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Dealing with Resistant Patients
by Judith S. Beck, Ph.D.
"If I try to make any changes in my life, I'll just fail."
"If I improve, my therapist will abandon me."
"If I get over this [psychiatric disorder], my life will get worse."
"If I trust my therapist, I'll get hurt."
These kinds of assumptions are often the key to why therapists sometimes encounter difficulties with patients and why "standard" cognitive therapy is sometimes just not effective enough. Of course, cognitive therapists encounter problems in therapy for a wide variety of reasons. Sometimes the problem is with the way the therapist is conducting therapy:
- structuring the session inappropriately
- adopting a faulty strategy for change
- having the patient set vague, non-behavioral goals
- not realizing the patient does not buy the cognitive model
- failing to focus on key cognitions or behaviors or eliciting key cognitions but not helping patients gain an alternative perspective
- doing too much or too little problem-solving
- applying techniques in a flawed way.
Or the therapist may have an ineffective treatment plan, due to:
- misdiagnosing the patient
- misconceptualizing the patient
- using an incorrect cognitive formulation for the patient's specific disorder (and therefore not varying therapy appropriately).
- omitting important target areas to work on.
Often patients are challenging because the therapeutic relationship is not strong enough. The therapist may have erred by:
- failing to elicit and respond to the patient's verbal and non-verbal feedback
- failing to grasp the patient's internal reality
- failing to convey his/her understanding
- having poor interpersonal effectiveness, with too much or too little warmth, empathy, concern, confidence, genuineness, and professionalism
- failing to vary his/her therapeutic style according to the needs of the patient
- failing to work collaboratively with the patient
At times, problems stem from the dysfunctional attitudes of therapists:
- "I should never give patients direct advice."
- "I should avoid having patients get upset in session."
- "It's the patients' responsibility to do homework and their fault if they do not do it."
- "Getting negative feedback from patients reflects poorly on me."
Sometimes the problem is out of the therapist's control: for example, the patient
- needs more intensive treatment
- has an undiagnosed organic disorder
- is in too damaging an environment
- requires medication or a change in medication
- needs couples of family counseling
Often it is difficult for therapists to step back and specify the problem, much less develop a plan to remediate it. The best source for the therapist may be patients themselves. Asking them what is helpful, and especially what is not helpful, about therapy may provide some answers.
(... to be continued in a later issue.)
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