All therapists, from time to time, encounter patients that just don't seem to get better or change in anyway. At first the treatment seemed to move along nicely, but then it stagnates. We may try new techniques, talk to colleagues or supervisors, read books, but the patient doesn't budge. Often this leads to frustration and hopelessness; we cling to treatment by trying to analyze it as transference and countertransference and work through that. Still no movement.

What is rarely discussed is that some patients might just be destined not to change or to improve beyond a certain point. Understanding and accepting this itself can lead to a profound change in the experience of therapy for both patient and provider, even if it does not yield progress. In some cases, we as providers can learn to find value in holding up the floor, seeing that, although the patient may not be moving up, they would be doing worse without us. In other cases, we may need to accept that the treatment should end and a referral should be considered.

All of this may be hard to accept for people who are dedicated caregivers, but, indeed, this may be a form of caregiving to our patients and often to ourselves. Guilt, shame, and fear of failure may all cloud our ability to see and accept these truths.

Patients do not cling to their defenses arbitrarily. For many, their defenses were forged out of necessity, survival strategies that kept them intact in environments of trauma, neglect, or overwhelming affect. Most defense mechanisms are shaped in early home life, while our brains are still very capable of learning. There is an irony in contemporary Western culture that, just when we enter a new........

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