"Difficult Patients": The Therapist’s Word For Their Own Impasse. A Commonly Seen Bottleneck

Brook Cheng

December 4, 2025

• "Saying a disease of a patient is 'incurable' just means the healer lacks skills" (Yellow Emperor's Inner Canon"(400 BC - 400 CE).

• “Do as much as possible for the patient, and as little as possible to the patient.” --Sigmund Freud (1856-1939)

" [W]hen the medical community doesn’t understand something it is easier to blame the patient. That also means… if the patient is not getting better under our care - we say things like

• they are non compliant

• they don’t want to get better

• it is in their head

• they are making it up

• it is “biopsychosocial” , what does this even mean?

Questioned Alison TAYLOR, a Certified Hand Therapist at The STAR in Frisco, TEXAS.

There Are No Difficult Patients

There are no difficult patients. This is the title of a post on linkedin by Giovanni Felice Pace, a Chartered Psychologist from UK. The post (posted on Dec. 3, 2025) quickly gained 485 supports and 76 comments in 3 days.

The post goes as below:

• There are no difficult patients. Only therapists who have not yet found the limits of their own listening. In teaching and supervision, I often hear about “resistant” or “non-compliant” patients.

• But let’s be honest: resistance is the therapist’s word for their own impasse. When we meet a patient who won’t “move", who “won’t comply", it is not they who are blocked.

• It is us. It is our inability to bear what they bring, to stay with the silence, to hold the unbearable, to listen past the noise of our own ego.

• Ogden said it with clarity:“So-called difficult patients are mirrors of our own limitations in listening, bearing, and creating meaning.”

• The truth is uncomfortable, but vital:

• Every “difficult” patient is an invitation — for us to suffer the work, stretch beyond our habits, and let go of the illusion that therapy unfolds on our terms.

• The “difficult” patient is not the obstacle. They are the mirror. And the reflection is of us. If we can endure that, the patient is no longer difficult.We are simply learning to be therapists.

(End of Giovanni Felice Pace’s post)

A "Hard to Admit" Truth in Medicine

Giovanni's post is revealing an "inconvenient" truth in medicine, "hard to admit" cold truth for many of us clinicians.

As a non-conventional therapist seeing diverse patients everyday, I commented:

• Thumb up to "There are no difficult patients.... let’s be honest: resistance is the therapist’s word for their own impasse."

• Your statement is a very truth in medicine. It is strongly echoed with what the ancient physicians say: "Saying a disease of a patient is 'incurable' just means the healer lacks skills" (Yellow Emperor's Inner Canon"(400 BC - 400 CE).

In my clinic, I see only less than 2 "difficult, resistant or non-compliant" patients out of every 100 patients with diverse conditions related to MSK, internal organs, hormonal issues, neurological issues .... In over 95% cases the symptom improvement happens instantly within 3 seconds upon the start of intervention. And in over 80% cases cure follows within 1 to 2 months.

What the physicians in 200 BC experienced as recorded in Yellow Emperor's Inner Canon and what is happening in my clinic today are demonstrating the same truth:

There are no "difficult patients".

The two exceptions in my clinic is telling me that I lack the corresponding skills. So I know I need to work even harder in searching, investigating and learning of new skills.

I don't blame patients. I know I still know too little.

Treatment Burden

Based on the numerous anecdotal clinical observations recorded in the last 2000 years including thousands of today's RCTs, I saw plenty of evidence that particularly in MSK medicine, ineffectiveness aside (even "placebo" is better than nothing), awkward, bothersome or untolerable treatment BURDEN is one commonly seen factor leading to too many "difficult",  “resistant” or “non-compliant" patients.

Treatment burden is the workload of healthcare and its effect on patient functioning and wellbeing. The cumulative treatment workload for patients with chronic conditions when enacting all recommendations in disease specific guidelines can be overwhelming (Powell P, et al,2020).

In the statue quo medine today, many medical interventions placed too much burden to the patients. In musculoskeletal field, take exercise therapy for neck pain as an example. In a 2012 study (Gert Bronfort et al, 2012), home exercise advice (HEA) by the clinicians required patients to do self-mobilization exercise on their painful neck, 5 to 10 repetitions each time up to 6 to 8 times per day!!! And for 12 weeks (3 months)!

The increase in treatment burden will result in the increase of non-adherence to treatment, disease progression, poor health status and quality of life, and caregiver burden (Powell P, et al, 2020). Sometime in 2016, an anonymous patient posted on reddit.com talking about how he or she deals with the homework given by a physiotherapist:

• Every time I have had physio, I have been told something like "you need to do these exercises twice a day for the next 30 days". I nod and agree but I know I will do these exercises once a day for the next one day and then get lazy.

• And when I go back to the physio after 30 days with barely no improvement but I will tell them that it's feeling a little better so they increase the amount of exercises I won't do.

• Giving people homework is not an effective treatment method. But there is no quick fix for a lot of conditions that require physio.

Why Treatment Burden Leads to "Difficult" Patients?

The answer is obvious: "Nobody wants therapy" (unless in desperate need).

So we need to think about more deeply about what those brilliant minds' medical wisdom means:

• “The art of medicine consists of amusing [comforting] the patient while nature cures the disease.” --Voltaire (1694 -1778)

• “Do as much as possible for the patient, and as little as possible to the patient.” (Sigmund Freud, 1856-1939).

References

Claudia C Dobler et al, Treatment burden should be included in clinical practice guidelines. BMJ 2018; 363

Gert Bronfort,  et al, Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial.Annals of Internal Medicine 2012 (Jan 3); 156 (1 Pt 1): 1–10

Brook Cheng, Nobody Wants Therapy: The More Treatment Burden, The Poorer A Therapy’s Outcomes. Newsletter on linkedin, 2025

Powell P, et al, Discussing treatment burden. Breathe (Sheff). 2021 Mar;17(1):200284. doi: 10.1183/20734735.0284-2020. PMID: 34295397; PMCID: PMC8291916.

Yellow Emperor's Inner Canon"(400 BC - 400 CE)