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Responding to Our Own Unhelpful Cognitions

By Amy Cunningham, PsyD

It’s quite challenging when clients engage in behaviors that we view negatively. This situation commonly arises when we work with clients with borderline personality disorder (BPD). These clients have a history of disturbed relationships and a tendency to engage in maladaptive interpersonal behavior. We ourselves often have negative thoughts about these clients, especially when our own core beliefs become activated. While it may be natural and understandable to have a negative reaction, it’s not helpful. We may suffer from burnout or provide less effective treatment.

It is critical for us to recognize when we are negatively evaluating our clients’ behaviors and to learn how to take a nonjudgmental stance. The unhelpful attributions we often make, though, can get in the way. Have you ever had thoughts such as, “My client is doing this on purpose just to make me mad;” “If I let her get away with this, she’ll think she’s pulling one over on me;” “She knows better. She’s just trying to manipulate me;” or “We’ve been over this 100 times; clearly she isn’t trying to get better.”  These thoughts may or may not be accurate and are usually quite maladaptive, especially when they interfere with the therapeutic relationship. In any case, viewing clients so judgmentally rarely leads to a change in their behavior.

In these moments, it is important to remember that intention and outcome are often unrelated when you’re working with clients with BPD. In other words, just because you feel manipulated (actually, more accurately, you perceive that you’re being manipulated) by a client does not mean it was the client’s intention to manipulate you. For example, if a client brings up intense emotional content at the end of session, and yells at you for not being willing to extend the session, doesn’t necessarily mean that the client intended to get special treatment from you. Searching for a compassionate understanding and conceptualizing according to a cognitive framework why the client is engaging in these behaviors is critical to being able to help change the behavior.

It’s important to remember that the behaviors we often label as manipulative have often been reinforced over the years. Maybe you have witnessed a typical example. I recently observed a situation in which a customer believed his needs were not being met. Feeling frustrated, he yelled and asked for a manager. Then he got what he wanted. Getting what he asked for after he yelled makes it much more likely that the next time he will also yell in a similar situation.  The same holds true for clients, and given the highly invalidating and harsh environments in which they live, their learning histories are filled with behavior patterns that are maladaptive, at least some of the time.

If you notice that you have experienced a strong desire to avoid thinking about a client or you’re feeling burned out or you find yourself secretly wishing that this client would cancel his or her appointment, it would be wise to examine the content of your own cognitions.

If you notice a negative judgment, ask yourself:

  1. What is the precise behavior(s) that the client is engaging in?
  2. What does his/her using this behavior mean to me?
  3. What is a compassionate understanding (an alternative explanation) of why the client is engaging in that behavior?
  4. What would I like to see the client do instead?

Here’s a clinical example.

I supervised Anne, a therapist who was working with Sally, a client diagnosed with BPD. We noticed that every time Anne highlighted Sally’s role in a problematic interpersonal situation, Sally started to yell at Anne. Anne then noticed herself thinking, “Sally doesn’t even want to change. She doesn’t respect me as her therapist!”

Here is how Anne answered the questions above:

Question:   What is the precise behavior the client is engaging in?

Answer: Yelling when I highlight an area for improvement.

Question: What does this behavior mean to me?

Answer: Sally is affecting what I do. Her yelling ultimately leads to my avoiding giving her feedback she needs so she can reach her goal of improving the relationships in her life.

Question: What is a compassionate understanding of why the client is engaging in that behavior?

Answer:  Sally probably feels shame when I highlight these areas. She may be fearful of experiencing shame, she may not know how to effectively cope with feelings of shame, and/or she may not know how, or may feel too vulnerable, to communicate how she’s feeling to me.

Question: What would I like to see the client do instead?

Answer: I would like for Sally to say, “That’s hard for me to hear. Can I have a few minutes to take it in?”

Having answered these questions, Anne was in a much better position to have a conversation with Sally about the impact of her yelling. Anne helped Sally learn how to change the behavior in session. Then they discussed how to generalize what she had learned so she could improve the quality of her relationships outside of therapy.

By striving for a nonjudgmental stance with clients, therapists will be better able to provide more effective treatment, help clients to a greater degree, and reduce their own burnout.