Examples of Resistance in Therapy
There are various forms of resistance that clients commonly use to avoid dealing with certain topics with their therapist, which include:
- Minimal talking or silence
- Irrelevant small talk
- Not doing homework/using suggestions
- Second-guessing the therapist
- Asking the therapist personal questions
- Skipping appointments
- Failing to pay for appointments
- No sign of progress or improvement
- Therapist is trying harder than the client
Clients may resist psychoanalysis by becoming silent
Dealing with Resistance
Resistance in therapy is normal and can be a helpful process. All therapists are trained to deal with the various forms of resistance their clients may display. Therapists may be able to reduce or eliminate resistance in therapy if they are able to identify and understand the resistance early on in treatment.
According to psychologists, one of the most effective ways to deal with resistance in therapy is to utilize a paradoxical approach, which means that instead of fighting the resistance, therapists support it. It has been found that many resistant clients are oppositional by nature, therefore a therapist may tell their client to continue their behaviors in hopes that they will do the opposite.
Another method a therapist may use to deal with resistance in therapy is to identify the goals that the client would like to work toward. Setting goals may be more effective when it is done at the beginning of the client’s treatment and may help motivate the client to make necessary behavior changes. A clear outline of a client’s goals can be beneficial when the client has gone off track due to resistance. The therapist can remind the client of their goals which may motivate the client to continue participating in therapy. In addition to the paradoxical approach and goal setting, therapists deal with resistance through:
- Anticipating resistance
- Developing patience and understanding
- Building strong relationships
- Using confrontation strategies
- Using metaphors
Therapists are taught to anticipate defensive attitudes in their clients; therefore, a lack of surprise allows them to continue working smoothly. Therapists are also taught that they cannot force a client change and there is only so much they are able to do. In addition, therapists are trained to treat resistant clients with respect, even if they do not agree or understand the client’s resistant behaviors. It is common for clients to express feelings of anger and frustration; however, the therapist must respond in an appropriate manner that will not escalate those feelings.
Developing Patience and Understanding
Therapists build trust with their clients through expressing patience and understanding for what their clients have to share. Validating what a client has to say, while being genuine, can help a therapist develop trust with their clients. In addition, a therapist can build trust with a client by expressing empathy. A client may be more receptive to therapy when they feel their therapist understands how difficult their situation is or when they feel like they have support from their therapist. It is important that a therapist remains patient because if they show signs of impatience, the client may continue their resistant behaviors.
Building Strong Relationships
Building strong relationships with clients can help therapists curb client resistance, as they are able to build strong therapist-client rapport. It is important that the therapist makes the relationship with their client a top priority during each and every session. A client is more likely to be open, honest, and receptive to treatment suggestions when they have a positive rapport with their therapist. To build rapport, the therapist should make eye contact appropriately, use the clients name, be approachable, act interested in what the client has to say, and attempt to match the client’s rhythm.
On occasion, in specific circumstances, therapists use confrontation to counter client resistance, in which they tell their clients that what they are doing is going to harm them. The goal of this form of confrontation is to bring attention to risks associated with the client’s behaviors. Additionally, a therapist may confront the client about their resistance; however, avoid fighting with the client about it. Studies have shown that fighting resistance is rarely successful in therapy and it may be more beneficial for a therapist to point out the resistance in their client and continue with the session. If the therapist confronts the resistance by making an open-ended statement, it may encourage the client to start a discussion about why they are being resistant.
Therapists sometimes use metaphors to keep the client from giving up. Metaphors can be beneficial because they allow the therapist to communicate with the client in an indirect way. During therapy sessions, metaphors may allow a therapist to address a topic that might otherwise be received with resistance. For some clients, metaphors are easier to understand than elaborate explanations. Metaphors can allow a client or therapist to understand thoughts or feelings that cannot be put into exact words. Often, clients themselves use metaphors when trying to explain their thoughts or feelings during therapy sessions.
Resistance in psychology is the opposition of the therapy process in which a client refuses or rejects suggestions made by a psychologist. Resistance in psychoanalysis is a client’s subconscious or conscious unwillingness to grow and change within therapy or treatment. Clients may be resistant to psychoanalysis for various reasons. For example, therapy topics can be emotionally difficult to discuss, therefore a client may be resistant to opening up to their therapist. In addition, if the client believes change is difficult or scary, or if the client was referred by a third party, they may be resistant to therapy.
There are various forms of resistance that a client may use to avoid therapy, which include: failing to pay for therapy services, second-guessing the therapists, becoming silent, making irrelevant small talk, or skipping therapy sessions. Resistance in psychoanalysis is normal and therapists are trained to anticipate feelings of frustration and anger is some clients. There are many methods that a therapist can use to deal with resistance in psychoanalysis, which include anticipating resistance, developing patience and understanding, building strong relationships, using confrontation strategies, and using metaphors.
Internet Editor’s Note: Ms. Sara Austin and Mr. Benjamin Johnson recently published an article in the Bulletin on “Stop, Drop, and Roll (With It): Addressing “Realistic” Resistance With Internalizing Clients.” You can access a free copy of their journal article here.
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.
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.