What do you do with someone who enters therapy for a mental health problem but refuses to make any changes? Let me clarify. The person admits that they have a problem. They are aware that their problem affects them and those around them deeply, emotionally and in a severely negative way. They also know that the problem they suffer with is treatable, even curable. Yet, they refuse to take medication and will not follow the therapeutic protocol that will alleviate their problem.
Yes, there are people like this. Some mental health specialists reading this will comment that the patient’s problem is one of resistance probably because the person has some deep-seated need to create negative attention, which they have worked hard for all of their lives. After all, negative attention is better than no attention at all. Others might suggest that the intransigence could be a sign that the individual was almost certainly abused in some way at some point in their childhood. The patient might even admit being victimized in their childhood but is still unwilling to make even the slightest effort to change beyond saying they went to therapy. Still others will have different theories to explain this person. Speculation is always accurate; at the very least, it is a starting point for further investigation in therapy.
What happens, though, when all the possible reasons for the patient’s resistance are explored and found to be highly unlikely? What if this person was just born this way and there is nothing we can do for them? They seem to live their negativity with an intensity of pleasure that others might envy if they could only have it in a positive form.
For those of us who are, on occasion, confronted with people like this in the consultation room it can be a most frustrating situation. We want to help others, which is why we do what we do.
During my fellowship when I had my first real experience with a treatment resistant patient I was lucky to have a clinical supervisor who educated me to all the possibilities. I do not give up easily. I was resolute in my desire to get through to this patient and find some way to help her get better in spite of herself. As I worked this through with my supervisor and it became clear that no one could help her he finally said to me “You have done everything you could possibly do. There is only one thing left for you to do. Be like an Eskimo. The Eskimos had a way to deal with this. They wave goodbye as the ice floe the terminally ill person is on slowly drifts away. This is not cruel. This is self-preservation – for both you and your patient.”
For a number of years I have been giving a series of lectures on the topic of sexual abuse. Hundreds of people show up for these talks. Some brave individuals speak about their victim-hood and how they managed to survive. They speak of their struggles in therapy and the work they do to rebuild their lives.
After the formal presentations people swarm to tell me how they were doubly hurt by their abuser and then by people who forced them to hide the abuse, not report the abuser to the authorities, and the threats they receive if they dare to report. Still too many community leaders insist that a report to the police may not be made until a rabbinic authority gives approval. The phrase used to justify this is that there must be “raglayiim la’davar” – if it has legs to stand; simply put, it must be substantiated by a rabbi before special victim investigators are called in.
I listened to a rabbinic leader lecture on why rabbis should be consulted first. His strongest argument was based on a case that had made it to the media from a different religious community. He reported that he saw in the papers that the accuser was not arrested which proved that too often false reports are made. I informed him after that the case he selected worked against his arguments. In that case the abuser was rearrested and in jail. The reason the first case was dismissed was that community leaders had sullied the evidence; the abuser was caught molesting others. The paradox in an approach that demands another layer of review is simple – only a trained investigator who has the ability to determine the veracity of sexual abuse can do so. An untrained person has no experience in assessing and evaluating sexual abuse.
There is an additional problem with this backward approach to reporting – victims are doubly abused when this happens. They are caught in a morass of feelings about themselves and their pain and then by a religious hierarchy that is in effect abandoning them, denying them protection, vindication and an avenue to healing. The only “legs” this approach ends up with are the legs that take victims away from the community they once belonged to. Maybe it is leaders, the holdouts, those unwilling to take the treatment, who should be placed on the ice floe so that we can wave goodbye to them and their lack of sensitivity and awareness.