The Use of Strategy in Clinical Work, Part II

The Impossible Patient: How Thinking Strategically May Help

How do you deal with patients who don’t understand how psychotherapy works or who simply can’t buy into it? The tolerance of patients for a process that makes little sense to them can be quite limited. Things may start out well enough, but soon that person begins to miss appointments or becomes contentious. Creating an intentional strategy generally improves the management of these challenging clinical situations.

In previous newsletters, we discussed the use of the patient’s support network to strategically buttress treatment: the parents of a teenager in The Use of Strategy in Clinical Work, Part I, and the grown children of a medically ill adult patient who was unwilling to comply with her treatment in Transparency and Confidentiality in Clinical Work, Part II. In this issue, we consider another type of patient, one who was resistant to embracing the medical and psychiatric help he needed. In important ways, all three of these cases were similar. They involved people with limited comprehension of how interpersonal treatment works, all of whom were initially skeptical about the value of psychotherapy.

Alan: An Unlikely Candidate for Psychotherapy

Alan: a good guy who we all miss. Myelofibrosis, a generally fatal disease where his bone marrow was progressively being obliterated, was diagnosed at age 56.  Alan died at the age of 60, leaving three children behind.

A hard-drinking, inveterate gambler, Alan could be both moody and generous. Born into urban poverty, he became wealthy after developing a luxury automobile business. Alan could be a finagler, a bit sly, not always telling the truth. For example, it was difficult to know whether Alan fooled around with women. His second wife insisted he did, however, and never let him forget it.

These enigmas introduce this fascinating man. They also provide a background for noting how poorly he cared for his health, even when he knew how sick he was. Over time, Alan became sicker, nonetheless maintaining his devil-may-care attitude until the end.

This is where the trouble for Alan’s doctors came in. While he religiously presented himself at his hematologist’s office and was compliant about medications and transfusions, he took risks, mischievously acting against medical advice. In fact, he continued to drink until his last months, regularly exhausting himself with his revelry. This was Alan’s character, the basis of his success, as well as the problems that dogged his life. He both cooperated and unceasingly cheated, a physician’s nightmare and a psychotherapist’s impossible patient.

Did Alan need psychiatric care to help him curb his self-destructive behavior and stick with his medical treatment regime? He didn’t think so. After all, what would a guy like him be doing with a shrink, even if his doctors insisted he see one?

Given his contradictory needs and attitudes, strategy in Alan’s case would need to be directed at making treatment stylistically acceptable to him, while at the same time technically potent. It would have to be pleasing for him, while simultaneously effective in addressing how Alan’s self-indulgent behavior was undermining his medical condition. This is a place where a therapist’s personal flexibility (in this case, Steve Frankel) becomes particularly important.

Alan craved something he had never experienced: an honest commitment from another person, especially one he respected. He longed for a relationship with someone who — unlike the typical recipients of his never-ending largesse — wanted nothing material from him. No one in Alan’s life had ever been interested in his welfare without there being strings attached.

So, I made every effort to get under Alan’s skin, working to make myself both credible and relevant to him. I began by providing counseling to Alan and his wife, and, as they began to trust me, shifted my attention to Alan. That suited his wife’s purposes since she assumed I could see Alan’s evil. Once Alan found himself feeling cared about by me, he began to climb on board, incrementally applying himself to the agenda I provided.

Sadly, however, it was too late to begin significant medical repair. In addition to the progressive disappearance of his bone marrow, Alan’s lungs were being destroyed by his illness. And, ironically, all this was happening as he was becoming committed to psychiatric treatment, allowing me to play a key role in the management of both his psychological and medical care.

Death came when Alan and his doctors were considering a bone marrow transplant, the only procedure that could have potentially saved his life. But, by then he was too sick for doctors to risk the transplant. Maybe he could have survived had he paid closer attention to his health or been more cooperative with his doctors. However, that was not how Alan wanted to live his life.

By the time Alan died, he was beginning to make sense out of the forces that dictated his actions. He actually had become a good collaborator in psychotherapy. According to his own testimony, he died with few regrets. The last few months of our work were devoted to this subject. In his words, “I overcame my background, made plenty of money, had fun, and now have had the experience of ‘real’ relationships.” He was referring to his children, nieces and nephews, and according to his own testimony, me. In formulating a clinical strategy, the practitioner takes into consideration the forces supporting the treatment and those that work against it, focusing on and bolstering the former. This process is both deliberate and spontaneous.

In support of the work in this case were Alan’s brilliance, generosity, and intense but often disguised desire to be valued for who he was. He progressively felt appreciated by me, in part because I refrained from criticizing him and conditionally championed his right to make final decisions about himself. Our mutual explorations nonetheless needed to include the constant reiteration of the costs of his revelry. Opposing success was Alan’s early conviction that he could rely only on himself, because compliance with others would rob him of his fiercely-held independence, potentially killing off his spirit.

In situations like these, intuition and judgment are powerful determinants of clinical action; the clinician gambling from moment to moment on the value of intervening in ways that he or she believes will be helpful to the patient. To support this kind of interpersonal risk taking, the therapist must maintain a collaborative stance, continually soliciting the patient’s feedback.

As clinicians, we can only judge the value of our strategic decisions retrospectively. The rest, as it is occurring, is all based on clinical judgment and experience, both sources riddled with subjectivity. Real certainty comes from patient feedback and results, which are best judged alongside goals set at the beginning of treatment and modified as the patient and therapist work together.