How to get a Client to Open Up in a Therapy?

Connecting with clients is one of, if not the most important aspect of forming a trusting relationship with your client. This is easier said than done. How do you connect with a client and form enough trust for them to talk to you so that you can help them?

Effective communication is central to the client-therapist relationship. It’s the underlying theory behind talk therapy. If you’re having trouble getting through to a client or find that many of your clients end counseling prematurely, you might be wondering how to get a client to open up.

Increasing client communication is about building trust and an open, honest relationship with your patients.

Know that establishing and nurturing the connections you have with your clients takes time. It starts with your first session and grows as you and your clients get to know one another. If you’ve hit a wall in your attempts to bond and communicate with your clients, there are several strategies you can try.

According to a 2012 meta-analysis, 20% of clients prematurely leave therapy. For many, difficulties opening up and sharing their emotions motivate the decision to drop out.

Successful therapy depends on a client honestly sharing their experiences and behavior. Yet many clients have spent a lifetime avoiding or concealing the very things they most need to discuss in therapy.

Many people harbor secret thoughts, feelings, and shame. Sharing these with a stranger, even a therapist, can be difficult. It takes time for a therapist to earn a client’s trust, and therapists should not expect that all clients will immediately open up.

Modern counseling models and techniques are as varied and diverse as the counselors and clients who use them. Most counselors have a particular theory, method, or school of thought that they embrace, whether it is cognitive behavior therapy, solution-focused therapy, strength-based, holistic health, person-centered, Adlerian, or other.

Yet all of these approaches and techniques have at least one thing in common — their potential effectiveness is likely to be squelched unless the counselor is successful in building a strong therapeutic alliance with the client.

Rather than seeing clients who won’t talk as “difficult,” therapists should devise strategies for building a safer and more supportive therapeutic environment. With patience and the right approach, therapists can help their clients talk openly about their lives.

What causes clients to feel tense in therapy?

Common criticisms of Positive psychology

Encountering resistance in clients can be disheartening because as therapists you would want your sessions to be effective and your clients to make the best use of their time (and money!). The first thing to remember when you have a silent and resistant client sitting in front of you is don’t panic! This is all part of the process.

Numerous issues can make clients feel anxious, hesitant, or tense in therapy. Some of the most common include:

Resistance

Resistance, like many defense mechanisms, is an often unconscious psychological response that has its beginnings in the amygdala, the almond-shaped part of the brain that is well known for the part it plays in fear conditioning. We develop defense mechanisms to help us mitigate feelings of anxiety or upset that can arise from harmful or unpleasant stimuli. Our defense mechanisms are primarily our friends – they help keep us safe and happy, and protect us against things that are upsetting.

The client’s mental health diagnosis

Some mental health conditions make it more difficult to trust a therapist. A person experiencing paranoid delusions may struggle to trust the therapist or worry they are an agent of a third party.

A client with posttraumatic stress (PTSD) may fear sharing their story requires reliving their trauma.

A history of bad therapy

Some therapists are unskilled or abusive. A client who has seen several therapists in a short period of time may have experienced abusive or ineffective therapy.

This can make them reluctant to open up again, though the decision to give therapy another try, points to their hope for a different outcome this time.

Therapist anxiety and experience

Clients are more likely to discontinue therapy when a therapist is new or unskilled. New therapists may feel anxious in therapy, and those feelings can affect their interactions with clients, making it more difficult for the client to share.

Some therapists do not know how to help clients open up. Others feel unusually anxious around silent clients or find these clients trigger their own feelings of insecurity or fears of inadequacy.

Fear of judgment

It’s natural to fear judgment, even in therapy. People who seek therapy may never have told anyone else the things they discuss in therapy. It takes time to warm up, and it’s critical that a therapist never make a client feel judged.

Client-therapist mismatch

Not all therapists are a good match for all clients. While therapists and their clients do not have to share the same personality or values, they must be able to establish a shared baseline.

When the therapist and client have radically different worldviews or approaches, there may be a mismatch.

For example, a very conservative Christian client may fear judgment from a very liberal atheist therapist, while the therapist may not know how to help the client live up to their own values.

Discomfort in the therapeutic environment

Subtle issues with the therapeutic environment itself can make it more difficult to open up. If the room has thin walls, a client may worry about privacy.

A draft, feeling too cold or hot, physical discomfort, and other easily remedied issues may also play a role. In some cases, decorations or other features in the room can undermine a client’s confidence.

For example, a client who sees a book that contradicts their own values or that stigmatizes mental health may be reluctant to share.

How therapists can strengthen the therapeutic alliance?

What is self psychology and how does it work?

There’s no one-size-fits-all approach to helping clients feel comfortable in therapy. Problems arise when we forget that whilst resistance and silence may once have been very effective at keeping us safe, they can become unhealthy or maladaptive mechanisms that hold us back.

Understanding this you may wonder how then to get a client to open up.  To strengthen the therapeutic relationship, therapists must first identify factors that undermine it. Some strategies that may help include:

Help the client feel more welcome

Consider specific steps that might make therapy more welcoming for the client. Is the room too cold? Would a white noise machine help the client feel less anxious about privacy? Is your body language standoffish? Tailor the structure of each therapy session, as well as the room itself, to the needs of your client.

For example, for anxious, quiet clients, adopt a calm and collected approach. With a tone of reserved confidence, you can encourage the patient to come out of their shell without being intimidating.

For a hyperactive client, take on an energized disposition while staying at ease. On the one hand, you want to mirror the client’s personality. On the other, you want to encourage them to relax more.

Studies have shown that when clients and psychotherapists have similar personalities, it leads to better symptom reduction after therapy ends.

Breathing Room

Breathing room is a comfortable space that therapists often create for their clients. The method is prevalent for adolescents who sometimes struggle to open up and acceptably express their emotions.

In the breathing room, therapists explain why it is okay to take some moments to think or do something unrelated to therapy. It can be anything that clients enjoy doing, as long as it ensures their health and safety.

For example, spending the first few minutes of the session in a coffee shop can be a suitable breathing room for some clients.

On the other hand, taking a short walk with the therapist and doing some small talk can be the right way for helping some clients open up.

Get Comfortable with Reflective Silence

Once a therapist reframes the silence as confirmation of a strong therapeutic alliance, it’s easier to become comfortable sitting with the client in silence. Continuing to build upon that alliance by demonstrating acceptance of the client’s ambivalence then becomes possible.

It can be therapeutically beneficial to allow clients to sit and reflect on their thoughts with your supportive presence.  Therapists can communicate support, understanding, and acceptance with gentle reflections and affirmations.

Some examples:

“This is really hard for you to process.”

“Take all the time that you need.”

“It’s very normal to feel at a loss for words.”

“I really value your presence here.”

“Thinking about change is really hard.”

“This is your space and I completely support you.”

“I’m so proud of you for being here.”

It’s important to limit the reflections and affirmations by seeing the potential value in the reflective silence.  Resist the urge to fill the empty space by reframing your supportive silence as unconditional positive regard for the client.

Remember that all change contains an element of ambivalence which can result in feeling frozen.  Remember the last big change that you made and how challenging the journey of change can be.

Music

Music is one common thing that interests all of us at some level or the other. It bridges the gap between verbal and nonverbal communication. Using music in therapy is, by far, one of the most reliable and effective strategies for sustaining client engagement in treatment.

Here are some ways we can use music as an active client engagement intervention. It works well for clients of all ages and backgrounds and adds meaning to the therapeutic alliance as a whole.

Talk about music and discuss each other’s interests in songs or other forms of music. Make the conversation mutual – be careful not to be pushy, try to make it progress as a smooth flowing conversation about each other’s music interests.

Ask Focused Questions

Even before your first session with a client, you have the chance to start asking the right questions. Most counselors use an intake form to get some basic questions answered.

A lot of these questions are procedural, such as date of birth, medical history, and history of mental illness. It’s also a chance for you to see a broad range of symptoms.

Some common questions on an intake form ask patients to rate symptoms on a scale of one to five. You might also ask how frequently a client has experienced a problem in the past month. Intake forms can be helpful for you to get information the client might not think to share.

For example, someone seeking therapy for depression might not realize how their relationships or their alcohol usage relate to their condition.

Before you begin the first session with a new client, review any initial information they provided. If you give clients intake forms a few days before the initial session, you can take some time to review it.

You’ll ask a lot of questions during the first session. The more informed your inquiries are, the more comfortable you can make your client feel.

A client might spend 10 or 20 minutes answering questions on a detailed intake form. If you repeat these same questions face to face, the client may feel as though you are wasting their time. Instead, use what information you have to ask for clarification.

Give your client space to expand upon the answers they already gave. One great way to get some information about a client’s concern is to ask, “What brings you in today? Why now and not three months ago?”

By asking specific, focused questions, you can uncover new nuggets of insight and encourage your clients to share. Pay attention to the kind of language they use. Know that the client relationship strengthens with time.

Some people will only share surface-level information at first. If the questions you ask aren’t working, try rephrasing or asking different ones.

As your relationship with your client grows, you can use questions to prompt further conversation. Here’s a breakdown of some short focused diagnostic evaluation:

  • Ask first about the main clinical concern by asking what brought them in, or how can you help?
  • Normalize and Validate that concern
  • Ask a few follow-up questions to get a broad understanding of the issue
  • Ask about previous therapy experiences, and what was helpful and not helpful about those experiences, so you can quickly learn how the client responds to therapy in general (I make sure to incorporate this into the ‘plan’ that I share towards the end of the consult)
  • Ask if there are any other major clinical concerns.
  • Ask about how the client has felt since your last meeting. What has he/she been doing? If the client had discussed upcoming plans, ask about how things went.
  • How has your mood been, on a scale of one to 10?
  • If a loved one approached you with this same problem, what would you say to them?

Talk about what the client wants from therapy

The client’s goals for therapy might be very different from what you assume they are or think they should be. Talk to the client about what they hope to get from therapy. Then use these goals as guideposts.

When the client clams up, explain to them how discussing a particular topic can help them achieve their goals.

Participation

Engagement as participation or involvement is all about creating equality and making clients feel as powerful as the therapist. Some strategies to promote client participation in mental health interventions are:

Making the treatment plan in collaboration with the client. Therapists and clients can sit together to discuss what they expect at termination and decide how to achieve the ultimate goal.

Engaging in active feedback sessions where both the therapist and the client can openly discuss what they like about the sessions and what they would like to change.

Listen to the client attentively (Active Listening)

Active listening is essential for any client relationship, especially for one where the client is nervous about opening up. Engaged listening validates a speaker’s thoughts and ideas by showing the person that their words are worth paying attention to.

Active listening has three stages.

Comprehension: First, you must actively hear and analyze what the speaker says. You cannot get distracted or start thinking about other things.

Retention: You should remember what people tell you. As a counselor seeing many patients, often with a week or two in between sessions, this can be challenging. You can try taking some notes or using memory tricks. When you can recall specific details about a client from week to week, it can help build rapport with the client and make them feel understood.

Response: You should provide verbal and nonverbal feedback to show you are both hearing and understanding what the speaker is saying.

Here are a few ways to show active listening:

  • Summarize what the client says and repeat it to them.
  • Ask clarifying questions when a client tells a story.
  • Make eye contact and use body language such as nodding, smiling, and leaning forward.
  • Use small verbal cues such as “tell me more” and “I see.”

Additional information that could help them understand a diagnosis

You may provide a diagnosis at the end of the session. If so, directing the person you’re working with, to a helpful book or article could help them understand their condition better if they’re interested.

This outside reading could also help prepare them for your next session.

Some people don’t return to therapy after their first appointment. Showing a person who has made the decision to reach out that you care about what they have to say and are interested in helping them will make it more likely they’ll return for future sessions.

Assign homework

You may or may not use homework as part of your approach. If you think it might help your client to complete a journaling or meditation exercise outside of the session, for example, you might bring this up at the end of the session.

Stay in Touch

Making the client feel connected to the therapeutic relationship can be crucial. With sessions sometimes a week or two apart, you want your clients to feel like they have resources to help them through a tough time.

Consider giving your clients an email or a phone number where they can reach you. Let them know they can get in touch with you if something comes up. Most clients will appreciate the gesture and will not abuse the privilege.

You can also provide them with some resources to turn to on their own, such as a mental health blog or a support group.

Another way to encourage your clients to stay in touch is to have them follow your social media and email newsletters. A digital presence gives your clients a way to feel connected with you throughout their daily life.

If you encourage clients to follow your social media pages or email blasts, it’s crucial to remain active and involved online. Post articles, relaxation tips, grounding exercises and other resources that will be helpful to your clients.

Confidentiality

The groundwork of client engagement in psychotherapy is trust and confidentiality. When an individual realizes that he is safe to share his feelings without being judged, he will naturally feel more inclined to participate actively.

Frequently Asked Questions (FAQs)

A deeper understanding of Positive psychology

  1. How do you deal with clients asking personal questions in therapy?

Tell them it is a personal question that you are not comfortable answering. Then explain the nature of a therapeutic relationship.

Then turn the question around to understand the motivation of asking the question. Maybe the client has trust issues and investigating as a way to feel safe.

  1. What are some red flags that would indicate client resistance?

Excusing. The client makes excuses for his/her behavior.

Challenging. The client directly challenges the accuracy of what the clinician has said.

Discounting. The client questions the clinician’s personal authority and expertise.

Hostility. The client expresses direct hostility toward the clinician.

  1. How would you deal with a difficult client in therapy?

Determine the Client’s Stage of Readiness. Give the Client Choices. Establish a set of Rules. Focus on Client Strengths. Don’t Ask “Why”. Pay Attention to Patient Behaviour. Provide Alternative Constructs. Be Aware of Client Questions.

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