“Resistance” is a word therapists are taught that means “the client is not being compliant”, or “the client is not doing what you requested of them.” I first came up against “resistance” in my early career in relation to homework. Using Cognitive-Behavioral Therapy (CBT), the client is to be given assignments to do at home between sessions to reinforce the learning that takes place in the session. I found that the sorts of homework that went along with much of CBT include worksheets, handouts, reading material, journaling, and what felt a lot like the busy-work I remembered from high school. I hated giving homework, but did feel that reinforcement of a theory was useful. When clients would return, having not returned or done the assignment, this was thought of as the client being willful or disengaged. I never like that as it never seemed to fit. The client was choosing to come to therapy. They were also choosing not to do the homework. Who was I to enforce these things? There’s certainly no failing grades in therapy; participation alone nets you a pass. I changed the kinds of homework I gave to be less intrusive. I had them seek out real-world examples of the teaching and tell me what they’d observed. There were sometimes memory issues that led to the homework not being remembered or recorded, and some people just didn’t like being given assignments. So I stopped doing that. In fact, I started pulling away from practicing CBT because of the homework aspect. But were my clients “resistant”? Did they not WANT to change? No.
So what is this “resistance” thing? What if it’s a myth? What if every client who is choosing to come to, and pay for, treatment is compliant with treatment and that dirty word is something to do with the therapist instead? I think it breaks down to 2 concepts: The client has to be ready for change, and the therapist and client have to be in alignment.
Readiness – I believe there is a readiness to therapy. I once worked with a man whose son had died 2 days before I met with him and he wanted to be over grieving, and another man whose best friend had died within the week and wanted to be over the visual trauma of seeing the event occur. These are extreme examples as most people do not seek out treatment that quickly. What timing is right for a given issue is absolutely personal and I believe that: If the goal of therapy is to reduce or eliminate pain and suffering, then the application of treatments should be applied as soon as possible. Therefore, I was happy to work with both of those given examples right after the events had occurred. But is immediate relief right for everyone? Certainly not. Some people need time to think, to process, to use their natural resources and social supports. Some people will not recognize that they need treatment until a significant amount of time has past. Some people will have no symptoms of discomfort for a long period of time until it is activated by another event (as in delayed-onset trauma). And all of those are perfectly normal responses. So, if timing is individual, how do we know the client is ready? They’ve come to your office.
Alignment – If the client and therapist are not aligned, or perceived by the client to be aligned, there will be hesitation. There is a perception that the therapist does some kind of magic to make the client feel or think in a certain way. Of course, that’s not so, though it might be nice if it were so, but we do apply techniques to shift thoughts or feelings. If the therapist is thought to hold a kind of magical power, the client can be uneasy in wondering if the therapist has their best interests at heart, or even understands them. Clients often probe for understanding, wanting to know if the therapist thinks like they do or has had similar life experiences. Therapists dread these personal questions because we know that there is an essence to life that is the basis from which we treat which has nothing to do with if we’re also married or in recovery, for example, because each person’s experience of those events is unique. So how do we get aligned with our client? I believe it breaks down to two steps: safety and agreement.
- Safety – Creating an atmosphere of safety can take time. A client has to know you enough to trust that you will keep their secrets, that you will have the skills and knowledge to carry them through their issue with a minimum of suffering, and that you will be there on the other side to process any feelings that come up. Whether the client is new to therapy or has been in therapy for years, these issues can carry different weights, but will likely be present. The part of the therapist begins with your online presence and carries through to the set up of the office, every person they interact with on the phone or in the office, and how the therapist carries themselves.
- Brief Therapy – I do short-term therapies, so I have very little time to build a trusting relationship. However, I am an expert in my field and I carry myself with that confidence; it’s in everything I do and say with a client: I don’t take a call in my car or when I can’t devote time to the call; I talk about success and set a client up to succeed; I speak in depth about privacy and ethics; and I tell clients how my type of therapy is different from what they’ve experienced and what they can expect from me.
- Continuing Safety – During the course of therapy, I continue to point out safety features to the client. For instance, if we are doing an eyes-closed hypnotic induction, I remind them that “if, at any time, you are uncomfortable and choose to stop participating, you can simply open your eyes and choose to stop” or “notice how you are aware of your body and can move your body. Notice how you are aware of touch and can feel the touch of your clothes on your body. If anyone were to touch your body, you would certainly be aware of that as well and could choose to stop participating if you so desired.” With the concept of “resistance”, the therapist runs the session. I do believe in the medical model of the therapist being the expert and the client being the patient who comes for help with an issue, but even under the medical model, if the client is not feeling that I am performing a service for them (not to them), we are out of alignment and they may feel unsafe. More often, therapists are pulling away from the medical model and having the client lead the session. It is, then, even more important for those therapists to remove “resistance” and improve the notion of safety.
- Agreement – Now that the client feels safe with you and feels you will be a qualified professional acting in their best interest, do they feel that you understand what their interest are? After all, a therapist may feel that a client needs to quit drinking alcohol, but the client themselves may not feel that alcohol has become a problem, and there is no reason to quit. Are we meeting the client where they are? Often, we’re not doing a good job of that, or we assume we are doing a good job and fail to check in.
- Checking In – It is likely that every 6th sentence I use in treatment is a check in. It is so vital that I am aligned with my client, that I will check in as often as I need to in order to prove that to both of us in the room. Being off by a single syllable will take us down the wrong path and I have just wasted my client’s time, they they are paying me to use wisely. I respect and revere the therapeutic relationship so much that I need to check in and use their their time as wisely as it can be done. Additionally, using a poor metaphor or confusing your client with the wrong technique can cause them to lose faith in you as their practitioner, or in therapy in general. That lack of faith can become a lack of hope for someone mired in pain. Instead, check in until you’re sure you know the right tool for the job.
Motivational Interviewing – The key to alignment and checking for readiness is Motivational Interviewing (MI). This wonderful and easy-to-use technique can be learned in a number of training courses and is how to apply carefully-worded questions to compare the client’s goals to their previous patterns of behavior. For instance, in working with a teenager who was brought in against his will by his caregivers, you can ask things like “I get that you don’t want to be here today. But, since you’re stuck here for the next hour anyway, maybe we could use that time to fix something at home or at school that’s not going great. What’s something that would be better if it were different at school or home?”
MI does not overcome readiness, necessarily, but it can administer a crack that lets the client see that there could be change, and that alone may get them closer to being ready for change. MI can also be used to nudge a client in a direction. For instance, you might ask the client who is seemingly unaware of the problems alcohol consumption is causing in their life things like “You’ve had 2 DUIs in the past month. Is that effecting things with work or your relationships?” “I know you have been saving up for a trip; is the cost of fixing the DUIs impacting that?” If you get a positive answer to either question, you can allow the client to see that their behavior (drinking and driving, in this example) is not aligned with their goals. Additional use of MI can allow the client to be closer to readiness for change as they see that the behavior is problematic to reaching their goals.
When you are discussing your client’s goals and not your goals for them, and you understand clearly both the problem(s) and the goal, you can then assist. Before that time, however, you cannot assist as you cannot be in alignment. I’ve heard it said that therapy is like golf: You have to know where the ball is and where the hole is before you take a swing.