Several reasons. Let’s go through the main problems in order that can prevent you and the patient from co-creating a relationship for change.
Perhaps the therapist and patient have not been able to reach a consensus on the problem the patient wants help with. That can occur when we don’t help the patient see and deal with his defenses against presenting a problem to work on. When that happens, neither the therapist nor the patient are clear about what problem the therapy is supposed to address.
Perhaps the therapist has not been able to deactivate the patient’s projection of will to do therapy onto others. For instance, “My wife thinks I need therapy.” Without the patient’s will to engage in therapy, the therapy will remain stuck. Sometimes patients will remain in therapy passively waiting for therapy to change them, but without actively engaging in the therapy. The patient’s will is the engine of therapy. Without the patient’s will, therapy cannot succeed.
Perhaps the therapist has not been able to help the patient see and let go of defenses against offering a specific example of his presenting problem. Without that specific example, you won’t be able to get a clear idea of the patient’s problem.
Perhaps, when exploring the patient’s problem, you did not arrive at a consensus on how the patient’s defenses are creating her problems. If you don’t get that consensus, you won’t have any agreement on why the patient should be in therapy. Many therapies get stuck because the therapist and patient don’t agree on what is causing the patient’s problems. Without that agreement, there is no reason for the patient to engage in the therapeutic task.
Perhaps the patient is projecting his will upon you (“What are we supposed to be doing here?) or his superego upon you (“I feel like you are criticizing me.”) or his capacity to think upon you (“I don’t know what to work on. I was hoping you could tell me.”) When the patient projects upon you, he is in a misalliance with a projection not a therapeutic alliance with you. If he remains in relationship to his projection, he will leave the therapy with the hope that he can leave his projection in your office. Projection of will (“That therapist kept trying to dig inside me so I had to leave.”). Projection of the superego: (“That therapist was critical and hurt me so I had to leave.”) Projection of the mind (“That therapist kept thinking I have problems with drugs, but I don’t think so. So I had to leave.”) As long as the patient relates to a projection instead of the therapist, the patient is at great risk of quitting therapy.
Let’s take a look at a few interventions for projection of will.
Pt: “What are we supposed to be doing here?” [Projection of will]
Th: “That depends on what your goals are here.” [Block the projection]
Pt: “I don’t know what to work on. I was hoping you could tell me.” [Projection of will]
Th: “Only you can know what you want to work on.” [Block the projection]
Pt: “That therapist kept trying to dig inside me so I had to leave.” [Projection of will]
Th: “The good news is that I have no right to dig in you. That’s your job. If you want to dig within yourself and share what you dig up, you can do that. But that’s up to you.” [Block the projection]
Perhaps the patient has a transference resistance where he enacts a past relationship. For instance, a patient may relate to you like his withholding father related to him. So he withholds information from you, making therapy impossible. Our blog on transference resistance describes ways these past relationships unfold in therapy, preventing a new one from developing. For more information on projection, see the chapter on regressive defenses in Co-Creating Change: Effective Dynamic Therapy Techniques at http://istdpinstitute.com/co-creating-change/.