Treatment Resistance & Therapeutic Obstacles

The following was originally posted to Psychiatry Talk.

I would like to start off this blog with two stories that happened many years ago.

The first was during my first year of residency when it was often the case in the program that I was training, that young psychiatrists would enter their own therapy even before they might enter a specific psychoanalytic training program where a personal psychoanalysis would be expected. A friend of mine was the first in our group to decide that he would be in his own treatment and he chose a very prominent analyst with whom to have a consultation. The rest of us were eager to find out what happened when we saw our colleague the day after his consultation. We found him somewhat glum as he told us that the senior person told him that he didn’t think he was motivated for his own treatment. He was scheduled to return a week later but the result was reported to be the same. Finally after the third or 4^th meeting my friend came back with a big smile on his face and told us that he now recognized that he had sufficient problems to enter therapy.

The second story occurred about 10 years later when I was director of an outpatient clinic. The court system had decided to send us many of the people who the court had deemed to require therapy. For example, a young woman with no history of criminal behavior and in no financial distress was caught shop lifting. Rather then sentence her to prison, she was mandated to come for therapy at our clinic. When the consulting psychiatrist doing the initial interview asked her why she wanted therapy, she replied“ “The judge sent me.”

Some variation of these themes has been played out in my office many times over the years. Some people may come to see a therapist because they are training to be a therapist, because a judge, spouse or a boss told them to do it, because they want to stop drinking, drugging, gambling, eating, , want a better job, relationship, or motivation for something or other.

In some situations, at least part of the problem may be addressed by entering into a program such AA, NA,GA or a weight reduction program. If there is a major psychiatric disorder such Major Depression, Bipolar Disorder or Schizophrenia medication plus some type of psychotherapy will be necessary. Some people who have been through a traumatic situation and are having recurrent symptoms as well as other conditions may respond to variations of CBT or various types of therapy that allow re-experiencing their trauma and becoming desensitized to it or perhaps they might need marital or family therapy. These are all potentially excellent therapy modalities and I have referred people to them or used them myself to help patients.

However, one of the most powerful and meaningful therapies, when it is appropriate, is psychodynamic therapy or even psychoanalysis where the patient’s earlier relationships and conflicts are understood and related to their current issues. This type of treatment not only requires a therapist trained in this modality but it requires patience on the part of the patient and therapist, as there is a therapeutic process that needs to develop which take months or even a year or two to reach full fruition. It involves and examination of past, present as well as the meaning of the relationship between the patient and the therapist.

Therefore it should be no surprise, even to the those who might not be very familiar with these forms of therapy, to appreciate that it is best to start with the patient recognizing that there are issues and conflicts within him or herself about which they are motivated to understand and even change. This is why I started off with those two examples. It is much more difficult to enter into this therapy if the patient starts with the premise that the only reason they are seeing the therapist is because the judge sent them or because their spouse insisted upon it etc. Similarly, you are far from getting to the important issues , if the patient believes that they are just coming because being in therapy will be useful for their work as a therapist themselves. When you start from this place, it doesn’t mean that you can’t get where you need to be, but there may need to be some exploration which may take 2-3 sessions or even 2-3 months or more before the therapy can begin to make significant progress.

It is often the obstacles and the resistances to therapy which once they are understood will not only break down the barriers to progress in treatment but they will themselves be the key to the insight to the internal conflicts and problems that the patient is facing.

This topic Psychodynamic Approaches to Treatment Resistance and Therapeutic Obstacles is the theme of the 55^th annual meeting of the American Academy of Psychoanalysis and Psychodynamic Psychiatry which is being held May 12- May 14^th at the Waikiki Hotel in Honolulu coinciding with part of the longer meeting of the American Psychiatric Association. Psychiatrists and other mental health professional who will be in Honolulu at this time should consider spending some time at the Academy meeting in order to focus on this critically important topic. There are some excellent speakers and topics at this meeting . The program can be reviewed on their website www.AAPDP.com. There is no registration fee for trainees and very reasonable fees for others. . Full disclosure is that I will become President Elect of this organization at this meeting.