Treatment Resistance and the Therapist's Shame

Where is the line between required effort and limitation? How much are we really capable of?

Clinicians possess a host of options for treatment, which also, maybe unsurprisingly, protect them. For example, we might say a patient is resisting when they reject a hard truth about their patterned way of responding to the world, which, if acknowledged, makes us appear right and right if not. We call it projective identification when we're "made" to feel confused, angry, and lost in our sessions. We describe the patient as self-sabotaging when they tend to find ways to ruin their relationships. And we label patients as treatment-resistant if our efforts persistently fail. Yet, all of these ideas hide an inconvenient and disabling truth: Sometimes, we just aren't that capable when we might have been.

Like other therapists, I chronically wrestle with how much responsibility I ought to take for a treatment's failure. On the one hand, if we don't accept our limitations, we're self-important, believing that we should succeed where others have failed. On the other, we might cast off all of the responsibility onto our patients, blaming them, or at least their disorders, for their lack of progress.

Here's how the process usually goes: Therapy begins with some level of enthusiasm on both ends. Then, after a period, it hits the inevitable wall that the patient usually finds himself up against. The therapist starts to feel inept and insecure. The patient believes the therapist doesn't care enough about him to try something beyond the scope of "regular" treatment; in other words, he transfers his understanding of how others perceive him onto her. The therapist then goes through the motions, waiting for each session to end—sprinkled with fleeting bursts of hope and renewed energy when the patient takes some degree of responsibility. And the patient finally decides to discontinue treatment, moving on to another therapist.

The therapist's desire to tank, or work on autopilot, is an instance of projective identification. Here, the patient's own tendency to make half-hearted attempts to improve is instilled in the therapist, which he's then blamed for: "It isn't me not trying; it's you." And while the therapist's colleagues and/or supervisor may graft this general process onto his experience, the therapist might continue to feel as though the feedback received is a mere rationalization. But he would, in part, be right. The patient, with a history of helping to create circumstances wherein others give up on him, did need something else, something beyond the regular treatment he was used to receiving. He needed to share the responsibility of treatment's stagnation. Fundamentally, the points of therapy that appear most effective involve the clinician's natural responses to the recognition of unguarded crevices in the patient's wall. Irv Yalom called these the "throw-ins" of treatment. And these take time to occur, as they're based on the foundation of the relationship; they're genuine perceptions granted when the patient is caught off-guard. If a therapist tanks, he and the patient tacitly sabotage it.

In writing this, I'm not looking for more affirmation that "It's not your fault"; my intention is to note that therapists are equally responsible for their patients' failures: That's sort of the deal we sign up for. Due to my own perfectionism and aggrandized self of self, I tend to give up when things become hard or when I believe that my work is being taken for granted. While, yes, I'm human, it's also my job to take these responses less personally, especially when they're why a patient found herself in treatment.

Being a therapist means living with shame.

I'm embarrassed to say that patients have given up on me and even more humiliated by having to admit that I employed these rationalizations to move on; it's a piercing feeling. Yet the hole that it leaves needs to be maintained. My shame is a reminder of what I should have done differently, of my cowardice and sense of entitlement, and of a co-dependent need from someone who was already giving as much as they could. It's true that many of us are too hard on ourselves but we're just as easily not hard enough. My losses are many and wins are few. And my limits are those of youth, which my mirror seems to have surpassed. Psychotherapy is a somewhat insulated field in which, because others are frequently unable to reach mentally ill loved ones, we're, in turn, often given an undeserved pass.

I continue to try to find the middle ground between too much and too little responsibility, reminding myself not to get lost in my wins or my losses. But I can only stress that the ideas we tend to use to help our patients should be seldom used to aid ourselves. Because therapy is so insular, and we're so protective of each other, we can easily split, perceiving ourselves, erroneously, as purely noble when the results indicate otherwise.

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