The concept of treatment resistance deserves reconsideration. Originally formulated in psychoanalytic terms, resistance in treatment referred to the inevitable ways patients unconsciously express their psychology in terms of defense mechanisms and transference enactment. This form of resistance provides a window into the patient’s problems; therefore, it is a major focus of the inquiry and intervention. Modern psychiatry defines treatment resistance as a lack of response to adequate treatment. Both conceptualizations locate treatment resistance within the patient, rather than as a product of limited, underdeveloped, and ineffective treatments. As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.
Treatment resistance is highly prevalent across most psychiatric disorders—even in common diagnoses generally associated with positive outcomes, such as depression. There are many more obstacles to effective treatment (Figure 1) than the patient’s psychological resistance alone. Identification of specific factors that diminish treatment response may provide more useful points of intervention than the label of treatment resistance.
Comorbid disorders contribute to poor treatment response. Treatment guidelines are often based on a false assumption that patients present with single disorders that respond to specific evidence-based treatments. Regardless of increasing attention to problems of comorbidity, guidelines for combining and prioritizing the treatment of different diagnoses remain largely underdeveloped.
Comorbid personality disorders complicate treatment. Over 50% of patients in specialized psychiatric settings have personality disorders.1 These patients are more likely to face social adversity, suffer from complex comorbidities, and drop out of treatment or not adhere to medication regimens—all of which contribute to an increased risk of a lack of response to treatment. The presence of a personality disorder, particularly borderline, predicts persistence of anxiety and substance use disorders as well as poorer outcomes in depressive disorders. Moreover, 13% of those who complete suicide have personality disorders.2
Clinicians often see patients with personality disorders as treatment resistant—and, in some cases, untreatable.3 While it is true that patients with personality disorders may be challenging to treat, they are treatable. The self-defeating coping skills and difficulty with relationships that are central to personality disorders make a productive treatment alliance difficult to sustain. Clinicians prototypically react with feelings of frustration, disengagement, incompetence, confusion, helplessness, and even rage.4 The identification of these countertransference reactions can facilitate the diagnosis of personality disorders but can overwhelm and disturb clinicians, leading them to avoid diagnosis and personalize problems as a product of either the patient’s immutable character or the clinician’s limitations.
Our progress in understanding and treating borderline personality disorder (BPD) illustrates the benefits of centralizing the personality disorder diagnosis in care management. For over half a century, patients with BPD were identified by their negative therapeutic reactions, that is, worsening with what was thought to be otherwise appropriate treatment. While pessimism and stigma about the disorder remain, our notion of BPD’s prognosis has radically improved with research.
A major longitudinal study of BPD and other personality disorders with 16 years of follow-up showed that virtually all subjects with BPD achieve sustained remission for at least 2 years, and 78% sustain remission for 8 years. Recovery, that is attending work or school and sustaining at least one meaningful relationship, occurred for 60% of patients for 2 years, and was maintained in 40% over 8 years.5 This evidence suggests that the majority of individuals with BPD (and other personality disorders) can achieve remission and most can recover some sustained functioning, which challenges the notion that patients themselves resist treatment.
Dr. Choi-Kain is Director, Adult Borderline Center and Training Institute and McLean Gunderson Residence at McLean Hospital in Belmont, MA, as well as Assistant Professor of Psychiatry at Harvard Medical School in Boston; Mr. Glasserman and Ms. Finch are research assistants, McLean Hospital, Harvard Medical School.
The authors report no conflicts of interest concerning the subject matter of this article.
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