We've all experienced it. Those clients that ask for help and then don't change despite our best efforts. It is very frustrating for both the client and the therapist and can greatly decrease our job satisfaction. So who is responsible when a client doesn't change? Is it their resistance or our approach? I believe that it is 100% both!
Those clients who seem resistant have reasons for not changing and our approaches sometimes exacerbate their difficulty with change.
I recently came across an article by David Burns in the Psychotherapy Networker titled "When Helping Doesn't Help." Since my primary interest as a psychologist is in understanding and resolving resistance to change (conceptualized as ambivalence), this title certainly caught my attention. Burns was one of the early and most influential proponents of cognitive therapy in the 70s, culminating in a seminal book called Feeling Good published in 1980. This book was mandatory reading for all therapy students at the time and for some time to come.
Burns who had been trained as a psychoanalist in the 60s, became frustrated with the slow pace of change that he experienced with his clients. When he learned of CBT he became impressed by the rapidity with which he saw people change and devoted himself to CBT practice. Over the years, however, he began to notice that while many people achieved their goals in less than 12 weeks, others took years to respond ~ if at all. He stated that his practice became less satisfying as it began to fill up with the longer term clients who weren't responding to CBT, thus weren't moving on. He became interested in studying the difference between the two groups. He conducted a study with hundreds of patients from several clinics and found that compliance with homework was by far the strongest differentiating factor. He then spent time focusing on what caused certain people to be motivated to do homework and others not. Burns has written about his findings and new strategies in his newest book called Feeling Great.
Burns talked about the need to understand how the problem might actually be helping the client and then to reframe the problem by exploring the positive things that the problem implied about the person. He uses what he calls a magic button and asks if they would push the button if they knew that their problem would immediately go away. He then asks them to explore all the reasons that they should wait or go slow. He also asks the client to ponder what positive things the problem implies about them. For instance, perfectionism implies that they are a hard worker and anxiety implies that they care deeply. Burns suggests that after working through the resistance in this way, they can then move into traditional CBT.
You can't solve a problem if the problem is a solution.
So when, as a therapist, you encounter what might be called resistance, don't work harder; slow down. Exploring the reasons that change is not occurring may be the most important thing that you can offer. In fact, if someone weren't ambivalent about change, they might not need you in the first place! Try using the following prompts when dealing with someone that seems stuck:
You seem torn.
So one part of you wants to do this, while another part doesn't.
I could tell you what to do but I wouldn't understand why that might be challenging for you.
What's the hardest part about this for you?
What will you lose if this changes?
Finally, my favorite strategy for dealing with resistance is to relabel and conceptualize resistance as ambivalence. If you'd like to learn more, I have written a book called A Clinician's Guide to Pathological Ambivalence: How to be on Your Client's Side without Taking a Side and a companion workbook for the client called Understanding and Resolving Ambivalence. I'd love to hear from you. If you found this helpful please click on the heart below or leave a comment.