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COGNITIVE AND BEHAVIORAL PRACTICE 1, 47-69, 1994

Understanding Client Resistance:


Methods for Enhancing Motivation
to Change
Cory E Newman
Center for Cognitive Therapy
University of Pennsylvania
Clients sometimes work in opposition to their therapists, a phenomenon known
as "resistance." Such behavi or is not simply an i mpedi ment to t reat ment , but also
a pot ent i al l y rich source of i nformat i on about each client. Thi s i nformat i on can
be assessed and utilized to strengthen the t herapeut i c relationship, hel p the ther-
apist bet t er underst and the ideographic obstacles to change, and devise interven-
tions t hat may motivate the client toward t herapeut i c activity and growth. Clinical
vignettes of t hree resistant clients are presented, illustrating bot h the commonal -
ties and uni que factors t hat l ead to resistance across cases. Eight i mpor t ant assess-
ment questions and 10 suggested interventions are listed and discussed in detail.
The practical applications of these methods in each of the t hree case studies shed
light on how therapists can enhance t hei r resistant clients' motivation for ther-
apeutic change.
Wh e n cl i ent s come t o t he r a py for hel p i n de a l i ng wi t h t hei r pr obl e ms i n l i vi ng,
i t is of t en cl ear t hat t hey a r e l ooki ng f or r el i ef f r om t he i r a c ut e affect i ve s ymp-
t oms . Fr equent l y, t hese cl i ent s a r e c ons i de r a bl y l ess c e r t a i n a b o u t wh e t h e r t hey
a r e wi l l i ng t o c ha nge t he i r l o n g s t a n d i n g pa t t e r ns of f unct i oni ng. The r e f or e , i t
is c o mmo n f or cl i ent s t o f ai l t o c ol l a bor a t e or c oope r a t e o p t i ma l l y wi t h t he t her -
api s t a n d t he t r e a t me n t pl an.
Thi s can cause t he r a pi s t s c ons i de r a bl e c ons t e r na t i on; af t er al l , i f we' r e us i ng
o u r c onc e r t e d ener gy, good wi l l , a n d exper t i s e t o hel p t he cl i ent s ove r c ome t he i r
47 1077-7229/94/047-06951.00/0
Copyright 1994 by Association for Advancement of Behavior Therapy
All rights O f reproduction in any form reserved.
48 NEWMAN
problems, why would they work in opposition to us? Furthermore, what are
we to do about this problem?
Therapeutic change is difficult and often somewhat frightening; therefore,
it is reasonable to expect many clients to evidence occasional signs of resistance
with treatment plans that attempt to induce such change. Indeed, traditional
psychodynamic therapists have viewed resistance as part and parcel of the ther-
apeutic process (Milman & Goldman, 1987; Wachtel, 1982)--the result of the
clients' ongoing conflict between their consciously professed desires to change
and their unconscious fears about losing their safe ground and sense of identity
(Fenichel, 1941; Glover, 1955; Greenson, 1968). From this theoretical point of
view, psychological symptoms serve a compensatory or defensive purpose for
the client (Basch, 1982). Therefore, at some level of awareness, the client 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 impediment
to the "real" work of therapy, cognitive-behavioral therapists would do well to
look at client resistance as important information in its own right -- information
that 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 understanding 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 function of the therapist's approach (e.g., Is the therapist acting
in 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 us t r a t i o ns o f Cl i e n t Re s i s t a nc e
The following are brief case illustrations that highlight various aspects of client
resistance. These cases will also be discussed in detail later in the paper in the
assessment and intervention sections.
Bart is a 43-year-old car salesman who is in therapy in the aftermath of his
divorce. His therapist attempts to educate Bart about the cognitive factors in-
volved in negative emotions such as dysphoria, anger, and guilt by encouraging
him to purchase the book Feeling Good(Burns, 1980). Week after week, Bart reports
that he has "forgotten" to buy the book, and the therapist politely explains that
although the book isn't necessary for treatment to proceed, it certainly will help
to facilitate progress. Therefore, it would be in Bart's best interest to get a copy
of the book as soon as possible. Finally, Bart arrives at a session and announces
that he has bought Feeling Good. The therapist, pleased to hear this, asks "What
have you read so far? Shall we discuss some of your reactions to what you've
U N D E R S T A N D I N G R E S I S T A N C E 49
read as part of our agenda for today' s session?" Bart smugly replies, "No, that
won' t work at all. I t hrew the book in the trash as soon as I got home. '
Sabri na is a 40 year-old, mar r i ed comput er pr ogr ammer who has ent ered
t herapy for chroni c depression and generalized anxiety. Earl y in t reat ment
Sabri na and her therapist conclude t hat the client's anxi et y and dysphori a are
triggered most often by thoughts about failing to meet her obligations, such
as deadlines for getting out the "bugs" in her programs at work, keeping up-to-
date in paying her bills, r et ur ni ng phone calls, and keeping her house from be-
comi ng cluttered and messy. She routinely assumes that there will be catastrophic
results from falling behi nd in these tasks, yet at the same time she minimizes
the potential positive effects of changi ng her behaviors so as to complete these
tasks. She chastises the therapist for showing optimism and giving encourage-
ment (e.g., "Oh, please! You can' t be serious! It's a hopeless situation and that' s
that. What' s the point of doi ng anyt hi ng different? It never works out anyway"),
and laments the fact that she isn't getting anyt hi ng out of this "Mi st er Rogers
therapy."
Mi t ch is a 26-year-old law st udent who presents with severe depression and
panic attacks. After 20 sessions of conjoint cognitive-behavioral therapy and phar-
macotherapy, Mi t ch has shown significant i mprovement on objective measures.
Hi s Beck Depression Invent ory (BDI: Beck, Ward, Mendel son, Mock, & Er-
baugh, 1961) and Beck Anxi et y Invent ory (BAI: Beck, Epstein, Brown, & Steer,
1988) scores have decreased markedl y (indicating reduced symptomatology),
he is socially mor e active, and he is no longer missing classes and assignment
deadlines due to hypersomni a and anergia. Nevertheless, Mi t ch continues to
present with subjective signs of distress, stating that "I know that everything
is going to fall apart in my life at any t i me" and "I think my problems are all
biological. I' m doomed to always have depression and anxiety" Each time the
therapist at t empt s to point out the client's objective progress, Mi t ch responds
incredulously, and continually asks the therapist to justify his position, where-
upon Mi t ch dismisses it anyway. The therapist begins to find working with Mi t ch
to be tiresome, repetitive, and frustrating, and has to work very har d to keep
these feelings in check.
In each of the cases above, the clients work in opposition to the therapist,
and they do so for seemingly unknown or "irrational" reasons. Further, their
actions do not effect any apparent benefit for themselves, and therefore come
across as gratuitously self-defeating. Ther e is often the t empt at i on on the part
of therapists to explain this occurrence by saying that "the client would rat her
suffer t han get well" "the client does not really want to change" or "the client
is not ' ready' for therapy" (comment s that the aut hor has caught hi msel f mut-
t eri ng under his breat h on mor e t han one occasion). At best, such pat explana-
tions are grossly oversimplified formul at i ons of the problem, and do not shed
any appreciable light on the clients' beliefs, learning histories, and motivations
t hat might account for t hei r part i cul ar form of resistance. At worst, such views
5 0 NEWMAN
prevent t herapi st s f r om t aki ng a dispassionate l ook at t hei r own cont ri but i on
to the pr obl em, increase t hei r count erproduct i ve feelings t oward t hei r clients,
and rei nforce clients' beliefs t hat t her apy is unhel pf ul .
We as therapists, when st umped and det erred by clients' resistant attitudes
and behavi ors, need to cur b our exasperat i on and t endency to arrive at general
(but per haps ill-informed) at t ri but i ons for the client' s behavior. Inst ead, t her-
apists must take an i deographi c approach to the assessment of each client' s re-
sistance or low mot i vat i on to engage in t r eat ment .
Assessment of Cl i ent Resistance
Some general signs of client resistance war r ant descri pt i on in great er detail,
for t hey represent c ommon phenomena in the t herapi st ' s clinical practice. How-
ever, al t hough the overt behavi or may l ook Similar across cases, it is vital to ex-
ami ne the uni que etiologic and mai nt ai ni ng factors for each client. For exampl e,
it is onl y mildly instructive to say t hat a client neglected to do a homewor k as-
si gnment because he or she was afrai d and lacking in confidence. I t is far mor e
i nformat i ve to be able to det er mi ne specifically what was fri ght eni ng for the
client, and precisely what aspects of the assi gnment he or she believed were be-
yond his or her capacity. Thi s involves an exami nat i on of how such fears and
low self-confidence developed, and how the client' s related cognitive, affective,
and behavi oral signs persist in spite of seemi ngl y negative consequences.
Summar i zed below are some of t he mor e common, general forms of client
resistance t hat t herapi st s encounter, followed by a series of assessment ques-
tions t hat can hel p t herapi st s to pr obe into the specific, i deographi c aspects of
the resistance.
Hi gh- Fr equency Forms of Cl i ent Resistance
A common ma nne r in which clients are resistant to t r eat ment is t h e i r f ai l ure
tofoUow through wi t h homework assignments or ot her agr eed- upon courses of action
between sessions. Thi s f or m of resistance is especially t r oubl esome in t hat many
opport uni t i es for t herapeut i c l earni ng and pract i ce in the nat ural envi r onment
are lost when clients neglect to engage in t hei r assignments. A numbe r of
cogni t i ve-behavi oral aut hors have not ed t hat neglect of homewor k is associated
wi t h slower rates of i mpr ovement and poor er post t herapy mai nt enance (Burns
& Auerbach, 1992; Burns & Nol en- Hoeksema, 1991; Nei meyer & Feixas, 1990;
Persons, Burns, & Perloff, 1988; Pri makoff, Epstein, & Covi, 1989). Unf or t u-
nately, many t herapi st s are apt to abandon f or mul at i ng and collaboratively as-
signing homewor k when t hei r clients are cont i nual l y resistant (in essence, the
clients' lack of responsi vi t y to the assi gnment s extinguishes the t herapi st s' ap-
pr opr i at e behaviors). Inst ead, it would be beneficial to investigate the clients'
overt and covert reasons for not doi ng t hei r homework, and to cont i nue to for-
mul at e assi gnment s.
UNDERSTANDING RESISTANCE 51
Anot her sign of client resistance is seen in those cases where clients react
to t hei r own objective i mpr ovement wi t h skepticism, rel uct ance to work t oward
independence (e.g., termination), and regression (Mei chenbaum & Gilmore, 1982).
These are the clients who seem to want to r emai n in t r eat ment l onger t han the
t herapi st ma y believe it is necessary or helpful to do so. These are also the clients
t hat therapists all too often see as merel y bei ng self-defeating and gladly choosing
to hol d ont o t hei r dysfunct i onal ways.
Yet anot her mani fest at i on of client resistance is in hi gh levels o f expressed emotion
t o wa r d the therapist, from hostility to overt flirtation. Al t hough t here may be times
when such client emot i ons may be under st andabl e in react i on to mal adapt i ve
t herapi st behavi ors t hat pull for these responses, t here are many cases when
ext reme levels of clients' emotionality represent their own characteristic patterns.
Ther api st s who t reat clients who suffer from borderl i ne personal i t y disorder,
for exampl e, are well aware of this phenomenon (Layden, Newman, Fr eeman,
& Morse, 1993; Li nehan, 1993).
Ot her less dramat i c, yet still pr obl emat i c signs of resistance involve subt l e
avoidances i n session. For exampl e, clients may state at the st art of a session t hat
t hey have "not hi ng to discuss today," or t hey may be pr one to answer most of
the t herapi st ' s salient, pr obi ng questions wi t h the pat answer "I don' t know:
Under st andi ng the Factors Tha t Are Uni que to Each Cl i ent
I n response to resistance, t herapi st s need to consi der the following eight as-
sessment questions:
(1) Wh a t i s the f u n c t i o n o f the client's resistant behaviors? I t is useful to engage the
clients in an earnest expl orat i on of the factors t hat make it in the client' s "best
interest" to oppose the t herapi st and/ or the course of t r eat ment . I n the case of
Mi t ch, the t herapi st noticed t hat the client would smile and become uncharac-
teristicaUy ani mat ed at precisely those t i mes when he would rebuff, contradict,
or challenge the therapist. I n response to Mitch' s next smile and energetic banter,
t he t herapi st asked, "I couldn' t hel p but notice t hat you were smiling j ust then.
What goes t hr ough your mi nd when we i nt eract like this?" Mi t ch chuckled, "I
guess it makes me feel good if I can make you sweat :
Upon furt her discussion, Mi t ch and the t herapi st hypot hesi zed t hat Mi t ch
felt mor e intelligent and wort hy if he could engage (and per haps defeat) the
t herapi st in debates. By contrast, Mi t ch felt weak and i gnorant when he would
accept new i nf or mat i on f r om the t herapi st wi t hout question. ( The t herapi st re-
plied t hat he wel comed the client' s questions and challenges, but added t hat
t here mi ght be a heal t hy mi ddl e ground bet ween meek accept ance and fierce
rej ect i on of all t hat the t herapi st would say).
Further, Mi t ch st at ed t hat he felt mor e "in control" when he would verbally
spar with the therapist. Thi s phenomenon calls to mi nd Br ehm and Brehm' s
(1981) "react ance theory," which holds t hat clients act to mai nt ai n t hei r sense
of freedom. The i mpl i cat i on is t hat clients may react adversely to the percept i on
52 NEWMAN
t hat t hei r t her api st s ar e t r yi ng t o cont r ol t hem, even i f t hei r hel pers seem be-
ni gn and t he t r eat ment seems t o make sense. I n this f r amewor k, clients who
def y t her api st s ar e not mer el y sel f-defeat i ng or gr at ui t ousl y opposi t i onal , but
r at her ar e a t t e mpt i ng t o def end t hei r a u t o n o my (albeit i n a dys f unct i onal way).
Th e r e are a n u mb e r of ways t hat a t her api st can ant i ci pat e t hat a cl i ent will
be likely t o def end his or her a ut onomy vi a t her apeut i c resistance. On e pr edi ct or
is a hi st or y of opposi t i onal behavi or t owar d aut hor i t y fi gures (see assessment
quest i on 2 bel ow for mor e i nf or mat i on on hi st ori cal factors). Anot he r pr edi ct or
is a hi gh score on pr et her apy assessment measur es such as t he Ther apeut i c Reac-
t ance Scale (Dowd, Mi l ne, & Wi se, 1984). Di agnost i c i nf or mat i on al so can ear-
ma r k such a client. For exampl e, clients who meet DS M- I I I - R (APA, 1987)
cri t eri a for personal i t y di sorders such as passive aggressive, obsessive-compulsive,
and ant i soci al are by def i ni t i on pr one t o be hi ghl y i nvest ed i n ma i nt a i ni ng con-
t rol over t hei r choi ces and behavi ors, even i f this creat es confl i ct wi t h ot hers,
i ncl udi ng t hei r t herapi st s.
(2) Ho w does the client's current resistance f i t into his or her developmental~historical
pattern of resistance? Sub- quest i ons t o ponder, and per haps t o ask t he client directly,
i n c l u d e - - " Wh e n and u n d e r what ci r cums t ances has t he cl i ent been si mi l arl y
di si ncl i ned t o t r y t o change or accept hel p i n t he past?"; " Wha t ot her r el at i on-
ships i n t he cl i ent ' s past and pr esent ar e called t o mi n d by t he cur r ent confl i ct
bet ween t he client a nd t herapi st ?"; and " How is t he cur r ent scenar i o i n t her apy
si mi l ar t o and di st i nct f r om pr evi ous si t uat i ons i n t he client' s life whe n he or
she resi st ed change or di r ect i on?"
I n Bart ' s case, t he client coul d i dent i f y n u me r o u s t i mes i n his life when he
bel i eved t hat someone' s offers of hel p and advi ce were t hi nl y- di sgui sed at t empt s
t o l ead hi m ast r ay and t ake advant age of hi m. He vi ewed t he t herapi st ' s sugges-
t i on t o pur chas e Feeling Good as i nvol vi ng mot i ves of f i nanci al self-interest on
t he par t of t he t her apeut i c agency, a nd he felt it was not i n hi s best i nt erest t o
compl y. As i n t he past, hi s chi ef mo d e of resi st ance was a passive demons t r at i on
of pr ot est and hostility. Bar t ha d f ound t hat passive resi st ance was t he easiest
way t o count er - at t ack what he vi ewed as hi s empl oyer ' s unr eas onabl e de ma nds
and hi s mot her ' s and f or me r wife' s undue at t empt s t o cont r ol hi m. Unwi t t i ngl y,
hi s r esponses had exacer bat ed t hei r at t empt s t o t r y t o change hi m, whi ch fur-
t her fuel ed his mi st r ust .
(3) What might be some of the client's idiosyncratic beliefs that are f eedi ng into his or
her resistance? I t is ver y useful t o l ook i nt o t he uni que ways t hat clients i nt er pr et
var i ous si t uat i ons, as this ma y shed l i ght on why t he clients t hi nk t hat it is war-
r ant ed, necessary, and benefi ci al f or t he m t o resist change. For exampl e, re-
gar di ng Bart ' s di s car di ng o f Feeling Good hour s af t er pur c ha s i ng it, t he t her api st
asked, "Bart, what was goi ng t hr ough your mi nd whe n you left t he st ore wi t h
t he book i n hand?" Af t er some puzzl ed refl ect i on, he repl i ed, "I not i ced t hat
t he guy who wr ot e it wor ks at this Cent er , and I said, ' Geez' ! " Th e t her api st
t hen added, "And what di d t hat me a n t o you?" Bart r et or t ed, "Well, you want
UNDERSTANDING RESISTANCE 53
peopl e like me to buy your books so you can make mor e money. It ' s really not
because it'll hel p me"
Once again, as Bart historically had done, he i nt er pr et ed a beni gn act as
a sign t hat someone was t ryi ng to take advant age of him. Therefore, even t hough
it seemed a waste to discard a book he had j ust purchased, Bart' s behavi or made
sense in the context of a bel i ef syst em t hat said it was a bad idea to compl y with
anyone who si mpl y wants to exploit you. Wi t hi n this bel i ef system, Bart had
not t aken into account the following da t a - - t ha t he was recei vi ng free therapy,
t hat the book was an inexpensive paperback, and t hat the aut hor had been inde-
pendent of the Cent er for many years. Bart' s f undament al mi st rust for others
became a focal issue in therapy, somet hi ng t hat mi ght have been overlooked
had the t herapi st mer el y ascri bed the client' s behavi or to a general mot i vat i on
not to get well.
I n the case of Sabri na, the t herapi st asked, "What goes t hr ough your mi nd
when I give you support and encour agement , and when I suggest t hat you can
make great strides by bei ng mor e active in t aki ng care of your bills, household,
and comput er work? What keeps you t hi nki ng t hat it's hopeless and futile to
change or i mprove your life?" Sabrina' s repl y was unexpect ed and quite enlight-
ening. She not ed t hat "all the great writers and intellects in the world are
depr essed" and t hat "you can' t take an opt i mi st seriously, because the world is
so screwed up t hat nobody wi t h an ounce of brai ns could possibly be an op-
timist!" Clearly, she had i nt erpret ed her therapist' s positive verbal rei nforcement
as indicative of a sappy, si mpl e-mi nded appr oach to life. Further, she viewed
hersel f as an intelligent person and wri t er (her chief avocation), and she cer-
t ai nl y wasn' t goi ng to give up her member s hi p in the "depressed great writer' s
society" wi t hout a fight. Therefore, she resisted change t hat mi ght i mprove her
mood.
As the case exampl es illustrate, a central met hod for calling at t ent i on to the
clients' resistance is the therapist' s i nqui ri ng about the clients' t hought s t hat pre-
cede or accompany t hei r negat i ve react i ons to the t herapi st s' suggestions. The
t herapi st can ask about t hought s t hat a resi st ant client is havi ng live in session
(e.g., "You rolled your eyes as I was expl ai ni ng my poi nt of view j ust now. What
went t hr ough your mind?"), or reflect on relevant t hought s t hat he or she had
bet ween sessions (e.g.; "What were you t hi nki ng as you cont empl at ed doi ng the
homework, and what were the t hought s t hat convi nced you not to do it?").
(4) What might the client fear will happen i f he or she complies? Al t hough the ther-
apist may believe t hat change is a good thing, clients may have mi sgi vi ngs t hat
must be acknowledged and addressed. For example, some clients (especially those
wi t h mor e l ongst andi ng issues and serious probl ems) cling t enaci ousl y to the
status quo in t hei r lives because to some ext ent it is fami l i ar and safe. To change
would mean to vent ure i nt o the unknown, which can be very fri ght eni ng and
di sori ent i ng to many clients (cf. Beck et al., 1990; Layden et al., 1993; Young,
1990), Clients may view changi ng as i ncur r i ng furt her difficulties in t hei r lives,
54 N E W M A N
such as increased demands and decreased caretaking from others. Thi s induces
fear, and often leads to avoidance. In some instances, clients fear t hat they will
lose t hei r sense of i dent i t y if they change. For example, Mahoney (1991) has
wri t t en about the "self-preserving function" of resistance, and presents a case
example where a client claims that in order for hi m not to be depressed he would
have to be a "different person." I n such cases, clients equat e change with annihi-
lation.
In the case of Mitch, the client did not fear change per se. However, he dreaded
the possibility that the therapist would take all the credit for whatever therapeutic
i mprovement s t hat Mi t ch made, while Mi t ch would be left feeling di scount ed
and possibly even shamed. (See poi nt 8 below for furt her explanation. )
(5) H o w mi ght the client be characteristically mi sunderst andi ng or misinterpreting the
therapist's suggestions, methods, a n d intentions? At times a client's failure or refusal
to collaborate with the therapist may be the result of a simple misunderstanding.
For example, Sabri na became silent in session because she t ook offense at what
she perceived to be an insult from the therapist. When the therapist i nqui red
about this, it became clear t hat Sabri na had misheard what the therapist said.
In reality, the therapist had been poking fun at h i ms e l f with a self-disparaging
comment .
In ot her more serious cases, the clients' negatively biased beliefs and infor-
mat i on processing lead t hem consistently to misconstrue i nt erpersonal situations
(Safran & Segal, 1990). Thi s leads to anger and ot her negative emotions that
contribute to the clients' resistance. For example, Bart tended to read threatening,
exploitive, and demeani ng things into what people were saying to him. Ther e-
fore, when the therapist suggested t hat he purchase and read Feeling Good, Bart
was predisposed to look for reasons why it would be against his best interest
to follow through. He did not underst and the concept of bibliotherapy, and there-
fore needed an explicit rationale as a starting point to overcome his reluctance
to read the book.
(6) Wh a t s ki l l s does the client lack t hat mi g h t make i t practically di f f i cul t or impossible
at t hi s p o i n t f o r h i m or her to actively collaborate w i t h treatment? Therapi st s must assess
t hei r clients' psychological skills (e.g., problem-solving, planning, communi ca-
tion, rational responding, perspective-taking; el. O' Donohue & Krasner, 1994)
in or der to det ermi ne how much of t hei r resistance is motivational and how
much represents deficits in funct i oni ng (Trower & Dryden, 1989). For example,
failure to follow t hrough on written homework assignments may reflect a reading
or at t ent i onal deficit. Similarly, a client's reluctance to engage in i nt erpersonal
behavioral experi ment s may signal a lack of social skills and/ or assertiveness.
When this is the case, graded instruction and practice are required in the therapy
sessions themselves before clients can be expected to generalize these behaviors
to everyday life ( Mei chenbaum & Turk, 1987; O' Donohue & Krasner, 1994).
Even when clients demonst rat e a reasonable level of psychological skills, they
may still manifest resistant attitudes and behaviors because t hey believe t hat they
UNDERSTANDING RESISTANCE 55
are incapable and helpless to follow through. In such cases, it is imperative to
critically exami ne the basis for the client's sense of hopelessness and low self-
efficacy (Beck, Rush, Shaw, & Emery, 1979).
(7) What factors in the client's natural environment may be puni shi ng the client's attempts
to change? It is sometimes unwise for therapists to assume t hat the client's
praiseworthy changes in session will be similarly positively reinforced in the client's
everyday life. For example, factors in the client's personal life or work situation
may serve as strong disincentives for the client to change (Gol den, 1989). I f the
therapist is unaware of these outside variables, he or she may conclude errone-
ously that the client alone is responsible for the impasse in therapy. Thus, the
therapist may become exasperat ed with the client's giving lip service to change,
and may fail to pursue relevant issues that explain the resistance.
Thi s can be seen in the case of a client who has been referred by his physician
for psychological t reat ment as a result of his hypert ensi on and related cardio-
vascular symptoms. The client states t hat his goal is to "learn to relax, not work
so hard, and not get so angry" However, the client does not follow t hrough with
the t reat ment pr ogr am t hat includes relaxation, revised work hours, and var-
ious anger control techniques. Although it is t empt i ng to explain the client's
resistance as bei ng a funct i on of his "Type-A" or "obsessive-compulsive" person-
ality, t here may be a host of envi ronment al factors that work against t herapeut i c
change. These may include a critical fat her who still demands perfection from
the client and a j ob where long work days and an aggressive approach are highly
lauded. When these types of variables are identified and addressed, the ther-
apist will have much great er leverage in hel pi ng the client to overcome his resis-
tance to change.
Anot her exampl e is the case of a woman who seeks t herapy for "depression
and low self-esteem" but doesn' t ment i on that her husband is emot i onal l y abu-
sive. When the therapist explains that the client's sympt oms could be alleviated
in part by her l earni ng to be more assertive, the client seems enthused. How-
ever, before the next session the client telephones the therapist, tearfully saying,
"You've been a great help to me, and I won' t need to come back anymore. Please
don' t t ry to call me, I'll be f i n e . . , really" The client's failure to follow t hrough
with t r eat ment in this case likely is based on the disapproval and puni shment
received from the abusive husband in response to the client's at t empt s to stand
up for herself. Therapi st s who are aware of such potential envi ronment al ob-
stacles to change, and who consider t hem in formul at i ng a t reat ment plan, have
a bet t er chance of effecting gradual changes t hat may encount er less backlash
t han the rat her tragic case described above.
(8) Does my conceptualization of this case need to be revised or amended? What do I
st i l l need to understand about this client in order to make sense of his or her resistance? When
a client rejects a therapist' s formul at i ons or suggestions by saying (or thinking),
"Doctor, you j ust don' t under s t and; sometimes they' re right! It is advisable for
t he r a pi s t s - whe n they are st umped by t hei r clients' r e s i s t a nc e - t o consider the
5 6 NEWMAN
likelihood t hat t hey are mi ssi ng or overlooking i mpor t ant data. For exampl e,
Mitch' s t endency to debat e wi t h the t herapi st and deny t hat he was i mpr ovi ng
was bet t er under st ood aft er the t herapi st reviewed old session notes in search
of concept ual clues. Specifically, Mi t ch had expl ai ned t hat his ol der br ot her had
always been the "favored son" in his fami l y of origin. The fat her often made
compari sons bet ween the client and his brother, and usually found the client
wanting. As a by-product of this set of fami l y interactions, Mi t ch grew to har bor
a fierce compet i t i veness and r esent ment t oward the older brother.
Exacer bat i ng this pr obl em was the ol der brot her' s t endency to t ry to "help"
Mi t ch by giving hi m unsolicited advice about what he should do and how he
should do it. I n therapy, Mi t ch bi t t erl y r ecount ed an episode f r om his school
days when he studied ext remel y har d to get an ' ~" on a mat h exam, onl y to
have his fat her sing the praises of the older br ot her for havi ng t ut ored Mi t ch
so well and "setting such a great exampl e"
These historical dat a hel ped the t herapi st to add a new and i mpor t ant facet
to his case concept ual i zat i on of Mi t ch. The therapist, real i zi ng t hat he was close
in age to Mitch' s brot her, hypot hesi zed t hat Mi t ch was percei vi ng and react i ng
to the t herapi st as he would his older brother. I f this were the case, Mi t ch likely
would resent the therapist' s professional status, his suggestions about what Mi t ch
"should do and how he should do i t ; and his role as "superior." Thi s phenomenon
is well-known in the t radi t i onal psychoanalytic l i t erat ure as "transference," but
has also been recogni zed by cogni t i ve-behavi oral clinicians under the rubrics
of"i nt erpersonal schemas; or"i n vivo interpersonal overgeneralization" (cf. Gold-
fried & Hayes, 1989; Gol dfri ed & Newman, 1992; Segraves, 1982).
The therapist postulated t hat Mi t ch was reluctant to acknowledge t hat t herapy
was hel pi ng hi m, lest the t herapi st (like the older brot her) take all the credit
for "setting such a great exampl e" while Mi t ch would receive no credit for his
own efforts in overcoming depression. I f this were how Mitch truly viewed therapy,
t hen it mi ght st and to reason t hat he believed he could succeed (i.e., defeat his
older brot her) onl y by t hwart i ng the t herapi st at every turn. The t herapi st
present ed this t ent at i ve hypothesis to Mi t ch in as humbl e and support i ve a
ma nne r as possible, with highly favorable results (see the Int ervent i ons section
for furt her details).
Interventions for Improving Client Motivation
Ther e are a numbe r of ways t hat t herapi st s can work to mot i vat e t hei r clients
to engage mor e actively and effectively in t r eat ment . These include met hods
such as: (i) Educat i ng the client about therapy; (2) Usi ng the Socratic met hod;
(3) Pr ovi di ng the client with choices and an active say; (4) Col l aborat i ng and
compr omi si ng; (5) Revi ewi ng the pros and cons of change, and the pros and
cons of cont i nui ng wi t h the psychological status quo; (6) Provi di ng accurat e
empat hy for the client' s resistance; (7) Di scussi ng the case concept ual i zat i on
U N D E R S T A N D I N G R E S I S T A N C E 57
with the client; (8) Speaki ng the client' s "language"; (9) Maxi mi zi ng the use of
client self-direction; (10) Being gently persistent when a client is "stuck"
I n general, all of these i nt ervent i ons are helpful in count eract i ng client resis-
t ance right f r om the out set of therapy. However, t hey become part i cul arl y effec-
tive to the ext ent t hat the t herapi st makes use of the af or ement i oned assessment
questions and comes to formulate a sophisticated case conceptualization (Persons,
1989) as t r eat ment progresses. I n this manner, the t herapi st can put special em-
phasis on those i nt ervent i ons t hat best fit the part i cul ar needs of each individual
client.
Educat e the Cl i ent About Ther apy
An i mpor t ant and basic way to maxi mi ze clients' preparedness for t herapy
is to provide education about therapy (Mei chenbaum & Turk, 1987; Young, 1990).
Clients often do not under st and what to expect when t hey ent er therapy, part l y
as a function of the diversity of the field, part l y due to mi sconcept i ons bor ne
of sensationalized or unfl at t eri ng port rayal s of t herapi st s on television and in
movies, and somewhat as a funct i on of t hei r own biases and mi sconcept i ons
(e.g., "Ther apy is like a magi c pill. I' ll j ust show up and the t herapi st will say
all the right things to make me better").
A cooperat i ve alliance can be established mor e readi l y by educat i ng clients
about t herapy (Macaskill, 1989; Maeaski l l & Macaskill, 1983). Thi s would in-
elude an expl anat i on of the model of t r eat ment (e.g., cogni t i ve-behavi oral
t herapy), a previ ew about the expect ed l engt h and subst ance of the course of
therapy, and a discussion about the roles and responsibilities of bot h the ther-
apist and the client. A numbe r of tacks can be t aken in or der to achieve this
goal, including: (1) Gi vi ng clients suppl ement al readi ngs at the start of therapy,
such as Beck and Gr eenber g' s (1976) Coping with Depression, which provides an
i nt roduct i on to the cognitive model of depression, or Burns' s (1980) Feeling Good,
which is perhaps the most widely read "t ake-home guide" to cognitive therapy;
(2) Provi di ng clients with a verbal and wri t t en ori ent at i on to their personal roles
in the t herapy process (e.g., Young, 1990), so as to ant i ci pat e and pr ompt l y ad-
dress the kinds of mi sgi vi ngs and apprehensi ons t hat clients often have about
t hei r decision to ent er t herapy; (3) Di st ri but i ng comprehensi ve gui debooks t hat
outline and explain the ent i re course of t herapy as it will unfol d (e.g., Grieger,
1989), a process t hat is anal ogous to following a t ext book chapt er by chapt er
as one progresses t hr ough a college course; and (4) Periodically discussing the
clients' progress wi t h t hem dur i ng the course of t r eat ment in order to reassess
and updat e goals, evaluate measur abl e gains to date, and answer questions t hat
have cropped up.
The process of educating clients about therapy continues t hroughout the course
of t reat ment . I t helps to demyst i fy the experience, it makes clients mor e
knowledgeable consumers, and it facilitates the clients' willingness to collaborate
wi t h the t herapi st t oward common goals.
58 NRWMAN
In the case of Sabrina, the therapist responded to the client's assertion that
she was receiving "Mi st er Rogers therapy" by explaining t hat rational restruc-
t uri ng techniques were not synonymous with idle positive thinking or "sticking
one's head in the sand?' He stressed that cognitive t herapy met hods involved
t eachi ng clients to t hi nk more objectively and constructively so t hat real prob-
lems could be put into bet t er perspective and dealt with proactively. The ther-
apist explained t hat he would not mi ni mi ze her problems or tell her superfi-
cially to "look on the bri ght side of life?' He added t hat t herapy was har d work,
involving empirical met hods and systematic application of techniques.
In order to intervene furt her in disabusing Sabri na of her misconstrual of
the purpose and met hods of cognitive-behavioral therapy, the therapist recom-
mended t hat she read Ellis and Harper' s (1975) A New Guide to Rational Living
and EUis and Knaus' s (1977) Overcoming Procrastination. The therapist specifically
chose books by Ellis and his colleagues as these publications t end to be very
direct in presenting the view t hat life/~ t ough and unfai r (a view with which
Sabri na was quite sympatico), but t hat t here is a mi ndset and a t echnol ogy to
deal with this unfort unat e fact.
Use the Socratic Met hod
Clients have been known to resist i ncorporat i ng t hei r therapists' most well-
meani ng and accurate feedback simply because the clients didn' t think of it first.
Therapists can circumvent this probl em if they make judicious use of the Socratic
met hod. Thi s involves asking a clever series of questions that leads the client
in the direction of synthesizing i nformat i on and drawing a set of conclusions,
the likes of which will be more likely to be r emember ed and followed because
it was the client who generat ed t he i nformat i on (Beck et al., 1979; Beck, Wright,
Newman, & Liese, 1993; Overholser, 1987; 1988; 1993). In or der to make the
most effective use of Socratic questioning, the therapist must have a goal in mi nd
(similar to plotting a chess strategy four or five moves in advance), must be willing
to accept and pursue client responses that seem counterintuitive, and must under
no circumstances browbeat the client (e.g., with hostile-sounding rhetorical ques-
tions) into agreei ng with the therapist' s viewpoint.
The Socratic met hod is especially useful in dealing with clients who highly
value t hei r autonomy, and/ or fear bei ng controlled by t hei r therapists. Addi-
tionally, the Socratic met hod helps to minimize misunderstandings between ther-
apist and client, as the client produces much of the data. Therefore, the chances
t hat a client who may frequent l y distort what others say will mi sread or mistrust
the therapist' s comment s are reduced.
Provi de Choices
Br ehm and Brehm' s (1981) "reactance theory" posits that clients will behave
in ways t hat preserve t hei r freedom, even if the behavi or seems count ert her-
apeutic. Wi t h this in mi nd, it is wise to give the client some say in the direction
UNDERSTANDING RESISTANCE 59
of a given session or in the entire course of therapy. One basic method of achieving
this goal is by showing respect for the client's agenda (e.g., "What would you
like to focus on in today' s session?"). Anot her is to provide options (e.g., "For
homework, you could choose to focus on the readings, the daily t hought records,
or our proposed behavioral experiments, or any combinations of the above. What
do you think would be best for you right now?"). The therapist does not com-
pletely t urn over the reins to the client, but instead provides a set of choices
within appropriate therapeutic limits and j udgment . Miller and Rollnick (1991)
report that they have had success in implementing this principle in working with
substance abusers who are ambivalent about change.
Bart's discarding of his copy of Feeling Good sparked therapeutic discussion
about his basic sense of mistrust. At the same time, the therapist backed off
his specific recommendat i on that Bart read Feeling Good, and presented him with
a list of self-help supplemental readings from which to select the materials of
his choice. He opted for Ellis and Harper' s (1975)A N e w Guide to Rat i onal Li vi ng,
and was satisfied t hat it would be beneficial for him to study and discuss its
principles in treatment.
Collaborate and Compromise
Give-and-take and reciprocity are two hallmarks of healthy relationships. To
a large degree, this is true of the therapeutic relationship as well (with the notable
exceptions of the lack of commensurate therapist self-disclosure or the ret urni ng
of romant i c gestures). Al t hough the therapists certainly "run the show" in that
they are on their own t ur f (their offices) and possess the specific expertise to
be the aut hori t y figures in the therapeutic relationship, t hey are likely to en-
count er significant resistance i f the clients view therapy as a benevolent dic-
tatorship (for some clients with mistrust issues this t erm is an o x y mo r o n - i n
their view, anyone who dictates is by definition malevolent). Therapists can create
an atmosphere of cooperation by bei ngf l exi bl e, such as by being willing to relin-
quish a hypothesis that doesn't fit the client's data, by respecting the client's wishes
to change the topic of discussion if anot her pressing mat t er needs to be given
attention, and by being willing to admi t mistakes or apologize when the situa-
tion calls for it (e.g., being late for a session) amongst other ways (Beck et al.,
1979; Beck et al., 1993).
On the other hand, good therapy, like good parenting, is not a popularity
contest. Although the therapist may be tempted at times to go along with whatever
the client's agenda may be in order to earn the client's positive regard and trust,
this strategy is decidedly inadvisable when taken to the extreme. Therapists must
be willing to provide some measure of structure, direction, guidelines, and limits
(Ellis, 1985; 1989), or else the client will not receive vital corrective feedback,
and therapy will be (at best) a very inefficient process. The key is for therapists
to remi nd their clients in a respectful, humbl e manner that collaboration is a
two-way street, and t hat al t hough the client's views will be taken seriously, there
60 N E W M A N
will be times when the t herapi st s' professional j udgment will need to prevail.
One particularly helpful met hod t hat is common in cognitive-behavioral t herapy
is to couch differing poi nt s of view bet ween client and t herapi st in t er ms of com-
pet i ng hypotheses t hat can be tested. By t aki ng this collaborative stance, therapists
can find a mi ddl e gr ound bet ween a pedagogi cal appr oach and a "permissive"
approach, each of which mi ght otherwise feed into the client's resistance to change.
Revi ew the Pros and Cons of Changi ng and Not Changi ng
A funct i onal analysis of a client' s mal adapt i ve behavi ors and at t i t udes t hat
seem resi st ant to change often reveals t hat the client idiosyncratically believes
t hat it is in his or her best interest n o t to change. For exampl e, a socially avoi dant
young ma n may under st and t hat his fear of appr oachi ng women is exacerbat i ng
his loneliness, but he may si mul t aneousl y believe t hat to t ry to speak to women
would be far worse, bri ngi ng rejection and humiliation. I n the eyes of this client,
all things considered, he has a choice bet ween "bad" (bei ng lonely) and "worse"
(being a lonely laughingstock), and t herefore chooses to r emai n avoidant, which
he views as the lesser of two evils.
These beliefs are fruitful poi nt s of i nt ervent i on in t r eat ment . Clients may
be mor e inclined to reconsider their st at us-quo-engenderi ng beliefs if they realize
t hat the t herapi st can under st and t hei r reasons for bei ng hesi t ant to change.
Gri l o (1993) suggests t hat t herapi st s engage t hei r clients in, " . . . a detailed
review of all the pot ent i al pros and cons in changi ng a behavi or pr i or to at-
t empt i ng to change . . ." (p. 220). He notes t hat t herapeut i c col l aborat i on is
facilitated when therapists show t hat they are willing to look at the cons of change.
I n si mi l ar fashion, Beck et al. (1979) have found t hat suicidal clients appreci at e
the t herapi st ' s bei ng willing to exami ne bot h the pros and cons of suicide. Beck
et al., 1993, likewise have hel ped addi ct ed i ndi vi dual s by eval uat i ng the pros
and cons of bot h usi ng and not usi ng drugs. Clients t hen become mor e apt to
cooperat e in the exercise of reviewing the l o n g - t e r m costs involved in n o t changing,
i ncl udi ng the ki nd of personal st agnat i on t hat has been i mpl i cat ed in some
people' s increasing unhappiness and bitterness as they grow older (Erikson, 1963).
Thus, client recept i vi t y to change is enhanced.
Sabr i na was rel uct ant to rel i nqui sh her cynical view of the world and life
because she believed t hat negative t hi nki ng was positively correl at ed wi t h hi gh
intelligence. One of Sabrina' s few sources of satisfaction in life was her intellect,
and she was loathe to adopt any measures t hat she deemed a t hreat to her high-
brow self-image. Therefore, she was able to identify t hat an "advantage" of mai n-
t ai ni ng her depressive t hi nki ng was t hat she would cont i nue to feel superi or to
others. On the ot her hand, Sabr i na acknowl edged t hat a di sadvant age to this
appr oach was t hat she would cont i nue to be depressed and anxious, and t hat
she would be less likely to enri ch her life. On the flip side, a di sadvant age to
changi ng her t hi nki ng style would be t hat she would feel di sori ent ed and "not
herself," while an advant age mi ght be i mpr oved success in compl et i ng i mpor -
t ant tasks and in getting al ong bet t er wi t h others.
UNDERSTANDING RESISTANCE 61
Provi de Empat hy for the Resistance
Clients are accust omed to encount er i ng di sapproval f r om the peopl e in t hei r
lives who have grown weary of exhort i ng the clients to change, and who now
have little sympat hy or tolerance for the clients' probl ems. Therefore, it is a breat h
of fresh air for clients to ascert ai n t hat t hei r t herapi st s have some measur e of
empat hy for t hei r rel uct ance to relinquish mal adapt i ve funct i oni ng ( Koer ner
& Li nehan, 1992; Layden, et al., 1993; Mahoney, 1991).
For exampl e, a t herapi st encount er ed a mi st rust ful client who screamed at
hi m because the t herapi st asked her to consi der her own role in her escalating
i nt erpersonal conflicts. Following her tirade, the client said, "I' ll bet you hat e
me now, and want me never to come back" The t herapi st replied, "Not so. I
know t hat you were onl y t ryi ng to prot ect yourself, and everybody has a right
to do that. What we have to find out is why you believed t hat I was at t acki ng
you, and what we can do about this pr obl em" The client' s degree of cooperat i on
wi t h the t herapi st i ncreased following this unexpect ed empat hy for her resis-
tance. I n essence, the t herapi st had demonst r at ed t hat he under st ood the func-
tion of her behavior, and t hat he had compassi on for her fears of bei ng attacked.
Mitch' s t herapi st demonst r at ed accurat e empat hy with the client' s resistance
by l ament i ng his percei ved "black sheep" status in the family, and by st at i ng
t hat "I believe t hat you have a right to receive credi t for your accompl i shment s"
The t herapi st added t hat he could under st and how Mi t ch mi ght feel compet i -
tive wi t h the t herapi st in light of the client' s hi st ory wi t h his fat her and brother.
The t herapi st told Mi t ch t hat he respect ed hi m for all t hat he had accompl i shed
t hus far in life (e.g., gai ni ng admi t t ance to a prestigious law school) in spite
of fami l y strife and a series of bout s of severe depression, the likes of which mi ght
have crushed someone wi t h less resolve, st rengt h, and ability. Mi t ch responded
favorabl y to these comment s, and began to see the t herapi st as an advocat e in-
stead of a mal evol ent compet i t or. The result was much less cont ent i ousness and
much mor e constructive di al ogue in session.
Discuss the Case Concept ual i zat i on Wi t h the Cl i ent
It is good practice for therapists to help the clients make sense of t hei r difficul-
ties by revi ewi ng the pr obl ems in the context of a devel opi ng case concept ual i -
zat i on (Persons, 1989). Thi s is a collaborative activity t hat solidifies the ther-
apeut i c rel at i onshi p and gains the clients' active interest and involvement. The
concept ual i zat i on involves such factors as the client' s l earni ng history, idiosyn-
cratic beliefs about the self, world, and fut ure (the cognitive triad, cf. Beck et
al., 1979), compensat or y strategies and st rengt hs in coping, and situational ex-
ampl es of how all of the above fit into the client' s funct i oni ng (Beck, in press).
As not ed earlier, a br eakt hr ough was achieved wi t h Mi t ch when the ther-
apist hypot hesi zed a new way to concept ual i ze the client' s t endency to debat e
wi t h the therapist. Mi t ch acknowl edged t hat he was pr i med to view the ther-
apist as bei ng pat roni zi ng and condescendi ng, and t hat Mi t ch needed to "de-
fend" hi msel f by present i ng count er ar gument s to all of the therapist' s comment s.
6 2 NEWMAN
Mi t ch added t hat he hadn' t given it much t hought before, but t hat the t her-
apeut i c relationship did seem to be remi ni scent of his relationship with his older
brother. When the t herapi st expressed accept ance and empat hy for Mitch' s self-
protective strategy, and added his heart-felt praise for Mitch' s accompl i shment s,
a maj or shift in Mitch' s vi ewpoi nt t ook place. Mi t ch began to view the t herapi st
(and by extension, anyone who would pur por t to be his advocat e and ment or )
on his own meri t s, and not aut omat i cal l y as a psychological clone of his brother.
Speak the Client' s Language
When clients are ambi val ent about bei ng in t r eat ment , t hei r decision as to
whet her or not to invest in t herapy somet i mes hinges on their percept i on of their
compat i bi l i t y wi t h the therapist. One i mpor t ant way for t herapi st s to augment
a sense of compat i bi l i t y is to use l anguage t hat is fami l i ar to the client (Beck
et al., 1993; Liotti, 1989). Thi s is not to suggest t hat t herapi st s should go out
of t hei r way to mi mi c clients, ei t her by usi ng slang, profanity, or par r ot i ng re-
sponses. Rat her, the t herapi st can make use of an accurat e case concept ual i za-
t i on to det er mi ne the sort of communi cat i on style that, while wi t hi n the t her-
apist' s sincere and nat ural repertoire, also strikes a resonant chord with the client.
For exampl e, when descri bi ng the nat ur e of cognitive t herapy to a histrionic,
"new age artist" client, the t herapi st may choose to say t hat a goal of t r eat ment
is to help the client t o"gai n a heightened consciousness of your i nnermost thoughts
when your feelings are i nt ense" while compulsive, overcontrolled busi nessman
mi ght be told t hat "cognitive t her apy helps you become mor e objective and
product i ve in dealing wi t h issues t hat give you a sense of subjective st ress: I n
this manner, the clinician maxi mi zes the chances t hat the client may view the
t herapi st as someone who is si mi l ar and an ally.
When the t herapi st ' s st andard f or m of verbal communi cat i on seems ineffec-
tive in connect i ng wi t h t he client, imagery and metaphors may be a useful al t erna-
tive in gai ni ng the clients' at t ent i on and interest (Layden et al., 1993; Mei chen-
ba um & Gi l more, 1982). The most efficacious use of i mager y and met aphor s
requi res an accurat e case concept ual i zat i on so t hat the t herapi st ' s "pictures and
stories" will be personal l y meani ngf ul to t he clients.
For exampl e, a histrionic client di d not f at hom the aversive i mpact her highly
dr amat i zed behavi ors had on ot hers in her life until the t herapi st made use of
an anal ogy t hat likened her to her favorite classical composer' s musi c played
at 200 decibels. The t herapi st expl ai ned that, "Nobody will be able to appreci at e
your subtleties and i nner beaut i es if your vol ume is so l oud t hat peopl e must
cover t hei r ears." Similarly, a conduct -di sordered and narcissistic t eenager who
was quite fond of the Star Wars t ri l ogy was likened to Luke Skywalker at the
critical crossroads in his life. He could ei t her use the power of The Force to be-
come a J e di Kni ght and fight for good, or go over to the Dar k Side of the Force
and become like Dar t h Vader. Ei t her way, the client would be ext remel y powerful.
UNDERSTANDING RESISTANCE 63
He could choose to harness his power for success, or become a colossal failure
in life (not just any run-of-the-mill failure, mind you). Truly, a good picture
that 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 change
and always 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. When clients demonstrate such flashes of cooperation and
motivation, 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 later
dates 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 makes
a practice out of asking clients to keep an archive of audiotapes of "our most
optimistic and productive sessions; so that the clients can listen to such tapes
in order to boost the moment um of therapy at those times when the client's moti-
vation once again flags. Although it may be easy for resistant clients simply
to 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 virtues
of change-- far more meaningful than hearing someone else saying the same
things. Further, it is a face-saving tactic to encourage a client to "take your own
good advice" rather than to risk shaming a client by insisting that he or she
listen to what others (including the therapist) are saying. In this manner, cooper-
ation is enhanced, because the clients essentially are complying with the most
functional aspects of themselves.
A comparably efficacious method of documentation involves having both the
therapist 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 of
session. A logbook serves the same function as the audiotapes-- namely, to record
the clients' most functional responses so that clients can become their own models
for change.
For those clients whose resistance extends to their refusing to be audiotaped,
and who neglect to take written notes or do homework assignments, therapists
can use their own notes as a way to remind clients about productive things that
they've said in previous sessions.
An example is described in Beck et al. (1993). Here, a substance-abusing client
admitted early in treatment that he was most prone to relapse during those times
when 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
6 4 NEWMAN
now, I ' m fine, so I don' t need t o come see you a n y mo r e : Th e t her api st r esponded
by r e mi ndi ng hi m t hat this was t he very si t uat i on t o whi ch t he client al l uded
earl i er whe n he sai d t hat he got i n t r oubl e every t i me he let hi s gua r d down.
For good measur e, t he t her api st added, "I wr ot e down what you said, because
I t hought it was par t i cul ar l y s mar t and honest of you t o make such a st at ement .
I t sounds like you pr edi ct ed t hat this woul d happen. Well done " I n this sce-
nari o, t he client was abl e t o admi t t hat his deci si on t o leave t her apy mi ght be
a bi t pr emat ur e, and he coul d make t hi s admi ssi on wi t h a mi ni mal loss of per-
ceived aut onomy.
Ge nt l y Persist Wh e n Cl i ent s Subt l y Avoi d
Ther api s t s somet i mes unf or t unat el y r ei nf or ce t hei r cl i ent s' resi st ance when
t hey accept t hei r cl i ent s' c omme nt s t hat , "I don' t have a nyt hi ng t o t al k about
this week" or "Not hi ng' s ha ppe ni ng i n my life r i ght now," o r " My mi n d is a com-
pl et e bl ank r i ght now" at face val ue wi t hout i nqui r i ng furt her. Thi s t act i cal mi s-
t ake of t en will l ead t o t he session be c omi ng filled wi t h idle chi t -chat , and/ or
t he client' s gai ni ng t he sense t hat t her apy is a wast e of time. On t he ot her hand,
if t he t herapi st addresses t he client' s appar ent l ack of a t her apeut i c agenda and/ or
r el uct ance t o t al k as t opi cs i n t hei r own ri ght , mu c h can be l ear ned about t he
client' s resi st ance (Beck et al., 1993; Saf r an & Segal, 1990; Young, 1990).
Us i ng t he me t hod of Socrat i c quest i oni ng, as well as an empat hi c, respect ful
approach, t he t herapi st may ask or state t he following in or der t o st i mul at e fruitful
di scussi on i n a session:
" I ' m sur pr i sed t hat you r epor t t hat ever yt hi ng is ' fine' this week. Last week
you present ed a very different picture, and you were qui t e worri ed about a numbe r
of ongoi ng pr obl ems. Ho w have t hi ngs changed so radi cal l y?"
" I f you feel t her e isn' t mu c h t o di scuss this week, we coul d revi ew t he overall
cour se of t her apy t hus far, so we can s umma r i z e t he most i mpor t a nt pri nci pl es
t hat you' ve l ear ned about your sel f and your life as a resul t of our wor k t oget her.
Wh a t do you t hi nk?"
"You a ppe a r t o be qui t e s u b d u e d - - ma ybe even a little di st ant this week. I ' m
a little concer ned about this. Do you real i ze t hat you ar e c omi ng across this
way? Wh a t coul d you be exper i enci ng r i ght now t hat mi ght account for this?"
" What are t he chances r i ght now t hat our l ack of a t opi c t o di scuss reflects
an ' out of sight, out of mi nd' t r ap t hat we' ve fallen i nt o? Is it possible t hat we' ve
got t en away f r om t al ki ng about t he mos t i mpor t a nt t hi ngs, and t her ef or e we' re
' f or get t i ng' t hat these issues exist? I ' m wi l l i ng t o expl ore this f ur t her i f you ar e"
"I f t hi ngs ar e goi ng s moot hl y i n your life r i ght now, do you t hi nk it woul d
be a good i dea t o do some t r oubl eshoot i ng? Do you t hi nk it woul d be hel pful
if we l ooked ahead t o some pot ent i al sources of stress i n t he fut ure, a nd dis-
cussed how you mi ght handl e t hem?"
' Nr e you aware of t hi ngs you ar e feel i ng or t hi nki ng r i ght now t hat you woul d
UNDERSTANDING RESISTANCE 65
rather not t al k a bout r i ght now? I f t hat ' s so, I ' l l r es pect your ne e d f or saf et y a n d
pr i vacy. Pe r ha ps we can get i nt o t hi s at a l a t e r t i me, wi t h your c ons e nt "
" Wh a t coul d be s ome of t he r eas ons t hat your mi n d has gone bl a nk j u s t now?
I s t he r e s o me t h i n g you mi g h t be e xpe r i e nc i ng t hat j us t s eems t oo di f f i cul t t o
deal wi t h at t hi s t i me? I s i t pos s i bl e t ha t t hi s c oul d be an i ndi c a t i on t hat t he r e
r eal l y is s o me t h i n g very i mp o r t a n t t o t al k a b o u t r i ght now, i f onl y we coul d f i nd
a way t o ma k e i t safe e n o u g h t o t hi nk about ?"
At t i mes cl i ent s wi l l r e s p o n d t o t he above ( a nd ot her ) ques t i ons by r e pe a t e dl y
ans wer i ng, "I don' t know" Some t i me s t hi s is a l e gi t i ma t e answer, a nd s ome t i me s
i t is an una s s e r t i ve s ubs t i t ut e f or t he s t a t e me nt , "Pl ease r es pect my ne e d t o keep
t hi s t o mys el f unt i l I feel r e a d y t o di scuss i t " b u t mo r e of t en t ha n not i t is a n
e xa mpl e of a cl i ent ' s p u t t i n g i nsuf f i ci ent e ne r gy i nt o de l i be r a t i ng a bout t he issue.
At ot he r t i mes i t r ef l ect s a mo r e act i ve pr oces s of s t onewal l i ng i n o r d e r t o avoi d
t al ki ng. Th e a u t h o r s t r ongl y bel i eves t hat t he r a pi s t s s houl d never t ake "I don' t
know" for an a ns we r wi t hout f ur t he r e xpl or a t i on ( or at l east wi t hout r e que s t i ng
t o c ome back t o t hi s i ssue at a l a t e r t i me) , ot her wi s e t he t her api s t ' s f ai l ur e t o
p u r s u e t he ma t t e r wi l l ne ga t i ve l y r ei nf or ce t he cl i ent ' s avoi dance. Th e f ol l owi ng
a r e e xa mpl e s of wha t t he r a pi s t s can say i n o r d e r t o get b e y o n d t he "I don' t know"
r oadbl ock:
"You don' t have t o know for certain. We can di scuss s ome of your e d u c a t e d
guesses a bout t he mat t er . "
"Gee, your ' I don' t know' s o u n d e d awf ul l y e mpha t i c . Have you ever h e a r d
t he expr es s i on, He dot h pr ot es t t oo muc h? Ar e you t r y i n g t o t el l me t ha t you' d
rather not di s cus s t he i ssue?"
" I ' m not c onvi nc e d t ha t you ' don' t know" be c a us e you' ve t ol d me i n gr e a t de-
t ai l a bout t i me s i n t he past whe n you' ve be e n t h r o u g h s i mi l a r s i t uat i ons . Do
you know t he t i mes I ' m r e f e r r i ng t o? Ca n you dr a w on t hese va l ua bl e pas t ex-
per i ences i n o r d e r t o hel p your s e l f wi t h t he c ur r e nt s i t uat i on?"
"You ma y not know r i ght t hi s i ns t ant , b u t woul d you be wi l l i ng t o gi ve t he
ma t t e r s ome t hought ? Let ' s s pe nd a mi n u t e or t wo p o n d e r i n g t hi s i ssue silently.
I ' l l l ook at my wat ch a nd l et you know whe n 2 mi n u t e s a r e up, or you can i nt er -
r u p t me i f a n i dea comes t o mi n d bef or e t hen. "
"We' r e t al ki ng a bout an i ssue of pot e nt i a l l y l ong- r e a c hi ng si gni f i cance i n your
life, a n d yet you d e t e r mi n e d al mos t i n s t a n t a n e o u s l y t hat you di dn' t know wha t
you coul d do a b o u t it. Wo u l d you a gr e e t hat a t opi c of such gr eat i mp o r t a n c e
deser ves mo r e of our a t t e nt i on, t i me, a n d effort , even i f t he s ol ut i ons a r e not
r e a di l y a ppa r e nt ? "
" Wh e n you say ' I don' t know' so qui ckl y, i t l eads me t o bel i eve t hat you ma y
be a voi di ng s ome cor e bel i efs. Was my que s t i on di s c omf or t i ng or ups e t t i ng t o
you? Th a t woul d be a n o t h e r i ndi c a t or t hat cor e bel i ef s wer e i nvol ved"
As one can gl ean f r om t he above quest i ons, t r yi ng to br e a k t hr ough t he cl i ent ' s
r es i s t ance s ome t i me s i nvol ves a me a s u r e of c onf r ont a t i on. However , t hi s does
66 NEWMAN
not me a n t hat t he t her api st needs t o behave har s hl y t owar d t he client. On t he
cont r ar y, t he most effective and humani s t i c uses of t her apeut i c conf r ont at i on
ar e e mbe dde d i n a spirit and style of col l abor at i on ( Ne wma n, 1988). For ex-
ampl e, t he t her api st can make l i beral use of t he t e r m "we" i n pl ace of t he mor e
adver sar i al "you," as in, "14~ need t o t r y t o unde r s t a nd what ' s get t i ng in t he way
of our fol l owi ng t hr ough wi t h our or i gi nal pl an" Fur t her , t he t herapi st ' s t one of
voice a nd non- ver bal ma nne r i s ms ar e of cri t i cal i mpor t ance. Al t hough t he con-
t ent of what t he t her api st is sayi ng ma y r ead as i f it is hi ghl y ar gument at i ve
or accusat or y, t he live pr es ent at i on of such can be done i n a cal m, car i ng t one,
al ong wi t h a rel axed post ur e a nd s ympat het i c facial expressi on. Addi t i onal l y,
t herapi st s can gent l y pr epar e t hei r clients f or conf r ont at i onal ( but car i ng) state-
ment s and quest i ons by pref aci ng t hei r r emar ks. For exampl e:
"I hope t hat this won' t s ound har s h or uns ympat het i c, but I mus t tell you
t hat . . . "
' ~ t t he ri sk of get t i ng you a ngr y wi t h me, can I poi nt s omet hi ng out t o you
t hat I' ve not i ced?"
"I hope you won' t t ake offense at wha t I ' m about t o say, because I have good
i nt ent i ons a nd good r easons; but as your t her api st it's my professi onal obl i ga-
t i on t o do all t hat I can t o hel p you, even if it means you mi ght be c ome a ngr y
wi t h me. I ' m wi l l i ng t o t ake t he heat if you ar e"
( Us i ng h u mo r ) "I ' m goi ng t o be a t r oubl e ma ke r her e and say s omet hi ng a
little cont r over si al : '
Th e t her api st can also check f or t he client' s r eact i ons aft er t he conf r ont a-
t i onal c o mme n t is made, by aski ng f or f eedback i n t he fol l owi ng ma nne r : " How
do you feel about what I' ve j ust said? I ' d wel come any r ebut t al , and I l l respect
what you have t o say. Af t er all, I ' m j us t ma ki ng an obser vat i on, but I don' t have
any i l l usi ons t hat I have t he i nsi de t r ack on ul t i mat e t r ut h"
Conc l us i on
Wh e n clients do not i mpr ove i n t r eat ment , we cannot hi de behi nd rat i onal i -
zat i ons such as, " The client di dn' t real l y want t o c h a n g e ; or " The client woul d
r at her suffer t han get wel l ; or " The client wasn' t ' r eady' f or t r e a t me n t : As cog-
ni t i ve- behavi or al scientists, we have an obl i gat i on t o unde r s t a nd and t o addr ess
t he phe nome non of resistance as part of our work i n assessing and t reat i ng clients.
I f clients seem insufficiently mot i vat ed for t reat ment , it is in l arge part our respon-
sibility t o t r y t o devel op and t o utilize our knowl edge and t echnol ogy t o i ncrease
clients' mot i vat i on for heal t hy change and growt h.
Ther api s t s can hel p modi f y t hei r cl i ent s' resi st ant behavi or s and at t i t udes
first by t r yi ng t o unde r s t a nd t he p h e n o me n a on a case-by-case basis, i nst ead
of pr e ma t ur e l y dr awi ng br oads weepi ng general concl usi ons. I n or der t o achi eve
this goal, t her api st s mus t f or mul at e t he case concept ual i zat i on on an ongoi ng
basis, and mus t ask t hemsel ves quest i ons such as " Wha t is t he f unct i on of t he
U N D E R S T A N D I N G RESISTANCE 67
client' s resi st ant behavi or s?" " Wha t i di osyncr at i c beliefs ma y be f eedi ng i nt o t he
client' s resi st ance?" " Wha t mi ght t he clients fear will h a p p e n i f t hey compl y?"
" What skills does t he client lack?" " What envi r onment al factors ma y be puni shi ng
t he client' s at t empt s t o change?" and ot hers.
Second, t herapi st s mus t be self-aware so t hat t hey are sufficiently ear nest and
mot i vat ed i n t he face of clients whose pr ogr ess is f r ust r at i ngl y slow. A benevo-
lent, persi st ent , i nvest i gat or y st ance will enabl e t her api st s t o make t he best use
of t he t echni ques t hat can mot i vat e resi st ant clients t o begi n t o mor e fully en-
gage i n t he process of t r eat ment .
Thi r d, de pe ndi ng on t he specific needs of a gi ven cl i ent (as ascer t ai ned, i n
part , by t he answer s t o t he assessment quest i ons above), t her api st s can choose
f r om a n u mb e r of t echni ques t o assist and encour age clients t o change. Thes e
t echni ques i ncl ude: us i ng educat i onal mat er i al s and pr e- br i ef i ngs; us i ng t he
Socr at i c met hod; pr ovi di ng t he clients wi t h choices; t aki ng a col l aborat i ve ap-
pr oach; r evi ewi ng t he pr os and cons of change and stasis; expr essi ng accur at e
empat hy based i n part on a well-articulated case concept ual i zat i on; usi ng i mages,
met aphor s , a nd ot her f or ms of t he "client' s l anguage"; ma xi mi z i ng t he client' s
free will and sel f-di rect i on i n t r eat ment ; a nd gent l y pr oceedi ng i n spite of subt l e
avoi dance i n session.
Cl i ni ci ans have wi t nessed and wr i t t en about client resi st ance since t he ear l y
days of psychoanal ysi s, and mu c h wor k has been done t hr ough t he years t o t r y
t o concept ual i ze this phe nome non. However, concret e, syst emat i c steps t o pr ac-
tically deal wi t h this issue have been l acki ng. Fort unat el y, a cogni t i ve- behavi or al
appr oach can pr ovi de cl i ni ci ans wi t h specific steps i n or der t o act i vel y i nt er-
vene, and t her ef or e i ncr ease t he effectiveness of t herapy.
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RECglVED: September 1, 1993.
ACCEPTED: February 28, 1994.