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Addressing and Managing Resistance with Internalizing Clients

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Austin, S. B., & Johnson, B. N. (2017, June). Addressing and managing resistance with internalizing clients. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/addressing-resistance

Ms. Sara B. Austin

Sigmund Freud originally described psychological resistance as a phenomenon wherein patients unconsciously “cling to their disease” through “tenacious” and “critical objections” in order to repress distressing thoughts, emotions and experiences as they are raised by the therapist (Freud, 1904; 1920; 1940). This understanding—a somewhat patronizing view that pitted expert doctor against oblivious patient—persisted in the psychotherapy literature for several decades. In recent years, however, psychotherapy researchers have begun to understand that resistance can be more than a transferential process (e.g., Ellis, 1983; Greenson, 1967). Indeed, clients often have valid objections to therapy and therapists in the “here-and-now.” This type of resistance, referred to as “realistic resistance” (Rennie. 1994), is the focus of this article.

What is “realistic resistance”?

In contrast to its unconscious (i.e., transferential) counterpart, realistic resistance is explicitly experienced by the client and thus reportable. Broadly defined, realistic resistance refers to clients’ conscious, deliberate opposition to therapeutic initiatives that they fail to understand or accept.

Realistic resistance refers to clients’ conscious, deliberate opposition to therapeutic initiatives that they fail to understand or accept.

Rennie’s (1994) qualitative analysis on client-centered perspectives of therapy characterizes various forms of realistic resistance, including:

  • Resistance to the therapist’s general approach to therapy (e.g., involving discrepancies in general expectancies and/or objectives for treatment)
  • Resistance to specific in-session techniques (e.g., session structure, particular interventions, etc.)
  • Resistance to words or phrases used by the therapist

Although a strong working alliance tends to buffer against the problems associated with the second and third type of resistance, the first type may predict conflict between the client and therapist and can be a particular obstacle to treatment.

Mr. Benjamin N. Johnson

The mouse in the room

Clients with internalizing disorders, such as depression or anxiety, may be especially prone to resistance that goes unnoticed by their therapists. These clients may be inhibited in their interpersonal style and reluctant to overtly challenge or confront their treaters (Hill, Thompson, Cogar, & Denman, 1993; Lynch, Seretis, & Hempel, 2016). Rather than make it an “elephant in the room”, internalizing clients often hide their disagreement or even claim to be on board with a therapist’s recommendations (Muran, Eubanks-Carter, & Safran, 2010). However, resistance in this population may still be apparent through covert acts such as statements that distance the therapist, avoidance of certain topics, or physical withdrawal (Ackerman & Hilsenroth, 2001; Hill et al., 1993). Therapists must be highly attuned to even subtle signs of such resistance in order to effectively address it and enhance collaboration.

Resistance is an opportunity, not a problem

When not addressed, resistance can lead to therapeutic alliance ruptures. Such, ruptures are unavoidable in therapy (Safran, Crocker, McMain, & Murray, 1990). When not appropriately addressed, such rifts interfere with client engagement and ultimately thwart therapeutic progress. Ruptures can stem from instances in which the therapist actively engages in techniques that do not resonate with the client, as well as when the therapist does not do what the client does want. However, despite their treatment-interfering potential, ruptures are not considered to be problematic by many therapists and clinical scientists. Rather, they are seen as vehicles that may be used to deepen the therapeutic bond and promote growth by allowing patients—and their therapists—to practice skills needed for interpersonal conflict resolution (Muran et al., 2009; Safran, Muran, & Eubanks-Carter, 2011). Indeed, rupture repair may foster a particular kind of therapeutic change that would be unlikely to occur within unruptured relationships. The resolution process often provides compelling and experiential disconfirmation of clients’ long-held, maladaptive interpersonal schemata (Safran et al., 1990).

In fact, rather than allow for a client’s resistance (whether communicated directly or indirectly to the therapist) to dictate the course of therapy, therapists should not avoid potential alliance ruptures and instead work with and address resistance as it arises. The use of “collusive resistance” (i.e., avoidance of painful topics due to countertransference reactions; Fox & Carey, 1999) is problematic on a number of different levels. It is not uncommon for certain internalizing clients who present as psychologically fragile to pull for this kind of reaction in their therapist. Therapists should take care not to reinforce clients’ desires for nurturance but rather to foster growth by encouraging the client’s agency. This can be done in many ways, including to:

  • Allow the client to develop his or her own ways of using skills or addressing problems in everyday life, as internalizing clients may acquiesce to, rather than agree with, a therapist’s recommendations
  • Ask open-ended questions to enable the client to explore personal experience without being unduly influenced
  • Let the client sit in moments of silence and experience emotions, even if they are uncomfortable. Skilled clinicians learn to navigate this tension between accommodating or reinforcing operant avoidant responses, which function to block dialogue about resistance, while remaining sensitive to the discomfort clients often feel about addressing the topic directly.

Recognizing and responding to resistance with internalizing clients

Realistic resistance is often subtle and easily missed. Below, we describe a few strategies for managing various types of realistic resistance. We structure this list in terms of specific examples of resistance, followed by suggestions for ways to address each type of resistance in therapy. This list is not exhaustive, and some of these examples may be more germane to specific therapeutic orientations (e.g., cognitive-behavioral, psychodynamic, humanistic); we thus encourage readers to draw connections to potential examples in therapies of other styles.

  • Your client did not do their homework. / Ask your client to cite back to you their understanding of the homework assignment to ensure it was clear. Then discuss with them what might have hindered their completion of it. Notice specifically any disagreement on treatment tasks or goals and consider collaborating to adjust them.
  • Your client misses a series of sessions in quick succession and may have legitimate excuses for the cancellations (e.g., being asked to work extra shifts). / Affirm that you recognize the validity of the explanations the client has for missing (e.g., “I understand that this is a busy time for you at work…”). Then ask if there may also be some other reason for their missing related to the therapy itself (e.g., “…I also wonder if there might be some part of you that was glad for the opportunity to miss?”). Consider bringing up recent difficult or distressing topics for the client as potentially also contributing to their change in attendance.
  • Your client explicitly disagrees or pushes back and does not join with you (signals contempt or hostility, acts dismissively, rolls eyes, laughs scornfully; Lynch, in press). / Reinforce direct and honest expression of your client’s emotions or opinions and solicit more explicit feedback from them, while simultaneously ignoring or compassionately confronting indirect signals of disagreement.
  • Your client employs verbal indicators of only partial agreement, such as “I’m fine,” “I suppose,” “I guess so,” “It’s not a problem,” or “I’ll try” (Lynch, in press). / Gently comment on discrepancies between the content of their statements (e.g., “I’m fine”) and the tone, affect, or expression that may belie such a statement (e.g., “You said things are going fine, but I’m noticing you seemed to be frowning when you said it. Perhaps I’m misreading that, but I thought I’d ask, is something else on your mind?”)
  • Your client signals “don’t hurt me” (e.g., head down, slumped shoulders, lack of eye contact, pouting; Lynch, in press). / Matter-of-factly acknowledge the client’s signal of distress, ask them to engage in the conversation (e.g., “despite this being difficult for you, I want you to do your best to stay with me”) or change their social signaling (e.g., sit up, take a deep breath), and reinforce your client’s attempts to re-engage.
  • Your client seems to be avoiding a particular topic. / Gently push the conversation back to this topic to assess if the client is truly avoiding it. Notice the client’s affect during the discussion and whether avoidance of the topic is consistent with symptoms of their clinical presentation or may rather suggest an unspoken disagreement with the therapist’s direction of the conversation.
  • Your client withdraws or distances. / Share your emotional response in the moment of feeling some distance between yourself and the client or that perhaps the two of you are not on the same page. Ask if the client noticed this and feels this as well. Perhaps posit that it might be related to the topic of conversation. Ask your client if he or she has anything they would like to share with you.
  • Your client subtly changes the movement, speed, or flow of his or her behavior in other ways suggestive of disengagement. / Notice these behaviors as potentially relevant to the discussion at hand. Observe if and when they change as the discussion changes. Do not necessarily comment on these behaviors but use them as further evidence for some of the other behaviors above. If the behavior becomes persistent, potentially ask for the client’s thoughts on the current topic of discussion. Commenting directly on such subtle behaviors may be jarring or disconcerting to internalizing clients who may be especially reserved, so be cautious about doing so.

Summing it up

In general, recognizing and addressing realistic resistance with internalizing clients often involves close monitoring of subtle signs of a rupture in the therapeutic alliance or places where the client and therapist may not be seeing eye-to-eye. As stated above, internalizing clients may be hesitant to voice such concerns aloud and this, in conjunction with the inherent power imbalance in therapy, may leave the responsibility to the therapist to gently raise these concerns. Successfully navigating incidents of resistance also requires the therapeutic relationship to take precedence over specific interventions. Ackerman and Hilsenroth (2001) eschew rigid adherence to treatment guidelines that preempt the formation of a collaborative relationship between therapist and client. Indeed, Aspland et al. (2008) observed that successful conflict resolution and alliance repair in CBT was facilitated only by therapists modifying their stance to focus on issues more salient to their clients. Therapists who suspect a potential alliance rupture should immediately slow the pace, drop their in-session agenda (i.e., technical intervention), and shift their attention to the relationship (Lynch, in press; Muran, Safran, & Eubanks-Carter, 2010). Competent management of ruptures resulting from realistic resistance can ultimately foster deeper exploration of relational patterns, strengthen the client-therapist bond, and foster therapeutic growth.

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References

Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy: Theory, Research, Practice, Training38(2), 171. doi:10.1037/0033-3204.38.2.171

Aspland, H., Llewelyn, S., Hardy, G. E., Barkham, M., & Stiles, W. (2008). Alliance ruptures and rupture resolution in cognitive–behavior therapy: A preliminary task analysis. Psychotherapy Research, 18(6), 699-710. doi:10.1080/10503300802291463

Fox, R., & Carey, L. A. (1999). Therapists’ collusion with the resistance of rape survivors. Clinical Social Work Journal, 27(2), 185-201. doi:10.1023/A:1022874807892

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Freud, S. (1940). An outline of psychoanalysis. New York, NY: Norton.

Freud, S. (1959). "Freud's psycho-analytic procedure". In J. Strachey (Ed. & Trans.) The standard edition of the complete psychological works of Sigmund Freud (Vol. 7, pp. 249–270). London: Hogarth Press. (Original work published in 1904.)

Hill, C. E., Thompson, B. J., Cogar, M. C., & Denman, D. W. (1993). Beneath the surface of long-term therapy: Therapist and client report of their own and each other’s covert processes. Journal of Counseling Psychology, 40(3), 278. doi:10.1037/0022-0167.40.3.278

Lynch, T. R. (in press). Radically open dialectical behavior therapy for disorders of overcontrol. Oakland, CA: New Harbinger.

Lynch, T. R., Seretis, D., & Hempel, R. (2016). Radically open-dialectical behaviour therapy for overcontrolled disorders: Including refractory depression, anorexia nervosa, and obsessive compulsive personality disorder. In A. Carr & M. McNulty (Eds.). The handbook of adult clinical psychology: An evidence based practice approach (pp. 990-1032). New York, NY: Routledge.

Muran, J. C., Safran, J. D., Eubanks-Carter, C., Muran, J. C., & Barber, J. P. (2010). Developing therapist abilities to negotiate alliance ruptures. The Therapeutic Alliance: An Evidence-Based Guide to Practice, 320–340.

Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C., & Winston, A. (2009). The relationship of early alliance ruptures and their resolution to process and outcome in three time-limited psychotherapies for personality disorders. Psychotherapy: Theory, Research, Practice, Training, 46(2), 233. doi:10.1037/a0016085

Rennie, D. L. (1994). Clients’ accounts of resistance in counselling: A qualitative analysis. Canadian Journal of Counselling and Psychotherapy/Revue Canadienne de Counseling et de Psychothérapie, 28(1), 43-57.

Safran, J. D., Crocker, P., McMain, S., & Murray, P. (1990). Therapeutic alliance rupture as a therapy event for empirical investigation. Psychotherapy, 27(2), 154-165. doi:10.1037/0033-3204.27.2.154

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87. doi:10.1037/a0022140

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