Treatment resistance is challenge for practitioners

Patient X doesn’t show up for an appointment–again. He calls and explains that his dog was sick/mother needed a ride/ car broke down. Client J is late for nearly every appointment. Patient K offers every excuse she can think of for why a particular solution will not work for her–no matter the solution. Patient N, a teenager, is openly critical of you, your clothes, your hair, and your skills as a therapist.

No one said that life as a therapist would be easy. No matter the population–younger, older, more or less seriously ill, there are at least one or two in every practice.

These are the patients that may make you cringe when you wake up the day they are on your schedule. At times, you may want to walk out the door or react in some other seriously “non-professional” way. You may think of them as your “difficult” patients or as “angry,” “troubled,” or “offensive.”

Treatment resistance happens in nearly every practice and there are ways to address the problem. Experts all over the internet offer valuable suggestions like stepping away if a session gets over-whelming; encouraging the client to offer solutions, to be the expert of their own treatment; or seeing a roadblock as a key to eventual success.

These experts agree that these patients may be “difficult” but they are not, in most cases, “impossible.” (Caveat: some patients may be better with another therapist if a relationship seems too fraught with emotion or rebellion).

Two experts provided novel ways to look at how to handle treatment resistance.

Jeremy Ridenour, Psy.D, is the director of psychological testing and associate director of admissions and a staff therapist at Austen Riggs Center, an open psychiatric hospital in Stockbridge, Mass.

Although many of the clients he works with have complex psychiatric problems, he believes that the steps to understanding and working with resistance to therapy are the same for every level of client.

The first step is understanding that symptoms are, in part, adaptive, and provide support in some way.

“Symptoms are an effort to manage life’s problems,” Ridenour said. It is when those symptoms are no longer helping or are getting in the way of living a full life that a client may come looking for help. Still, that doesn’t mean they have resolved the reason they developed the symptoms.

A key to understanding resistance is understanding how clients benefit from the symptoms and helping them find another way to provide themselves the same thing, but in more healthy ways.

It’s important to see your own role in the relationship especially when you are feeling frustrated. “If you are finding yourself in a position where you need to push a client, maybe it’s time to step back and see if you are too invested in a certain direction,” Ridenour said.

Keeping the client’s stated goals at the forefront of treatment can help keep the focus on the client’s journey.

“Make the patient’s agenda preeminent and allow it to set the stage,” he said. “Make sure to engage them and work towards their agenda to promote their sense of agency.”

‘We are not respectful enough of what our patients care about,” he said. “A lot of resistance might go away if we take seriously the patient’s agenda.”***

Mitch Abblett, Ph.D, is a clinical psychologist in Wellesley, Mass., and the executive director of the Institute for Meditation & Psychotherapy. Among other books for the general public, he wrote one for clinicians, “The Heat of the Moment in Treatment: Mindful Management of Difficult Clients” (W. W. Norton & Company, 2013).

He believes understanding clients starts with understanding oneself.

Start, he explained, by recognizing that you will have emotional and/or physical responses to certain patients.

“We are trained to maintain empathy, to be a blank slate and focus on the client’s struggles, reactivity, pathology, but when we are working with patients who push our buttons for one reason or another, we have to understand that we are going to have emotional reactions,” he said.

“It seems like common sense but a lot of therapists need that reminder to understand that it is universal.”

The next step is to practice mindfulness, both in and outside of the office.

“The ability to be in the moment can help a therapist better understand what lies behind the behavior for the client, compassionately, and be able to be more effective at pulling out tools from your own tool kit to deal with a situation.”

Practicing mindfulness throughout the day is the key, he said. In addition to setting aside time daily for a 10-15 minute meditation, set up certain markers to remind yourself to take a moment, breathe and center yourself.

“Notice what arises as it arises without judgment,” he said. “Maybe you have a reaction when seeing one client’s name in your appointment book. Watch it and let it move through you which, in turn, will help to create more presence when the person walks into the room.”

One last tip, he offered, is to use that mindfulness to notice how you speak, with yourself or others, about certain difficult clients or disorders and what message you are sending with your words.

“I hear people say, ‘I don’t treat borderlines,’ or ‘That person is manipulative.’” He said. “It’s not that we have to treat people with borderline personality disorder, but can we hold these people in our minds with compassion? How we frame our clients says so much.”

Catherine Robertson Souter is a freelance writer and social media agent based in New Hampshire. A contributor to New England Psychologist since its inception, she previously wrote for Massachusetts Psychologist among other media outlets.