Author: Allen Berger/Thursday, February 5, 2009/Categories: Chemical Dependency
“The question arises as to whether psychotherapy, to be successful, must necessarily operate to lead to resistance in the client, or whether therapy can be practiced so as to eliminate, or minimize client resistance”. C.H. Patterson (2000).
If you have worked with addicts then I am certain you have confronted the so called “difficult patient” and said something like, “You don’t want to get well! Your disease is in control.”
Many well intentioned therapists and counselors have accused patients of “being resistant” and “not wanting to get well.” I have too, unfortunately. Today I look at what we label as “resistance” from a radically different and more useful point of view. I no longer think of people in these terms and because of this shift in my thinking I am a better therapist.
In this article I want to share my current understanding of resistance. Before I do, however, I think it will be useful to discuss the evolution in our understanding of resistance.
Psychoanalysis and Resistance
The concept of resistance was first discussed in Psychoanalysis. Simply stated, the process of analysis involved helping a patient work through their resistance to experience repressed memories. Here’s what Freud said:
“It is hard for the ego to direct its attention to perceptions and ideas which it has up till now made a rule of avoiding, or to acknowledge as belonging to itself impulses that are the complete opposite of those which it knows as its own.” Sigmund Freud (1926/1959).
According to Freud resistance manifested itself in five different forms: 1) Repression resistance – which is denial and avoidance; 2) Transference resistance – which is essentially projection; 3) Epinosic Gain – which occurs when one is getting a secondary gain from one’s illness; 4) Repetition Compulsion Resistance – which is acting out the unconscious; and 5) Sense of guilt or need for punishment – which is feeling unworthy of success or happiness.
Psychoanalysis employed three therapeutic processes to deal with a patient’s resistance: recollection, repetition and working through.
A Shift in Thinking
Humanistic therapists objected to the psychoanalytic deterministic view of human nature or what we can call “painting the patient dark.”
Humanistic therapists posited that a desire for resolution, growth, and wholeness existed in our psyche and that this force was constantly nudging us forward in our emotional and spiritual development. This was a major shift in the thinking of the time. It was in stark contrast to the psychoanalytic notion of a pathological resistance that was keeping us stuck and sick.
This new perspective argued that it was what was “right” about us that manifested through our symptoms. It wasn’t pathology. Being depressed or anxious or becoming an alcoholic or addict meant that something was “right” about us. A wonderful example of this can be found in Carl Jung’s letter to Bill Wilson where Dr. Jung described alcoholism as a “spiritual thirst.” Our symptoms were calling attention to our spiritual or true-self: That Ebby was ignoring his need for spirituality, growth and maturity.
So now a counselor’s or therapist’s task shifted from “removing resistance” to “unlocking potential.” This is an incredibly important change in the therapeutic process. You can imagine the different climate this would create in therapy. Family therapists provided the next important contribution to the process of therapy.
The Family Therapy Revolution
Family therapists were iconoclastic. It’s hard to imagine that just sixty years ago a therapist was violating the rules of therapy when they interviewed and treated the entire family. This out of the box thinking contributed to the next major shift in therapy. From this point of view the focus of therapy was on what was occurring between people rather than within: behavior was determined by the interactions or sequences of interactions in the family. Therefore psychological problems were understood as necessary to maintain the family’s homeostasis.
The patient was no longer the individual. It was rather the entire family. The person with the presenting problem was not the sole focus of treatment; it was the interaction of the family. The person with psychological problems was referred to as the “identified patient” or the person saying “Ouch – I have a pain in my family.” Therefore, it was necessary to interview the entire family together to see how they interacted to find a solution and understand the problem.
This redefined our understanding of the therapist’s impact on the therapy. Harry Stack Sullivan, one of the first interpersonally oriented therapists, viewed the therapist as a “participant observer.” This meant that the therapist was no longer the cool objective professional making the “immaculate perception.” Instead the therapist was understood to be actively involved in the dynamics of the family, either in a helpful way or in a harmful way. As Minuchin and Baracai (1972) stated, “The family therapist operating as a change-agent is not in the position of the ‘cool’ professional, aiding a system from outside. By his intervention he forcibly enters a system, becoming a participant member, thus inducing change from the within”.
The family therapy perspective teaches that we each have the ability to influence each other in either a positive or negative way. We are either a part of the problem or a part of the solution. If a family is not responding to the therapy – blaming the family would be harmful and make the therapist a part of the problem. Instead of blaming the family the experienced family therapist would focus on how he or she is contributing to what he or she needs to do to shift the dynamics.
The Myth of Resistance
From the family therapy perspective labeling a patient as “resistant” or “not wanting to get well” is a cop out. It is an interpersonal maneuver designed to blame the patient for the therapist’s incompetence. Family members do this to each other all the time and as therapists we label their behavior as dysfunctional. However, when we do this we justify it because we are of course making a “professional judgment.” Bullshit! A wolf in sheep’s clothing is still a wolf.
In 1961 Carl Roger’s hypothesized that “…resistance to counseling and to the counselor is not an inevitable part of therapy, nor a desirable part, but it grows primarily out of poor techniques in handling the client’s expression of his problems and feelings. Insight is an experience which is achieved and not experience which is imposed.”
We readily encourage patients to be authentic and honest. Yet many therapists do not hold themselves to this same standard. Are you willing to admit to a patient that you are incompetent? If you are, good for you! If you aren’t, you might want to take a look at what would stop you.
Here is how I currently integrate the ideas previously discussed in my current thinking: It has been helpful to know that each of us wants to grow, to mature, and complete unfinished business. This is the part of each patient that I engage in therapy. If a person is not honoring this part of themselves then this becomes the focus of our session. If I can’t reach that healthy part of a person then it is not their fault, it is mine. Carl Withaker, M.D., a pioneer in family therapy once said, “The family is responsible for their life, while the therapist is responsible for the therapy.”
I have mostly stopped labeling a patient as resistant and lacking motivation. Instead, I now face my incompetence. This has helped me become a better therapist because I focus on what I am doing that is contributing to the impasse we are experiencing in therapy. I focus on what goes on between us rather than blaming the patient. I have also discovered that discussing my dilemma openly and honestly creates a very valuable dialogue.
This new approach is responsible for opening up the door to learning how to be therapeutic. The results speak for themselves. Today I am able to help many clients that I would have failed 20 years ago.
Freud, S. (1959). Inhibitions, symptoms, and anxiety. In J. Strachey (Ed. & Trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 20, pp. 75-175). London: Hogarth Press. (Original work published in 1926).
Patterson, C. H. (2000). Resistance in psychotherapy: A Person-Centered view. In Understanding Psychotherapy: Fifty Years of Client Centered Theory and Practice. PCCS Books.
Rogers, C. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston: Houghtin Mifflln.
Minuchin, S. and Bracai, (1972). Families and family therapy. New York: Norton Books.
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