Working With the Helpless-presenting Client

Most therapists have had the experience of psychotherapy clients who feel helpless and depressed, and  lack the belief that they have the power to change their lives.  They implicitly or explicitly expect the therapist to “cure” them.  And many therapists, particularly those who are new to the profession,  try to take the responsibility of making these clients change.  This, in my experience, is usually doomed to failure.  Here are the reasons:

1.  The therapy outcome research shows that the most important factor in a positive therapy outcome, even more important than the alliance between therapist and client,  is the client’s personal resources.  It accounts for 40% of the outcome variables; they are termed “extra-therapeutic” variables.  Among them  include the belief they have the ability to change and grow and have a good support system in the form of friends and family members and interesting activities in their lives.   A successful, steady work history is often a very good diagnostic indicator.

2.  Clients who lack these resources usually feel helpless, alone, shame-based and secretly want to be taken care of by someone else.   They are often developmentally stunted and yearning for the caring, empowering parents they never had.

3,  The therapist, out of his or her feeling of genuine caring for the client, can start to believe he or she really is helpless.  The therapist might then do any one of a number of things to attempt to help the client:    giving advice, being overly sympathetic, reassuring the client that he or she can do better, agreeing with the client’s view that their problems are due to being mistreated by others, extending the therapy session beyond the therapist’s usual ending time, and in a myriad of other ways.   When the client doesn’t improve or follow the therapist’s advice,  the latter can become very frustrated and feel like a failure.  After all, therapists  have their own personal needs, among which is the feeling of being successful in helping their clients grow.  But all of his or her efforts are not resulting in client improvement.   In many cases I have seen, the therapist starts feeling burdened and  resentful  toward the client.   Clients can usually sense the therapist’s feeling of frustration,  which can make them feel even more helpless and unworthy.  Sometimes they redouble their efforts to get the therapist to “help” them.  In any case, the therapy is going nowhere.

My own viewpoint is that psychotherapy is a cooperative process, with the client and I being a team, working together to help the client take those steps necessary for his or her growth.  I am willing, when it is necessary, to offer options for the client to consider if he or she is stuck at a certain point.   But the client is the one who has to decide on the best option to follow.   I have found that personal growth can take a long time for some clients , and I must patiently work with them while he or she takes small,  incremental steps in growth.

Here is what I have found to be successful in working with clients who feel helpless and see themselves as not having, even potentially, the resources for their growth.

1.  I try to determine in the first session what the client’s ideas are about how growth can occur in our working together.  As part of my intake form, I ask clients what is troubling them and what they want from therapy.  Typically, I get answers such as “I’m very depressed,” or “I want help in my relationships” or “I am anxious all the time.”  I then ask the very important question, “How do you see yourself accomplishing these goals here with me?”  How the client responds to this question can be very diagnostic.  The helpless-feeling client might say something like “I don’t know; you’re the doctor.”

2.  I then identify the feeling of helplessness as the first issue we need to work on.  Without making some headway with that issue, I have learned, through much painful experience, that there will not be much progress in the therapy.

Note that it is important for the therapist to highlight  the client’s sense of helplessness in a way that results in the client understanding that this was an inevitable result of past experience.  This will tend to mitigate his or her sense of shame about being this way.   While I  point out that the core issue, at least at this point in the therapy, is the client’s sense of inadequacy and helplessness, I then explore how her or she got to be that way. This can help the client realize that his or her helplessness is not the result of some core moral flaw, but the inevitable result of childhood experiences that negatively reinforced a sense of ineffectiveness  in dealing with problems in living.   The implicit, sometimes explicit, message I communicate is:  “Of course you feel like you can’t do anything to help yourself {be happier} {more successful} {more self-sufficient}.  You were not given the tools during your formative years to achieve these things.”  Note also that dealing with feelings of helplessness is not a linear process.  It will probably recur at numerous times during a long-term, intensive course of psychotherapy, and needs to be dealt with again and again.

A clinical example.  Shortly before I moved from Los Angeles to the Portland, OR area, a woman was referred to me by her psychologist, whom she had seen for about a year.  They weren’t making any progress and the psychologist  thought I might be better  able to help her.  She was a heavy-set, middle-aged woman who was unemployed and was living rent-free in an apartment owned by one of her siblings.  I picked up very quickly from the way she presented herself to me that she was intelligent,  but saw herself as a helpless failure.  She spoke in  a whiney voice, was self-deprecating, and obviously felt hopeless about her ability to grow.  I felt sad for her and an urge to reassure her that she wasn’t hopeless,  but have learned to resist such impulses.  I also was able to use my feelings as important diagnostic information about the way she viewed her own abilities to grow and was framing our relationship as me being the expert who would do it for her.

I said to her, “it sounds like you feel really depressed, like you’re not getting anywhere in your life.”  She tearfully agreed to that.  I also asked if perhaps she felt helpless and hopeless to do anything about it.  She agreed to that also, saying she had been to a number of therapists, including Dr. X, the one who had referred her to me, with very little change.    I asked her if she hoped I would rescue her and make her better.   After a brief hesitation,   she looked embarrassed and admitted that was so.  She said she didn’t feel she could do anything about her hopeless situation and she had just about given up the idea that anyone else could help her.   I said that she seemed embarrassed to admit that and she agreed.  I suggested that she probably has good reason to feel this way and began to explore her history.

I found out that her father had died when she was about 12 and that her mother, whom she saw as always  somewhat childlike and very dependent on her husband, had fallen apart and withdrew to her room for hours every day.  The client had two younger siblings and the mother expected her to take over and be the Mom to them.  She had actually done that to the best of her ability.  Her siblings had prospered to the extent that they became successful in their lives and were later on able to support her financially.   She wasn’t working and was living rent-free in an apartment her younger sister owned.  Her mother was still alive and,  because the client was unemployed,   was expected by her siblings to spend much time with her mother.  It was clear that she resented her mother ,but I began to suspect that, although she said her mother was a demanding, critical burden to her,  she was emotionally dependent on her.

In subsequent sessions I found that she had never been able to  hold onto a job for long and had never had a successful relationship with a man.    I suggested that perhaps she had resented having to assume so many responsibilities at a such a young age she didn’t really want to take responsibility for herself now.   She was surprised at this interpretation and, although hesitantly agreeing with it,  expressed shame about feeling this way.  I said “Of course you would feel this way; you weren’t taken care of properly when you were a child.  I imagine that there must be a little girl part of you that still wants that.”  She again agreed to this.  Further exploration revealed  that she really felt unworthy of others’ care and subconsciously believed that, if she did become  self-sufficient, she would be all alone.  I suspected that the only solid tie she felt she had  to others, particularly her family,  consisted in her being dependent on them  financially and emotionally.    Her belief was that if she became self-sufficient, she would be alone.

We didn’t have enough time together to work through these issues thoroughly because of my move, but, in the time I was still practicing in LA, we did make enough progress for her tentatively to begin to feel that she could create a more satisfying, more self-sufficient life for herself.  I was able to refer her to another therapist in Los Angeles who was aware of this syndrome.   In subsequent contacts with hert, I learned that she  was making good progress.

In conclusion, this approach to therapy is an existential-humanistic one.  I believe that almost all people have the potential to grow and lead more satisfying lives, even people who feel helpless, inadequate and ashamed of themselves.    The last thing people like this need, however,  is a therapist who silently agrees that they really are helpless, lacking in the basic resources to grow and becomes a kind of directive or pitying parent will probably end up feeling helpless himself or herself.  Of course, if the therapist at some point becomes aware of the parallel process between himself or herself and the client, the therapist will have learned something important and will then really start to be able to be effective with this type of client.