Client Resistance in Therapy: How to Help Difficult Clients

Facing a client who is resistant or possibly hostile to the therapeutic process or therapist can be unsettling and challenge the treatment’s success (Clay, 2017).

However, the therapist must be careful. Labeling behavior as resistant may result from a lack of knowledge or therapeutic skills, and an inadequate response to the situation can damage the client’s progress (Shallcross, 2010).

Reframed, uncomfortable interactions can strengthen the therapeutic relationship and further treatment, and encourage client growth.

This article explores resistance in therapy, the therapist’s potential to reduce its negative impact, and its use as part of the therapy process.

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What Is Resistance to Change?

While some clients may have unconscious (also known as transferential) resistance to therapy, others have “conscious, deliberate opposition to therapeutic initiatives that they fail to understand or accept” (Austin & Johnson, 2017).

Such resistance, or objection, to both the therapist and therapy is sometimes referred to as ‘realistic resistance’ and includes opposition to (Rennie, 1994):

• The therapist’s overall approach to therapy
• Specific in-session techniques
• Some of the terms used by the therapist

While having an issue with the general approach to therapy is an obstacle that may need specific focus, the therapist may moderate difficulties with in-session techniques and terms by building a solid working relationship between therapist and client (Austin & Johnson, 2017).

Perhaps the biggest issue is not so much the client’s objections, but their potential invisibility. The client may claim and even appear to be on board with the therapy process and the therapist’s recommendations, yet keep their disagreement hidden.

However, observant therapists are likely to spot covert acts of resistance when the client (Ackerman & Hilsenroth, 2001):

• Uses statements that distance the therapist
• Avoids particular topics
• Physically withdraws from the conversation

Training and experience can help mental health professionals recognize the subtle acts of defiance, address them, and strengthen the collaboration with the client (Austin & Johnson, 2017).

2 Examples of Resistance to Change

The following two real-world examples provide insight into the types of resistance a psychologist may face:

• After 15 years as a therapist, Kirk Honda experienced his worst case of resistance working with two parents and a daughter. The father, annoyed by the process, began verbally attacking Honda, and before long, the daughter joined in. Sweating and feeling about to have a panic attack, Honda said that he almost ran out of the office (Clay, 2017).

Regaining his composure, he could eventually repair the therapeutic relationship, but it left him shaken and questioning his competence. On reflection, Honda realized that resistance, while uncomfortable, can be a valuable path to success in therapy (Clay, 2017).

• Therapist Robert Wubbolding offers the example of a resistant teenager taking drugs, dropping out of school, and rebelling against school and parents.

“Self-evaluation is key in dealing with resistance,” says Wubbolding (Shallcross, 2010).

Connecting with the client and understanding their perception as a victim with little control is vital. The therapist can then help the client realize that the path they have been on has not helped them – or has made things worse – and it may be time to try a new approach.

Client resistance may take different forms, including (Miller, 1999):

• Arguing — The client contests the accuracy of what is said by the therapist, questions their expertise and authority, and acts with hostility.
• Interrupting — The client repeatedly interrupts the therapist by talking over them or cutting them off.
• Denying — The client is unwilling to recognize the problems, accept responsibility, or take advice; for example:
  • Blaming others for their own problems
  • Making excuses for their behavior
  • Being unwilling to change
• Ignoring — The client ignores the therapist by not paying attention, not answering, giving no audible reply, or changing the conversation’s direction.

Reasons for Resistance: 3 Psychology Theories & Models

While breaks in the therapeutic alliance are often inevitable, they can obstruct client engagement and hinder the therapeutic process. Such resistance can result from (Safran, Crocker, McMain, & Murray, 1990):

• Using techniques that fail to resonate with the client
• Not being able to follow or do what the client expects or wants

The client may also attempt to avoid specific topics, known as ‘collusive resistance.’ Or they may present themselves as psychologically fragile and seek a reaction from the therapist (Austin & Johnson, 2017).

Several theories attempt to explain resistance in psychotherapy. While they differ in their assumed causes and how to deal with resistant patients, they recognize similar behavior as resistant (Beutler, Moleiro, & Talebi, 2002).

They include:

Psychoanalytic model of resistance

Freud’s model suggests that resistance results from the patient’s confrontation with unresolvable conflicts.

According to this theoretical framework, the ego has several specific defenses, such as “denial, sublimation, isolation, intellectualization, displacement, regression, projection, and reaction formulation” (Leahy, 2003).

As a result, clients may be unaware of their actual problems because their defenses protect them from the truth, exhibited as resistance (Leahy, 2003).

Behavioral models of resistance

Behaviorists may not like the term resistance, but they recognize that clients often fail to comply with therapeutic instructions (Leahy, 2003).

According to the behavioral model, the “failure of the patient to comply with therapy may be the result of inappropriate reinforcers or reinforcement contingencies” (Leahy, 2003). Resistant behavior may occur when positive actions are not reinforced immediately or the client has to wait for their desired result.

Cognitive models of resistance

In cognitive models such as Albert Ellis’s, resistance is often the result of unrealistic expectations and other irrational beliefs.

According to such models, resistance, like other irrational beliefs, requires head-on confrontation. The client must be helped to surrender irrational beliefs to move forward (Leahy, 2003).

How to Deal With Difficult and Resistant Clients

While resistance can interfere with collaboration and therapy, it should not cause it to stop.

Such therapeutic ruptures can serve as vehicles “that may be used to deepen the therapeutic bond and promote growth” (Austin & Johnson, 2017). They allow both client and therapist to practice interpersonal conflict resolution skills and promote growth that may not occur in their absence.

The process of resolution can overturn the client’s long-term, maladaptive interpersonal schemata.

The therapist should not avoid situations that risk challenging the process, but work to address the resistance (communicated directly or indirectly). Unless confronted, the therapist risks strengthening the client’s need for nurturance rather than growth (Safran et al., 1990).

There are several ways of “fostering growth by encouraging the client’s agency” (Austin & Johnson, 2017):

• Allow the client to find and develop their skills and means to address problems.
• Use open-ended questions to help the client explore their personal experience without influence.
• Let the client sit and silently experience their emotions, even uncomfortable ones.

Skilled counselors balance how they handle avoidant responses, remaining sensitive to the client’s needs and feelings while still tackling the reason for being in therapy.

But this is not easy; it can be both tiring and frustrating.

Several techniques and strategies can help therapists remain calm and manage the challenging and potentially damaged therapeutic process (Clay, 2017).

Calm yourself

Fighting back will quickly escalate an already difficult situation. Rather than react to it, become aware of your emotional and physical state (confusion, dread, racing heart, etc.) and pause, even briefly.

Daily mindfulness practices can help you remain connected to your values as a therapist and become more aware of your sensations and thoughts.

Express empathy

While challenging, validate what the client is saying. Tell them you are sorry for doing something that has made them angry or that they feel is not helpful.

It is crucial to sound genuine and authentic to avoid further escalation. Once the emotion is acknowledged, clarify that swearing, threatening behavior, failure to show up, or refusing to pay for services is not acceptable.

Reframe resistance

If the client is resisting and the therapist gets irritated or annoyed, you have two people fighting one another, and the therapeutic relationship breaks down.

Instead, encourage the client to explore and explain their feelings and show that you recognize and understand them.

Cultivate patience

As a therapist, it can help to remember that you are there to bear the burden of your client’s pain.

Remembering the bigger picture can help you handle the frustration while developing patience that can be valuable in this situation and beyond.

Seek support from peers

All mental health professionals have challenging clients.

Sharing stories (confidentially) can remove feelings of isolation, lead to positive suggestions, and identify valuable techniques.

Consider terminating the relationship

Ultimately the client’s needs are paramount.

If the client truly believes the therapist is not meeting them, it may be time to end the relationship and refer them to another professional.

Reducing & Addressing Resistance: 7 Exercises

According to the American Counseling Association, there are several exercises and approaches counselors can use to manage and reduce the negative impact of resistance (Shallcross, 2010):

• Reality approach
  The therapist must encourage the client to see that the resistance approach is unhelpful and has no long-term benefit.

Ask the client how others in their environment treat them. Find out “how they oppress them, reject them, make unreasonable demands on them and control them” (Shallcross, 2010).

Encourage the client to self-evaluate. Ask them what techniques they have used in the past to cope and manage the situation and whether they were successful.

The counselor should try to connect with the client’s reality rather than focus on their own agenda. They can then encourage the client to recognize that while unable to control others’ behavior, they can manage their own – and that the therapist can help.

• Two-way street
  Counselors and therapists may have a part to play in the client’s resistance.

According to Clifton Mitchell, a professor at East Tennessee State University, “Resistance goes two ways. The challenge is finding more creative and effective ways to interact” (Shallcross, 2010).

The outcome of therapy is often decided by managing the obstacles and challenges encountered during the process.

The following techniques can help form a safe and trusting relationship that is ultimately productive:

• • Reach mutually agreed-upon goals for the therapy. They can bring clarity and strengthen the therapeutic relationship.
  • Do not waste time being frustrated or discouraged by “I don’t know” answers. Instead, accept, embrace, and empathize with them rather than fighting the response.
  • Empathize with the client to show you agree that the problem is hard to figure out, but you can work together to resolve it.
  • Rather than do the expected, disrupt the typical (often anticipated) pattern of thinking, questioning, and answering with alternative questions and approaches.
  • Do not push the client until they are ready. It will lead to resistance. Instead, listen and “focus on not creating resistance and not fostering defensiveness” (Shallcross, 2010). Then step back and let change happen.
  • Reduce or stop excessive questioning. Each one can become a micro-confrontation and lead to unproductive answers. Encourage dialogue.

Engaging Difficult Clients in Group Therapy

Each of the following strategies can be valuable in group (and often one-on-one) settings (modified from Austin & Johnson, 2017):

Client did not do their homework

Ask the group to confirm their understanding of the homework to ensure instructions were clear; discuss any confusion or obstacles they faced.

Pay particular attention to disagreements, challenges, and resistance within the group, and consider how increasing and improving collaboration may help.

Client misses several sessions

Discuss why the client could not attend one or multiple group sessions, and ask if there are any other underlying reasons.

For example, did recently discussed issues that caused distress factor in the decision not to attend?

Client verbally indicates only partial agreement

The client may be using phrases such as I’m fine or I’ll try.

Discuss the discrepancies between what they are saying and the tone they are using in the group.

Perhaps I’m misreading, but it sounds like…

Understand the thinking behind how they are responding, and share your assessment with the client.

Client signals don’t hurt me

Acknowledge the client’s distress and encourage them to engage fully in the group conversation. Ask them to sit up, remain focused, and talk openly in this safe space.

Client is avoiding specific topics

Bring the group conversation back to the topic, and become aware when avoidance tactics are evident.

Consider whether their behavior is consistent with the client’s problems or indicative of a disagreement with the therapist.

Client is behaving withdrawn or distant

Discuss with the client that you are sensing some distancing (from you or the group) or that you are concerned you are not on the same page.

Ask the client if they feel the same way or have anything they wish to share individually or with the group.

Client signals disengagement through other behavior

The client may be behaving in a way that signals complete disengagement from the group.

Take care drawing attention to the behavior in a group setting, as it may be upsetting to hear and cause further resistance. Use the information to shape the ongoing therapy, and attempt to draw them into future discussion.

8 Helpful Interview Questions

Solution-focused therapy focuses on the discussion of solutions rather than problems and helps overcome resistance.

Miracle questions invite the client to visualize how the future may look when the problem no longer exists and may be less daunting for the client than dwelling on existing issues.

Invite the client to envision and describe how the future could be different once the problem has been resolved.

The following therapy questions bring the exercise to life (and are less confrontational), potentially avoiding the triggering of resistance mechanisms:

• What do your senses pick up?
• What do you feel?
• What are you doing? (In as many aspects of your life as possible)
• With whom are you doing it?
• Where are you living?
• How much fun are you having?
• How much income are you earning?
• What difference are you making in the world each day?

The questions help create a picture of how life could look and may feel less contentious and pressuring than direct questions.

PositivePsychology.com’s Helpful Resources

We have plenty of tools, techniques, and worksheets to encourage cooperation within the therapeutic process and improve clients’ self-image and hope for the future.

• Motivational Interviewing in Social Work
  This template presents five questions based on Prochaska and DiClemente’s (1986) Stages of Change model to help practitioners assess clients’ readiness for change.
• Your Miracle Worksheet
  This worksheet can be used to capture a client’s vision of how the future could look once their problems were no longer issues, serving as the first step toward goal-setting and action.
• Things I Love
  This exercise invites a group of participants to share and discuss the things they love, encouraging self-reflection while nurturing group cohesiveness.
• What I See in YOU
  This group exercise helps clients gain insight into the many wonderful qualities others perceive in them, helping to boost self-esteem and support more positive self-appraisals.

If you’re looking for more science-based ways to help others enhance their wellbeing, this signature collection contains 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

A Take-Home Message

Recognizing resistance and taking the appropriate action in therapy may not always be straightforward.

Practitioners must watch for subtle indications of avoidance or evidence that the therapeutic alliance is straining (Austin & Johnson, 2017).

The therapist can then gently raise concerns regarding either what is being avoided or the tensions that arise. They must bear in mind that, ultimately, resistance can provide helpful input to the therapeutic process, offering new insights and the opportunity for growth.

It is important to remember that the therapeutic relationship is ultimately the priority. Observing and navigating resistance may require changing approaches and interventions. Indeed, when identified, it may be appropriate to let go of the planned agenda and focus on more pressing issues (Austin & Johnson, 2017).

The theories, examples, and techniques in this article should help you recognize that encountering resistance may be a significant breakthrough with a client, leading to a more robust client–therapist bond and valuable growth in the client.

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