When a patient or client isn’t doing better in psychotherapy, sometimes a therapist may fall back onto that old familiar refrain, “Well, the patient just isn’t doing the work. He’s to blame for his lack of progress in getting better.”
Dr. Richard Friedman describes this strategy in a thoughtful article in yesterday’s New York Times. It’s not uncommon for a psychotherapist, when faced with a client who doesn’t seem to be improving after months (or even years) of therapy, to blame the patient.
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They aren’t trying.
They’re not doing their homework.
They don’t really want to get better.
There’s a dozen different reasons a therapist will come up with depending upon the specific client.
More often than not, though, as Dr. Friedman points out, perhaps the client just hasn’t found the right combination of the right diagnosis, psychotherapist, and medications to help them:
Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.
“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.
But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.
In this case, the diagnosis was right from the onset, but the mental health treatment team just hadn’t hit upon the right medication that works best for her. Sometimes it takes 2, 3, or even 4 or more tries to find a medication that is the “right” one for the person.
The same is true for type of psychotherapy or psychotherapist tried. While some may believe that such things don’t matter (since research has long shown that any psychotherapy seems to work better than nothing), they do.
Finding the right therapist can be as frustrating and as challenging as finding the right medication. But at this time, we have no sure-fire way to identify what those “right” treatments are for any given individual. You must do it yourself (or with the help of your therapist or psychiatrist) through trial and error.
At the end of the day, the patient’s not to blame. What’s to blame is our inability to adequately or reliably predict treatment response to any given treatment that is prescribed. Psychotherapists and doctors should always question what’s really going on when they find themselves “blaming the patient.”
Read the full article: When All Else Fails, Blaming the Patient Often Comes Next
6 comments
Hi John,
Yes patients do need to find a therapist that they can work with and medication that suits.
In my professional opinion as a brief solution focused therapist. I believe that if movement is to take place, it will, in the first 3-4 sessions. Sessions need, to have a beginning, middle and an end; And as a supervisor, I would seriously question the motive of therapists offering longer term therapy: by all means they can return with an open door policy.
Regards
Dawn Pugh
http://www.dawnpugh.com
Dr. John,
In reference to psychotherapy, I think that the best healers are those who have been healed themselves. So many psychotherapists chose that field because they want healing themselves. The problem comes when they are still needing significant closure on their issues and are working with the general population.
At the risk of being perceived as arrogant, I will say that I am one of the best in my field in my city. This has come at a very high price, both financially, emotionally, and with much sweat and “blood.” I have made it almost my mantra to learn from the best healers out there. I have endeavored to always seek to be a humble learner and receive truth anywhere it comes from. I have sought to learn from my mistakes and continually make corrections and improvements. As a result I often see significant healing right from the first session. Most of my patients only see me for a few sessions.
I sadly find that a great majority of clinicians in this field are not great. They might be good or mediocre but there are few great one. A great therapist in my city who founded a well known rehabilitation center firmly believes that most psychotherapists are incompetent and know little about how to get a person to heal. If it was a new graduate saying this then he would not have credibility, but he isn’t.
Let us strive to be the best for the sake of our patients. If we love and take care of ourselves and strive towards wholeness then we can truly love and help our patients.
Samuel LOpez De Victoria, Ph.D.
http://www.DrSam.tv
I think it’s common to ‘blame’ the patient, or to try to do the same thing again and again and wonder why nothing different happens.
Some things to think about:
– sometimes it’s the ‘diagnosis’ or formulation about what’s really going on that is wrong. Treating a common cold with antibiotics isn’t going to fix the cold. Treating a chronic pain problem as if it’s an acute pain problem won’t stop the pain!
– sometimes it’s about readiness to change in the patient (especially if it’s about behaviours the patient needs to do). There are a million and one ways to resist other than actually saying ‘no’! And if we’re the health professional, it’s up to us to work out at which stage in the process of change the person is at!
– and sometimes it’s about the intervention itself – not that it’s the ‘wrong’ problem being addressed, but simply that for this person it’s not working for them. It took me numerous antidepressants and AD augmentations and psychotherapies until I finally found the combination that worked well for me.
It’s not as if the person seeking help for their health is the only factor in the therapeutic interaction, it takes two to tango and more than a sandwich to make a picnic!
one thing that I have found, and observed over, and over again, is that not only do therapists often blame the patient, but that they tend to, sometimes exclusively, try ‘harder’ when the patient stops making progress by ‘pushing’ for issues relating to ‘abuse history’.
That is a horrible thing to do. I myself believe that in more cases than not ‘abuse’ is a symptom of ‘neglect. But therapists don’t know ‘shit’ about neglect because it’s not about what someone did to you, but the absence of something.
A good patient, and even if he/she is honest, often is so dependent on the therapist that they go along with the therapists suggestiveness and to please him/her, and also because they are anxious because of a lack of ‘progress’ will actually make up ‘abuse stuff’ in order to please the therapist, and to avoid rejection. In this case, as a result things become ‘well’ again for some time, and until this happens again. it ends up that the whole therapy becomes a lie, and I do blame the therapist for this, and not the patient, even if he/she has good intentions and doesn’t know any better.
I find that the toughest struggle often with therapy lies in the relationship between the therapist and the client himself, and that this issue is always, or almost always , in the foreground, especially if the therapist doesn’t reveal himself and thereby creates more anxiety.
A patient who is dealing with issues of neglect doesn’t usually tolerate a wonderful therapist who at first sort of acts like the ‘good parent’, and he/she listens, and understands everything, and validated the patient’s experience, and is just generally way too nice and empathic for this patient’s own good.
The deal is that the patient wants this understanding, validation and empathy more than anything on the one hand, but on the other hand he/she cannot tolerate it.
This eventually leads not only to extreme dependence but to destructive and ‘self-destructive’ acting out.
I once heard this therapist say that she has done everything for this patient, and had been so nice and so attentive and so very caring and helpful, and what did she get? An abusive patient.
Well yes, mam, it’s too bad you didn’t learn anything by becoming a PhD except to take good notes and be politically correct.
I think I was the only student in my class who never, ever took notes because it’s hard to listen, think and process when you just try to get all your notes down.
Anyway, I just meant to touch upon a couple of things.
In this case I described above, the therapy almost always ends up with the therapist going over her limits, and not being honest with himself, or herself. At last she explodes and really blames the patient and practically, if not literally, she freaks out and fired him/her.
PS: Oh great, I am way too late, and just realized this.