This morning I was called to be an expert witness at county court. Not my favorite thing to do. What makes it hard is the tendency lawyers have to ask complex questions and expect a "Yes" or "No" answer. I have learned to slow myself down, detach myself from the process, and be absolutely truthful while remaining as unprovoked as possible. Otherwise it is an exhausting exercise.
One question today did get me going, though. It revolved around whether or not a person can change and what causes a person in therapy to improve or not improve. The conversation below is a dramatic re-enactment of real events:
Lawyer: Under what circumstances does a person in therapy not get well?
Me: Are you assuming the therapist is perfect? Because one reason a person does not improve may be the skills, knowledge and training limitations of the therapist.
Lawyer: Assume the therapist is perfect.
Me: So the lack of improvement is totally the responsibility of the patient?
Dear reader, this is never the case. Therapy by definition involves a minimum of two people who are human. In which case perfection is impossible because to be human is to be imperfect. But we are in a court of law where reality seems always to be in question so…
Lawyer: Yes. Would level of intelligence be a reason?
Me: No. People with very high intelligence can be resistant to treatment, just as less intelligent people can.
Lawyer: Could the presence of a diagnosed mental illness or personality disorder be a reason?
Me: The presence of a mental illness diagnosis or personality disorder alone is not a reason for lack of improvement in therapy.
Lawyer: Then what would be a reason?
Me: There could be many reasons but underlying them is often anxiety. 'What will happen to me if I change?' Fear, basically.
At this point the lawyer switched to a completely different topic. My answers probably weren't suitable to his argument so he gave up on me. Fine, but these questions kept echoing in my head.
Any therapist worth their salt will admit that they have had patients who seem to stay stuck for session after session. Maybe you have been in therapy and wondered if anything is really getting any better after making a big investment of time and money. What could be the reasons for lack of improvement?
Therapists learn about treatment resistance clients in the cradle of graduate school. Hitting a wall in therapy is not a reason to panic. In fact it could be an opportunity to step back and reassess. From the therapist's point of view:
1) If someone is not showing improvement after a reasonable amount of time we may ask ourselves, are we the right therapist for this patient? Occasionally our patient would be better served with a specialist, sometimes in addition to, or in lieu of our own work. The patient may need supplementary professional help, for example a psychiatrist if medication might help.
2) Have we, with the patient, identified clear goals that give us a way of measuring improvement? Do we need to redefine or recalibrate our goals to be more achieveable? We may decide to target specific behaviors, or identify mini-goals as appropriate steps toward the bigger one or stepping back or sideways to step ahead.
3) Are our interventions accessible to the patient? In other words, are we giving our patient tools within their reach? Tools they can use? Sometimes this takes thinking creatively, stepping out of the usual cookie-cutter solution.
4) Is it possible there is something about the patient we don't like and therefore we are ineffective because we are holding ourselves back? This type of counter-transference can lead to therapist resistance if unchecked.
5) Are we being patient enough? If most resistance to improvement comes from fear, what can we do to address the fear?
Years ago, after I complained that I didn't understand why a patient kept coming to see me week after week with no visible improvement, a great supervisor of mine said to me, "Who makes you the judge? Your patient does not wish to fire you. She is getting something out of therapy. Be patient. Listen."
Months later my patient revealed childhood sexual and physical abuse that she could not reveal until she was good and ready.
Usually the goal in therapy is some kind of change. To achieve this goal, both parties need to be truthful. What things may make a person in therapy afraid of revealing the truth and afraid of change?
1) Fear of judgement. If I could have a nickle for every time a patient prefaced a sentence with some variation of, "You will think this is awful…" I'd be on a beach in Maui right now. If you can identify with this, you held onto this awful thing for ages so it takes up an extraordinary amount of space in your brain and has probably bored a hole in your self-worth.
The therapist has a different perspective. He/she is trained to be non-judgmental. He/she has probably heard a ton of stuff much worse than whatever it is you think will horrify us. Even so, it is human to want others to think the best of us. It takes a lot of trust to tell the truth to your therapist. It takes faith to believe that the awful thing you are about to reveal will be treated with kindness. Yet to get unstuck that is precisely what is needed.
2) Fear of rejection. Underneath the fear of being judged is fear of rejection; a primal fear. That's why shunning is such a devastating punishment. You may be wondering, 'If I get better, will my family who is so used to my problems, still have a place for me? Will they still love me?'
3) Fear of assuming greater responsibility. Sometimes if we stay childlike we are rewarded by people taking care of us. It can be very uncomfortable to give up the sense of protection that staying dependent on others can give. The rewards of being an adult are rich and complex, not always obvious. It takes risk and belief in ourselves to grow up.
4) Fear of success. What if I get better and I no longer have a reason to see my therapist? Fear that if I change too much my life will become unrecognizable could be a factor. People can get used to failing. It can be their comfort zone. In that case, the lack of discomfort actually feels uncomfortable.
5) Fear of intimacy. Sharing our truth to another who respects it, "gets" it and reflects it back in kind, is the essence of intimacy. If we get close to people, if we reveal ourselves to another, we become vulnerable and that is scary.
Fundamentally we are talking about fear of pain and like every living being on the planet, we humans are hard-wired to resist pain by either running away from it or fighting it, tooth and nail. Why should therapy be any different?
We therapists need your feedback to work effectively for you. If you like your therapist and still feel stuck, try to get through the fear enough to bring up your feelings of stuckness so that you and your therapist can work on it together. You do not have to have the reasons for being stuck figured out. It's enough just to say, 'I feel stuck. Could we please look at that?'
It takes a skilled, compassionate therapist and a motivated, brave patient to give the therapy process a chance. My admiration goes to everyone who has the courage to try to change the things you can.