Help-Seeking-Rejecting Clients and The Therapist’s Ego By Mallory Behar, PsyD on 5/26/21 - 11:55 AM

I realized the other day that over the course of my lifetime, I have probably joined and cancelled gym memberships about 25 times. I always enter these contracts with a bright sense of optimism and hope—“This is my year!” I usually proclaim proudly. I may even go a few times before my motivation starts to dwindle. My pattern then dictates that I consult with a personal trainer. The personal trainer is always very optimistic and willing to help. However, after I beg the trainer to push me in the workouts and give me at-home routines, it usually takes about a week or two before I am back in the manager’s office asking to cancel my membership. It is never that I do not want the help, but rather that binging television shows and napping on the couch will always feel better in the short term than sweating through my pants while trying to pretend that I am not as winded as I look.

I relate this experience to my work with the patient who ostensibly seeks but ultimately rejects help. I often find myself frustrated and overwhelmed by that person who comes in asking for help but does not seem to be interested in the coping skills and practices I offer to support them in their improvement. In a sense they seem stuck, and, in turn, I feel stuck right along with them.

I have worked with patients before who continue to stay in their romantic partnerships despite their feelings of unhappiness and desire to date other people. I can remember one patient in particular who had been in a romantic partnership for over two years despite describing herself as unhappy. She noted that each time she engaged in sexual intercourse with her partner, her vulva burned and spasmed. She noted that when she engaged in extramarital affairs with other men, such a reaction did not occur. Despite trying different positions, lubricants, and doctors, the problem persisted. It was discussed that the relationship was making her so unhappy that her body was physically rejecting her partner. Sessions focused on processing the meaning of this relationship and noting why it was so hard for her to leave this person. They also focused on exploring feelings related to the breakup process and using effective communication strategies to foster mutual respect. However, as time continued and the extramarital affairs increased, it was clear that this was not the right time for the patient to end the relationship. At one point I became so frustrated that I myself wanted to grab her phone and send a break up text! The more I have reflected and thought about my reactions, the more I realize that they have more to do with my own ego than with the patients and their progress, or lack thereof.

Each time I encounter a help-seeking-rejecting patient, I want to hear that they have used the coping skills offered that week, and their lives have changed for the better because of those actions. I want this outcome not only because I want them to live happier and more authentic lives, but also because it would mean I have been successful in some way. It would mean that something I did or suggested mattered and helped change an outcome. Clearly, it is difficult not to personalize my patients’ wins and struggles as my own. As if I really had some power to control what happens! It is ironic because it is also me who frequently recites the common therapist phrase “You cannot control others; you can only control yourself and your reactions/perceptions.”

And so I realize it is my job as a therapist to meet patients where they are, letting them know that sometimes it is okay not to be able to or want to change right now. Just as it is okay for me to cancel a gym membership I am not using, sometimes it is okay to be stuck. That is not to say that this patient cannot and will not change in the future (I will keep joining gyms, and one day it may work for me!), but more to accept that patients are not always in a place in their lives where they can (or want to) change. Sometimes clients, like therapists—me included—must accept they are doing the best they can in the moment with the tools and circumstances they have.

I think it is great when patients improve in some measurable, objective, and defined way. However, I do not think therapy is an exact science, and I have come to learn (and accept) that clients will experience lapses, relapses, and periods of stagnation. In doing so, I am better positioned to help them find a sense of peace in a world that tries to shape and change them beyond what they can do.



File under: The Art of Psychotherapy, A Day in the Life of a Therapist