Internet Editor’s Note: Dr. Henny Westra and colleagues recently published an article titled “Testing a Deliberate Practice Workshop for Developing Appropriate Responsivity to Resistance Markers,” in Psychotherapy.
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Resistance is a phenomenon that tends to be universally dreaded by therapists. Therapists have described feeling frustrated, confused, guilty, and hurt after disagreement with their clients, and can even end up doubting their competence (Coutinho et al., 2011). Not only this, but it is well-documented that conflict will return if it is not effectively addressed by therapists, harming the therapeutic relationship and client outcomes (e.g., Constantino et al., 2019). So, how can therapists learn to effectively respond to resistance?
This article will outline:
- What resistance is
- How to respond to resistance using appropriate responsivity
- How to practice and improve these skills
What is Resistance?
Resistance is any client statement/behaviour that blocks the therapist’s direction or agenda in therapy. It can be present in the therapeutic process and/or the verbal content of therapy (Chamberlain et al., 1984). For example, the client may be resistant to the process of therapy when they become disengaged from the session, perhaps checking their phone, or looking away from the therapist. Alternatively, resistance can appear in their therapeutic content when the client verbally opposes the therapist/therapy. For example, a client might say the following in response to a therapist suggesting relaxation exercises:
“I have never found that to work… It takes a lot of effort, and I don’t seem to get the benefit.”
Importantly, there must have been a clear direction from the therapist that the client is going against for the statement to be considered resistance (Chamberlain et al., 1984). In the above example, the therapist’s direction is to try relaxation exercises, and the client is opposing this direction. However, if the therapist had simply asked whether the client had tried relaxation exercises before, the above statement would not be resistance. Here the therapist’s direction is to explore previous experiences, and the client is following this direction by stating their experience.
One good indicator of resistance is how the therapist feels in the interaction (Coutinho et al., 2011). As a therapist, if you feel irritated, disrespected, or an urge to argue or justify your statements, this might be an indicator that there is some disconnect between you and your client. This should be a signal to slow down, pay attention to the client’s verbal and non-verbal messages, and use the skill of appropriate responsivity.
How to Respond to Resistance
Appropriate responsivity is the skill of flexibly responding to the client in a way that considers the context (Constantino et al., 2013; Stiles et al., 1998). In other words, doing the right thing at the right time. This involves both identifying the context (e.g., resistance) and responding appropriately. In other words, responding in a way that is likely to be helpful, rather than harmful, for therapy outcome.
Consider the earlier example of a client expressing resistance about relaxation exercises. Upon noticing this, a therapist using appropriate responsivity might explore the resistance in a curious and supportive manner. For example:
“It sounds like the exercises have never felt worth it, and you are maybe feeling kind of hopeless?”
This response meets the client 'where they are at' and offers space for the client to share conflicting feelings about the exercises. In contrast, an inappropriate therapist response might involve trying to persuade the client in a directive manner, such as by saying:
“These exercises take practice - they will work if you keep at it!”
Rather than 'rolling with' resistance, this response demands change and creates another direction for the client to resist, potentially leading the therapist and client into an argument about the merits of relaxation exercises. In addition to perpetuating resistance (Westra & Norouzian, 2018), inappropriate directive responses during the context of resistance (rather than appropriate supportive responses) are associated with worse client outcomes (Aspland et al., 2008).
One therapeutic approach that is well-suited to managing moments of resistance is Motivational Interviewing (MI). This is a therapy that focuses on promoting client motivation for change through exploring ambivalence and resistance (Miller & Rollnick, 2013). However, knowledge of MI is different from being able to effectively implement MI. Resistance can often evoke anxiety in therapists due to its challenging and sometimes personal nature (e.g., criticism of the therapist/therapy), and therapists can therefore forget their skills and be unintentionally pulled into being defensive or argumentative (Binder & Strupp, 1997; Boswell et al., 2013). Thus, practice is essential for therapists to master the skill of appropriate responsivity.
Practicing Your Skills
Deliberate practice is a promising new training approach for therapists involving repeated practice that is guided by expert feedback (Rousmaniere et al., 2017). A recent study examined the efficacy of a 2-day MI workshop that used deliberate practice to train therapists in appropriate responsivity to resistance (Westra et al., 2020). Therapists who attended the deliberate practice workshop demonstrated significantly better responding to resistance, compared to therapists who attended a traditional workshop with fewer opportunities for practice and feedback.
Importantly, deliberate practice can help therapists learn appropriate responsivity to resistance regardless of their initial empathic skill (an important skill in the context of MI). Low empathic skill prior to the workshop predicted poorer learning of appropriate responsivity in the traditional workshop group, but this did not hinder therapists in the deliberate practice group (Norouzian et al., 2021). Thus, deliberate practice appears to be a fruitful approach for learning appropriate responsivity to resistance, and this seems to be a skill that any therapist (highly empathic or not) can learn.
So, at this point, you might be wondering: how does one practice the skill of appropriate responsivity?
The deliberate practice workshop in the Westra and colleagues (2020) study involved learning to identify resistance within video vignettes, discriminating appropriate versus inappropriate therapist responses, and repeatedly practicing possible supportive responses to resistance. As well, therapists who maintained their appropriate responsivity skill over time were more likely to regularly attend supervision and review tapes of therapy sessions, relative to therapists who declined in skill over time (Poulin et al., 2019). In particular, therapists who reviewed tapes of master therapists had much better maintenance of skills. This kind of tape review allows therapists to compare their own performance to that of master therapists, and it can therefore constitute a form of feedback.
Resistance can be challenging for therapists to navigate. Research suggests that supportive, rather than directive, therapist responses are indicated in the context of resistance. However, given the emotionally provocative nature of resistance, appropriately responding to resistance takes practice. To address this, deliberate practice is emerging as an effective approach for training therapists in appropriate responsivity to resistance.
For therapists, the key take-home messages are:
- Pay attention to how you feel. Therapists often have personal reactions to resistance. So, notice your own feelings (e.g., irritation) as a marker of resistance.
- Don’t take it personally. Though it can feel like an attack or criticism, remember that resistance is not about you. Keep in mind that resistance is an indication that there is something important to understand about the client’s experience.
- Slow down. During moments of resistance, pause and be mindful of the ‘pull’ to argue. Instead, adopt a supportive, curious stance of exploring resistance as a source of useful information.
- Practice, practice, practice. Consider reviewing tapes of your own sessions to practice identifying moments of resistance, and then brainstorming possible supportive responses. Viewing tapes of master therapists can also be a helpful guide.
Resources for Further Exploration
Aviram, A., Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Responsive management of early resistance in cognitive–behavioral therapy for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 84, 783–794. https://doi.org/10.1037/ccp0000100
Bischoff, M. M., & Tracey, T. J. G. (1995). Client resistance as predicted by therapist behavior: A study of sequential dependence. Journal of Counseling Psychology, 42, 487–495. https://doi.org/10.1037/0022-0188.8.131.527
Norouzian, N., Westra, H. A., Button, M. L., Constantino, M. J., & Antony, M. M. (2021). Ambivalence and the working alliance in variants of cognitive-behavioural therapy for generalised anxiety disorder. Counselling and Psychotherapy Research, 21, 587-596. https://doi.org/10.1002/capr.12332
Poulin, L. E., Button, M. L., Westra, H. A., Constantino, M. J., & Antony, M. M. (2019) The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder. Cognitive Behaviour Therapy, 48, 369-384. https://doi.org/10.1080/16506073.2018.1517390
Westra, H. A. (2012). Motivational Interviewing in the Treatment of Anxiety. Guilford Press.
Westra, H.A. & Aviram, A. (2013). Core Skills in Motivational Interviewing. Psychotherapy, 50, 273-278. https://doi.org/10.1037/a0032409
Westra, H. A., Constantino, M. J., & Antony, M. M. (2016) Integrating MI with CBT for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84,768-782. https://doi.org/10.1037/ccp0000098
Cite This Article
Poulin, L., Norouzian, N., & Westra, H. (2022, April). Practicing appropriate responsivity: A key skill for managing resistance. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/practicing-appropriate-responsivity
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, 699-710. https://doi.org/10.1080/10503300802291463
Binder, J. L., & Strupp, H. H. (1997). “Negative process”: A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4(2), 121-139. https://doi.org/10.1111/j.1468-2850.1997.tb00105.x
Boswell, J. F., Gallagher, M. W., Sauer-Zavala, S. E., Bullis, J., Gorman, J. M., Shear, M. K., Woods, S., & Barlow, D. H. (2013). Patient characteristics and variability in adherence and competence in cognitive-behavioral therapy for panic disorder. Journal of Consulting and Clinical Psychology, 81(3), 443–454. https://doi.org/10.1037/a0031437
Chamberlain, P., Patterson, G., Reid, J., Kavanagh, K., & Forgatch, M. (1984). Observation of client resistance. Behavior Therapy, 15, 144–155. https://doi.org/10.1016/S0005-7894(84)80016-7
Coutinho, J., Ribeiro, E., Hill, C., & Safran, J. (2011). Therapists’ and clients’ experiences of alliance ruptures: A qualitative study. Psychotherapy Research, 21, 525-540. https://doi.org/10.1080/10503307.2011.587469
Constantino, M. J., Boswell, J. F., Bernecker, S. L., & Castonguay, L. G. (2013). Context-responsive integration as a framework for unified psychotherapy and clinical science: Conceptual and empirical considerations. Journal of Unified Psychotherapy and Clinical Science, 2, 1–20.
Constantino, M. J., Westra, H. A., Antony, M. M., & Coyne, A. E. (2019). Specific and common processes as mediators of the long-term effects of cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder. Psychotherapy Research, 29, 213-225. https://doi.org/10.1080/10503307.2017.1332794
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
Norouzian, N., Poulin, L. E., Westra, H. A., Hara, K. M., Constantino, M. J., & Antony, M. M. (2021, June 23–26). Does Receiving Deliberate Practice Training Moderate the Relationship between Baseline Empathic Skill and Training Outcomes? [Brief paper session] 52nd Annual Meeting of the Society for Psychotherapy Research, Heidelberg, Germany.
Poulin, L. E., Norouzian, N., Westra, H. A., Hara, K., Constantino, M. J., & Antony, M. M. (2019, June 6-8). Factors differentiating learning trajectories following a training workshop for therapists using deliberate practice. In H.A. Westra (Chair), Testing the efficacy of a deliberate practice workshop for identifying and navigating markers of ambivalence and resistance. [Symposium] 35th Annual Meeting of The Society for the Exploration of Psychotherapy Integration, Lisbon, Portugal.
Rousmaniere, T., Goodyear, R. K., Miller, S. D., & Wampold, B. E. (2017). The Cycle of Excellence (pp. 1–22). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781119165590.ch1
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Westra, H. A., & Norouzian, N. (2018). Using motivational interviewing to manage process markers of ambivalence and resistance in cognitive behavioral therapy. Cognitive Therapy and Research, 42, 193-203. https://doi.org/10.1007/s10608-017-9857-6
Westra, H. A., Norouzian, N., Poulin, L., Coyne, A. E., Hara, K., Constantino, M. J., & Antony, M. M. (2020). Testing a deliberate practice workshop for developing appropriate responsivity to resistance markers. Psychotherapy. Advance online publication. https://doi.apa.org/doi/10.1037/pst0000311