10

The “Impossible” Patient

Chronic Disempowerment

Even among a very symptomatic and extensively traumatized patient population, there seem to be subsets of patients who have a more difficult clinical course and whose disabilities appear to be more chronic in nature. Over many years in a hospital setting, we have observed hundreds of patients with posttraumatic and dissociative disorders resulting from childhood traumatization. All of these patients have been seriously ill and/or disabled. Many patients that we have seen have maximally utilized available treatment and have rapidly achieved stabilization of symptoms and overall improvement. In contrast, we have also seen at least two groups of patients who have had a more difficult and chronic clinical course. Patients in one of these groups have had major DSM-IV Axis I disorders in addition to posttraumatic and dissociative disorders. These comorbid disorders have included major mood disorders, psychosis, and substance abuse, resulting in complicated clinical presentations with complex differential diagnosis issues that often require prolonged treatment.

A second group of patients who have a more difficult and chronic course have a clinical presentation I have called chronic disempowerment. Even among patients with complex trauma-related disorders, these patients present long-standing difficulties that seem impervious to change. They seem to come to treatment with a combination of intense psychological distress and a truly entrenched and unchanging sense of despair, hopelessness, and helplessness. This group of patients represents an extraordinary clinical challenge. They are highly symptomatic and utilize extensive amounts of psychiatric and psychological care. They are prone to severe regression in treatment, which can lead to considerable morbidity and even mortality. And, they elicit strong and often negative reactions from their caregivers. Understanding chronically disempowered patients is a clinical necessity, for without expert treatment they are likely to remain “impossible” patients.

CHRONIC DISEMPOWERMENT

Generations of theorists and investigators of early childhood development have concluded that healthy psychological growth derives from appropriate parent-child attachments and interactions in a protective and nurturing environment. Good parenting requires that parents be attuned to the needs of a child, and they must interact in a way that validates the child’s positive sense of self, soothes and protects the child from overwhelming stimuli, and challenges and encourages the child’s developing coping capacities. Good parenting allows a child to achieve healthy and mature characterologic development including (a) a sense of self-esteem and self-efficacy, (b) a stable sense of self in relation to others, (c) a capacity for self-soothing, and (d) an ability to flexibly respond to the environment. In contrast, in our patient population, we have observed that childhood traumatization leads to (a) a sense of self as hateful and defective, (b) intense difficulties in managing relationships, (c) dependency on others for soothing, and (d) dysfunctional and rigid responses to the environment.

Many of the patients with posttraumatic and dissociative symptomatology that we see in the inpatient setting have horrific histories of childhood abuse. The effects of this kind of maltreatment on psychological development are profound. As discussed in previous chapters, early and prolonged traumatization often leads to massive disturbances in characterologic and ego development, and some of these fundamental impairments can easily evolve into a syndrome of chronic disempowerment. An ingrained sense of self as defective, helpless, and powerless perpetuates the effects of early victimization and interferes with abuse survivors’ ability to take control of their lives. Moreover, profound difficulty in negotiating supportive relationships results in chronic isolation and promotes a tendency toward reenactment and revictimization. These negative thoughts and beliefs can perpetuate shame, misery, and torment long after the etiologic abuse has ended.

The concept of empowerment has become a part of the psychological literature, particularly concerning the psychological development of women. Psychologist Janet Surrey, PhD (1991), has written:

I define psychological empowerment as: the motivation, freedom and capacity to act purposefully, with the mobilization of the energies, resources, strengths, or powers of each person through a mutual, relational process. Personal empowerment can be viewed only through the larger lens of power through connection, that is, through the establishment of mutually empathic and mutually empowering relationships. (p. 164)

In contrast to this view of empowerment, many persons who have been victims of extensive childhood abuse can be described as strikingly disempowered. Survivors of childhood traumatization often have little sense of any freedom to act in a way that asserts a sense of control or autonomy. Rather than be able to engage with others in a mutually empowering fashion, they repeatedly relate to others in ways that recapitulate abusive or exploitative past relationships or flee into dysfunctional isolation.

Views of healthy empowerment have absolutely no meaning to victims of chronic childhood traumatization. They may even cling to their sense of disempowerment as the only reality they have known. Very often, patients’ disempowerment creates dissonance in the therapy when therapists assume that patients share their own assumptions about the world and relationships. When therapists assume that patients naturally feel empowered, an impasse can occur based on therapists’ failure to understand their patients’ deep sense of disempowerment. Patients react by becoming more resistant, distant, or angry, and therapists tend to become overwhelmed, frustrated, and blaming. Moreover, because patients only understand their own disempowered world, they may have difficulty articulating what is wrong; they simply feel confused, misunderstood, and not heard, as in the following clinical illustration.

Janice, an attractive 27-year-old woman, sought psychotherapy after a series of failed relationships. The young and enthusiastic therapist quickly ascertained that she had a history of severe emotional abuse and neglect. Janice’s mother and father routinely used her as the family scapegoat, demeaning her and blaming her for the failure of the family to get along together, calling her “stupid,” “gross,” and “ugly.” They would punish her by refusing to speak to her for days, denying her food, and even putting her out of the house. Not surprisingly, Janice developed patterns of behavior based on her early experience. She engaged with others in a defensive and angry way, assuming they would grow to hate her. Unfortunately, this self-fulfilling prophecy resulted in her relationships often ending with the other person blaming her for all the difficulties they had experienced together. Janice also learned to punish herself for these relational failures, sometimes starving herself and even taking small overdoses of aspirin.

The therapist was horrified by the history of abuse and was determined to help her patient overcome her abusive past. She tried to be positive and encouraging, urging Janice to work on social skills issues and to make practical steps toward meeting others, such as joining a dating service. Janice became progressively less responsive in therapy and began to lose weight and to neglect her grooming. When pressed to explain this behavior, she seemed to struggle for words, finally saying, “I guess I don’t like myself very much.” Frustrated, the therapist said, “You’re going to have to try and have a more positive attitude about yourself if you’re going to get anywhere!” to which Janice responded, “I knew you would come to hate me, too.”

The treatment of chronically disempowered patients poses several painful dilemmas for both patients and therapists. Most therapists have only a minimal number of these so-called impossible patients in their practice but find that they create a disproportionate amount of clinical crises, personal distress, and uncomfortable countertransference responses. Certain clinical problems are commonly presented by such patients. Each of these problems must be well understood, and treatment approaches must be well conceived and skillfully implemented.

Rigid and Repetitive Reenactments

Reenactments of past abuse and past abusive relationships are particularly difficult with chronically disempowered patients and tend to be remarkably rigid and repetitive. Patients often interact with seemingly prescripted scenarios that are resistant to change. From the patient’s vantage point, the reenactments feel like familiar but painful interpersonal situations. From the caregiver’s point of view, the clinician may feel pulled into an interaction in which the responses seem prearranged. Such scripted scenarios can vary from repetitious discussions of despair and helplessness that seem impervious to alteration to statements that seem to demand certain responses from the therapist. Or conversely, therapists may even feel as though the patient seems to be stuck in a drama played out for the therapist as audience, sometimes not even requiring a response, as in the following example:

Diane, a 38-year-old woman, was admitted to the hospital in crisis and was having flashbacks of sexual abuse and intense suicidal impulses. Although she was advised by her long-term therapist and inpatient treatment team to find ways to contain and stabilize her symptoms, she insisted that the only real treatment was for her to abreact some episodes of childhood abuse. Furthermore, she insisted that the only safe way this exploration could occur was for her to be in physical restraints. The staff felt that Diane should work on her controls and that restraints would only reinforce the notion that she could not control her impulses. As this conflict in treatment philosophies escalated, Diane became more angry and accused various staff members of deliberately mistreating her in order to trigger even more flashbacks of abuse.

In one interaction with her therapist, she angrily recited a litany of complaints and accused the therapist and staff of malpractice and abuse. The therapist felt uncomfortable and defensive but also noticed that the patient was staring at the floor and seemed caught in a somewhat unreal prescripted scenario. The therapist said, “It feels to me as though you are talking at me as though I were an audience and not to me. I wonder if you can remember that I have tried very hard to listen to you and to try to resolve our differences, and that I am not at all interested in hurting you.” Diane stopped talking abruptly, turned and looked at the therapist, and said, “Oh! That’s right. I keep forgetting that you have actually been very helpful to me.”

In the chronically disempowered world of the patient, change does not seem possible—neither internal change that helps the patient better adapt to the world nor change in the nature of abuse-related relationships. Hence, the patient and therapist are caught in a conundrum: the therapist attempts to promote change while the patient cannot conceive of positive change and resists any change at all. This profound resistance to change may be a key characteristic of some patients that appear impossible. Chronically disempowered patients are unable to ally with others and to use support to reach new understandings and solutions. Instead, the scenarios of childhood abuse are reenacted in displacement without substantial change in their scripts. Although much tension, despair, and rage are vented, little is changed in patients’ views of themselves or the world.

Enmeshment

Reenactments of past abusive relationships frequently involve interpersonal enmeshment. In the treatment of patients who have been profoundly mistreated, therapists may need to be active and involved in a way that fosters trust and attachment. However, this type of necessary involvement has the potential for intense dependency and enmeshment. To the extent that the therapist initially is able to respond to the patient in a helpful or gratifying manner, the patient develops a deep dependency on the therapist. Patients’ dependency combined with the angry and paranoid transferences that inevitably derive from past abuse often lead to intensely painful interpersonal struggles, as the therapeutic relationship becomes an arena for acting out hostile dependency. Patients may find themselves repeatedly testing and challenging the therapists to determine if they can be trusted. Repetitive and excessive efforts of therapists to reassure patients can lead to the escalation of a kind of struggle that becomes a reenactment of abusive relationships, as in the following clinical example:

Marilyn, a young woman with a horrendous history of abandonment, neglect, and abuse, repeatedly told her therapist that she was terrified that she would be abandoned by him. This conflict was also acted out in many ways. There were many occasions (such as the therapist’s vacation, change in appointment times, the therapist being late to appointments, misinterpretation of the therapist’s comments) when Marilyn would panic about being abandoned. On such occasions, she would isolate herself, refusing any contact with the therapist or friends. Overwhelmed with anger, self-blame, and despair, she would act self-destructively, drinking heavily, taking overdoses of medication, and engaging in risky behavior. The therapist redoubled his efforts to reassure Marilyn and on several occasions promised never to abandon her. These promises failed to reassure her, and she engaged in increasingly serious self-destructive acts, almost as if to challenge the sincerity of the therapist’s commitment.

Finally, the therapist, feeling exhausted and frustrated, sought consultation. In a series of interactions with Marilyn, the therapist explained that he would continue to be committed to her, but only if the therapy was helpful. The therapist made it clear that he did not feel it was helpful to engage in a way that recapitulated the enmeshed and abusive relationships of her childhood. The therapist emphasized that Marilyn had control over the relationship and could ensure an ongoing relationship by learning to take care of herself. A very painful period ensued as Marilyn and her therapist tried to negotiate how they would relate to each other, but eventually the therapy proceeded in a more positive direction.

In work with chronically disempowered patients, management of the therapeutic relationship may be the most difficult part of therapy. Many of these patients have grown up being the target of hostile projection or profound neglect, and they may have little concept of normal functional patterns of relating. Explicit attention to the therapeutic relationship must be a priority throughout the course of the treatment, as relational issues become the most important factors in the success or failure of treatment.

One of the basic skills of dynamic therapy that has particular relevance to work with chronically disempowered patients has to do with attention to both the content and process of therapeutic interactions. The content is what the patient says, and the process is reflected by the manner in which the patient interacts. At any given point, the therapist must decide whether to respond to the content or process, whichever is more important. For the most part, responding to the content is most appropriate. However, for patients with whom anger and enmeshment become prominent in the interaction, the process of therapy must be clarified and interpreted. Often, this takes the form of a simple observation: “You seem upset about how I am responding to you. Is there something I am doing (or not doing) that is making you angry or frustrated?” If this kind of relational disruption is a frequent occurrence in the therapy, it is often wise to routinely and periodically reflect with the patient concerning the status of the therapeutic alliance: “I’d just like to take a moment to ‘check in’ with you. How are we doing in our work together?”

Many chronically disempowered patients have no understanding or expectation of being able to change their patterns of relating. Rather than change, their primary goals in relationships are to hold onto important nurturing relationships (particularly the relationship with the therapist), to discharge intolerable feelings such as anger, and to obtain comfort. The following clinical illustration demonstrates how both intense dependency and covert manifestations of anger result in complex, painful, and repetitive scenarios.

Carol, a 31-year-old woman with a 15-year history of psychiatric treatment and lifelong impairment, began work with her fifth therapist. Work with previous therapists had ended when she had overstepped boundaries, made suicide attempts, or, in one case, when a therapist had moved out of town (because in part, she implied, the work with Carol was too stressful). Carol had a known history of extensive neglect and intrusive abuse over the course of her childhood. She had been briefly married and had a child who was in the custody of the state social services department. She was on disability insurance. In addition to the diagnosis of PTSD, Carol also strongly hinted that she had DID, and she frequently referred to herself as “we.” She had many medical difficulties, including migraine headaches, chronic fatigue syndrome, irritable bowel syndrome, and asthma.

Because of Carol’s history of intrusiveness, the therapist set firm guidelines around the nature of the therapy, appointment times, and her availability. Over the first several weeks of treatment, all seemed to go well. Carol seemed surprisingly workable, and the therapist wondered if prior treatments had gone poorly simply because of a poor treatment frame and clashes in personalities. As the therapy continued, Carol began bringing in small gifts for the therapist. Although the therapist first accepted the gifts (a collage and a small bouquet of wildflowers), she became quite uncomfortable when she was presented with a Valentine’s Day card. She attempted to discuss the meaning of this card with Carol, who reacted with surprise, wounded innocence, anger, and then intense shame and guilt. The therapist emphasized the importance of boundaries, and Carol apologized for her behavior.

A similar pattern emerged concerning telephone calls. The therapist initially agreed to talk to Carol in emergencies outside the office “occasionally,” although she was permitted to leave messages on the therapist’s answering machine. Although initial calls were intermittent and benign, she soon began to leave numerous messages, some of which were so long as to exhaust the message capacity of the answering machine. Finally, she called the therapist in a panic several times in one week because it was “really important.” When the therapist brought up the issue of limits, Carol seemed again surprised and deeply ashamed. She later left a note of apology on the windshield of the therapist’s car in the clinic parking lot, which the therapist found somehow disconcerting. However, following this incident, the treatment seemed to progress reasonably well until the therapist announced she was going on vacation. In the session just before the vacation, Carol asked if the therapist was going away with her husband. When the therapist asked why Carol assumed that she (the therapist) was married, Carol initially was silent, but she eventually confessed that she had driven by the therapist’s house, opened the mailbox, and looked at some letters she had found. In the shocked silence that followed, Carol hastened to add, “But I didn’t open and read anything!”

When working with chronically disempowered patients, even many experienced therapists find that they have more difficulty maintaining usual boundaries and setting limits. Some of this difficulty has to do with the intensity of the therapeutic relationship and the patient’s conviction that only the therapist can provide the relief that they cannot provide for themselves. This is the crux of the disempowerment. Rather than expecting that they can develop tools for self-soothing, the disempowered patient feels totally reliant on others. Patients who feel tormented by their uncertainty about relationships may seek reassurance by asking therapists to blur boundaries, maintain dual relationships, and to provide constant caretaking. Particularly in times of crisis, it may seem reasonable for therapists to extend themselves to an extraordinary degree. However, any significant alteration of the normal structure of therapy should be made with great caution. Blurred boundaries and inadequate limits will almost certainly result in the recapitulation of the lack of boundaries and limits in the patient’s abusive family of origin. It is a necessary and integral part of the early phase of treatment for disempowered patients to begin to learn the ability to collaborate in treatment and to work with therapists to respect and maintain the structure of the treatment.

Control and Manipulation

Lacking the ability to engage with others in a collaborative way, chronically disempowered patients continue to rely on control and manipulation as some of the only ways that they know they can get their needs met. From the patient’s viewpoint, this interactive style is familiar and adaptive; because it feels impossible to trust enough to do things with others, the only alternative is to do things to others. From the therapist’s viewpoint, control and manipulation can be perceived as intentionally hostile and noxious; clinicians should remind themselves that many patients have no other experience of effective ways of getting their needs met. Although these ways of relating are understandable, they may nonetheless be extremely painful for caregivers. At times the demands on therapists may be infused with anger and entitlement, as was evident when one patient said to me, “You can’t terminate with me and you can’t leave me; you’re stuck with me because no one else would be willing to see me at the ridiculously low fee you agreed to.” Another patient who was admitted to our program told her outpatient therapist, “You better do what I say, because if you don’t I’ll kill myself.” She enacted an extremely coercive scenario by carrying around a deadly poison on her person at all times as evidence that she was willing to execute her threat. Of course, no such way of relating is therapeutically workable, and limits must be set while pursuing whatever measures necessary to protect both the patient and the therapist. Extreme control and manipulation very often results in termination of the therapeutic relationship (as it did in the latter example while the patient was hospitalized).

Therapists’ responses may also be molded in much subtler ways. One common pattern of interaction occurs when patients react by taking a victimized position whenever they are confronted with dysfunctional behavior. They may react with anger and hostility, but more often they reflexively have responses of intense shame and guilt. This kind of response can then lead to therapists avoiding necessary interventions or retreating from crucial therapeutic stances. This type of control and manipulation through chronic victimization is both common and remarkably effective, as in the following clinical illustration:

Lorraine, a 30-year-old lesbian woman, began the Women’s Treatment Program at McLean Hospital, a residential outpatient program designed to teach a variety of skills to help patients transition from inpatient hospitalization to outpatient treatment. There was, at the time, a two-month limit to participation in the program, with patients expected to meet individual behavioral goals every two weeks as a condition of remaining in the program. After the first two weeks, Lorraine had made little progress toward the goal she had set. She met with her case manager, who tried to question her about why she hadn’t worked toward achieving her goal. Lorraine reacted strongly: “I know I screwed up! You’ll probably tell me that I have to leave the program. I’m sorry. I’m sorry. I’m sorry.” The case manager apologized for having upset her with her “demanding” inquiries and approved an additional two-week stay in the program.

Two weeks later, when again Lorraine failed to make any progress toward achieving her goals, the case manager approached her with considerable trepidation and anxiety. Lorraine responded by bursting into tears and saying, “I know I’ve been a failure in this program. I’m sure you have all been talking about me, and how I’ve been just avoiding doing the work I need to do. I know you think I’m stupid and lazy, and you probably hate me because I’m gay. I’ll leave and won’t bother you again.” The case manager hastened to offer another extension in the program.

Fixation on the Trauma

Some chronically disempowered patients appear to be fixated on exploration of the trauma, regardless of the lack of safety and ongoing chaos in their lives. Having no sense of their own ability to gain a sense of control over their experiences, these patients see abreaction as a magical panacea for their difficulties—a cathartic process from which they will emerge somehow changed. Unfortunately, however, this kind of premature abreaction is not only overwhelming but also self-perpetuating. Predictably, the intense affects of past abuse are poorly tolerated, and patients retreat to dysfunctional solutions such as isolation and self-harming behaviors. In addition, the dissociative barriers, which previously kept traumatic memories from flooding into consciousness, are weakened. Chronically disempowered patients lack the skills to have a sense of control over these memories, and they are vulnerable to repeated intrusions of unwanted and intolerable memories and experiences. They nonetheless persist in trying to work on the memories that they are ill-equipped to tolerate.

Most chronically disempowered patients will require a very long period of preliminary work prior to active focus on past trauma. In some patients, the extended focus of treatment will remain on these basic issues for many years. The following case—which went well—illustrates the importance of sometimes deferring the focus on the trauma:

An experienced therapist, Dr. P., sought consultation for a patient he had been treating for more than 12 years. Although the treatment seemed to be going smoothly, he was concerned about the pace of the treatment. In describing the patient and the therapy, he noted, “About two years ago she started telling me about memories of sexual abuse which she had hidden until then, and about six months ago she started talking about a sense of having other ‘people’ inside of her, which sounds like DID. Do you think I really missed the boat?” After hearing about the extraordinary chaos of the patient’s life and the long, stabilizing, and ego-supportive therapy, I felt strongly that although Dr. P. might have suspected the role of trauma and presence of dissociative symptoms at an earlier point, the treatment probably had gone in the right direction. It seemed as though this patient needed a very lengthy period of growth and stabilization before accessing traumatic material. This sense of the patient was confirmed some years subsequently, as she began to reveal a long history of intentional and malevolent sadistic abuse. It was only her well-learned coping mechanisms and her strong relational bonds with her therapist and her social support network that kept her from becoming decompensated and disorganized at that time.

Developing a primary identity as a trauma survivor may have deleterious effects with chronically disempowered patients. Such an identity may have the unintended consequences of patients’ acceptance of their helplessness and victimization. More disturbingly, such patients may even develop a sense of entitlement; having been victimized they may feel that they deserve reparations. They may come to feel that they do not have to meet societal expectations in terms of functioning, and they may expect that they are due some kind of compensation for their maltreatment. Because these kind of reparations are not forthcoming from the original perpetrators of abuse, they may expect that others—including their treaters or society as a whole—should provide extra considerations in compensation for their traumatic experiences. Such expectations may be understandable, but they are rarely realistic and never fulfilled.

Inauthenticity

There are occasions where disempowered patients with a combination of chronically poor functioning, disability, and dependence present with a strong sense of inauthenticity. They have learned how to behave appropriately as psychiatric patients or therapy patients, but their responses have a kind of rote quality: “I’ve been working on my issues…” “I’ve been trying to keep myself safe…” Therapists can sometimes observe that there is no shared underlying therapeutic agenda and little real progress in treatment, but that the patients need to present the appearance of therapeutic work even though they don’t feel close to being empowered enough to make changes in their lives. It can be frustrating and unproductive for therapists to engage in a kind of pseudo-therapy that continues without ever addressing the underlying real issues. Yet, therapists generally find it very difficult to address patients’ inner emptiness and chronic disempowerment for fear of appearing critical and destabilizing patients’ rather brittle and fragile defenses. In addition, patients’ fear of losing crucial attachments leads them to nonverbally influence therapists into colluding with avoidance of these issues. However, it can be much more productive to find a way to restore some sense of authenticity. As a consultant to stalemated therapies (a role that makes it sometimes easier to promote change), I have sometimes been able to talk directly to the issues in an effort to restore some sense of authenticity:

My impression is that you feel that you have to give your therapist the sense that you think you can make progress in therapy even though you’ve never believed that you could do that. I don’t want you to feel ashamed because I think you’ve come by your sense of powerlessness and despair for very understandable reasons. But, I think the reason why you continue in treatment is that the relationship with your therapist is the most important one in your life and the closest you think you can come to a real relationship. You think if you admit to your therapist that you don’t think you can make progress that the therapy will end. But, I think you have legitimate problems, and it will serve you better to be able to talk candidly about what you really feel. Instead of talking about issues that you think interest your therapist and goals that are unrealistic, why not talk about what might be more possible to achieve. What do you think you can honestly accomplish? Perhaps you and your therapist could work on how you might be able to get yourself out of bed and showered by 9:00 a.m. once or twice a week? I know that doesn’t seem like much, but it’s a start and something real that you could work on together.

CLINICAL WORK WITH “IMPOSSIBLE PATIENTS”

The general principles of clinical practice used to treat patients with complex posttraumatic and dissociative disorders are described elsewhere in this volume; they are critically important in treating chronically disempowered patients. Some other particularly relevant elements of treatment are also essential in treating these most vulnerable patients.

Clarification of the Therapeutic Agenda

In the treatment of chronically disempowered survivors of childhood abuse, therapists’ understanding of the nature of therapy may differ considerably from patients’ assumptions about therapy. For example, therapists may place a high value on patients gaining a sense of mastery over their lives through better self-care, achieving control over their feelings and impulses, and learning from their experiences. In contrast, chronically disempowered patients may not be able to even conceive of developing a sense of mastery over their lives. Patients may assume that the therapy will simply help them to feel better and that their therapists should do whatever is necessary to care for them and to deal with their feelings and impulses. Given patients’ assumptions about themselves as chronically victimized and powerless, it is not surprising that they assume that there must be some external locus of control in their lives.

Differences in assumptions about the agenda of therapy are remarkably commonplace in the treatment of disempowered patients. Even experienced therapists repeatedly make the mistake of implicitly assuming that treatment goals are shared. When there is not a mutually agreed-upon agenda for the therapy, impasses inevitably arise, particularly around issues such as being taken care of versus learning self-care, and impulsive tension-release versus learning to cope with dysphoric affect. It is the therapist’s responsibility to provide explicit explanation and teaching to patients about the process of therapy. Furthermore, given the chronic disempowerment that patients experience, therapists must provide such psychoeducation at the beginning of the treatment and then again throughout the course of the treatment. The following clinical example illustrates some common issues concerning the treatment process:

Judy, a 32-year-old married woman, had a long history of depression and had been treated for years with psychotherapy and medication. She was on disability and had few demands on her life, but she reported feeling overwhelmed by her family responsibilities. She began a new therapy, and it soon became clear to the therapist that she had problems related to many experiences of childhood abuse that had included intense devaluation and physical abuse. Both outside the office (as described by the patient) and within the therapy sessions, Judy would seem to reenact being victimized. She would bitterly describe how she knew that others (including the therapist) thought of her as worthless, how helpless she was to change her life, and how suicidal she felt. She was convinced that it was her fate to be abandoned (despite a 12-year marriage) and felt that she was of no importance to anyone else.

The therapist would gently try to comfort Judy, empathizing with her despair, but also expressing his conviction that she was worthwhile. He would also remind her of her many accomplishments and her value to her family, helping her gain a better sense of perspective. As the therapy continued, Judy began making increasing numbers of emergency telephone calls to the therapist. Typically, she would feel panicky and overwhelmed and call the therapist saying that she was about to kill herself. The therapist responded patiently at first but soon became both frustrated and worried at the increasing frequency of the telephone calls. Finally, following some consultation, the therapist began to talk to Judy about the need to limit emergency calls. She was furious and incredulous. “What am I supposed to do when I’m going to kill myself?” she demanded. The therapist responded, “I hoped that you would use the therapy to learn to soothe yourself and to know how to cope when you feel overwhelmed and unhappy,” to which Judy replied with genuine confusion, “I thought that was your job!”

It is inevitable that in the course of treatment the therapist will provide support and comfort to traumatized patients. Such interventions may be very differently understood by different patients. For example, patients with a greater sense of self-empowerment may implicitly understand that a therapist who provides support, validation, and caring is modeling ways of thinking and behaving that the patient can internalize (e.g. “How can I learn to provide this for myself?”). Chronically disempowered patients, however, may simply see the therapist’s interventions as a substitute for the seemingly impossible work of learning self-regard, self-soothing, and self-care (e.g., “How can I get my therapist to do more of this for me?”). Moreover, because these patients may not have any real sense of interpersonal relatedness, they see learning to care for themselves only as a lonely, impossible, and unwanted task and the route to losing the critically important relationship with their therapists. This dysfunctional, albeit understandable, outlook has enormous regressive potential; as more support is provided by the therapist, the patient becomes less competent. This impasse often results in an increasing intensity of the therapy and an associated deterioration of the patient’s clinical condition.

Therapists must provide ongoing psychoeducation and support to help disempowered patients understand that they must learn about self-care and mutuality in relationships. Therapists should be empathic about the difficulties that disempowered patients have in facing these tasks, and they must be prepared to repeatedly encourage patients to take a stance that will help them gain an internal sense of control. Therapy is only helpful in this context, and therapists must not collude in perpetuating patients’ disempowerment through endless cycles of regressive caretaking. After all, the goal of any therapy is increased self-esteem and self-efficacy, and no therapist would knowingly participate in any therapy that increases patients’ disempowerment.

Treatment Intensity and Functioning

The intensity of treatment with chronically disempowered patients should be closely monitored. There is a real danger that treatment can come to substitute for coping with the real world, and that functioning is abandoned in favor of an identity as an impaired psychiatric patient. In general, a frequency of sessions of once or twice a week is optimal. More frequent sessions are generally regressive. Although very frequent sessions encourage a sense of object constancy, they allow patients to surrender too much of their own control and coping mechanisms, and engender an interpersonal intensity that is threatening and consuming for many patients. If more frequent contact with others is needed, it should be structured as part of a therapeutic program or activities, preferably not involving the primary therapist.

An enhanced emphasis on functioning is especially important with chronically disempowered patients. Even completing very minimal tasks can be the beginning of building a sense of accomplishment and self-efficacy. Such basic efforts as getting out of bed, showering, and taking care of daily needs can be the beginning of seeing oneself as having control over one’s self and the environment. Such elementary efforts may progress toward structured activities, volunteer efforts, or even paid employment. A progressive ability to function—even if not initially perceived by the patient as important—may be one of the keys to growth beyond chronic disempowerment.

Learning Relational Skills and Authenticity

As in the therapy of all severely traumatized patients, the essential interpersonal process for chronically disempowered patients is to help them establish patterns of relatedness that are mutual and collaborative. As patients repeatedly bring the reenactments of abusive interactions into the therapeutic arena, therapists must help them move toward respect and mutuality. Unfortunately, it often is a lengthy process of seemingly endless cycles of disconnection and reconnection before patients can begin to internalize a healthy model of interpersonal interactions. However, it is crucial in the treatment of chronically disempowered patients that therapists understand that corrective emotional experience involves patients learning to care for themselves in the context of supportive relationships, and not simply to be cared for by others.

Chronically disempowered patients adapt to the culture of the institutions of psychiatric treatment. They become facile in the language of therapeutic settings, and learn to talk about their “treatment,” “working in therapy,” and “safety.” All of these terms sometimes seem to be used in going through the motions of being in therapy and to obscure the underlying agenda of seeking contact and nurturing from caregivers. However, to truly make progress in treatment, patients must learn a new kind of authenticity, acknowledging their sense of helplessness and their wish for passive dependency and gratification. Only this kind of authenticity can allow patients to begin to grow and move from their disempowered positions. Therapists must be sensitive to patients’ difficulty in coming to terms with acknowledging their real-life situations and internal life, using tact rather than brutal honesty. Patients’ authenticity is only gradually achieved with therapists taking a nonjudgmental and empathic stance and helping them begin to grapple with difficult and painful realities.

A common scenario often occurs with patients who are struggling to control dysfunctional and maladaptive behaviors. There are inevitably lapses of control and regression to actions (or inactions) that are counter to the goals of therapy. That is, patients frequently return to old dysfunctional behaviors that are familiar but countertherapeutic. When confronted about this regression, patients typically react primarily with intense shame and guilt that appears to be traumatically based, as if their behaviors are yet another manifestation of their defectiveness and “badness.” This regression/acting out/shame/guilt cycle is not productive, as it does not allow the patient and therapist to reflect on the behaviors as being understandable albeit maladaptive and to find alternative solutions. Instead the cycle only reinforces negative self-perceptions and contributes to inauthenticity as the patient tries to suppress regressive impulses in an effort to be “good.” Because the pull toward regression is not effectively processed and understood, there is a heightened likelihood that the dysfunctional behaviors will recur, perpetuating the cycle. One way to resolve this dilemma is to address it directly:

I can see by your responses that you feel bad and shamed by my observations. That is not my intent and is not useful to you. I can easily understand how you can lapse into behaviors that feel familiar, and how difficult it must be to take the risk to do things differently. I want you to leave the shame and guilt outside of this discussion. It is not helpful and only further complicates your efforts to find a solution to your problems. It is important that we understand how you have come to this point and what we can do together to make it different.

A critical and necessary trait for therapists who treat “impossible” and chronically disempowered patients is endless patience. Therapists must learn how to empathically set limits over and over again, being aware that the cycles of dysfunctional behavior rarely abate quickly and that only small incremental changes can be expected. However, lapses with regression to old behaviors or minor violations of the therapeutic contract should be tolerated only if there is progress over time toward the agreed-upon goals of treatment. The therapist is in the best position to provide productive treatment by being clear that the therapy is not only about sustaining the therapeutic relationship, but that incremental change is a prerequisite for continuing the treatment. Persistent absence of any perceived benefits in treatment or major violations of the therapeutic agreement should prompt therapists to consider whether the therapy is worthwhile, workable, or tolerable, and whether an alternative kind of clinical management is indicated.

The treatment of chronically disempowered patients represents a significant challenge to individual clinicians and to the mental health profession. Many of these patients have been so egregiously abused that they have no belief in their own self-efficacy and little ability to relate to others in ways that might help them. As a result, clinicians must exercise sensitivity and skill to find ways to engage them and to work with them in a way that will maximize the possibilities for their growth and minimize regression. In our era of limited health care resources, the treatment of chronically disempowered and traumatized patients must be closely examined. On an outpatient basis, the frequency and intensity of treatment must be carefully balanced to provide both opportunities for growth and also to limit the regressive potential of excessive caretaking. In some instances where individual therapy proves to be too regressive, alternatives such as group treatment should be considered. The utilization and nature of inpatient hospitalization must also be carefully evaluated. Although hospitalization is clearly indicated when patients are seriously at risk, inpatient treatment must emphasize stabilization and containment rather than exploration and abreaction. The inpatient setting must not become an arena for flight from impasses in outpatient therapy, for reenactment of abuse scenarios, or as a substitute for learning to live in the world. Partial hospitalization may be an attractive alternative treatment modality for some patients with a more long-term course, but much still needs to be learned about the optimal mix of structure and programming needed to work with these challenging patients.

Clinicians must be patient and respectful of chronically disempowered survivors of abuse and the psychological prisons in which they live. Even at best, the objectives of the treatment seem formidable to most patients, and the process of therapy is long and arduous. However, therapists must also insist that these patients begin to share an agenda that will help them truly take control of their lives, even in small increments. Therapists must refuse to collude in interactions that result in reenactments of abuse or revictimization. The ultimate prognosis of many chronically disempowered patients is uncertain. Although many will improve steadily with skillful treatment, others may have more long-term disability. In either case, therapists will provide good treatment if they approach therapeutic work with compassion, patience, skill, and a commitment to enhancing authentic growth while ensuring that they do no harm.