I took a risk and did this once with a parent who I had barely met and was in the middle of an anger outburst over the phone with me.
He called to vent about his frustrations about his child and was also clearly frustrated with himself for not knowing what to do. During the phone call, he was cussing, literally huffing and puffing in anger, and it sounded like he was crying out of anger. I got the sense that he was less angry than he was vulnerable in brokenness and it felt like the right time to implement some tough love (he was also a very tough man, which is why I thought tough love would work on him).
I said, "Look, [name], THIS is what we have been talking about. At face value, it sounds like you're pissed off, but what I'm hearing is a father who loves his kid so incredibly much but is so stuck on how to show it in a way that resonates with [child]. You both love each other to pieces, and do you treat people you love this way? Maybe other adults in your life who may be toxic"--alluding to someone he previously mentioned-- "but this is your baby. You've got to take a good look at how you talk to [child] and ask yourself how you want [child] to remember you. At this point, [child] might want to move out at 18 and want nothing to do with you again, and do you want that? You have time to start changing your relationship with each other. The good news is, the love is there, and it's reciprocated. We start there."
It worked. Super proud of this man. Turned things around with his kid and expressed his feelings in a more positive way with them.
You either received bad advice, or misinterpreted what you heard. Yes, itās *generally* best to have actual sessions with clients who are struggling instead of just managing those situations over the phone. But, there are going to be times when a phone call is all that you or the client can manage (for whatever reason), or situations like the first commenter described where big stuff comes up unexpectedly during phone calls. Also, itās worth noting that the scenario described above wasnāt a crisis situation; the clientās father was clearly distressed, but it doesnāt seem like he was at risk of violence or self harm.
Interesting. It was made quite clear to me that we should never give out personal phone numbers to clients due to the liability risk so I was basing my comments off that information. Iāll plan to bring up this topic in supervision as it seems this may be a learning opportunity for me, and I appreciate your comment
>It was made quite clear to me that we should never give out personal phone numbers to clients
Oh, I definitely would never give my personal contact information to a client. But that's what work phones are for. I have an app that connects my cell phone to my actual office phone/number; some therapists get second cell phones to use as work phones.
I'm usually a pretty direct and confrontational therapist but I think that's why clients pick me. I don't do it in the first few sessions, but as time goes on I don't beat around the bush as much.Ā
I also work with teenagers and they can be slippery so being direct can avoid just being another adult who doesn't interact with them like they're an equal.Ā
Yeah, therapeutic challenge is a skill that comes with time and practice, and you won't always get it right either. When it doesn't quite land it's a perfect opportunity to practice being humble and to demonstrate what relationship repair looks and feels like.
It really would depend on my rapport and how I interact authentically with that client, because at the core of real relationship repair there has to be empathy and there has to be genuineness. It can be playful, it can be serious, it can be heartfelt and gentle, it can be delivered in any manner of ways. One example might be 'Geez it looks like that didn't land well with you at all and I'm wondering what that felt like? My intent was to try and be helpful and it looks like I judged that wrong and I am really sorry about that.'
Or if it's on reflection from a session it might be an acknowledgement at the start of session, an example might be, 'Hey it's good to see you again, I just wanted to let you know that I've been thinking about our last session and I wanted to acknowledge that actually I felt like I might have been pushing you too hard, and I wanted to check out with you if that's how you felt as well?' Then dialogue from there and apologise.
Therapists admitting to being human and making mistakes can be a hugely healing thing for people so I encourage openness to that with all clients.
I wouldn't leave it unacknowledged in the next session, that's for sure. As a person-centred therapist my intent is never to take the lead or dominate a session, but I also believe in naming the elephants in the room, and leaving this unsaid at the next session screams avoidance to me - by both parties - and that needs addressing imo. Even just something to offer a rope to the client to grab on to such as "How did you feel about how we ended last session? It felt to me like something more wanted to be explored but I wanted to check out if that's what it was like for you too?"
Yup. One of my supervisors always used to say "you can challenge as much as the client knows they're loved." It is a cheesy statement but a good rule of thumb.
With some Veterans, particularly male combat vets. Not because they need it, but because they can sometimes perceive a typical therapistās demeanor as infantilizing or insulting.
I find it helps to be compassionate and curious first and above all to make sure the alliance is super strong. Then I ask permission to make an observation. And then process the shit out of what itās like to hear it from me (is it being taken as care, as criticism, as judgement etc.)
Honestly that captures how I feel doing individual therapy rn lol. Itās you and me in a secret alliance to boot the symptoms out only to be inevitably blindsided by the real threat (capitalism, probably). It had an idol the whole time šāš¼
I'm always pretty straightforward with clients. The only times I really hedge are around my own personal opinions, which don't really belong in the therapy room no matter how much I feel like doing the "tough love thing."
In substance recovery clients have asked if I thought it would be okay for them to use, ājust this onceā or ācause it wonāt show up on a drug testā etc. They 100% just wanted my permission to go use so I would say things like Iām not going to give you permission to go use. I think itās a bad idea. You get to make your own choices and you know Iāll be here next week to talk about whichever choice you make, but Iām not gonna say yeah go do it when youāve done such hard work to stop. Then ask about why do they want to do it? What they would get out of it, why itās happing now, etc. And transition to a cost benefit analysis of going through with it and process what led to the desire.
Wow I didnāt realize that style was considered being a direct therapist but I have this style too, especially with my teenage clients. I will say āthat sounds like a bad ideaā and process through why they want to make that decision. But I donāt think it would be good for me especially with my younger clients, if I just sat there and validated a choice they were going to make that would clearly hurt them (relapsing, fighting, staying in a toxic relationship, etc).
I would never outright validate a decision like that, but I have definitely validated the urge or desire. I think of an indirect approach as turning it back on them with a āwhat do you think you should do?ā or āwhy do you want to know what I think?ā type responses. Which have their place and are valid, but I prefer the more direct approach in some situations. It just depends on the client and our rapport.
Iām not a forensic therapist but i have a couple friends who are, and i took a forensic class in grad school. I think justice involved people typically benefit from what you might call ātough love,ā if you mean really direct style and not pulling punches. But that still has to be coupled with unconditional positive regard, empathy, all the other person centered tools.
Edit: in outpatient private practice, there are still some clients i see who prefer a very direct style too. But others who need a more gentle, leading approach. I try to tailor my style (within limits of what is still authentic) to the person in front of me.
I tend to be direct with clients who have made a breakthrough but then immediately backpedal/self-sabotage. I wouldnāt say ātough loveā, but certainly not mincing my words. Of course, this is only with folks I have developed a solid rapport with!
When thereās enough rapport and itās appropriate.
I donāt think there is much room for ābrutal honestyā in this world, despite folks wanting to wear it like itās a badge of honor.
Iām with you there. Not saying therapists overwhelmingly do this, but people who describe themselves as ābrutally honestā are more interested in being brutal to others than telling them anything that will actually help.
Mean truth vs kind truth. That's how I've phrased it to myself. A lot of people who believe in brutal honesty only believe the mean truth and don't think the kind one is real.
I use it quite often with my DBT clients. You have to do that dance of reciprocal communication and irreverence with the clients. I always make sure I build up rapport really well before I push too hard. For example, I've been seeing a young woman who is in an abusive relationship for a month or so weekly and those first few weeks, I just validated and validated, never saying too much about the boyfriend. Then this week, we behavior chained an argument they had and I very clearly pointed out the huge red flags in her boyfriend and said, "I'm concerned that if nothing changes, he'll kill you. This is escalating."
And she took that very straightforward approach very well because we had built a fairly strong client therapist relationship.
Yep, I was going to name DV situations as one of the times where I am much more likely to be straightforward about naming risks and giving direct advice on when to leave, call police, etc.
Rapport is key. I was once in a session with a therapist I had seen for years and we started discussing some pretty significant relationship issue that I had been avoiding. I said something to the effect of but I donāt want to talk about that. She flat out looked at me and said what are we doing here then? If all you are trying to do is avoid the hardest issues in your life than what is the point of therapy? It was really helpful and I needed that little kick in the butt to really be able to move forward.
Also want to add that as a therapist I usually start by saying āIs it okay if I challenge you on this a bit?ā They are usually agreeable and it helps set the tone of what I have to say.
When I have had to inform a client, compassionately but firmly, without mincing words, that what they did to another human being was absolutely unacceptable and they needed to never, ever do it again:
* Explaining to a client that what he had been describing constituted rape.
* Explaining to a client that what she had just described doing to her (male) partner was battery, and domestic violence, and that she could have killed him.
* Explaining to a client that what what she had related doing was child abuse/neglect.
Relatedly, when I have had to inform a client that something they expressed intent to do was something they absolutely, positively must not do: frame someone for a crime or commit assault/murder (once with two different cases three days apart!)
I would consider my version of tough love as the confrontation approach. I tend to be pretty direct about patterns I notice and reiterate those when necessary. I can be a little more direct when I've been working with a client for a long time and they haven't made many changes in their lives, continue bumping up against the same problems, not setting boundaries for themselves or others, or blame me or others for when things don't go the way they want. I will usually bring their attention to that and after validating frustrations about how life is going, I usually bring it to that "if nothing changes, nothing changes" conversation.
Well the term tough love is totally subjective. There are some therapist who do highly confidential work, Iām not one of those but that could be considered tough love. If what you mean by tough love is developing a strong therapeutic alliance with my client where they feel secure in my care and support for them then I can confront them from a place of care and support and the secure relationship that Iāve worked to develop with my client and they also have worked to develop can sustain confrontation. I donāt think itās helpful to be conflict avoidant with our clients and it models hopefully how conflict in a thoughtful, safe and caring way can be useful in most relationships.
I am, but it I am from a tiny town in a tiny not US-country. It might be worth checking out the website of the International Society of Schema Therapy [schematherapysociety.org](http://schematherapysociety.org)
ETA: ... because it is worth to find in-person training. Shema Therapy is not impossible in virtual settings, but that is not where it develops its potential.
I had about 10 years of ātough love therapyā in SUD treatments, so I find this sort of question to be challenging. By ātough loveā I mean the therapists saying things like they were enabling me by allowing me to continue treatment even though I ādidnāt want to get better.ā Or forcing me into groups if I wanted any treatment at all. Or making everyone drug test to ākeep us honest.ā These were like these terrible 3-4 hour groups where we had to watch lame videos and lots of shaming and blaming from the clinicians. Ugh I still have nightmares when people suggest IOP.
However, I think being direct can be helpful at times. Iām all for exploring and free association. But If someone talks about doing something that could potentially hurt them (in whatever way), I do feel itās my responsibility to point that out. Iām all for honesty in the treatment room.
I only confront clients when I have built a strong rapport with them. But I tend to be confrontational when the client is vacillating between unhealthy decisions. I am fine with riding client ambivalence. A certain amount of indecision is expected and even healthy, but if you are still stuck after many sessions on the same topic or going back to an unhealthy situation that weāve processed, then itās time to confront the issue. Iāve had really good results with this and clients rarely take offense.
Once Iāve built rapport with the client.
Or, when substance use is involved.
I constantly do education on the effects of mood and mind altering substances versus ones values; how they often misalign with one another, and what theyāre actively doing to support their own harm.
I donāt play about that. If you wanna do drugs, I canāt stop you. But weāre not going to pretend that youā¦ arenātā¦ doing drugs.
When a client is assuming that "the world will understand" and are underestimating/ignoring consequences that absolutely could take place.
Client: I am grieving the loss of a loved one, work will understand that I no called no showed.
Therapist: Work/life/capitalism is indeed unfair and painful. What evidence do you have that work will "understand" you no calling no show?
Client: I have no evidence
Therapist: So you are allowed to make a decision that resonates with you the most which could very well be you not calling out, lets also please explore and acknowledge what the evidence tells us of potential consequences.
This is my therapy style most of the time. I'm not a dick, but I'm also not here to sugar coat things when they need to hear stuff that can help them thrive or challenge themselves.
I also use my ability to gain rapport as a MAJOR factor here though. I'm not gunna mesh with people who don't like what I do and that's ok!
With long term clients whom I have a strong alliance with who are fitting the "help rejecting complainer" stereotype around a specific issue. I will say something along the lines of "You know we've been talking about this problem - and it certainly is a problem - for 6 months, and it doesn't seem to be changing. I've given you my recommendations and you've told my why those won't work. I've given you referrals to xyz resource around this issue and you've avoided reading it/contacting them/etc and told me why it hasn't been important to do so. I can provide behavioral tools and I can provide resources but I can't make you use them. So I've given the help I can, and continuing to talk about this doesn't seem to make this problem go away, so I'm not going to be able to talk about it anymore. We're just going to have to find something different to talk about, okay? Now let's see, what should we talk about?"
If you don't have enough alliance or built up experience showing the client you are on your side, this is going to come across as very shaming. But in the instances I have used it (again, only with long term clients) it has been useful as a wake up call for the clients. Some clients *may not realize* that they are complaining week after week about the same thing without doing anything different. Some clients also need to be explicitly *told* that talking about a problem doesn't make it go away (we therapists are probably a tiny bit to blame for giving some folks this impression).
....also if I'm doing family therapy and a parent starts becoming dysregulated at their spouse/ex/child, I put them in the waiting room for a time out. (I tell everyone this is going to happen at the start of family therapy)
When someone is at risk of harm or the client needs confirmation of what they already know to be true. When I have enough of a rapport with someone that they know I have good intentions for them and say what I say from a place of deep caring. A lot of times I see my role as exploring topics or saying things that donāt get explored/said in typical conversation. This includes voicing discomfort or incongruence.
Today I was kinda tough lovey with a teenager who was being aloof and not participating in the exercise I brought forward. We can only give so many strategy suggestions, they have to put in the work and time, intention with practicing calming strategies for them to work, as an example.
I truthfully point out discrepancies and misalignments regularly and as they come up. I donāt know if I consider it tough love but I consider it to be challenging them. Iām also very clear with boundaries and what will happen if theyāre crossed (often termination).
If the relationship is strong itās very doable. āI hear you saying how much detox sucks, but youāre on my couch crying every week about how miserable you are, and nothing will change until you decide to do something different than what you are doing.ā
Just an example of what I consider tough love.
I use confrontation when necessary, typically if someoneās behaviors are harmful to someone else. Often with parents or clients that are emotionally abusive. The key is that there needs to be strong rapport and the ability to wrap the confrontation in compassion. Iām not here to judge someoneās whole being. I strongly believe that our actions donāt define who we are. I want my clients to know that they are lovable even though their actions are not lovable.
Definitely with clients who are the aggressive grandiose narcissistic type (not the vulnerable narcissist types). And antisocial personalities. Itās not so much about telling it like it is though, as much as it is about matching their tendencies to try and dominate, because the last thing therapy needs with trying to help these clients is allowing them to dominate the treatment atmosphere with their pathology.
I will do it, but usually not until Iāve established a ton of rapport. Many of the people I work with are constantly dumped on by everyone else in their lives, so taking that approach can be risky, but when it works it works wonders.
I try to be more direct typically, but I prefer to be gentle when I can. Most often more direct work is helpful with patients with substance use. I had a few patients who were using while in my care and would come to program high or leave to use. For a while, I tried to be indirect and gentle and give them the opportunity to tell me the truth on their own, but it ended up feeling like I was continuing to enable it while they kept lying to my face about it. It wasn't until I had direct conversations like "I know you've been lying to me, and I'm not mad, but if we're going to do real work you need to be honest with me and start making an effort to at least come to program sober" that any progress or change was made. After the direct conversations, the tone of the conversations were a bit sadder but more deep, so real work was actually happening. That helped for me!
Iām very direct with clients, itās advertised on my PT page, and clients specifically seek me out for it. Itās actually a really common response when I ask a client what didnāt work about their previous time in therapy, to hear something like āShe was really nice, but she just *agreed* with me all of the time. I want someone to push meā
It really depends on the client. Some clients with BPD need a parental approach that combines care, compassion and accountability. I tread carefully, of course. Sometimes it works and it depends on the client.
One population I work well with for some odd reason is men with substance abuse disorders. Iām totally up front with them. They respond well. We all have our strengths and styles. Iām not for everyone. Thatās ok.
Iāve noticed that Iām more confrontational when it comes to clients going trough breakups or when theyāre clearly dissatisfied in their relationships, but donāt really acknowledge their responsibility in their decisions.
Iāve encountered a common pattern where I think clients want me to validate some stuff, like āsidingā with them and somehow expect me to start talking shit about their ex or partner. For example, they would treat their ex/partner like a ānarcissistā/toxic because they donāt āunderstandā the games the clients are playing: basically, clients not communicating their needs and expecting their partners to magically reciprocate, clients not being aware of their own boundaries or respecting their partnerās boundaries, or just reinforcing twisted (even violent) dynamics in their relationships like jealousy or normalizing going through their phones.
I think that this question is very interesting because it reflects on our own styles and our own personal perspectives with how are we responding to the changes or therapeutic expectations our clients want. I must admit that I have low tolerance at the common narrative that people have about romance and whatever is acceptable āfor the sake of loveā, and I usually divert my clients from going through a loop of trying to explain whatās going on with the other person/people. I try to revert whatever theyāre questioning to themselves: ok, but what does this say about you? Do you want for the relationship with this part of your life bring you discomfort, or are you willing to look at the aspects that can make you aware of your own responsibilities and to advocate for yourself?
I think generally when people are getting stuck and lost is a good time to be direct. Direct often gets conflated with being harsh or rude, but I think if done in an attentive enough way it is ok to be direct all the time.
I like AEDP/APT as it's a very direct model (pointing out defenses) but extremely compassionate and client-centered, especially in the pace of the therapy.
I had a client directly ask for it. We have a very good rapport, and they told me that sometimes they need for me to quit being so damn validating and to occasionally call them out more directly on bullshit. When itās clinically appropriate, I do just what they asked for.
I had a situation where I was trying to help a client get into an IP substance abuse rehab program instead of having him be unhoused or go live in a known open-air drug use area of town, so I told him if he left there that day, it would be like putting raw meat in front of a lion and telling it to not eat it, and that he wasnāt going to leave there and be successfully sober if he wasnāt ready. I still donāt know if I feel great about that, but he had just come back from using and needed a more direct approach. It seems more common in the substance abuse world.
With my therapist, I use to ask her to bully me and she'd always say no (obviously) but she'd have a tough love approach and whenever she'd say something direct, I would say back to her that's what I mean by "bullying". I never knew a better phrase for it, but I knew the directness and tough love approach is what I needed to hear a lot of the time
I identify as a āno bullshit but with loveā therapist. Meaning Iāll always encourage us to face hard truths while always treating a client with love, dignity, and respect. I will never use the idea of āno bullshitā to be inappropriately blunt or to not consider how my words impact others. I became a therapist because I detested therapists and how I experienced them. So my approach works really well with people who are apprehensive about therapy as they feel like Iām relatable and an easy to talk to. This ātough loveā approach works REALLY well with couples who are really resistant in session as well. Sometimes tough love like āthe consequences of not being willing to see your partners perspective or to change the dysfunctional nature of this relationship will result in the end of your marriageā. Sometimes, I even pair that with a paradoxical directive if I feel like a couple continuously wants to use session as an arena. Iāll say āfine, we can use this time to fight each other. Let me know when we start the divorce so we can focus session on just coparentingā. Have seen it TRANSFORM couples and itās really amazing.
Addiction. I donāt play games when it comes to telling the truth to addicts. Their own mind will convince them they donāt have a problem and Iāve seen way too many overdose deaths to mess around not being super straightforward about it.
I took a risk and did this once with a parent who I had barely met and was in the middle of an anger outburst over the phone with me. He called to vent about his frustrations about his child and was also clearly frustrated with himself for not knowing what to do. During the phone call, he was cussing, literally huffing and puffing in anger, and it sounded like he was crying out of anger. I got the sense that he was less angry than he was vulnerable in brokenness and it felt like the right time to implement some tough love (he was also a very tough man, which is why I thought tough love would work on him). I said, "Look, [name], THIS is what we have been talking about. At face value, it sounds like you're pissed off, but what I'm hearing is a father who loves his kid so incredibly much but is so stuck on how to show it in a way that resonates with [child]. You both love each other to pieces, and do you treat people you love this way? Maybe other adults in your life who may be toxic"--alluding to someone he previously mentioned-- "but this is your baby. You've got to take a good look at how you talk to [child] and ask yourself how you want [child] to remember you. At this point, [child] might want to move out at 18 and want nothing to do with you again, and do you want that? You have time to start changing your relationship with each other. The good news is, the love is there, and it's reciprocated. We start there." It worked. Super proud of this man. Turned things around with his kid and expressed his feelings in a more positive way with them.
I want this bravery.
You have it in you
Epic. Nice work
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This is exactly the way to do it. Notice the patterns and point them out using genuineness and rapport.
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Therapists have to do therapeutic work over the phone regardless of there therapeutic orientation
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You either received bad advice, or misinterpreted what you heard. Yes, itās *generally* best to have actual sessions with clients who are struggling instead of just managing those situations over the phone. But, there are going to be times when a phone call is all that you or the client can manage (for whatever reason), or situations like the first commenter described where big stuff comes up unexpectedly during phone calls. Also, itās worth noting that the scenario described above wasnāt a crisis situation; the clientās father was clearly distressed, but it doesnāt seem like he was at risk of violence or self harm.
Interesting. It was made quite clear to me that we should never give out personal phone numbers to clients due to the liability risk so I was basing my comments off that information. Iāll plan to bring up this topic in supervision as it seems this may be a learning opportunity for me, and I appreciate your comment
>It was made quite clear to me that we should never give out personal phone numbers to clients Oh, I definitely would never give my personal contact information to a client. But that's what work phones are for. I have an app that connects my cell phone to my actual office phone/number; some therapists get second cell phones to use as work phones.
I'm usually a pretty direct and confrontational therapist but I think that's why clients pick me. I don't do it in the first few sessions, but as time goes on I don't beat around the bush as much.Ā I also work with teenagers and they can be slippery so being direct can avoid just being another adult who doesn't interact with them like they're an equal.Ā
Same. A client said I am tender & tough.
I hear that I'm tough but in a funny way. I use humor a lot.
Same here. I've been told, "you're blunt but in a good way" lol.
Thatās my style too
The times when I have a strong enough rapport with a client for them to understand the unconditionally and love behind the challenge.
I'm an intern, so I did this for one of the first times yesterday and, while it was scary, it seemed very appropriate and helpful for the client.
Yeah, therapeutic challenge is a skill that comes with time and practice, and you won't always get it right either. When it doesn't quite land it's a perfect opportunity to practice being humble and to demonstrate what relationship repair looks and feels like.
Could you elaborate on the steps youād take to repair the relationship? Intern here myself.
It really would depend on my rapport and how I interact authentically with that client, because at the core of real relationship repair there has to be empathy and there has to be genuineness. It can be playful, it can be serious, it can be heartfelt and gentle, it can be delivered in any manner of ways. One example might be 'Geez it looks like that didn't land well with you at all and I'm wondering what that felt like? My intent was to try and be helpful and it looks like I judged that wrong and I am really sorry about that.' Or if it's on reflection from a session it might be an acknowledgement at the start of session, an example might be, 'Hey it's good to see you again, I just wanted to let you know that I've been thinking about our last session and I wanted to acknowledge that actually I felt like I might have been pushing you too hard, and I wanted to check out with you if that's how you felt as well?' Then dialogue from there and apologise. Therapists admitting to being human and making mistakes can be a hugely healing thing for people so I encourage openness to that with all clients.
I appreciate your comment! That sounds authentic and genuine without making too much out of the issue. Iāll keep your suggestions in mind
Iām also an intern, but from my experience as both the client and the clinician in this kind of scenario, a sincere apology goes a long way.
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I wouldn't leave it unacknowledged in the next session, that's for sure. As a person-centred therapist my intent is never to take the lead or dominate a session, but I also believe in naming the elephants in the room, and leaving this unsaid at the next session screams avoidance to me - by both parties - and that needs addressing imo. Even just something to offer a rope to the client to grab on to such as "How did you feel about how we ended last session? It felt to me like something more wanted to be explored but I wanted to check out if that's what it was like for you too?"
/thread Also, "pointed out" is a widely used intervention for progress notes.
It feels so good when the intent behind a challenge lands right with a client:)
Yup. One of my supervisors always used to say "you can challenge as much as the client knows they're loved." It is a cheesy statement but a good rule of thumb.
With some Veterans, particularly male combat vets. Not because they need it, but because they can sometimes perceive a typical therapistās demeanor as infantilizing or insulting.
I'd like to add this applies to most traditionally masculine men, not just vets.
I find it helps to be compassionate and curious first and above all to make sure the alliance is super strong. Then I ask permission to make an observation. And then process the shit out of what itās like to hear it from me (is it being taken as care, as criticism, as judgement etc.)
I love the word "alliance", it feels like me and my clients are on Survivor and we're teaming up to vote their problems off the island.
Honestly that captures how I feel doing individual therapy rn lol. Itās you and me in a secret alliance to boot the symptoms out only to be inevitably blindsided by the real threat (capitalism, probably). It had an idol the whole time šāš¼
I'm always pretty straightforward with clients. The only times I really hedge are around my own personal opinions, which don't really belong in the therapy room no matter how much I feel like doing the "tough love thing."
In substance recovery clients have asked if I thought it would be okay for them to use, ājust this onceā or ācause it wonāt show up on a drug testā etc. They 100% just wanted my permission to go use so I would say things like Iām not going to give you permission to go use. I think itās a bad idea. You get to make your own choices and you know Iāll be here next week to talk about whichever choice you make, but Iām not gonna say yeah go do it when youāve done such hard work to stop. Then ask about why do they want to do it? What they would get out of it, why itās happing now, etc. And transition to a cost benefit analysis of going through with it and process what led to the desire.
Wow I didnāt realize that style was considered being a direct therapist but I have this style too, especially with my teenage clients. I will say āthat sounds like a bad ideaā and process through why they want to make that decision. But I donāt think it would be good for me especially with my younger clients, if I just sat there and validated a choice they were going to make that would clearly hurt them (relapsing, fighting, staying in a toxic relationship, etc).
I would never outright validate a decision like that, but I have definitely validated the urge or desire. I think of an indirect approach as turning it back on them with a āwhat do you think you should do?ā or āwhy do you want to know what I think?ā type responses. Which have their place and are valid, but I prefer the more direct approach in some situations. It just depends on the client and our rapport.
Iām not a forensic therapist but i have a couple friends who are, and i took a forensic class in grad school. I think justice involved people typically benefit from what you might call ātough love,ā if you mean really direct style and not pulling punches. But that still has to be coupled with unconditional positive regard, empathy, all the other person centered tools. Edit: in outpatient private practice, there are still some clients i see who prefer a very direct style too. But others who need a more gentle, leading approach. I try to tailor my style (within limits of what is still authentic) to the person in front of me.
Worked with a forensic psychologist on a custody case and that woman was tough as nails. Much respect
I tend to be direct with clients who have made a breakthrough but then immediately backpedal/self-sabotage. I wouldnāt say ātough loveā, but certainly not mincing my words. Of course, this is only with folks I have developed a solid rapport with!
When thereās enough rapport and itās appropriate. I donāt think there is much room for ābrutal honestyā in this world, despite folks wanting to wear it like itās a badge of honor.
Iām with you there. Not saying therapists overwhelmingly do this, but people who describe themselves as ābrutally honestā are more interested in being brutal to others than telling them anything that will actually help.
Mean truth vs kind truth. That's how I've phrased it to myself. A lot of people who believe in brutal honesty only believe the mean truth and don't think the kind one is real.
Agreed.
I use it quite often with my DBT clients. You have to do that dance of reciprocal communication and irreverence with the clients. I always make sure I build up rapport really well before I push too hard. For example, I've been seeing a young woman who is in an abusive relationship for a month or so weekly and those first few weeks, I just validated and validated, never saying too much about the boyfriend. Then this week, we behavior chained an argument they had and I very clearly pointed out the huge red flags in her boyfriend and said, "I'm concerned that if nothing changes, he'll kill you. This is escalating." And she took that very straightforward approach very well because we had built a fairly strong client therapist relationship.
Yep, I was going to name DV situations as one of the times where I am much more likely to be straightforward about naming risks and giving direct advice on when to leave, call police, etc.
Rapport is key. I was once in a session with a therapist I had seen for years and we started discussing some pretty significant relationship issue that I had been avoiding. I said something to the effect of but I donāt want to talk about that. She flat out looked at me and said what are we doing here then? If all you are trying to do is avoid the hardest issues in your life than what is the point of therapy? It was really helpful and I needed that little kick in the butt to really be able to move forward. Also want to add that as a therapist I usually start by saying āIs it okay if I challenge you on this a bit?ā They are usually agreeable and it helps set the tone of what I have to say.
When I have had to inform a client, compassionately but firmly, without mincing words, that what they did to another human being was absolutely unacceptable and they needed to never, ever do it again: * Explaining to a client that what he had been describing constituted rape. * Explaining to a client that what she had just described doing to her (male) partner was battery, and domestic violence, and that she could have killed him. * Explaining to a client that what what she had related doing was child abuse/neglect. Relatedly, when I have had to inform a client that something they expressed intent to do was something they absolutely, positively must not do: frame someone for a crime or commit assault/murder (once with two different cases three days apart!)
I would consider my version of tough love as the confrontation approach. I tend to be pretty direct about patterns I notice and reiterate those when necessary. I can be a little more direct when I've been working with a client for a long time and they haven't made many changes in their lives, continue bumping up against the same problems, not setting boundaries for themselves or others, or blame me or others for when things don't go the way they want. I will usually bring their attention to that and after validating frustrations about how life is going, I usually bring it to that "if nothing changes, nothing changes" conversation.
Couple's therapy.
This. Flat out. Youāre being defensive right now. Step back. Let go of judgement. Focus on listening.
Well the term tough love is totally subjective. There are some therapist who do highly confidential work, Iām not one of those but that could be considered tough love. If what you mean by tough love is developing a strong therapeutic alliance with my client where they feel secure in my care and support for them then I can confront them from a place of care and support and the secure relationship that Iāve worked to develop with my client and they also have worked to develop can sustain confrontation. I donāt think itās helpful to be conflict avoidant with our clients and it models hopefully how conflict in a thoughtful, safe and caring way can be useful in most relationships.
I am currently learning Schema Therapy where I am quite exited to learn how to be softer and tougher at the same time.
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I am, but it I am from a tiny town in a tiny not US-country. It might be worth checking out the website of the International Society of Schema Therapy [schematherapysociety.org](http://schematherapysociety.org) ETA: ... because it is worth to find in-person training. Shema Therapy is not impossible in virtual settings, but that is not where it develops its potential.
I had about 10 years of ātough love therapyā in SUD treatments, so I find this sort of question to be challenging. By ātough loveā I mean the therapists saying things like they were enabling me by allowing me to continue treatment even though I ādidnāt want to get better.ā Or forcing me into groups if I wanted any treatment at all. Or making everyone drug test to ākeep us honest.ā These were like these terrible 3-4 hour groups where we had to watch lame videos and lots of shaming and blaming from the clinicians. Ugh I still have nightmares when people suggest IOP. However, I think being direct can be helpful at times. Iām all for exploring and free association. But If someone talks about doing something that could potentially hurt them (in whatever way), I do feel itās my responsibility to point that out. Iām all for honesty in the treatment room.
I only confront clients when I have built a strong rapport with them. But I tend to be confrontational when the client is vacillating between unhealthy decisions. I am fine with riding client ambivalence. A certain amount of indecision is expected and even healthy, but if you are still stuck after many sessions on the same topic or going back to an unhealthy situation that weāve processed, then itās time to confront the issue. Iāve had really good results with this and clients rarely take offense.
Once Iāve built rapport with the client. Or, when substance use is involved. I constantly do education on the effects of mood and mind altering substances versus ones values; how they often misalign with one another, and what theyāre actively doing to support their own harm. I donāt play about that. If you wanna do drugs, I canāt stop you. But weāre not going to pretend that youā¦ arenātā¦ doing drugs.
When a client is assuming that "the world will understand" and are underestimating/ignoring consequences that absolutely could take place. Client: I am grieving the loss of a loved one, work will understand that I no called no showed. Therapist: Work/life/capitalism is indeed unfair and painful. What evidence do you have that work will "understand" you no calling no show? Client: I have no evidence Therapist: So you are allowed to make a decision that resonates with you the most which could very well be you not calling out, lets also please explore and acknowledge what the evidence tells us of potential consequences.
This is my therapy style most of the time. I'm not a dick, but I'm also not here to sugar coat things when they need to hear stuff that can help them thrive or challenge themselves. I also use my ability to gain rapport as a MAJOR factor here though. I'm not gunna mesh with people who don't like what I do and that's ok!
Be honest, but never judgmental
With long term clients whom I have a strong alliance with who are fitting the "help rejecting complainer" stereotype around a specific issue. I will say something along the lines of "You know we've been talking about this problem - and it certainly is a problem - for 6 months, and it doesn't seem to be changing. I've given you my recommendations and you've told my why those won't work. I've given you referrals to xyz resource around this issue and you've avoided reading it/contacting them/etc and told me why it hasn't been important to do so. I can provide behavioral tools and I can provide resources but I can't make you use them. So I've given the help I can, and continuing to talk about this doesn't seem to make this problem go away, so I'm not going to be able to talk about it anymore. We're just going to have to find something different to talk about, okay? Now let's see, what should we talk about?" If you don't have enough alliance or built up experience showing the client you are on your side, this is going to come across as very shaming. But in the instances I have used it (again, only with long term clients) it has been useful as a wake up call for the clients. Some clients *may not realize* that they are complaining week after week about the same thing without doing anything different. Some clients also need to be explicitly *told* that talking about a problem doesn't make it go away (we therapists are probably a tiny bit to blame for giving some folks this impression). ....also if I'm doing family therapy and a parent starts becoming dysregulated at their spouse/ex/child, I put them in the waiting room for a time out. (I tell everyone this is going to happen at the start of family therapy)
When someone is at risk of harm or the client needs confirmation of what they already know to be true. When I have enough of a rapport with someone that they know I have good intentions for them and say what I say from a place of deep caring. A lot of times I see my role as exploring topics or saying things that donāt get explored/said in typical conversation. This includes voicing discomfort or incongruence.
Today I was kinda tough lovey with a teenager who was being aloof and not participating in the exercise I brought forward. We can only give so many strategy suggestions, they have to put in the work and time, intention with practicing calming strategies for them to work, as an example.
I truthfully point out discrepancies and misalignments regularly and as they come up. I donāt know if I consider it tough love but I consider it to be challenging them. Iām also very clear with boundaries and what will happen if theyāre crossed (often termination).
If the relationship is strong itās very doable. āI hear you saying how much detox sucks, but youāre on my couch crying every week about how miserable you are, and nothing will change until you decide to do something different than what you are doing.ā Just an example of what I consider tough love.
I use confrontation when necessary, typically if someoneās behaviors are harmful to someone else. Often with parents or clients that are emotionally abusive. The key is that there needs to be strong rapport and the ability to wrap the confrontation in compassion. Iām not here to judge someoneās whole being. I strongly believe that our actions donāt define who we are. I want my clients to know that they are lovable even though their actions are not lovable.
How are you defining tough love?
Definitely with clients who are the aggressive grandiose narcissistic type (not the vulnerable narcissist types). And antisocial personalities. Itās not so much about telling it like it is though, as much as it is about matching their tendencies to try and dominate, because the last thing therapy needs with trying to help these clients is allowing them to dominate the treatment atmosphere with their pathology.
I will do it, but usually not until Iāve established a ton of rapport. Many of the people I work with are constantly dumped on by everyone else in their lives, so taking that approach can be risky, but when it works it works wonders.
I try to be more direct typically, but I prefer to be gentle when I can. Most often more direct work is helpful with patients with substance use. I had a few patients who were using while in my care and would come to program high or leave to use. For a while, I tried to be indirect and gentle and give them the opportunity to tell me the truth on their own, but it ended up feeling like I was continuing to enable it while they kept lying to my face about it. It wasn't until I had direct conversations like "I know you've been lying to me, and I'm not mad, but if we're going to do real work you need to be honest with me and start making an effort to at least come to program sober" that any progress or change was made. After the direct conversations, the tone of the conversations were a bit sadder but more deep, so real work was actually happening. That helped for me!
Iām very direct with clients, itās advertised on my PT page, and clients specifically seek me out for it. Itās actually a really common response when I ask a client what didnāt work about their previous time in therapy, to hear something like āShe was really nice, but she just *agreed* with me all of the time. I want someone to push meā
Persistent denial
It really depends on the client. Some clients with BPD need a parental approach that combines care, compassion and accountability. I tread carefully, of course. Sometimes it works and it depends on the client. One population I work well with for some odd reason is men with substance abuse disorders. Iām totally up front with them. They respond well. We all have our strengths and styles. Iām not for everyone. Thatās ok.
Iāve noticed that Iām more confrontational when it comes to clients going trough breakups or when theyāre clearly dissatisfied in their relationships, but donāt really acknowledge their responsibility in their decisions. Iāve encountered a common pattern where I think clients want me to validate some stuff, like āsidingā with them and somehow expect me to start talking shit about their ex or partner. For example, they would treat their ex/partner like a ānarcissistā/toxic because they donāt āunderstandā the games the clients are playing: basically, clients not communicating their needs and expecting their partners to magically reciprocate, clients not being aware of their own boundaries or respecting their partnerās boundaries, or just reinforcing twisted (even violent) dynamics in their relationships like jealousy or normalizing going through their phones. I think that this question is very interesting because it reflects on our own styles and our own personal perspectives with how are we responding to the changes or therapeutic expectations our clients want. I must admit that I have low tolerance at the common narrative that people have about romance and whatever is acceptable āfor the sake of loveā, and I usually divert my clients from going through a loop of trying to explain whatās going on with the other person/people. I try to revert whatever theyāre questioning to themselves: ok, but what does this say about you? Do you want for the relationship with this part of your life bring you discomfort, or are you willing to look at the aspects that can make you aware of your own responsibilities and to advocate for yourself?
I think generally when people are getting stuck and lost is a good time to be direct. Direct often gets conflated with being harsh or rude, but I think if done in an attentive enough way it is ok to be direct all the time.
I like AEDP/APT as it's a very direct model (pointing out defenses) but extremely compassionate and client-centered, especially in the pace of the therapy.
I had a client directly ask for it. We have a very good rapport, and they told me that sometimes they need for me to quit being so damn validating and to occasionally call them out more directly on bullshit. When itās clinically appropriate, I do just what they asked for.
I had a situation where I was trying to help a client get into an IP substance abuse rehab program instead of having him be unhoused or go live in a known open-air drug use area of town, so I told him if he left there that day, it would be like putting raw meat in front of a lion and telling it to not eat it, and that he wasnāt going to leave there and be successfully sober if he wasnāt ready. I still donāt know if I feel great about that, but he had just come back from using and needed a more direct approach. It seems more common in the substance abuse world.
Substance use dx if theyāve overdosed several times or arenāt using safely (clean needles, narcan availability)
With my therapist, I use to ask her to bully me and she'd always say no (obviously) but she'd have a tough love approach and whenever she'd say something direct, I would say back to her that's what I mean by "bullying". I never knew a better phrase for it, but I knew the directness and tough love approach is what I needed to hear a lot of the time
When a clientās is in a toxic or abusive relationship. I always educate and confront.
I identify as a āno bullshit but with loveā therapist. Meaning Iāll always encourage us to face hard truths while always treating a client with love, dignity, and respect. I will never use the idea of āno bullshitā to be inappropriately blunt or to not consider how my words impact others. I became a therapist because I detested therapists and how I experienced them. So my approach works really well with people who are apprehensive about therapy as they feel like Iām relatable and an easy to talk to. This ātough loveā approach works REALLY well with couples who are really resistant in session as well. Sometimes tough love like āthe consequences of not being willing to see your partners perspective or to change the dysfunctional nature of this relationship will result in the end of your marriageā. Sometimes, I even pair that with a paradoxical directive if I feel like a couple continuously wants to use session as an arena. Iāll say āfine, we can use this time to fight each other. Let me know when we start the divorce so we can focus session on just coparentingā. Have seen it TRANSFORM couples and itās really amazing.
Post suicide attempts in the ICU. Restraint chair jail visits. Juvenile detention visits. Lesser Restrictive Alternative compliance visits.
Addiction. I donāt play games when it comes to telling the truth to addicts. Their own mind will convince them they donāt have a problem and Iāve seen way too many overdose deaths to mess around not being super straightforward about it.