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Overcoming Treatment Resistance - Dan

By Jack Rosberg, Ph.D.

Case Examples and Specific Treatment Techniques:

The case of Dan, illustrates the difficulty in dealing with the patient who is quiet. Sometimes, these patients are presumed to be resistant to treatment, because of their purported inability to speak. And, sometimes they don’t speak because the therapist does not know how to help them talk. Helping a patient speak to us is one of the most important tasks we have. If we are to do this with any success, we must remember that the quiet patient is not always the same as the withdrawn patient or isolated patient. Nor is the quiet patient the same as the suspicious or guarded patient. Some people don’t talk very much and schizophrenics are no different. But, this quiet style can also lead to confusion during treatment.

If we are to understand this kind of problem, we must examine carefully why patients behave in a quiet way and what special value that behavior may have. For example, many patients are quiet in the presence of a therapist because the therapist is perceived as an unnatural part of their life. The patient tries to do whatever can be done to escape the situation. Or, if it is too dangerous, like the rabbit, the patient will freeze and do nothing. These people, have lost so much faith in the world they cannot afford to place their trust in anyone. Dan, for example, had no way of believing in my intentions no matter what I said. Somehow, I had to recognize this and help Dan alter his distorted perceptions.

The Magic of Words
As Otto Fenichel, a great contributor to psychoanalytic literature, reminds us, that one of the pathological factors sometimes associated with quietness is the attribution of magical significance to the words themselves. With Dan, words were loaded with powerful meanings. He was afraid that if he said the wrong thing it might harm the people around him or himself. Some people might refer to Dan as anal-retentive; a person whose pathology is expressed in the withholding of speech. Certainly this factor contributed to Dan’s quiet style. However, it is also important to understand that Dan is a person whose ability to communicate with others had been thwarted by both cultural and familial repression. Dan is from a conservative European, background where generational difference of family members discouraged the free flow of ideas or the expression of feelings.

The Sources of Fear
Finally, many patients are quiet because their fear makes it impossible for them to participate in the treatment process. This fear may arise from many sources. Generally, it begins with the patient’s fear of the illness itself. At first the patient must respect the illness because it has become the center of their life and of the lives of others. Then, when the illness itself becomes inescapable it evolves into something so important and powerful that it must be treated with dread, awe and wonder. Now the patient must protect the illness and keep it from growing so powerful that it can no longer be contained. When this stage occurs, the patient could be totally afraid of the therapist; of what might be uncovered, of what might be done, of how the therapist might interfere with a carefully crafted structure that is the psychosis. Sometimes these fears will cause the patient to believe the therapist has magical powers; can read minds, can see into souls, or has the power to kill. When this happens, the patient becomes immobilized. The terror makes them mute or encourages them to engage in other tactics designed to avoid the therapeutic encounter.

When the patient is so afraid they are unable to respond and their eyes will reveal this. The fear is there and the non trusting attitude is there and it can be seen. When this occurs, the therapist is faced with a formidable task in overcoming this condition. Often some reasonable amount of self disclosure will disrupt the guardedness of the patient so that a tentative alliance can be formed. At times like this therapists must reach down into themselves and come up with humanizing tactics that reveal who they really are. If the patient cannot be helped to reduce their feelings of apprehension about the importance of their illness, they will never respond to treatment. Thus, it is more important to help the patient overcome their fear of the illness than it is to treat the illness itself. Otherwise, the fear, not the illness, will become the straight jacket from which they cannot escape and which will limit their capacity for living. It was obvious that Dan had been suffering this way for a long time.

The Early Sessions
In discussing my feelings about the importance of spontaneity as a device to reduce the therapists’ feelings of frustration, which can arise while working with quiet patients, I talked and/or revealed my inner process in my initial contact with Dan. One could see the quality of the relationship Dan and I have with each other. It is clear that we like each other and have regard for each other. Looking back at the initial sessions I repeated some of the unique interventions a therapist can offer which will result in a positive disruption of the schizophrenia. I repeated to Dan in some detail what I did when I first met him. Out of my frustration with Dan’s inability to speak, and after a great deal of effort for some period of time, I yelled out “fuck” and “shit”. The words where taboo words for Dan as they are for most of us and it later became clear that the taboo had been lifted when I said these words in Dan’s presence. To repeat, the words were uttered out of frustration, however, the lifting of the taboo gave Dan a great sense of relief and permitted him to laugh, relax and speak more easily. He had discovered that there was something different about me. In a following session I continued to reinforce the importance of the relationship and how I could help Dan suppress the voices. I stressed that this would allow Dan and I to talk to one another without interference. I said: “you know that I care for you. Do you know that? I am going to kill the voices.” It was obvious from Dan’s reaction that the idea of killing the voices was frightening. The anxiety aroused required Dan to think in a concrete way. It may even have been pushing him to return to magical thinking. Certainly, he was not able to separate himself from the act of destruction that I threatened. I did not appear to recognize what had happened but did notice that Dan’s demeanor had changed. I said “do you want to stay sick”? I was focusing on my awareness of Dan’s newly revived resistance to treatment. I then said, “You don’t want to be sick anymore - - to hell with them”. (Again, referring to the voices.) Dan disclosed something of his own thought processes when he asked me how he can bring back something that is not there anymore. The voices were gone. This discussion from Dan clarified the threat he was experiencing when I offered to “kill the voices”. Dan was genuinely puzzled by my reification of the auditory hallucinations. He had already recognized that the voices were not real and couldn’t understand why I would treat them as if they were. Resolving this problem might be crucial in maintaining the therapeutic relationship. However, even if it was not resolved then, it would be resolved later. The relationship between the two of us was strong enough to withstand an error of the head. I said: “one thing for sure, they do eventually have to go away”. Dan continued to be confused about what I meant. I finally recognized the problem and said in a reassuring way “do you want to hear them? You don’t have to, if you don’t want to”. I finally identified the source of the confusion and the anxiety that Dan was experiencing. I refocused Dan on the relationship and how that would protect him. Then I suggested in a repetitive, almost hypnotic manner that Dan should listen to my voice as a way of overcoming the hallucinations. Dan was reassured, although somewhat still uncertain. I realized that not all of Dan’s confusion was related to his schizophrenia. I was reminded that Dan can misunderstand what is said for the same reasons the rest of us do. This kind of disruption in treatment probably occurs more frequently than we would like to think. It is troublesome, but not insurmountable. What is interesting is that it portrays for us some of the normal human limitations that are often overlooked as therapists struggle with the demands of the patients’ illness.

In Conclusion
I am pleased to report that Dan currently lives in an apartment and even though he continues in treatment, he lives a productive and enrichened life. He is physically active he works part-time and has an active social life. He has a renewed interest in literature and is reading books that he read years ago. It is possible to predict that the future will even be brighter for this worthy person.