Psychological resistance

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Psychological resistance, also known as psychological resistance to change, is the phenomenon often encountered in clinical practice in which patients either directly or indirectly exhibit paradoxical opposing behaviors in presumably a clinically initiated push and pull of a change process. In other words, the concept of psychological resistance is that patients are likely to resist physician suggestions to change behavior or accept certain treatments regardless of whether that change will improve their condition. [1] It impedes the development of authentic, reciprocally nurturing experiences in a clinical setting. Psychological resistance can manifest in various ways, such as denying the existence or severity of a problem, rationalizing or minimizing one's responsibility for it, rejecting or distrusting the therapist's or consultant's suggestions, withholding or distorting information, or sabotaging the treatment process. [2] It is established that the common source of resistances and defenses is shame. [3] This and similar negative attitudes may be the result of social stigmatization of a particular condition, such as psychological resistance towards insulin treatment of diabetes. [4]

Contents

Examples of psychological resistance may include perfectionism, criticizing, disrespectful attitude, being self-critical, preoccupation with appearance, social withdrawal, need to be seen as independent and invulnerable, or an inability to accept compliments or constructive criticism. [3] Resistance can be very high, such as inducing conflict, or low such as conceding to everything. In order to fully understand psychological resistance one must understand its roots.

Psychoanalytic origins

The discovery of resistance (German : Widerstand) was central to Sigmund Freud's theory of psychoanalysis: for Freud, the theory of repression is the cornerstone on which the whole structure of psychoanalysis rests, and all his accounts of its discovery "are alike in emphasizing the fact that the concept of repression was inevitably suggested by the clinical phenomenon of resistance". [5] Freud's theory established psychological resistance as a passive, unconscious process. It inherently places blame on patients for the inability to accept proper treatment as an avoidance measure. [6] It failed to consider patients having deliberate, conscious concerns relating to treatment that is driving their psychological resistance. This is known as realistic resistance. [6]

Contemporary understandings

Realistic resistance

Realistic resistance is the understanding of the conscious and deliberate aspect of psychological resistance in therapeutic treatment. "Realistic resistance refers to clients' conscious, deliberate opposition to therapeutic initiatives that they fail to understand or accept". [6] There are several things an individual may disagree with in the therapy setting that can lead to realistic psychological resistance, such as general therapeutic technique or words and phrases utilized by a physician or therapist. [6]

Realistic resistance can be identified by behavioral markers. Some examples include avoidance of certain lines of questioning, outright refusal to cooperate, and sudden loss of effort and interest during sessions. [6] Realistic resistance can have negative consequences for the therapeutic process and outcome, such as reducing client engagement, motivation, and adherence to treatment [7] because of avoidance of certain lines of questioning, outright refusal to cooperate, and sudden loss of effort and interest during sessions. Therefore, it is important for therapists to identify the above mentioned behavioral markers to address realistic resistance in a collaborative and empathic manner. [7]

Strategies to address realistic resistance

To manage realistic resistance, it is important to ensure that the client is kept in the loop which can be done by explaining the rationale and evidence for the therapeutic approach and techniques. This could be achieved by inviting feedback and questions from the client. [7] Additionally, therapists often use motivational interviewing techniques to elicit the client's reasons for change, explore ambivalence, and enhance self-efficacy. [7] Adapting the language and style of communication to match the client's preferences, needs, and level of understanding as well as involving the client in setting goals and choosing interventions, and offering choices and alternatives when possible also helps validate the client's feelings, thereby lowering the resistance. These strategies help in reframing resistance as a sign of strength, and highlighting the client's autonomy and responsibility for change. [7]

Interpersonal resistance

Resistance is based on instinctively autonomous ways of reacting in which clients both reveal and keep hidden aspects of themselves from the therapist or another person. These behaviors occur mostly during therapy, in interaction with the therapist. It is a way of avoiding and yet expressing unacceptable drives, feelings, fantasies, and behavior patterns.

Examples of causes of resistance include: resistance to the recognition of feelings, fantasies, and motives; resistance to revealing feelings toward the therapist; resistance as a way of demonstrating self-sufficiency; resistance as clients' reluctance to change their behavior outside the therapy room; resistance as a consequence of failure of empathy on the part of the therapist. [8]

Examples of the expression of resistance are canceling or rescheduling appointments, avoiding consideration of identified themes, forgetting to complete homework assignments, and the like. This will make it more difficult for the therapist to work with the client, but it will also provide him with information about the client.

Strategies to manage Interpersonal Resistance

Some strategies that can help therapists deal with interpersonal resistance include exploring the meaning and function of the resistance for the client, and how it relates to their interpersonal patterns and goals. Providing feedback and interpretation about the resistance and its impact on the therapy relationship, and inviting the client's response and perspective. Using empathy and validation to acknowledge the client's feelings and concerns, and to convey understanding and acceptance. Using humor and paradox to diffuse tension and challenge the client's assumptions or behaviors in a non-threatening way. Negotiating and compromising with the client about the pace, direction, and focus of therapy, and respecting their autonomy and preferences. [9] By using these strategies, therapists can reduce interpersonal resistance and enhance the therapeutic relationship with their clients, which can facilitate change and improve outcomes.

State and trait resistance (situational and characteristic)

Resistance is an automatic and unconscious process. According to Van Denburg and Kiesler, [10] it can be either for a certain period of time (state resistance) but it can also be a manifestation of more longstanding traits or character (trait resistance).

Trait resistance refers to the stable tendency to resist change or challenge, regardless of the situation or the content of therapy. [11] Both state and trait resistance can interfere with the therapeutic alliance, the client's engagement, and the client's progress. [12]

In psychotherapy, state resistance can occur at a certain moment, when an anxiety-provoking experience is triggered. Trait resistance, on the other hand, repeatedly occurs during sessions and interferes with the task of therapy. The client shows a pattern of off-task behaviors that makes the therapist experience some level of negative emotion and cognition against the client. Therefore the maladaptive pattern of interpersonal behavior and the therapist's response interfere with the task or process of therapy. This 'state resistance' is cumulative during sessions and its development can best be prevented by empathic interventions on the therapist's part. [10]

Outside therapy, trait resistance in a client is demonstrated by distinctive patterns of interpersonal behavior, which are often caused by typical patterns of communication with significant others, like family, friends, and partners.

Strategies to manage State and Trait Resistance

Some strategies that can help therapists cope with state and trait resistance include matching the therapeutic approach and techniques to the client's level of resistance, readiness for change, and preferred mode of coping; using cognitive restructuring techniques to challenge the client's irrational beliefs, cognitive distortions, or self-defeating thoughts that contribute to resistance; using exposure techniques to help the client face their fears, anxieties, or discomforts that underlie resistance, and using paradoxical techniques to use the client's resistance as a therapeutic tool, such as prescribing the symptom, reframing the problem, or exaggerating the consequences.

Handling resistance in psychotherapy

Nowadays many therapists work with resistance as a way to understand the client better. They emphasize the importance to work with the resistance and not against it. [8] [10] [13] This is because working against the resistance of a client can result in a counterproductive relationship with the therapist; the more attention is drawn to the resistance, the less productive the therapy. Working with the resistance provides a positive working relationship and gives the therapist information about the unconscious of the client. [13]

A therapist can use countertransference as a tool to understand the client's resistance. The feelings the client evokes in the therapist with his/her resistance will give you a hint what the resistance is about. [8] For example, a very directive client can make the therapist feel very passive. When the therapist pays attention to their passive feelings, it can make him/her understand this behavior of the client as resistance coming from fear of losing control.

It can also be useful to identify resistance with the client. This can not only work towards addressing the issue but can also allow the client to think about and discuss their resistance and the cognitive processes that underlie it. In this way, the client takes an active involvement in their therapy, which may reduce resistance in the future. It also helps the client's ability to identify their resistance in the future and respond to it.

Relevant to the question of treatment planning are research studies that have looked at resistance traits as indicators and contra-indicators for different types of interventions. Beutler, Moleiro, and Talebi reviewed 20 studies that inspected the differential effects of therapist directiveness as moderated by client resistance and found that 80% (n=16) of the studies demonstrated that directive interventions were most productive among clients who had relatively low levels of state or trait-like resistance. In contrast, nondirective interventions worked best among clients who had relatively high levels of resistance. These findings provide strong support for the value of resistance level as a predictor of treatment outcome, as well as treatment-planning. [13] In these studies cognitive behavioral therapy has been used as a prototype for directive therapy and psychodynamic, self-directed, or other relation oriented therapy have been used as a prototype for non-directive treatment.

Behavioral models of resistance

Behavior analytic and social learning models of resistance focus on the setting events, antecedents, and consequences for resistant behavior to understand the function of the behavior. [14] At least five behavioral models of resistance exist. [15] These models share many common features. [16] The most explored research model, with more than ten years of support, is the model created by Gerald Patterson for resistance in parent training. [17] [18] With supporting research, this model has even been extended to consultation. [19] [20]

Patterson's suggested intervention of 'struggle with and work through' is often contrasted as an intervention with motivational interviewing. In motivational interviewing, the therapist does not attempt to prompt the client back to the problem area but reinforces the occurrence when it comes up as opposed to 'struggling with and working through' where the therapist directly guides the client back to the problem. Behavior analytic models can accommodate both interventions, as pointed out by Cautilli and colleagues [21] depending on the function and what needs to be accomplished in the treatment.

See also

Related Research Articles

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Rational emotive behavior therapy (REBT), previously called rational therapy and rational emotive therapy, is an active-directive, philosophically and empirically based psychotherapy, the aim of which is to resolve emotional and behavioral problems and disturbances and to help people to lead happier and more fulfilling lives.

Integrative psychotherapy is the integration of elements from different schools of psychotherapy in the treatment of a client. Integrative psychotherapy may also refer to the psychotherapeutic process of integrating the personality: uniting the "affective, cognitive, behavioral, and physiological systems within a person".

Transference is a phenomenon within psychotherapy in which repetitions of old feelings, attitudes, desires, or fantasies that someone displaces are subconsciously projected onto a here-and-now person. Traditionally, it had solely concerned feelings from a primary relationship during childhood.

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on behaviorism's theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems.

<span class="mw-page-title-main">Psychological intervention</span>

In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.

The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client.

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice for depression.

Multitheoretical psychotherapy (MTP) is a new approach to integrative psychotherapy developed by Jeff E. Brooks-Harris and his colleagues at the University of Hawaii at Manoa. MTP is organized around five principles for integration:

  1. Intentional
  2. Multidimensional
  3. Multitheoretical
  4. Strategy-based
  5. Relational

Emotionally focused therapy and emotion-focused therapy (EFT) are a set of related approaches to psychotherapy with individuals, couples, or families. EFT approaches include elements of experiential therapy, systemic therapy, and attachment theory. EFT is usually a short-term treatment. EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment. This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors that are suited to treatment of particular problems.

<span class="mw-page-title-main">Insight-oriented psychotherapy</span>

Insight-oriented psychotherapy is a category of psychotherapies that rely on conversation between the therapist and the client. It involves developing the patient's understanding of past and present experiences, how they are related to each other and the effect they have on the patient's interpersonal relationships, emotions and symptoms. Insight-oriented psychotherapy can be an intensive process, wherein the client must spend multiple days per week with the therapist.

Clinical behavior analysis is the clinical application of behavior analysis (ABA). CBA represents a movement in behavior therapy away from methodological behaviorism and back toward radical behaviorism and the use of functional analytic models of verbal behavior—particularly, relational frame theory (RFT).

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences — even when doing so creates harm in the long run. The process of EA is thought to be maintained through negative reinforcement — that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the avoidance behavior will persist. Importantly, the current conceptualization of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings is thought to be linked to a wide range of problems.

Paradox psychology is a counter-intuitive approach that is primarily geared toward addressing treatment resistance. The method of paradoxical interventions (pdxi) is more focused, rapid, and effective than Motivational Interviewing. In addressing resistance, the method seeks to influence the clients' underlying attitude and perception by providing laser beam attention on strengthening the attachment-alliance. This is counter-intuitive to traditional methods since change is usually directed toward various aspects of behavior, emotions, and thinking. As it turns out, the better therapy is able to strengthen the alliance, the more these aspects of behavior will change.

Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.

References

  1. ↑ Jost, John T. (2015). "Resistance to Change: A Social Psychological Perspective". Social Research. 82 (3): 607–636. ISSN   0037-783X. JSTOR   44282124.
  2. ↑ Serpell, Lucy (2006). "Robert L. Leahy (Ed.) (2003). Overcoming resistance in cognitive therapy. Guilford: New York, pp. 309, ISBN 1572309369". European Eating Disorders Review. 15 (1): 78–79. doi:10.1002/erv.756. ISSN   1072-4133.
  3. 1 2 Edward Teyber; Faith Teyber (2010). Interpersonal Process in Therapy: An Integrative Model. Cengage Learning. pp. 136–137. ISBN   978-0-495-60420-4.
  4. ↑ Petrak, Frank; Stridde, Elmar; Leverkus, Friedhelm; Crispin, Alexander A.; Forst, Thomas; Pfützner, Andreas (2007-09-01). "Development and Validation of a New Measure to Evaluate Psychological Resistance to Insulin Treatment". Diabetes Care. 30 (9): 2199–2204. doi:10.2337/dc06-2042. ISSN   0149-5992. PMID   17575092.
  5. ↑ Angela Richards, "Editor's Note", in Sigmund Freud, On Metapsychology (Middlesex 1987), p. 141-2.
  6. 1 2 3 4 5 "Addressing and Managing Resistance with Internalizing Clients | Society for the Advancement of Psychotherapy". societyforpsychotherapy.org. Retrieved 2022-04-16.
  7. 1 2 3 4 5 Portis, Mary (September 1998). "Stop, Drop, & Roll: A Lifesaving Physical Education Lesson". Strategies. 12 (1): 11–12. doi:10.1080/08924562.1998.10591364. ISSN   0892-4562.
  8. 1 2 3 Messer, S.B. (2002). "A Psychodynamic Perspective on Resistance in Psychotherapy: Vive la Résistance". Journal of Clinical Psychology. 58 (2): 157–163. doi:10.1002/jclp.1139. PMID   11793328.
  9. ↑ "Countertransference and the Therapist's Experiential World", Countertransference and the Therapist's Inner Experience, Routledge, pp. 83–104, 2007-02-15, doi:10.4324/9780203936979-7, ISBN   978-0-429-24127-7 , retrieved 2023-07-30
  10. 1 2 3 Van Denburg, T.F.; Kiesler, D.J. (2002). "An Interpersonal Communication Perspective on Resistance in Psychotherapy". Journal of Clinical Psychology. 58 (2): 195–205. doi:10.1002/jclp.1143. PMID   11793332.
  11. ↑ Beutler, Larry E.; Edwards, Christopher; Someah, Kathleen (2018-10-18). "Adapting psychotherapy to patient reactance level: A meta-analytic review". Journal of Clinical Psychology. 74 (11): 1952–1963. doi:10.1002/jclp.22682. ISSN   0021-9762. PMID   30334254. S2CID   52985820.
  12. ↑ Beutler, Larry E.; Harwood, T. Mark (February 2000). Prescriptive Psychotherapy. Oxford University Press. doi:10.1093/med:psych/9780195136692.001.0001. ISBN   978-0-19-513669-2.
  13. 1 2 3 Beutler, L.E.; Moleiro, C.; Talebi, H. (2002). "Resistance in psychotherapy: What conclusions are supported by research". Journal of Clinical Psychology. 58 (2): 207–217. doi:10.1002/jclp.1144. PMID   11793333.
  14. ↑ Cautilli, J. D., & Santilli-Connor, L. (2000) "Assisting the Client/Consultee to Do What is Needed: A Functional Analysis of Resistance and other Forms of Avoidance". The Behavior Analyst Today, 1(3), pp. 37-42.
  15. ↑ Cautilli, J.D., Riley-Tillman, T.C., Axelrod, S., & Hineline, P.N. (2005). "Current Behavioral Models of Client and Consultee Resistance: A Critical Review". International Journal of Behavioral Consultation and Therapy, 1 (2), 147 –154.
  16. ↑ Cautilli, J.D., Riley-Tillman, T.C., Axelrod, S., & Hineline, P.N. (2005). "Current Behavioral Models of Client and Consultee Resistance: A Critical Review". International Journal of Behavioral Consultation and Therapy Archived 2013-09-27 at the Wayback Machine , 1 (2), pp. 147–154.
  17. ↑ Patterson, G. R. & Chamberlain, P. (1994). "A functional analysis of resistance during parent training". Clinical Psychology: Science and Practice, 1(1), pp. 53-70.
  18. ↑ Patterson, G. R. & Forgatch, M.S. (1985). "Therapist behavior as a determinant for client noncompliance: A paradox for the behavior modifier". Journal of Consulting and Clinical Psychology, 53(6), pp. 846-851.
  19. ↑ Joseph Cautilli, T. Chris Tillman, Saul Axelrod and Phil Hineline (2006). "Brief Report: An Experimental Analogue of Consultee "Resistance" Effects on the Consultant's Therapeutic Behavior". The Behavior Analyst Today, 7 (3), pp. 351-365.
  20. ↑ Joseph Cautilli, T. Chris Tillman, Saul Axelrod, Halina Dziewolska, Philip Hineline (2006). "Resistance Is Not Futile: An experimental analogue of the effects of consultee "resistance" on the consultant's therapeutic behavior in the consultation process: A replication and extension". International Journal of Behavioral Consultation and Therapy Archived 2013-09-27 at the Wayback Machine , 2 (3), pp. 362-374.
  21. ↑ Cautilli, J. D., & Santilli-Connor, L. (2000). "Assisting the Client/Consultee to Do What is Needed: A Functional Analysis of Resistance and other Forms of Avoidance". The Behavior Analyst Today, 1 (3), pp. 37-42.
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