Why do Patients Quit Therapy Prematurely

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/.

 

6 thoughts on “Why do Patients Quit Therapy Prematurely

  1. Anna

    Or, perhaps the therapist doesn’t respect the client, by treating the client like a diagnosis and not a person. Or perhaps the therapist isn’t skilled at shutting a client’s painful emotions down toward the end of a session, and the client too often leaves sessions feeling re-traumatized, without resolution or healing. Or perhaps the therapist mocks the client.

    Therapists need to be aware of if and how they undermine the therapeutic process.

    A good start, I suggest, is calling the client a “client” and not a “patient.” “Client” honors the fact that the person paying for the therapist’s services came voluntarily to therapy, willing to work (despite any resistance) and, quite often, willing to pay. That deserves some respect.

    Reply
    1. Jon Frederickson Post author

      These are excellent points. We should never forget how the therapist may contribute to failure of a therapy. The possibilities you suggest, sadly, are only a few of the mistakes therapists can make. I use the term “patient” to honor the Latin meaning: one who suffers. In that sense, as a human being, one who suffers, I sit with another sufferer. And hopefully, through my compassion (my willingness to suffer with the patient: bear his experience) we can form a healing relationship. But rather than suffer with the patient, we might use defenses like distancing, treating the person like a diagnosis, or mockery. But these would not technically speaking be therapy. They would be mistakes caused by the therapist’s countertransference, his unwillingness to feel with and identify with another human being in the room. Thank you for reminding us of this important point.

      Reply
  2. disequilibrium1

    This article is so far a theoretical rabbit hole, so strongly blames the therapist failures on “patients” (because everyone is sick, right?) it’s difficult to know where to start.

    But let’s start by “analyzing” therapy in normal terms. Therapists essentially are performers, playing roles of fantasy parents and omniscient shamans. They lead clients into regression and submissiveness. They provoke their clients’ core wounds and self-doubts, stoking self-recrimination. They coax clients into exposing their most irrational, defective aspects, while reclining in note-taking detachment. They present a synthetic, robotic relationship as intimacy.

    And you puzzle why some of those sick “patients” reject that this sterile, mechanical interaction will heal them. And more news from earth normal: if someone understands the source of her unhappiness and the road to fixing it, she might not seek a therapist.

    The clinician and client don’t stop being two human beings at the consulting room door. It’s not “sick” or “resistant” to dislike someone who responds to us like a robot, who regards us as a sick theoretical specimen or views our normal human traits as illness. As a consumer, I read this article as brimming with its own resistance and projection. I hope theoreticians will emerge from this contorted world and find some lost humanity. http://disequilibrium1.wordpress.com/

    Reply
  3. ultraviolet

    But what if you as a client genuinely, really, truly DO NOT KNOW what to work on? I’m not projecting my will, I really have no idea what I’m supposed to be doing–if I did, I wouldn’t be seeing a therapist!

    I’m in therapy for grief. I’m sad because I miss someone who’s not there. I can’t bring back the person that I miss, and obviously my therapist can’t either. To state that I should “know what I we’re supposed to be working on,” and that if I don’t I’m “refusing to engage in therapy,” is both extremely hurtful and insulting. I don’t know! If I did I wouldn’t be going to a therapist for help! The whole point of my therapist’s expertise is supposed to be that they know how to help!

    Reply
    1. Jon Frederickson

      Actually, in this case the patient does know what to work on: grief over the loss of a loved one. Here, the therapist simply needs to help the patient experience the grief and help the patient notice any defenses against accepting the loss and grief. By paying close attention to the patient’s responses, the therapist can discern what, if anything, may be slowing down the grieving process, in order to give the patient the relief she needs. Here, the patient knows what the problem is: her grief. What she does not know is what causes her grief to be stuck. As you rightly point out, it would be hurtful to say she should know what she can’t know: the unconscious defenses that are getting in her way. The patient has done her job, saying she needs help with grief. Now it’s time for the therapist to do his job, find out what is perpetuating the patient’s suffering. Thank you for pointing out this essential differentiation: the patient relates the problem to work on (grief), but the therapist must figure out what unconscious defenses are causing the problem. The patient does not and cannot know what is unconscious. That’s why she comes to a therapist.

      Reply
    2. Jon Frederickson Post author

      If you are in therapy for grief, and you know who you are missing, you know what to work on and you are working on it: your grief. If your therapist does not realize that, then it’s time for a heart to heart talk. If you are not sure about how to “work” on your grief, then the therapist, indeed, should be able to help you. Grief is not just a feeling but a becoming at one with the truth in your life right now. You need someone who sees that, helps you see that, and can help you bear that.

      Reply

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