Monday, February 2, 2009

Managing the Difficult Therapist

This entry wasn’t supposed to be this lengthy, but I wanted to give it the attention it deserves and trying to be balanced in the discussion made for an even lengthier article…

It is easy enough to find literature on managing the difficult patient (notice how articles are typically titled with an emphasis on the as if being difficult was its own special DSM category), but it is, surprisingly, difficult to find advice on how to work with frustrating therapists.

Any relationship in life is going to be difficult, but the therapist-patient relationship could well be the most effortful. If you have some financial security, the search for an appropriate therapist, though still timely, is somewhat easier. However, if money isn’t available, you will be referred to a psychiatrist through another physician (this referral itself can prove to be difficult to obtain) and after months of being on a waiting list, you finally get to see someone only to discover you and your doctor are incompatible. Most therapists do want to help you get better. They might not care as much as you would like them to, but they don’t want to harm you. And yet, they may. Therapists are people too and they will make mistakes and get angry and be difficult. It may be that the relationship is just not manageable and you will have to search for other treatments/therapists, but trying to work through obstacles in the therapeutic relationship, if nothing else, can be regarded as a mature exercise of perseverance.

Of course, your illness may make your mature attempts appear as juvenile manipulations to your therapist, but quite honestly, if you are showing up for your appointments and doing your homework, that should be indication to the therapist that you are trying the best you can.

Unless you’re not. You very well might hate your doctor for very legitimate reasons, but since it is easier to understand and change yourself than someone else, you should first look at your behaviour. Do you change therapists before there’s been sufficient time to learn how to work together? Do you change therapists often? Are you putting your best effort into a therapeutic strategy that might not be your most preferred because it might work? Do you articulate your feelings and difficulties with your therapist? Do you find you regularly refuse suggestions of treatment without trying them first? Do you suggest alternatives or modifications to treatments that might be more well suited to yourself?

Things won’t always work out the way you want them to, in this or any relationship, and sometimes the benefit of the doubt must be given and if something you are doing isn’t working than maybe trying something you don’t like would be a good new strategy. But it is also important to remember that you are the vulnerable person in this relationship, and you should check in every once in a while, preferably in dialogue with your therapist, but at least with yourself to monitor how the therapy is working and if you can, work towards some middle ground where disagreements occur. If you have been in the therapy for some time, examine times when you felt things were working and when things were definitely not working. You may discover your therapist is helpful with depressive episodes but not so much during manic times, in which case you need to decide if your current therapy should be supplemented (after trying to fix it first, of course). If you do decide to stay in the therapy for some specific benefit, you have to let everything else go; any resentment towards the therapist for not doing a better job in other areas will quickly depreciate the value of their other resources. It may be that the relationship simply isn’t working (anymore), and it’s time to move on (or take a break for, ideally and ethically, which your therapist should help you prepare for), but before you do so make sure to attempt reconciliation first and preferable have back-up support available while you begin the search for another therapist (other sources of treatment are listed at the bottom).

What follows is a list of inappropriate therapist behaviours from Linehan’s book Cognitive-Behavioral Treatment of Borderline Personality Disorder. (A lot of these would be contextual; certainly the therapist is going to be checking the clock periodically and sometimes hearing about personal experience with other patients who have recovered can be a good thing).

A list from a website on client abuse:

1. Undervalue, criticize or mock you
2. Forget or be late for your appointments
3. Exaggerate or misdiagnose your problems
4. Repeatedly re-schedule your appointments
5. Refuse to answer your reasonable questions
6. Be preoccupied or daydream during your sessions
7. Refuse to consider your perceptions or point of view
8. Claim that you are overreacting
9. Withhold important information from you
10. Label your communication as bad or wrong
11. Express mood changes and / or emotional outbursts
12. Refuse to discuss topics which you want to discuss
13. Claim that you cause the therapist to act inappropriately
14. Talk endlessly about the therapist's beliefs and opinions
15. Use your sessions to help themselves
16. Extend your sessions without benefit to you
17. Arrange to meet you for a non-therapeutic purpose
18. Tell you that you do not deserve love, care or support
19. Invite you to participate in emotional or physical intimacy
20. Later deny or justify emotional or sexual intimacy with you
21. Threaten to end your sessions unless you comply with a demand
22. Talk about his or her own problems
23. Increase your dependence on him or her
24. Write emails or text messages as you talk
25. Act pompous, condescending or officious
26. Give you harmful post-hypnotic suggestions
27. Advise you to change your sexual orientation
28. Continually defer solutions to "the next session"
29. Ask you for help with promotion and advertising
30. Cause you to distrust other helping professionals

Here are a few more inappropriate behaviours:

1. Asks to borrow money or asks for personal favours.
2. Makes sexual advances, physically or verbally.
3. Refuses, or neglects, to change medication even when the patient has previously been compliant with all other treatments but has specific concerns about the current medication.
4. Attributes the patients worsening condition to manipulative acts and not because they have had to go without medication.
5. Assumes that the patients inability to adequately communicate their concerns is an indication that the patient is being difficult, not a result of a worsening condition.
6. Fails to recognise the patients honest attempts at treatments. E.g., the therapist reprimands the patient for not calling between appointments when there is evidence the patient is suffering from a paranoid delusion in which they are convinced that calling would lead to negative consequences or assuming a depressed patient who has trouble with positive lists in CBT exercises isn’t trying when it is quite obvious that their condition is preventing them from being able to think positively and then abandoning exercises that might have worked.
7. Does not inquire or try to engage patient in dialogue, assuming that the patient isn’t communicating (well) because they are being difficult on purpose. There are times when patients need to practice self-reliance, but when their current disposition is dramatically different from previous sessions, an inquiry should be made; ‘Why didn’t you call as scheduled?’ probably won’t be enough to draw conversation out of a paranoid patient and should be followed up with a line of questioning, ‘Did you forget that we has scheduled a phone call? Did you lose track of time? Was there another person who prevented you from calling? Was this person someone you know? Was this person real or imaginary? Was there something you were afraid of?...’
8. Avoids important topics of discussion such as apparent worsening of condition and, just as importantly, bettering of condition. Both parties in the relationship need to be aware of what is and is not working. Not all issues need to addressed directly, metaphor and jokes and general talking are all very good therapy, but the therapist needs to assume some responsibility if they suspect something may not be working.
9. Assumes all behaviours of the patient are directly related to the therapist himself.
10. Ignores the patients cries for help, whether communicated directly ‘I’m going to kill myself and I need you to help stop me,’ or indirectly such as with silence or anger during appointments. Again, some self-reliance is necessary, but when a patient has previous good standing with their behaviour and does not regularly act out in a manipulative manner, the situation needs to be addressed. For example, if the therapist runs into a patient in the hall after session and the patient is obviously distressed, muttering, pacing, crying…, and the patient has never been witnessed in such a manner before (or rarely), then they should probably not be ignored. The therapist may have reasons for not intervening in the moment, but the event should certainly be addressed during the next session. Furthermore, some cries for help, even those not intended to be seen by the therapist, are because the patient needs help, not because they are being difficult.
11. Purposely withholds treatment or gives insufficient treatment for other physical ailments out of pettiness. E.g., writing incomplete lab orders, always referring the patient to another physician or to the emergency room for simple things like checking their temperature, especially when they admittedly regularly perform such examinations on their other patients.
12. Starts the patient on a new medication before they leave for an extended absence and then informs the patient that they will absolutely not allow any communication during this hiatus. Especially, if they previously indicated, when the patient brought up concerns of how therapy would be managed during this time, that something would be worked out.
13. Threatens to charge for missed appointments and forces the patient to commit or cancel when the patient has never missed an appointment and has rarely been late (always calling to indicate their tardiness) when a patient is in distress rather than taking the risk that the patient might not show up this time, but that they will have a place to go if they decide to.
14. Assumes the patient won’t show up for their next appointment because they are being difficult, even though they showed up for the current session. Furthermore, not giving the patient credit for showing up when they are obviously distressed, afraid , angry, and acknowledging that just by showing up they are proving that they are trying.
15. Verbally insults the patient.
16. Does not listen to the patient and after the patient has repeated themselves several times, possibly over several sessions, insists the patient never made any such declarations.
17. Never acknowledges or sufficiently apologises for their own inappropriate behaviour (these things happen, people have bad days).
18. Insists a particular course of treatment is the only one.
19. Needs the patient to console or validate them.
20. Physically or verbally abuses the patient, especially if they insist the abuse is actually treatment.

Letting by-gones be by-gones

So you’ve identified the limitations of your therapeutic relationship, but having decided to remain working with that particular therapist and have made arrangements to compensate for important inadequacies. Your therapist may not listen to you or acknowledge your concerns or admit to their limitations, but it would be a good idea to very clearly communicate, as soon as you are able to, why you were considering terminating therapy and why you have decided to continue. Depending on the behaviour of your therapist you might have to accept that you do not forgive, nor will you forget, that they were negligent and disrespectful, but in order for future therapy to work you have to let the anger of the situation go. On the other side of things, ending a relationship is extremely difficult, and it is important that you very clearly understand that your reasons for staying are beneficial to you, and that you don’t make excuses for the therapist and remain in an unhealthy relationship. And if you do decide to stay, you need to do your part in respecting or tolerating some of the therapists behaviours. Ideally, you should both be comfortable talking about the therapeutic relationship and compromising when necessary. Realistically, you may have to carry the weight of this management by yourself, but congratulations to you for working through things in such a mature manner!

Other Links:

This site has a well balanced interpretation of what therapy is and some good advice within a personal story.

Another site with suggestions on evaluating your therapeutic relationship with a nicely organised check list on which is the most important thing to consider – is therapy making you better or worse? A particular good suggestion was to get a second opinion before terminating.

What to expect from therapy and questions to ask potential therapists.

WITNESS aims to promote safe boundaries between professionals and the public in order to prevent abuse. We do this by providing support, education and research services and by working for change. This is a UK site.

Bad Therapy: Master Therapists Share Their Worst Failures. A novel I haven’t looked too closely at.

How to Choose a Competent Counselor

Good descriptions of counter-transference and recovering from harmful therapy.

A sad story of a woman who was sexually abused by her therapist.

Psychiatric Patient Advocate Office if you need to take legal recourse.

Other therapeutic resources:

1. GP. If you don’t have a family doctor, walk-in clinic doctors will treat you (though they may be a bit more hesitant.
2. Private counsellors.
3. Group therapy. This might be either government funded (with a wait list) or you can find a private practitioner.
4. Community support groups such as Alcoholics Anonymous and Emotions Anonymous.
5. Hotlines.
6. Emergency departments at hospitals.
7. Websites with motivational stories and support.

Has a very thorough list of resources in the Vancouver area.

Because some laughs are necessary at this point – How to Drive Your Psychiatrist Crazy.


  1. Wonderful post - great resource list - thanks!!


  2. The book you've listed here "Bad Therapy: Master Therapists Share Their Worst Failures" I strongly recommend. It's nice to see them being so candid about their errors. It makes me hope that some of the therapists who wronged me might realize they messed up even if they didnt admit it to my face and that they were able to grow from it like these folks.

  3. I appreciate this discussion to empower therapy clients as consumers. I found therapy contains many traps, including manipulating the client's self-doubts until it creates a highly unbalanced authoritarian-subordinate relationship. It also can create the intoxicating fantasy that it delivers a healing that is utterly unrealistic.

    Therapists are no more than performers who once attended grad school, learned a bunch of names for never-proven disorders and hung a shingle to deliver an empathy act. They are no more perfected or wise than whom they treat.

    It creates far less damage to keep this in perspective.