The AAMFT Blog

Working with “Resistant” Clients: An MFT Perspective

As therapists, we are natural healers and helpers. We build a strong alliance, set goals, implement interventions, and achieve positive outcomes. More than anything, we want our clients to make consistent gains toward their therapeutic goals. Marriage and family therapists (MFTs) are acutely skilled and interested in shifting negative patterns in their lives and relationships. We are holistic in our approach and want our clients to connect with their strengths and make desired changes in their lives.

MFTs treat individuals, couples, and families and view problems in the context of relationships. We meet a range of clients in our practice and face various issues. One of the most challenging therapeutic presentations is resistance. When a client resists therapy, it leaves the therapist feeling discouraged. Even a seasoned therapist will tell you that resistance can make them feel deskilled, stuck, and unsure of what to do next.

There are, however, other ways to frame this experience. While uncomfortable, resistance provides essential information about what is happening in the client system. As MFTs, our training tells us that this is an isomorphic moment. Resistance is a standard defense mechanism activated in response to fear. It may serve an adaptive purpose to the client but feels like a barrier to the therapist.

Therapeutic resistance can be covert or overt, showing up in several different ways. Clients may come in for therapy with their spouse and announce that they don’t believe treatment works. In this instance, the resistance is manifest. Another client may resist therapy due to a cultural norm according to which accepting outside help cannot solve personal problems, or at any rate is embarrassing. Yet for others, resistance may be a symptom of another problem. It may be the discouraged or fearful surface response of someone who is feeling depressed or anxious. Either way, we need to have some strategies for recognizing and handling resistance so that we don’t miss the opportunity to connect clinically with our clients.

Here are some ways to work with resistant clients:

1. Use it as an opportunity to join and build trust with the client: If a client announces that therapy is not for them, do not try to convince them otherwise. Instead of making a sound argument for the benefits of therapy, be agreeable and curious. Our job is not to persuade anyone to believe in therapy but rather to validate their perspective and gain more understanding of their narrative about therapy.

2. Check-in and ask for feedback: It is important, in the first place, to notice the resistance which may be masked by broader cultural beliefs. You may think your alliance is strong and your connection with your client is close. However, the client may still be harboring resistance and concealing it from you. Therefore, check-in and ask specific questions and invite direct feedback. For example, you may let your client know upfront that the therapeutic process takes time, and the therapist might miss something important to the client. Encourage the client to ask clarifying questions and to give candid feedback about what is and is not working for them.

3. Keep an eye out for underlying causes of apparent resistance: If your client is in a cycle of “help-rejecting complaining,” remind yourself that it is not personal, but it may be a symptom of underlying depression or anxiety. Clients who present themselves as high functioning may appear to be resistant when in fact, they are experiencing inner turmoil. We need to be sure that we check-in and are screening for any underlying conditions before concluding that the client is being “difficult” or not open to help.

Our work as therapists can be rewarding and challenging. When you find yourself overwhelmed or puzzled by resistance, seek professional supervision. The objective feedback of another MFT can relieve the stress of working with resistance.

Setting Your Therapy Private Practice Salary

Guest blog post by: Miranda Palmer at zynnyme

Let’s face it, you were called to do this work. You believe in the power of relationships and systems, and you’ve invested years and tens (or hundreds) of thousands of dollars into your training to deeply help heal systems and families.

But what happens when you sit down and do the math and realize what you’ve trained and worked so hard for won’t actually pay the bills (much less give you an option for retirement or reducing your hours at some point)? The truth is, most of us haven’t done that math. In fact, some of you chose this career so you could AVOID all that math. And yet, here we are. You’re noticing that your paychecks aren’t stretching as far, and your savings account is dwindling.

If that’s you, you aren’t alone. Marriage and Family Therapy and other counseling degrees are among the worst paid Master’s degrees in the United States. But, it does NOT have to be this way. In fact, many therapists make a sustainable income with their degree in private practice as either private-pay or an insurance-based practice.

So, what’s the big difference between therapists who are paid well and ones that aren’t? Is it their value as humans? As therapists? Their outcomes? Their location? I’m going to go out on a limb and say no. While location and other factors may impact insurance reimbursements, cost of living, etc., the biggest impact is therapists’ understanding of finances and making conscious choices about what they say “yes” and “no” to.

Therapy is priceless. Each one of you is priceless. However, when the bulk of therapists say “yes” to insurance reimbursements that fall below the poverty line, then insurance companies have no reason to increase reimbursements. When therapists shame other therapists who’ve done their math and charge a sustainable fee, then we lose as a profession both in connection and in our ability to do the work if those therapists feel shamed out of the profession.

Unlike work at nonprofits, it’s the responsibility of the owner of the practice to set the salary and benefits in their private practice. Unfortunately, many private practice owners set the salary without accounting for expenses, time off, time required to work on the business, retirement, or other benefits that are built into W-2 employment for other agencies or businesses.

So, a therapist who sets their income goal at $100k annually, for example, might consider that their salary. But, in a business, gross income and net income are VERY different. Many therapists average close to 40% in expenses, which drops that quickly down to $60k in a salary. However, that $60k salary in private practice is NOT the same as $60k in W-2 Income. You’re taxed at a higher rate for that income AND that $60k needs to include benefits.

Therapists often also set their available hours to work with clients based on their responsibilities while working for another organization. In most organizations, billing, scheduling, cleaning, bookkeeping, marketing, etc. are outsourced to others. In a private practice, however, it may initially be just one person who’s responsible for all aspects of running the business. A therapist who easily saw 30 clients a week at an agency and worked a total of 35 hours may find that even 25 clients a week translates to 50-60 work hours per week.

So, how do you set your salary in private practice?

You need to get clear on the number of hours you want to work per week both in the chair and out of the chair. If you want to work 32 hours per week, for example, I’d recommend starting with a clinical goal of no more than 60% of those hours. So, in this case, a max of 19 clients a week.

You need to explore the weeks you’ll work per year. How many weeks do you need to plan on being out due to illness, vacation, taking care of loved ones, attending clinical trainings? Setting your fee based on this can have a HUGE impact on your bottom line. If you work with families or children who take summers off or you find you have a summer slump, you might also work this number into your total weeks worked per year.

You need to get clear on the costs of starting a business and expenses, including your need for a salary and benefits. Technology, internet, office space, malpractice insurance, retirement, clinical training, etc. There’s a LOT to starting a private practice – it’s a business, after all. Simply setting a random fee without understanding what’s involved is not going to have the impact you hope for! Take some real time putting costs together for your unique situation and practice to develop your gross income goal.

You need to understand the tax implications of being a business owner so you don’t end up with 15% less than you thought you would after accounting for self-employment taxes!

As a VERY rough starting point, you need to look at your gross income and divide that by the number of weeks worked per year. That lets you know what income you need to bring in weekly on the weeks you work on average. After that, you take the weekly average and divide it by the number of clinical hours you want to work.

Feeling a little overwhelmed? You’re completely normal! We believe this is something best done with support and as part of a community. Our next AAMFT-sponsored training, we’ll dive into this for an hour in more detail with lists of expenses to plan for and answering your burning questions about insurance, sliding scale, and more! Click here to register today.