Throughout my career, I have struggled with how consent is understood in the mental health field. Across the agencies and settings where I’ve worked, it has often been approached as a binary: the person either consents to therapy or they don’t. When they don’t, families are often told, “We can’t help without their consent.”
Looking back, I can see that my own understanding of consent began long before I became a therapist. At fifteen, I was a camp counsellor working with four- and five-year-olds. Some were frightened of the water and refused to go in. Having been a sensitive child myself, I believed their fear deserved patience and understanding. I also believed learning to swim mattered, and I was confident they could learn, even if it took several weeks of easing them in and encouraging each small step. Eventually, every one of my campers was swimming and enjoying the water.
Growing up, I saw people hurt others and then refuse to take responsibility for their behaviour. In my family, there was considerable blaming and externalizing. Someone could be yelling, insulting, or demeaning another person while remaining convinced that the other person was the problem. Their refusal seemed to communicate, “Leave me alone. Don’t hold me accountable.” I came to recognize this as wilful refusal: refusing to acknowledge the reality of a problem and the need to address it. Even then, I struggled to accept that someone could cause harm and then insist that their behaviour was beyond discussion. I sensed that shame, fear, and anxiety could make it difficult for someone to acknowledge the harm they were causing.
Throughout my career, I have worked with many people who initially refused help. That experience has taught me, repeatedly, how much can sit behind a refusal. “No” may mean “I don’t feel safe with you,” “I don’t trust you,” or “I’m afraid you’ll use what I tell you in ways I can’t control.” It may mean “You’ll judge me,” “You won’t like me once you know,” or “I’m ashamed of what I’ve done, and talking about it will make me feel worse.” These are the kinds of concerns many people have shared once we got to the other side of their “no.”
Over my thirty years in not-for-profit mental health agencies, my willingness to work with externalizing teenagers increasingly shaped my caseload. These were young people with conduct and behavioural problems who acted out, blamed others, and fought with parents and teachers. They often saw the problem as residing entirely in other people and saw little reason to take responsibility for changing their own behaviour. Many came to therapy under pressure from families, schools, or the courts.
Creating conditions for participation involved two tasks: working with families, schools, and others to establish incentives and disincentives that supported attendance; and helping the young person experience me as an ally. I needed to give them enough control to tell me when I pushed too far or left them feeling judged. I could then back off and repair. Many told me I was the first therapist who had ever apologized to them. I also needed to convey confidence that I could help, connect with something they wanted to change, and cheerlead by acknowledging their fears and helping them see what they could gain by participating.
This is the movement that a binary understanding of consent can obscure. “No, because I’m ashamed” can become “I want help, but I’m ashamed,” and then “Yes, even though I’m ashamed.” The function of the refusal matters. Understanding what it protects and communicates helps us recognize where willingness might develop. The person still needs meaningful choice and influence over what happens.
The stages-of-change framework recognizes that people may initially see little reason to change. DBT gives explicit attention to contingencies, commitment, and cheerleading. I was doing this work long before I encountered those concepts; they gave language and structure to a responsibility I had understood early in my career.
A persistent refusal ultimately stands, and sometimes the surrounding system cannot provide the support needed to make participation possible. Yet I have successfully engaged the majority of the externalizing clients I have worked with.
When families seek help for a young person whose behaviour is causing harm, “Your child doesn’t consent, so there’s nothing we can do” is a devastating response. The mental health system’s unwillingness to engage people who initially refuse help leaves families, schools, and communities living with the same problems. We need more services with the willingness and capacity to understand what lies behind the refusal and address it so that consent can develop.
Reflecting on my career, I can see how my willingness to undertake this work led to a concentration of demanding cases in my caseload. Many young people who began in wilful refusal later told me that our work together had saved their lives. Seeing profound changes in their lives, and experiencing their appreciation and that of their families, has been among the most deeply gratifying experiences of my life.
As I step back from direct clinical work, I want to encourage and support fellow clinicians to undertake this demanding and deeply rewarding work. That means helping clinicians develop the skills and willingness to ask, “This young person is refusing help. What can I do to make participation possible?” Helping young people move from wilful refusal to voluntary consent can open the way to life-changing help—for them, their families, and their communities.
