What I Do When My Client Says, "No."
There was a question about working with persons with the diagnosis of Oppositional Defiance Disorder (ODD) on one of my social media links, and a friend of mine tagged me to respond. I started to think about the folks that I know who have come in with this label, and how I worked with them. In my years of working with children and adolescents with a variety of concerns, I have found that the way I work with those with the initials ODD as part of their mental and developmental health diagnoses is not that different from how I work with those without those particular letters.
When I start to sit down and think deeply about what I want the therapeutic relationship to look like, I want my clients to make decisions about their own treatment. I want my clients to know that they have a say in what we do, and how we do it. I want to foster a mutual respect for the clients who come to music therapy with me. To that end, I find that there are times when my clients don't want to do what I have in mind. They say, "No."
This is defeating. I've spent lots of time with my therapy strategy, and I'm ready to try something that I have in mind, and my client says, "No."
I admit, as a novice therapist, I would kind of stand there blinking and halfheartedly try to get them into the therapeutic music experience (TME) while my brain was racing around questions such as "Oh no. This is a failure." or "$#^@! Now what?" I'd like to say that those questions have gone away, but they still arrive occasionally. I usually can move into one of my strategies (listed below) without too much of a pause, but there are still moments when my mind goes blank.
The first thing that I try to do from the very beginning of working with a client is to establish that refusal is okay, but I still expect manners and communication. I tell my clients that they can choose if they want to participate. If they choose not to participate, they can say, "No, thank you," and (and this is the REALLY IMPORTANT PART) I will respect their wishes. If they change their minds, they can join in any time.
There are other expectations as well - I ask that my clients sit up during music therapy (they are so hard to waken when the next group arrives for their session), and we have our school-wide Positive Behavior Interventions and Strategies (PBIS) expectations in place too. The first expectation, polite choosing, is the most important to me.
If a client does not communicate, then I proceed as if their answer is "yes." We have that discussion as well. "If you don't answer, then it is my job to believe that you want to do what I have prepared, so I keep going and going and going." We usually go through this process at least once during each relationship, and then we both know what will happen and we don't have to do it again.
In a group session, I allow clients to sit and watch their peers engage. Often, clients refuse from a place of insecurity and/or fear of embarrassment, so I've found that if they can watch their peers engage, they often join in - especially if their refusal is respected and supported by the therapist. Interestingly, I have more difficulties with classroom staff members not respecting choices than I do with my clients. I have to support the decision of the client, even if it goes against what a co-worker is insisting upon. (That's a whole other blog post!) No one likes to look foolish, especially in front of peers, so refusal may happen.
In an individual session, I don't often have the same issues. I can mold all of my music therapy interactions around one client, so there is lots of opportunity for choices. We work on finding things we can mutually engage in during treatment.
I have several strategies that I use when a client initially refuses to engage in music therapy. Here they are (in no particular order):
The ideas and strategies presented here do not work with everyone. There are some people who simply do not respond to either me or to music and who will not engage. That also has to be acknowledged and supported as a choice. I don't think I do too badly - I think there are about 107 out of 111 clients that engage in music therapy, and the 4 that don't really don't engage in anything, so that's not a bad percentage. For some reason though, I am often more concerned about the 4 who do not participate than I am about the 107 who do. This is typical, I think (I hope). I keep trying to engage those 4 clients, but I do have an ethical responsibility to the others who do want to participate. I cannot ignore the others for the sake of the ones who are not interested.
There you go. That's what I do when any of my clients say "no."
Happy Wednesday!
When I start to sit down and think deeply about what I want the therapeutic relationship to look like, I want my clients to make decisions about their own treatment. I want my clients to know that they have a say in what we do, and how we do it. I want to foster a mutual respect for the clients who come to music therapy with me. To that end, I find that there are times when my clients don't want to do what I have in mind. They say, "No."
This is defeating. I've spent lots of time with my therapy strategy, and I'm ready to try something that I have in mind, and my client says, "No."
I admit, as a novice therapist, I would kind of stand there blinking and halfheartedly try to get them into the therapeutic music experience (TME) while my brain was racing around questions such as "Oh no. This is a failure." or "$#^@! Now what?" I'd like to say that those questions have gone away, but they still arrive occasionally. I usually can move into one of my strategies (listed below) without too much of a pause, but there are still moments when my mind goes blank.
The first thing that I try to do from the very beginning of working with a client is to establish that refusal is okay, but I still expect manners and communication. I tell my clients that they can choose if they want to participate. If they choose not to participate, they can say, "No, thank you," and (and this is the REALLY IMPORTANT PART) I will respect their wishes. If they change their minds, they can join in any time.
There are other expectations as well - I ask that my clients sit up during music therapy (they are so hard to waken when the next group arrives for their session), and we have our school-wide Positive Behavior Interventions and Strategies (PBIS) expectations in place too. The first expectation, polite choosing, is the most important to me.
If a client does not communicate, then I proceed as if their answer is "yes." We have that discussion as well. "If you don't answer, then it is my job to believe that you want to do what I have prepared, so I keep going and going and going." We usually go through this process at least once during each relationship, and then we both know what will happen and we don't have to do it again.
In a group session, I allow clients to sit and watch their peers engage. Often, clients refuse from a place of insecurity and/or fear of embarrassment, so I've found that if they can watch their peers engage, they often join in - especially if their refusal is respected and supported by the therapist. Interestingly, I have more difficulties with classroom staff members not respecting choices than I do with my clients. I have to support the decision of the client, even if it goes against what a co-worker is insisting upon. (That's a whole other blog post!) No one likes to look foolish, especially in front of peers, so refusal may happen.
In an individual session, I don't often have the same issues. I can mold all of my music therapy interactions around one client, so there is lots of opportunity for choices. We work on finding things we can mutually engage in during treatment.
I have several strategies that I use when a client initially refuses to engage in music therapy. Here they are (in no particular order):
- Offer choices often. Most of the time, I don't require that clients engage in the opening TME, but I do encourage them to do so. I genuinely like to know what is going on in their lives, and I have a chance to assess their state of being when we focus on that communication. I offer choices of instruments to play, music to listen to, time-filler TMEs, where and how to sit, etc. There are many opportunities for choice making during each session, and I try to get to them all.
- Ask for suggestions. I ask my clients to suggest music, TMEs, things to do, things to learn about, and every other thing I can think about. I then follow through and attempt to accommodate those suggestions into music therapy sessions.
- Establish ground rules for non-negotiable expectations. There are some things that just cannot happen in a music therapy session. Emotional expression is expected, physical aggression from that emotion is never appropriate. We talk about these ground rules from a position of what we do want to happen rather than the "No" rules. As the session "authority," I then have to keep those expectations every session, every day, every situation.
- Stick with those expectations. No one can possibly learn what is expected of them if those expectations change every single time. I have to stick with my expectations, and I have to respond the same way each time in order to assist my clients in learning what is appropriate and what is not.
- Limit the emotional response to what a client says. My professor once told us all, "Whatever you are most insecure about about yourself, get over it. Clients will pick up on that insecurity and will use it." It is difficult to mask my emotion when a client makes threats against me, but it is important to do so. As soon as a client finds my weakness, he or she will use it in moments of intense emotion. When a client is screaming obscenities, I have to focus on something other than the words. When a client refuses to participate in a TME, I have to remember that getting upset or frustrated about that will probably increase the likelihood that the client will refuse the next TME. I have to shrug it off and remind the client that he or she is entitled to choose to participate. At that point, I tend to make a general announcement about the points that clients can earn during sessions to remind folks about the expectations of manners and safety.
- Offer choices again. I offer multiple opportunities for choices. Saying "no" once doesn't mean that you are done during the session. There are always opportunities to engage.
- Offer choices within a fixed structure. This is one of the subtle linguistic things that many of us are unable to do. Here is an example: Me: "Are you ready to go back to class?" Client: "No." Me: Uhhhh. I have set up a situation when I gave the power of making the decision to the client. The client chose something that I didn't want, but I gave that decision to the client. If I say, "Well, you have to go to class," then I have negated the decision that I gave to the client. Not good. I usually wait a couple of minutes, and then offer a choice again. Me: "Would you like to sing 'Na Na Na' or 'On Our Way' as we go back to class." Now I am offering a choice opportunity, but the targeted behavior (that of going back to class) is not the negotiable part.
The ideas and strategies presented here do not work with everyone. There are some people who simply do not respond to either me or to music and who will not engage. That also has to be acknowledged and supported as a choice. I don't think I do too badly - I think there are about 107 out of 111 clients that engage in music therapy, and the 4 that don't really don't engage in anything, so that's not a bad percentage. For some reason though, I am often more concerned about the 4 who do not participate than I am about the 107 who do. This is typical, I think (I hope). I keep trying to engage those 4 clients, but I do have an ethical responsibility to the others who do want to participate. I cannot ignore the others for the sake of the ones who are not interested.
There you go. That's what I do when any of my clients say "no."
Happy Wednesday!
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