A Therapist's Guide to When It's Enough

"All therapists, from time to time, encounter patients that just don't seem to get better or change in anyway. At first the treatment seemed to move along nicely, but then it stagnates. We may try new techniques, talk to colleagues or supervisors, read books, but the patient doesn't budge. Often this leads to frustration and hopelessness; we cling to treatment by trying to analyze it as transference and countertransference and work through that. Still no movement."

"What is rarely discussed is that some patients might just be destined not to change or to improve beyond a certain point. Understanding and accepting this itself can lead to a profound change in the experience of therapy for both patient and provider, even if it does not yield progress. In some cases, we as providers can learn to find value in holding up the floor, seeing that, although the patient may not be moving up, they would be doing worse without us."

Some patients reach a therapeutic plateau and fail to improve despite varied interventions. Acceptance that some patients may not change beyond a limit can alter therapeutic experience for patient and provider. Providers can adopt a caretaking role by stabilizing risk—holding up the floor—so patients do not deteriorate further, or conclude treatment and arrange referral when appropriate. Dedicated caregivers may struggle with guilt, shame, and fear of failure. Many defenses developed in early life served survival functions in traumatic or neglectful environments. As biological adolescence ends and neuroplasticity lessens, longstanding behavioral patterns become more neurologically entrenched, making relinquishing defenses more difficult.

Read at Psychology Today