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Patient `Resistance’ is Self-Protection

Treating Pain in Psychiatric PatientsMarne has missed more than half of her scheduled appointments. When she does show up, she is often late – sometimes very late.

Joe, age 15, comes on time but then refuses to talk beyond a surly hello and a grunt or two.

Suzy is smart and engaging but is also an expert at rationalizing, justifying and intellectualizing. Her therapist hasn’t found a way to access genuine feelings.

Marla starts crying as soon as she enters the office. Her therapist has remarked to colleagues that she needs to buy stock in tissue companies.

And Will? Well, he regularly gets so threatening during sessions that his therapist wonders if he is really safe.

These patients do want relief. They come to therapy for help with fixing a long-standing distress. But their sessions are often derailed by behaviors that telegraph: “Help me but don’t ask me to talk about the real issues or to do anything differently. It’s too frightening!”

There are some schools of therapy that name such behavior as “resistance.” It assumes that the clinician is offering the help that is needed and the patient is “resisting” doing the work of therapy. That idea blames and shames the patient – a stance that isn’t at all helpful if we want to gain that person’s’ trust.

I was introduced to an alternative formulation some 30 years ago by Lynn Hoffman, a pioneer in family therapy. (I haven’t been able to trace whether this was her original idea). She suggested that a client doesn’t resist treatment. Rather, the client “persists” in engaging in the same behaviors (or feelings or ideas), not because he is in power struggle with the therapist or because she doesn’t want to change but because those behaviors keep them safe.

The patient and therapist haven’t sufficiently recognized long-established coping tools the patient has practiced in order to avoid distress and pain. The client is doing in therapy only what has “worked,” albeit painfully, in life.

Useful therapy is often uncomfortable. Healing trauma, strained relationships or internal conflicts often means revisiting events and feelings that are difficult and painful. It is only to be expected that our clients will, at times, avoid the pain that goes with treatment in ways that are well-practiced even if those very behaviors impede their ability to manage their lives.

6 Common Self-Protective Behaviors

There are, of course, as many ways to persist in self-protection as there are patients. But the following are some of the most common:

1.Chronic lateness/ missing appointments: The client is frequently late or regularly calls to say she can’t come due to illness, a family emergency or the car breaking down. Emergencies do happen. We don’t want a client to come when ill. But a pattern of missing minutes of her hour or entire appointments is an effective way to be in therapy but never have the time to delve deeply into issues.

2. Refusing to engage: The client comes to the appointment but doesn’t have much to say after “hello.” The message seems to be “I have to be here (maybe I even want to be here) but I don’t have to say anything. The client doesn’t respond meaningfully to the clinician’s attempts to join with him. Some clients, especially adolescents, refuse to talk at all.

3. Over intellectualizing/rationalizing: This patient has an intellectual answer for everything. I overheard one patient tell another in the waiting room that she is smarter than every therapist she ever saw so there wasn’t much point to even being there. Her strategy for staying safe was to play a game of wits with her therapist rather than risk uncovering the roots of her distress.

4. Lying: Some clients have learned to keep themselves safe through lies. It has become so reflexive that they may not even be aware that they are doing it. They weave compelling stories. They leave out important information. They deny that they said something you were sure you heard only minutes before.

5. Crying so much you can’t get a word in: The tears start as soon as the patient walks in the door or as soon as you attempt to address anything of substance. The patient has learned through years of practice that anyone with compassion will respond with sympathy and concern. Those without compassion may deride them. In either case, they won’t have to participate in the conversation any more.

6. Anger: Turning up the volume, looking angry, balling the fists and making threats are all ways to make another person (including a therapist) back off.

What to Do

“Firing” a client who regularly doesn’t show may make financial sense for the therapist but it doesn’t help the client. Confronting, cajoling, arguing or even suggesting that fear is at work seldom helps. For the client, the vulnerability of self-disclosure that therapy requires is just too scary.

When clients persist in using protective strategies that help them avoid meaningful discussion, we need to ask ourselves: Have we done enough to establish trust? Is therapy going too fast? Are there frightening issues that might come forward if the client truly engaged? We need to slow way down and adjust our words and our pace accordingly. Suggestions for simple symptom relief are sometimes non-threatening enough to begin establishing trust.

But equally important, maybe more importantly, these clients often require more than reassuring words or gentle suggestions. It usually takes waiting in compassionate silence as well. That does not mean colluding with the client in avoidance. It does mean watching with sympathy and noticing and remarking kindly when there is any sign that the person is tentatively opening. Sometimes gentle reminders like, “I’m here whenever you are ready” reassure the client that we will be there when they feel safe.

The pace can be excruciatingly slow. It calls on us to use every ounce of our capacity to stay centered and mindful and to use our own body language and eyes instead or our mouths. It is not a waste of time. It is how, for these patients, therapy begins.

Patient `Resistance’ is Self-Protection

Marie Hartwell-Walker, EdD

Marie Hartwell-Walker, Ed.D. is an author, licensed psychologist, and a marriage and family therapist who has been in practice for more than 35 years. She is a regular contributor to Psych Central and one of the therapists who answer questions at Ask the Therapist.

 

APA Reference
Hartwell-Walker, M. (2018). Patient `Resistance’ is Self-Protection. Psych Central. Retrieved on December 10, 2018, from https://pro.psychcentral.com/patient-resistance-is-self-protection/

 

Scientifically Reviewed
Last updated: 17 Jan 2018
Last reviewed: By John M. Grohol, Psy.D. on 17 Jan 2018
Published on PsychCentral.com. All rights reserved.