Monday, August 29, 2011

Resistance is Relational

"Resistance" is a common issue in psychotherapy - that moment when a client metaphorically digs in his or her heels, refusing either the direction of treatment, or change more generally. It can be confusing and exasperating for therapists. Haven't we all said at one point or another: "Why is this client even coming to therapy if s/he's not going to do anything?"

In the past, resistance was understood to be a problem with the client - a function of the client's unconscious defenses, and/or "secondary gains." More recently, however, the field has started to understand resistance a bit differently. Motivational Interviewing is an approach largely based on such a reinterpretation of resistance. Its creators, Miller and Rollnick (2002) define resistance as something that occurs in the relationship between therapist and client when there is a mismatch between the therapist's approach and the client's readiness for change.

Motivational Interviewing assumes that change is difficult, and that ambivalence (feeling torn) is a normal part of the process. Resistance becomes an issue when the therapist doesn't adequately address this ambivalence, and instead jumps ahead to change. It often looks something like this:
  • Client: "I'm not going to the party - I just feel like staying home." (expressing intention not to change)
  • Therapist: "That's the depression talking. You'll start feeling better if you get out and socialize more." (assuming the expert role)
  • Client: "I don't feel better when I'm trying to be social - I feel worse because it's more obvious what a loser I am!" (arguing the disadvantages of change)
  • Therapist: "Maybe you'll find out that other people have similar worries - that you're not the only one" (arguing advantages of change)
  • Client: "Whatever." (shutting down)
As this dialogue shows, therapists often respond to client statements against change by arguing more strongly in favor of change. Consequently, the client then feels compelled to argue the anti-change side of the ambivalence just as strongly - in the process, convincing him/herself not to change.

We can conclude from this phenomenon that directly confronting resistance only serves to strengthen the resistance. Instead, Motivational Interviewing suggests "rolling with resistance" - reframing or shifting it to create momentum toward change (think judo). In rolling with resistance, the therapist avoids arguing in favor of change or trying to impose new ideas on the client. Instead, the client is invited to consider new perspectives, but is given responsibility for generating answers or solutions to their problems (based on the assumption that he or she is knowledgeable about the problem and what may help).

Resistance, when it occurs, is a signal to the therapist that he or she needs to change tack and respond differently. It may be that the therapist's response doesn't match the client's stage of change (the right intervention at the wrong time), or that the therapist is responding in ways that tend to trigger resistance (the wrong intervention). Responses that invite resistance include: directly arguing in favor of change, taking on an "expert" or paternalistic role, acting rushed, and criticizing, shaming, blaming, or labeling the client.

So if those are the responses to avoid, what are effective responses to resistance? The general principle is to respond to resistance with nonresistance. Below are examples of responses to the client statement about ("I'm not going to the party - I just feel like staying home"):
  • Direct reflection of the client's statement   "You feel more comfortable staying home"
  • Amplified reflection of the client's statement (slightly exaggerate the client's stated thought/feeling, which can cause them to back off a bit, perhaps expressing the other side of the ambivalence - i.e., the pro-change side)     "You just feel like staying home. In fact, why leave the house at all?"
  • Double-sided reflection (acknowledging the anti-change side of ambivalence the client has just expressed, and adding to it the pro-change side of ambivalence based on things the client has said at other times - i.e., not just your own opinion or agenda)    "You'd prefer to just stay home, but you also feel lonely at home sometimes, and have wanted to make friends."
  • Shifting focus away from whatever seems to be the barrier    "You don't have to go to the party; maybe you'd rather just hang out with one or two people."
  • Reframing (acknowledging the validity of the facts behind the client's statement, but offering an alternate interpretation)   "Depression makes the idea of going to a party feel daunting, but once you're there you know you'll feel better."
  • Agreeing...with a twist (reflection, followed by reframing)   "You really feel like staying home - but sometimes you can push through that feeling."
  • Emphasizing personal choice and control     "It's up to you whether to go to the party."
  • Coming alongside (the therapist makes an anti-change statement, which may cause the client to argue the alternate - pro-change - side of the ambivalence)    "You're right. If you feel like staying home, you shouldn't go."
How do you "roll with resistance?" When do you find it hardest to do so?

For a fuller discussion, see Miller and Rollnick (2002) Motivational Interviewing, Second Edition: Preparing People for Change

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