Psychological resistance is the phenomenon often encountered in clinical practice in which patients either directly or indirectly oppose changing their behavior or refuse to discuss, remember, or think about presumably clinically relevant experiences.
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The discovery of resistance was central to Freud's theory of psychoanalysis: for Freud, the theory of repression is the corner-stone on which the whole structure of psychoanalysis rests and all his accounts of its discovery "are alike in emphasizing the fact that the concept of repression was inevitably suggested by the clinical phenomenon of resistance".[1]
In an early exposition of his new technique, Freud wrote that "There is, however, another point of view which you may take up in order to understand the psychoanalytic method. The discovery of the unconscious and the introduction of it into consciousness is performed in the face of a continuous resistance (Widerstände) on the part of the patient. The process of bringing this unconscious material to light is associated with pain (Unlust), and because of this pain the patient again and again rejects it".[2]
He went on to add that "It is for you then to interpose in this conflict in the patient's mental life. If you succeed in persuading him to accept, by virtue of a better understanding, something that up to now, in consequence of this automatic regulation by pain, he has rejected (repressed), you will then have accomplished something towards his education...Psychoanalytic treatment may in general be conceived of as such a re-education in overcoming internal resistances".[3]
Although the term resistance as we know it today in psychotherapy is largely associated with Sigmund Freud, the idea that some patients cling to their disease [4] was a popular one in medicine in the nineteenth century, and referred to patients whose maladies were presumed to persist due to the secondary gains of social, physical, and financial benefits associated with illness (Leahy, 2001). While Freud was trained in what is familiar to us as the (secondary) gain from illness that follows a neurosis,[5] he was more interested in the unconscious processes through which he could explain the primary gains that patients derive from their psychiatric symptoms (Fenichel, 1945; Wolitzky, 2003).
The model he devised to do so suggests that the symptoms represent an unconscious tradeoff in exchange for the sufferer being spared other, experientially worse, psychological displeasures (Unlusten), by way of what Freud (1959/1896) labeled a "compromise formation", (Kompromisslösung; p. 163): "settling the conflict by constructing a symptom is the most convenient way out and the one most agreeable to the pleasure principle".[6]
Thus, contrasting the primary gain (internal benefits) and secondary gain (external benefits) from illness, Freud wrote: "In civil life illness can be used as a screen to gloss over incompetence in one's profession or in competition with other people; while in the family it can serve as a means for abcdefghijklmnopqrstuvwxyz the other members and extorting proofs of their love or for imposing one's will upon them… we sum it up in the term "gain from illness"… But there are other motives, that lie still deeper, for holding on to being ill… [b]ut these cannot be understood without a fresh journey into psychological theory" (1959/1926b, pp. 222–223).
To Freud, the primary gains that stood behind the patient's resistance were the result of an intrapsychic compromise, reached between two or more conflicting agencies: "psychoanalysis...maintains that the isolation and unconsciousness of this [one] group of ideas have been caused by an active opposition on the part of other groups".[7] Freud (1959/1896) called the one psychic agency "the repressing" (p. 163) - consciousness - and the other agency, the unconscious, eventually referred to as the "id" (Freud, 1959/1937a; Wyss, 1973).
The compromise the two competing parties strive for is to achieve maximum drive satisfaction with minimum resultant pain (negative reactions from within and without). Freud (1959/1911) theorized that psychopathology was due to unsuccessful compromises - "We have long observed that every neurosis has the result, and therefore probably the purpose, of forcing the patient out of real life, of alienating him from actuality" (p. 13) - as opposed to "successful defense" (S. Freud, 1959/1896, p. 163) which resulted in "apparent health" (p. 163).
Key players in the Kompromisslösung theory of symptom production, at the core of Freud's theory of resistance, were: Repression (often used interchangeably with the term anticathexis), defense, displeasure, anxiety, danger, compromise, and symptom. As Freud (1959/1926) wrote, “The action undertaken to protect repression is observable in analytic treatment as resistance. Resistance presupposes the existence of what I have called anticathexis” (p. 157).
In 1926, Freud was to alter his view of anxiety, with implications for his view of resistance. "Whereas the old view made it natural to suppose that anxiety arose from the libido belonging to the repressed instinctual impulses, the new one, on the contrary, made the ego the source of anxiety".[8]
Freud still understood resistance to be intimately bound up with the fact of transference: "It may thus be said that the theory of psycho-analysis is an attempt to account for two observed facts that strike one conspicuously and unexpectedly whenever an attempt is made to trace the symptoms of a neurotic back to their source in his past life: the facts of transference and resistance. Any line of investigation, no matter what its direction, which recognizes these two facts and takes them as the starting-point of its work may call itself psychoanalysis, though it arrives at results other than my own" (S. Freud, 1959/1914b, p. 298). Indeed, to this day most major schools of psychotherapeutic thought continue to at least recognize, if not "take as the starting-point", the two phenomena of transference and resistance (e.g., Beutler, et al., 2002; Leahy, 2001; Anderson & Stewart, 1983; Wachtel, 1982).
Nevertheless his new conceptualisation of the role of anxiety caused him to reframe the phenomena of resistance, to embrace how "The analyst has to combat no less than five kinds of resistance, emanating from three directions - the ego, the id and the superego".[9]
He considered the ego the source of three types of resistance: Repression Transference Gain from illness, i.e., secondary gain.[9]
Freud defined a fourth variety, arising from the id, as resistance that requires "working-through"[8] the product of the repetition compulsion. A fifth, coming from the superego and the last to be discovered...seems to originate from the sense of guilt or the need for punishment' [8] -i.e., self-sabotage.
All these serve the explicit purpose of defending the ego against feelings of discomfort, for, as Freud (1959/1926) wrote:
It is hard for the ego to direct its attention to perceptions and ideas which it has up till now made a rule of avoiding, or to acknowledge as belonging to itself impulses that are the complete opposite of those which it knows as its own.—(p. 159)
Freud viewed all five categories of resistance as requiring more than just intellectual insight or understanding to overcome. Instead he favored a slow process of working through.
Working through allows patients "...to get to know this resistance" and "...discover the repressed instinctual trends which are feeding the resistance" (1959/1914a, p. 375) and it is this experientially convincing process that "distinguishes analytic treatment from every kind of suggestive treatment" (p. 376). For this reason Freud (1959/1913) insisted that therapists remain neutral, saying only as much as "is absolutely necessary to keep him [the patient] talking" (p. 343), so that resistance could be seen as clearly as possible in patients' transference, and become obvious to the patients themselves. The inextricable link suggested by Freud between transference and resistance ("transference-resistance", Freud, 1959/1912; Fenichel, 1945; see also empirical support in Patton, Kivlighan, Jr., & Multon, 1997) perhaps encapsulates his legacy to psychotherapy.
Resistance is based on personal automatic ways of reacting in which clients both reveal and keep hidden aspects of themselves from the therapist or another person. These behaviors occur mostly during therapy, in interaction with the therapist. It is a way of avoiding and yet expressing unacceptable drives, feelings, fantasies, and behavior patterns.
Examples of causes of resistance: resistance to the recognition of feelings, fantasies, and motives; resistance to revealing feelings toward the therapist; resistance as a way of demonstrating self-sufficiency; resistance as clients' reluctance to change their behavior outside the therapy room; resistance as a consequence of failure of empathy on the part of the therapist.[10]
Examples of the expression of resistance are canceling or rescheduling appointments, avoiding consideration of identified themes, forgetting to complete homework assignments and the like. This will make it more difficult for the therapist to work with the client, but it will also provide him with information about the client.
Resistance is an automatic and unconscious process. According to Van Denburg and Kiesler,[11] it can be either for a certain period of time (state resistance) but it can also be a manifestation of more longstanding traits or character (trait resistance).
In psychotherapy, state resistance can occur at a certain moment, when an anxiety provoking experience is triggered. Trait resistance on the other hand occurs repeatedly during sessions and interferes with the task of therapy. The client shows a pattern of off-task behaviors that makes the therapist experience some level of negative emotion and cognition against the client. Therefore the maladaptive pattern of interpersonal behavior and the therapist's response interfere with the task or process of therapy. This ‘state resistance' is cumulative during sessions and its development can best be prevented by empathic interventions on the therapist's part.[11]
Outside therapy, trait resistance in a client is demonstrated by distinctive patterns of interpersonal behavior which are often caused by typical patterns of communication with significant others, like family, friends and partners.
Nowadays many therapists work with resistance as a way to understand the client better. They emphasize the importance to work with the resistance and not against it.[10][11][12] This is because working against the resistance of a client can result in a counterproductive relationship with the therapist. You could say that the more attention is drawn to the resistance, the less productive the therapy. Working with the resistance provides a positive working relationship and gives the therapist information about the unconscious of the client.[12]
A therapist can use countertransference as a tool to understand the client's resistance. The feelings the client evokes in you (as therapist) with his/her resistance will give you a hint what the resistance is about.[10] E.g., a very directive client can make the therapist feel very passive. When the therapist pays attention to their passive feelings, it can make him/her understand this behavior of the client as resistance coming from fear of losing control.
It can also be useful to identify resistance with the client. This can not only work towards addressing the issue, but can also allow the client to think about and discuss their resistance and the cognitive processes that underlie it. In this way, the client takes an active involvement in their therapy, which may reduce resistance in future. It also helps the client's ability to identify their resistance in the future and respond to it.
Important to the question of treatment planning are research studies that have looked at resistance traits as indicators and contra-indicators for different types of interventions. Beutler, Moleiro and Talebi (in press, as described in[12]) reviewed 20 studies that inspected the differential effects of therapist directiveness as moderated by client resistance and found that 80% (n=16) of the studies demonstrated that directive interventions were most productive among clients who had relatively low levels of state or trait-like resistance, while nondirective interventions worked best among clients who had relatively high levels of resistance. These findings provide strong support for the value of resistance level as a predictor of treatment outcome, as well as treatment-planning.[12] In these studies cognitive behavioral therapy has been used as a prototype for directive therapy and psychodynamic, self-directed, or other relation oriented therapy have been used as a prototype for non-directive therapy.
Behavior analytic (see Applied behavior analysis) and social learning models of resistance focus on the setting events, antecedents, and consequences for resistant behavior with the goal to understand function of the behavior [13] At least five behavioral models of resistance exist. (for review see [14] ). These models share many common features.[15] The most explored research model, with more than 10 years of support, is the model created by Gerald Patterson for resistance in parent training.[16][17] With supporting research, this model has even been extended to consultation.[18][19]
Patterson's suggested intervention of struggle with and work through is often contrasted as an intervention with motivational interviewing. In motivational interviewing the therapist makes no attempt to prompt the client back to the problem area but reinforces the occurrence when it comes up as opposed to struggle with and working through where the therapist directly guides the client back to the problem. Behavior analytic models can accommodate both interventions as pointed out by Cautilli and colleagues[20] depending on function and what needs to be accomplished in the treatment.