My patient asks the impossible of me … What should I do?

Whatever your experience is as a therapist, sooner or later, some patient is going to put you in a difficult situation in which, in that moment, you just won’t know what to do.

Probably, the patient won’t do it on purpose or to send you a subliminal message.  Remember that the patient isn’t obligated to know what is possible in the context of therapy; rather, it is your job to frame the therapeutic relationship in clear terms.  You should dedicate the necessary time during the first sessions to explain the parameters of your therapeutic contract with your patient, and when requests arise to which you can’t attend, you should explain well to your patient the reasons for which you can’t accommodate them.

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Sometimes, the reason why you need to set clear limits with your patient is that their objectives for therapy aren’t realistic or feasible.  Other times, the problem is that you lack the requisite specialization to deal with their particular requests.  In still other instances, the problem could be that your patient’s suggestion could engender ethically-fraught situations that you can’t responsibly handle.

Throughout therapy, there are numerous situations that can put you in a jam with your patient because he asks something of you that, for different reasons, you can’t fulfill.  The tight spot doesn’t have to be very grave: normally, the patients are intelligent and reasonable people who know how to approach therapy correctly.  Don’t fear using your experience to explain to them openly why their therapy can’t proceed in their desired direction.

Regardless, we will continue by laying out three situations in which, in an assertive and compassionate manner, you will have to tell your patient, “I’m sorry, but no.”

1. Your patient thinks you so caring that s/he wants to be friends and have a drink outside of the therapy setting.  This is nothing to worry about; remember that this is a sign that your therapeutic relationship is really good.  At the end of the day, it’s always preferable for your patient to want to associate with you outside of therapy as opposed to not even wanting to cooperate with you during therapy.  However, it is important that you explain to your patient that, at this time, it is imperative for the sake of his/her progress that you maintain a strictly professional relationship.  The relationship can include all of the closeness of the world, but it must remain an asymmetrical relationship (not of camaraderie, not of an equal partnership, and not of an “I scratch your back; you scratch mine” spirit).  Your patient can be an interesting and likable person with whom you get along really well, and you don’t have to banish the thought that in the future, you could be friends, but in the present moment, your relationship is strictly one in which you provide a service to facilitate his/her personal development.  If you encounter your patient in a bar, you can say hi to each other with total neutrality, but then you should return to your respective groups of friends.

2. Your patient asks you to begin to treat his/her partner in parallel, or even to commence partner therapy with both of them at once. There isn’t any problem with talking once with the partner of your patient, or even with seeing them simultaneously once or twice, explaining to them both a series of considerations to take into account.  Two things can’t happen, though: you can’t begin the full therapeutic process with the partner, and you can’t start partner therapy with them both.  Consider that you owe it to your original patient to be continuously available to him/her. What would happen if, unfortunately, the partner of your patient told you in confidence that s/he was thinking about leaving your patient even though your patient told you last week that the relationship was going really well?  Imagine if you have the two of them as your patients: how are you going to approach the recently-arrived partner knowing that your initial patient has spent weeks telling you about all of the infidelities that s/he has committed, especially if the new patient knows nothing about the cheating?  Again, you can see the partner once in a limited scope, but you can’t start anything continual.  Concentrate on your first patient, and suggest to the patient that s/he seek his/her own therapist.

3. Your patient has therapeutic objectives with which you can’t possibly comply: identifying the way to reclaim his/her ex-partner, forgetting all of the damage that the ex-partner did to him/her, curing completely all of the traumas of his/her life, quickly changing his/her sexual orientation … And there are so many more well-intentioned, misinformed expectations about what therapy can plausibly accomplish.  Our patients charge us with the responsibility of achieving the impossible, and it is our responsibility to clarify from the first moment what will and won’t be possible during therapy.  We have to reformulate together with the patient the route along which we will progress during therapy: a realistic path, ethically uncompromising, informed by psychological knowledge, and within our capacity as responsible professional.

In fact, speaking of professional capacities, there is a special case: when your patient has the right goal, but you don’t have the right training to tackle it.  For example, it is possible that you’re a specialist in partner problems, but if patients with borderline personality disorder (BPD) request your services because of the difficulties that they are having with their partners, the best thing for you to do would be to explain why you can’t take on their case.

Remember that it is fundamental for the safety of your patient and for the quality of the work that you do that you be aware of your personal limits and the limits that circumscribe your profession.  You can recognize those limits thanks to your training, but above all, you will become increasingly familiar with them because of your advancement in your clinical practice.  Taking risks in some moments might advance your skills, but sometimes, you have to know how to refuse certain things that your patients ask of you.  Orienting your patients toward goals with which you can help is part of the therapeutic process that you are realizing together.  If you can successfully set limits, everything else will be much easier.

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