Qualitative Study of Effective Interventional and Management Strategies for Psychotherapists and Counselors Dealing with Difficult Clients

Document Type : Research Paper


1 Department of Counseling, Faculty of Education and psychology, University of Isfahan, Isfahan, Iran.

2 Department of Psychology, Faculty of Psychology and Educational Science, University of Khatam, Tehran, Iran.

3 Department of Educational Psychology and Counseling, Faculty of Psychology and Educational Sciences, University of Tehran, Tehran, Iran.


 The primary objective of this study was to ascertain the experiences of Iranian therapists who dealt with challenging customers and to examine the approaches they utilized. The present research employed a qualitative form of phenomenology as its research methodology. In 2021 and 2022, the community of this study comprised active therapists in Tehran. With the purposeful continuation of sampling until the saturation limit was reached, seventeen therapists were ultimately chosen. The participants were subsequently asked to complete semi-structured interviews. The data were analyzed utilizing Colaizzi’s method of descriptive data analysis. Through the examination of the data, 60 primary concepts, 9 sub-themes, and 2 main themes were identified. The overarching theme comprises two components: firstly, efficacious approaches during the therapeutic session (encompassing general therapeutic communication strategies, general individual strategies, specialized strategies pertaining to clients experiencing marital difficulties, specialized strategies pertaining to clients confronting family issues, and specialized strategies pertaining to clients diagnosed with personality disorder); and secondly, successful strategies implemented outside of the session (including general social strategies, support systems. Overall, the findings of this study indicated that clinicians’ approach to challenging clients influences the caliber of care they provide. Therefore, training and a competent supervisor are required in this field.


آسایش، م. ح.، گلپاشا، ا.، و باهنر، ف. (1400). تبیین تجارب رفتاری و مقابله‌های روان‌شناختی زنان قربانی رابطۀ فرازناشویی: یک تحقیق کیفی. پژوهش‌های کاربردی روان‌شناختی. 12 (4)، 269-251. https://doi.org/10.22059/JAPR.2022.327642.643921
آسایش، م. ح.، فرحبخش، ک.، دلاور، ع.، و سلیمی، ح. (1397) . شناسایی و تبیین تجارب و واکنش‌های معنوی زنان قربانی خیانت زناشویی: یک مطالعۀ پدیدارشناسی. پژوهشنامۀ اسلامی زنان و خانواده. 6(3)، 78-57. http://pzk.journals.miu.ac.ir/article_2113.html
آسایش، م. ح.، قاضی‌نژاد، ن.، و باهنر، ف. (1399). تبیین واکنش‌های عاطفی دختران با نشانگان شکست عشقی؛ مطالعه‌ای کیفی. فصلنامۀ فرهنگی-تربیتی زنان و خانواده. 15(53)، 154-125. https://cwfs.ihu.ac.ir/article_206019.html
ایمان، م. ت. (1397). روش‌شناسی تحقیقات کیفی. چاپ چهارم. قم: حوزه و دانشگاه.
بازرگان، ع. (1402). مقدمه‌ای بر روش‌های تحقیق کیفی و آمیخته: رویکردهای متداول در علوم رفتاری. چاپ پنجم. تهران: دیدار.
باهنر، ف.، آسایش، م. ح.، و قاضی‌نژاد، ن. (1398) . تبیین واکنش‌های رفتاری و مقابله‌های دانشجویان دختر با نشانگان ضربۀ عشقی: یک مطالعۀ پدیدارشناسانه. فصلنامۀ پژوهش‌های علمی زن و فرهنگ. 11(41)، 134-111. https://journals.iau.ir/article_669166.html
بنی‌اسد، ع.، و صالحی، ک. (1398). مقدمه‌ای بر اصول و فرایند ساخت و رواسازی پروتکل مصاحبه. مجلۀ نامۀ آموزش عالی. 12(46)، 203-177. https://journal.sanjesh.org/article_36128.html
خاتمی، ا. (1387). بررسی آداب پیوند زناشویی و امور خانواده در شاهنامۀ فردوسی. خانواده‌پژوهی. 4(3)، 320-302. https://jfr.sbu.ac.ir/article_95182.html
دهقانی، م.، و آزرمی بستان‌آباد، ک. (1401). روایت‌پژوهی تجارب زیستۀ یک مشاور: بررسی اختلالات اضطراب در دانش‌آموزان دبیرستانی. پژوهش‌های کاربردی روان‌شناختی. 13(4)، 232-217. https://doi.org/10.22059/japr.2023.340944.644221
شفیع‌آبادی، ع. (1400). روش‌ها و فنون مشاوره (مصاحبه بالینی). چاپ سی و نهم. تهران: فکر نو.
محمدپور، ا. (1392). روش تحقیق کیفی ضد روش. چاپ اول. تهران: جامعه‌شناسان. https://www.adinehbook.com/gp/product/6002230607
مدیری، ف.، و مهدوی، م. ص. (1396). ارزش‌های پست‌مدرن خانوادگی در شهر تهران. خانواده‌پژوهی. 3(3)، 296-281. https://jfr.sbu.ac.ir/article_96700.html?lang=fa
مفتون، ف.، شریفان، م.، و نقی‌زاده‌موغاری، ف. (1397). تبیین محورهای اصلی خودمراقبتی به تفکیک سطوح پیشگیری و تعیین ابعاد مدیریتی آن. نشریۀ پایش. 17(4)، 370-361. http://payeshjournal.ir/article-1-31-fa.html
یوسفی‌لویه، م. (1388). راهبردهای ارتقای سلامت مشاوران: راهبردهای شناختی (2): شناخت اجتماعی و درک دیدگاه. نشریۀ مشاورۀ مدرسه، 15(4)، 30-28.
Asayesh, M. H., Hoseinzei, E. & Golpasha, E. (2017). Violence against women and its relationship with self-esteem of married women in Tehran. New Trends and Issues Proceedings on Humanities and Social Sciences, 3(2), 59-64. https://un-pub.eu/ojs/index.php/pntsbs/article/view/1600
Asayesh, M. H., Golpasha, E., & Bahonar, F. (2022). Explaining the Behavioral Experiences and Psychological Coping of Women Who Are Victims of an Extramarital Relationship: A Qualitative Study. Journal of Applied Psychological Research12(4), 251-269. https://doi.org/10.22059/japr.2022.327642.643921 (In Persian(
Asayesh, M. H., Farahbakhsh, K., Salimi Bajestani, H., & Delavar, A. (2018). Identifying and explaining the spiritual experiences and reactions of women victims of marital infidelity: a phenomenological study. The Islamic Journal of Women and the Family6(3), 57-78. http://pzk.journals.miu.ac.ir/article_2113.html (In Persian(
Asayesh, M. H., Farahbakhsh, K., Salimi Bajestani, H., & Delavar, A. (2020). Explanation of Experiences and Emotional Reactions in Women Victims of Infidelity: A Qualitative Study. Journal of Qualitative Research in Health Sciences6(4), 355-372. https://jqr1.kmu.ac.ir/article_91102.html
Asayesh, M. H., Qazinejad, N., & Bahonar, F. (2021). Explanation of the Emotional Reactions of Girls with Love Trauma Syndrome: A Qualitative Study. The Women and Families Cultural-Educational15(53), 125-154. https://cwfs.ihu.ac.ir/article_206019.html?lang=en (In Persian(
Bahonar, F., Asayesh, M., & Ghazinezhad, N. (2019). Explanation of Behavioral Reactions and Comparisons Girl Students with Love Truma Syndrome: A Phenomenological Study. Woman and Culture11(41), 111-134. https://jwc.ahvaz.iau.ir/article_669166.html?lang=en (In Persian(
Baniasadi, A., & Salehi, K. (2019). Introduction on the Principles and Process of Construction and Validation of the Interview Protocol. Higher Education Letter12(46), 177-203. https://journal.sanjesh.org/article_36128.html?lang=en (In Persian(
Baum, N. (2009). Dealing with difficult patients. The Journal of Medical Practice Management: MPM25(1), 6-33.‌ https://pubmed.ncbi.nlm.nih.gov/19743707/
Bazargan, A. (2023). An introduction to qualitative and mixed research methods: common approaches in behavioral sciences (5th Ed.). Tehran: Didar. (In Persian(
Bos, M. V., Kool-Goudzwaard, N., Gamel, C. J., Koekkoek, B., & Van Meijel, B. (2012). The treatment of ‘difficult’patients in a secure unit of a specialized psychiatric hospital: the patient's perspective. Journal of Psychiatric and Mental Health Nursing19(6), 528-535. https://doi.org/10.1111/j.1365-2850.2011.01827.x
Burns, N., & Grove, S. K. (2015). Understanding Nursing Research-eBook: Building an Evidence-Based Practice. 6 Edition. Texas: Elsevier Health Sciences. https://evolve.elsevier.com/cs/product/9781455772520?role=student
Butler, E. A., Egloff, B., Wilhelm, F. H., Smith, N. C., Erickson, E. A., & Gross, J. J. (2003). The social consequences of expressive suppression. Emotion, 3(1), 48-67. https://doi.org/10.1037/1528-3542.3.1.48
Crutcher, J. E., & Bass, M. J. (1980).The difficult patient and the troubled physician. JFam Pract, 11(6), 933-8. https://pubmed.ncbi.nlm.nih.gov/7452158/
Curtis, C. (2006). Dealing with the difficult client. Canadian Family Law Quarterly25(3), 291-299.
Dehghani, M., & Azarmi Bostanabad, K. (2022). Narrative research of a counselor's lived experiences: A study of anxiety disorders in high school students. Journal of Applied Psychological Research13(4), 217-232. https://doi.org/10.22059/japr.2023.340944.644221 (In Persian(
Denyes, M. J., Orem, D. E., & Bekel, G. (2001). Self-care: A foundational science. Nursing Science Quarterly, 14(4), 48-54. https://doi.org/10.1177/08943180122108526
Fischer, C., Cottin, M., Behn, A., Errázuriz, P., & Díaz, R. (2019). What makes a difficult patient so difficult? Examining the therapist's experience beyond patient characteristics. Journal of Clinical Psychology75(5), 898-911.‌ https://doi.org/10.1002/jclp.22765
Garcia, H. A., McGeary, C. A., Finley, E. P., McGeary, D. D., Ketchum, N. S., & Peterson, A. L. (2016). The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes. Psychology and Psychotherapy: Theory, Research and Practice89(1), 66-81. https://doi.org/10.1111/papt.12057
Gerritsen, S., Widdershoven, G., Van der Ham, L., van Melle, L., Kemper, M., & Voskes, Y. (2021). Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations. International Journal of Mental Health Nursing30(1), 317-325.‌ https://doi.org/10.1111/inm.12786
Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 105–117). Sage Publications, Inc.
Haas, L. J., Leiser, J. P., Magill, M. K., & Sanyer, O. N. (2005). Management of the difficult patient. American Family Physician, 72(10), 2063–2068. https://pubmed.ncbi.nlm.nih.gov/16342837/
Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B., Linzer, M., & DeGruy, F.V. (1996). The difficult patient: prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11(1), 1-8. https://doi.org/10.1007/BF02603477
Holloway, I., & Galvin, K. (2017). Qualitative Research in Nursing and Healthcare (4th Ed.). Hoboken, Wiley-Blackwell.
Hunter, S. V., & Schofield, M. J. (2006). How counsellors cope with traumatized clients: Personal, professional and organizational strategies. International Journal for the Advancement of Counselling28(2), 121-138. https://doi.org/10.1007/s10447-005-9003-0
Iman, M. T. (2017). Qualitative Research Methodology (4th Ed.). Qom: Hawzeh and University. (In Persian(
Khatami, A. (2009). Examining the rituals of marriage and family affairs in Ferdowsi's Shahnameh, Family Research, 4(3), 320-302. https://jfr.sbu.ac.ir/article_95182.html (In Persian(
‌Koekkoek, B. (2011). Ambivalent Connections: Improving Community Health Care for NonPsychotic Chronic Patients Perceived As ‘Difficult’. Radboud Universiteit, Nijmegen.
Koekkoek, B., Hutschemaekers, G., Van Meijel, B., & Schene, A. (2011). How do patients come to be seen as ‘difficult’? A mixed-methods study in community mental health care. Social Science & Medicine, 72(4), 504–512. https://doi.org/10.1016/j.socscimed.2010.11.036
Koekkoek, B., Van Meijel, B., & Hutschemaekers, G. (2006). Difficult patients in mental health care: a review. Psychiatric Services57(6), 795-802. https://doi.org/10.1176/ps.2006.57.6.795
Maftoon, F., Sharifan, M., & Naghizadeh Moghari.F. (2018). Self-care in health system: Prevention and management dimensions. Payesh, 17(4), 361-370. http://payeshjournal.ir/article-1-31-fa.html (In Persian(
Magrath, C. (2019). Dealing with difficult clients. The Veterinary Record184(11), 358-369. https://doi.org/10.1136/vr.l1194
Mayer, M. L. (2008). On being a ‘difficult’ patient. Health Affairs (Project HOPE), 27(5), 1416–1421. https://doi.org/10.1377/hlthaff.27.5.1416
Medeiros, M. E., & James O. P. (1988). Coping strategies that psychotherapists use in working with stressful clients. Professional Psychology: Research and Practice, 19(1), 112-114. https://doi.org/10.1037/0735-7028.19.1.112
Millon, T. (2016). Millon Clinical Multiaxial Inventory -III manual. Minneapolis, MN: National computer systems.
Modiri, F., & Mahdavi, M. S. (2016). Postmodern Family Values in Tehran. Journal of Family Research11(3), 281-296. https://jfr.sbu.ac.ir/article_96700.html?lang=en (In Persian)
Mohammadpour, A. (2012). Qualitative research method against method 1. Tehran: Sociologists. https://www.adinehbook.com/gp/product/6002230607 (In Persian)
Morse, J. M. (2015). Critical Analysis of Strategies for Determining Rigor in Qualitative Inquiry. Qualitative Health Research, 25(9), 1212-1222. https://doi.org/10.1177/1049732315588501
Moukaddam, N., Flores, A., Matorin, A., Hayden, N., & Tucci, V. T. (2017). Difficult patients in the emergency department: Personality disorders and beyond. The Psychiatric Clinics of North America, 40(3), 379–395. https://psycnet.apa.org/doi/10.1016/j.psc.2017.05.005
Ozen, M. E., Orum, M. H., & Kalenderoglu, A. (2018). Difficult patient in psychiatry practice: A case-control study. Health Sciences Journal of Adıyaman University, 4(3), 1064-1073. https://doi.org/10.30569/adiyamansaglik.458680
Quinn, B. (2002). How psychotherapists handle difficult clients: Lessons for librarians. The Reference Librarian, 36(75-76), 181-196.‌ https://doi.org/10.1300/J120v36n75_17
Russel, S., Daly, J., Hughes, E., & Hoog, C. C. (2003). Nurses and difficult patients: negotiating non-compliance. Journal of Advanced Nursing, 43(3), 281–287. https://doi.org/10.1046/j.1365-2648.2003.02711.x
Seligman, L., & Gaaserud, L. (1994). Difficult clients: Who are they and how do we help them? Canadian Journal of Counselling and Psychotherapy28(1), 145-165. https://cjc-rcc.ucalgary.ca/article/view/58491
Serour, M., Othman, H. A., & Khalifah, G. A. (2009). Difficult Patients or Difficult Doctors: An Analysis of Problematic Consultations. European Journal of General Medicine6(2), 10-20. https://doi.org/10.29333/ejgm/82646
Shafi Abadi, A. (2022). Counseling methods and techniques (clinical interview) (39th Ed.). Tehran: Fekr-e Now. (In Persian(
Snippe, E., Schroevers, M. J., Tovote, K. A., Sanderman, R., Emmelkamp, P. M., & Fleer, J. (2019). Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement. Clinical Psychology & Psychotherapy26(1), 84-93.‌ https://doi.org/10.1002/cpp.2332
Softas-Nall, L., & Hanna, F. (2013). Counseling and Psychotherapy with Difficult Clients/Family Members: An Interview with Fred Hanna. The Family Journal21(1), 117-121.‌ https://doi.org/10.1177/1066480712456830
Stringer, B., Van Meijel, B., De Vree, W., & Van der Bijl, J. (2008) User involvement in mental health care: the role of nurses. A literature review. Journal of Psychiatric and Mental Health Nursing, 15(8), 678– 683. https://doi.org/10.1111/j.1365-2850.2008.01285.x
Wasan, A. D., Wootton, J., & Jamison, R. N. (2005). Dealing with difficult patients in your pain practice. Regional Anesthesia & Pain Medicine30(2), 184-192.‌ https://doi.org/10.1016/j.rapm.2004.11.005
Williams, L., & Day, A. (2007). Strategies for dealing with clients we dislike. The American Journal of Family Therapy35(1), 83-92. https://doi.org/10.1080/01926180600550494
Yousefi Louye, M. (2008). Counselors’ health promotion strategies: cognitive strategies (2): social cognition and perspective understanding. School Counseling Journal, 15(4), 28-30. (In Persian)
Yourman, D. B., & Farber, B. A. (1996). Nondisclosure and distortion in psychotherapy supervision. Psychotherapy: Theory, Research, Practice, Training, 33(4), 567–575. https://doi.org/10.1037/0033-3204.33.4.567