Reducing Resistance in Psychotherapy
Historically, resistance in psychotherapy has been conceptualized as “residing” within clients. Such perspectives likely grew from early Freudian definitions that characterized resistance as clients’ efforts to repress anxiety-provoking memories and insights (Otani, 1989) or as disputing the therapist’s interpretations of their problems.
Alternatively, in the last half century resistance has frequently been conceptualized as a result of a negative interpersonal dynamic between the therapist and the client. Or, as Strong and Matross (1973, p. 26) state, “Resistance is defined as psychological forces aroused in the client that restrain acceptance of influence (acceptance of the counselor’s suggestion) and are generated by the way the suggestion is stated and by the characteristics of the counselor stating it.” From this perspective, the psychotherapist co-creates a mutual (p. 259) communication pattern that hinders treatment and that promotes resistance. This perspective empowers therapists to prevent and minimize resistance through adjustments in their interaction style by remaining aware of what they may be doing that promotes resistance and by developing alternative responses. This chapter presents ideas for managing psychological resistance by disrupting typical therapeutic interaction patterns and replacing them with interaction styles that resolve resistance.
1. Do the unexpected. A foundational principle in managing resistance is to strive to disrupt clients’ common patterns of thinking, feeling, and behaving. This is first begun by responding in an unexpected manner and avoiding socially typical responses. Clients who have talked to non–mental health professionals (and some professionals) have likely heard the standard “how-to-fix-your-situation” advice. Frequently, this advice is not well received. Typical responses beget typical reactions, and typical reactions keep clients stuck in their situation. This is one reason why brief therapists assert that problems are maintained by solutions that are ineffective (Walter & Peller, 1992). Clinicians’ typical responses are likely to be incorporated into established, ineffective solutions. The more we respond in a typical manner, the more likely we are to become part of the system that maintains resistance and problems.
To avoid the pitfalls of typical responses and the resistance that follows, you can avoid typical verbal and nonverbal responses. In doing this, you surprise clients, confound their anticipation of your response, and begin disrupting the patterns that are inherent to their thinking and problems.
The unexpected does not have to be complex. The better techniques taught in training programs are unexpected by most clients. The empathic response, the absence of criticism, the nonjudgmental posture, and the response that has the appearance of puzzlement or agreement out of sync with common rebuttals are examples of unexpected responses that potentially disrupt client patterns.
2. Slow the pace. When resistance is encountered, the prevailing urge is to increase the pace of the session and break through the resistance. This is a classic mistake. Instead, slow the pace. Make sure that each statement by the client is fully addressed and processed in detail.
To slow the pace, increase the space between your words and increase your use of silence. This does two things: It creates pressure to fill the space and it provides time to think and feel (Gerber, 1986). Most resistant clients avoid both of these tasks. Yet it is the pressure to fill the space as well as the time to think and feel that leads clients to doing their work. The real therapeutic work is done in the time between the words, during the quiet moments when new perspectives are examined and embraced. Another subtle benefit of slowing the pace is that it provides a few extra moments for clients’ defenses to dissipate. When you try to progress too fast, you often move into a position of attempting to do the work yourself and, thus, hinder the change process.
Yet another benefit of slowing the pace is that it keeps the therapeutic tension within clients and does not place the therapeutic tension between clients and you (Mitchell, 2010). Increasing the therapeutic tension between you and clients is typically unhelpful because it tends to amplify resistance. The therapeutic tension should be within clients as they face their inner struggles. Slowing the pace does not mean to become passive and slow the therapeutic work. To the contrary, slowing the pace typically intensifies the therapeutic work. You slow the pace in order to focus on and magnify clients’ internal struggles and search for answers. Resistance is overcome with an emphasis on direction, not speed.
3. Focus on details. Much of what appears to be resistance is a failure to acquire enough information about the richness of clients’ worlds in order to increase understanding of why clients are responding as they are and to increase junctures at which interventions can be implemented (Mitchell, 2010). By assessing details you show genuine concern and respect for the client and are more likely to get to the crux of the conflicts. Broad, general discussions are rarely productive. “The devil is in the details” is more than a bit of folk wisdom; details are essential for solution creation and (p. 260) resistance management. Another benefit from a heightened attention to details is that choices emerge. Details create choices because, with every detail, options become more evident to clients. If a client feels that not enough options are available, you do not have enough details about that client’s world.
4. Avoid logic and excessive direct guidance. Despite the masses of information regarding the dangers of harmful, unhealthy behaviors, people continue to do them. Information and logic alone rarely compel change and therapists who rely on them as motivators for change frequently meet frustration. If people changed because of logic, no one would smoke, no one would drink, and everyone would exercise. This is not to say that logic is unimportant to some aspects of change; however, when you closely examine the underlying forces that actually move people to change you discover that people most often change because they have emotionally compelling reasons to change (Mitchell, 2010). This is particularly true with reluctant, involuntary clients. With reluctant clients, direct guidance and logic often increase resistance and, as such, are less effective and can waste time. Instead, focus on discovering the underlying component of change that arouses the most emotional reaction in clients. Once discovered, construct a dialogue that keeps clients in touch with this emotion as a motivator. In this manner motivation for change comes from within clients and resistance is resolved (Miller & Rollnick, 2002).
5. Increase empathic responding. Too often empathy is seen as a tool to build rapport only. As a result, therapists may discount and limit the consistent use of empathy once rapport has been established. The logic here is something like, “Now that I have rapport, I will build a case for change.” Such an approach is a mistake that can increase what appears to be resistance.
Empathy gets clients in touch with their emotionally compelling reasons for change. A well-worded empathic response always includes at least one reference to the specific emotion that the client is experiencing at the moment. The more resistant the client appears, the more empathic statements are needed to tap into internal motivations for change. For most resistant clients, logic without an underlying emotional impact is just talk. Failure to consistently include empathic statements in psychotherapy inevitably makes the task of overcoming clients’ ambivalence to change more difficult and results in clients being wrongly labeled as resistant (Miller & Rollnick, 2002).
6. Avoid responding from an expert position. Clients enter therapy with a host of problems and you often become certain that your knowledge will be beneficial. As a consequence, you begin suggesting solutions to clients. To your dismay, resistant clients reject your suggestions and you start hearing “Yes, but …” responses. Often, you become frustrated with the clients’ rejection of your suggestions and begin labeling clients as resistant. “Yes but …” responses are a signal that the current therapeutic interaction is not working. In such situations, the more knowledge you present about solutions, the greater the likelihood you will encounter what appears to be resistance.
The way out is to reverse the paradox—become curious, naïve, and puzzled. The reason behind this is that the more of an expert you become, the more you provide the needed ingredient to create resistance—that is, someone or something to argue against. The more naïve and puzzled you become, the less the client has to resist against. In addition, your expertise may result in clients losing the sense of freedom needed to explore possibilities on their own and willingly embrace change.
Moving to a position of naiveté and unknowing is sometimes difficult because your suggestions would likely benefit clients. However, it is not how much you know or how much you want to help that matters. What matters is the relationship between you and your clients at any particular moment. If clients are rejecting your suggestions, they are signaling that they are not “buying” what you are “selling.” When this occurs, stop selling and return to gathering information about what clients might accept. Resistance is created when there is a mismatch between the method of delivering influence and clients’ current propensity to accept the method by which the influence is delivered (Mitchell, 2010).
(p. 261) If clients are motivated and cooperative, and you have a good idea, by all means tell them. If they accept your suggestions and try them, move forward. Yet, if they are reluctant to accept your suggestions, become naïve. As a general rule, the more resistant the client, the less you know; the more motivated the client, the more you know (Mitchell, 2010).
7. Accommodate client preferences. Matching client preferences in psychotherapy has been shown to reduce dropout rates by about a third and improve treatment outcomes (Swift, Callahan, & Vollmer, 2011). Thus, it is recommended that therapists assess client preferences in initial meetings and periodically throughout the treatment process. Preferences are typically assessed through directly asking clients; however, written descriptions, rating scales, and surveys can also be used.
It is important to create an environment where clients can openly express preferences as they may be reluctant to state them for a number of reasons, including a lack of information about options, distrust in the system or therapist, and a low readiness to change. Accommodating preferences whenever clinically and ethically possible reduces resistance. Even when preferences cannot be accommodated, genuine efforts to discuss and address them can also prove beneficial in reducing resistance.
8. Establish mutual goals. One of the primary therapist errors that create resistance is failure to establish mutually agreed-upon goals. The key word here is mutually. Clients, particularly resistant clients, should be active participants in goal establishment. People do not resist what they want; they resist what they do not want and what is imposed upon them. If we start by first seeking what clients want, we build a foundation for mutually agreed-upon goals.
The centrality of mutual goals appears at two levels. First, there is agreement on the overall goal of treatment—what would constitute a successful outcome. Second, there is agreement between the client and therapist on the momentary goal within the session. Do the client and therapist agree that what is being done in that session is important to a successful outcome? Clients who do not view the content and tasks as important are likely to “resist.”
9. Deal with fears surrounding goals first. Some people come to therapy because they realized that the probable solutions to their problems terrify them (Walter & Peller, 1992). This is common with clients in the contemplation stage. In cases where fear of change is considerable, focusing too strongly on goals may increase fear and slow progress. Instead, first focus on the fear before moving to discussions of actions to take. Therapists may inadvertently create “resistance” because the therapeutic interaction is mistimed and unaligned with clients’ predominant apprehensions and readiness to change.
10. Funnel problems to a particular person, place, and time. At a seminar, David Burns stated that you are most helpful when the problem is defined at a level of clarity that includes a specific person, place, and time. Until this clarity and specificity are reached, clients may appear resistant; however, the underlying barrier to change may be that the problem is unmanageable because it is too broadly and vaguely defined. The problem has not been funneled down to the point where the client perceives that something can be usefully accomplished.
11. Avoid early confrontation. Although there is a place for negative feedback in psychotherapy, the research consistently shows that an early confrontive style tends to backfire. If you confront too early in the process, it tends to prove counterproductive and promote resistance.
There are two fundamental reasons to avoid early confrontation. First, the right to confront must be earned over time. Confrontation that occurs before a critical level of respect is achieved can increase resistance because it provides clients a strong stimulus to resist against. Second, rarely are the presenting problems the “actual” or “real” conflicts. To effectively deal with resistance, deeper problems need to be discovered and processed. Confrontation should be delayed until deeper concerns are revealed or until it is clear that genuine concerns are being discussed.
12. Use paradox when appropriate. Paradox is particularly useful for resistant clients because it alters resistive behavior without (p. 262) directly confronting it. Often defined as prescribing the symptom or giving clients permission to continue or increase unwanted behavior, paradoxical techniques have the therapeutic advantage of placing clients in a bind where the more they resist, the more they comply with therapists’ suggestions. The benefit of paradoxical approaches is that they utilize the resistant behavior as a tool to promote therapeutic movement. A more subtle benefit is that therapists are conveying confidence that clients will make wise decisions about what to do when they see the consequences of their behavior from a magnified perspective. Thus, with the use of paradox, resistance is circumvented and a healthy independence is reinforced.
13. Change your treatment approach. Regardless of the client’s preferences, if you have been working from a particular theoretical approach and it has proved ineffective, change. It is often difficult to predict which treatment or format will work with individual clients. Sometimes the approach that initially appears to fit with a particular client is the opposite of what works.
Some therapists are unwilling to accept that their favorite approach is not applicable for certain patients and circumstances. Those who continue with ineffective practices are resistant therapists; sadly, this is sometimes characterized as client resistance.
14. Openly discuss clients’ and your resistance. When little has been accomplished and clients’ resistance has become the elephant in the room, it can be beneficial to directly discuss their resistance with them (Ellis, 2004). Such a discussion will include acknowledgement of your own contributions to resistance, as resistance occurs only within the context of a relationship or a system (Miller & Rollnick, 2002). It is unlikely clients will directly address their own resistance openly; thus, therapists will likely have to take the lead in this discussion.
Addressing your contributions to the resistance is unexpected, leads to a productive focus on the therapeutic relationship, and models taking responsibility for actions contributing to the lack of progress (Mitchell, 2010). This, in turn, opens the door for a direct discussion of clients’ resistance, which frequently leads to an explication, if not resolution, of the core conflicts.
References and Readings
Ellis, A. (2004). Methods to reduce and counter resistance in psychotherapy. In G. P. Koocher, J. C. Norcross, & S. S Hill (Eds.), Psychologists’ desk reference (2nd ed., pp. 212–215). New York: Oxford University Press.Find this resource:
Gerber, S. K. (1986). Responsive therapy: A systematic approach to counseling skills. New York: Human Sciences Press.Find this resource:
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.Find this resource:
Mitchell, C. W. (2010). Effective techniques for dealing with highly resistant clients (2nd ed.). Johnson City, TN: Clifton Mitchell Publishing.Find this resource:
Otani, A. (1989). Resistance management techniques of Milton H. Erickson, MD: An application to nonhypnotic mental health counseling. Journal of Mental Health Counseling, 11, 325–334.Find this resource:
Strong, S. R., & Matross, R. P. (1973). Change process in counseling and psychotherapy. Journal of Counseling Psychology, 20, 25–37.Find this resource:
Swift, J. K., Callahan, J. L., & Vollmer, B. M. (2011). Preferences. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 301–315). New York: Oxford University Press.Find this resource:
Walter, J. L., & Peller, J. E. (1992). Becoming solution-focused in brief therapy. New York: Brunner/Mazel.Find this resource: