Sunday, April 17, 2011

I don't do magic

I suppose it's only normal to become frustrated with patients at times but I hope I can eventually learn to approach it with equanimity.  What frustrates me?  I find it exceedingly difficult to work with people who expect me to do all of the work.  It's like they come to therapy expecting a magic cure;  I'll wave a wand, say a few words, and - voila - they'll be better.  It doesn't bother me that people arrive with these expectations.  Most people have no idea what to expect when they come to therapy.  Part of my job is to explain to patients what they can expect from me and from the therapeutic process.  I typically share just the basics.  After all, I don't really know what to expect from the therapeutic process with a given individual; everyone is different.  Most people readily embrace therapy as a two-way process that requires a certain level of commitment and effort from both parties involved.  These are the people who seem to make the best use of therapy and who generally receive the most benefit.

Then there are people who seriously consider what we discuss in individual sessions and store it away for future reference.  They might not run home and immediately try to make changes in their thoughts and/or behaviors.  Over time, however, they keep referring back to the past conversations they've stored away in their minds.  For these people, change tends to happen very gradually and in very subtle ways.  Still, they make use of our time together; they listen to and seriously consider what takes place in session.

Then there are people who keep showing up to session every week or two, just waiting for me to make them better.  They make no effort to do anything different in their lives outside of session and return the following week complaining that they still feel the same.  In session, it's frequently obvious that they aren't taking anything in.  They cling fervently to their pre-existing beliefs and are not open to exploring where these beliefs came from, how they are affecting their lives, or whether or not they are accurate.  Attempts on my part to engage in such exploration are met by defensiveness or by blank stares.

Often times, this type of patient has worked with other therapists before coming to me.  Recently, I even had a patient who revealed that he's been seeing another therapist on an almost daily basis in between our weekly individual sessions.  (Although it might seem to be the case, having more therapists does NOT equal getting more benefit.  It can, in fact, be counterproductive, particularly if the therapists are unaware of each other or if they are using different approaches that, on the surface, appear contradictory).  I was not at all offended by this revelation.  In fact, I was hopeful.  I was getting nowhere with this patient.  Maybe things were going better with the other therapist.  Since we are not permitted to offer duplicate services, patients are not allowed to have two therapists.  I was sort of hoping to transfer the patient's care to the other therapist.

Alas, this was not meant to be.  Upon inquiry, the patient indicated that treatment with this other therapist was not beneficial.  "I don't think it's helping," he said.  Actually, this was the exact same thing he said to me about our therapy as well, about a week earlier.  In fact, before he started therapy with me he was involved in another treatment program.  After two days, he asked to try something different because he didn't think the treatment was working.

This patient has had three treatment providers in the past month and has reportedly gained no benefit whatsoever from any of them.  What's going on here?  The first thing that comes to mind is that the patient isn't making a real effort to take anything from therapy.  He's waiting for a "magic cure."   He has decided that getting better is not HIS responsibility.  Rather, he has placed that responsibility on other people.  He does not say to himself, "I'm not getting better."  He says to himself, "This treatment is not making me better."

To me, this is the most likely scenario.  However, there is this nagging voice in the back of my mind that will not allow me to buy completely into this.  For one thing, it causes frustration.  It also leaves me with no viable course of action.  Even if this interpretation of the situation is accurate it is not helpful for me to think about it this way.  It's a dead end.

So I've decided to take a different approach.  Maybe this guy has some serious issues that require an exceptionally skilled therapist and some kind of intense, targeted intervention.  There's always the possibility that he is what we refer to as a "complicated case."  If so, then I have a couple of options.  The first thing I'm going to do is to move completely outside of my comfort zone.  I've done some research and have identified some new (or new to me) interventions that I'm going to try with him.  In the end, at least I can say that I've given this patient my best effort.  If this doesn't work, I'll probably refer the patient to another provider with more experience (most likely a Ph.D. or Psy.D. psychologist).

I guess the challenge for me in this situation is not to allow my frustration to interfere with my work.  Even frustrating patients deserve the best treatment I can give them. 


  1. Good post!!!! I don't provide therapy, but do case management and see a lot of the same things you describe with many of the clients I work with. I'd be eager to know what kind of approaches you use with them.

  2. You might just be feeding into his dependency by trying harder and harder. Maybe it's time to just sit back and wait.

    I tend to see therapy not as us pushing or pulling the client along, but walking alongside of them, helping them see the obstacles that keep them stuck. If they can't walk, or can't see the point of walking, we sit with them and explore that.

    Or we walk away. And that might be just what the client needs. It seems like he's been the one to walk away. It might be incredibly powerful for him to have a therapist say that he's not doing enough on his own and that YOU can't work with him due to that. That might, in a way, be the best treatment you can give them.

  3. Something strikes me about the leaving of so many therapists. I'm not a therapist but maybe he's replaying some pattern with the therapist as a parent figure who he leaves and replays it over and over again, to soothe or fulfill a need. Just thinking!


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