It is essential that therapists understand the concept of resistance, especially in treating a client with an extensive childhood abuse history. These clients are a very vulnerable population within the mental health community. Therapists have long perceived resistance in therapy as a negative client issue, and, as such, clients were treated in a way that was blaming and shaming. Resistance continues to be a crucial topic to discuss. With the changes in thinking related to an understanding and greater awareness of the impacts of trauma, there has been a significant shift that has improved mental health for all. Resistance is the therapist’s issue, not the client’s. The hypocrisy exists when therapy is viewed from the perspective that one cannot change another person, only a person can change themselves. Therapists were expecting and asking clients to change the way they prescribed and teaching clients that they cannot change other people; they can only change themselves. Yet, the therapists were not asking themselves what they are or are not doing to create that working therapeutic alliance.
The therapist’s responsibility to the client is to change their approach when met with resistance. Client resistance is information about what is not therapeutically working in the relationship. Resistance is natural to being human and is an important safety mechanism for survival. All people seek to resist what is threatening, scary, or painful. Understanding resistance can be helpful to the therapist in navigating and decreasing resistance to improve the therapy relationship, hence improving therapy outcomes. Although relevant to all therapists, the issue of resistance is addressed in this discussion related to those therapists working with those clients with histories of severe childhood abuse. Those clients often have mental health histories of being stigmatized, marginalized, and labeled in a derogatory manner as resistant. A therapist’s mindset regarding what resistance is or is not related to the necessary therapeutic conditions and the nature of the therapeutic processes can contribute to barriers to care and retraumatization, or it can improve therapeutic outcomes.
Resistance Defined and Uncovered
There are many ways of looking at and defining resistance. Psychological defenses are unconscious strategies used to protect us from feeling negative emotions. These psychological defenses can be termed resistance. Some of these defenses consist of repression, denial, reaction formation, projection, and dissociation, to list a few (Bateman et al., 2010; Schwartz, 2000; Temple, 2019). Resistance is not the same as ambivalence, yet it can be the result of that, much like ‘stuckness’ (Urmanche et al., 2019). A therapist may see resistance as a client not understanding themselves or what may stop the client from making necessary changes to alter what the client does not like. The therapist may say this lack of understanding is ‘stopping us.’ Alternatively, the therapist may think it is frustrating that a client cannot see themselves more clearly. Nevertheless, this blind spot has a function, and the inertia in removing it is what later becomes resistance to the therapeutic process.
Symington points out that Freud came to a realization and “stated that the work of analysis was not the recovery of memories but rather the overcoming of resistances” (Symington, 1986, p. 86). The uncovering of memories is a complex and subjective matter where the therapy process from the lens of these resistances is a source of new awarenesses and insight. People go to therapy to get rid of the pain and unhappiness. Even when they know that change may be inevitable and necessary, our unconscious is not convinced, hence resistance. To risk change is scary. Therapy brings the client into territory where their self-image is questioned (Bateman et al., 2010). The idea of change is uncomfortable and frightening. The client attempts to keep their self-image together, defending against those feelings and thoughts threatening it. The client regards those feelings and thoughts as disturbing, wrong, or “other” (Bateman et al., 2010; Schwartz, 2000). In therapy, the client begins the process with a guide that they cannot trust yet and the resistance sets the pace for the process unfolding.
A Working Therapeutic Alliance
Resistance often shows up among childhood abuse survivors in the routine therapeutic milieu. The most common underlying issue related to resistance is childhood abuse’s ongoing manifestations and impact. Resistance occurs due to the inability to feel safe, secure, trusted, and not threatened by relationships. Relationship refers to both relations with self and others. Freud’s ‘Pleasure Principle’ describes how people instinctively prefer to repeat familiar old dysfunctional patterns in the hope that what they always wanted from their parent will eventually occur, even when it never has and never will. It is psychically easier to repeat this familiar pattern than to risk change because change delivers unknown risks. The familiar has become part of who the person thinks they are and how that person makes sense of the world (Bateman et al., 2010; Schwartz, 2000). “Relational trauma requires relational healing” (Schwartz, 2000). Consent to confront the pain in relation while simultaneously acknowledging the pain that initially occurred in relation is the paradox (Schwartz, 2000)). According to Schwartz, the therapy relationship paradox creates a “threat of annihilation” (2000). This will show up as resistance.
The therapeutic alliance is critical to the therapy’s progress and outcomes. The alliance, or rapport, must be strong enough between client and therapist to bear these inevitable relational ruptures as the client works through resistance. Whether a direct or non-direct approach, empathy is a vital feature of the alliance. Whether or not the client perceives the therapist as the expert, a power differential exists and is the nature of the agreed-on therapy contract. It is a choice to enter into this relationship. It is to the client’s benefit, not the therapist’s. The client is the emotionally vulnerable one regardless of the therapist’s vulnerabilities outside of the professional relationship. The therapist is human, too; however, the therapist’s power is real within the setting, and it makes sense that the client will have a relationship with this power differential.
The client’s feelings of distrust, anxiety, enhanced vulnerability, ambivalence, avoidance, confusion, wanting to please, and drive to challenge the terror of being abandoned are what humans feel within this unequal relationship; the transference of those of authority in childhood (Bateman et al., 2010). This transference leading to resistance means that the patient’s feelings are not a sign of weakness or being difficult, but are affirmations of the client’s disempowerment. Transference is the expression of being human, and those thoughts and feelings need validation (Bateman et al., 2010; Symington, 1986). A therapist has power in the transference. The power differential in the therapeutic setting and the newly uncovered vulnerabilities will tap into the experiences a patient had at the hands of the original figures of power, back when the patient’s vulnerability and dependence on the powerful adults as a child were absolute (Bateman et al., 2010; Schwartz, 2000; Symington, 1986). This means that the patient will “use their unconsciously constructed defenses to safeguard against the danger of repeated past wounding or terrifying experiences” (Schwartz, 2000).
Traditional Perspectives of Resistance
Resistance has primarily been seen as a client issue, not a therapist issue. Resistance in therapy has been a term that therapists have used to blame the client or believe that the client sabotaged their growth. Freud thought it was an “unconscious opposition to revealing memories” in psychoanalysis (Bateman et al., 2010). As therapy progressed, the term was used to understand the difficulties a client was experiencing during treatment and acting them out. Many therapists had adopted the term resistance to mean that a client was not making progress or not making progress quickly enough, did not want to feel better, was not following advice, and these clients were deemed “difficult” or challenging and at times unable to be helped or not wanting help. Clients would be terminated, retraumatized, and referred out.
Adequately establishing an empathetic working therapeutic relationship with the client happens when the client feels safe and secure in the alliance. In addition, the client needs to feel seen, heard, valued, and not judged. Elements of the person-centered approach are critical to the relationship regardless of theoretical orientation. Clients with a history of severe childhood abuse necessitate the therapeutic conditions of empathy, unconditional positive regard, and genuineness (Ivey et al., 2018). This is a crucial piece of this relationship to build trust and rapport and is an essential piece of how therapy will or will not unfold. It is the therapist’s responsibility to create a therapy environment of safety. Safety for clients that do not have a reference for what safety is. This will incite survival defenses or resistance.
Addressing Resistance
In treating clients with abuse histories, it is unhelpful and, at times, harmful to use the word resistance with the client or even think of them as resistant. A therapist must do their best to acknowledge and appreciate, to the client, the survival-enabling value of the defensive strategies that the patient is going to deploy in response to the power imbalance, which recalls the even more threatening original power imbalance as a child. It is vital for the client not to internalize their image as resistant, difficult, problematic, or impossible. It is critical that a client does not get handed off to another therapist for reasons of ‘not responding to treatment’ (Bateman et al., 2010). A therapist’s mission is to help clients understand and appreciate that their reaction to the power imbalance is not pathological but is connected, in a powerful, unconscious way to their experiences in the time of complete dependence and powerlessness. This is the nature of what the client agrees to when entering therapy. It can be seen as a choice and not a choice. Both the therapist and the client willingly enter the therapy relationship and it is necessary for healing; however, the imbalance is paradoxical (Bateman et al., 2010; Schwartz, 2000; Symington, 1986).
Empathy
Many therapists define themselves as a particular kind of therapist and follow a particular therapy theory of causation or change. The problem is that some clients will not respond to that specific treatment but will respond to another approach; therefore, all therapists need to be able to do therapy with different types of clients and be able to utilize various modalities and approaches. It is vital that the therapist understands what is going on or what is at stake.
Resistance should never be met with the therapist’s own defensiveness. A therapist needs to be both unquestionably respectful and empathetic towards the value of the client’s resistance. The therapist creates a safe space while the client learns to trust and slowly lowers the defenses. “The resistance is against the emotional closeness which is part of the healing process.” (Symington, 1985, p. 251). The therapist’s ability to create a safe space within the therapeutic process is the key to therapeutic success. The therapist respects the social construct and the cultural context of the client’s reality, and the therapist agrees without question to enter this. Too often, a therapist’s inability to remain non-defensive to a client’s communications injures, retraumatizes, and brings an end to the therapeutic process. A scenario that occurs at the client’s expense. The therapist not being open to changing their approach, understanding the client’s reality, and being unable to have empathy. If the therapist cannot fix the client or if a client cannot choose health, then the client is wrongfully terminated, referred out, and once more abandoned and rejected.
Some direct questions could be used, such as if the client thinks they are avoiding the topic, their emotions, or the therapist, and allow them to find their truth instead of assuming the therapist knows why the behaviors are occurring. Sometimes the client does not know the answer. The therapist’s job is to help the client connect with themselves, explore the possibilities, and become aware of their motivations for what they do or do not do. Nobody chooses to be mentally or emotionally challenged. The client blamed for their difficulties exacerbates stigma, and marginalization creates barriers to care and is retraumatizing. Therapists are there to empower, not judge or use names to classify them or their actions. As Symington points out in his recounting of ‘Child Analysis in the Analysis of Adults’ by psychoanalyst Ferenzi, “‘as long as a patient continues to come at all, the last thread of hope has not snapped’…’ Is it always the patient’s resistance? Is it not our own convenience, which disdains to adapt itself, even in technique, to the idiosyncrasies of the individual?’ (1931, p. 128).” (Symington, 1986, p. 183). Traditional therapists blame resistance in therapy on the client. “Victim Blaming” (“psychology of victim blaming,” 2021). Resistance is almost always the fault of the therapist.
-Written By Michelle
References
Allen E. Ivey; Mary Bradford Ivey; Carlos P. Zalaquett. (2018). Intentional interviewing and counseling: Facilitating client development in a multicultural society (9th ed.). Cengage Learning US.
Bateman, A., Brown, D., & Pedder, J. (2010). Introduction to psychotherapy: An outline of psychodynamic principles and practice, fourth edition (4th ed.). Routledge.
Schwartz, H. L. (2000). Dialogues with forgotten voices: Relational perspectives on child abuse trauma and treatment of dissociative disorders. Basic Books.
Symington, N. (1986). The analytic experience: Lectures from the Tavistock. Free Association Books.
Temple, M. (2019). Understanding, identifying, and managing severe dissociative disorders in general psychiatric settings. BJPsych Advances, 25, 14-25. https://doi.org/10.1192/bja.2018.54
The psychology of victim blaming. (2021, May 11). Mental Health @ Home. https://mentalhealthathome.org/2020/04/24/what-is-victim-blaming/
Urmanche, A. A., Oliveira, J. T., Gonçalves, M. M., Eubanks, C. F., & Muran, J. C. (2019). Ambivalence, resistance, and alliance ruptures in psychotherapy: It’s complicated. Psychoanalytic Psychology, 36(2), 139-147. https://doi.org/10.1037/pap0000237