When a Patient is Resistant to Psychotherapy

In this video, taken at the 2024 Psych Congress NP Institute Annual Meeting in San Diego, Saundra Jain MA, PsyD, LPC, Steering Committee Member, and Andrew Penn, MS, PMHNP-BC, Co-Chair, discuss what to do when a patient who has been referred to psychotherapy expresses doubt or resistance to the treatment plan. Dr Jain and Andrew emphasize the utility of empathy and getting curious about the patient to work through negative attitudes that may arise.

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Saundra Jain MA, PsyD, LPC: Andrew, I was thinking about a patient that I saw recently. She had been referred in by her prescribing clinician, and you could tell she just wasn't quite right, but she didn't really want to say why. She was a little bit disgruntled—

Andrew Penn, MS, PMHNP-BC: About coming to therapy.

Dr Jain: About coming into the office, sort of being in that space. And she said finally she got around to it and she said, “don't really want to be here. I've been seeing my prescriber for about six months and they have been encouraging me to see somebody like you, but I don't want to do it. Don't take it personal. I just don't want to be here. I just want my prescription. I want to take my medicine. That's it. So, I'm wondering from the other side of the table, as the prescriber, what do you think about that?

Andrew: I mean, I think my first question would be why does that prescriber want this patient to see a therapist? That's the question. Because we know that when patients don't want to be there, it generally doesn't go very well. Most people don't want treatment against their will. So, the question I would have would be, first of all, for that prescriber, help me understand what do you think that therapy could help this person with that whatever medication you're prescribing isn't helping with.

But then I'd also get curious about the patient. I'd want to know what is it about therapy that you're apprehensive about? Because honestly, feelings are uncomfortable a lot of times, right? Let's be honest. Medications sometimes reduce symptoms, but they often can also reduce the intensity of other emotions as well. We hear this from people on antidepressant medications. They'll say things like, I feel less depressed, but I don't feel much of anything.

Dr Jain: I feel flat

Andrew: I feel flat. And for some people that's kind of what they want, but other people don't. So, that's a challenge sometimes is when you're doing pharmacology. But I also wonder about this particular patient. What are the feelings that this person is feeling apprehensive about getting into? That's the curiosity that comes up for me.

Dr Jain: What you said I think is critical to all the work we do, whether it's pharmacology, psychotherapy, or a combination of both, is maintaining the sense of curiosity. If we can keep that alive, we can keep relationships alive because it shows interest. We don't get overly attached to a certain story about a patient. So I love your two questions

Andrew: Can we have empathy for that patient say like, oh gosh, that must feel kind of strange. You got sent to see me and you're not even sure why.

Dr Jain: Felt a little bit pressured into doing it.

Andrew: Yeah, yeah, absolutely. So I would say that empathy is a low cost, but high yield intervention that one can insert many stages in the conversation. So just to even express, Hey, wow, that must be kind of strange to be sent to go talk to somebody. You don't even know why you're being sent here. So let's try and figure that out together.

Dr Jain: Yeah, great conversation about that.

Andrew: Yeah, thanks.

Saundra Jain, MA, PsyD, LPC, is an Adjunct Clinical Affiliate at the School of Nursing at The University of Texas at Austin and a psychotherapist in private practice. Dr. Jain is a co-creator of WILD 5 – A Proven Path to Wellness and co-author of The Science and Practice of Wellness: Interventions for Happiness, Enthusiasm, Resilience, and Optimism (HERO). She is the co-creator of the Psychedelics and Wellness Survey (PAWS), exploring the intersection between psychedelics and wellness. Dr. Jain is active in peer-to-peer education, especially in the disease states of depression, bipolar disorder, anxiety disorders, and ADHD. Another strong clinical and educational interest involves the differential diagnosis of major psychiatric disorders. She serves as a member of the Psych Congress Steering Committee, providing direction regarding educational gaps/needs for mental health practitioners.

Andrew Penn, MS, PMHNP, is a Clinical Professor in the University of California, San Francisco, School of Nursing where his teaching has received the UCSF Academic Senate Distinction in Teaching Award, among other recognitions. He works as a psychiatric/mental health nurse practitioner, treating veterans at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF. A leading voice in nursing, he is a cofounder of the Organization of Psychedelic and Entheogenic Nurses (OPENurses.org), advocating for the perspective of nurses in psychedelic therapy, he has published on psychedelics in the American Journal of Nursing, Frontiers in Psychiatry, The Journal of Humanistic Psychotherapy, and JAMA. An internationally invited speaker, he has lectured at SXSW, Aspen Health Ideas Festival, TEDx, the Singapore Ministry of Health, and Oxford University and can be found at Andrewpennnp.com.

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