Working With Difficult Clients

by Joanne Dozor, RN, CPM

© 2001 Midwifery Today, Inc. All Rights Reserved.

[Editor's note: This article first appeared in The Birthkit No. 29, Spring 2001.]

When you are having frequent difficulties with a client, it may be that childhood issues are being triggered for this woman. Do not get pulled into her drama. If you keep the issues current and stay in the ego place of the adult, responding rather than reacting, you will have a better chance of actually working effectively with your client.

We have all dealt with women who are extremely needy and demanding. If a woman does not respond well to healthy boundaries you set for yourself as a midwife, then you are in trouble. Each of us must decide what limits are healthy for us.

My experience is that the longer you work as a midwife, the more you realize how important it is to set limits where you are not forsaking yourself or your family. Burnout is often caused by lack of boundaries. Better to have disagreements in the prenatal period than in labor. Express your need for limits then and set a healthy precedent. Communication over boundary issues can be very telltale and may make or break the midwife-client relationship.

If the situation feels unworkable with a particular woman, it is important to let this client go. Chalk it up to experience. Make sure that you are schooled in the correct legal and political method, however. You do not want to be charged with abandonment.

A woman who has very particular opinions about standards of care may prove to be a difficult client. If you decide to have this client sign a waiver, you nonetheless must be sure that you are really comfortable working with her. You are the one who will be held responsible even if a client signs a waiver—maybe not legally, but medically and in the community. You may find yourself resentful of a woman who refuses everything. You want to feel certain that your client will cooperate if you find yourself in a difficult birth situation. While midwifery is not about control, it is also not about being controlled. This is a cooperative venture, between midwife and client. Keep it honest.

Women who intellectually try to control labor by giving us a long list of demands are often women who do not feel safe in the world and do not trust. When you're working with such a woman, you will need to help her get in touch with her need to control, a process that can be tricky. Again, honesty on your part can be powerful, but often such a woman, because of her severe lack of trust, will not trust you either, and she may have a hard time hearing what you are saying.

Another difficult client to work with is the co-dependent woman who focuses on everyone but herself and in this way does not deal with her own need and her own pain. Co-dependent women sometimes have a difficult time birthing because they have learned to deal with their pain by focusing outside themselves, and they have a difficult time focusing within.

Another kind of woman that should attract your attention is the one who gets too friendly too quickly. She may walk into your kitchen and open your refrigerator. If she befriends you that easily she may also turn her back on you that easily. Issues of severe abandonment tend to plague this kind of woman. She may make you into a goddess one moment and an enemy the next. Remember, if a client has just left another practitioner and is ranting and raving about the care she had, she may also rant and rave about you next week! Watch out here for your own need. We all love to be loved. Again, you must remember to set appropriate boundaries.

The most difficult client to work with is the woman who sees herself as a victim. I have found that there is only one way to work with such a woman, and that is to be blatantly honest, saying things such as, “I am really concerned that no matter what I do and no matter how well I care for you, somehow you will find a reason to blame me.” Unless this client can own her pattern, she is definitely not a good risk for a homebirth. A woman who can talk about her issues no matter how complicated is a much better risk than a woman with few issues who is totally in denial.

If any of your clients is displaying inappropriate behavior, she may be coming from the ego state of a child. She may therefore feel easily shamed and criticized and may take things that you say personally. Being honest is always best; however, your client may become alienated easily.

Remember, you need to look at someone's pattern of behavior, not just what she is saying in the moment. The behavior that you're having trouble with is how your difficult client has learned to cope in the world up to this point. This is how she has survived. Don't take an attitude of blame. However, her behavior can affect her birth and be dangerous to you as her midwife.

If you feel a woman is a good enough risk and you decide to accept her as a client even though she is prone to one or more of these behaviors, then I suggest that you use specific counseling techniques designed to bring more self-awareness, break patterns of denial and uncover the subconscious.

Active Listening

Goal

Productive and responsible communication, with each person responding rather than reacting.

Use

Communicating with your clients, especially when communication is difficult. In couples counseling you are mediator and container and express no opinion. If a couple gets stuck ask one of them, “What are you feeling?” Or go to a body awareness question.

Techniques

1. Checking for accuracy: “Am I hearing you correctly?” If there is some tension in a dialogue, give yourself at least three seconds before you respond.
2. Paraphrasing: Feed back what client just said by shortening and clarifying.
3. Encouraging: Verbal or nonverbal responses, such as “Uh-huh” or “I hear you.”
4. Reflective response: “Can you tell me more about that?”
5. Validation: “That must have been hard for you.”
6. Using I messages: “I'm surprised to hear how strongly you feel.”
7. Repetition: Repeating back what your client has said.
8. Ask client: “Is there more?”

Ego States

In transactional analysis, Eric Berne, MD, describes three different ego states: parent, adult and child. In your role as midwife or other birth practitioner, you will improve your communication with difficult clients by being conscious of your ego state. The goal is to be in the adult ego state as much as possible.

1. Parent: "Critical parent" or "nurturing parent." Shadow side is co-dependency, possibly enabling or patronizing.
2. Adult: The "reality reader" who sees the situation as it is. The ideal adult, with an ability to listen and with developed communication skills. Regardless of where your client is, you stay in the mode of reality reader, able to respond rather than react.
3. Child:

• Natural child (untrained, spontaneous, impulsive, expressive).
• Attached child (whines, complies and rebels).
• Sleepy child (goes away, disassociates, sleeps a lot).
• Spunky child (mischievous, rebellious).
• Spooky child (fearful, takes things personally). Three major fears: fear of suffocation, fear of abandonment or being invisible, fear of annihilation. The more fiercely defensive someone is, the greater his or her fear.

Notes

• Ivey, Allen E. (1988). Intentional Interviewing and Counseling.
• Frye, Anne. (1998). Holistic Midwifery.
• Thanks to Alice Rutkowski, founder of Motional Processing, for her explanation of transactional analysis (TA).

Joanne Dozor, RN, CPM, has been a practicing midwife and childbirth educator for nearly 25 years. Three years ago she began an entry-level midwifery program, the Art of Midwifery, in the Philadelphia area. Her background as a counselor for women and a Gestalt practitioner has given her the ability to integrate counseling skills and practice into her midwifery-training program.

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