People who aren't in the health professions often think of therapists as warm and fuzzy humans who offer unconditional emotional support and constantly ask their patients, "How do you feel?" While many psychotherapists and psychiatrists enter the mental health field because they are empathetic and compassionate individuals, there are times when they don't exactly feel positive towards their patients. They're human, after all. As a psychologist myself for 14 years, I've faced challenging interactions with some patients. I've sometimes struggled to understand the reason for their behavior and use my insight in a meaningful way.
This is why difficult patients—especially those who seem racist, sexist, or hostile—can ignite powerful emotions like anger, frustration, and anxiety in the therapist. And unlike in real life (or on social media), a therapist can't exactly clap back whenever they want. Our psychological forefather, Sigmund Freud, called this phenomenon transference. Transference is like an emotional contagion. It occurs when the patient places unwanted, and often negative feelings onto the therapist. For example, if the patient is extremely agitated or overly pessimistic, the therapist may end up feeling similar after a session.
When therapists experience these feelings, they have to figure out how to respond professionally. Their negative reactions may affect the therapeutic process, so they have to respond in a way that benefits the patient, managing their own prickly emotions regardless of how hard that this sometimes. I asked four therapists—all of whom preferred to stay anonymous—how they've handled difficult patients. Certain identifying details about their patients have been changed.
Brian, Portland, OR
I once met with a patient, a retired police officer with a particularly gnarly personality. He didn't come to see me because he wanted my psychological help. He wanted me to sign disability papers because he had some memory deficits, and he believed they stemmed from a previous injury. But neuropsychological testing revealed severe alcohol abuse, which explained his cognitive problems. I got the feeling he was using me to game the system; I can't stand being manipulated.
Then it turned ugly. As I took a psychological history, I asked the patient if he had ever taken antidepressants. He referred to his former psychiatrist as a "New York Jew who should have died in the ovens of Auschwitz." His statement shocked me, and I felt irate. He was hitting many stereotypes of the racist cop.
At the time, multiple fantasies went through my mind. I imagined kicking this patient out of my office and telling him that my wife was Jewish, and several of her family members had died in the Holocaust. Even though I didn't feel like helping him, I remembered one of my core clinical beliefs: Patients who present with unsavory personalities are usually decent people who manifest their pain uniquely.
While this helped me find a dose of patience for this surly patient, in the disability report, I told the truth. My patient's memory deficits didn't stem from an injury at all. When I gave him a copy, he was furious. He accused me of ruining his chances of securing disability. His response gave me a small dose of satisfaction, but I was also pleased that I didn't let my disgust or displeasure distort my clinical opinion of this man.
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Denise, New Orleans, LA
My most frustrating patient was just so narcissistic that it irritated me. He felt really entitled. He was at Tulane, and couldn't finish for some reason because he didn't pay for something. And then they gave him the opportunity to finish so he could graduate. He needed to do one last assignment. And he just wouldn't do it.
He started seeing me because he was depressed. And his narcissism and the depression were kind of fighting with each other because he felt like he wasn't motivated to do it but he also felt like he was over it, too—like he didn't need to do it. He almost wanted me to act like his mother.
Every week I was trying to help him get his life together because all he would do literally every day was be on Facebook on his phone playing games. He didn't have a job or money coming in, so I was trying to get him to apply to a couple of jobs every day. We would make a list, every session, of things he would need to do. Every week he'd come back and he hadn't done a damn thing.
In the middle of that, though, he did do a graphic design project. And some of his work got put in this book affiliated with a rapper. He kept talking about him. Those with narcissism love to be associated with people who have a name.
This was in my residency, and after a certain point we could pick we who wanted to continue working with. I did not want to work with him. The only reason I didn't reveal how annoyed I was to him was that I was able to vent to everybody else. Our supervisors, from the very beginning of residency, told us that whether it's good countertransference or bad countertransference, you need to tell someone else about it.
Whether you like the patient—which can sometimes be just as bad as not liking the patient—or not, always talk to [your supervisor] about it. Just to make sure you're not doing anything you're not supposed to do. Every week I was talking about this guy. He was irking the shit out of me.
Adam, Columbus, OH
Every once in awhile, I see therapists in my practice for psychotherapy. I'm clear that this isn't supervision and that I'm not going to advise them on how to do therapy. Nevertheless, therapists who are patients often discuss their clinical work during our sessions.
One of my patients, Mark, told me how shocked he was when one of his teenage patients, a black male, swore at him constantly. Mark, a white man, told me he had handled his patient's swearing by being very direct with him. I asked Mark what it might be like for a black teenage male to experience a direct, authoritative conversation with a white man. I was curious if they had talked about their racial differences during the session.
Mark responded, "Why should I talk about race?"
My jaw dropped to the floor. I felt angry, and my face flushed. I told Mark he came across as insensitive and he seemed oblivious to my concern. Instead of apologizing, he became defensive. While I found Mark's comment racially insensitive, I didn't want to criticize him or call him a racist, because that would make it harder for him to engage with me. Instead, I said, "That seemed like an insensitive statement about black people, particularly black men."
Mark was blind to my concern. I continued to ask him about his views on race, power and gender. But he shut down and became more defensive. I finally managed to salvage the session by asking Mark about his defensiveness. He opened up a little and told me about his need to always feel like he's doing a good job.
Sarah, Seattle, WA
"HD," a 17-year-old male, came to see me because he struggled with depression and anger management. He had been aggressive with his classmates. During our initial session, I learned that HD had always had difficulty making friends. He also obsessed about certain topics and had a hard time controlling his emotions.
He was struggling with his friendships. He had an unhealthy peer group. For fun, he and his friends often bullied each other. He told me that they called each other names and made fun of each other often. Eventually, the bullying became so awful that he got into a physical fight with another peer. One friend in the peer group was Jewish, and after the altercation, HD became preoccupied with Holocaust denial groups.
While I understand that teenagers say things for shock value, I was taken aback by his confession. Instead of challenging him, I invited him to tell me about his fascination with this group. He neglected my question, but said that he spent most of his day online, researching arguments against the Holocaust. He became so obsessed with the topic that he neglected his homework and his grades plummeted.
He used the information that he had read to argue with this peers about the existence of the Holocaust. He also began harassing his peer with racial epithets. It was difficult for me to listen to HD relay these stories. They were mean and filled with aggression and hatred. At times, I disliked this patient. It was excruciating to sit with him and hear him debate the existence of the Holocaust. I even fantasized that he'd leave treatment.
But then I had a clinical epiphany. I realized HD was fixated on Holocaust denial because he had denied his own mental health concerns. He had spent his entire life feeling like an outcast, but instead of talking about his pain, he tried to make his classmate the "outcast" by accusing him of lying about the Holocaust.
Unfortunately, HD was not open to hearing any of my interpretations. As a therapist, I had to accept that sometimes we can't help our patients, especially when they don't want our help. In the end, HD was expelled from school.
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