Monthly Archives: October 2016

Healthy/Unhealthy? Judging patients

There is nothing wrong in therapy. Feelings aren’t wrong. Defenses aren’t wrong. Resistance is not wrong. Even judging ourselves, in a certain sense, is not wrong. These responses are how patients tell us, “Heal me. This is where I hurt.”

But sometimes we tell patients, “This is your unhealthy side.” Patients already judge themselves enough; they don’t ours. They already have a pathological superego, why add our superego to the mix? After all, who among us can claim to have the “right” superego for other people to have? Imitate me? I don’t think so. It’s not the patient’s job to imitate me or my superego. It’s his job to become him, to fulfill his destiny in life, not mine.

When we tell patients they have an “unhealthy” side, we encourage them to split, to judge, and to disavow that so-called “unhealthy” side. While it is true that defenses cause the symptoms and problems that bring patients to therapy, telling them that they “have” an unhealthy “side” encourages splitting. Beyond these notions of right and wrong, healthy and unhealthy, there is this thing called self-compassion, unconditional love that embraces feelings, anxiety, defenses, and resistance in this moment.

This moment, the now in therapy, can be a place where we and the patient accept all of the reality of the patient. Although we can see defenses, and it’s important that we do, we can misuse those defenses to judge the patient as “unhealthy”, “pathological”, or “primitive.” How often we convey these judgments: 1) resistance = “bad” patient; 2) collaboration = “good” patient.

Judging is how we resist the reality of the patient in this moment. And our resistance is futile. The reality of the patient will keep on existing whether we resist or not. The question is whether we can learn to be with the patient’s defenses, to see them as his secret unconscious form of collaboration (showing us what needs to be healed now).

The patient’s resistances and defenses are not an invitation for our judgment. They invite our healing. Defenses show us the sore points, inviting us to come closer. And who will we find? We don’t know. When we judge the patient as “unhealthy”, we claim to “know” who he is. We relate to our projection (validated by cherry picked theories) rather than the mystery of the person before us.

When we judge the patient, we say, “He is not-me. I am healthy. He is not.” Pretty big claim for any of us to make. Perhaps if we can be gentler with the patient’s humanity, we can be gentler with our own. And part of that gentleness may be accepting our tendency to judge, our own refusal to identify with another human being who is struggling. Accepting our own humanity so we can accept the patient’s.


Are You Suffering in Therapy

Are you suffering while working with a resistant patient these days?

Perfect. This patient is just trying to help you grow. Yeah. You. (Me too.) No patient can cause us to suffer in therapy unless we resist the way he is with us right now. We don’t have to like what we feel when we are with that patient. It’s just if we refuse to experience what we feel with him, we will suffer. Suffering as a therapist almost always originates from saying NO to the patient you have. It’s how we divorce ourselves from the way life is presenting itself to us in this moment.

I’m not saying you have to give up on the patient changing. But for a start we may need to accept our rejection of the patient, and then accept the feeling in ourselves we are rejecting. Accepting him and ourselves is how we align ourselves with reality, no matter how bad it seems with that patient.

How often we comment on the patient’s resistance, reciting the collaborative things he doesn’t do, that we want him to do, because our fantasy patient would do those things. That’s our resistance. It’s not his job to be the way we want him to be. He should be the way he is with us: that’s how he collaborates. An oncologist doesn’t get upset that a cancer patient has cancer. Why get upset when the patient demonstrates all of his relational cancer in therapy? We need to know what to treat. He’s just showing us what we need to know. But rather than explore what his behavior is hiding, we try to change his behavior. We become control freaks, but rationalize it as therapy.

Patients are not fooled. They see we have an agenda to get them to “shape up”. They see we want control over their behavior. They see our resistance. As long as we resist being with them as they are, they will resist us. Once we stop resisting the patient we have, encounter begins.

How to facilitate that? First, remember that resistance is just the impersonal defenses the patient uses to deal with his feelings in relationships. If you don’t take them as personal, you can “decenter” from your feelings, desires, and reactions, and focus instead on his feelings and desires which are hidden underneath his relational behavior.

When your patient’s resistance continues, you are probably resisting him. So ask yourself: how I am I resisting this patient? What feelings are coming up in me? How am I trying to control him so I don’t have to feel my feelings? When I stop trying to control him, what do feel within myself? What do my feelings tell me about myself and my history? Can I let myself have these feelings, so I can get some new information about myself?

In fact, we are not resisting the patient. We resist the feelings rising within us when we are with that patient. If we cannot tolerate that rise of feelings within us, acting out begins, although we call it “intervening.” The most common form of acting out is challenging the patient to change his behavior.

Instead, we need to tolerate the feelings that rise within us while the patient avoids contact with us, then do the work:

1) point out his relational behavior and then ask for feelings toward you;

2) point out the price and function of his behaviors and ask for feelings toward you;

3) differentiate him from his behavior; and

4) challenge the resistance: ask what he would like to do about his self-defeating behavior.

If the patient can see his resistance, its price and function, and the fact that his behavior is not him, then he will realize you are challenging his behavior, not him. And you won’t get a misalliance. If you can see your resistance behavior in session, its price and function, and the fact that this resistance is not you, then you will be able to relate to him instead of your resistance.

There are two people in the room, both with feelings. If the patient resists a close relationship with the therapist, we call it resistance. If the therapist resists a close relationship with the patient, we call it counter-resistance. Hmm. Another thing we share in common with our patients.