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 https://istdpinstitute.com/co-creating-change/.

Jon Frederickson is the author of Co-Creating Change (May 2013), the first-ever guide to intensive short-term dynamic psychotherapy that includes both an integrative theory of conflict and a moment-by-moment method of assessment to guide therapist interventions. Available for ordering now.

“What if you have an anorexic patient at an eating disorders unit who has no wish to be there, no goal for therapy, and no wish to engage psychotherapy? Why does she show up? She does not explicitly want my help, yet comes willingly. As soon as I ask what she wants, she withdraws, becomes quiet, or argues. It’s a totally lost battle. She has to accept a life on these harsh terms. Nobody can help her.”

A new study will be coming out soon from Allan Abbass showing the effectiveness of ISTDP with eating disorders. When discussing eating disorders, clinicians often make the mistake of focusing on the symptom (the eating disorder) rather than the underlying personality organization. You can have eating disordered patients who have neurotic, borderline, or even psychotic levels of character pathology. Thus, the defenses and resistances involved, the pathway of anxiety discharge, and the self-observing capacity can vary dramatically among these patients. Key point: always do a thorough psychodiagnosis of the patient so you will be treating the patient who has the eating disorder, rather than trying to treat just the eating disorder itself.

A patient claims she does not want to come to therapy, yet comes. This is denial. We block denial by reminding the patient of contradictory realities: She says she does not want to come. You respond, “And yet you are here.”

When you ask what she wants, she withholds. This is typical with anorexic patients. The anorexic patient enacts an object relation of a withholding mother and a starving child. Thus, the character defense: “I withhold from myself.” The transference resistance: “I withhold from you. I act in such as way that you, the therapist, will be the mouthpiece for my desires. Then I will reject them and withhold from you.” In this type of transference resistance, the patient is identified with the resistance and is inviting you to express her healthy wishes. To block her projection, mirror her resistance.

Pt: “I don’t want to get better.”

Th: “Getting better may not be something you want.”

Pt: “Maybe I should give up.”

Th: “You may want to give up on yourself now.”

Pt: “It’s a totally lost battle.”

Th: “Perhaps all we can do is watch the battle for your life get lost.”

Pt: “I have to accept a life on these terms.”

Th: “Then I have to accept that this is what you accept.”

Often, when the patient is identified with her resistance, we make the mistake of talking to the patient as if she is identified with her healthy longings. Then we get stuck. When she is identified with her resistance, mirror the resistance.

Pt: “Nobody can help me.”

Th: “I’m so glad we are in agreement. You’re right. I can’t help you. If I offer 100% and you give up, we’ll have a zero percent result. If you offer 100% and I offer 100% we can have the best result possible. But as long as you withhold from yourself, yes, you’re right. This process is doomed to fail. Don’t get me wrong. You don’t have to fight for your life. You can give up. Your life is yours. Your starvation is yours. If this is working for you, you should keep it up. But as long as you give up on yourself here, yes, I will just become another person who can’t help you. Why? Because I can’t do it by myself.”

As you mirror her resistance, you will be blocking the projection of her healthy wishes upon you. Since she can’t project onto you, she experiences internal conflict between her wish to live and her resistance. This internal conflict causes a rise of feelings and anxiety within her.

Another way to address the resistance, in a non-ISTDP way, is through interpretation. Here is a Kleinian type.

Pt: “It’s a totally lost battle.”

Th: “You are warning me that you have given up fighting for you and that there is nothing I can do about that. That is true. If you have given up fighting for you, I can’t do it by myself. At the same time and on another level, you are letting me know that you are afraid that by joining forces with this demon, I will then be totally useless to you, and you will remain the hostage of the demon.”

Keep in mind: you easily get lured into the role of asking, wanting, desiring. Then the anorexic patient can withhold. Once you understand this dynamic of the transference resistance, you will be able to stop from enacting her disavowed desires. If you enact and express her desires, she doesn’t have to experience them. In my book, Co-Creating Change: Effective Dynamic Therapy Techniques, we have an entire chapter devoted to these problems of the transference resistance.

Jon Frederickson is the author of Co-Creating Change (May 2013), the first-ever guide to intensive short-term dynamic psychotherapy that includes both an integrative theory of conflict and a moment-by-moment method of assessment to guide therapist interventions. Available for ordering now.