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Wednesday, December 20, 2017

Contemporary Psychotherapy: Redefining the Traditional View of "Resistance" in Therapy

The concept of resistance in psychotherapy originated with Sigmund Freud while he was developing psychoanalysis.  He noticed that some clients refused to talk about certain aspects of their life or, from Freud's perspective, they unconsciously behaved in uncooperative ways that sabotaged the therapy.  Ever since that time, the concept of resistance has taken on a negative connotation and, in my professional opinion, is pathologizing of the client.  In an earlier article,  Reconceptualizing the So-Called "Help Rejecting Client", I discussed the importance of depathologizing this concept because calling the client "help rejecting" is neither helpful to the client nor to the therapist to understand what's going on in therapy.  Similarly, in this article, I'm advocating for psychotherapists to redefine resistance in therapy and to take a more nuanced look at what's going on.

Contemporary Psychotherapy: Redefining the Traditional View of "Resistance" in Therapy

The Traditional View of Resistance in Psychotherapy
Freud conceptualized resistance to be any unconscious behavior by the client in therapy that was, from his perspective, oppositional and uncooperative.

He indicated that there could be different types of resistance, including transference resistance where the client responds to the psychotherapist as if the therapist is someone from the client's past (typically, parents), self sabotage, ego resistance where the client regresses to an earlier stage of development, repression where the client unconsciously pushes down memories that s/he is avoiding, and other similar forms of so-called resistance.

There might still be psychotherapists, including Classical psychoanalysts, who see the concept of resistance in the same way that Freud did, but many more contemporary psychotherapists have taken a less pathologizing perspective of resistance, and I include myself among those contemporary therapists.

Depathologizing the Concept of Resistance in Contemporary Psychotherapy: Shifting Self States
The traditional way of looking at resistance sees the psychotherapist as being authoritative, someone who knows what's best for the client.  Looking at it from that perspective, when a client is being resistant, the therapist's view is that the client isn't following what the therapist says is best for him or her.

Needless to say, this traditional way of working with clients in therapy is from a time when there was little to no mutuality in psychotherapy between the client and the therapist.  The therapist was seen as the expert and the client needed to follow the therapist's ways of working or, it was believed, the client wouldn't get better.  This way of working tended to shame the client.

During the last 20 or so years, there have been many changes to psychotherapy and, fortunately, this traditional way of seeing the therapist as the authority figure and the client as being in a subordinate position is, for the most part, not practiced any more.

Most contemporary psychotherapists work in a collaborative way.  There is a recognition that psychotherapists don't have all the answers and that the client and therapist need to work together in therapy (see my article: Why It's Important For Your Therapist NOT Have All the Answers).

In my opinion, along with working in a collaborative way, it's also important to recognize that there are two people in the room and there's an intersubjective experience between the client and the therapist (see my article: The Psychotherapy Session: A Unique Intersubjective Experience).

Rather than the psychotherapist being the all-knowing authority figure, I believe it is much more helpful for the therapist to use her clinical skills and expertise to be attuned to what is going on with client in the therapy session and help the client to formulate his or her own understanding (see my article: The Psychotherapist's Empathic Attunement).

This is a much more client-centered way of working in psychotherapy and tends to help the client to feel more comfortable with the therapist and the therapeutic process, as opposed to the former traditional stance in therapy where the psychotherapist was the authority figure and was "always right."

In a prior article, Understanding the Different Aspects of Yourself That Make You Who You Are, I discussed that we all have many different aspects of self (or self states) that make us who we are, and these self states are continuously shifting in all of us (see my article: How Your Shifting Self States Can Affect You For Better or Worse).

Depending on the person, these self states often shift in a barely perceptible way because they are integrated as part of the person's overall makeup of who s/he is.  Or, in some cases, they might be less integrated, which would mean that shifts in self states might be more intense and noticeable.

As I've mentioned in other articles, when I discuss self states that are shifting, I'm not referring to multiple personality disorder or, as it's currently known, dissociative identify disorder.  I'm referring to shifting self states as a natural part of what occurs in everyone.

When we look at the concept of resistance in psychotherapy as part of shifting self states, it's a much more useful way of looking at it.  Rather than seeing the client as being resistant, when we take into account shifting self states, we can see that there are different parts of the client that might feel different ways about a particular part of therapy.

Let's take a look at a fictional clinical vignette that illustrates these concepts:

Contemporary Psychotherapy: Redefining the Traditional View of "Resistance" in Therapy

Ken
Ken began psychotherapy because he felt stuck in his personal life and in his career.

Contemporary Psychotherapy: Redefining the Traditional Concept of "Resistance" in Therapy 

He was unable to sustain a relationship for more than a few months.  After that initial stage of dating, Ken would become fearful of being engulfed in his relationship and he would end it.  Afterwards, he would have regrets, but his fear of engulfment kept him from trying to reconcile his former relationship.  Then, the pattern would begin again with the next person.

At 32, Ken was starting to despair that he could ever be in a long-term relationship.  He was afraid  that his fear of engulfment would continue to sabotage any potential relationship and he would be alone.

With regard to his career, Ken was a middle-level manager, and he usually had problems with his superiors.  Intellectually, he understood that there was a hierarchy at his company, and he understood the reason for the hierarchy.  But on an emotional level, he resented it, and he would sometimes challenge his bosses in subtle and not so subtle ways at staff meetings, which tended to cause problems for him.

Ken was told by the senior vice president at his company that he was viewed as a hard worker and a creative thinker, which was valued at the company, but his "attitude" towards his superiors was getting in the way of his career advancement.

The senior vice president told Ken that, even though Ken was seen as being capable of advancing in terms of his work and creativity, he was also seen as "difficult" and some of the senior managers were hesitant about having Ken as a direct report.  He advised Ken to work on changing his attitude because if he didn't change, he was probably jeopardizing his future with the company.

Deep down, Ken knew that the senior vice president was right.  He knew he could be provocative at times with his boss.  After these incidents, Ken wasn't sure what came over him.  He regretted his behavior and he would apologize to his boss.

Even though his boss was very understanding, Ken knew that he couldn't continue to do this and survive at the company.  He knew he needed to understand himself better and change.

He explained to his current psychotherapist that he had been in therapy in his late teens and early 20s, and he found it to be a discouraging experience.  He would often challenge his psychotherapist's interpretations and it caused friction in their relationship, especially when his therapist called Ken "resistant."

That therapy ended when Ken felt too ashamed to continue, and both Ken and his therapist ended the therapy feeling frustrated.  This experience in psychotherapy kept Ken away from therapy--until now.  He decided to give therapy another chance because he knew he wouldn't be able to change without help.

When Ken's current psychotherapist heard Ken describe his family background, she began to understand what might be contributing to his problems in relationships and in his career.

Ken grew up as the older of two sons.  His father, who was a successful attorney, tended to be cold and authoritative with everyone in the family, including Ken.  Ken said, "My father definitely ruled the roost and everyone had to fall in line with what he wanted, and I resented this."

Ken's mother tended to be overly protective and "smothering" of Ken and his brother.  Even when he was a child, Ken felt overwhelmed and engulfed by his mother's anxious ministrations.

In his teens, even though he loved them, Ken often felt angry with his parents.  He would frequently argue with them and, once, almost came to blows with his father.  By that time he was 18, he was relieved to go away to college to get away from both parents.

Ken's current psychotherapist explained that she worked in a contemporary way that is interactive and collaborative (see my article: Why It's Important For Psychotherapists to Provide Clients With Psychoeducation in Psychotherapy).

His therapist also explained the concept of shifting self states to help Ken understand his ambivalence about relationships and his career.  Specifically, it seemed to her that part of Ken wanted to be in a long-term relationship, but part of him was fearful.  The part of Ken that was fearful would become dominant as the relationship got serious and this part contributed to the demise of the relationship (see my article: Wanting and Dreading a Relationship).

Similarly, his psychotherapist explained, that it seemed that part of him wanted to be more cooperative with his boss at work, but another part resented that the boss was an authority figure, and this part would dominate at times and get Ken into trouble.

Then, rather than assuming that she was right, his therapist asked Ken if what she said resonated with him.

Ken responded by saying that he never thought of himself as being made up of different parts, and this idea intrigued him.  As he thought about it, he could see how the different aspects of himself interacted with others at various times.

His therapist also explained that it seemed as if these parts of him that were creating problems for him were based on his earlier experiences, and these parts were actually trying to protect him from feeling overwhelmed like he felt when he was younger.  But now, these parts were getting in his way (see my article: Understanding Why You're Still Affected By Trauma That Occurred a Long Time Ago and Coping With Trauma: Becoming Aware of Triggers).

Since Ken was open to the idea, his therapist recommended that they do Ego States work, which is an experiential form of therapy, to help him to differentiate the different parts of himself, understand when they get triggered, and address the fears that were contained in these parts.

Rather than talking about the different parts of himself, Ken would experience these parts in Ego States work (see my article: Experiential Therapy Helps to Achieve Psychological Breakthroughs).

At first, Ken agreed that this was a good idea, and he was enthusiastic about it.  But soon after they started doing Ego States work, Ken got anxious and he wanted to stop.

When his therapist attempted to explore with Ken what happened, Ken told her that he didn't know--he just didn't want to do it.

His therapist explained that she respected his choice.  She just wanted to understand and help Ken understand what shifted for him.  She said that if Ken was open to this exploration, it might help him to understand what shifted for him in terms of shifting self states.

The particular memory they were working on was an experience Ken had with his former girlfriend when he felt overwhelmed by her suggestion that they talk about where their relationship was going.  He remembered feeling the same as when he was younger and he felt engulfed by his mother.

It was at the point when Ken wanted to stop doing this experiential work and he said to his therapist, "I know you're going to tell me that I'm being 'resistant' just like my prior therapist used to say to me."

But Ken was surprised that his current therapist told him that she didn't find it especially helpful to tell clients that they're being "resistant."  Instead, she went back to the concept of shifting self states and that a particular self state, whose motive might be protective, might be the cause of this change in him.

Ken was relieved that his therapist wasn't blaming him, and he became less defensive.  This allowed him to think about what shifted for him internally as they were doing Ego States work.  As he calmed down, he realized that he thought of his mother while they were working with the memory and he remembered how he felt so overwhelmed by his mother when she was too much for him.

His therapist said she understood and introduced the idea of internal resources.  As part of developing internal resources, she asked Ken if he could imagine someone who could have been helpful to him when he felt engulfed by his mother (see my article: Using Imagery as a Powerful Tool in Therapy).

Ken thought about it for a few minutes and said he thought his uncle, his mother's brother, would have been helpful.  In fact, when his uncle was around and he saw Ken's mother being intrusive with Ken, he would tell Ken's mother to relax and she would back off.  But, unfortunately, he wasn't always around.

Ken's therapist asked Ken if he would be willing to imagine his uncle being here with him now when he went back into that memory.  Ken agreed, and he was surprised that by using his imagination and sensing his uncle was with him, he felt calmer.  At that point, with the help of this internal resource, they were able to go back to doing the Ego States work.

As they continued to work together doing Ego States work and discussing it afterwards, Ken developed a better understanding of himself.  He also noticed a positive shift in how he interacted with his boss at work, and his boss commented that he noticed it too.

When Ken began dating again, he recognized when a fearful self state was about to get in the way and he was able to calm himself.  He also continued to explore this issue with his psychotherapist.  This allowed Ken to remain in a relationship with a woman that he really liked.

Overall, Ken felt calmer and more emotionally integrated at work and in his romantic relationship.

Conclusion
In my opinion as a psychotherapist, the traditional view of resistance is not helpful to the client, the therapist or to the work in therapy.

It tends to be an all-or-nothing concept that doesn't take into account that people are much more nuanced in their behavior.

As I mentioned before, calling a client "resistant" is pathologizing. This also makes it shaming, which creates a lot more problems for the client in therapy.

Taking a more contemporary view in psychotherapy and seeing what might be called "resistance" as shifting self states helps the therapist and the client to understand ambivalence and to work through that ambivalence with the parts of the client that are getting in the way.

Getting Help in Therapy
If you feel stuck in your life, even though you really want to make changes, you might be struggling with self states that are ambivalent about the change.

Ego States therapy is one way to work in therapy to help to distinguish the different self states involved in the ambivalence, give them "a voice," and work towards overcoming whatever fear might be contained in the particular self state.

When you're able to overcome the obstacles in your way, you can live a more fulfilling and meaningful life free from your earlier problematic history (see my article: The Benefits of Psychotherapy).

Rather than blaming yourself or remaining stuck, you could benefit from working with an experienced contemporary psychotherapist who works in a non-pathologizing way (see my article:  How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who tends to work in an integrative way in therapy (see my article: The Therapeutic Benefits of Integrative Psychotherapy).

I work with individual adults and couples.

I have helped many clients, in a nonjudgmental and interactive way, to overcome the obstacles that are keeping them from leading a more fulfilling life.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (212) 726-1006 or email me.




















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