Understanding Client Resistance

8/12/2019 Understanding Client Resistance

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COGNITIVE AND BEHAVIORAL PRACTICE 1 4 7 - 6 9 , 1994

Understanding Client ResistanceMethods for Enhancing Mot ivat ionto Change

ory E Newmanenter for ogn i tive TherapyUn ivers ity of P ennsylvania

C l i e n t s s o m e t i m e s w o r k i n o p p o s i t i o n t o t h e i r th e r a p i s ts , a p h e n o m e n o n k n o w na s r e si st a nc e . S u c h b e h a v i o r i s n o t s i m p l y a n i m p e d i m e n t to t r e a t m e n t , b u t a l s oa p o t e n t i a l l y r i c h s o u r c e o f i n f o r m a t i o n a b o u t e a c h c l i e n t. T h i s i n f o r m a t i o n c a nb e a s s e s s e d a n d u t i l i z e d to s t r e n g t h e n t h e t h e r a p e u t i c r e l a t io n s h i p , h e l p t h e t h e r -a p i s t b e t t e r u n d e r s t a n d t h e i d e o g r a p h i c o b s t a c le s t o c h a n g e , a n d d e v i s e in t e r v e n -t i o n s t h a t m a y m o t i v a t e t h e c l i e n t t o w a r d t h e r a p e u t i c a c t i v i t y a n d g r o w t h . C l i n i c a lv i g n e t t e s o f t h r e e r e s i s t a n t c l i e n ts a r e p r e s e n t e d , i l l u s t r a ti n g b o t h t h e c o m m o n a l -t i e s a n d u n i q u e f a c to r s th a t l e a d t o r e s i s ta n c e a c r o s s ca s es . E i g h t i m p o r t a n t a s s es s -m e n t q u e s t i o n s a n d 10 s u g g e s te d i n t e r v e n t io n s a r e l i s t e d a n d d i s c u s s e d in d e t a i l .T h e p r a c t i c a l a p p l i c a t i o n s o f th e s e m e t h o d s i n e a c h o f t h e t h r e e c a s e s t u d ie s s h e dl i g h t o n h o w t h e r a p i s t s c a n e n h a n c e t h e i r r e s i s t a n t c l ie n t s ' m o t i v a t i o n f o r t h e r -a p e u t i c c h a n g e .W h e n c l ie n t s c o m e t o t h e r a p y f o r h e l p i n d e a l i n g w i t h t h e i r p r o b l e m s i n l iv i n g ,

i t is o f te n c l e a r t h a t t h e y a r e l o o k i n g f o r r e l i e f f r o m t h e i r a c u t e a f fe c ti v e s y m p -t o m s . F r e q u e n t l y , t h e s e c li e n t s a r e c o n s i d e r a b l y le s s c e r t a i n a b o u t w h e t h e r t h e ya r e w i l l i n g t o c h a n g e t h e i r l o n g s t a n d i n g p a t t e r n s o f f u n c t i o n i n g . T h e r e f o r e , i ti s c o m m o n f o r c li e n t s t o fa i l t o c o l l a b o r a t e o r c o o p e r a t e o p t i m a l l y w i t h t h e t h e r -a p i s t a n d t h e t r e a t m e n t p l a n .

T h i s c a n c a u s e t h e r a p i s t s c o n s i d e r a b l e c o n s t e r n a t i o n ; a f t e r a ll , i f w e ' r e u s i n go u r c o n c e r t e d e n e r g y , g o o d w i ll , a n d e x p e r t i s e to h e l p t h e c l i e n t s o v e r c o m e t h e i r

47 1077-7229/94/047-06951.00/0Copyright 1994 by Association for Advancement of Behavior TherapyAll rights O reproduction in any form reserved.


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problems, why would they work in opposition to us? Furthermore, what arewe to do about this problem?

Therapeutic change is difficult and often somewhat frightening; therefore,it is reasonable to expect ma ny clients to evidence occasional signs of resistancewith treatment plans that attempt to induce such change. Indeed, traditionalpsychodynamic therapists have viewed resistance as part a nd parcel of the ther-apeutic process (Milma n & Goldman, 1987; Wachtel, 1982)--the result of theclients' ongoing conflict between their consciously professed desires to changeand the ir unconscious fears abou t losing their safe groun d and sense of identity(Fenichel, 1941; Glover, 1955; Greenson, 1968). From this theoret ical point ofview, psychological symptoms serve a compensatory or defensive purpose forthe client (Basch, 1982). Therefore, at some level of awareness, the cl ient under-stands that he or she becomes even more vulnerable if the protective symp-toms are relinquished.

Rather than viewing client resistance merely as an annoying impedimentto the real work of therapy, cognitive-behavioral therapists would do well tolook at client resistance as imp ortant info rmat ion in its own right -- info rmat ionthat can shape the case formulation, increase the therapist's accurate empathy,and suggest interventions that are tailor -made for the client. Armed with a con-ceptual u nders tand ing of clients' reluctance to change, cognitive-behavioral ther-apists are in a better position to implement the active, systematic, structured,and testable methods that are the strengths of their orientation.

Additionally, therapists must examine resistance not only as a client vari-able, but also as a funct ion of the therapist's approach (e.g., Is the therapist actingin a disengaged manner?), as well as a by-product of contextual factors (e.g.,Does the client have a spouse who is actively sabotaging the client's progress?)(Golden, 1989).

I l l u s t r a t i o n s o f C l i e n t R e s i s t a n c e

The following are b rief case illustrations that highlight various aspects of clientresistance. These cases will also be discussed in detail later in the paper in theassessment and intervention sections.

Bart is a 43-year-old car salesman who is in therapy in the af termath of hisdivorce. His therapist attempts to educate Bart about the cognitive factors in-volved in negative emot ions such as dysphoria, anger, a nd guilt by encouraginghim to purchase the book FeelingGood Burns , 1980). Week after week, Bart reportsthat he has forgotten to buy the book, and the therapist politely explains thatalthough the book isn't necessary for trea tment to proceed, it certainly will helpto facilitate progress. Therefore , it would be in Bart's best interest to get a copyof the book as soon as possible. Finally, Bar t arrives at a session and announcesthat he has bought Feeling Good. The therapist, pleased to hear this, asks Whathave you read so far? Shall we discuss some of your reactions to what you've


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U N D E R S T N D I N G R E S I S T N C E 9

r e a d a s p a r t o f o u r a g e n d a f o r to d a y ' s s es s io n ? " B a r t s m u g l y r e p li e s, " N o , t h a twon ' t wor k a t a l l . I t h r ew t he book i n t he t r a s h a s s oon a s I go t hom e . '

S a b r i n a i s a 4 0 y e a r - o l d , m a r r i e d c o m p u t e r p r o g r a m m e r w h o h a s e n t e r e dt h e r a p y f o r c h r o n i c d e p r e s s i o n a n d g e n e r a l i z e d a n x ie t y . E a r l y i n t r e a t m e n tS a b r i n a a n d h e r t h e r a p i s t c o n c l u d e t h a t t h e c l i e n t ' s a n x i e t y a n d d y s p h o r i a a r et r i g g e r e d m o s t o f t e n b y t h o u g h t s a b o u t f a i l i n g t o m e e t h e r o b l i g a t i o n s , s u c ha s d e a d l in e s f o r g e t t i n g o u t t h e " b u g s " i n h e r p r o g r a m s a t w o r k , k e e p i n g u p - t o -d a t e i n p a y i n g h e r b il ls , r e t u r n i n g p h o n e c a ll s, a n d k e e p i n g h e r h o u s e f r o m b e -co m i ng c l u t t e r ed and m ess y. S he r ou t i ne l y a s s um es t ha t t he r e will be ca t a s t r oph i cr e s u lt s f r o m f a l l in g b e h i n d i n t h e s e ta s ks , y e t a t t h e s a m e t i m e s h e m i n i m i z e st h e p o t e n t i a l p o s i ti v e e ff e c ts o f c h a n g i n g h e r b e h a v i o r s s o a s t o c o m p l e t e t h e s et a sk s . S h e c h a s ti s es t h e t h e r a p i s t f o r sh o w i n g o p t i m i s m a n d g i v i n g e n c o u r a g e -m en t (e . g ., "O h , p l ea s e You can ' t be s e r i ous I t 's a hope l e s s s i t ua t i on and t ha t ' st h a t . W h a t ' s t h e p o i n t o f d o i n g a n y t h i n g d i f f e r e n t ? I t n e v e r w o r k s o u t a n y w a y " ) ,a n d l a m e n t s t h e f a c t th a t s h e is n 't g e t t in g a n y t h i n g o u t o f t h i s " M i s t e r R o g e r stherapy."

M i t c h is a 2 6 - y e a r- o l d l a w s t u d e n t w h o p r e s e n t s w i t h s e v e re d e p r e s s i o n a n dpan i c a t t a cks. Af t e r 20 s e ss ions o f con j o i n t cogn i t i ve - behav i o ra l t he r apy and pha r -m a c o t h e r a p y , M i t c h h a s s h o w n s i g n if i ca n t i m p r o v e m e n t o n o b j e c t iv e m e a s u r e s .H i s B e c k D e p r e s s i o n I n v e n t o r y (B D I : B e c k, W a r d , M e n d e l s o n , M o c k , & E r-b a u g h , 1 96 1) a n d B e c k A n x i e t y I n v e n t o r y ( B A I : B e c k , E p s t e i n , B r o w n , & S t e e r,1 9 8 8 ) s c o r e s h a v e d e c r e a s e d m a r k e d l y ( i n d i c a t i n g r e d u c e d s y m p t o m a t o l o g y ) ,h e i s s o c ia l ly m o r e a c ti v e, a n d h e is n o l o n g e r m i s s i n g c l as s es a n d a s s i g n m e n td e a d l i n e s d u e t o h y p e r s o m n i a a n d a n e r g i a . N e v e r t h e l e s s , M i t c h c o n t i n u e s t op r e s e n t wi t h s ub j ec t i ve s igns o f d i s tr e s s , s t a t i ng t ha t " I know t ha t ev e r y t h i ngi s g o in g t o fa ll a p a r t i n m y l i fe a t a n y t i m e " a n d " I t h i n k m y p r o b l e m s a r e a llb i o lo g i ca l . I 'm d o o m e d t o a lw a y s h a v e d e p r e s s i o n a n d a n x i e t y " E a c h t i m e t h et h e r a p i s t a t t e m p t s t o p o i n t o u t t h e c l ie n t' s o b j e c ti v e p r o g r e s s , M i t c h r e s p o n d si n c r e d u lo u s l y , a n d c o n t i n u a l l y a s k s t h e t h e r a p i s t t o j u s t i f y h is p o s i t i o n , w h e r e -up on M i t ch d i s m i s se s it anyway. T he t he r ap i s t beg i ns t o f ind wor k i ng wi t h Mi t c ht o b e t ir e s o m e , r e p e t i ti v e , a n d f r u s t r a t in g , a n d h a s t o w o r k v e r y h a r d t o k e e pt hes e f ee l i ngs i n check .

I n e ach o f t he ca s e s above , t he c l i en t s wo r k i n op pos i t i on t o t he t he r ap i s t ,a n d t h e y d o s o f o r s e e m i n g l y u n k n o w n o r " ir r a ti o n a l " r e a s o n s . F u r t h e r , t h e i ra c t i o n s d o n o t e f f e c t a n y a p p a r e n t b e n e f i t fo r th e m s e l v e s , a n d t h e r e f o r e c o m ea c r o ss a s g r a t u i t o u s l y s e l f- d e fe a ti n g . T h e r e is o f te n t h e t e m p t a t i o n o n t h e p a r to f th e r a p i s t s t o e x p l a i n t h i s o c c u r r e n c e b y s a y i n g t h a t " t h e c l i e n t w o u l d r a t h e rs u f f e r t h a n g e t w e l l " " th e c l i e n t d o e s n o t r e a l l y w a n t t o c h a n g e " o r " t h e c l i e n tis n o t ' r e a d y ' f o r t h e r a p y " ( c o m m e n t s t h a t t h e a u t h o r h a s c a u g h t h i m s e l f m u t -t e r i n g u n d e r h is b r e a t h o n m o r e t h a n o n e o c c a s io n ) . A t b e st , s u c h p a t e x p l a n a -t i o n s a r e g r o s sl y o v e r s i m p l if i e d f o r m u l a t i o n s o f t h e p r o b l e m , a n d d o n o t s h e dany ap p r ec i ab l e l i gh t on t he c l ien t s ' be l ie f s , l e a r n i ng h i s t o r ie s , an d m o t i va t i onst h a t m i g h t a c c o u n t f o r t h e i r p a r t i c u l a r f o r m o f r e s is ta n c e . A t w o r s t, s u c h v i ew s


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p r e v e n t t h e r a p i s t s f r o m t a k i n g a d i s p a s s i o n a te l o o k a t t h e i r o w n c o n t r i b u t i o nt o th e p r o b l e m , i n c r e a s e t h e i r c o u n t e r p r o d u c t i v e f e e l i n g s t o w a r d t h e i r c li e n ts ,a n d r e i n f o rc e c l i en t s' b e l ie f s t h a t t h e r a p y i s u n h e l p f u l .

W e a s t h e r a p is t s , w h e n s t u m p e d a n d d e t e r r e d b y c li e n ts ' r e s i st a n t a t ti t u d e sa n d b e h a v i o r s , n e e d t o c u r b o u r e x a s p e r a t i o n a n d t e n d e n c y t o a r r i v e a t g e n e r a l( b u t p e r h a p s i l l - i n f o r m e d ) a t t r i b u t i o n s f o r t h e c l ie n t 's b e h a v i o r . I n s t e a d , t h e r -a p i s ts m u s t t a k e a n i d e o g r a p h i c a p p r o a c h t o th e a s s e s s m e n t o f e a c h c l ie n t' s r e -s i s t a n c e o r l o w m o t i v a t i o n t o e n g a g e i n t r e a t m e n t .

s s e s s m e n t o f C l i e n t R e s i s ta n c eS o m e g e n e r a l s i g n s o f c l i en t r e s i s t a n c e w a r r a n t d e s c r i p t i o n i n g r e a t e r d e t a i l,

f o r t h e y r e p r e s e n t c o m m o n p h e n o m e n a i n t h e t h e r a p is t ' s c li n ic a l p r a c ti c e. H o w -e v e r, a l t h o u g h t h e o v e r t b e h a v i o r m a y l o o k S i m i l a r a c r o ss c a s es , i t is v i ta l t o e x -a m i n e t h e u n i q u e e t i o lo g i c a n d m a i n t a i n i n g f a c t o r s f o r e a c h c li en t . F o r e x a m p l e ,i t i s o n l y m i l d l y i n s t r u c t iv e t o s a y t h a t a c l ie n t n e g l e c t e d t o d o a h o m e w o r k a s -s i g n m e n t b e c a u s e h e o r s h e w a s a f r a id a n d l a c k i n g in c o n f i de n c e . I t i s f a r m o r ei n f o r m a t i v e t o b e a b l e t o d e t e r m i n e s p e ci fi c al ly w h a t w a s f r i g h t e n i n g f o r th ec l ie n t , a n d p r e c i s e l y w h a t a s p e c t s o f t h e a s s i g n m e n t h e o r s h e b e li e v e d w e r e b e -y o n d h i s o r h e r c a p ac it y . T h i s i n v o lv e s a n e x a m i n a t i o n o f h o w s u c h f e a rs a n dl o w s e l f - c o n f id e n c e d e v e l o p e d , a n d h o w t h e c l i en t 's r e l a t e d c o g n i t iv e , a f f e c ti v e ,a n d b e h a v i o r a l s i g n s p e r s i s t in s p i t e o f s e e m i n g l y n e g a t i v e c o n s e q u e n c e s .

S u m m a r i z e d b e lo w a r e s o m e o f t h e m o r e c o m m o n , g e n e ra l f o r m s o f c li en tr e s i s t a n c e t h a t t h e r a p i s t s e n c o u n t e r , f o ll o w e d b y a s e r i es o f a s s e s s m e n t q u e s -t i o n s t h a t c a n h e l p t h e r a p i s t s t o p r o b e i n t o t h e s p e c i f i c , i d e o g r a p h i c a s p e c t s o fthe r e s i s t ance .H i g h - F r e q u e n c y F o r m s o f C l i e n t R e s i s ta n c e

A c o m m o n m a n n e r i n w h i c h c l ie n t s a r e re s i s ta n t to t r e a t m e n t i s t h e i r f a i lu r eto fo ow through w i th homework ass ignmen t s o r o t h e r a g r e e d - u p o n c o u r se s o f a c t i o nb e t w e e n s es si o ns . T h i s f o r m o f r e s i st a n c e i s e s p e c ia l ly t r o u b l e s o m e i n t h a t m a n yo p p o r t u n i t i e s f o r t h e r a p e u t i c l e a r n i n g a n d p r a c t i c e in th e n a t u r a l e n v i r o n m e n ta r e l o s t w h e n c l i e n t s n e g l e c t t o e n g a g e i n t h e i r a s s i g n m e n t s . A n u m b e r o fc o g n i t i v e - b e h a v i o ra l a u t h o r s h a v e n o t e d t h a t n e g l e c t o f h o m e w o r k i s a s so c i a t edw i t h s l ow e r r a te s o f i m p r o v e m e n t a n d p o o r e r p o s t t h e r a p y m a i n t e n a n c e ( B u r n s

A u e r b a c h , 1 99 2; B u r n s N o l e n - H o e k s e m a , 1 99 1; N e i m e y e r F e i x a s, 1 99 0;Pe r sons , Bu rns , Pe r lo f f , 1988 ; P r im ako f f , Ep s t e in , Cov i , 1989 ). U nf o r tu -n a te l y, m a n y t h e r a p i s ts a r e a p t t o a b a n d o n f o r m u l a t i n g a n d c o l l ab o r a t iv e l y a s -s i g n i n g h o m e w o r k w h e n t h e i r c l i e n t s a r e c o n t i n u a l l y r e s i s t a n t ( i n e s s e n c e , t h ec l ie n t s ' l a c k o f r e s p o n s i v i t y t o th e a s s i g n m e n t s e x t i n g u i s h e s t h e t h e r a p i s t s ' a p -p r o p r i a t e b e h a v i o r s ) . I n s t e a d , i t w o u l d b e b e n e f i c i a l t o i n v e s t i g a t e t h e c l i e n t s 'o v e r t a n d c o v e r t r e a s o n s f o r n o t d o i n g t h e i r h o m e w o r k , a n d t o c o n t i n u e t o f o r -m u l a t e a s s i g n m e n t s .


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UNDERST NDING RESIST NCE 5

A n o t h e r s i g n o f c l i en t r e s i s t a n c e i s se e n i n t h o s e c a s e s w h e r e c l i e n t s r e a c tt o th e i r o w n o b j e c t i v e i m p r o v e m e n t w i t h s k e p t i ci s m , r e l u c t a n c e t o w o r k t o w a r dindependence ( e . g . , t e rmina t i on ) , and regression ( M e i c h e n b a u m & G i l m o r e , 1 9 82 ).T h e s e a r e t h e c li e n ts w h o s e e m t o w a n t t o r e m a i n i n t r e a t m e n t l o n g e r t h a n t h et h e r a p i s t m a y b e l i e v e i t i s n e c e s s a r y o r h e l p f u l t o d o s o . T h e s e a r e a l s o t h e c l i e n tst h a t t h e r a p i s t s a l l t o o o f t e n s e e a s m e r e l y b e i n g s e l f- d e f e a ti n g a n d g l a d l y c h o o s i n gt o h o l d o n t o t h e i r d y s f u n c t i o n a l w a y s .

Y e t a n o t h e r m a n i f e s t a t i o n o f c l i en t r e s i s t a n c e i s i n high level s o f expressed emo t iontow ar d the therapis t , f r o m h o s t i l i ty t o o v e r t f l ir t a t io n . A l t h o u g h t h e r e m a y b e t i m e sw h e n s u c h cl ie n t e m o t i o n s m a y b e u n d e r s t a n d a b l e i n r e a ct io n t o m a l a d a p t i v et h e r a p i s t b e h a v i o r s t h a t p u l l f o r th e s e r es p o n s e s , t h e r e a r e m a n y c a s e s w h e ne x t r e m e l e v el s o f c li e n ts ' e m o t i o n a l i t y r e p r e s e n t t h e i r o w n c h a r a c t e r is t i c p a t t e r n s .T h e r a p i s t s w h o t r e a t c l i e n t s w h o s u f f e r f r o m b o r d e r l i n e p e r s o n a l i t y d i s o r d e r ,f o r e x a m p l e , a r e w ell a w a r e o f t hi s p h e n o m e n o n ( L a y d e n , N e w m a n , F r e e m a n ,& M ors e , 1993 ; L i ne ha n , 1993 ).

O t h e r l es s d r a m a t i c , y e t st il l p r o b l e m a t i c s i g n s o f r e s i s t a n c e i n v o l ve s u b t l ea vo i d a n ces i n s e s si o n . F o r e x a m p l e , c l i e n t s m a y s t a t e a t t h e s t a r t o f a s e s s io n t h a tt h e y h a v e n o t h i n g t o d i sc u s s to d ay , o r t h e y m a y b e p r o n e t o a n s w e r m o s t o ft h e t h e ra p i s t 's s al ie n t , p r o b i n g q u e s t io n s w i t h th e p a t a n s w e r I d o n ' t k n o w :U n d e r s t a n d i n g t h e F a c t o r s T h a t A r e U n i q u e t o E a c h C l i e n t

I n r e s p o n s e t o r e s is t a n c e , t h e r a p i s t s n e e d t o c o n s i d e r t h e f o l l o w i n g e i g h t a s -s e s s m e n t q u e s t i o n s :

(1) W h a t i s t h e f u n c t i o n o f t h e c l ien t s r e s i s ta n t b eh a v io r s ? I t i s u s e f u l t o e n g a g e t h ec l i e n ts i n a n e a r n e s t e x p l o r a t i o n o f t h e f a c t o r s t h a t m a k e i t i n th e c l i e n t' s b e s ti n te r e st t o o p p o s e t h e t h e r a p i s t a n d / o r t h e c o u r s e o f t r e a t m e n t . I n t h e c a s e o fM i t c h , t h e t h e r a p i s t n o t i c e d t h a t t h e c li e n t w o u l d s m i le a n d b e c o m e u n c h a r a c -t e ri s ti c aU y a n i m a t e d a t p r e c i s el y th o s e t i m e s w h e n h e w o u l d r e b u f f, c o n t r a d i c t,o r c h a l l e n g e t h e t h e r a p i s t. I n r e s p o n s e t o M i t c h 's n e x t s m i l e a n d e n e r g e t i c b a n t e r,t h e t h e r a p i s t a s k e d , I c o u l d n 't h e l p b u t n o t i c e th a t y o u w e r e s m i l i n g j u s t t h e n .W h a t g o e s t h r o u g h y o u r m i n d w h e n w e i n t e r a c t l ik e t h is ? M i t c h c h u c k l e d , Ig u e s s it m a k e s m e f e e l g o o d i f I c a n m a k e y o u s w e a t :

U p o n f u r t h e r d i s c u s s i o n , M i t c h a n d t h e t h e r a p i s t h y p o t h e s i z e d t h a t M i t c hf e lt m o r e i n t el li g e n t a n d w o r t h y i f h e c o u l d e n g a g e ( a n d p e r h a p s d e f e a t) t h et h e r a p i s t i n d e b a te s . B y c o n t ra s t , M i t c h f e l t w e a k a n d i g n o r a n t w h e n h e w o u l da c c e p t n e w i n f o r m a t i o n f r o m t h e t h e r a p i s t w i t h o u t q u e s t i o n . ( T h e t h e r a p i s t re -p l i ed t h a t h e w e l c o m e d t h e c l i e nt 's q u e s ti o n s a n d c h a ll e n g es , b u t a d d e d t h a tt h e r e m i g h t b e a h e a l th y m i d d l e g r o u n d b e t w e e n m e e k a c c e p t a n c e a n d f ie rc er e j e c t i o n o f a l l t h a t t h e t h e r a p i s t w o u l d s a y ).

F u r t h e r , M i t c h s t a t e d t h a t h e f el t m o r e i n c o n t r o l w h e n h e w o u l d v e r b a ll ys p a r w i t h th e t h e ra p i st . T h i s p h e n o m e n o n c al ls t o m i n d B r e h m a n d B r e h m ' s(1 98 1) r e a c t a n c e th e o ry , w h i c h h o l d s t h a t c l i e n t s a c t t o m a i n t a i n t h e i r s e n s eo f f r e e d o m . T h e i m p l i c a t i o n i s t h a t c l i en t s m a y r e a c t a d v e r s e ly to t h e p e r c e p t i o n


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52 NEWMAN

t h a t t h e i r t h e r a p i s t s a r e t r y i n g t o c o n t r o l t h e m , e v e n if t h e i r h e l p e r s s e e m b e -n i g n a n d t h e t r e a t m e n t s e e m s to m a k e s e ns e . I n t h is f r a m e w o r k , c l i e n ts w h od e f y t h e r a p i s t s a r e n o t m e r e l y s e l f - d e fe a t i n g o r g r a t u i t o u s l y o p p o s i t i o n a l , b u tr a t h e r a r e a t t e m p t i n g t o d e f e n d t h ei r a u t o n o m y ( a lb e it i n a d y s f u n c t i o n a l w ay ).

T h e r e a r e a n u m b e r o f w a y s t h a t a t h e r a p i s t c a n a n t i c i p a t e t h a t a c l ie n t w il lb e li k el y t o d e f e n d h is o r h e r a u t o n o m y v i a t h e r a p e u t i c r e s is t a nc e . O n e p r e d i c t o ris a h i s t o r y o f o p p o s i t i o n a l b e h a v i o r t o w a r d a u t h o r i t y f i g u re s (s e e a s s e ss m e n tq u e s t i o n 2 b e l o w f o r m o r e i n f o r m a t i o n o n h i st o r ic a l fa c t or s ). A n o t h e r p r e d i c t o ris a h i g h s c o r e o n p r e t h e r a p y a s s e ss m e n t m e a s u r e s s u c h a s t h e T h e r a p e u t i c R e a c -t a n c e S c a le ( D o w d , M i l n e , & W i s e , 1 98 4) . D i a g n o s t i c i n f o r m a t i o n a l s o c a n e a r -m a r k s u c h a c li en t. F o r e x a m p l e , c l ie n ts w h o m e e t D S M - I I I - R ( A P A , 1 98 7)c r i t e r i a f o r p e r s o n a l i t y d i s o r d e r s s u c h a s p a s si v e a g g re s s iv e , o b s e s s i v e - c o m p u l s i v e ,a n d a n t i s o c i a l a r e b y d e f i n i t i o n p r o n e t o b e h i g h l y in v e s t ed i n m a i n t a i n i n g c o n -t r o l o v e r t h e i r c h o i c e s a n d b e h a v i o r s , e v e n i f t h i s c r e a t e s c o n f l i c t w i t h o t h e r s ,i n c l u d i n g t h e i r t h e r a p i s t s .

(2 ) H o w does the client s cu rrent resis tance f i t into h is or her developmental~historicalpattern of resis tance? S u b - q u e s t i o n s t o p o n d e r , a n d p e r h a p s t o a s k th e c l i e n t d i re c tl y ,i n c l u d e - - " W h e n a n d u n d e r w h a t c i r c u m s t a n c e s h a s t h e c l i e n t b e e n s i m i l a r l yd i s i n c l i n e d t o t r y to c h a n g e o r a c c e p t h e l p i n th e p a s t ?" ; " W h a t o t h e r r e l a t io n -s h ip s i n t h e c li e n t' s p a s t a n d p r e s e n t a r e c a l le d t o m i n d b y t h e c u r r e n t c o n f l ic tb e t w e e n t h e c li e n t a n d t h e r a p is t ? " ; a n d " H o w i s t h e c u r r e n t s c e n a r i o i n t h e r a p ys i m i l a r t o a n d d i s t in c t f r o m p r e v i o u s s i t u a t io n s i n t h e c l ie n t' s l if e w h e n h e o rs h e r e s i s t e d c h a n g e o r d i r e c t i o n ? "

I n B a r t ' s c a s e , t h e c l i e n t c o u l d i d e n t i f y n u m e r o u s t i m e s i n h i s l i f e w h e n h eb e l ie v e d t h a t s o m e o n e ' s o ff e r s o f h e l p a n d a d v i c e w e r e t h i n l y - d i s g u i s e d a t t e m p t st o l e a d h i m a s t r a y a n d t a k e a d v a n t a g e o f h i m . H e v i e w e d t h e t h e r a p i s t 's s u g g e s -t i o n t o p u r c h a s e Feel ing Good a s i n v o l v i n g m o t i v e s o f f i n a n c i a l s e l f - i n t e re s t o nt h e p a r t o f t h e t h e r a p e u t i c a g e n c y , a n d h e f e lt it w a s n o t i n h i s b e s t in t e r e s t t oc o m p l y . A s i n t h e p a s t , h i s c h i e f m o d e o f r e s i s ta n c e w a s a p as s iv e d e m o n s t r a t i o no f p r o t e s t a n d h o s ti li ty . B a r t h a d f o u n d t h a t p a s s i ve r e s i s t a n c e w a s t h e e a si e stw a y t o c o u n t e r - a t t a c k w h a t h e v i e w e d a s h i s e m p l o y e r 's u n r e a s o n a b l e d e m a n d sa n d h i s m o t h e r ' s a n d f o r m e r w i fe 's u n d u e a t t e m p t s t o c o n t ro l h i m . U n w i t t i n g ly ,h i s r e s p o n se s h a d e x a c e r b a t e d t h e i r a t t e m p t s t o t r y t o c h a n g e h i m , w h i c h f u r -t h e r f u e l e d h i s m i s t r u s t .( 3 ) W ha t m ight be some of the c lient s id iosyncrat ic bel ie fs that are eed ing in to h is orher resistance? I t is v e r y u s e f u l to l o o k i n t o t h e u n i q u e w a y s t h a t c l ie n t s i n t e r p r e tv a r i o u s s i t u a t i o n s , a s t h i s m a y s h e d l i g h t o n w h y t h e c l i en t s t h i n k t h a t i t i s w a r -r a n t e d , n e c e s s ar y , a n d b e n e f i c ia l f o r t h e m t o r e si s t c h a n g e . F o r e x a m p l e , r e -g a r d i n g B a r t 's d i s c a r d i n g o f Fee ling G ood h o u r s a f t e r p u r c h a s i n g i t , t h e t h e r a p i s ta s ke d , " B a rt , w h a t w a s g o i n g t h r o u g h y o u r m i n d w h e n y o u le ft t h e s t o re w i t ht h e b o o k i n h a n d ? " A f t e r s o m e p u z z l e d r e f l e c t i o n , h e r e p l i e d , " I n o t i c e d t h a tt h e g u y w h o w r o t e i t w o r k s a t t h is C e n t e r , a n d I sa i d, ' G e e z ' " T h e t h e r a p i s tt h e n a d d e d , " A n d w h a t d i d t h a t m e a n t o y o u ? " B a r t r e t o r t e d , " W e l l, y o u w a n t


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UNDERSTANDING RESISTANCE 5

p e o p l e l ik e m e t o b u y y o u r b o o k s s o y o u c a n m a k e m o r e m o n e y . I t ' s r e a ll y n o tb e c a u s e i t'l l h e l p m e

O n c e a g a i n , a s B a r t h i s t o r i c a l l y h a d d o n e , h e i n t e r p r e t e d a b e n i g n a c t a sa s i gn t h a t s o m e o n e w a s tr y i n g t o t a k e a d v a n t a g e o f h i m . T h e r e f o r e , e v e n t h o u g hi t s e e m e d a w a s t e to d i s c a r d a b o o k h e h a d j u s t p u r c h a s e d , B a r t 's b e h a v i o r m a d es e n s e i n th e c o n t e x t o f a b e l i e f s y s t e m t h a t s a i d it w a s a b a d i d e a t o c o m p l y w i t ha n y o n e w h o s i m p l y w a n t s t o e x p l o it y ou . W i t h i n t h is b e l i e f s y s te m , B a r t h a dn o t t a k e n i n to a c c o u n t t h e f o l lo w i n g d a t a - - t h a t h e w a s r e c e i v in g f re e th e r a p y ,t h a t t h e b o o k w a s a n i n e x p e n s i v e p a p e r b a c k , a n d t h a t t h e a u t h o r h a d b e e n i n d e -p e n d e n t o f t h e C e n t e r f o r m a n y y e a r s. B a r t 's f u n d a m e n t a l m i s t r u s t f o r o t h e r sb e c a m e a f oc a l i s su e i n th e r a p y , s o m e t h i n g t h a t m i g h t h a v e b e e n o v e r lo o k e dh a d t h e t h e r a p i s t m e r e l y a s c r i b e d t h e c l ie n t' s b e h a v i o r t o a g e n e r a l m o t i v a t i o nno t t o ge t we l l .

I n t h e c a s e o f S a b r i n a , t h e t h e r a p i s t a s k ed , " W h a t g o e s t h r o u g h y o u r m i n dw h e n I g iv e y o u s u p p o r t a n d e n c o u r a g e m e n t , a n d w h e n I s u g g e st t h a t y o u c a nm a k e g r e a t s t ri d e s b y b e i n g m o r e a c ti v e in t a k i n g c a r e o f y o u r b il ls , h o u s e h o l d ,a n d c o m p u t e r w o r k ? W h a t k e e p s y o u th i n k i n g t h a t i t 's h o p e l es s a n d f u ti le t oc h a n g e o r i m p r o v e y o u r l if e? " S a b r i n a 's r e p l y w a s u n e x p e c t e d a n d q u i t e e n l i g h t -e n i n g . S h e n o t e d t h a t " a ll t h e g r e a t w r i t e r s a n d i n t e ll e c ts i n th e w o r l d a r ed e p r e s s e d " a n d t h a t " y o u c a n ' t t a k e a n o p t i m i s t s e r i o us l y, b e c a u s e t h e w o r l d iss o s c re w e d u p t h a t n o b o d y w i t h a n o u n c e o f b r a i n s c o u l d p o s s i b ly b e a n o p -t i m i s t " C l ea r ly , s h e h a d i n t e r p r e t e d h e r t h e r a p i s t 's p o s it i v e v e r b a l r e i n f o r c e m e n ta s in d i c a t i v e o f a s a p p y , s i m p l e - m i n d e d a p p r o a c h t o life . F u r t h e r , s h e v i e w e dh e r s e l f a s a n i n t e l li g e n t p e r s o n a n d w r i t e r ( h e r c h i e f a v o c a t i o n ) , a n d s h e c e r-t a i n l y w a s n 't g o i n g to g i v e u p h e r m e m b e r s h i p i n t h e " d e p r e s se d g r e a t w r i t e r' ss o c ie t y" w i t h o u t a f i g ht . T h e r e f o r e , s h e r e si s te d c h a n g e t h a t m i g h t i m p r o v e h e rm o o d .

A s t h e c a s e e x a m p l e s i l lu s t r at e , a c e n t r a l m e t h o d f o r c a l li n g a t t e n t i o n t o t h ec l ie n t s ' r e s i s ta n c e i s th e t h e r a p i s t ' s in q u i r i n g a b o u t t h e c l i e n ts ' t h o u g h t s t h a t p r e -c e d e o r a c c o m p a n y t h e i r n e g a t i v e r e a c t io n s t o t h e t h e r a p i s t s ' s ug g e s ti o n s. T h et h e r a p i s t c a n a s k a b o u t t h o u g h t s t h a t a r e s i s t a n t c l i en t is h a v i n g l iv e i n s e s si o n( e. g ., " Y ou r o l l e d y o u r e y e s a s I w a s e x p l a i n i n g m y p o i n t o f v i e w j u s t n o w . W h a tw e n t t h r o u g h y o u r m i n d ? " ), o r r e f le c t o n r e l e v a n t t h o u g h t s t h a t h e o r s h e h a db e t w e e n s e ss io n s ( e. g. ; " W h a t w e r e y o u t h i n k i n g a s y o u c o n t e m p l a t e d d o i n g t h eh o m e w o r k , a n d w h a t w e r e t h e t h o u g h t s t h a t c o n v i n c e d y o u not to do i t?") .

(4) W hat m ight the client ear w ill happ en if he or she complies?A l t h o u g h t h e t h e r -a p i s t m a y b e l ie v e t h a t c h a n g e i s a g o o d t h i n g , c l ie n ts m a y h a v e m i s g i v i n g s th a tm u s t b e a c k n o w l e d g e d a n d a d d r e s se d . F o r e x a m p l e , s o m e c l i e n ts ( e sp e c ia l ly th o s ew i t h m o r e l o n g s t a n d i n g i ss u e s a n d s e r io u s p r o b l e m s ) c l in g t e n a c io u s l y t o th es t a t u s q u o i n t h e i r li v e s b e c a u s e t o s o m e e x t e n t i t is f a m i l i a r a n d s a fe . T o c h a n g ew o u l d m e a n t o v e n t u r e i n t o th e u n k n o w n , w h i c h c a n b e v e r y f r i g h t e n i n g a n dd i so r i en t i ng t o many c l i en t s ( c f . Beck e t a l . , 1990 ; Layden e t a l . , 1993 ; Young ,1 99 0), C l i e n t s m a y v i e w c h a n g i n g a s i n c u r r i n g f u r t h e r d i f f ic u l ti e s i n t h e i r l iv e s,


8/23

5 N E W M A N

s u c h a s i n c r ea s e d d e m a n d s a n d d e c r e a s e d c a r e ta k i n g f r o m o t h e r s. T h i s i n d u c e sf ea r, and o f t en l e ads t o avo i dance . I n som e i n s t ances , c l i en t s f ea r t ha t t h ey w i lll o se t h e i r s e n s e o f id e n t i t y i f t h e y c h a n g e . F o r e x a m p l e , M a h o n e y (1 99 1) h a sw r i t t e n a b o u t t h e s e l f- p r e s e r v in g f u n c t i o n o f r e s is t a n ce , a n d p r e s e n t s a c a s ee x a m p l e w h e r e a c l i e n t c l a im s t h a t i n o r d e r f o r h i m n o t t o b e d e p r e s s e d h e w o u l dh a v e t o b e a d i f f er e n t p e r s on . I n s u c h c as e s, c l ie n t s e q u a t e c h a n g e w i t h a n n i h i -l a t i on .

I n t h e c a s e o f M i t c h , t h e c l ie n t d id n o t f e a r c h a n g e p e r se . H o w e v e r , h e d r e a d e dt he pos s i b i li t y t ha t t h e t he r ap i s t w ou l d t ake a l l t he c r ed i t f o r w h a t eve r t he r ap eu t i ci m p r o v e m e n t s t h a t M i t c h m a d e , w h i le M i t c h w o u l d b e l ef t f e el in g d i s c o u n t e da n d p o s s i b l y e v e n s h a m e d . ( S e e p o i n t 8 b e l o w f o r f u r t h e r e x p l a n a t i o n . )

(5) H o w m i g h t t h e c l ien t b e ch a r a c te r is ti ca ll y m i s u n d er s t a n d i n g o r m i si n te r p r e ti n g t h etherapis t s sugges t ions , methods , an d in ten t ions? A t t i m es a c l i en t ' s f a i l u r e o r r e f usa lt o c o l l a b o r a te w i t h t h e t h e r a p i s t m a y b e t h e r e s u lt o f a s i m p l e m i s u n d e r s t a n d i n g .F o r e x a m p l e , S a b r i n a b e c a m e s i le n t in s e s s io n b e c a u s e s h e t o o k o f f e n se a t w h a ts h e p e r c e i v e d to b e a n i n s u l t f r o m t h e t h e r a p i s t. W h e n t h e t h e r a p i s t i n q u i r e da b o u t t h is , i t b e c a m e c l e a r t h a t S a b r i n a h a d m i s h e a r d w h a t t h e t h e r a p i s t s ai d.I n r e a l i t y , t h e t h e r a p i s t h a d b e e n p o k i n g f u n a t h i m s e l f w i t h a s e l f - d i spa r ag i ngc o m m e n t .

I n o t he r m o r e s e r i ous case s , t he c l i en t s ' nega t i ve l y b i a se d be l i e f s and i n f o r -m a t i o n p r o c e s si n g l e ad t h e m consistent ly t o m i s c o n s t r u e i n t e r p e r s o n a l s i t u a t io n s( S a f r a n & S e g a l, 1 99 0). T h i s l e a d s to a n g e r a n d o t h e r n e g a t iv e e m o t i o n s t h a tcon t r i bu t e t o t he c l i en t s' r e s is t ance . F o r exam pl e , B a r t t ende d t o r ead t h r ea t en i ng ,e x p l o it iv e , a n d d e m e a n i n g t h i n g s i n t o w h a t p e o p l e w e r e s a y in g t o h i m . T h e r e -f o r e , w h e n t h e t h e r a p i s t s u g g e s t e d t h a t h e p u r c h a s e a n d r e a d Feel ing Good, B a r tw a s p r e d i s p o s e d t o l o o k f o r r e a s o n s w h y i t w o u l d b e a g a i n s t h i s b e s t i n t e r e s tt o f o ll ow t h r o u g h . H e d i d n o t u n d e r s t a n d t h e c o n c e p t o f b i b li o th e r a p y , a n d t h e r e -f o r e n e e d e d a n e x p l i c i t r a t i o n a l e a s a s t a r t i n g p o i n t t o o v e r c o m e h is r e l u c t a n c et o r e a d t h e b o o k .

(6) W h a t s k i l l s d o es th e c li en t l a ck t h a t m i g h t m a ke i t p r a c ti ca ll y d i f f i cu l t o r im p o s s i b lea t t h i s p o i n t f o r h i m o r h er to a c t ive l y co l la b o r a te w i t h t rea t m en t ? T h e r a p i s t s m u s t a s s es st he i r c l ien t s ' p sycho l og i ca l skills ( e .g . , p r ob l em - so l v i n g , p l ann i ng , co m m un i ca -t i o n , ra t i o n a l r e s p o n d i n g , p e r s p e c t i v e - ta k i n g ; el . O ' D o n o h u e & K r a s n e r , 1 99 4)i n o r d e r t o d e t e r m i n e h o w m u c h o f t h e i r r es is t an c e i s m o t i v a t io n a l a n d h o wm u c h r e p r e s e n t s def ici ts i n f u n c t i o n i n g (T r o w e r & D r y d e n , 1 98 9). F o r e x a m p l e ,f a il u r e t o f o ll ow th r o u g h o n w r i t t e n h o m e w o r k a s s i g n m e n t s m a y r e fl e ct a r e a d i n gor a t t en t i ona l de f i c i t . S i m i l a r l y , a c l i en t ' s r e l uc t ance t o engage i n i n t e r pe r sona lbeh av i o r a l exp e r i m en t s m a y s i gna l a l a ck o f soc i a l ski lls a nd / o r a s se r t i venes s .W h e n t h is i s t h e c a se , g r a d e d i n s t r u c t i o n a n d p r a c t ic e a r e r e q u i r e d i n t h e t h e r a p ys e ss io n s t h e m s e l v e s b e f o r e c l i e n ts c a n b e e x p e c t e d t o g e n e r a l i z e th e s e b e h a v i o r st o e v e r y d a y l if e ( M e i c h e n b a u m & T u r k , 1 98 7; O ' D o n o h u e & K r a s n e r , 1 99 4).

E v e n w h e n c l ie n t s d e m o n s t r a t e a r e a s o n a b l e l e v el o f p s y c h o l o g i ca l sk ills , t h e ym a y s t il l m a n i f e s t re s i s ta n t a t t i t u d e s a n d b e h a v i o r s b e c a u s e t h e y bel ieve t h a t t h e y


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UNDERSTANDING RESISTANCE

a r e i ncap ab l e an d he l p l e s s to f o ll ow t h r o ugh . I n s u ch ca s e s, i t is i m pe r a t i ve t oc r i t i c a l ly exam i ne t he ba s i s f o r t he c l ien t 's s ens e o f hope l e s s nes s an d l ow s e lf -e f f i c acy ( Beck , R us h , Shaw, & E m e r y , 1979).

(7) W ha t acto rs in the c l ient s natural environment ma y be pu nis hin g the c l ient s a t temptsto change? I t is s o m e t i m e s u n w i s e f o r t h e r a p i s t s t o a s s u m e t h a t t h e c l i en t 'spra i sew or thy chan ges in session wi ll be s imi la r ly pos i t ive ly re info rced in th e c l i en t 'seve r yda y l if e . Fo r exam pl e , f a c t o r s i n t he c l i en t' s pe r s on a l l if e o r w or k s i t ua t i onm ay s e r ve a s s t r ong d i s i ncen t i ve s f o r t he c l i en t t o chan ge ( G o l d en , 1989). I f t het h e r a p i s t i s u n a w a r e o f t h e s e o u t s i d e v a ri a b le s , h e o r s h e m a y c o n c l u d e e r r o n e -o u s l y t h a t t h e c l i e n t a lo n e i s r e s p o n s i b l e f o r t h e i m p a s s e i n t h e ra p y . T h u s , t h et h e r a p i s t m a y b e c o m e e x a s p e r a t e d w i t h t h e c l ie n t 's g i v i n g l ip s e r v ic e to c h a n g e ,and m ay f a i l t o pu r s ue r e l evan t i s s ues t ha t exp l a i n t he r e s i s t ance .

T h i s c a n b e s e e n i n t h e c a s e o f a c l ie n t w h o h a s b e e n r e f e r r e d b y h is p h y s i c i a nf o r p sy c h o l o g i c a l t r e a t m e n t a s a r e s u l t o f h i s h y p e r t e n s i o n a n d r e l a t e d c a r d i o -v a s c u l a r s y m p t o m s . T h e c l i en t s ta t e s th a t h i s g o a l is to " l e a r n t o r e l ax , n o t w o r ks o h a r d , a n d n o t g e t so a n g r y " H o w e v e r , th e c l i e n t d o es n o t f o l lo w t h r o u g h w i t ht h e t r e a t m e n t p r o g r a m t h a t i n c lu d e s r e la x a t i o n , r e v i s e d w o r k h o u r s , a n d v a r -i o u s a n g e r c o n t r o l t e c h n i q u e s . A l t h o u g h i t i s t e m p t i n g t o e x p l a i n t h e c l i e n t ' sr e s i s t ance a s be i n g a f un c t i on o f h is "Type -A" o r "obs e s s i ve - com pu l s i ve" pe r s o n -a li ty , th e r e m a y b e a h o s t o f e n v i r o n m e n t a l f a c t o r s t h a t w o r k a g a i n s t t h e r a p e u t i cc h a n g e . T h e s e m a y i n c l u d e a c ri ti c a l f a t h e r w h o s till d e m a n d s p e r f e c t i o n f r o mt h e c l i e n t a n d a j o b w h e r e l o n g w o r k d a y s a n d a n a g g r e ss i v e a p p r o a c h a r e h i g h l yl a u d e d . W h e n t h e s e t y p e s o f v a r i a b le s a r e i d e n t if i e d a n d a d d r e s s e d , t h e t h e r -a p i st w i ll h a v e m u c h g r e a t e r l e v e r a g e in h e l p i n g t h e c l i e n t t o o v e r c o m e h i s r es is -t a n c e t o c h a n g e .

A n o t h e r e x a m p l e i s t h e c a s e o f a w o m a n w h o s ee k s th e r a p y f o r " d e p r es s io na n d l o w se l f- e st e em " b u t d o e s n ' t m e n t i o n t h a t h e r h u s b a n d is e m o t i o n a l l y a b u -s iv e. W h e n t h e t h e r a p i s t e x p l a i n s t h a t t h e c l ie n t' s s y m p t o m s c o u l d b e a l l e v i a te di n p a r t b y h e r l e a r n i n g t o b e m o r e a s s e r ti v e, t h e c l i e n t s e e m s e n t h u s e d . H o w -eve r , be f o r e t he n ex t s e s s i on t he c l i en t te l eph one s t he t he r ap i s t , t e a r f u l l y s ay i ng ," Y o u 'v e b e e n a g r e a t h e l p to m e , a n d I w o n ' t n e e d t o c o m e b a c k a n y m o r e . P l e a s ed o n ' t t r y to c a ll m e , I 'l l b e f i n e . . , r e a l ly " T h e c li e nt 's f a il u r e to f o ll o w t h r o u g hw i t h t r e a t m e n t i n t h i s c a s e l i k e l y i s b a s e d o n t h e d i s a p p r o v a l a n d p u n i s h m e n tr e c e i v e d f r o m t h e a b u s i v e h u s b a n d i n r e s p o n s e t o t h e c l ie n t 's a t t e m p t s t o s t a n du p f o r h e r se l f. T h e r a p i s t s w h o a r e a w a r e o f s u c h p o t e n t i a l e n v i r o n m e n t a l o b -s ta c le s t o c h a n g e , a n d w h o c o n s i d e r t h e m i n f o r m u l a t i n g a t r e a t m e n t p l a n , h a v ea b e t t e r c h a n c e o f e f f e c ti n g gr adua l c h a n g e s t h a t m a y e n c o u n t e r l e s s b a c k l a s ht h a n t h e r a t h e r t r a g i c c a s e d e s c r i b e d a b o v e .

(8) Doe s my conceptual iza tion o f th is case need to be revised or amended? W ha t do Isti l l need to understand about this client in order to mak e sense o f his o r her resistance? W h e na c l i en t r e jec t s a t he r ap i s t ' s f o r m ul a t i o ns o r s ugges t i ons b y s ay i ng ( o r t h i nk i ng ) ," D o c t o r , y o u j u s t d o n ' t u n d e r s t a n d ; s o m e t i m e s th e y ' r e r i g h t I t is a d v i s a b l e fo rt h e r a p i s t s - w h e n t h e y a r e s t u m p e d b y th e i r c lie n ts ' r e s i s t a n c e - t o c o n s id e r th e


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6 N E W M A N

l ik e l ih o o d t h a t t h e y a r e m i s s i n g o r o v e rl o o k i n g i m p o r t a n t d a t a . F o r e x a m p l e ,M i t c h ' s t e n d e n c y t o d e b a t e w i t h t h e t h e r a p i s t a n d d e n y t h a t h e w a s i m p r o v i n gw a s b e t t e r u n d e r s t o o d a f t e r t h e t h e r a p i s t r e v i e w e d o l d s e s s i o n n o t e s i n s e a r c ho f c o n c e p t u a l c l ue s . S p e ci fi ca l ly , M i t c h h a d e x p l a i n e d t h a t h i s o l d e r b r o t h e r h a da lw a y s b e e n t h e f a v o re d s o n i n h i s f a m i l y o f o r ig i n . T h e f a t h e r o f t e n m a d ec o m p a r i s o n s b e t w e e n t h e c l i e n t a n d h i s b r o t h e r , a n d u s u a l l y f o u n d t h e c l i e n tw a n t i n g . A s a b y - p r o d u c t o f th i s s et o f f a m i l y in t e ra c t io n s , M i t c h g r e w t o h a r b o ra f i e r c e c o m p e t i t i v e n e s s a n d r e s e n t m e n t t o w a r d t h e o l d e r b r o t h e r .

E x a c e r b a t i n g t h i s p r o b l e m w a s t h e o l d e r b r o t h e r ' s t e n d e n c y t o t r y to h e lpM i t c h b y g i v in g h i m u n s o l ic i te d a d v i c e a b o u t w h a t h e s h o u l d d o a n d h o w h es h o u l d d o i t . I n t h e r a p y , M i t c h b i t t e r l y r e c o u n t e d a n e p i s o d e f r o m h i s s c h o o ld a y s w h e n h e s t u d ie d e x t r e m e l y h a r d t o ge t a n '~ o n a m a t h e x a m , o n l y toh a v e h is f a t h e r s i n g t h e p r a is e s o f t h e o l d e r b r o t h e r f o r h a v i n g t u t o r e d M i t c hs o w e l l a n d s e t t in g s u c h a g r e a t e x a m p l e

T h e s e h i s to r i ca l d a t a h e l p e d t h e t h e r a p i s t t o a d d a n e w a n d i m p o r t a n t f a c e tt o h is ca s e c o n c e p t u a l i z a t i o n o f M i t c h . T h e t h e r a p i s t , r e a l i z i n g t h a t h e w a s c l os ei n a g e t o M i t c h 's b r o t h e r , h y p o t h e s i z e d t h a t M i t c h w a s p e r c e i v i n g a n d r e a c t i n gt o t h e t h e r a p i s t a s h e w o u l d h i s o l d e r b r o t h e r . I f t h i s w e r e t h e c a s e, M i t c h l ik e l yw o u l d r e s e n t t h e t h e r a p i s t 's p r o f e ss i o n a l st a tu s , h i s s u g g e s t io n s a b o u t w h a t M i t c h

s h o u ld d o a n d h o w h e s h o u l d d o i t ; a n d h i s r o le as s u pe ri or . T h i s p h e n o m e n o ni s w e l l - k n o w n i n t h e t r a d i t i o n a l p s y c h o a n a l y t i c l i t e r a t u r e a s t r a n s f e re n c e , b u th a s a l s o b e e n r e c o g n i z e d b y c o g n i t i v e - b e h a v i o ra l c li n ic i a ns u n d e r t h e r u b r i c so f i n t e r p e r s o n a l s c h e m a s ; o r i n v iv o i n t e r p e r s o n a l o v e r g e n e ra l iz a t io n (c f. G o l d -f r i ed & Ha yes , 1989 ; G o ld f r i ed & Ne w m an , 1992 ; Seg raves , 1982) .T h e t h e r a p i s t p o s t u l a t e d t h a t M i t c h w a s r e l u c t a n t t o a c k n o w l e d g e t h a t t h e r a p yw a s h e l p i n g h i m , l e s t t h e t h e r a p i s t ( l i k e t h e o l d e r b r o t h e r ) t a k e a l l t h e c r e d i tf o r s e t t in g s u c h a g r e a t e x a m p l e w h i l e M i t c h w o u l d r ec e i v e n o c r e d i t f o r h i so w n e f fo r ts i n o v e r c o m i n g d e p r e ss i o n . I f t h is w e r e h o w M i t c h t r u l y v i e w e d t h e ra p y ,t h e n i t m i g h t s t a n d t o r e a s o n t h a t h e b e l i e v e d h e c o u l d s u c c e e d (i.e ., d e f e a t h iso l d e r b r o t h e r ) o n l y b y t h w a r t i n g t h e t h e r a p i s t a t e v e r y t u r n . T h e t h e r a p i s tp r e s e n t e d t h is t e n t a ti v e h y p o t h e s i s t o M i t c h i n as h u m b l e a n d s u p p o r t i v e am a n n e r a s p o s s ib l e , w i t h h i g h l y f a v o r a b l e r e s u l t s ( s e e t h e I n t e r v e n t i o n s s e c t i o nfo r fu r the r de t a i l s ) .

In t e r v e n t i o n s f o r Im p r o v i n g l ie n t M o t i v a t i o nT h e r e a r e a n u m b e r o f w a y s t h a t t h e r a p i s t s c a n w o r k t o m o t i v a t e t h e i r c li e n ts

t o e n g a g e m o r e a c t iv e l y a n d e f fe c ti v el y i n t r e a t m e n t . T h e s e i n c lu d e m e t h o d ss u c h a s : ( i ) E d u c a t i n g t h e c l i e n t a b o u t t h e r a p y ; ( 2 ) U s i n g t h e S o c r a t i c m e t h o d ;( 3 ) P r o v i d i n g t h e c l i e n t w i t h c h o i c e s a n d a n a c t i v e s a y ; ( 4 ) C o l l a b o r a t i n g a n dc o m p r o m i s i n g ; ( 5 ) R e v i e w i n g th e p r o s a n d c o n s o f c h a n g e , a n d t h e p r o s a n dc o n s o f c o n t i n u i n g w i t h t h e p s y c h o lo g i c al s t a tu s q u o ; ( 6 ) P r o v i d i n g a c c u r a t ee m p a t h y f o r th e c l i e n t 's re s i s ta n c e ; ( 7 ) D i s c u s s i n g t h e c a s e c o n c e p t u a l i z a t i o n


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U N D E R S T N D I N G R E S I S T N C E 57

w i t h t h e c li e n t; ( 8) S p e a k i n g th e c l ie n t 's l a n g u a g e ; (9 ) M a x i m i z i n g t h e u s e o fc l i en t s e l f -d i r ec t i on ; (10 ) Be ing gen t l y pe r s i s t en t w he n a c l i en t i s s t uck

I n g e n e r a l , a l l o f t h e s e i n t e r v e n t i o n s a r e h e l p f u l i n c o u n t e r a c t i n g c l ie n t r e si s-t a n c e r i g h t f r o m t h e o u t s e t o f th e r a py . H o w e v e r , t h e y b e c o m e p a r t i c u l a r l y e ff ec -t iv e t o th e e x t e n t t h a t t h e t h e r a p i s t m a k e s u s e o f t h e a f o r e m e n t i o n e d a s s e s s m e n tques t i ons an d co me s t o f o rmu la t e a soph i s t i c a ted ca se conce p tua l i z a t i on (Pe r sons ,1 98 9) a s t r e a t m e n t p r o g r e s s e s . I n t h is m a n n e r , t h e t h e r a p i s t c a n p u t s p e c i a l e m -p h a s i s o n t h o s e i n t e r v e n t i o n s t h a t b e s t fi t t h e p a r t i c u l a r n e e d s o f e a c h i n d i v i d u a lc l ien t .E d u c a t e t h e C l i e n t A b o u t T h e r a p y

A n i m p o r t a n t a n d b a s i c w a y to m a x i m i z e c l ie n ts ' p r e p a r e d n e s s f o r t h e r a p yi s t o p r o v i d e e d u c a t i o n a b o u t t h e r a p y ( M e i c h e n b a u m & T u r k , 1 9 8 7; Y o u n g , 1 9 90 ).C l i e n t s o f te n d o n o t u n d e r s t a n d w h a t t o e x p e c t w h e n t h e y e n t e r t h e ra p y , p a r t lya s a f u n c t i o n o f t h e d i v e r s i t y o f t h e f i el d , p a r t l y d u e t o m i s c o n c e p t i o n s b o r n eo f s e n s a t i o n a l i z e d o r u n f l a t t e r i n g p o r t r a y a l s o f t h e r a p i s t s o n t e l e v i si o n a n d i nm o v i e s , a n d s o m e w h a t a s a f u n c t i o n o f t h e i r o w n b i a se s a n d m i s c o n c e p t i o n s( e .g . , T h e r a p y i s l ik e a m a g i c p il l. I ' l l j u s t s h o w u p a n d t h e t h e r a p i s t w i ll s a ya l l t h e r i g h t t h i n g s t o m a k e m e b e t t e r ) .

A c o o p e r a t i v e a l l i a n c e c a n b e e s t a b l i s h e d m o r e r e a d i l y b y e d u c a t i n g c l i e n t sa b o u t t h e r a p y ( M a c a s k i l l , 1 98 9; M a e a s k i l l & M a c a s k i l l , 1 98 3). T h i s w o u l d i n -e l u d e a n e x p l a n a t i o n o f t h e m o d e l o f t r e a t m e n t ( e. g., c o g n i t i v e - b e h a v i o r a lt h e r a p y ) , a p r e v i e w a b o u t t h e e x p e c t e d l e n g t h a n d s u b s t a n c e o f t h e c o u r s e o ft h e r a p y , a n d a d i s c u s si o n a b o u t t h e r o l e s a n d r e s p o n s i b i l it i e s o f b o t h t h e t h e r -a p i s t a n d t h e c li en t. A n u m b e r o f t a c k s c a n b e t a k e n i n o r d e r t o a c h ie v e th i sg o a l, i n c lu d i n g : (1 ) G i v i n g c l ie n t s s u p p l e m e n t a l r e a d i n g s a t t h e s t a r t o f t h e r a p y ,s u c h a s B e c k a n d G r e e n b e r g ' s ( 1 9 7 6 ) Co ping w ith D epression w h i c h p r o v i d e s a ni n t r o d u c t i o n t o th e c o g n i t iv e m o d e l o f d e p r e s s i o n , o r B u r n s ' s (1 98 0) FeelingGoodw h i c h i s p e r h a p s t h e m o s t w i d e l y r e a d t a k e - h o m e g ui d e t o c o g n i ti v e t h e r a p y ;( 2 ) P r o v i d i n g c l i e n t s w i t h a v e r b a l a n d w r i t t e n o r i e n t a t i o n t o t h e i r p e r s o n a l r o l e si n t h e t h e r a p y p r o c e s s (e .g ., Y o u n g , 1 99 0), s o a s to a n t i c i p a t e a n d p r o m p t l y a d -d r e ss t h e k i n d s o f m i s g i v i n g s a n d a p p r e h e n s i o n s t h a t c l i en t s o f te n h a v e a b o u tt h e i r d e c i si o n t o e n t e r th e r a p y ; ( 3 ) D i s t r i b u t i n g c o m p r e h e n s i v e g u i d e b o o k s t h a to u t l i n e a n d e x p l a i n t h e e n t i r e c o u r s e o f th e r a p y a s it w i ll u n f o l d ( e .g ., G r i e g e r ,1 9 8 9 ) , a p r o c e s s t h a t i s a n a l o g o u s t o f o l l o w i n g a t e x t b o o k c h a p t e r b y c h a p t e ra s o n e p r o g r e s s e s t h r o u g h a c o ll e g e c o u r s e ; a n d ( 4 ) P e r i o d i c a l l y d i sc u s s i n g t h ec l ie n t s' p r o g r e s s w i t h t h e m d u r i n g t h e c o u r s e o f t r e a t m e n t i n o r d e r t o r e a ss e ssa n d u p d a t e g o al s, e v a lu a t e m e a s u r a b l e g a i n s to d a t e, a n d a n s w e r q u e s t i o n s t h a th a v e c r o p p e d u p .

T h e p r o c e s s o f e d u c a t i n g c l i en t s a b o u t t h e r a p y c o n t i n u e s t h r o u g h o u t t h e c o u r s eo f t r e a t m e n t . I t h e lp s t o d e m y s t i f y t h e e x p e r i e n c e , i t m a k e s c li e nt s m o r ekno wled geab l e consu m er s , an d i t f a c i l it a t e s t he c l i en t s ' w i l l i ngnes s to co l l abo ra t ew i t h t h e t h e r a p i s t t o w a r d c o m m o n g o a l s .


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8 NRWMAN

I n t h e c a s e o f S a b r i n a , t h e t h e r a p i s t r e s p o n d e d t o t h e c li e n t' s a s s e r t io n t h a ts h e w a s r e c e i v i n g M i s t e r R o g e r s t h e r a p y b y e x p l a i n i n g t h a t r a t io n a l r e s tr u c -t u r i n g t e c h n i q u e s w e r e n o t s y n o n y m o u s w i t h id l e p o s i ti v e t h i n k i n g o r s t ic k i n go n e 's h e a d i n t h e s a n d ? ' H e s t re s s e d t h a t c o g n i t iv e th e r a p y m e t h o d s i n v o lv e dt e a c h i n g c l ie n t s t o t h i n k m o r e o b j e c t iv e l y a n d c o n s t r u c t i v e l y s o t h a t r e a l p r o b -l e m s c o u l d b e p u t i n t o b e t t e r p e r s p e c t i v e a n d d e a l t w i t h p r oa c ti v e ly . T h e t h e r -a p i s t e x p l a i n e d t h a t h e w o u l d n o t m i n i m i z e h e r p r o b l e m s o r t e l l h e r s u p e r f i -c i a ll y t o l o o k o n t h e b r i g h t s id e o f life ?' H e a d d e d t h a t t h e r a p y w a s h a r d w o r k ,i n v o l v in g e m p i r i c a l m e t h o d s a n d s y s t e m a t i c a p p l i c a ti o n o f t e c h n i q u e s .

I n o r d e r t o i n t e r v e n e f u r t h e r in d i s a b u s i n g S a b r i n a o f h e r m i s c o n s t r u a l o ft h e p u r p o s e a n d m e t h o d s o f c o g n i t i v e - b e h a v i o r a l t h e ra p y , t h e t h e r a p i s t re c o m -m e n d e d t h a t s h e r e a d E l l i s a n d H a r p e r ' s ( 1 9 7 5 ) A N ew Guide to Ra t iona l Liv ingan d EUi s an d K nau s ' s ( 1977) Overco ming Procrastination T h e t h e r a p i s t s p e c if ic a ll yc h o s e b o o k s b y E l l i s a n d h i s c o l l e a g u e s a s t h e s e p u b l i c a t i o n s t e n d t o b e v e r yd i r e c t in p r e s e n t i n g t h e v i e w t h a t l i f e /~ to u g h a n d u n f a i r ( a v i ew w i t h w h i c hS a b r i n a w a s q u i t e s y m p a t i c o ) , b u t t h a t t h e r e i s a m i n d s e t a n d a te c h n o l o g y tod e a l w i t h t h i s u n f o r t u n a t e f a c t .U s e t h e S o c r a t i c M e t h o d

C l i e n t s h a v e b e e n k n o w n t o r e s is t i n c o r p o r a t i n g t h e i r t h e r a p i s t s ' m o s t w e ll-m e a n i n g a n d a c c u r a t e f e e d b a c k s i m p l y b e c a u s e t h e c l ie n t s d id n ' t t h i n k o f i t f ir st .T h e r a p i s t s c a n c i r c u m v e n t t h is p r o b l e m i f t h e y m a k e ju d i c i o u s u s e o f t h e S o c r a ti cm e t ho d . Th i s i nvo l ves a s k i ng a c l eve r s er i es o f ques t i on s t ha t l e ads t he c l i en ti n t h e d i r e c t i o n o f s y n t h e s i z i n g in f o r m a t i o n a n d d r a w i n g a s e t o f c o n c l u s io n s ,t h e l ik e s o f w h i c h w i ll b e m o r e l i k e ly to b e r e m e m b e r e d a n d f o ll o w e d b e c a u s ei t w a s t h e c l i e n t w h o g e n e r a t e d t h e i n f o r m a t i o n ( B e c k e t a l. , 1 97 9; B e c k , W r i g h t ,N ew m an , & L i e s e , 1993; O ve r ho l s e r , 1987 ; 1988 ; 1993). I n o r d e r t o m ake t hem o s t e f fec t ive u s e o f Soc r a t i c ques t i on i ng , t he t he r ap i s t m u s t have a goa l i n m i nd( s i m i l a r t o p l o t t i ng a ches s s t ra t egy f ou r o r f ive m oves i n adva nce ) , m us t be w i ll ingt o a c c e p t a n d p u r s u e c l ie n t r e s p o ns e s th a t s e e m c o u n t e r in t u i ti v e , a n d m u s t u n d e rno c i r cum s t anc es b r ow bea t t he c l i en t ( e .g . , w i t h hos t i l e -s ound i ng r he t o r i ca l ques -t i o n s ) i n t o a g r e e i n g w i t h t h e t h e r a p i s t ' s v i e w p o i n t .

T h e S o c r a t ic m e t h o d is e s p e c ia l ly u s e f u l in d e a l i n g w i t h c l i e n ts w h o h i g h l yv a l u e th e i r a u t o n o m y , a n d / o r f e a r b e i n g c o n t r o l l e d b y t h e i r t h e ra p i s ts . A d d i -t io n a ll y, t h e S o c r a ti c m e t h o d h e l p s to m i n i m i z e m i s u n d e r s t a n d i n g s b e t w e e n t h e r -a p i s t a n d c l ie n t , a s t h e c l ie n t p r o d u c e s m u c h o f t h e d a t a . T h e r e f o r e , t h e c h a n c e st h a t a c l ie n t w h o m a y f r e q u e n t l y d is t o r t w h a t o t h e r s s a y w i ll m i s r e a d o r m i s t r u s tt h e t h e r a p i s t ' s c o m m e n t s a r e r e d u c e d .P r o v i d e C h o i c e s

B r e h m a n d B r e h m ' s (1 98 1) r e a c t a n c e th e o r y p o s i ts t h a t c l i en t s w i ll b e h a v ei n w a y s t h a t p r e s e r v e t h e i r f r e e d o m , e v e n i f t h e b e h a v i o r s e e m s c o u n t e r t h e r -apeu t i c . W i t h t h i s in m i nd , i t i s wi s e to g i ve t he c l i en t s om e s ay in t he d i r ec t i on


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6 N E W M A N

M i t c h a d d e d t h a t h e h a d n ' t g i v en i t m u c h t h o u g h t b e f o r e , b u t t h a t t h e t h e r-a p e u t i c r e l a t i o n s h i p d i d s e e m t o b e r e m i n i s c e n t o f h i s r e la t i o n s h i p w i t h h is o l d e rb r o t h e r . W h e n t h e t h e r a p i s t e x p r e s se d a c c e p t a n c e a n d e m p a t h y f o r M i t c h 's s el f-p r o t e c t i v e s tr a te g y , a n d a d d e d h i s h e a r t - f e l t p r a i s e f o r M i t c h ' s a c c o m p l i s h m e n t s ,a m a j o r s h i ft in M i t c h ' s v i e w p o i n t t o o k p l ac e . M i t c h b e g a n t o v i e w t h e t h e r a p i s t( a n d b y e x t e n si o n , a n y o n e w h o w o u l d p u r p o r t t o b e hi s a d v o c a t e a n d m e n t o r )o n h i s o w n m e r i t s , a n d n o t a u t o m a t i c a l l y a s a p s y c h o l o g ic a l c l o n e o f h i s b r o t h e r .S p e a k th e C l i e n t 's L a n g u a g e

W h e n c l ie n ts a r e a m b i v a l e n t a b o u t b e i n g i n t r e a t m e n t , t h e i r d e c is i o n as t ow h e t h e r o r n o t t o i n ve s t i n t h e r a p y s o m e t i m e s h i n g es o n t h e i r p e r c e p t i o n o f t h e i rc o m p a t i b i l it y w i t h t h e th e r a p i s t. O n e i m p o r t a n t w a y fo r t h e r a p i s ts t o a u g m e n ta s e n s e o f c o m p a t i b i l i t y i s t o u s e l a n g u a g e t h a t i s f a m i l i a r to t h e c l i en t ( B e c ke t a l. , 1993; L io t t i , 1989 ). T h i s i s no t t o sugges t t ha t t he r ap i s t s sh ou ld go ou to f t h e i r w a y t o m i m i c c l ie n t s, e i t h e r b y u s i n g s l a n g , p r o f a n i t y , o r p a r r o t i n g r e -s p o n se s . R a t h e r , t h e t h e r a p i s t c a n m a k e u s e o f a n a c c u r a t e c a s e c o n c e p t u a l i z a -t i o n to d e t e r m i n e t h e s o r t o f c o m m u n i c a t i o n s t yl e t h a t , w h i l e w i t h i n t h e t h e r -ap i s t ' s s i nce r e and n a tu r a l r epe r to i r e , a l so s t r ike s a r e son an t c ho r d w i th t he c l ien t .

F o r e x a m p l e , w h e n d e s c r i b i n g t h e n a t u r e o f c o g n i ti v e t h e r a p y t o a h i s t ri o n ic ,n e w a g e a r t is t c l ie n t , t h e t h e r a p i s t m a y c h o o s e t o s ay t h a t a g o a l o f t r e a t m e n t

i s t o h e l p t h e c l ie n t t o g a i n a h e i g h t e n e d c o n s c io u s n e s s o f y o u r i n n e r m o s t t h o u g h t sw h e n y o u r f e el in g s a r e in t e n s e w h i l e c o m p u l s i v e , o v e r c o n t r o ll e d b u s i n e s s m a nm i g h t b e t o ld t h a t c o g n it iv e t h e r a p y h e l p s y o u b e c o m e m o r e o b j e c t iv e a n dp r o d u c t i v e i n d e a l i n g w i t h i s su e s t h a t g i v e y o u a s e n s e o f s u b j e c t i v e s t r e s s : I nt h is m a n n e r , t h e c l i n ic i a n m a x i m i z e s t h e c h a n c e s t h a t t h e c l ie n t m a y v i e w t h et h e r a p i s t a s s o m e o n e w h o i s s i m i l a r a n d a n a l l y .

W h e n t h e t h e ra p i s t 's s t a n d a r d f o r m o f v e r b a l c o m m u n i c a t i o n s e e m s in e f fe c -t iv e in c o n n e c t i n g w i t h t h e c l ie n t , imagery a n d metaphors m a y b e a u s ef u l a l te r n a -t iv e i n g a i n i n g t h e c l i e n t s ' a t t e n t i o n a n d i n t e r e s t ( L a y d e n e t a l ., 1 99 3; M e i c h e n -b a u m & G i l m o r e , 1 98 2). T h e m o s t ef f ic a c io u s u s e o f i m a g e r y a n d m e t a p h o r sr e q u i r e s a n a c c u r a t e c a s e c o n c e p t u a l i z a t i o n s o t h a t t h e t h e r a p is t 's p i c t u re s a n ds t o ri e s w i ll b e p e r s o n a l l y m e a n i n g f u l t o t h e c l ie n t s.

F o r e x a m p l e , a h i s tr i o n ic c l i e n t d i d n o t f a t h o m t h e a v e r si v e i m p a c t h e r h i g h l yd r a m a t i z e d b e h a v i o r s h a d o n o t h e r s i n h e r li fe u n t i l th e t h e r a p i s t m a d e u s e o fa n a n a l o g y t h a t l i k e n e d h e r t o h e r f a v o r it e c la s si ca l c o m p o s e r ' s m u s i c p l a y e da t 2 0 0 d e c i b el s . T h e t h e r a p i s t e x p l a i n e d t h a t , N o b o d y w i l l b e a b l e t o a p p r e c i a t ey o u r s u b t l et ie s a n d i n n e r b e a u t i e s i f y o u r v o l u m e i s so l o u d t h a t p e o p l e m u s tc o v e r t h e i r ea r s. S i m i l a r ly , a c o n d u c t - d i s o r d e r e d a n d n a r c i s s i s ti c t e e n a g e r w h ow a s q u i t e f o n d o f t h e tar Wars t r i l o g y w a s l i k e n e d t o L u k e S k y w a l k e r a t t h ec r i ti c a l c ro s s r o a d s i n h i s li fe . H e c o u l d e i t h e r u s e t h e p o w e r o f T h e F o r c e t o b e -c o m e a J e d i K n i g h t a n d f i gh t fo r g o o d, o r g o o v e r t o th e D a r k S i d e o f t h e F o r c ea n d b e c o m e li k e D a r t h V a d e r . E i t h e r w a y , t h e c l i e n t w o u l d b e e x t r e m e l y p o w e rf u l.


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UNDERSTANDING RESISTANCE 6

He could choose to harness his power for success, or become a colossal failurein life (not just any run-of-the-mill failure, mind you). Truly, a good picturethat has personal meaning is worth a thousand words for some clients.Maximize the Use of Client Self-Direction

It is the rare client who is so resistant that he or she never tries to changeand l w y s opposes the therapist. Most clients occasionally demonstrate a will-ingness to try new behaviors and attitudes, and sometimes agree with the ther-apist's point of view. Whe n clients demonst rate such flashes of cooperation andmotivation, it is imperative for the therapist to make ample use of the situation.

The best way to accomplish the above is to document the occurrence of adap-tive client responses, so that they may be remembered and reviewed at laterdates when the client's resistances once again impede progress. One particu-larly accurate method of documentation is the use of audiotaped and video-taped recordings of sessions (Ellis, 1985; Newman, 1993). The author makesa practice out of asking clients to keep an archive of audiotapes of our mostoptimistic and productive sessions; so that the clients can listen to such tapesin order to boost the mo ment um of therapy at those times when the client's moti-vation once again flags. Although it may be easy for resistant clients simplyto contradict their therapists, it is almost impossible for them to deny the exis-tence of their own tape-recorded comments. Clients have noted that it is partic-ularly compelling to hear themselves sounding motivated and extolling the virtuesof change -- far more meaningful than hearing someone else saying the samethings. Further, it is a face-saving tactic to encourage a client to take your owngood advice rather than to risk shaming a client by insisting that he or shelisten to what others (including the therapist) are saying. In this manner, cooper-ation is enhanced, because the clients essentially are complying with the mostfunctional aspects of themselves.

A comparably efficacious method of documentat ion involves having both thetherapist and the client take written notes of the client's most important, healthy,insightful, and mature comments and behaviors that occur both in and out ofsession. A logbook serves the same function as the audiotapes-- namely, to recordthe clients' most functional responses so that clients can become their own modelsfor change.

For those clients whose resistance extends to the ir refusing to be audiotaped,and who neglect to take written notes or do homework assignments, therapistscan use their own notes as a way to remind clients about productive things thatthey've said in previous sessions.

An example is described in Beck et al. (1993). Here, a substance-abusing clientadmitted early in treatment that he was most prone to relapse during those timeswhen he thought things were going well and he would let his guard down. Later,this same client expressed a desire to leave treatment , saying everything's cool


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6 N E W M A N

n o w , I ' m f in e, s o I d o n ' t n e e d t o c o m e s e e y o u a n y m o r e : T h e t h e r ap i s t r e s p o n d e db y r e m i n d i n g h i m t h a t t hi s w a s t h e v ry s i t u a t i o n t o w h i c h t h e c l ie n t a l l u d e de a r li e r w h e n h e s a i d t h a t h e g o t in t r o u b l e e v e r y t i m e h e l e t h i s g u a r d d o w n .F o r g o o d m e a s u r e , t h e th e r a p i s t a d d e d , I w r o t e d o w n w h a t y o u sa id , b e c a u s eI t h o u g h t i t w a s p a r t i c u l a r l y s m a r t a n d h o n e s t o f y o u t o m a k e s u c h a s t a t em e n t .I t s o u n d s li ke y o u p r e d i c t e d t h a t t h i s w o u l d h a p p e n . W e l l d o n e I n t h is s ce -n a r i o , t h e c l i en t w a s a b l e t o a d m i t t h a t h i s d e c is i o n t o le a v e t h e r a p y m i g h t b ea b i t p r e m a t u r e , a n d h e c o u l d m a k e t h i s a d m i s s i o n w i t h a m i n i m a l l o s s o f p e r -c e i v e d a u t o n o m y .G e n t l y P e rs is t W h e n C l i e n ts S u b t l y A v o i d

T h e r a p i s t s s o m e t i m e s u n f o r t u n a t e l y r e i n f o r c e t h e i r cl i en t s ' r e s i s ta n c e w h e nt h e y a c c e p t t h e i r c li e n ts ' c o m m e n t s t h a t, I d o n ' t h a v e a n y t h i n g to t a l k a b o u tt hi s w e e k o r N o t h i n g ' s h a p p e n i n g i n m y li fe r i g h t n ow , o r M y m i n d i s a c o m -p l e t e b l a n k r i g h t n o w a t f a ce v a l u e w i t h o u t i n q u i r i n g f u r t h er . T h i s t a c t ic a l m i s -t a k e o f t e n w i l l l e a d t o t h e s e s s i o n b e c o m i n g f i l l e d w i t h i d l e c h i t - c h a t , a n d / o rt h e c l ie n t 's g a i n i n g t h e s e n se t h a t t h e r a p y i s a w a s t e o f t im e . O n t h e o t h e r h a n d ,i f t h e t h e r a p i s t a d d r e s s e s t h e c l ie n t 's a p p a r e n t l a c k o f a t h e r a p e u t i c a g e n d a a n d / o rr e l u c t a n c e t o t a lk a s t o p i c s i n t h e i r o w n r i g h t , m u c h c a n b e l e a r n e d a b o u t t h ec l i e n t ' s r e s i s t a n c e ( B e c k e t a l ., 1 9 9 3 ; S a f r a n & S e g a l , 1 9 9 0 ; Yo u n g , 1 9 9 0 ) .

U s i n g t h e m e t h o d o f S o c r a t i c q u e s t i o n i n g , a s w e ll a s a n e m p a t h i c , r e s p e c t fu la p p r o a c h , t h e t h e r a p i s t m a y a s k o r s ta t e t h e f o l lo w i n g i n o r d e r t o s t i m u l a t e f r u it f u ld i s c u s s i o n i n a s e s s i o n :

I ' m s u r p r i s e d t h a t y o u r e p o r t t h a t e v e r y t h i n g i s ' fi n e ' t h is w e e k . L a s t w e e ky o u p r e s e n t e d a v e r y d if f er e n t p i c tu r e , a n d y o u w e r e q u it e w o r r i e d a b o u t a n u m b e ro f o n g o i n g p r o b l e m s . H o w h a v e t h in g s c h a n g e d s o r a di c al ly ?

I f y o u f e e l t h e r e i s n 't m u c h t o d i s c u s s t h i s w e e k , w e c o u l d r e v i e w t h e o v e r a l lc o u r s e o f t h e r a p y t h u s f ar , so w e c a n s u m m a r i z e t h e m o s t i m p o r t a n t p r in c i pl e st h a t y o u ' v e l e a r n e d a b o u t y o u r s e l f a n d y o u r li fe a s a r e su l t o f o u r w o r k t o g e t h e r.W h a t d o y o u th i nk ?

Y o u a p p e a r t o b e q u i t e s u b d u e d - - m a y b e e v e n a l it tl e d i s t a n t t h i s w e ek . I ' ma li tt le c o n c e r n e d a b o u t t h i s. D o y o u r e a l iz e t h a t y o u a r e c o m i n g a c r o s s th i sw a y ? W h a t c o u l d y o u b e e x p e r i e n c i n g r i g h t n o w t h a t m i g h t a c c o u n t f o r t h is ?

W h a t a r e t h e c h a n c e s r i g h t n o w t h a t o u r l a c k o f a t o p i c t o d is c u s s r e fl e ct sa n ' o u t o f s ig h t , o u t o f m i n d ' t r a p t h a t w e ' v e f a l l e n i n t o ? I s it p o s s ib l e t h a t w e ' v eg o t t en a w a y f r o m t a l k in g a b o u t t h e m o s t i m p o r t a n t t h in g s , a n d t h e r ef o r e w e ' re' f o r g e t t i n g ' t h a t t h e s e i s s u e s e x is t ? I ' m w i l l i n g t o e x p l o r e t h i s f u r t h e r i f y o u a r e

I f t h i n g s a r e g o i n g s m o o t h l y i n y o u r li fe r i g h t n o w , d o y o u t h i n k i t w o u l db e a g o o d id e a t o d o s o m e t r o u b l e s h o o t i n g ? D o y o u t h i n k i t w o u l d b e h e lp f u li f w e l o o k e d a h e a d t o s o m e p o t e n t i a l s o u r c e s o f st re s s i n t h e f u t u r e , a n d d i s-c u s s ed h o w y o u m i g h t h a n d l e t h e m ?

' N r e y o u a w a r e o f t h i n g s y o u a r e f e e l in g o r t h i n k i n g r i g h t n o w t h a t y o u w o u l d


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n o t m e a n t h a t t h e t h e r a p i s t n e e d s t o b e h a v e h a r s h l y t o w a r d t h e cl ie n t. O n t h ec o n t r a r y , t h e m o s t e f fe c ti v e a n d h u m a n i s t i c u s e s o f t h e r a p e u t i c c o n f r o n t a t i o na r e e m b e d d e d i n a s p i ri t a n d s t yl e o f c o l l a b o r a t i o n ( N e w m a n , 1 98 8) . F o r e x -a m p l e , t h e t h e r a p i s t c a n m a k e l ib e r a l u s e o f t h e t e r m w e i n p l a c e o f t h e m o r ea d v e r s a r i a l y o u, a s i n , 1 4~ n e e d t o tr y to u n d e r s t a n d w h a t ' s g e t t in g in t h e w a yo f o u r f o ll o w i n g t h r o u g h w i t h o u r o r i g i n a l p l a n F u r t h e r , t h e t h e r a p i s t' s t o n e o fv o ic e a n d n o n - v e r b a l m a n n e r i s m s a r e o f c r it ic a l im p o r t a n c e . A l t h o u g h t h e c o n -t e n t o f w h a t t h e t h e r a p i s t is s a y i n g m a y r e a d a s if i t is h i g h l y a r g u m e n t a t i v eo r a c c u s a t o r y , t h e l iv e p r e s e n t a t i o n o f s u c h c a n b e d o n e i n a c a l m , c a r i n g t o n e ,a l o n g w i t h a r e l a x e d p o s t u r e a n d s y m p a t h e t i c f a c ia l e x p r e s s io n . A d d i t i o n a ll y ,t h e r a p i s ts c a n g e n t l y p r e p a r e t h e i r c li e n ts f o r c o n f r o n t a t i o n a l ( b u t c a r i n g ) s t a t e -m e n t s a n d q u e s t i o n s b y p r e f c i n g t h e i r r e m a r k s . F o r e x a m p l e :

I h o p e t h a t t h is w o n ' t s o u n d h a r s h o r u n s y m p a t h e t i c , b u t I m u s t t el l y o utha t . . .

' ~ t t h e r is k o f g e t t in g y o u a n g r y w i t h m e , c a n I p o i n t s o m e t h i n g o u t t o y o ut h a t I ' v e n o t i c e d ?

I h o p e y o u w o n ' t t a k e o f f e n se a t w h a t I ' m a b o u t t o s a y, b e c a u s e I h av e g o o di n t e n t i o n s a n d g o o d r e a s o n s ; b u t a s y o u r t h e r a p i s t i t' s m y p r o f e s s io n a l o b l i g a -t i o n t o d o a ll t h a t I c a n t o h e l p y o u , e v e n i f i t m e a n s y o u m i g h t b e c o m e a n g r yw i t h m e . I ' m w i l li n g t o t a k e t h e h e a t i f y o u a r e

( U s i n g h u m o r ) I ' m g o i n g t o b e a t r o u b l e m a k e r h e r e a n d s a y s o m e t h i n g al i t t l e c o n t r o v e r s i a l : '

T h e t h e r a p i s t c a n a l s o c h e c k f o r t h e c l ie n t 's r e a c t i o n s a f t e r th e c o n f r o n t a -t i o na l c o m m e n t i s m a d e , b y a s k i n g f o r f e e d b a c k i n t h e fo l lo w i n g m a n n e r : H o wd o y o u f ee l a b o u t w h a t I ' v e j u s t s a i d? I ' d w e l c o m e a n y r e b u t t a l , a n d I l l r e s p e c tw h a t y o u h a v e t o say . A f t e r a l l, I ' m j u s t m a k i n g a n o b s e r v a t i o n , b u t I d o n ' t h a v ea n y i l l u s i o n s t h a t I h a v e t h e i n s i d e t r a c k o n u l t i m a t e t r u t h

o n c l u s i o nW h e n c li en ts d o n o t i m p r o v e i n t r e a tm e n t , w e c a n n o t h i d e b e h i n d r a ti o n a li -

z a t i o n s s u c h as , T h e c l i e nt d i d n ' t r e a l ly w a n t to c h a n g e ; o r T h e c l ie n t w o u l dr a t h e r s u f f er t h a n g e t w e l l ; o r T h e c l ie n t w a s n ' t ' r e a d y ' f o r t r e a t m e n t : A s c o g -n i t i v e - b e h a v i o r a l s c i en t is t s, w e h a v e a n o b l i g a t i o n t o u n d e r s t a n d a n d t o a d d r e s st h e p h e n o m e n o n o f r e s i st a n c e a s p a r t o f o u r w o r k i n a ss e s s in g a n d t r e a t i n g c l ie n ts .I f c l ie n ts s e e m i n s u f fi c i e n tl y m o t i v a t e d f o r t r e a t m e n t , i t i s i n l a r g e p a r t o u r r e s p o n -s ib i li ty t o t r y t o d e v e lo p a n d t o u ti l iz e o u r k n o w l e d g e a n d t e c h n o l o g y to i n c r e a s ec l ie n t s' m o t i v a t i o n f o r h e a l t h y c h a n g e a n d g r o w t h .

T h e r a p i s t s c a n h e l p m o d i f y th e i r c l ie n t s' r e s i s ta n t b e h a v i o r s a n d a t t i tu d e sf ir s t b y t r y i n g t o u n d e r s t a n d t h e p h e n o m e n a o n a c a s e- b y - c a s e b a si s, i n s t e a do f p r e m a t u r e l y d r a w i n g b r o a d s w e e p i n g g e n e ra l c o n c lu s i o ns . I n o r d e r t o a c h ie v et h i s g o a l , t h e r a p i s t s m u s t f o r m u l a t e t h e c a s e c o n c e p t u a l i z a t i o n o n a n o n g o i n gb a s is , a n d m u s t a s k t h e m s e l v e s q u e s t io n s s u c h a s W h a t i s t h e f u n c t i o n o f t h e


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O ' D o n o h u e , W . , & K r a s n e r , L . ( 19 94 ). Ha ndb ook o f psychological skills training . N e e d h a m H e i g h t s ,M A : A l l y n & B a c o n .O v e r h o l s e r , J . C . ( 19 87 ). F a c i l i ta t i n g a u t o n o m y i n p a s s i v e - d e p e n d e n t p e r s o n s : A n i n t e g r a t i v e m o d e l .Journ al o f C ontemporary Psychotherapy, 1 7 ( 4 ) , 2 5 0 - 2 6 9 .O v e r h o l s e r , J . C . ( 19 8 8) . C l i n i c a l u t i l i t y o f t h e S o c r a t i c m e t h o d . I n C . S t o u t ( E d . ) , Annals of c l inicalresearch ( p p . 1 - 7 ) . D e s P l a i n e s , I L : F o r e s t I n s t i t u t e .O v e r h o l s e r , J . C . ( 1 99 3) . E l e m e n t s o f th e S o c r a t i c m e t h o d : I . S y s t e m a t i c q u e s t i o n i n g . Psychotherapy,3 0 (1 ) , 6 7 -7 4 .P e r s o n s , J . B . (1 9 8 9 ). Cog nitive herapy in practice: A case orm ulation approach. N e w Y o r k : W . W . N o r t o n .P e r s o n s , J . B . , B u r n s , D . D . , & P er l o ff , J . M . ( 1 98 8) . P r e d i c t o r s o f d r o p - o u t a n d o u t c o m e i n c o g n i -t i v e t h e r a p y f o r d e p r e s s i o n i n a p r i v a t e p r a c t i c e s e t t i n g . Co gnitive Therapy and Research, 12 , 5 5 7 - 5 7 5 .P r i m a k o f f , L . , E p s t e i n , N . , & C o v i , L . (1 98 9) . H o m e w o r k c o m p l i a n c e : A n u n c o n t r o l l e d v a r i a b l ei n c o g n i ti v e t h e r a p y o u t c o m e r e s e a rc h . I n W . D r y d e n & E T r o w e r ( E d s .) , Cognitivepsychotherapy:Stas is and change ( p p . 1 7 5 - 1 8 7 ) . N e w Y o r k : S p r i n g e r .S a f ra n , J . D . , & S e g a l , Z . V . (1 9 9 0 ). Interperson alprocess in cogn itive therapy. N e w Y o r k : B a s i c B o o k s.S e g ra v e s , R . T . (1 9 8 2 ). M arita l therapy: A combinedp sychodynam ic-behavioralapproach. N e w Y o rk : P l e n u mP re s s .T r o w e r , E , & D r y d e n , W . ( 1 98 9 ). R e s i s t a n c e i n a p r o c e s s a p p r o a c h t o s o c i a l s k i ll s t r a i n i n g : T h er o l e o f c o g n i t i v e b l o c k s a n d h o w t h e s e c a n b e o v e r c o m e . I n W . D r y d e n & E T r o w e r ( E d s . ),Cogn itive psychotherapy: Stasis an d change ( p p . 1 2 3 - 1 3 8 ) . N e w Y o r k : S p r i n g e r .Wa e h te l , E L . (E d . ) . (1 9 8 2 ) . Resistance. Psychodynamican d behavioralapproaches.N e w Y o rk : P l e n u m P r e ss .Y o u n g , J . E . (1 9 9 0 ). Co gnitive therapy or personality disorders: A schema-focusedapproach. S a r a s o t a , F L :P r o f e s s i o n a l R e s o u r c e E x c h a n g e .

T h e a u t h o r m a y b e c o n t a ct e d a t T h e C e n t e r f o r C o g n i t iv e T h e r a p y , 3 6 0 0 M a r k e t S t r ee t , S u i te 7 5 4,P h i l a d e l p h i a , P A 1 9 1 0 4 - 2 6 4 8 .R E C g lV E D : September 1, 1993.ACCEPTED: February 28, 1994.

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