More on Treatment Resistance

From an interesting new article on treatment resistance in today’s edition of Current Psychiatry entitled “The patient refuses to cooperate. What can you do? What should you do?”

"…specific points need to be addressed and the following questions need to be answered:

• Does the patient understand the nature of his (her) condition?
• Does the patient understand what treatment we are proposing or what he should do?
• Does the patient understand the con­sequences (good or bad) if he rejects our proposed action or treatment?"

See the whole thing at…

Comments? (And is your p-doc following this regimen with you?)


When I wasn’t very compliant with treatment everything the doctor told me went in one ear and out the other. It took years and years for me to finally start following treatment.

You have to find a balance between asserting yourself and consenting. Like Moses says, you have to understand what’s going on, which is sometimes difficult given the situation.

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Yup. Same here. I was okay with the meds part, but the psychotherapy groups bored me senseless, and I refused to do the “homework.”

Amen to that. How are we supposed to “understand” if we have 1) very reduced sensory observation skills, and 2) little or no reality-rooted, conceptual frame of reference from which one could make realistic evaluations? (It’s not like we took classes in “How to Be Functionally Psychotic” in high school, after all.)

What actually is " treatment resistance " is it about refusing to co operate/take medication as the article suggests or is it about taking the medication and it not working for you ?
How do you distinguish between someone for whom the diagnosis is right but the medication doesn’t work and someone for whom the medication doesn’t work because it’s the wrong treatment for a wrong diagnosis? Ie how to distinguish between what I call a treatment resistant patient vs a wrongly diagnosed patient?
I ask because one of the reasons I ended up with a change of diagnosis (poor relations with the mental health team was the other) was an admittance that the meds only had a partial effect. What I did not say at the time was that I was only taking the meds 40-50% of the time. Common sense tells me there will be a wide range of response among those properly diagnosed ranging from a strong response through a moderate/partial response to what gets classified as treatment resistant. It’s not a simple case of the medication works well or not at all.
Even though I take meds through depot far more consistently than 40-50% I would still say though meds have more of an effect it’s still what I call a partial effect.
I am able to live independently in a rather restricted way-no friends,no emplooyment,would flounder if faced with changes- but am not recovered or functioning independently at a high level.

The technical use of the term by the profession refers to the former. The less sophisticated (usually, but not always, psych nurses and ER people) tend to blame the patient because they have little or no experiential, empathic grasp of the patient’s experience with meds. The more sophisticated (usually, but not always, psychotherapists and psychopharmacologists) tend to understand why patients are tx-resistant.

The former tend to argue or get disgusted with and give up on tx-resistant patients. The latter tend to use motivational enhancement techniques to try to open a path for the patient to make decisions in his or her own best interest.

My story as well in the late '90s, though I was able to go to school. The more CBT I did back then, the more I was able to make my “box” a little bigger. The therapeutic tools we have today are far more effective than CBT was then.

10 StEP –

@notmoses Those therapeutic tools may(or may not )be good but the likelihood I’d ever have access to them is very slim .

This is a very good topic @notmoses The problem with Schizophrenia is that more often than not the patient has no insight or limited insight into his/her condition. That makes treatment all the more harder for SZ patients.

Delusional Disorder is of a lower spectrum than Schizophrenia since the delusions are generally not Bizarre or wierd.

In my case, I can see that the Intensity of my delusions/and the Time it remains causing an effect on cognition has reduced to now 1 from 8-9(0 being no intenstiy - 10 being highest intensity) and the time my episode lasts is half a day to 1 day from the 2 weeks it was earlier.

That’s why I keep pitching workbooks. They are cheap (rarely more than $20 on, including shipping) and so effective that more and more therapists are utilizing them in both one-on-one, as well as skills training and therapy group set-ups.

Most of the good ones are published by New Harbinger. The Guildford Press also has some good ones. I have done more than 20 of them and gotten way more out of that than I ever did from anything I did en vivo. When one combines them with “contextual door openers” like the books listed below, for example, those workbooks work wonders for many.

Brown, N.: Children of the Self-Absorbed: A Grown-Up’s Guide to Getting Over Narcissistic Parents, 2nd. Ed., Oakland, CA: New Harbinger, 2008.

Gibson, L.: Adult Children of Emotionally Immature Parents: How to Heal from Distant, Rejecting, or Self-Involved Parents, Oakland, CA: New Harbinger, 2015

Golomb, E.: Trapped in the Mirror: Adult Children of Narcissists in Their Struggle for Self, New York: William Morrow, 1992.

Payson, E.: The Wizard of Oz and other Narcissists: Coping with One-Way Relationships in Work, Love and Family, Royal Oak, MI: Julian Day, 2002.

Which is why I keep pitching the book at the link below on this forum. Even if the “medicated strugglers” read one page a day, they’ll get somewhere over time.

Although it is out of fashion currently, to my knowledge, and a touchy subject to say the least, I do endorse the view that some delusions are fueled by motivational factors. I also belief these motivational factors can be tapped into to persuade, rather than convince, a patient towards insight. A thorough and genuine insight into the nature of the condition seems to me to be key in treatment compliance.

Prochaska and DiClemente thought so too after a decade of struggling with folks trying to quit smoking. They developed what is today THE accepted heuristic for all forms of professional psychotherapeutic treatment. I think you will see your notion (above) in it.

The diagram fits perfectly my own struggle with delusion and insight, including the relapse into delusion. In my own case, stigma played a role here. For once I reached the thesis that all of what was happening was some psychotic disorder, once I did not merely contemplate that but felt it, so to speak, I broke down and relapsed into the, in some aspects, comforting delusion. For I thought all the thoughts that belong to (self)stigma. It wasn’t until I wanted the diagnosis that I could thoroughly endorse it. Motivated reasoning can work two ways, in my experience.

Maybe it’s a cognitive thing but I struggle with self help/workbooks. Have looked at a few briefly but struggled to get my head around them.

I would imagine that there are probably many people here on this site that have trouble with motivation and cognition.

I know that I have a difficult time reading books - My focus is poor and I just dont have the motivation, it could be because of depression.

I would love to be able to turn to self help books/workbooks but my Negative symptoms/depression makes it difficult if not impossible.

I had the same experience. Someone had to tell me to read and digest them one sentence at a time. Some of us have difficulty with that when our stress levels are high, for sure. I just kept plodding. It worked (not fast, but over time).

cc: @Wave