Understanding and Working with Resistance
A deep understanding of resistance should be a part of every therapist’s toolbox, regardless of the tools they employ in their work. As a young therapist, I remember feeling increasingly frustrated with client resistance. I believed, at the time, that resistance was something I needed to push aside in order to do the work I wanted to do - take those dramatic deep dives into the unexplored areas of the psyche – like in the movies. As my frustration would build, I would go from gentle hints to increasingly more blunt confrontations, hoping to help them “get over it.”
It took quite some time - lots of reading, supervision, thinking and even more self-awareness to realize what resistance actually is - the embodiment of the adaptational challenges we have all had to make during development and throughout life. Resistance is the living, breathing manifestation of our clients’ history that we spend so much time trying to get to through words. I learned that the resistance I was trying to push aside, was actually at the very core of what I was hoping to get to. The gold was right in front of me, but my ignorance kept me from seeing it.
Understanding and Working with Resistance
Resistance is embodied in an array of defenses. The purpose of defenses is to distort reality in the service of affect-regulation – primarily, anxiety reduction. The early analysts distinguished between neurotic and psychotic defenses: The neurotic defenses - like sublimation, repression, and humor - use a minimal level of reality distortion to achieve their purpose and can be quite adaptive.
The psychotic defenses - like dissociation, hallucinations, and fantasy - make adaptation very difficult because they distort reality to the point where experience is not shared with those around you. This is the old analytic view - a good starting off point – but the reality of defenses is more complex.
Types of Resistance
The various types of resistance range from those which are a conscious part of the client’s communication to those embedded within their automatic behaviors, personality, and character of which they have not a clue. We will start with the more surface form of defense and work our way down.
Resistance to Content: The client is reluctant or refuses to discuss certain topics.
Specific Defense Mechanisms: The use of the defense mechanisms such as intellectualization, denial, humor, sublimation, etc. during the treatment.
Resistance to "Patient-hood": Resistance of the sick role and being seen as weak, sick, dependent or crazy. Sometimes masked behind “cultural” differences.
Secondary Gain Resistance: The problem serves a purpose and is reinforced by the environment.
Neurotic Equilibrium Resistance: A fear of change; "I don't like the way that I am but at least I know what to expect."
Superego Resistance: A harsh superego not allowing for the possibility of positive change. "I would never be a member of a club that would have me."
Indications of Resistance
1) Reducing the amount of time spent in treatment.
2) Restricting the amount and range of conversation.
3) Isolating therapy from the rest of life.
4) Acting out.
5) Flight into health.
6) Questioning your professional qualifications.
7) Questioning your ability to understand.
8) Questioning your ability to help.
Responding to Resistance
The goal is to create experiments where a person is able to risk navigating their relationships with their lives, or different experiences, with a decreased level of defensiveness.
The process involves a gradually increasing ability to tolerate a slightly higher level of anxiety, avoiding the activation of prior defenses, and risk feeling all their feelings a little more deeply.
Include an understanding of a client’s resistance as part of your case conceptualization and treatment plan
Find out how your client tends to leave relationships – a possible model for premature termination
Be receptive to and respectful of resistance and provide support for it
Understand the need for the resistance and its value and purpose for the individual
Allow it to build and gather evidence - don't interpret it at the first indication
Call attention to resistance / create awareness
Explore resistance
Interpret resistance
Provide alternative methods of coping and affect regulation
Defenses are the shadows of the past, put in place to tolerate difficult experiences and decrease fear and anxiety. They are a time-capsule of unconscious history with a great deal of explanatory power in the present. When we come into self-awareness at 18 or 48, we see ourselves and the world around us through the prism of these defenses – defenses contain a cognitive and/or emotional strategy for engaging with the world. Your client knows no other world other than the one that has been shaped by these invisible apps. They take their experience as reality.
The poet Robert Bly describes a baby as coming into this world full of stardust, cosmic energy wanting to take over the world, yet all our parents want is a good boy or a good girl. To the degree that this is true, we all run into the wall of reality. We are all hurt by reality and we have to figure out some way of managing our selfish primitive drives with the realities of our social and physical worlds. Freud presented this as the basic dilemma faced by the clashing of id and superego that the ego had to somehow negotiate a peace. How do we get our needs met and still play well with others and maintain our parents' love?
Some important points:
Your client’s defenses are not about you, no matter how personal they feel.
The strength of a clients’ defenses are proportional to the amount of pain they were put in place to cope with.
They contain important emotional information about the client that they usually don’t know.
They need to be accepted and appreciated for the role they have played in allowing your client to survive to the point where they sought therapy.
Don’t resist resistance, defenses get stronger when they are under threat.
Accept them into the therapy and help your client to slowly become aware of them, their value, and the role they play in psychic equilibrium.
The client should slowly begin to see that while their defenses have been helpful, they may also have unintended negative consequences for their ability to love, work, and find peace.
The process is to gradually shift them from being ego syntonic to ego dystonic – in other words, as needed parts of the self, to ego alien aspects of experience and behavior that would be better left behind.
Swimming in the Deep End
Transference Resistance: This client projects past material onto the therapist and thus avoids the anxiety of the present situation. This can be understood as a form of regression.
Negative Transference: Negative transference embodies past negative experiences with significant others. A failure to recognize negative transference is common due to our own narcissism. We are highly receptive to compliments and blind to expressions of negative transference unless it is “crudely expressed.”
1) The "good" patient “I brought you cookies!”
2) Rigidly conventional and correct “Can I have some homework please”
3) Paralyzed affect and compulsive
4) Narcissistic condescension “I am observing from above”
Character Resistance: Armor is developed for defense against real and imagined dangers. Usually invisible to its owner, the client will not bring it up of his or her own accord – it must be unmasked by the therapist. "...the patient has to realize that he is resisting, then by what means, and finally against what." The character defenses must be made ego alien or ego dystonic.
"Every patient has the tendency to remain sick...many analysts...accuse the patient of not wanting to get well...a stagnation in the analysis which remains unclear is the fault of the analyst." (23)
Although there are many excellent books on resistance, the one that was most helpful to me was Wilhelm Reich‘s Character Analysis. As you probably already know, Reich was one of Freud‘s early disciples, you may not know that he died in a US federal prison. There is no doubt that, like many other geniuses, he lost hold of reality, and dipped in and out of psychosis. But the first 120 or so pages of Character Analysis is one of the most brilliant pieces of writing about the therapeutic process I’ve ever read. Reich came to realize that there are multiple processes of learning and memory throughout the brain and body. He also realized that the emotional experiences of childhood and traumatic experiences which occur later in life, and now I’m speaking more in contemporary language than the Latin language of his day, can be stored outside of conscious autobiographical narratives.
Reich explained that some forms of memory are embodied in our musculature, our posture, how we hold ourselves, and the manner in which we interact with others. Reich’s work is credited with being the foundation of Gestalt Psychotherapy and much of the body work and body focused therapies of today - from the somatic work of Pat Ogden, to the deep massage to unlock memories of Rolfing, and a variety of alphabet therapies that have sprung from his basic insights. From Reich, I first learned that language is a very narrow window into the experience of our clients. I have to admit as someone with intellectual defenses, this was quite unsettling. The strength of my defenses had primarily relied on my ability to use words to regulate my feelings so my initial approach to therapy was to help my clients do the same. This is where most of us begin as therapists, parlaying our defenses into a therapeutic modality.
I’ve come to understand that most of the verbal output we receive from our clients has already been filtered, edited, and shaped to embody a clients’ defenses. This left hemisphere-based, self-conscious narrative, is subject to modifying influences from the client, the family, and their social and political environments in addition to their emotional needs. I came to learn that you can work with someone’s narrative for a long time and still get nowhere near their emotional center.
On the other hand, the language of gestures, facial expressions, posture, muscular tightness, interpersonal bearing, and many others from implicit, right hemisphere memory systems, contain a wealth of information that the client usually doesn’t know they are sending across the social synapse. These signals provide a much greater opportunity to gather information and generate hypotheses that are much closer to a client’s experiential Ground Zero.
What Reich first gave me was a way to see and think about all of this unspoken information. We can shuttle from our left frontal neural circuits of language comprehension to visually processing the content of their bodily communication. We can get an internal emotional model via mirror neurons and emotional resonance while also applying our ability to process their potential significance. We can watch a client grip the arms of their chair and feel the tension in our bodies as our hands and hearts do the same. We can then take this information back to our case conceptualization and treatment plan and strategize as to how to use this new input to shape an interaction or interpretation.
A client, Nadia, a woman in her mid 30’s, came to the United States after escaping from an authoritarian regime of her homeland in an Eastern European Communist country. Her fear and defenses were very strong and completely understandable given that she grew up with parents telling her to keep quiet because you never know who is listening, whether their apartment had been bugged, or whether someone they thought was your friend was actually a collaborator with the regime. And because she was perfectionistic and English was her second language, she would often hesitate to express herself for fear of using the wrong word or phrase.
I noticed that when there was a noise in the hall which was to her left, she would lean her body to the right, put her left hand up with the palm facing her face, look down and to the right, and close her eyes. The first time I saw this, I didn’t comment on it because it may have been an individual reflex on that given day. But I noticed at once again when a car pulled into the driveway outside the window, which was to her right. She made a similar gesture without adjustment for the side the sound came from. This made me hypothesize that this was a stereotyped reflex related to some past experience.
When it happened more subtly a few weeks later when she was discussing running into an old boyfriend, I had confidence that this gesture had, for some reason, been burned into her somatic reflexes.
When I asked her about it, she dismissed it as a result of a lack of sleep and that she was feeling “jumpy.” Remembering a Gestalt technique I saw Fritz Perls do decades earlier, I asked her if she would do the gesture again, but this time exaggerating it and to try and put some sound to it. Not necessarily a word, but whatever sound that came to her. Being an old-school pragmatist, she gave me a look that clearly said, “Are you kidding me.” But after some cajoling and asking her to humor me, she gave it a try.
The movement was a full body gesture – I demonstrated what I saw, careful to assure her that I wasn’t mocking her. She enjoyed dancing so I was able to frame it in the context of a choreography. I leaned to my right, put my hand up, palm facing my face, looked to the left and closed my eyes – describing each step as I demonstrated it.
She did it perfectly the first time as I had seen her do it before – the combination of movements appeared to be well ingrained as a motor ensemble. I had her do it about 5 times, each time encouraging her to exaggerate the movement and to pay attention to any feeling, visual images, or thought that bubbled up.
By the third repetition, I could see that her facial expression changed and her body became more tense. She appeared to be getting more anxious with each repetition, her face had grown pale, and I noticed a tremor in her right hand. We sat in silence for a while and as I watched her face, she appeared to be watching a scene play out before her eyes. I asked her if she could describe what she was experiencing but she remained silent for a number of minutes.
When she finally broke her silence, she told me that the man that she married to escape her country had turned out to be a sadist, who was physically and psychologically abusive. When she couldn’t take his abuse any longer, she told him she was leaving him, which sent him into a rage. He attacked her, tied her up and put her in the trunk of his car as he yelled about how unappreciative she was. She was in the trunk for hours as he drove them to a remote spot in the desert where he leaned her against the side of his car and began digging her grave. As he frantically dug the hole next to her, he screamed that he would rather she be dead than ever be with someone else. The posture that was activated in my office was the one she was locked in for the time it took for him to dig her grave.
This was obviously very traumatic for her but this particular experience turned out to only be the tip of the iceberg. Nadia was expert in suppression, repression, and denial and this characterological defensive structure needed to be unmasked and made ego dystonic in order for her to begin to integrate so many difficult and dissociating experiences. The gesture she made when she heard a noise was a way in – there probably were others – but this is the one I saw and climbed through.
As you can see, understanding her physicality to be a potential source of memory, can be a valuable source of information. Reich was the first I’m aware of to describe this in an articulate and instrumental way. He provided an early understanding of the fact that we have multiple memory systems that can become dissociated.
Resistance has been described in many ways, but one of my favorites is paradoxical reluctance. Our clients come to therapy to relieve their suffering and help them understand why certain aspects of their lives aren’t working. They pay with time, money and discomfort for a therapeutic experience only to seemingly thwart our efforts.
As a beginning therapist, I remember how difficult this was for me to tolerate – it was also hard not to take it personally. After all, I had a lot invested in becoming a therapist and, of course I wanted to be successful. I experienced my clients’ resistance as a threat to my success. I tried everything to be patient and wait for it to pass, but this was not a successful strategy. I remember that Rogers talked about a natural tendency to get better and that the arc of therapy bends in the direction of health. Reich, on the other hand, believed that people tend to remain sick unless something new is added to their experience. In this context, resistance – especially character resistance – leads a person to the same conclusions again and again because it contains an unchanging internal logic that brings us back to the same place.
During the 1980’s and more so into the 90s, trauma became the focus of therapy and gave me a greater appreciation of the complexity and importance of focusing on resistance. It was much easier to see how someone who is dissociating was doing so because they were reverberating with the memory of an overwhelming threat to their physical and psychological integrity. A disturbance in their psyche that was proportional to the physical, sexual, and emotional abuse they experienced.
As time went on, this deep appreciation of the value of resistance became woven into our work with clients who hadn’t experienced T trauma and brought us back to Reich’s original insights. At the same time we came to a deeper understanding of the fact that children are not small adults, and that their early trauma was experienced with a more primitive and less defended brain. Understanding a child’s experience from the adult perspective wasn’t very helpful. The intrusions, impingements, and adverse experiences of childhood can be experienced by the body as extremely traumatic even if they seem less significant through the eyes of an adult. Children lack perspective, emotional-regulation, and independence.
Reich said that no interpretation of content should be made before interpretations of process – process meaning the defensive structure a client brings to the therapy. His point was that if you are making interpretations about the material a client is bringing into therapy but avoiding examining process, charter armor, and defenses – the interpretations are going to be utilized by the defenses to make them even stronger. If you send someone with a personality disorder for CBT, they may use what they learned to strengthen their defenses in the way a loud moralist will use their piety to bludgeon others to distract themselves from their own shame. In Reich’s words, analyzing content without analyzing defenses will result in “a catastrophic comprehension of the psychic surface.”
What we don’t want to do is collude with the client’s defenses and give them more ammunition for their defenses. The first focus is to expose the defenses. Say for example that a paternal countertransference for Nadia may have led me to discount and avoid her resistance and given her strategies for relaxation or spent the sessions discussing her conflict with her brothers or the particular boyfriend of the moment. We could have discussed all of these things for years and never gotten to the terror she held inside her at every moment.