Digesting psychotherapy

Last updated:

12 November 2012


therapeutic alchemy: turning heartsinks into heroes

by Douglas McFadzean

This article was aimed at psychotherapists and counsellors working in primary care, and was developed from a training workshop held during the 1998 COSCA conference in Perth, Scotland.

The article was originally published in CMS Journal, 60, 10-12, August 1999 and reprinted in Counselling in Scotland, 10-12, Summer 2000.

Note: Clients are referred to as 'patients' in this article, because of its medical context and audience.


Every psychotherapist and counsellor working in health care encounters patients who remain apparently unmoved by the best efforts of the medical and therapeutic professions. For this small minority of 'heartsink' patients, inordinate resources seem to be expended on maintaining a vicious circle of treatment effort, failure and despondency. Examples of heartsinks' prolonged misery are not hard to find:

But what causes therapy cases to become intractable? Can research findings better inform therapeutic understanding and practice? What can we do as individual therapists to overcome intractability and help our patients achieve successful outcomes? This article will explore these issues and hopefully foster a belief in therapeutic alchemy: that ways can be found to turn heartsinks into the heroes of their own recovery. My aim is not to teach practitioners new therapeutic tricks but rather to suggest how their existing skills might be successfully redeployed with intractable cases. In doing this, I will lean heavily on the work of others (particularly that of Duncan, Hubble & Miller (3)) but freely acknowledge that heartsinks themselves are ultimately our greatest mentors.

what causes intractability

Before looking into the reasons for intractability, we have to remind ourselves that the term 'heartsink' aptly describes both the therapist's and the patient's experience of the situation. You may have many descriptors (probably mostly unspoken) of your heartsink patients: exasperating, manipulative, pig-headed, clueless, cantankerous, devious, lazy, unmotivated, time-wasting, uncooperative, resistant, and so on. Now think for a moment how they may describe you as a therapist: superior, nagging, coercing, useless, not in the real world, boring, smug, waste of time, criticizing, always questioning, just another shrink, and so on.

Acknowledging the depth of feeling invoked by such cases is a necessary first step towards understanding how any of us can become ensnared in the following traps set by the therapeutic process:

Expecting trouble
Even before we converse with the real person, we are being influenced by the labels and language applied to patients by others (5). This may happen formally, through diagnosis, prognosis, referral letters, medical records, etc, or informally in ways such as seeing the thickness of the medical records file, hearing mutterings from GPs, "Oh, her/him ..." comments, etc. The seeds of negative presupposition and low expectation grow fast and feed our professional anxieties, especially when they are sown by those with expert status or by those whose judgement we normally trust. The power of psychopathological labels such as "psychotic" and "schizophrenic" was amply demonstrated in research done by Temerlin and Rosenhan (4). No matter their source, or even their objective degree of accuracy, negative attributions inevitably close down the possibilities we see for patient change. When we go looking for trouble, we usually find it.

Elevating theory over therapy
Through therapeutic traditions and schools of training, therapists find security and structure for their practice and professional development. Loyalty to a particular model of therapy is therefore understandable and reasonable, but only insofar as the model has empirical evidence to validate it. Unfortunately, substantial research has shown that model and technique factors generally play a minor role in effective psychotherapy (2,6,7) (see below). The heartsink's subjective views of reality and change are much more relevant to outcome than the distorted images of the case seen through an invalid or insensitive therapy model. When belief systems clash, and the therapist refuses to yield sufficiently to the patient's views, we can confidently predict treatment resistance or drop-out.

Doing more of the same
Persistence pays, up to a point. But each time we apply "one more push" to solve a problem, we run the risk of adding to our legacy of failed solutions while the original problem continues to fester. An ordinary difficulty can quickly develop into a seemingly impossible problem shrouded in overwhelming failure. "Doing more of the same" comes in various forms, for example: long-term psychotherapy without monitoring of patient change; repeated treatment with the same or similar drugs (of which antidepressants are probably the best example); or repeatedly failing to take account of the patient's preferred mode of treatment. Indeed, the evidence tells us that psychotherapy "doing more of the same" to itself - generating models of therapy (now numbering 200 plus) - has notably failed to find a winner in the therapy stakes (2,6,7).

Neglecting motivation
The patient's active participation in therapy is critical to its success(2,6). Neglecting or misunderstanding the patient's own motivation, goals and readiness for change undermines the therapeutic collaboration and diffuses its energy. Even heartsinks are always motivated, but often not in the direction we are looking. If we impose our own therapeutic agenda, for whatever theoretical, well-meaning or personal reason, or fail to gear the therapy to the patient's stage of change (8), we invite intractability.

Threatening dignity
Heartsinks are acutely aware of their predicament: they need no further reminding or criticism of their prolonged failure to achieve beneficial change. Even when successful change is clearly desired and comes within grasp, the impulse to "save face" can become compelling. Resistance is a natural reaction when the therapist pushes for change at a rate which threatens the patient's dignity or compromises what little control they have over the situation.

what makes therapy effective

Four decades of psychotherapy outcome research has confirmed that therapy is generally effective, efficient, and of lasting benefit (2,6). A good understanding of what actually leads to positive patient outcomes is obviously desirable, even more so when dealing with heartsink patients and intractable cases. From the research evidence, Lambert concludes that four groups of pantheoretical or common factors principally account for the improvement in patients (1). These factors ("the Big Four") and their average contributions to improvement are as follows:

40%Client and extratherapeutic factors
The patient's own resources, environment and chance events that aid recovery regardless of formal participation in therapy.
30%Relationship factors
The quality of the therapeutic alliance between patient and therapist.
15%Placebo, hope and expectancy factors
The belief that therapy can and will help.
15%Model and technique factors
Methods and procedures unique to specific treatments.

ten ways to avoid intractability

It seems that, statistically at least, patients are already cast as the heroes of their own recovery. By directing therapy towards the empowerment of the above factors (3,6,7), in their order of importance, we can surely avoid or alleviate intractability. Some practical suggestions follow to achieve this.

  1. Calm yourself
    Acknowledge your own feelings of anxiety, over-responsibility, helplessness, etc. Take enough time to calm yourself, step outside your emotional trances and deliberately look at the case from different perspectives. Share your concerns and discuss ideas with colleagues, consultants and/or the patient if appropriate. Remember the relative importance of the common factors, especially the 40% contribution from client and extratherapeutic factors.
  2. Challenge your attributions
    Consider how the course of therapy or your attitude to the patient may be influenced by negative labelling or theoretical dogma. Remind yourself that diagnostic labels and therapy models are only useful shorthands, signposts and maps. They are intrinsically crude representations of the complex reality of the person in front of you. Would you confuse the menu in a restaurant with the actual meal?
  3. Keep an open mind
    Of course, no two cases can be the same because every patient has their own unique set of beliefs, abilities, resources and circumstances. Avoid "doing more of the same": make sure this therapy is different from previous unsuccessful therapies (even so-called "treatments of choice"). Give the patient a new experience and keep the possibilities for learning and change open. Be prepared to begin anew if change is not evident within a few sessions (2).
  4. Validate the patient
    The more intractable the case, the greater the need to validate the patient's experience of their predicament. Their concerns, struggles and priorities need to be heard and legitimized. Demonstrate belief in their story and in their ability to solve their problems. Use the patient's frame of reference as the starting point for therapy, though it may seem unrealistic or even bizarre. Remember that resistance is not a quality of the patient, but a symptom of a faltering therapeutic collaboration.
  5. Let the patient feel positive about therapy
    The patient's view of the therapeutic relationship is critical to outcome (2,6,7). Be flexible and responsive, fitting in with the patient's idea of what your role should be. Regularly check out the patient's level of satisfaction. Help the patient to shift their opinion of therapy and therapists away from previous bad experiences.
  6. Involve the patient
    Maximize the extent of the patient's involvement in therapy. Respect the patient's collaborative style and let therapy revolve around their abilities and ideas. Foster cooperation and collaboration rather than imposing a treatment. Make suggestions by all means, but let the patient choose which ones are implemented.
  7. Learn the patient's theory of change
    Each patient enters therapy with their own informal theory about their problems, how they developed, and how they can be solved (6). Converse using the patient's language to learn their theory of change. Find out what the patient wants from therapy and from you. Adjust your own beliefs and expectations rather than trying to convince the patient that their theory of therapeutic change is inferior to yours.
  8. Realize the patient's theory of change
    Work with the patient to identify exceptions, solutions, connections and conclusions that will enable or consolidate positive change. Learn from prior solution attempts. Do more of what works and avoid what doesn't. Only suggest interventions consistent with the patient's goals and their theory of change. Nurture early success by encouraging the patient to start with small but salient goals.
  9. Be sensitive to change
    Listen for and validate beneficial change whenever and for whatever reason it occurs. Help the patient to attribute change to their own efforts. Gear therapy to the patient's stage of change and let them weigh the pros and cons of further change. Determine what they need to move to the next stage of change (accept that it may not necessarily be therapy at this time). Remember that the longer a patient goes without experiencing change, the greater the likelihood of a negative outcome (2).
  10. Preserve dignity
    Approach your patient as a competent human being first and foremost, rather than as a diagnosis, heartsink, or other pejorative label. Give them sufficient time and space to bow out of their symptoms gracefully. See the patient as the potential hero of therapy who will bring most of the skills and tools, do most of the work, and be the most important person in its evaluation.

Alchemy means "a mysterious or magical transformation" figuratively, according to my dictionary. I hope that this article has encouraged a belief that you can effect such therapeutic transformations with intractable cases. In respect to our heartsinks, I will end with the words of an old Egyptian proverb: "Before you call me difficult, try wearing my shoes."


  1. Asay, T P, & Lambert, M J (1999). The Empirical Case for the Common Factors in Therapy: Quantitative Findings. In reference #6.
  2. Bergin, A E, & Garfield, S L (Eds) (1994). Handbook of Psychotherapy and Behaviour Change (4th ed). New York: Wiley.
  3. Duncan, B L, Hubble, M A, & Miller, S D (1997). Psychotherapy with "Impossible" Cases: The Efficient Treatment of Therapy Veterans. New York: W W Norton.
  4. Eysenck, H, & Eysenck, M (1981). Mindwatching. London: Book Club Associates.
  5. Hawkes, D, Marsh, T, & Wilgosh, R (1998). Solution Focused Therapy: A Handbook for Healthcare Professionals. Oxford: Butterworth-Heinemann.
  6. Hubble, M A, Duncan, B L, & Miller, S D (Eds)(1999). The Heart and Soul of Change: What works in therapy. Washington, DC: American Psychological Association.
  7. Miller, S D, Duncan, B L, & Hubble, M A (1997). Escape from Babel: Toward a Unifying Language for Psychotherapy Practice. New York: W W Norton.
  8. Prochaska, J O (1999). How do people change, and how can we change to help many more people? In reference #6.

© 1997-2009 Douglas McFadzean. All rights reserved