Can a therapist be a limit

Everyday professional life and mental hygiene: Difficult situations in therapy

Arbitrary break-offs of contact, aggressiveness or transgressions on the part of a patient are not easy for the therapist to endure. There are no patent remedies for this, but there are a few principles that can defuse the problems.

In their everyday work, psychotherapists occasionally get into situations in which they do not know what to do next. Examples of this are sessions with patients who are listless or aggressive, who do not allow for emotions or who do not keep appointments. Since the number of such possible situations would go beyond the scope given here, two situations are shown below as examples. The book "Difficult Situations in Therapy and Counseling" by Alexander Noyon and Thomas Heidenreich (1) deals in depth with these and other difficult situations and suggested solutions.

The first example relates to the patient breaking off contact. Usually, the end of a treatment is sought by mutual agreement. However, it happens again and again that patients stop treatment more or less suddenly, unilaterally and for various reasons. In principle, patients have the right to discontinue treatment. Psychotherapists should know and accept this. However, it is beneficial for the patient and the therapist to talk about the reasons. If the patient enables a discussion about the reasons for the termination, these should be openly recorded and clarified in detail.

Self-critical attitude

A self-critical attitude on the part of the therapist and restraint are appropriate in this case. "In order not to overlook crises, it could be useful to encourage patients to share everything they feel and to share their possible dissatisfaction," says psychotherapist Dr. Antje Gumz from Leipzig University Hospital.

On the other hand, disappointed, offended or reproachful reactions on the part of the therapist should be avoided, because they increase the patient's tendency to withdraw from therapy. If it is possible to find out the reasons for discontinuing treatment, then the therapist will benefit because he can learn more. In addition, there is a chance of persuading the patient to continue treatment after the problems have been resolved, so that it may be possible to further reduce the patient's psychological problems. Should the patient insist on ending the treatment anyway, this must be respected. If, on the other hand, the patient is in an acute crisis situation or is at risk of suicide, for example, then the therapist cannot and must not just let him go, but must make his concern clear to him and at least try to continue the treatment, or he may have to tell the patient to other therapists or handed over to institutions.

If a patient breaks off the treatment without any possibility of contact, this is not easy for many therapists to cope with. They perceive the termination as a criticism of themselves or of the treatment. According to Roman psychotherapists Claudio Neri and Marzia Rossetti, it is not uncommon for psychologists, psychotherapists, and psychiatrists to suffer from feelings of guilt, shame, and feelings of worthlessness and failure when rejected by patients.

The psychologists Prof. Dr. Alexander Noyon, Mannheim, and Prof. Dr. Thomas Heidenreich, Esslingen, recommend psychotherapists not to lose oneself in self-reproach after discontinuing treatment and to constantly undermine one's own professional self-esteem, but to try to deal professionally with one's own error behavior. In her opinion, it is not a question of trying desperately to avoid mistakes, but of getting used to a competent style in dealing with one's own mistakes, which includes addressing, clarifying, admitting, apologizing and dealing with problems and any mistakes to correct.

Restore trust

In this way, possible treatment errors can even have a positive effect and, for example, restore trust between patient and therapist and strengthen the working alliance. Since the lack of knowledge of the reasons for discontinuing treatment is usually perceived as unsettling and grueling, therapists should endeavor to find out the specific reasons of the patient. If this is not possible, appropriate, but not self-doubtful, self-critical reflection should take place, which is best accompanied by a colleague or supervisor.

The second example relates to recognizing and respecting one's own limits. There are always situations in which patients exceed the boundaries of psychotherapists with regard to attitudes or interaction. This is the case, for example, when the patient has values ​​and attitudes that are completely different from those of the therapist, for example with regard to religious, political or sexual issues. The limits of a therapist are often exceeded by aggression on the part of the patient, for example when the patient verbally attacks and devalues ​​the therapist or when he uses threats, intimidation and physical violence. In the opinion of Noyon and Heidenreich, it is wrong in these cases to pretend not to notice the discrepancies or to ignore the attacks. In addition, it does not help therapists if they identify their hurt and anger with themselves, defend themselves, allow themselves to be intimidated or start a counterattack and appear threatening to the patient. A professional way of dealing with such problems is to determine your own limits and act accordingly. This can mean that you explain to the patient your own rules for dealing with each other and that you ask questions, address your concerns and ensure your own safety. In addition, it is sometimes helpful to illustrate the patient's behavior with the help of video recordings and to offer him training in social skills. However, after careful consideration, it may also be right to drop the case.

There are no patent remedies for dealing with the above and other difficult situations. However, there are a few principles that can help take the headache out of problems. This includes, for example, dealing openly, self-critically and constructively with yourself and the accusations or negative behavior of the patient. Excessive demands should not be placed on oneself, and therapists should also keep in mind that a patient's will to treat, a good working alliance, and a cure cannot be forced. Therapists can only offer a treatment that is accepted by the patient or not.

It can also help to keep calm in the face of a difficult situation, to take a break and to establish inner distance. In the long term, psychotherapists should ensure that they balance their private and professional life as well as possible and that they take care of themselves, because only then can they muster enough energy and serenity to be able to deal constructively with difficult situations. It is also important not to want to deal with everything yourself, but to seek help and support. “Don't stay alone with your difficult situations, but discuss them with colleagues,” advise Noyon and Heidenreich. Psychotherapists learn from this that colleagues are also familiar with these or similar situations and sometimes also have no advice.

Exchange with colleagues

This can help to dispel self-doubt and to free yourself from excessive demands on yourself. In addition, the exchange with colleagues offers the opportunity to look at a problem from different perspectives and to find solutions that you would not have come up with on your own. However, this is only possible in a group of like-minded people, in which one can speak openly about insecurities and weaknesses and in which there is a relationship of trust. Difficult situations quickly lose their horror in such a circle and, in retrospect, can perhaps even be counted as valuable experiences.

Dr. phil. Marion Sonnenmoser

Noyon A, Heidenreich T: Difficult situations in therapy and counseling. Weinheim: Beltz PVU 2009.
Gumz A: Critical moments in the therapy process. Psychotherapist 2012; 57 (3): 256-62 CrossRef
Neri C, Rossetti M: Feelings of guilt, shame, and unworthiness. European Journal of Psychotherapy and Counseling 2012; 14 (2): 189-200 Cross Ref