As trainees, we often hear the word resistance and think that it is a bad thing, something that needs to be worked through. There are hundreds if not thousands of articles and books that talk about resistance, some of which I will eventually discuss and cite. However, in the meantime, let's talk about befriending our patient's resistance.
Many people in the helping profession find self-exploration fascinating. In fact, I would venture to guess that many psychologists and other mental health professionals enter into their profession to cultivate a deeper understanding of meaning, truth, internal equanimity, and self-knowledge. However, it would be credulous for us to think that everyone wants to know more about themselves. Many of our patients just want their symptoms to go away, leading some to pursue treatments that are not psychodynamic in nature (e.g., CBT/3rd-wave, medications, alternative medicine, religion/spirituality). Finding out more about oneself can be incredibly painful, perhaps even leading to the exacerbation of symptoms temporarily.
There is some relief when I talk about the benefits of the treatment with patients, but when I discuss the risks of psychotherapy, it's almost like I'm looking into the eyes of a ghost. Therapy can be painful. Incredibly painful. Finding out more about oneself can be not only difficult, but it may lead some to leave treatment prematurely.
So what does this mean for our clients? If we believe that self-knowledge and exploration will lead out patients to recovery, how are we supposed to work with their resistance? One of the best pieces of advice I have ever been given is this: A patient resists the frame of therapy, not the therapist. When I first started working with patients, I thought of their resistance as a personal attack [Yes, all my insecurities were at the surface]. I am, and have always been, a fairly passive, but quite curious, therapist, so I rarely did anything with these perceived personal attacks. However, their resistance surely got me thinking about what was happening in the relationship.
I've come to realize that many new patients do not yet have the capacity to think about resistance. Though I'm thinking about it frequently, rarely do I confront/interpret patient resistance unless it is affecting the treatment significantly (e.g., missing appointments regularly or other significant acting out behaviors). What I try to do is get a better picture of the resistance and create a relatively cohesive narrative around it, while providing empathy every step of the way (e.g., I rely heavily on Self-Psychology's idea of the "forward edge" or "leading edge" interpretation). Then, after I have a better understanding of the patient's resistance, and our relationship is strengthened through time, I can begin to share some of my observations and insights to the patient in the form of confrontation, clarification, or more classical interpretation, depending on the patient's ego strength or level of functioning.
Uncovering resistance is a form of self-knowledge. A very painful self-knowledge. There are very good reasons why patients resist the frame of therapy, and as therapists, we have to be open to what those reasons are rather than thinking we have all the answers. We cannot let our own curiosities/narcissistic needs get in the way of the patient's own pace of their self-discovery, though we can surely help them begin to understand parts of themselves that are keeping them sick.
Underneath resistance is a whole lot of pain. Though we cannot see or feel that pain, the patient has at some time in their life. The resistance protects the patient from feeling that pain again, and we have to be willing to have patience, empathize with it, and start to begin to understand it.
- cg
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