time.
The client often feels relieved with this, since the rules and rewards (saying good-bye to the counselor) are clear. Also, since the consequence follows immediately, the client has a therapeutic experience of receiving immediate feedback about his behavior.
Obviously, Metered Therapy can be combined with the family and network therapy notions mentioned above.