How Do You Handle a Therapeutic Impasse?
When mental health professionals encounter a standstill in therapy, the expertise of psychotherapists and clinical directors becomes invaluable. From navigating impasses with time and referrals to revisiting goals to foster a collaborative alliance, discover the eight strategies these experts employ to break through therapeutic stalemates.
- Navigate Impasses with Time and Referrals
- Build Trust and Set Therapy Boundaries
- Address PTSD with Tailored Interventions
- Utilize Mindfulness for Emotional Regulation
- Encourage Client Growth Through Impasses
- Employ Motivational Interviewing and Rapport-Building
- Seek Feedback and Respect Cultural Perspectives
- Revisit Goals and Foster Collaborative Alliance
Navigate Impasses with Time and Referrals
Therapeutic impasses are unavoidable and can be 'normal' to any therapeutic relationship. They can be in a power struggle with the therapist, have irreconcilable differences, be a mismatch regarding personalities, or be in denial themselves. As a mental health professional, unfortunately, the only thing that can resolve this is time and their own abilities to see what is needed to really address their needs in the treatment being provided. Otherwise, it's okay to make a referral to another clinician to work with the patient or to actually discuss the process itself. It's important to remember that neither person is a mind reader and being transparent is the best decision possible to improve the treatment.
Build Trust and Set Therapy Boundaries
The client-therapist relationship in therapy is unique and special. Despite initial differences, trust and understanding can be built. As a proactive therapist, I explain my therapy approach and set clear boundaries with clients. If a client doesn't align with my perspective, we discuss the best way forward, such as referral or transfer of notes. Leaving ego aside, therapists guide clients on their healing journey, driven by their mindset and willingness to engage in therapy.
Address PTSD with Tailored Interventions
It depends on the type of impasse. I work mainly with women experiencing different levels of PTSD after undergoing traumatic events. If the impasse is rooted in fear, I am honored to help the client through that. The client must feel safe and supported before I can implement methods that take neuroscience into account, such as EMDR or Eye Movement Desensitization and Reprocessing. If the impasse is rooted in a lack of motivation from, let's say, depression, the right balance of therapeutic support and challenging the client to do something different—incorporating at least one healthy new behavior at a time—would be required in addition to what we learn in session. These are impasses that can be dissected and overcome.
However, if the impasse is rooted in deceit, then we have a problem. Let's say a client comes in because the spouse insists. We lay out the treatment plan, but the client's accounts do not match behaviors, or the spouse will report that the client is lying in session. If this continues, then I let the client know that he or she is wasting time and money, both theirs and mine. If there is no 'buy-in' from the client, no real desire to change, but only to manipulate the session to keep the status quo, then I refer out. Often in these types of cases, a specialist trained in another area is required. That could mean that further assessments are needed to rule out addictions of any type, such as sexual impulsivity or substance abuse, etc. Those areas must be addressed first. There can be no therapeutic progress if the client is not honest and motivated on his or her own to grow and change for the better.
Utilize Mindfulness for Emotional Regulation
Incorporating mindfulness techniques in therapy sessions involves teaching clients to focus on the present moment nonjudgmentally. Techniques like mindful breathing or body scans help cultivate awareness and reduce stress. Research shows that mindfulness-based interventions can decrease symptoms of anxiety, depression, and PTSD, with meta-analyses indicating moderate to large effect sizes.
Benefits include improved emotional regulation, enhanced self-awareness, and better coping skills. Mindfulness also fosters a therapeutic environment conducive to exploring thoughts and emotions without immediate reactivity, promoting long-term psychological resilience and well-being.
Encourage Client Growth Through Impasses
A therapeutic impasse can be an opportunity for the client to grow if the therapist encourages the client to openly clarify and express needs that are not being met in therapy. Therapy will either become deeper, or the client may decide a different therapist or therapy will serve him or her better. I advocate and encourage a client to choose the path that is best. A client's growth always comes first.
It has happened that a client who left over an impasse returned after a year or two, having made progress in an area I couldn't help with. He was now ready and wanting to get down to work on unresolved issues. Our therapeutic relationship was enriched by the experience. The client becomes more comfortable and trusts that his therapist is sincere and authentic and will always support what is best for his growth and mental health.
Employ Motivational Interviewing and Rapport-Building
When I encounter a therapeutic impasse with a client, I turn to Motivational Interviewing techniques, rapport-building, and/or psychoeducation on the client's diagnosis. Motivational Interviewing techniques tend to involve open-ended questions, affirmations, reflection, and summarization (OARS). Rapport-building is a focused conversation on activities, hobbies, and topics that are of personal interest to the client. One or a combination of these three modalities has always proven effective in working through impasses. This is especially applicable when working with adolescents, who tend to accept therapy simply because Mom and Dad told them to go.
Seek Feedback and Respect Cultural Perspectives
A therapeutic impasse may sometimes be a message that can help shift the sessions or therapeutic relationship to a better place. I do take time to ask for feedback from my clients/patients because of my own human errors or biases that may be coming up and blocking them from truly receiving my interventions. If the impasse is due to our lack of connection, it is important for me to understand their cultural perspectives and process any past issues that may be a barrier. If the impasse is due to my lack of knowledge or incompetence on the subject matter, diagnosis, or certain interventions needed, then I discuss this with them. It is always more important to help my clients/patients find the best support for them than to force the therapeutic relationship to continue if it is no longer safe or helpful. If the impasse is due to my lack of safety, I find support from supervisors and colleagues to navigate so that I can still cause the least harm as I terminate with that client/patient, despite any personal feelings or countertransference coming up for me.
Revisit Goals and Foster Collaborative Alliance
When facing a therapeutic impasse with a client, I find it crucial to revisit the therapeutic goals and reestablish a collaborative alliance. In one instance, a client and I were stuck on progress regarding his anxiety. I introduced the concept of "third-party perspective," where the client views the situation as an outsider. This shift in perspective helped him gain new insights and led to breakthroughs in our sessions. Additionally, I incorporate motivational interviewing techniques to explore any ambivalence the client might have about change. This approach helps re-engage the client by validating their feelings and fostering a sense of partnership in overcoming the impasse.
