Come Sit in My Chair: Confronting Patient Resistance

In the last blog entry, I wrote that engaging the patient in behavioral change in small ways gets parlayed into bigger changes that keep on snowballing in a positive direction. 

Of course, that is the ideal goal of psychotherapy. But sometimes your patient repeatedly resists treatment. 

He misses numerous appointments; he has not been putting new behaviors into practice; and when you raise concerns, he is quick with the many reasons he hasn’t practiced new behaviors. He whines and complains that things are just not changing as fast as he wants or that no one realizes how hard it is to change. After all, he had a terrible childhood. 

What do you do when all the tools at your disposal lead nowhere and resistance continues unabated?  It’s time to look at what else is going on. The tip-off is when the therapist realizes she’s working harder than the patient. 

It really helps if you have a colleague or group of colleagues who can provide consultation on an ongoing basis. I am not talking about the kind of supervision that novice therapists endure for certification or licensure. I’m referring to an ongoing relationship with a trusted colleague who knows you well and will tell you when you’re missing something. 

As a young therapist, you may yearn for the day when your work is no longer being scrutinized, but believe me, having this kind of consultation is invaluable to keep clinicians at all levels out of the therapeutic morass. Just when I think I’ve thought of everything, my colleague gives me another perspective – or confirms that, indeed, I have considered all options. 

Then you must have “the conversation” with your patient. Ideally, this conversation started at the beginning of therapy, when the two of you discussed the patient’s goals—what she hopes will be different or better.    

However, even if you haven’t discussed goals, talking about how your patient’s behaviors are maintaining the status quo is important, along with the idea that patients sometimes tell us with their behavior that they have gone far enough in therapy for now. And that taking some “time off” might help her in the long run—along with reassurance that your door is not one-way and she really can return when she wants to. 

I have had patients take a time out from therapy and then return. One woman made the round-trip twice, and her complaints were the same both times: she lamented that she couldn’t get a job because she was just too exhausted to try, but she somehow was able to do other things she wanted to do.  

After hearing this litany several times and pointing out the inconsistencies in her self-portrayal, I asked her to change seats with me and tell me what I was going to say to her—she should play me. She got it perfectly. She laughed and admitted she was content to let her life stay the same for now. And we agreed that that was her choice. Realizing that she had the power to make that choice resonated differently from feeling like she was powerless to do anything. 

Then I told her it was clear to me that I wasn’t helping her, and we left the door open for when she was ready to make changes. She called about eight months later to make an appointment. I reminded her of what I would be saying and asked her if she was ready to do the work of therapy.  After a long pause, she said probably not. I never heard from her again. 

Therapists who refuse to confront patients’ resistance because they depend on the income from a full patient schedule are doing no one any good, least of all themselves. 

For nurses, this obligation is addressed in the Code of Ethics for Nurses (1) under the heading, ‘1.4 The right to self-determination’:  “…Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination. The nurse preserves, protects, and supports those interests by assessing the patient’s comprehension of both the information presented and the implications of decisions.” 

Without any doubt, other mental health disciplines address this, too. How have you handled patient resistance? Have you had a resistant patient return? 

Reference

1. American Nurses Association. (2001). Code of Ethics for Nurses. PUB# 9781558101760. Washington D.C.

Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.