This article conveys some of the wisdom and professional acumen of the late Dr Maurice Kouguell, teacher, bon vivant, musician, my friend and excellent therapist. Maurice was much more than simply a superb hypnotherapist. He held two doctoral degrees and throughout his life continued to learn more and more about psychology, methods of psychotherapy, and the human condition. He drew inspiration from classical music. His great sense of humour and sardonic wit livened any conversation we enjoyed. Maurice was too good at playing chess but would never deliberately let me win. The article below contains salutary lessons that I have glossed over recently so this piece is a welcome re-discovery that will help me and my "resistant" clients. Maurice died April 15, 2008. He is sorely missed, especially by his artist wife Kathi, by his screenplay doctor daughter Susan and adorable grandchild, Tatiana. BMK.
Recognizing and Dealing with Resistance
by Maurice Kouguell
While it takes a good deal of courage for clients to seek help and to express their desires for change, they will still exhibit signs of resistance.
Resistance is basically a manifestation of a fear related to uncovering unconscious material.
Although historically the behavior therapists, such as Wolpe and Lazarus, claimed that resistance did not exist in behavior therapy, they have come to recognize that resistance is a rationalization which the therapist uses "against" the client to account for his own inability or his own failure to reach the client.
Some behavior therapists thus imply that the client was at fault for not taking responsibility in the process of getting well.
One could speculate that any therapeutic failure is due either to the therapist or the method, or the resistance of the client, but it is important to remember that one does not sit in judgment and that resistance needs to be seen as a motivational factor. Thus, both client and therapist should be absolved from taking responsibility and being blamed for the failure.
In order to examine sources of resistance and how to handle them, perhaps one of the most significant sources are described by Golden in an article published in the British Journal of Cognitive Psychotherapy 1 (2), 33-42. He lists three sources of resistance and the following are some selected ones that occur most frequently and are recognized by the therapist.
I.Therapy And Therapists Factors: Absence of rapport between therapist and client.
Failure to recognize that the client is avoiding a higher order anxiety; thus an overweight client might fear that after the weight loss a new readjustment may have to occur dealing with social and sexual anxieties about dating.
There are some secondary benefits that clients hold on to although the discomfort is in their way. Frequently clients prefer not to get well because they do get benefits by being incapacitated.
Resistance could be created by incorrect use of the technique which needs to be applied for the given client -- this is usually due to a lack of experience or training on the therapist's part.
Beginning therapy without the client's understanding or accepting the rationale for that particular therapy.
Giving assignments or homework related to the client's goal which are not relevant or understood by the client.
Assignment given to the client is too time consuming and the therapist's lack of sensitivity in recognizing it.
II. Environmental And Other External Factors:
Thus, a deliberate sabotage from others (a client might be concerned about his position in the family or in a marriage should he become more successful or assertive).
Sabotage from other family members. In addition to dealing with the agoraphobia of the client, the therapist may choose also to work with family members who might be fostering unhealthy dependency relationships.
The therapist may be confronted with direct gains from not getting better. For instance, clients who are experiencing chronic pain and are on disability may consciously or unconsciously hold on to the affliction, for it does bring rewards. In such cases, the therapist needs to establish a differential diagnosis.
III. Client Factors: The client may have some "hidden agendas" that could prevent treatment from progressing satisfactorily. For instance, getting a spouse into therapy so that one could leave the marriage.
Motivation. When a client is referred by a family member or a physician, he may not really value the desired outcome of the therapy to give it the necessary effort.
Feeling very strongly about a self-fulfilling prophecy and negative expectation. Thus, a client may come to therapy to prove that his belief of not being able to succeed is going to be correct. Sometimes clients will exhibit a low frustration tolerance which then leads to self-defeating behaviors.
Some of the manifestations of resistance can be seen through the rationalizations for delaying receiving help.
For instance, a client might express all kinds of reasons, such as the therapeutic process is too expensive, too long, and so on.
The therapist needs to be aware that his resistant client is offering in him a very important fund of information, namely it sets already a pattern for the interpersonal relationship between the client and the therapist.
Resistance is often "caused" by the inability of the therapist to get into sync with the client. The client comes in with a certain set of` beliefs, one of them being that he is so disturbed or so sick or so uncomfortable, or so miserable that nobody can help him.
The therapist may believe that it is important for him to succeed with any client. While the client is entitled to his own attitude, the therapist does not have that luxury but needs to examine his resistance and his own negative feelings about the situation.
It is important to recognize that any change is difficult because it requires a relearning process and also the companion, which is to continue with the practice of the newly acquired skill.
The therapist needs to recognize that any therapeutic process is similar to a process of growth and the client will go through a growth curve, which means that progress will be accomplished quickly at first, followed by a plateau, then a possible regression and then a surge towards health.
The resistance on the part of the client is a recognition that the discomfort or the pain might represent only one part of a larger problem.
That realization can be a very frightening one and some people prefer not to address it and just keep it under control a little bit longer. Walking away from the problem becomes part of the learned behavioral pattern the client has assimilated. Walking away from a therapeutic experience is an indicator that when fear is greater than pain the result is so intolerable that clients prefer not to address it.
At the first contact it is usually revealed that the pain is great and the client seems to focus only on a one dimensional problem, and yet, through the use of evaluative techniques, the therapist becomes aware that there are several problems.
Clients come to the hypnotherapist with the myth that they will be put into trance, will experience trance, and they will feel fine after one session.
I have found some clients finding the way to my office because they have tried other techniques which were too painful to have to relive.
Of course, with the advent of hypnosis, guided imagery, Time-Line Therapy, Neurolinguistic Programming, Ericksonian approaches to therapy, the modern therapist is equipped to bring about changes certainly faster than with previously accepted methods. However, even with a shortened therapy program, in order to feel better, one must first feel worse by going through a cleansing process, or catharsis.
Frequently, the therapist can tell when the client resists recommendations or suggestions. However, deep seated unconscious resistance to change is usually beyond the client's awareness and can usually only be discussed and uncovered in the therapeutic process.
A client has a right to be resistant or not. He has a right to be cooperative or not. A resistant client is not to be condemned or disapproved of but the therapist must accept the fact that he needs the resistance at this time.
Some young practitioners feel that a resistance technique is an expression of ill will on the part of the client. In our daily practice, we can remain courteous and yet we do not necessarily anticipate that all our clients will reciprocate with courtesy. I have developed a repertoire of ways to handle the overt hostility of a client who becomes verbally abusive by simply telling the individual that I am flattered that he has so much trust in me that he can feel frank enough to tell me what he thinks of me.
The therapist cannot lose sight of the fact that the client comes for help.
In establishing a therapeutic relationship one must accept the behavior of the client and facilitate the expression of the behavior. It is the role of the therapist to indicate to the client that his behavior can be used in a way that can be of help to him.
Thus, the important thing is not for the therapist to agree with his behavior but for the individual to be able to use the behavior to successfully meet any situation.
The inexperienced hypnotist tries frequently very hard to correct such behavior immediately and tell the client how to behave. Of course, such a tendency to give advice goes against sound therapeutic practices.
Resistance needs to be respected by the therapist. We need to recognize that when resistance is exhibited, it means that we, as therapists, are moving too fast or expecting changes too soon.
The expression of resistance is symbolic of the beginning of change. J.G. Watkins states in his personal notes, "with any patient I assume that there are at least two personalities. One wants to get well or he would not be coming to my office, the other does not want to get well, or he already would be well. Too much of the wrong kind of reassurance to the first might make an immediate enemy of the second, sabotaging treatment."
Erickson is in agreement with Watkins, and explains that "many therapists who talk about bypassing, neutralizing or turning around a patient's resistance to achieve a desired end convey an implicit negative judgment against the part that is doing the resisting -- the resistant part is formally resisting for a valid reason and possibly expressing very potently the life survival instinct that so often appears to be missing in psychiatric patients. The goal should be instead to contact that aspect looking for its positive force and make an ally instead of conceiving it as a resistance." (from Erickson Approaches to Hypnosis and Psychotherapy, edited by Jeffrey K. Zeig).
In traditional therapy or counseling, resistance is supposed to be "interpreted," and when the counselor has no further interpretation to offer, he might rationalize by simply saying that the client is not ready to benefit from therapy.
However, resistance can be skillfully used by a therapist when one can compare the handling of resistance with the philosophy used in judo: rather than opposing the thrust, join it and increase it, thus this throws the client off balance. This technique can be easily applied in hypnosis as well as in psychotherapy. To clarify, the client is encouraged to behave in resisting behavior, thus by allowing resistance, changes will begin to happen. When somebody is invited to resist there are two choices to be made, one can either comply, and once compliance occurs resistance no longer exists, or one can refuse to comply which then brings the person to give up that resistance.
My own concept of resistance is when the therapist is unable or unwilling to see the client's point of view. Added to that there are some strategies that can be applied for preventing resistance.
The client needs to know, before he can accept the therapy, what is the rationale for the therapy. The client needs to understand, if he requests it, the application of paradoxical techniques, such as prescribing symptoms or encouraging a relapse.
I have found it useful to explain to the client the law of reverse effect. Thus, a client suffering from symptoms such as blushing or insomnia, can have it pointed out to him that the harder he tries, the less he will succeed. Then the therapy might go into intensifying one symptom in order to reduce the symptom.
The hypnotic technique to be adopted must be custom tailored to each client.
A script is not always suitable for the same symptom removal. Even assignments need to be custom made for each client. When a client who tells you that he never has any time to do the self-hypnotic techniques or exercises, that "he is always on the go," you might suggest that the best time to do these relaxation exercises could be while sitting down comfortably on the toilet seat.
Interpersonal factors outside of the therapist's office can be of great help. The family therapist, trained in hypnosis or vice versa, can elicit cooperation of family members in assisting with the therapy for phobics.
I have found that in most cases, giving a client choices for selecting his own technique reduces resistance.
Watzlawick in his book, The Language of Change, suggests that one can anticipate resistance, especially with oppositional clients, and thus diffuse by predicting what will happen before it happens. For instance, telling the client, "I think this will really help you, but you're probably not ready to do it yet" or "you're probably going to think this is too hard for you to do it right now." The client either opposes the therapist and does the assignment or the credibility of the therapist is maintained although the client does not accept the assignment.
Of course, the well-known distracting techniques such as described by Erickson and Rossi and others will be of great assistance here. For instance, one can ask the client to count backwards from 999 to I by 3's. By doing so, the client bypasses consciousness and reduces the likelihood of resistance and thus the client becomes more receptive to suggestion.
In summary, resistance is not good or bad. It just is and needs to be respected for it is the expression of many years of adjustment that the client has had to live with and now he is expected to give it up.