Treatment Resistance: Client Issue or Counselor Challenge? DEBRA E. ORR-BROWN, MSW, CAP CORRECTIONS CORPORATION OF AMERICA (CCA)

Why Talk about It? After completing this workshop, the participant will be able to: 1. Identify and describe the forms of resistance. 2. Understand the importance of the therapeutic alliance in reframing resistant thoughts and behaviors. 3. List effective communication and behavioral skills to increase motivation for change in difficult clients.

Who Are We Talking About?  Involuntary Clients  Clients who talk excessively or are quiet and withdrawn  Clients who overwhelm themselves  Clients who blame others  Clients who deny needing help  Clients who are overly dependent on you  Clients who manifest passive-aggressive behavior  Clients who rely primarily on their intellect.  Clients who use emotion as a defense.

Contributors to Resistance: Client-Based  Feelings of Hopelessness  Fear of Change or Fear of Success  Self-Punishment  Perfection and Grandiosity  Reactance and Rebelliousness  Secondary Gain or Hidden Agendas  Resistance created by fear or discomfort  Fear of Disclosure or Shame  Pessimism, Depressive Outlook, and Lack of Risk-Taking

What Behaviors are We Likely to See?  Arguing: challenging, discounting, hostility  Interrupting: talking over, cutting off, defensive manner  Denying: blaming, disagreeing, excusing, claiming impunity, minimizing, pessimism, reluctance, unwillingness to change  Ignoring: inattention, no reply, inaudible reply, sidetracking

How Do We Define Resistance?  Behavior designed to avoid exploring personal conflicts or painful feelings.  Reluctance to bring to conscious awareness threatening material that has been previously repressed or denied.  Any client behavior that shows a reluctance or unwillingness to comply with treatment interventions.

Contributors to Resistance: Counselor Induced  Counselor's Moralistic Attitude  Client-Counselor Mismatch  Love-Hate or Transference Problems of Counselor and Client  Counselors' Countertransference Problems

Transference Examples of transference situations include: Clients who make you into something you are not Clients who see you as a super person Clients who make unrealistic demands on you Clients who are not able to accept boundaries Clients who displace anger on you Clients who easily fall in love with you

Countertransference Signs of potential countertransference effects: You become irritated by certain clients With some clients you continually run overtime You quickly take pain away from a grieving client You regularly feel depressed after seeing a particular client You are aware of typically working much harder than your client You become aware of giving a great deal of advice and wanting to have clients do what you think they should do. You find yourself lecturing or debating with certain clients.

Reactive Counselor Responses  Arguing, disagreeing, challenging  Judging, criticizing, blaming  Warning of negative consequences  Seeking to persuade with logic or evidence  Interpreting or analyzing  Confronting with authority  Sarcasm or incredulity

Resistance Reframed  Outdated Coping Strategy  Ambivalence About Change  Counselor-Client Struggle  Signal of important client issues

Therapeutic Alliance The relationship between the therapist and a client; particularly the collaborative aspect of the relationship that includes three components:  The emotional bond that allows the client to make therapeutic progress.  Agreement about the goals of treatment  Agreement about the therapy tasks to accomplish the goals

Collaborative Communication  Use empathic understanding  Express nonjudgmental understanding  Avoid "hierarchical" dialog  Encourage process discussions  Tolerate ambiguity  Use appropriate self-disclosure

Reactive vs. Reflective Responses  Arguing, disagreeing, challenging  Judging, criticizing, blaming  Warning of negative consequences  Seeking to persuade with logic or evidence  Interpreting or analyzing  Confronting with authority  Sarcasm or incredulity  Simple Reflection  Amplified Reflection  Double-sided Reflection  Agreement with a Twist  Shifting Focus  Reframing

Therapeutic Alliance  Ruptures  Reenactments  Resistance

Activity

References Corey, M. S. (2007). Becoming a Helper (5th ed.). Belmont, CA: Thomson Brokks/Cole. Ellis, A. (2002). Overcoming Resistance: A Rational emotive Behavior Therapy (2nd ed.). New York: Springer Publishing Company. Horvath A. O. & Luborsky, L. (1993). The Role ot the Therapeutic Alliance in Psychotherapy. Journal of Consulting and Clinical Psychology, 61(4), Miller, W. R. (2002). Motivational Interviewing: Preparing People for Change. New York: Guilford Press. Mitchell, C. (2015, January 30). "You Can't Make Me": Effective Techniques for Managing Highly Resistant Clients. Retrieved July 13, 2015, from Teyber, E. &. (2011). Interpersonal Process in Therapy: An Integrative Model. Belmont, CA: Thomson Brooks/Cole.