What would you consider to be effective and helpful psychotherapy? Would you be able to describe or define it if you had to? Many of my clients (current and previous) have stated they could. But when asked to define it, they struggle.
One of the reasons may be because therapy is not 100% dependent upon the therapist providing a service. Psychotherapy is dependent on “group effort” (i.e., the effort of both client and therapist). Without the cooperation and consent of the client (or the client’s guardian), therapy can be a losing battle.
This article will discuss some of the barriers that often prevents effective treatment from occurring in therapy.
For most people “effective treatment” is being able to connect with the therapist, develop a trusting relationship, and heal from challenges faced in life. Sounds easy enough right? Not so much. Effective treatment cannot occur, however, if there are barriers. Barriers could be anything from behaviors, negative thought patterns, or attitudes of the client to therapist incompetence, attitude, or lack of knowledge.
Being a client can be very difficult. Client’s come to therapy to sit in front of a therapist who is “reading” them, evaluating them, and challenging their life perspective. Clients can feel vulnerable, embarrassed, or self-conscious. Some clients may even feel “nude” in front of their therapist. A client’s feelings and thoughts are often put to the test. It’s uncomfortable.
All of these things can create barriers to effective treatment. They can become real roadblocks.
Although effective treatment may include an experienced psychotherapist and scientifically sound techniques, the real barrier in therapy can actually be the client.
Sometimes talk therapy and scientifically sound treatments are ineffective because of common denominators such as client attitudes or behaviors, personality disorders, triangulation, manipulation, narcissism, or psychotic symptoms such as delusions.
I have seen a few clients in the past who make therapy very difficult on themselves and for the therapist as well. Such clients often engage in the following behaviors:
- Refusal to allow therapy to work: Because of a negative experience in therapy, a desire to do the complete opposite of what should be done, or outright opposition for the sake of being difficult can all result in failed treatment. Adults diagnosed with borderline personality disorder (or youths who are diagnosed with oppositional defiant disorder) may display behaviors that interfere with the progression of treatment. I have treated individuals with personality disorders who intentionally disrupt therapy for the purpose of controlling, dominating, or throwing it off course.
- Rejection of medication management: Medication can be tricky and it isn’t for everyone. When I see clients I recommend they try holistic and natural options before trying medication, unless they have a severe mental health or medical condition that requires it. In most cases involving children and teens, parents are highly concerned about meds that may result in negative side effects, dependency, or severe withdrawal symptoms. I certainly don’t blame those who fall into this category. But some clients intentionally reject medication to be difficult or to protect their right to choose. Other clients are afraid of what might happen if they start or continue medication. When mental health conditions create discomfort or dysfunction in the person’s life, medication is necessary and refusal can prolong treatment or recovery.
- Lack of empathy: Empathy is an important attribute to have because it allows you to put yourself in the shoes of someone else. To feel what they feel. To imagine how they must feel about something. Without empathy, therapy is difficult because therapy is all about discussing challenges, family dynamics, social relationships, emotions, thoughts, feelings, behaviors, etc. etc. etc. Without the ability to empathize with others, growth will be stunted in treatment. For example, how can a father grow in therapy if he cannot understand the embarrassment he causes his 14 year old daughter when he shows up to her school drunk? How could a controlling and emotionally detached husband understand his wife’s feelings if he can’t see how much stress he places on her when he calls her names or attempts to control her freedom? Empathy is important. A lack of empathy is often a sign that therapy may be prolonged or not achieve anything at all.
- Lack of insight: Lack of insight means no ability to grow, adapt, or learn. Insight is important for evaluating decisions, attitudes, perspectives, and behaviors. Without insight, therapy will suffer. A person who is unable to evaluate themselves or others will often remain confused in therapy. Therapy can begin to feel like an uphill climb to nowhere. Therapy doesn’t truly begin until the individual is able to see how they affect others, how others affect them, and how they react and engage with the world around them. Children diagnosed with oppositional defiant disorder may fall under this category. They want what they want no matter how much pain they may inflict on someone else.
- Strong or oppositional temperament: Being strong-willed isn’t always a bad trait. I’m sure you would agree. But when a strong-willed person begins to exhibit an oppositional, rebellious, uncaring, and dominating personality, treatment will suffer. I often admire clients who are able to speak up for themselves, weigh the pros and cons of things, engage in back and forth evaluation with a therapist, or speak up when needed. But I often foresee major challenges with clients who refuse to cooperate, even after seeking treatment for themselves and asking for help. Sometimes this contradictory behavior is a cry for help. But other times, it is simply a game being played for the heck of it.
- History of difficulty with healthcare providers: A history of challenges with healthcare providers can be a clear sign of potential challenges in the future with other providers. Do you know someone who has had a difficult journey with healthcare professionals and cannot seem to find someone they connect with or trust? Throughout my career I have met clients with histrionic personality traits or borderline personality traits who struggle with trusting healthcare providers of all kinds and work very hard to either avoid them or control them. Difficult adolescents such as those in the juvenile delinquent system or those with conduct disorder (i.e., fire setting behaviors, animal cruelty, opposition, disregard for the rights of others or authority, etc) may also struggle with multiple healthcare providers. Can you see why this would be a barrier to treatment? Individuals who struggle will “hop” from one provider to the other until they find “the right one.” While I totally get that this can be healthy, “hopping” around is sometimes a game or attempt to avoid something.
- Borderline Personality Disorder traits: As I have discussed in previous articles, some individuals with BPD traits often find themselves in limbo when it comes to therapy. On one hand they truly want to get better, while on the other hand they want to avoid responsibility and treatment. An inability to trust, develop healthy bonds or expectations, fear of abandonment, etc. can all lead to the individual putting up as many barriers as possible to avoid fully engaging in treatment and trusting the pros. Clients may also derail therapy each week by reporting drama to the therapist to throw things off course. BPD traits can slowly corrode the therapeutic relationship.
- Embarrassment, shame, or guilt: These negative emotions can cause clients to avoid therapy altogether. When feeling guilt over something the first thing you most likely want to do is hide or avoid. When these emotions are difficult to overcome, therapy is often stagnated.
- Substance abuse: Alcohol addiction or drug abuse makes therapy very, very difficult for a variety of reasons. Some reasons include but are not limited to: inability to commit to treatment, lack of focus or concentration, low motivation to change or pursue D&A treatment, internalized shame and guilt, challenges with severe mental illness and substance addiction, etc. Individuals who are struggling with a dual diagnosis (e.g., substance abuse and bipolar disorder), may struggle the most to commit to therapy and accept that they need support.
Do you know someone who may fit the above descriptions? Do you fall into any of these descriptions?
As always, I look forward to hearing from you.
All the best to you
This article was originally written 8/23/17 but has been updated to reflect comprehensiveness and updates to the points discussed.
Photo by ImNotQuiteJack