This online course is the second half of a two part series. (The first half, Part One, is available from the online course catalog, and should be read first.) Methods for managing difficult situations are addressed, along with additional linguistic techniques and approaches. Specifically, techniques for dealing with “I don’t know” responses, silence from clients, and challenges to therapist competence are presented. Next, various linguistic methods are offered, which greatly aid in circumventing resistance. Most of these linguistic methods are often overlooked by therapists. Various other approaches involving a number of techniques are discussed. Techniques include: reframing, paradox, confrontation, and explaining the limits of therapy, among others. The author of this online course is Clifton W. Mitchell, Ph.D.
Upon completion of this course participants will be able to:
Resistance is all
- Identify and discuss the methods for dealing with “I don’t know” responses.
- List approaches for dealing with silence in therapy.
- Explain how to respond to challenges from clients regarding therapist competence.
- List linguistic approaches therapists can adopt to circumvent resistance.
- Explain a number of other approaches to managing resistance including: reframing, paradox, explaining the limits of therapy, and surrendering to the client.
Anderson & Steward
Managing "I Don’t Know" Responses
"I don’t know" responses are so common they deserve special attention. In order to maintain your sanity, it is essential that you develop a firm understanding of and techniques for dealing with "I don’t know" responses. Most likely, your comfort with "I don’t know" responses is directly related to your stress levels as a therapist. Interestingly, "I don’t know" responses are not that difficult to deal with provided you understand the possible meanings behind the statement and have some approaches for managing them.
It is unfortunate that "I don't know" responses are often frustrating. This is because, in virtually all counseling situations, it is imperative to get to the "I don't know" component of the problem. This is the point where the client is stuck. This is the place you must get to in order to make progress. This is the place where we can be of benefit as a therapist. Once you develop skills for handling "I don't know," you will find that you actually promote and like reaching this point. This is because you will know that you are at an important juncture and can be helpful. Meanings behind "I don't know" will first be explored followed by some approaches.
What Does "I Don’t Know" Mean?
•"I don’t know" may mean that the client truly does not know. The client genuinely does not have certain knowledge or possibilities in his/her mind. In this case, the client is truly stuck and perplexed when the current situation is considered. Therapists frustrated with clients or who feel pressed to rush the therapeutic process, may discount the literal interpretation of the response. As will be explained however, this is the most viable interpretation on which to base responses.
•One step removed from the above interpretation of "I don't know" is that the client has no clear formulation of the answer. More specifically, no words or sentences can readily be stated that sound correct as an answer for the client. There may be a vague intuitive understanding or feeling of the answer, yet the client is truly at a loss when it comes to putting this answer in clear, explicit terms.
•It could indicate that the client does know the answer; yet, does not want to say it because it is threatening in some way. To speak the answer may be the same as admitting a personal flaw or having made a mistake or not being capable or not wanting to face certain consequences. It may also be threatening in that the answer would result in the client having to face a reality he/she has been avoiding. Here "I don't know" is a deflection to avoid painful realizations.
•It could be an indication that there is a known answer; however, to provide it would only elicit controversy. In this instance, "I don't know" is used as a means to keep the peace in relationships.
•It could mean that the client has an answer but does not want to voice that answer because he/she is afraid that it is not the answer that you desire. You may have directly or indirectly conveyed a bias toward certain ideas that inadvertently encouraged an "I don’t know" response.
•It could be an indication that the client is oppositional and, regardless of what he/she knows, he/she is not about to provide a response and be cooperative.
•"I don’t know" may be an indication of a host of other meanings, beyond those listed above, that clients experience nonetheless and that may require additional discussion to ferret out and understand.
Responding to "I Don’t Know"
With all clients, whether resistant or not, I have several suggestions for dealing with "I don’t know" answers. The first is to try to avoid statements (i.e., questions) that you are relatively certain will elicit the response. More on this later. The second is to empathize with the meaning behind the "I don't know" response. Literal interpretations of "I don’t know" will be addressed first, followed by responses for other possible meanings.
In my experience, most "I don't know" responses can be responded to with a literal interpretation. That is, your response conveys an understanding of the reality that the client simply does not know or cannot formulate an answer. Even if the client is avoiding the answer, responding literally is the safest way to deescalate the potential for more resistance. A literal response to "I don't know" would be to reflect and empathize with the client's inability to provide an answer. Examples of such responses would be:
"At this moment, you are really stumped as you search for an answer."
"Right now, you are really stumped about what to do."
"It is very difficult for you to see a way to deal with this, currently."
"You really cannot think of a possible approach that you can take that
appears better than what you are doing."
If you suspect that a client has stated "I don’t know" in order to avoid revealing some threatening reality about him/herself, simply empathize about your suspicion:
"It is difficult and scary to actually say aloud the truth about…"
"You are really uncomfortable facing this aspect of your life."
If you suspect the "I don’t know" is a peacekeeping deflection, then respond similarly with an understanding of this perspective.
"You are concerned that if you provide the answer it will cause a lot of controversy and conflict among your family."
"You are reluctant to tell me the answer because you worry about how I might feel with regard to your answer. You are worried that I might take it the wrong way."
In order to understand the importance of responding with an empathic comment, consider the alternative relative to resistance. If you respond in a manner that implies that the client knows and is holding back on the answer, you move into a position of opposition to the client. Once you do this, the client can either "give in" and provide you an answer, or "dig in" and defend not knowing. The more resistant the client, the more you should strive to avert such situations.
Too often, therapists are convinced that clients do know the information asked and subsequently, focus exclusively on manipulating clients into revealing the answer. Although this may work with motivated, cooperative clients, it can be disastrous with unmotivated, uncooperative clients. This is because it pits you against clients in a game of "I-bet-you-do-know-and-I-can-get-it-out-of-you." Such power struggles only fuel resistance.
When you create the power struggle inherent in "give in" or "dig in" situations, you are gambling with your dialogue. You are placing a bet that clients will "give in" and provide an answer. But what if they don't? You have now created resistance because you have positioned yourself in opposition to your clients. So, why take the gamble? With an empathic response, you keep the discussion going. By accepting clients' struggles to answer, you create an atmosphere where they are freer to provide an answer at some later time, after the surrounding issues have been discussed. You have created this freedom because, through your acceptance and understanding, you have provided nothing to resist against.
The key to responding to "I don't know" is to respond to the meaning behind the response and not the response itself. To respond to the meaning, simply ask yourself, "Why is the client compelled to answer with 'I don’t know' at this time?" If you have a moderate knowledge of your client's world, you should have at least a general understanding of the motivation behind the "I don't know." A supportive, empathic comment that demonstrates an understanding of the meaning and motivations behind the response is the safest way to decrease resistance and move forward. Effective therapeutic dialogue is created through such conversation skills.
When you directly fight resistance, counseling becomes an
act of veiled coercion. To prevent resistance, avoid any
agenda that has a coercive component.
How to Avoid "I Don’t Know" Responses
Most "I don't know" responses are a result of asking questions. As noted, questions are perilous with highly resistant clients. And, the "I don’t know'' response is perhaps the consummate example of what can happen when you utilize a questioning style. If you are rather certain that a particular question will result in an "I don't know" response, you would be better off doing one of two things, depending on the client and the situation.
The easiest thing to do to avoid "I don't know" responses is to simply omit the question altogether. Instead, respond with the empathic statement that you would have made if the client had just answered your question with "I don't know." For example, "I sense that you are stuck as to what to do. You have no idea how to begin doing something about your problems. You are really searching for some new approach that might work." Here, you have avoided eliciting an "I don't know" response because you omitted the question that would have spawned it. If you are correct in what you have said, the client will likely agree and you can proceed. If you are incorrect, the client will likely feel compelled to tell you what he/she does know about solving the problem. Again, you have therapeutic movement. Similarly, if your client is oppositional, by skipping the question and responding to an assumed "I don’t know" answer, the only way to oppose you is to know! Hence, the advantage of this approach is that, regardless of how the client responds, you are likely to promote movement.
A second related approach is to change your question or statement to something less threatening. For example, rather than asking, "What should you have said to your spouse?" You might instead say, "That must have felt very demeaning to have that said to you, tell me what you wish you would have done." The first approach is a question and, thus, carries the implications of questions. It presupposes that there is an alternate response and may again feel demeaning if your client is at a loss for an answer. Depending on the client, the question style dialogue may be asking for an answer outside of his/her current insights or capabilities. If the client knew what should have been said, then he/she might have said it. And even if the client knew a better response, this does not necessarily mean it will be provided to you. This is because providing an alternative response also carries with it the expectation that the client will have to possibly say it in the future. Such an expectation may be too threatening at this point in time, thus, provoking an "I don’t know" answer.
Although not a perfect statement, the second statement above leads with an empathic comment and follows with a request (grammatically, it is a command) to express the inner feelings at the pretend level. By inquiring as to the client’s "wish" you are not looking for a solution, simply the fantasized response. The client’s response to his/her spouse does not have to be words either because you inquired about what "you would have done." Notice that, "…would have done," is less specific than "…would have said." The word "said" suggests that there was an appropriate statement that could have been made. The word "done" is broader and allows for other options, such as walking away. In this instance, the second approach is less threatening and less likely to result in an "I don't know" answer.
If the second style statement results in an "I don't know" answer, this is important information. It is telling you that the client cannot even imagine an alternate way of dealing with the event. In such a case, you might respond with, "Right now, it is difficult to imagine saying or doing something different in these situations." Here, you continue to show an understanding of the client's world, suggest the state is only temporary, and prime toward imagining something different.
In summary, if you see an "I don't know" response coming, stop, assess what you are saying and adjust your statements; you may be able to avoid hearing "I don't know" altogether.
Inquire of a Wise Friend
Another approach to "I don't know" is to inquire if the client has a friend who often appears to be insightful and has answers to many things. Many times clients do have such a person in their life and these friends are familiar with their situation. If they do, you simply ask what they hear their friend saying in response to your question. Obviously, the use of this technique is predicated on what you know about clients, their situation, and their friends. Be aware that the friend's response may not be useful or worthy. If it is not, discuss the benefits and drawbacks.
Although this approach is a bit of a gamble, it does not pit the client against you. By eliciting the response of a third party who is not there, any opposition can be framed as being against the friend. Thus, you avoid moving into a position opposing your client.
The Classic Pretend Technique
Although I do not generally like this technique, it is amazing how many times it works. It is presented here out of a need to be thorough more than it is as a recommendation.
In an attempt to make the answer less real and, in a manner of speaking, "trick" clients into responding, the approach simply asks clients to pretend they knew the answer. Thus, when clients state that they do not know something, you suggest that the lack of knowledge can be imagined away. Examples include statements such as:
"Pretend you weren't confused, what would you be saying if you knew what
"Make up an answer."
"Guess what you think you might say if you did know."
The reason that I do not like this technique is because it can appear disrespectful and it negates clients' realities. If clients state that they do not know something, I would prefer to first recognize and embrace "not knowing" before trying to move clients into a state of knowing. To do the above technique does not recognize that clients may truly not know, which is often the case. Problems also arise if clients become aware of what you are attempting to do. In such instances, the tricky feel of the approach may result in a sarcastic response or a loss of rapport. However, this technique does work a fair amount of the time and, under the right circumstances, it can be very effective. If you are fully aware of the pitfalls and are prepared to deal with them, try this approach if it appears befitting. When dealing with resistant clients, you use what works.
All a client has to do to thwart your efforts is nothing.
adapted from King
Dealing with Silence
Silence is a special situation that may or may not fall in a category with resistance. Just because a client is silent, does not mean that he/she is being resistant. To assume so would be a mistake. However, some silence is clearly related to a reluctance to approach problems. For new therapists, silence can be a painstaking event. For those more experienced, silence is more easily respected. Yet, after a client remains quiet for a while, some type of response is needed. Let’s begin with a brief discussion of what silence may mean.
The Meaning Behind the Silence
Silence can have a host of meanings. I was once going to write an article on the meaning of silence in therapy. After reviewing the literature, I concluded that the meanings were virtually endless. I could not see a logical way to organize the material. The task became too daunting and I abandoned the idea.
Silence may mean your client is frightened, does not know how to proceed or respond, or is simply not verbal. It could be an indication that your client has been raised in an environment that does not reinforce talking, or does not promote talking openly about problems. It may also mean the client is seriously pondering what has just been said, is using the time to reflect, or is carefully planning what to say. It may mean that your client is at peace, or, conversely, in turmoil. The meanings are almost limitless. Refer to the section entitled "Other Possible Implications Of Resistance" in Chapter 2 for some additional ideas.
And always remember that silence, too, is a response.
Moursund & Kenny
General Points to Keep in Mind When Encountering Silence
There are a number of general points to keep in mind when you encounter silence. When you take time to step back and think about your position as a counselor and the dynamics of silence, most of these points are obvious.
To begin with, aside from some sort of strong threat, we cannot make people talk. If someone uses threats in order to get a client to talk, they have moved into a position of opposition. In such cases, the initial actions will likely generate resistance—not a good way to start.
Because of real or self-imposed pressures to attempt to move quickly, some therapists become frustrated and uncomfortable with silence. This is a mistake. If your client is silent, there is a reason. The first task is to show respect for the silence. If you take any other position, you are gambling on provoking resistance. Even if you are confident that you know the reasons for silence, you still need to show respect. Unless the reasons for the silence have been explicitly expressed by the client, you cannot be completely certain that you are correct. The client also knows this and can easily use any unsubstantiated assumption you present against you, if desired.
Along with respect, it is also important for you to genuinely display calmness and patience. This serves several purposes. First, it enhances respect for the silence. Second, it is the safest presence to display in order to keep you from moving into a position of opposition to the client. Further, if the client's silence is oppositionally based, your ease and patience will avoid any secondary reinforcement for the underlying attitude. How satisfying is it to not talk to someone who fully embraces your right to not talk? If the silence is a result of other reasons and is not oppositionally based, your ease will convey understanding. Finally, your comfort and respect for the silence will be doing the unexpected—an overarching theme present in almost every approach to dealing with resistance. Most people are not comfortable with silence. It is this discomfort that gives silence its power. The least common approach to silence is to be comfortable and respect it. To deal with resistance, do the unexpected.
As a counselor you should have an understanding of the possible meanings of silence, an understanding of the pitfalls and benefits of various approaches, as well as several techniques to aid in moving the client toward talking openly. Ultimately, your understanding and skills will allow you to be quite comfortable with silence and use it therapeutically.
Specific Techniques for Dealing with Silence
There are a number of ways to deal with exceptional amounts of silence or non-verbal clients. Below are those that I have found to be effective.
Other Mediums of Communication:
One way to deal with silence or non-verbal clients is to use other mediums of communication. These would include writing, drawing, working with clay, the use of props such as toys or any other expressive tools, or other non-verbal communication techniques such as play therapy. We are fortunate that others have developed such alternative approaches to use when needed. However, it is not the scope of this manual to delve into the many alternative approaches to communication and therapy. (See Change Your Communication Mode
in Chapter 12 for additional ideas.)
One method is to simply empathize with and validate the silence. Try your best to grasp the client's state and deliver genuine empathic comments. I am told that Carl Rogers did this for a number of sessions with a client who never spoke. As the story was told to me, a number of months after the sessions ended the client wrote Rogers and told him that the experience was very meaningful. Evidently, the client had never experienced someone trying so hard to understand his world. This is the purpose of this approach. Specifically, you try to understand and validate the client's world, convey what you perceive and, through this empathy, provide a supportive atmosphere in which the client will eventually feel safe to talk. Truly, this would be an unusual, moving experience. Of course, this approach could be interwoven with the other approaches presented below.
For clients that are not completely silent but who say and mumble very little, it is sometimes helpful to match their behavior. Match their posture, their vocal style, the timing of the space between the words, their level of eye contact, etc. Of course this must be done in a sincere, non-mocking style. Any hint of mockery would likely be quite harmful. As you match the client, you very slowly increase your verbal responses and pace in an attempt to bring the client along with you into a beneficial conversation. Obviously, timing is critical with this approach.
I did this once with a preadolescent boy who had been seriously abused and, after being verbal in previous sessions, suddenly shut down. Frankly, I was uncomfortable and at a loss as to what to do. In my desperation I decided to match his behavior. As I matched his behavior and we mumbled along, I very gradually increased my pace and tone. To my surprise and relief, he began cueing off of my lead and, in about 30 to 40 long minutes, we were again talking normally. I was amazed at how well it worked. I have also seen this approach work with teenagers who are reluctant to talk to adults and authority figures.
I think this approach works because of several factors. Overall, this style of matching is quite unexpected by the client. The counselor shows that he/she is not distracted or disturbed by the silence; thus, the power struggle that may be embedded in the silence is dissipated. When done respectfully, the matching has a non-threatening, empathic feel. As time passes the client realizes that the silence will not thwart the therapist and send him/her away. As this becomes apparent to the client, there is likely some sort of obligation to speak that develops from recognizing the therapist's efforts. Obviously, patience is the cornerstone from which success with this technique is built.
Talk for the Client:
Corey (2001) presents an approach from William Glasser that I also find appealing. When the client doesn't talk, Glasser respectfully explains that he will talk for the client. That is, Dr. Glasser speaks both sides of the therapeutic conversation. To do this, he assumes and states what he thinks the client would say in response to his statements. When done with care, there should be a good attempt toward understanding the client's position. Thus, there would hopefully be feelings of empathy even though you may not explicitly know with what to empathize. In addition, I assume Dr. Glasser would include a dose of Reality Therapy.
What may happen is that the therapist does a good job of talking for the client up to a point. Eventually the therapist will likely go so far astray of the client's world that the client will be provoked to correct the therapist and, thus, will be motivated to join the conversation. Depending on the client, another possibility is that the client finds the therapist's efforts to understand his/her world humorous, thus resulting in smiling or laughing. A disarming therapist could certainly parlay this into some sort of conversation. If nothing else, this would begin to "break the ice." Alternatively, the client may find the efforts of the therapist quite moving, for it is likely that no one has ever tried so hard to understand his/her world. Depending on the skills of the therapist, this is an interesting approach that may be very effective.
Even if clients do not eventually join the conversation, this approach has merit if done with care. This is because a number of therapeutically positive procedures and ideas can still be presented to clients. Clients will hear their struggles being discussed and empathized with. They may realize that someone does care about their problems—that the counselor is not their enemy. They may begin to realize that someone does understand their problems to some degree. This understanding can be coupled with an effort to normalize the problems as is appropriate. As noted with other approaches, clients learn that the therapist is not distracted by the silence and thus, any power struggle inherent in the silence is reduced. Although they should not be overdone, embedded suggestions and priming for new perspectives and responses could also be utilized. Much caution should be used here, lest you appear too controlling in trying to suggest changes. Such overdoing could backfire on you, resulting in even greater shutdown.
All of this adds up to clients being left with something new to contemplate. They will be provided with "food for thought." If done well, the stage may be set for more verbal sessions in the future. Keep in mind that the overall key to the success of this approach is that it be done with great respect.
Depending on the situation, it may be helpful to include some paradoxical comments in conjunction with the above approaches. Thus, instead of promoting conversation, you reframe the silence to be meaningful and suggest that the client "not speak." (Notice the dominant thought here!) Below is an example of how such a paradoxical statement could be structured. Note that it also includes a number of embedded suggestions aimed at promoting conversation.
"As I consider your situation, it appears that there is a significant need not to…talk. People who do not understand the inner workings of human beings often try to force others to talk. Sometimes clients try to force themselves to talk
. However, this is a mistake. The need not to talk should be respected, because it is serving an important psychological purpose. I suggest that you allow yourself the freedom not to…enter into a conversation
…until you are reasonably certain you…feel a desire to speak
. Only when you…become aware, either consciously or unconsciously, of the urge to speak
…should you…allow yourself to talk
Another reframe is to interpret the silence, not as silence, but as simply moving slowly or cautiously in discussing the problem. Thus, the silence is viewed not as a complete shutdown, but as a very long pause in the conversation. As a therapist, this is also a much more viable, healthy, less stressful perspective to take when trying to conceptualize and deal with silence. Think about it. Do you assume that the client is never going to talk again? Not likely. Below are some statements that illustrate this perspective of silence.
"It's sometimes helpful to move slowly."
"It is important to take time to consider what you want to say."
"You are wise to be cautious and move slowly before presenting your feelings."
"It is important to take as much time as needed to think about your situation before…saying what you want to say with regard to it."
"Please do not let me rush you, take all of the time you need to gather your thoughts before you …say what you want to say…about things that are of concern to you."
"I hope that I am not creating a feeling in you that you are under any pressure to speak, please feel free to take all the time you need to…gather your thoughts and…present your ideas."
"It is obviously important for you to fully think about what you really want to say before you speak. I want you to know that it is not necessary to respond to me at this time. When, in later sessions, you are ready to…speak your mind…please do. Until then, please do not…put pressure on yourself to talk with me at this time."
Paradox is effective for most of the same reasons as the other aforementioned approaches. First, it removes the power play that may be fueling the silence. It does this because it goes beyond just accepting the silence to actually supporting and promoting it. What more can we do to remove all psychological barriers to resist against? Paradox is also quite unexpected. In addition, while delivering your paradoxical response, you have ample opportunity to prime the client for conversation.
As with most paradox, the above statements must be delivered with absolute candor and congruent paralanguage. If clients perceive that you are using "reverse psychology" on them, this technique will likely backfire and create further resistance.
At the risk of being redundant, I will again comment on the language used in delivering paradoxical reframing statements with regard to silence. As your ultimate objective is to promote therapeutic conversation, you would be wise to avoid terms such as "silence," "silent," "being quiet," "shut down," "hushed," "mute," etc. These terms bring to mind the very behavior we do not want to promote. Likewise, you would be wise to frame your statements with terms such as "talk," "talking," "converse," "speak," "communicate," "dialogue," "discuss," "explain," "say," etc., in order to bring to mind that which you ultimately desire. See Chapter 5, the section entitled, The Influence of Words on Mental Processing: Why the Words You Choose are so Important
, for a detailed explanation of the importance of your wording.
Responding to Challenges Regarding Therapist Competence
A special category of resistance occurs when clients challenge the therapist's competence in one way or another. Examples of these sorts of challenges might include some of those listed below.
- Questioning the therapist's qualifications, degree, or license.
- Questioning if the therapist is old enough and experienced enough to understand the problems of a client who is older.
- If the issues involve the raising of children, asking if the therapist has children and the knowledge of the difficulties in raising children.
- Clients involved in drug and alcohol dependency enjoy questioning the therapist's experience with drugs and alcohol and the ability to understand the client's experience with addiction.
- If the client is seeking a divorce, he/she may raise concerns regarding the therapist's knowledge of marriage and divorce. This is particularly true if the therapist is young and single.
- Inquiring as to your religious affiliation or about information regarding your personal moral beliefs.
Such challenges are not difficult to handle, provided you are prepared with your answers. It is an error to be caught off guard and to fumble through a response with uncertainty. The key is to provide a response that neutralizes the concerns and circumvents the challenge/resistance.
To effectively respond to such challenges you need to remember several basic points: Never get defensive. Never profess knowledge of an area that you do not have. Never let the client pressure you into revealing anything about yourself that you do not want to reveal. Empathize with the underlying meaning that appears to be motivating the challenge. Calmly and confidently hold your ground in areas where you do have knowledge. Always thank and praise the client for asking, reframing the thinly disguised resistance as being the prudent inquiry of a wise consumer (see Reframing in Chapter 12). Always talk openly and directly regarding the issue presented. Let your candor and honesty be fully present.
There are a number of reasons for responding to challenges in this manner. The overriding reason is because the client's questions may not be resistance at all; the client may be truly interested in the issues raised. Because such comments may be legitimate and not a sign of resistance, there is a professional obligation to provide some information. Such informed consent duties compel some type of explanation from the therapist. Interestingly, it is this same duty to respond that also provides the client a legitimate appearing pretense for his/her questions when the underlying dynamic is resistance. The clue to whether you have a genuinely inquiring client versus a challenging, resistant client is in the paralanguage of the inquirer. Does the paralanguage convey real concern or a confrontive challenge? Either way, you should treat all such inquiries with respect, particularly if they occur during initial rapport building sessions.
When such challenges are more resistant in nature, they tend to come from a bold client intent on testing the therapist. These challenges are a form of resistance that attempts to provide the reluctant client the upper hand in the potential debate that the client perceives is going to occur in future sessions. (What he/she does not know at this time is that you are not about to get into such debates!) Your objective is to not take the bait but to establish a tone that neutralizes the issue presented, as well as other similar challenges that might follow. Remember, defensiveness and dishonestly are your enemies. Openness and candor are your allies.
If you allow yourself to be placed in a defensive position, highly reluctant clients will work to keep you defending yourself whenever they feel threatened by their own struggles. If you profess knowledge you do not have, you will be "called" on it and your credibility will be questioned. If you are pressured into revealing personal information that is not pertinent, you open the door for that information to be turned against you in the future.
Commending clients for posing their concerns demonstrates a lack of defensiveness and displays confidence that is quite unexpected. Also, it does not allow a "you-versus-me" or "us-versus-them" atmosphere to develop. Clarifying areas in which you are skilled and openly admitting areas in which you are less knowledgeable, displays honesty and is a good first step in establishing a "not knowing" stance. Thus, you begin to establish your position of naiveté, explaining to clients that they must educate you in areas with which you are unfamiliar. At the same time, you point out that, although you are not an expert in all areas, you are skilled at finding ways to help people work through their issues and at helping people discover the changes needed for problem resolution. You explain that you are a catalyst that aids the discussion as clients find their solutions to their problems. Thus, you remove yourself from the position of one who gives advice and instead, begin placing the responsibility for change with clients. You clearly indicate that you are not about to tell them what to do—something that is unexpected from clients who present such challenges.
To further neutralize the challenge, you explain to clients that they are not bound to the relationship and that, if things are not satisfactory, they are free to leave. You openly state that you will be glad to refer them to another therapist who better suites their needs. You also comment that you will be checking with them at various times and strongly desire feedback on their perceptions of how the relationship is progressing.
Many times you might go straight to the heart of the challenge by stating an empathic response to the perceived meaning behind the question. In this instance, you do not answer the question but bring to the surface presumed feelings and doubts about your skills. Again, you remain undefensive and allow a discussion of the concerns to proceed.
It is also important not to respond in a manner that confronts clients and attempts to puts clients on the defense. Such responses display a lack of professionalism and promote resistance. Confrontation has its place after rapport has been well established and thorough discussions have developed. However, initial challenges to competence are not the place for confrontation. I once heard of an instance where upon being challenged the therapist responded with, "I am not the one with the problem here, you are." What an excellent way to spawn resistant clients!
Below are some sample responses that demonstrate the general approach recommended. Other challenges would employ a similar approach.
Client Challenging Training and Degree:
"Just what is your degree and what makes you so qualified to think you can help me?"
"Thank you so much for asking. Most people never do and I sometimes wish I could tell my qualifications. I am surprised at how many people go to therapists and never ask their credentials, you are a wise consumer and I am impressed that you asked."
"I have a Master's degree in counseling from XYZ University. The degree took two and half years of course work beyond my bachelor's degree and included over six hundred hours of internship training. Then I had to practice for two years before becoming licensed by the state as a Licensed Professional Counselor which requires both a written and oral test. I currently see about ____ number of clients a day and have a total caseload of ____. I have worked with a broad array of problems that include depression, abuse, anxiety, family of origin issues, and divorce, to name a few. Is that enough or is there some other information I could provide to give you a more complete answer? Do you have any other questions about my degree or training? Thank you again for asking, and I want to let you know now that if you have any other questions in the future, please feel free to ask."
The idea here is to be so open and forthcoming with information beyond that which clients are likely seeking that the challenge is thoroughly neutralized. You might provide just enough excess information to make clients almost wish they had not asked.
If you deem it better to respond with an empathic statement that addresses the meaning behind the challenge, you might begin the discussion with a response similar to the one that follows. Of course you could combine the two response styles by providing information and empathizing with concerns.
Empathic Response to Qualifications Challenge:
"You sound concerned and worried that I might not be qualified to deal with your particular problem, and I sense that you are seeking some assurance that you have been placed with the right therapist."
Drug and alcohol clients are particularly fond of challenging the therapist's drug experiences. This is usually an attempt to build from the faulty assumption that, if you have not used drugs yourself, you are not qualified to understand their world and be of benefit. If you have a personal drug or alcohol history it is much easier to answer concerns. However, depending on your personal philosophy and approach, you might not disclose your personal experiences early in the relationship. Therapists who do not have or do not desire to disclose their personal history with drugs and alcohol should be prepared to respond to such challenges. An example follows.
Client Challenging Drug Experience and Knowledge:
"Who are you to think you can understand my world and help me with my drug problems? What makes you think you can understand what I've been through? Have you ever been addicted to heroin?"
"I am glad you asked and I appreciate your concerns. This is a legitimate concern that often arises with drug and alcohol problems. I do not profess to be an expert on your life and your experiences with drugs. I do not think I can ever fully understand your experiences even though I am open to listening if you want to give me a chance. As far as knowledge about drugs goes, even though I know a little, I do not profess to be an expert in that area either. I was hoping that you would teach me what you know. I do, however, know a fair amount about helping people work through their issues and at helping people discover in themselves the changes needed for problem resolution. I see myself as a catalyst that aids the discussion as you find your solutions to your problems. If during our discussions you see me getting off track in my understanding, please let me know and guide me toward a better understanding. I really want to hear your feedback. Also, if you do not think that our relationship is working, please let me know and I will help you find someone more suitable."
Again, the purpose is to neutralize the concerns while, at the same time, establish a not knowing, naïve position. Clients are encouraged to provide feedback if they perceive a lack of knowledge. If you deem that it is better to respond to the meaning behind the challenge in a more empathic manner, you might say something like the following:
Empathic Response to Drug Knowledge Challenge:
"It sounds as if you are wondering if I have enough life experience to fully understand the powerful dynamics of drug addiction. Perhaps you doubt that anyone can fully grasp the forces at play when addiction is present unless they have been through it themselves. You are seeking some assurance that you are talking to a qualified person. These are very legitimate concerns. Tell me what you specifically have concerns about."
Client Challenging Religious Orientation:
"Are you a Christian?" "Do you believe in God?" "What church do you attend?" "Do you believe in Christian values?" (Although this is the most common religious perspective presented by clients in the West, please note that this is only an example and that other religions may just as easily be inserted into the questions.)
"I sense that you are concerned about my values and perhaps my position on moral issues. Perhaps you are worried that I might suggest a solution that runs counter to your personal beliefs or religion. I am pleased that you have presented you concerns now so you can gain an understanding of my role and position regarding religious beliefs and moral issues."
"My job is to work within the bounds of your beliefs. I do not want to impose my views on you. I appreciate that you have deep convictions, whatever they may be, and will work hard to respect your views. If at any time you feel that your beliefs are not respected, please let me know with the same candor that you have just displayed."
"Because this is your time for you to work on your concerns, I generally prefer to keep my views out of the discussion so as to not influence you in a manner that might be unacceptable. Also, I might add that, after carefully considering all of the issues, occasionally people make decisions with which even they are surprised. I have found that, the more I limit my personal views, the more freedom I provide my clients to chart their own course."
Challenges of religious and moral beliefs can be particularly complex and troublesome. In this instance, there is a greater likelihood that the questions posed stem from a genuine concern rather than being a form of resistance. Discerning the underlying motives may be more difficult than with other similar challenges. Still, such challenges should be treated respectfully. Striking the balance between being candid, neutral, and non-offensive is difficult when addressing such strong core convictions. We are often admonished to never discuss religion and politics. This is because it is so easy to offend or not be liked when we present a position. Very few topics so quickly provide such powerful reasons to form strong opinions toward others. There is a good chance that your response will significantly influence the counseling relationship.
Because such issues can significantly impact relationships, I suggest that you remain neutral if at all possible, even if you find that you align with clients in their beliefs. There are several reasons for this stance. The first is that when questions regarding religion are posed, you can never be certain what the underlying concerns are. It may be that the client does not want a counselor with religious convictions and has posed the questions in a manner that disguises his/her position. It may be that the client desires a counselor with religious convictions. It may be that the client is from a particular religious sect that has unusual beliefs and he/she wants to know if you can accept his/her unique positions on issues. How do you know? With so many possibilities that carry such significance, remaining neutral is the most professional approach. A discussion of underlying concerns may be warranted.
Another reason to remain neutral is that clients with religious beliefs may find that they ultimately make decisions that are contrary to their own convictions. There have been many deeply religious people who have divorced, had an abortion, or accepted their own homosexuality despite strong beliefs against such. If you present your religious beliefs and they align with the client, you make it more difficult for the client to make decisions counter to his/her convictions. Knowing that you have similar values may deter a decision in order not to appear unfaithful in your presence.
I know counselors who are Christians who face this particular challenge regularly and never present their religious views even though their views align with clients'. Yet, most clients with religious concerns continue with these counselors. The reason these counselors are able to establish a suitable level of comfort with these clients is because they are skilled at empathizing with clients' concerns. These counselors are not afraid to directly address and process the issues in a professional manner. What generally happens is that, after a few minutes of discussion with a healthy dose of empathy, clients feel understood and safe. The clients recognize that they are with a counselor who will respect their views and who does not compromise good standards of practice just to appease them. This balance is apparent in the conversation as clients are educated about the counseling relationship. Clients begin to recognize that they are dealing with a person who practices with a high level of professionalism. Usually clients make a statement to the effect of, "You know, after talking with you about this, I feel comfortable with you and think you are a good person. I want to continue to work with you." It appears that the establishment of a suitable comfort level and a recognition that the counselor is a "good" person are the primary underlying factors that filter out as consequential. Of course, the comfort level is dependent on conveying a respect for the client's religious views.
If clients insist that you state a definitive position, you are left with revealing your values or not, and facing the consequences of each. Counseling is a profession built on relationships. The reality is that not all relationships mesh and work out. Being provided no option to remain neutral reveals important information about how the client operates in his/her world. Approaches to change will have to be assessed relative to the implications.
Approaches similar to those above can be used with challenges in other areas. If you have not taken the time to prepare a response to challenges across a variety of areas, I suggest you consult with a colleague and role play possibilities.
There is a reason that clients are often called ‘patients’: one
needs to cultivate one's ‘patience’ in order to work effectively
with them! Like struggling in quicksand, pushing impatiently
will only serve to further mire the process.
Moursund & Kenny
Other Linguistic Techniques for Dealing with Resistance
This chapter discusses more language-based techniques for dealing with resistance. When used in combination, these linguistic approaches create a style of dialogue not commonly encountered. This style of dialogue is unique because each of these approaches sends an underlying message that is perceived more at an unconscious level than a conscious level. Thus, as clients receive, process, and respond to the overt component of the statements, they are unconsciously accepting the underlying communication. Being covert, the underlying message does not readily provide clients something to resist against. Ideas are often introduced later in the most subtle way—from clients' own subconscious. This stealth characteristic is what gives these techniques their power to influence.
Many of the example responses presented in this manual include the linguistic techniques presented in this section. After studying this section, you will be more aware of the many linguistic techniques that can be continually employed in the therapeutic conversation to disrupt resistance. You will also gain insight into the many linguistic errors that therapists make that may result in an escalation of resistance. Such errors are made because many therapists are not aware of the underlying messages they are sending as they dialogue. This lack of awareness results in a haphazard use of language and counterproductive responses from therapists. In my work as a supervisor, I have witnessed hundreds of instances in which inexperienced beginning counselors have worded comments in an unproductive manner. Unfortunately, the resistance that results is, in part, due to an error in therapist wording.
It is very difficult to categorically organize these techniques. It is also difficult to present them in some sort of logical order. Further, these techniques are impossible to explain without recognizing the significant degree of overlap between them. They are not mutually exclusive. Lacking a logical way to proceed, I will begin with what is perhaps my favorite overall linguistic approach to chipping away at resistance—the use of embedded suggestions.
Embedded Suggestions: The Frazzled Therapist’s Friend
Embedded suggestions are a way of indirectly placing an idea in the client's mind. By introducing an idea indirectly, you avoid arousing the feeling that the idea is imposed or that you are compelling the client to consider it. Typically, embedded suggestions direct the client to do something. Yet, because the suggestion is included within a response, it is not perceived as directive in nature. For example, if you were to say, "It is difficult for you to…imagine making an assertive statement," the suggestion "to imagine making an assertive statement" is built into what appears to be a typical reflective response. Although there is rarely any conscious recognition of such a suggestion, the idea of making an assertive response is subtly delivered, nonetheless.
Embedded suggestions are much more influential than most people tend to realize. Their power lies in the fact that it is impossible to avoid thinking about what has been stated, at least momentarily. Their strength is also rooted in the manner in which they are presented, usually in a context that makes them appear insignificant and therefore, non-threatening.
Upon understanding the impact of embedded suggestions, some therapists tend to regard their use as manipulative and deceptive. However, such a perspective is naïve with regard to understanding language. Virtually every statement you make carries with it some implication or suggestion. As noted, all language is hypnotic and you cannot, not manipulate. The only question is: In what direction will you manipulate? One component of the art of therapy is to understand this reality and to use it for the benefit of clients.
Many of the example responses in this manual include embedded suggestions. The following example was presented earlier in the section that noted the importance of avoiding labeling clients with terms that suggest or imply resistance. As you study the responses, note that each implies a certain reality. This phenomenon is inevitable when you use language. However, notice how the first two bring to mind "stubbornness"—an idea we would prefer to avoid. The third and forth statements, on the other hand, introduce the idea of "openness," which was embedded in benign reflective statements. By including the word "be," the fourth statement includes the suggestion to "…be open to other options."
Bad: "You really are stubborn.
Often Taught: "At that point in time, you responded in a rather stubborn
Better Yet: "At that point in time, you responded in a 'less than open'
Even Better: "At that point in time, you struggled to…be open to other
Tip for Increasing the Impact of Embedded Suggestions
Here is a paralanguage technique that is sometimes used to increase the impact of embedded suggestions. Just before you say the embedded suggestion component of a response, pause briefly. This pause should have a completely natural feel, as if you have briefly stopped to think and make sure you will say the right words as you describe the situation. When done properly, there will be no telltale signs that you are doing anything unique to increase the impact of your statement.
The reason the impact is increased stems from the fact that, when someone speaks, the listener anticipates each word that follows with the already established cadence. When that cadence is broken, the listener briefly wonders what happened to the next word anticipated. When using embedded suggestions, your brief pause captures clients' attention as they await the completion of the statement. This slightly enhanced attending response increases the focus given to the part of your statement that follows. Thus, the embedded suggestion is given increased attention. And having been given the slightly increased attention, it is more likely to have an increased impact.
Again, there is a caveat. Such pauses should only be employed when you are certain that they are not recognized at face value by your clients. An excessively long, readily apparent pause may appear too transparent in its purpose, resulting in a rejection of the suggestion. When in doubt, omit the pause. The embedded suggestion will still have impact.
Men must be taught as if you taught them not
And things unknown proposed as things forgot.
How to Talk Positive to Negative People Without Them Knowing It
I have used and lectured on this specific linguistic approach for a number of years. Out of a need to name it with terms a lay person would understand, it has come to be called the rather lengthy title of, "How to Talk Positive to Negative People Without Them Knowing It." Even though a bit long, this title does a very good job of describing what you are doing with the technique. The technique is a specific use of the embedded suggestion. Its uniqueness lies in the linguistic "formula" that is always used in creating the opportunity to state the suggestion. The formula is this: Make an empathic statement and then follow it with a statement of how difficult it is to do, or imagine, or comprehend, or consider the very behavior the client is having difficulty doing or facing.
When done without any special attention or inflection given to the suggestion, the client never consciously realizes the thought introduced. I have never seen anyone become aware of what was being suggested. When stated at appropriate moments throughout a session, the thought is re-seeded and the impact grows subtly. Many times clients will introduce the suggested idea after a period of time has passed without any awareness of what was previously stated.
Below are some examples of responses using this formula.
"I can tell you're deeply hurt by the loss of your boyfriend, and it's at times like these that it's so hard to…imagine all of the other men available to date
"You’ve wanted to divorce for a long time, but it’s hard to…comprehend reestablishing yourself with another partner
"You’re so angry with your ____ that you could really give him/her a piece of your mind. It’s at times like these that you just can’t…imagine sitting down and having a mature conversation about this situation
"At this time it appears that you get very nervous before a test, it’s hard for you to…see yourself sitting there calmly taking a test."
As with most of therapy, timing is critical to the success of techniques. If you suggest something that is too far removed from the client's mind, you will likely have minimal impact. However, if you suggest something that it appears the client is close to considering, you are very likely to influence the client toward discussing the suggested idea. Remember, it is helpful to frame your job as providing responses that have a high probability of moving the client the smallest possible step toward resolution of problems. (See Chapter 3, the section entitled, Timing is Everything and "Baby Steps" are not a Joke.) Attempts to move the client too far too fast are more likely to create resistance. Below are some statements regarding a hypothetical case in which a client needs to have a difficult conversation with another person. As you read the statements, notice how the suggestions move from the general to the specific in small increments. This is done in an effort to match the client's current deliberations.
"As you sit there and assess your situation, it is hard to…imagine yourself doing something different
"Right now, you are struggling to…consider if a conversation could possibly impact the situation
"As you are sitting there now, it is hard to…see yourself having a face to face conversation with…about
"As you…consider possibilities of how to handle this situation, it is difficult to… hear yourself saying an assertive statement."
Adapting to Prochaska's Stages of Change:
In an effort to present other examples of embedded suggestions while demonstrating how they can be adjusted to clients' current deliberations, the following examples are offered relative to Prochaska's stages of change. Note how each embedded suggestion attempts to meet clients at their current stage, resolve their current issues, and move them toward the next stage of change.
"As you sit here discussing how others are blowing this situation out of proportion, it is difficult to…begin to grasp their perspective
"Right now, it is difficult to even…imagine and…clarify the internal conflicts you are experiencing as you move toward resolving and moving forward.
"As you are discussing your concerns you are searching for a way to…begin taking steps toward resolving the pros and cons surrounding making this change
"At this point in time you…see yourself taking the first proactive steps. Yet, it's at times like these that it is a bit difficult to…begin to comprehend the impact of the positive benefits that will follow
"You are reaping the rewards of your efforts and you can readily…see yourself continuing the new behaviors
"It is difficult to…imagine when staying the course will be virtually effortless
Divide and Conquer: Separating Thoughts, Feelings, and Actions
(Although this is as much an approach as it is a linguistic technique, it is presented here for lack of a distinct chapter in which to introduce the concept.)
Thoughts, feelings, and actions are highly interconnected. The deeper you delve into human behavior, the more you are likely to view them as inseparable. It could be argued that the reason that they are deemed as separate concepts is more a result of western thought and language than reality. Fortunately, if you genuinely change any one, the other two will eventually follow. When encountering resistant clients, we joyfully take what we get toward change in any of the three areas.
Even though thoughts, feelings, and actions are highly interconnected, they are often perceived to be at odds with one another when it comes to new behavior. If we can decrease the influence of the most resistant of the three and seek advice from the most cooperative, we often create movement. One way to do this is to separate a resistant thought from a resistant behavior. Or you might separate the resistant feeling from the resistant action. Or you might separate thoughts and feelings. Any component of resistance that can be isolated and addressed separately, should be. Divide and conquer, Napoleon ruled the world with this strategy.
Below are some example responses that seek to separate thoughts, feelings, and actions in order to promote change.
"It's perfectly acceptable for you to think that counseling will not be helpful, and even though you have mental
doubts, perhaps you might just begin talking about your concerns and see if anything beneficial results."
"It's certainly reasonable to think that it may not be helpful to ________, but what's to stop you from testing it in reality?"
"I can understand that you might feel a bit uneasy about this; however, actions do not have to match feelings. Tell me how you could proceed in the midst of your less than optimistic feelings."
"It is ok to feel uncomfortable about _______. However, it is amazing how many times we do things in life in which our feelings do not perfectly align with our behavior. This is very common. Setting your feelings aside for the moment, tell me things you can do that you reason may have an impact."
"I can readily see how you might feel less than at peace with this situation. Yet, many times we have perfectly sound ideas in our mind that do not align with our feelings. Parking your feelings for the moment, tell me what the logical side of you has to say about this situation."
Note in the last two statements the direct command (embedded suggestion) to temporarily disregard feelings that are thwarting movement.
Continually Suggest That the Resistance is Temporary
The Brief Therapists are quick to point out that change is constantly occurring—that change is inevitable (Walter & Peller, 1992). To assume otherwise is an error and may unconsciously lead to behaviors that promote resistance. Building from this fundamental premise, it is important to avoid talking in terms of permanence when discussing perspectives that promote stagnation. To the contrary, when discussing perspectives that promote the status quo, couch them in terms that imply they are temporary. By doing so, you unconsciously imply that resistance promoting perspectives of your client will eventually change or fade away.
In order to avoid giving permanence to unproductive, status quo behaviors, language that suggests that the current state (i.e., resistance) is temporary is helpful. This use of transience is also a subtle way to imply that movement in the direction desired is forthcoming. Below are some examples of phrases that should be used when discussing current behaviors that do not help in problem resolution. Clients are very unlikely to discern, at the conscious level, the suggestion that the current behaviors are transient.
you do not want to directly discuss your concerns with your boss."
"...and, at this time
, you only want to address these concerns."
"...and for now
it is clear that you do not want to discuss issues regarding your parents."
you are feeling as if there is not more than one perspective from which to view this situation."
"At this point in the considerations
, the idea of compromise is difficult to entertain. "
"The way you see it at this moment
the problem is a result of their errors."
"For the moment you
find it difficult to find the courage to discuss this with anyone else."
Build from What Currently Exists
It is easier to build from a behavior that is currently being done rather than to try to gain acceptance for a completely new behavior. The same is true for ideas. If possible, add to an old, already existing behavior or idea rather than suggest something completely new. Find out what clients are already doing and suggest that they do a little something extra. In the examples below, notice how new behaviors are introduced as an adjunct to current behaviors. Ideas and behaviors introduced in this manner have a natural, flowing feel and are less likely to arouse resistance.
"So right now you are 'saying hi'…perhaps you can add a smile and a compliment with that."
"So for now you have only told me about this issue. Tell me who else you might also let know of your problem."
"And the last time you argued, you walked out of the room…perhaps you might make a statement of why you are leaving or what you desire."
"As you develop your position toward your dysfunctional family…tell me what you are considering as a position toward your other relationships."
"You are excited and motivated about your idea to pursue this new hobby, tell me what other new pursuits you are considering"
"As you park your bike, close the garage door."
"As you go up stairs, please take the laundry."
The Disempowering Power of "We"
It is a common error among those wanting to help others to refer to problem solutions as something that "we" need to work on. Typically such statements sound something like: "Let’s see what we can do about that." "We need to begin working on how to…." "I wonder what we can do to deal with this." Such statements are meant to convey support and assistance. Unfortunately, they also create dependence and allow clients to assume a more passive role in changing their lives. In reality, such statements are disempowering. There are several interrelated negative dynamics that arise from the inappropriate use of the term "we" in relation to problem ownership.
Difficulties arising from the use of "we" stem from the fact that clients often infer from the "we" that you, the therapist, are going to be an active player in the actual resolving of issues. To many clients it is as if you have a magical solution that you are going to give them, or better yet, that you are going to do! As a result, clients may appear resistant as they passively await the thing that they assume you are eventually going to do to resolve their issues. Yet, real solutions only occur as a result of clients perceiving or doing something differently. Here, the passivity of clients is, in part, a result of the therapists’ communications and language style. Using "we" is deceptive because it implies that clients do not have to take full responsibility for change.
The use of "we" is also directly tied to the proper management of therapeutic tension. As noted earlier, change only occurs when there is an emotionally compelling reason supporting it. Thus, it is imperative that counselors help clients to find, clarify, and keep in the forefront emotionally compelling reasons for making desired changes. Therapeutic tension develops, to a large degree, from clients' explorations of emotionally compelling reasons for change. As such, this tension should stay with clients to provide motivation for change. As noted, it is a mistake to take the therapeutic tension away from clients in order to help them momentarily feel better. Such approaches prolong the therapeutic process and create dependence. Inappropriate uses of "we" take the therapeutic tension from clients because it implies more power on the part of the counselor than is realistic. To the degree that the use of "we" takes therapeutic tension from clients, it promotes resistance. In this sense, the use of "we" promotes what is commonly referred to as band-aiding.
Ultimately, inappropriately using "we" disempowers clients. This is because the more the counselor uses the word, the more responsibility the counselor assumes for the change. When change does occur, the implied message is that the counselor was responsible for part of it. Many clients are reluctant to take responsibility for their improvement and change. They often over praise their counselor for the changes in their life. What usually follows is a conversation in which the counselor tries to convince clients that they should take full responsibility for the change arguing that the counselor's job is just to be a catalyst. Such dialogues are brought on, in part, by the messages implied by the use of "we." Clients need the empowerment that comes from success. In order to promote empowerment, use "we" appropriately.
Embedded suggestions are two sided swords. Depending on what is implied, they can work for us or against us. When the meanings behind "we" are assessed, it becomes apparent that "we" is an embedded suggestion that works against therapeutic movement for the reasons noted. Most therapists would do well to eliminate "we" from their vocabulary when referring to ownership of problems or working toward solutions, lest they find that they have inadvertently created resistance.
People who want to help in the worst way usually do.
The Power of Using "If" Wisely
Change is inevitable. This being the case, when you speak in terms of the inevitability of change, you embed the suggestion of change and show faith in your clients' ability to implement that change. A common mistake is to talk in terms of "if" when making statements regarding desired future change. For example, the wrong message is sent when you say, "If you were to…." when referring to a new behavior. The wrong message is sent because of the subtle meanings that "if" conveys.
The primary problem with "if" is that it includes in its meaning the presupposition that clients may not change. "If" implies or presupposes the possibility of clients not doing anything. Depending on its use, it may also include the presupposition that clients may not be able to do the task before them. At the unconscious level, "if" implies a lack of faith in clients. As with the word "we," "if" has its own underlying meanings that can work against the therapeutic process. Thus, the use of "if" contributes to resistance when referring to beneficial future change. Fortunately, a simple adjustment of terms circumvents the implied messages of "if." "If" can usually be replaced by phrases beginning with "when," "as," "while," etc.
"If" is usually placed at the beginning of sentences. Note how the alternative introductory phrases presented below remove the implication that change may not occur and convey faith in clients' abilities.
"If you were to move forward with…" (poor)
"As you move forward toward…" (better)
"If you were to change…" (poor)
"While you change…" (better)
"If you were to speak out more to groups…" (poor)
"As you look ahead and see yourself beginning to speak out more in groups…" (better)
"If you said these things to…" (poor)
"When you say these things to…" (better)
"As you hear yourself having this conversation with…" (better)
It also works in reverse!
Analogous to the negatives that accompany the use of "if" when referring to desired future change, is the beneficial, implied message sent by "if" when referring to current, unwanted behavior. Because "if" implies that things may not occur, it would be appropriate and beneficial to use "if" when discussing the consequences of maintaining an unproductive behavior. For example:
"Tell me what you see as the outcome, if you continue to do what you are doing."
"If you were to continue drinking, tell me what you know will occur."
In these examples, "if" does not convey an underlying message of permanence to the current behavior. Here, "if" implies a lack of permanence to the current behavior. It also implies that alternative behaviors exist that should be considered.
When "if" is removed from discussions of future desired behavior and consistently used in conjunction with current unwanted behavior, the unconscious influence is amplified. All underlying suggestions are uniformly biased toward implementing new behaviors. Using "if" in this manner utilizes the power of creating expectancies and primes clients for change. The research investigating the influence of creating expectancies and priming strongly supports the efficacy of such linguistic nuances (Kirsch & Lynn, 1999). Understanding and consistently applying such nuances significantly enhances the probability for change.
Increasing Impact Through Deliberate Use of the Client's Name
You would think that a counseling text would not have to discuss the importance of using clients' names. However, I am often struck by how quickly names are replaced with "you" in conversations. I am quite guilty of this practice. I have also noted this regrettable practice with new counselors in training. Thus, a few comments on the inherent power of using names are warranted.
Due to the powerful orienting response that accompanies hearing your own name, you should regularly use clients' names, particularly when making poignant statements. When you hear your own name, you are exceptionally prone to tune-in to what follows. I am sure you have noticed that, even in a noisy, crowded room, when you hear the sound of your name among the voices, you tune in. Or perhaps you might have been one of those poor souls who dazed off in school, engrossed in some splendid fantasy, only to have your fantasy disrupted by the sound of your name as the teacher asked you a question of which you had no idea of the answer. You could have easily remained in the fantasy had any other words been spoken. This orienting response is so engrained that it occurs more as a reflex than as a conscious action.
I once read an example of a deceitful, negative use of the power of using a person's name that occurred during the Korean war. Korean interrogators brainwashed American prisoners, turning them against each other and leading them to believe Korean propaganda. In the brainwashing process, the interrogators were skilled at using each soldier's name at just the precise moment in brainwashing statements in order to increase the influence of propaganda suggestions. At that point in time, American soldiers were not trained to resist brain washing and fell prey to the influence of the interrogator's techniques.
Recognizing the impact of saying a person's name, we should strive to use this inherent power in a positive way to increase the influence of therapeutic statements. This can be done by stating clients' names at the beginning, middle, or end of responses. It is particularly useful when wanting to focus and attune clients toward a new idea. The likelihood of clients being consciously aware of your purpose is remote. Most likely, clients will interpret the use of their name as increased personal attention.
Clients' names can be added to any of the example responses presented in this manual. By subtly pausing for a brief moment after the name, you can increase the orienting response and the anticipation of what follows. In the examples that follow, note how stating the client’s name increases the impact of the message.
To increase the impact of the message that change is inevitable:
, as you hear yourself having this conversation with…"
"As you look ahead and see yourself beginning to speak out more in groups, John
…tell me how…"
To increase the impact of building from what currently exists:
"And the last time you argued, you walked out of the room, Sue…, perhaps you might make a statement of why you are leaving or what you desire."
"As you develop your position toward your dysfunctional family, tell me what you are considering as a position toward your other relationships, Phil."
In the following statements, notice how the client's name is used to increase the client's orientation just prior to making a key point.
"I can understand that you might feel a bit uneasy about this; however, Jerry…, actions do not have to match feelings. Tell me how you could proceed in the midst of your less than optimistic feelings."
"It is ok to feel uncomfortable about _______. However, it is amazing how many times we do things in life that our feelings do not perfectly align with our behavior. This is very common. Doris…, set your feelings aside for the moment and tell me things you can do that you reason may have an impact."
To increase the impact of the temporal nature of current perceptions;
, you do not want to…"
"...and, at this time, Rebecca
, you only want to…"
"...and for now, William
, it is clear that…"
In the following embedded suggestions, notice that initiating an embedded suggestion with the client's name creates a subtle command to do what follows.
"You’ve repeatedly stated that you have wanted to divorce for a long time, but it’s hard to… Mary…comprehend reestablishing yourself without a partner
"You’re so angry with your ____ that you could really give him/her a piece of your mind. It’s at times like these that you just can’t…Bill…imagine sitting down and having a mature conversation about this situation
Remember that a man's name is to him the sweetest and most
important sound in any language.
Pacing and Leading
Pacing is the art of making a statement that tracks and joins the client’s actions, thoughts, and/or emotions in the current moment. Leading adds to the pacing component an idea, suggestion, inquiry, etc. that encourages the client to consider new perspectives and actions. For example, "As you are sitting there reading this book, perhaps you might consider which of these techniques you would like to incorporate into your work." In this example, the pacing component joined readers, noting what they are currently doing (sitting there reading this book). The leading component added to this the idea that readers might consider which techniques to apply to their work.
Pacing and leading are powerful linguistic techniques that are under-utilized by most therapists. The beauty of these techniques is that they provide one of the least threatening, tempered methods for introducing new perspectives and actions. Clients very rarely respond in a resistant manner when a well-phrased pace and lead are delivered with appropriate paralanguage. Another strength of these techniques is that they can be used in conjunction with empathy, deficit statements, embedded suggestions, etc.
Pacing and leading are effective because they take advantage of several well- established therapeutic principles. The first is empathy. A well-stated pace is actually a reflective or empathic statement regarding the client's state at the moment. This establishes a disarming, understanding atmosphere from which to build. The second advantage stems from the fact that it is much easier to build from an existing behavior than to create a completely new behavior. In this instance, the pace is the existing behavior and the lead is the added behavior. A third principle is that of the embedded suggestion. A well-stated lead can also be an embedded suggestion inviting the client to do or consider a new perspective or behavior. A well-stated pace is also the most effective way to introduce the therapeutically beneficial question. For example, “While you are sitting there contemplating alternatives, have you considered…?” (See Chapter 7, the section entitled, Generally, Use Questions for These Purposes
, for a discussion on therapeutic uses of questions).
As noted, you can even pace and lead as someone reads. As you are reading this manual and considering the ideas presented
, perhaps you will generate some ideas of your own
that will be effective in enhancing client movement. When you become awar
e of your own ideas, please inform the author
so he can include your ideas in his next edition and future trainings.
The following table presents a very general formula for creating statements that include pacing and leading components.
Putting it All Together: How to Create Highly Therapeutic, Fully Influential Responses
|General Formula For Creating Pacing and Leading Types of Responses|
|Physical Pace||Current State||Emotional|
|As you're sitting here||aware of your||disgust||and are thinking about…|| perhaps you might…|
|As you are||getting in touch with your||frustration||and pondering the options…||just what would happen if…|
|While you're||experiencing your||sorrow||and analyzing the…||tell me…|
|While here in this office||discussing your||anger||and recognizing…||explain to me…|
|While taking the time to||review(ing) your||pain||and assessing…||have you considered…|
| || tell me what is preventing…|
At the most basic level, therapy is a conversation. How we conduct that conversation is why clients are paying. One of the primary skills that clients pay for is the ability to provide a conversation that incorporates a language style promoting growth and movement. Much of what has been presented centers around the eloquent use of language in therapeutic conversation. The following examples demonstrate how a number of language techniques can be combined into one highly effective statement.
The first statement below is a typical counselor statement in response to a reluctant client. The responses that follow present ways in which it can be modified in order to greatly reduce the potential for creating resistance. Such modifications will likely create responses that are experienced by the client as less threatening and more acceptable. As such, they increase the probability that the client will move forward. Understanding and applying the concepts involved in creating highly therapeutic responses is essential to becoming a master therapist.
"The closer we get to discussing your childhood and parents, the more you seem to shut down." (Immediacy—what is occurring at the moment.)
Potential Modification 1:
"The closer we get to discussing your childhood and parents, the more you seem to struggle to find the desire to talk." (Positive reframe on "shut down.")
Potential Modification 2:
"Talking about your childhood and parents scares you, and you are struggling to find the desire to talk." (The emotion that is present is clarified, thus moving to a higher level of response; a positive reframe on "shut down," and "we" replaced with "you.")
Potential Modification 3:
"The closer you get to discussing your childhood and parents, the more you struggle to be comfortable talking. You are searching for a way to…be comfortable talking about your childhood and parents." (A deficit was added that is also an imbedded suggestion to "…be comfortable talking.")
Potential Modification 4:
"As you’re sitting here, thinking about and discussing all of the difficulties of your life, the frustrations with yourself, the anger over the support you did not receive (include appropriate detail), the closer you get to discussing your childhood and parents, the more you struggle to…be comfortable talking. You are searching for a way to, Mary…be comfortable talking about your childhood and parents."
(Physical, mental and emotional pace was added, as well as the client's name strategically placed before the embedded suggestion to "…be comfortable talking.")
Potential components of the fully influential therapeutic statement:
- Includes physical, mental, and/or emotional pacing
- Includes client's name
- Includes an empathic component, which may be part or all of the pacing
- Includes a recognition of the deficit that may also be a positively worded, imbedded suggestion
- Does not include "we" (instead use "you" or client’s name)
- Does not include "if" (instead uses "when," "as," "while," etc.)
Of course it would be very cumbersome to include all of the above components with every response. It is suggested that fully influential therapeutic statements be reserved for use primarily when leading clients to explore new perspectives or when they are psychologically stuck. Examples might include situations such as: when goal setting, when clarifying how the situation is a problem for the client, preceding a leading question, when confronting, etc. Below are some therapist responses with which to practice. Assuming you have additional knowledge of the client's situation, expand the impact of the therapist's response by including additional influential components.
"My husband got angry and I got a stomachache."
"Is there something else you can do the next time your husband
"I've always gotten my way. I was always the biggest guy. I bullied
anybody who got in my way."
"Anyone who gets in your way gets pushed aside."
"This thing has really done a job on me."
"How do you feel as you talk about it now?"
If you do not want to learn to use words carefully and accurately you
should probably consider another profession.
Other Approaches for Dealing with Resistance
Reframing has been defined as, "…the art of attributing different meaning to behavior so the behavior will be seen differently… (Constantine, Stone Fish, & Piercy, 1984, p. 313), or as "…changing a perception by explaining a situation from a different context" (Gladding, 1995, p. 431).
Much of what is accomplished in counseling is a result of shifting client perspectives. Perspectives often shift as a result of modifying the meaning behind a behavior. As the client’s perspectives change, situation conceptions shift and, as a result, new approaches are taken. A change in perspective is the psychological adjustment needed to give the client permission to approach life differently. In one sense, the situation is not different; it has only been viewed differently. In another sense, if the situation is viewed differently, it is different. Regardless of your philosophical position, the art of reframing enhances the possibility for change and, therefore, is a core skill of good therapists.
All counseling theories incorporate reframing to some degree. When compared across therapeutic approaches, the approach that most frequently and readily uses reframing is likely Solution-Focused Therapy. With its strong focus on the first session (or better, the current session), Solution-Focused therapists like to begin reconstructing the problem almost immediately (Murdock, 2004). This is usually accomplished through some form of reframing, and often has the goal of trying to make the problem not be viewed so much as a problem, but as the lack of some positive skill. For example, a person who sees him/herself as compulsive may be told that he/she has time management concerns.
Effective reframing requires two skills. The first is to formulate another way of conceptualizing a situation. This new conceptualization disrupts the client's current way of thinking by providing an alternative meaning to a behavior. The second skill is to create a reframe that is acceptable to the client. Many times whether or not a reframe is accepted by the client is determined by the dialogue that precedes the reframe, as well as the way it is presented. Ultimately we are seeking a new perspective that is acceptable to the client and which provides a reason to cease an old behavior or begin a new behavior.
Resistant clients can be quite stunned by a well-stated reframe. It is rarely what is expected and, therefore, results in a moment of confusion that is followed by a consideration of the alternative perspective. If the client rejects the reframe, fine. At the very least, a new idea or perspective is introduced, and the idea is still somewhere in his/her consciousness for contemplation. In the best cases, the reframe is accepted and opens the door for beneficial discussion. Regardless, the reframe is a way to introduce new ideas without being confrontational and therefore, it can be very effective against resistance.
Most reframes attempt to state the negative as a positive. When dealing with resistant clients, the idea is to reframe the negative elements of the resistance as a positive component in counseling. In order to do this you must point out the desirable aspects of the resistive behavior. If clients cling to their position, it is now an asset; if they reject their position, they reject their resistant stance. Thus, the well-stated reframe creates a therapeutic bind for clients. The reframe is a therapeutic win-win for therapists and, ultimately, for clients.
The best way to understand reframing is by studying examples. The best way to learn reframing is through braining storming different perspectives that may be applied to situations and practice. A number of examples are provided below in no particular order. You will also find examples of reframing throughout this manual. Because reframing is often part of paradoxical approaches, the next section on paradox also contains many reframing examples.
Example Reframing Responses:
"I've always done poorly in math!"
"I'm glad to see that you have pinpointed the subject you need to work on. If you have consistently done poorly, you must be consistently doing something incorrectly. This consistency will make it easier to spot the problem and correct it."
"I get so nervous when I get up before people, I'll never be able to make this speech!"
"I am glad to see that you have a keen awareness of your feelings of nervousness, this provides us with a clear place to start."
"I shouldn't be crying so much about this."
"Isn't it nice for your tears to allow you to finally get these feelings out."
"...so that's why everyone always says I'm a trouble maker."
"...It appears you may have some leadership skills."
"I've tried it and it won't work!"
"Sounds like you have experienced some real frustration. I'm glad to hear that you have been exploring possibilities and making some efforts. Tell me what you did."
"I've tried everything and nothing works!"
"That's great, the more things you have tried, the more things we can learn from and we will not waste so much time continuing to do things that you know won't work. I am impressed with you efforts."
Yes, you can even reframe the troublesome "I don’t know" response!
"I don’t know."
"That's actually a benefit. I have so many clients that waste a lot of time because they think they do know and, unfortunately, are wrong. Because you are stumped at this time and admit you don't know, we don't have to waste time negating ineffective ideas and behaviors. You can start fresh with a blank slate and build from there."
Brief General Examples of Reframes:
If clients are reluctant to try a new approach, it could be a mistake to frame such behavior as resistant. Instead, tell them that they are rightfully cautious, prudent, and wise to fully consider any new behavior before moving forward. (You could follow these comments with a bit of paradox by suggesting that the new, alternative behavior is perhaps not a good idea, including a statement to the effect: "You decide for yourself if it is worth trying." Thus, you remove any position to fight against.)
Moursund and Kenny (2002) suggest that client's abrupt endings can be reframed as a vacation from therapy, or a leave of absence, or a time out for integration. If a resistant client wants to end counseling and is confronted about abruptly ending, you may fuel resistance. By providing a positive reason to take a break, you leave the door open for a continuation at a later date.
You could reframe a workaholic as showing concern for his/her family in the best way currently known by that individual.
When appropriate, you might reframe misbehavior from a child as an attempt to keep a divorcing family together and as a way of showing caring. Though it may appear as a reframe to a child or a parent, it is well known that this may be psychologically true. Similarly, when parents are initially applying a behavioral approach to control behavior, the behavior usually gets worse before improvement occurs. Here it should be explained that this is actually a positive sign that the removal of a positive reinforcer is working. Again, although scientifically you are presenting a fact, to the parents this is a reframe of what otherwise might appear to be an approach that is not working.
I recently consulted with a counselor who had a teenager who was in and out of state custody. The youth had a step-mother whom he despised and, from all accounts, the step-mother despised him as well. Furthermore, she very much desired that he be placed in state custody. The youth had failed his drug test several times because of marijuana use. One more failure would send him back into state custody. He apparently had little desire to stop smoking marijuana. The most emotionally compelling motivation the young man had was to not please his step-mother. Upon hearing this, the reframe was constructed.
From the young man's own words it was clear that the step-mother wanted him out of the house. Thus, it was pointed out that if he smoked marijuana, he was playing into his step-mother's desires for him to be gone. He was reminded that all he had to do to make his step-mother extremely happy was to smoke marijuana and fail his drug test. This was apparently an entirely new perspective for the youth. For the first time, he actually had an emotionally compelling reason not to smoke marijuana. Consequently, passing his drug test provided the step-mother with a more positive outlook on her stepson.
Perhaps resistance and defensiveness are often encouraged
unwittingly by pessimistic therapists who never think of
alternative views that might allow clients to save face and
preserve what little self-esteem they have.
Hammond, Hepworth, & Smith
Paradoxical approaches were specifically developed to deal with resistance. They are also some of the most eloquent and powerful techniques employed to circumvent resistance. Paradox is particularly useful for resistant clients because it alters resistive behavior without directly attacking or confronting it. Thus, paradoxical techniques will be given additional attention.
Paradox is often defined as "prescribing the symptom" because frequently the client is told to continue to do more of the undesired behavior. Gladding (1995) defined paradox as, "A form of treatment in which therapists give (clients)…permission to do what they were going to do anyway…" (p. 429).
Paradox is often referred to as "reverse psychology" by lay persons. This is actually a rather good term to describe paradox because all paradoxical approaches appear to do the opposite of what is desired. Many of the approaches in this manual are paradoxical in nature. When we allow and even suggest that the silent client not talk, we are incorporating paradox. When we praise the client who challenges ours skills as being a good consumer, we are using paradox. In both instances we are going east to reach west. We respond in a manner that is opposite of what is commonly done, in order to get the client to act in a way opposite of what he/she typically does. We approach the client with a behavior that appears to not be leading to what is actually desired.
The beauty of paradoxical approaches is that they not only thwart resistance, they also utilize the resistant behavior as a tool to promote therapeutic movement. The therapeutic advantage comes from clients being placed in a bind where the more they display resistant behavior, the more they comply with therapist suggestions. Depending on how the paradoxical approach is incorporated, there are several potential benefits of paradox.
One is that clients, through continuing the unhealthy behavior, acquire an increased awareness of the uselessness of the behavior relative to accomplishing their goals. The consequences of clients' behaviors are rather dramatically brought into awareness. Many times clients view unwanted behaviors as uncontrollable. When the behaviors are practiced, it becomes apparent that they are voluntary and controllable. Another benefit is that paradox takes the wind out of resisting. There is no therapeutic battle or confrontation to be overcome because clients are allowed to do what they would do anyway. A more subtle benefit is that there is an implicit message that the therapist has faith in clients to recognize what they need to do for problem resolution. The therapist is conveying confidence that clients will make wise decisions about what to do when they see the consequences of their behavior from a magnified perspective (Dinkmeyer, Pew, & Dinkmeyer, 1979). Thus, through the use of paradox, not only is resistance circumvented, but the boundaries of the therapeutic relationship are kept intact and a healthy independence is reinforced.
Paradoxical approaches generally work well on unharmful behaviors of which clients appear to have little control. Their use is appropriate when resistance is significant, and the unhealthy behavior is playing a part in maintaining the problem or is obviously a futile attempt toward problem solution. Paradox is also suggested for use when it provides a simple antidote to the problem. Of course, paradoxical interventions are highly dependent on the therapist's ability to maintain a serious, candid paralanguage that conveys earnestness toward the assignment. Readers are reminded to never paradox dangerous behaviors that may result in physical harm such as drug and alcohol use, suicide, abusive behaviors, etc.
Paradoxical techniques generally come in two forms. The first is to merely reframe the undesired behavior without any additional comment or instruction. In this instance, the bind is created and the client is left to contemplate it and react as he/she will. The second approach is to reframe the undesired behavior, attitude, etc., and then prescribe that the client do more of it. The logic for continuing and increasing the ultimately undesired behavior is usually couched in the reframe that precedes the paradoxical prescription. However, sometimes there is not an openly discussed reframe to the undesired behavior. In such instances, the client is just instructed to do it without explanation.
In order to learn to incorporate paradox, you must ask yourself a series of questions about your client's behavior.
- What is the client doing?
- Is it truly harmful (e.g., suicide, abusive behavior), or is it a psychological nuisance?
- Would it be harmful if the behavior was to continue or increase?
- Does the behavior simply need to be reframed? Or, does the behavior need to be reframed and prescribed? Or, would it be more productive to just prescribe it without a reframe?
- How can the behavior be reframed to bring a completely new meaning to it? Alternatively, depending on the approach, how can the behavior be reframed as important or at least something that needs to be practiced, or treated with care, etc.? What would be a legitimate appearing reason to prescribe doing this symptom?
- How will you respond to various client reactions and statements regarding the assignment? Preparation for all reactions and outcomes is very important. Sometimes a second or third paradoxical comment is needed to deal with client reactions.
One of the best ways to understand the many possibilities for paradoxical approaches is to study examples. Below are a series of discussions and examples of paradoxical approaches. These examples are presented to stimulate ideas and are in no particular order. Hopefully, a study of these examples will provide insight into the power and utility of this approach. Various forms of paradox are presented elsewhere in this manual also. The use of paradox when dealing with non-verbal clients is discussed at length in Chapter 9. Challenges to therapists' competence are also managed with paradox in Chapter 10.
As long as people are going to resist you may as well ask
them to do so.
Case Examples and Discussion
Perhaps the least subtle form of paradox is to have clients continue to do or even exaggerate what they are doing (i.e. prescribe the symptom). One of my favorite uses of this approach is with clients who are undecided about some important decision. In some instances, the decision is about whether to continue a relationship or not. Here I simply instruct clients to stay in limbo, to remain undecided. I often add to the instruction that much of the time in life we do not know something and that this is perfectly all right, we cannot know exactly what to do at all times. The dialogue may go something like this:
"As you have been discussing your situation, you keep stating that you're confused and don't know what to do. It's ok to be confused and in limbo over what to do. It's ok not to know. If you really take a look at life, we are constantly moving from a state of knowing, to not knowing, to knowing, etc. Much of life is spent in a state of not knowing something. Not knowing is really a natural part of life. Perhaps confused and in limbo is the best place to be right now. I would like for you to stay in limbo, allow your confusion to exist, allow yourself not to know, and just see what happens." This approach almost always works. By allowing the confusion and limbo to exist, clarity emerges. Most people seek clarity and end up with confusion. Why not reverse the process?
I am also compelled to point out the dominant thought and the logical impossibility in the injunction to "not know." First, note that the dominant thought is "know." (See Chapter 5, the section entitled, The Influence of Words on Mental Processing: Why the Words You Choose are so Important
.) Thus, the mind is led toward "knowing" regardless of any effort exerted to "not know." The "not" simply does not receive much attention and consideration by the mind; it is secondary to the thought of "knowing." How can one actively "not know" anything? Genuine "not knowing" is a completely passive state. Take a moment and try to "not know" something. What a quandary you place yourself in! What you discover is that you must be completely void of knowledge of something to really "not know" it. If you have the slightest intuitive awareness of some information, any active attempt at not knowing will bring it to the forefront. Such is the case with clients who always have much more information about their own situations than they are willing to face and overtly acknowledge. Any active attempt at not knowing information will certainly bring it into consciousness. Paradoxical techniques are almost the perfect tool for accomplishing this with resistant clients.
If you would like to test this assertion, ask yourself this: How many countries are on the continent of Africa? Assuming you do not know, stay with the "not knowing" state for a minute and notice what happens. Notice how all sorts of information about Africa starts to bubble up in your mind. You will likely see a picture of the continent. You might think about where to get the information from a map of which you are familiar. You will likely find yourself almost instinctively making educated guesses about the number of countries. Pay attention to how trying not to know leads to an awareness of the knowledge you do have
An understanding of this concept is vital to skillful therapeutic dialogue. You are constantly generating thoughts in your client's mind with your responses, whether you are aware of it or not. If you do not fully grasp the concept being explicated here, study Chapter 5.
I once knew a mother who had to travel several days a week in her work. She was a very conscientious parent who loved her children dearly. However, when it came time to leave, her 12 year old daughter would experience considerable separation anxiety. As a result, the daughter would cry and cling to her mother rather dramatically as the mother left the house. Initial attempts at reducing the crying and clinging included telling the daughter not to worry, that mother would be back, and assuring the daughter of how much she was loved. These efforts had little effect. In an attempt to get the crying and clinging under control, the mother was instructed to openly reframe the crying to the daughter as a positive reaction that demonstrated how much she cared for her mother. This was followed with the instruction to cry all she wanted because it displayed her love for her mother. She was also told that she had a right to cry because of her awareness that her mother would be gone for a few days.
When the mother left to travel the next time, these comments were repeated to the crying daughter. The time following, when the mother had to travel, the crying and clinging stopped. The paradox worked because the daughter had cried in an effort to keep her mother home. However, the reframe neutralized the child's logic that, if I cry, my mother might stay. The more she cried, the more the mother appreciated and supported it, thus further demonstrating that the crying would not have any manipulative power. At the same time the daughter was reminded of her awareness of the reality that her mother would leave and would return.
Other examples when clients might be asked to continue their current behavior include the following:
- Instruct the shy person not to talk.
- Instruct the nervous person to shake.
- Instruct the person with sweaty palms to make them sweat.
- Instruct the smoker to continue smoking and to consciously enjoy each cigarette.
- Instruct the person with a tic to practice in front of a mirror (Dinkmeyer, Pew, & Dinkmeyer, 1979).
- Instruct the person with insomnia to stay awake.
- Instruct the worry wart to worry. Sometimes you might have a scheduled period of time for worry each day.
- Instruct the sad person to allow his/her self to be sad (Be careful. As with all paradox, the use should be case specific. In some cases of depression, paradox may not be appropriate.)
- Instruct the complainer to have a designated period of time each day to complain.
- Instruct the couple who fights to have a regularly scheduled time period for fighting each night.
- Instruct the person who compulsively cleans his/her house to clean it more.
Sometimes when you suggest clients increase the negative, undesired behavior, they become more amenable to suggestions of healthy alternative behaviors. This is particularly true if such clients are initially resistant to productive suggestions. If clients resist healthy productive suggestions, they are told that the unhealthy behavior must have great psychological meaning and purpose (reframe) and are instructed to continue doing the unhealthy behavior in an exaggerated manner (paradox). If the approach works, either or both of two outcomes may happen. One is that clients recognize the futility and absurdity of the unhealthy behaviors to such a degree that they cease them. Another is that clients may stop the unhealthy behavior in order to defy the therapist's instructions. Regardless, change is likely.
Some years ago I ran smoking cessation groups in which we incorporated this notion. The program was well-designed and recognized the difficulties inherent in getting participants to quite smoking. Many participants had real doubts about their ability to quit and came with a fair degree of resistance. In an attempt to circumvent much of this initial resistance to quitting, for the first few weeks we did not ask people to quit. To the contrary, we asked them to tally their smoking behavior, really think about smoking when doing it, and enjoy smoking more. Thus, we instructed participants to do the opposite of the original reason they came to group. This was perplexing to many group members. I can recall one participant asking with a slight irritation in her voice and much anticipation, "When are you going to give the order to quit?" From this reaction, it was clear that the approach was working well, and that she was now amenable to move into the quitting phase of the program.
This initial paradoxical approach made movement into the quitting phase much easier and more acceptable to participants. Instead of fighting the initial resistance common to quitting, we pushed clients further toward smoking. In reaction, participants more readily moved in the opposite direction, toward quitting.
Sometimes clients are instructed to not move too quickly toward a new behavior or change. This dissipates the natural ambivalence and reluctance toward change. There is nothing to fight. Interestingly, without a fight, the ambivalence often fades rather quickly. Sometimes a reframe that includes the negative consequences of changing can also be included in the dialogue. Corey (2001) offers the following example of how a depressed person is told not to give up the symptom too quickly. "Maybe you should not give up this symptom too quickly. It gets you the attention that you say you want. If you got rid of your depression, your family might not notice you" (p. 425).
Similarly, you can reframe resistant behavior as a healthy cautiousness or as being prudent. This can be followed by a comment that the alternative approach may not work, and that your client is wise to take time to consider it thoroughly before any attempt is made at implementation. You might also add a comment that too much of the new behavior might be too burdening. Thus, your client should go slowly, only doing that which is comfortable.
Murphy and Dillon (1998) suggest that, when you encounter balking at the recommendation to discuss difficult topics, you allow the freedom to refuse. The following was offered as a possible response:
"I think you're absolutely right to stop here for now. It's good to see you being careful of yourself and not just plunging into topics because I suggest them. I agree with you. I don't think we should go anywhere near this topic right now, and I want you to keep on waving me off of anything like this that seems absurd or hurtful" (p. 127).
Note the reframing of the client's reluctance as "being careful of yourself," as well as the two embedded suggestions which serve to frame the reluctance as a temporary state—"for now" and "right now."
A bold paradoxical approach was skillfully done by a colleague of mine during his doctoral training. He was seeing a couple. The husband had recently lost his job and had become a lazy slug, sitting around the house in a rather depressed state. As he gathered more information about the couple's patterns of behavior, it became apparent that the wife, in feeling sorry for the husband, was waiting on him hand and foot. The couple was also quite religious and believed in doing for others. In an attempt to break the current pattern, my colleague explained to the wife that her efforts at supporting her husband were commendable, but that she should do even more to show her caring for him in his current state. In an effort to show unending support for her husband, the wife was instructed to go to him, take off his shoes and socks, and wash his feet in a pan every night.
The next counseling session was only attended by the wife. When asked how the feet washing went she replied in slightly sarcastic tone, "I get the message." The session continued with little discussion about the instructed task. Apparently, not only did the wife not wash her husband's feet, but she withdrew her waiting on him completely. As I recall, later reports indicated that the husband was back to work within two months. People who want to help in the worse way usually do. It sometimes takes a magnifying glass for them to see it.
Resistance is very important. Once you learn to use it, you
really have come to a point where you can be effective.
Watzlawick, as cited in Anderson & Steward
I once supervised a reality therapist who dealt with troubled youth in an inpatient facility. Many of the young males in this facility were quite oppositional. As you know, Reality Therapy focuses almost exclusively on current behavior addressing the question, "Is your current behavior helping you reach your goals?" To this end reality therapists are fond of using paradox. Sometimes clients are asked to perfect certain (unproductive) behaviors in order to assess how well they are leading toward desired goals.
In one particular case this reality therapist had a quite oppositional male teenager who got into trouble daily. In his dialogue, the therapist challenged the oppositional young man stating emphatically that, "I bet you can't go through one day without getting into trouble!" The oppositional youth replied that he could, to which the therapist replied even more emphatically, "I bet you can't even describe what you would be doing if you weren't getting into trouble!" This challenge was too much for the oppositional teenager and he began to describe how to be well-behaved. The bet was on. The youth did make it through a day. With this approach the behavior was improved and much discussion of good behavior was promoted.
I had a student who worked in a school system with a young man doing very poorly in school and prone to getting into trouble. In our consultation it was pointed out that this boy had already failed one grade. He also had a younger brother in the same school one grade below him. Further, the older brother did not want to be closely associated with the younger kids, desiring instead to be one of the older kids in the school. Recognizing the significant embarrassment that accompanied association with the younger kids, the reframe and paradox were created.
Instead of continuing the battle for good behavior, the teacher took the young man aside one day and had a heart to heart conversation. With all sincerity she pointed out that she knew why this young man constantly got into trouble. It was because he knew that he was going to fail another grade so that he could be in the same class as his younger brother. She pointed out that she recognized his strong desire to be able to study the same subjects and be in class with his brother all day. She even hinted at some understanding of his tactics and concluded by stating that she would continue to assist him by catching him every time he broke the rules. In this way she would help him to be successful at failing again.
Although not verbally expressed, it was apparent that this young man had never really thought about this horrifying possibility until this moment and that he was visibly shaken. The young man's behavior immediately began to improve with little disciplinary action. As noted, people do not change from logic, they change when they have an emotionally compelling reason.
The sweetest treatment example with a paradoxical component that I have ever come across was offered by Lynn Hoffman (1981) who reported how Jay Haley employed a clever strategy to treat a child with a phobia of dogs. The young boy was instructed to find a puppy that was afraid of humans and to "cure" it. Here the child was placed in a position not unlike his own but in reverse. Through teaching the puppy not to be afraid of humans, he overcame his own fear of dogs. Notice that a puppy was used and not a full grown dog. The use of a puppy is a wonderful example of taking baby steps in the treatment process. The use of a puppy brings the task to a much more accomplishable level relative to a child and to many adults.
Dangling the Carrot
Another difficult situation that sometimes arises is when clients reveal that they have pertinent information, which they have yet to disclose, but which they avoid directly discussing. Such clients continue to "talk around" the undisclosed information, leaving the therapist to wonder what it might be. In such instances you are left to ponder if you should pursue the specifics of the information or let it sit. To complicate matters, every time you direct the conversation elsewhere, clients often bring the undisclosed information back into the conversation. When you pursue the information, such clients stop short of revealing the specifics. The end result is that the session goes in circles, accomplishing nothing.
Many years ago, in one of my first sessions, I had this happen to me. I spent the better part of the session chasing after some mysterious information that the client keep talking around. As a result, nothing was accomplished. My supervisor later explained that the client had lured me into chasing this information. The result was that I was working like a dog while the client avoided confronting any of her issues. It was as if the client was dangling a carrot just in front of me out of reach and, as I pursued, the carrot moved to a new position still just out of my reach.
When you encounter this dynamic, the initial strategy should be to explore the fears around revealing the information. This may involve a discussion of the counseling relationship and include issues of trust, confidentiality, your ability to hear shocking things, your gender in relation to the client, etc. Many times such discussions resolve the underlying fears and lead to the information being revealed. However, sometimes clients continue to dangle the information and it becomes apparent that this is more of an avoidance tactic. When you first experience these dynamics, you are usually so caught up in the chase that you fail to see the underlying resistance that is fueling the diversion. When you step back, you realize that such clients have consciously or unconsciously discovered an effective way to avoid facing struggles and to consume time.
The way to handle such instances is simple and follows from the themes repeated throughout this manual. Don't take the bait. Or, in this instance, don't chase the bait. Use a paradoxical approach to deal with what is occurring by instructing such clients to hold back on revealing the information. Explain that you recognize that they have something that is weighing on them rather significantly. Empathize with the conflict. State that you realize how people sometimes struggle to reveal difficult information. Then state that, because of the apparent conflict over whether or not to reveal the information, now is perhaps not the time to discuss it. Further assure that, when they are ready, you will be willing to listen to whatever it is that is weighing on them so heavily. Then move the conversation to another area stating something to the effect, "I realize that there are some things that you do not want to tell me. And until you feel it is ok, I would rather you not do anything unless you are comfortable. So, let's spend this time talking about the things you feel you can tell me."
If such clients keep dangling the undisclosed information, repeat your position assuring that, when ready, you will be glad to listen. Of course this must all be done with absolute candor and honesty. If you reveal through your paralanguage that you are using paradox, the approach may backfire. Eventually they will get the message that you are not about to chase after information. Ultimately, the information will be revealed or dropped from the discussion. If you do not hear of it again, it is likely that it was a ruse. There is a general rule of thumb in counseling: anything important will be mentioned more than once.
Expanding the Context
King (1992) offered a rather sophisticated technique that employs a bit of a paradoxical twist. This twist involves expanding the context in which the problem is taking place. In the example that follows, instead of the client being asked to continue to do what he was doing, the family members around the client are instructed to begin doing the problematic behavior. As with more straightforward paradoxical techniques, the dynamics and benefits of continuing the behavior are thrown into chaos. In this instance, the purpose behind the behavior is nullified by removing the uniqueness, and thus, changing the meaning. In the example that follows, the lying loses its benefit and is eventually abandoned.
A family came to therapy because of the son's lying (King, 1992). The son apparently would lie randomly about anything and punishment was of no benefit in attempts to get him to stop. Rather than confront the son and risk creating more resistance, the therapist instructed the other family members to tell a lie of their own at a later time each time the son told a lie. "For example, the son might lie about doing a chore; the parents could respond by later telling the son that supper was ready when it was not" (p. 172). Here the context in which the problem behavior was occurring was expanded, thus, removing the power of the lie. The exceptionally strange behavior of the other family members threw the son's world and motives into chaos. The son stopped lying by the end of the first week.
Encouragement Does Not Always Encourage
As peculiar as it may seem, with highly resistant clients it is often not productive to over encourage movement or excessively praise accomplishments. Although this is not a hard and fast rule, and individual differences in clients should always be considered, it is an important dynamic to keep in mind in order to avoid inadvertently creating resistance. Those therapists who do not have an understanding of this dynamic are puzzled when they sense that the harder they try to help, the worse things get. There are several possible explanations why excessive encouragement and praise have a negative effect on improvement.
The first is that too much encouragement and praise gives the client something against which to resist. For those resistant clients who are oppositional in nature and oppose any and everything presented, the urge to go against the status quo is just too great to accept a genuine affirmation of their accomplishments. Thus, they rebel against even the most sincere encouragement and praise.
Second, it may be that some clients praise themselves for not allowing you to manipulate them. Here, your encouragement and praise are perceived more as manipulation rather than reward. If you perceive that your encouragement and praise are viewed as manipulation, you would be wise to greatly limit such comments, perhaps to the point of encouraging less movement (i.e., paradox). With resistant clients, independence may be valued to a much greater degree than praise.
Third, with resistant clients (and perhaps all clients to various degrees), encouragement and praise may create dependence in lieu of fostering self-motivation. Ultimately, self-motivation is the objective. If clients act only to gain your approval, they are not responding out of a genuine inner desire to change the self. Frequently, clients enter therapy with an excessive degree of dependence. Such people lack the confidence and belief in themselves to make decisions and act. This degree of dependence may appear as resistance. Although encouragement and praise may be extremely helpful, they can be a double-edged sword. The more you praise dependent clients, the more they may change solely as a result of your praise. Such change fosters the already existing dependence and, because it did not develop from a genuine inner desire, it may fade as soon as the therapeutic relationship ends. A lack of awareness of the dynamics of dependent clients may result in short-lived change. Be careful that your approval does not unduly replace self-motivation and inadvertently promote what later appears to be resistance.
With motivated clients such inconsistencies are rarely a problem. They want to change and appreciate your support. This, to some degree, is why they are paying you. The more resistant the client, the more aware you should be that the usual rules of responding may not apply. Solution-Focused approaches frequently allude to this point (Walter and Peller, 1992). They suggest that if encouraging the client to do more does not work, then encourage doing less. The more reluctant the client, the more you might suggest that only the smallest changes be adopted after much consideration.
From this discussion it is apparent that the dynamics of what is commonly practiced may change substantially when considered within the context of resistance. An awareness of such dynamics is critical to effectively dealing with resistant clients. Please note that this discussion in no way suggests that therapists eliminate encouragement and praise. Indeed, many clients are so void of confirmation from others that the affirmation received in counseling is critical to growth. In such instances, well-stated praise may be life changing. The point is that the dynamics of encouragement and praise must be considered within the context of each unique client.
Change Your Theoretical Approach
If you have been working from a particular theoretical approach and it has not been working, change. One of the interesting things about counseling is that just about nothing consistently works across all situations. It is often difficult to predict which theoretical approach will work with which clients. Sometimes the approach that appears to "fit" with a particular client is the opposite of what actually works.
Adherence to one theoretical approach, with no adaptation to client differences, personality styles, and needs, can result in what appears to be resistance from clients. In actuality, such therapists are being resistant because they are unwilling to accept that their favorite approach is not applicable to the personality of certain clients. This is a case in which therapist resistance is interpreted as client resistance. As experts on change, we should be the ones that adapt to clients' personality styles. It is unreasonable and unprofessional to expect a psychologically uneducated public to adapt to the theory of our liking. Counselors who impose their theoretical orientation on clients, without regard to clients' personality, are like salespersons who try to sell you a product that you do not like or need. We should strive to stay in a customer service mode where we aid shoppers in finding what they desire and need. This is also less stressful on both clients and therapists.
I once had a client who was brilliant at analyzing his life and the family dynamics. The analysis was so compelling that it constantly appeared he was on the verge of a breakthrough. Yet, things did not improve. After some time I realized that the client used his analyzing to avoid facing the real pain in his life. I then switched to Gestalt approaches and, with the client's permission, forbade any analyzing. Almost immediately the client began to make changes in his life.
Therapists who continue to do approaches and techniques that do not work are highly resistant therapists. They assume that one size fits all and continue to beat a dead horse. One size rarely fits all. This is particularly true with counseling. If the horse is dead, dismount.
There are no resistant clients, only inflexible therapists.
Bandler & Grinder
Strengths and Weaknesses of Several Major Theories:
A brief discussion of the strengths and weaknesses of a few commonly used major theoretical approaches may shed some light on this point. As many therapists are aware, the shortcomings of theories are often amplified when they are applied to highly resistant clients. Each approach will be discussed as if it was applied in its purist form; however, it is recognized that this is rarely the case. Most therapists are eclectic and readily mix components of various approaches in order to control for the inherent weaknesses of each.
Rogerian approaches are great for rapport building and sorting out the emotionally compelling reasons for change. Yet, they are often slow to move clients to action. In its purist form, Rogerian Therapy is often criticized for being too non-directive. Some clients can go for months dumping their concerns without any definitive inner summons for movement and change. When this happens, the unskilled Rogerian therapist often follows along without any progress being made. More skilled Rogerians learn to tap into the inner calls for change that are deeply hidden in clients' words and ferret out a case for new action. To this end, Rogerian approaches are often augmented with the call-for-action components of Reality Therapy and Solution-Focused Therapy.
Gestalt approaches are fantastic at helping clients experience the internal conflicts that surround problems and at getting clients in touch with emotionally compelling reasons for change. However, it is sometimes difficult for clients to go along with Gestalt experiments because the exercises are either too threatening or too foreign relative to clients' personalities. In addition, even after experiencing emotions fully, some clients struggle to determine the action that needs to be taken in order to reach resolve. When practiced in its purist form, the Gestalt therapist does not offer guidance on what to do with the insights that emerge from the guided experiences. Clients are left on their own to find direction. Here again, it may be helpful for therapists to use Reality Therapy and Solution-Focused Therapy approaches in order to aid in defining needed actions.
On the other hand, Solution-Focused "Brief" Therapy and Reality Therapy often call for action too soon in the process, before emotions are adequately addressed. Although I am convinced that good Solution-Focused therapists do tune into emotions and use empathy, the Solution-Focused literature is noticeably void of a strong emphasis on empathy and the importance of establishing an emotionally compelling reason for change. Empathy and emotions are always mentioned, but appear to be given less priority and discussed as a minor component of the therapeutic process. Reality Therapy is similar in its consideration of empathy and emotions. With Reality Therapy, emotions are secondary in therapeutic significance when compared to doing and thinking.
Both Solution-Focused and Reality Therapy efforts can be enhanced by allowing time and consideration for the emotional components of problems. Time and consideration for emotional issues increases the client's respect for the counselor which, in turn, results in a greater exchange of influence. In addition, emotional content is critical to developing the motivation for change—the real challenge.
The cognitive theories have drawbacks similar to the Solution-Focused and Reality Therapy approaches; they tend to treat emotions, and the subsequent motivations that accompany them, as minor components of the change process. It is quite common to encounter people who have a cognitive understanding of their flawed logic and need for change, yet who do not make changes because they are not emotionally inclined or ready. With respect to Albert Ellis, virtually every counselor who has ever tried the basic A-B-C's approach to change has met with a blank stare from clients who are not emotionally ready for such pure, unmitigated logic. Because of the collaborative emphasis, the cognitive approaches of David Burns and Aaron Beck are less inclined to suffer the pitfalls of Ellis's A-B-C's. Needless to say, cognitive approaches benefit when empathy is used as a companion to aid in dealing with emotional factors.
I would like to comment here that I am a bit bothered with the term "brief" when describing any therapeutic process which, of course, includes Solution-Focused "Brief" Therapy. That Solution-Focused "Brief" Therapy is brief is a bit of a misnomer. I have seen no scientific evidence that what is referred to as "Brief" Therapy is any briefer than any other approach. Any therapeutic approach can be brief depending on the problem, the client, and the skills of the therapist. I have seen powerful, brief interventions with every theory discussed here, all of which I am inclined to use. The term "brief" is, however, an excellent and timely choice of terms to include in a theory's title to increase its popularity at a time when managed care is a dominant force.
Change Your Communication Mode
Most of counseling is done through talking. Although talking is the most common method of communication and the focus of this manual, it is not the only communication method available. It is not infrequent that some clients prefer and greatly benefit when alternative communication modes are employed. Alternatives include writing, drawing, experiential play, working with clay or other mediums, drama, etc. Although it is not the intention or scope of this manual to elaborate on the many alternative modes of communication, they do deserve mentioning for two reasons. The first is that any of the linguistic approaches discussed here can and should be used in conjunction with alternative treatment modes. The second is to remind readers that, in order to circumvent resistance, they should be open to utilizing clients' preferred communication tools.
If clients mention that they write poetry, explain that you would like to read some of their work. It is likely that mentioning that one writes poetry is related to the presenting issue in some way. If it is not related, fine. At worst, you read some poetry that you may not enjoy. If it is related, you may open the door for a medium of expression that can more rapidly allow clients to resolve their inner struggles and move forward.
The same is true for art, journaling, dance, etc. Many non-verbal clients are inclined to expression in other modes. One of the most common is writing. If they like to write, then ask them to write. If they like to draw, ask them to draw. Sometimes what appears to be resistance is the result of not finding the most suitable medium for communication.
Immediacy: Discussing What’s Occurring Right Now, Right Now
Immediacy brings to the forefront what is transpiring between you and your client at the current moment. Because it is commonly taught in training programs, it will not be discussed extensively. To use immediacy you must be able to dissect the elements of the interaction that are occurring, and then clearly state them to the client. Because it is not something that is typically done in everyday conversation, immediacy can feel quite foreign and uncomfortable to clients. Therefore, I would suggest that it is done in a most supportive manner. In many instances, immediacy may be a form of mild confrontation. It is also one of the primary tools used in breaking through barriers and bringing issues to the forefront.
Immediacy can be effective against resistance because, by talking about what is occurring, you begin to disrupt the resistive interaction style of clients. Remember that most of the time resistance is as much an interaction style as it is a characteristic of clients. When you point out what is repeatedly occurring, you disrupt the pattern. This is particularly true with conscious behavior. The more unconscious the behavior, the more likely it will be repeated and will have to be pointed out again. A few examples of therapist responses utilizing immediacy are presented below.
"Mary, let's stop here a minute. I noticed that you are having great difficulty talking about your brother. Every time we mention him you begin to squirm and appear nervous. Tell me what is happening in you now."
"I've noticed that every time you begin to discuss your father you have a tendency to change the subject and begin discussing something else." (subtle confrontation)
"The closer you get to discussing your childhood, the more you seem to have trouble finding the desire to talk. This is what appears to have occurred just moments ago. At such times, it is as if there is an automatic response to not talk."
"I feel as if we are sitting here now in a sea of confusion and just about everything I say makes you uncomfortable. This discomfort is present right now. My sense is you don’t have a clear picture of your situation and you are unsettled by my attempts at clarifying what I am picking up."
Go with the Energy
Going with the energy is a commonly practiced Gestalt technique in which the therapist allows clients complete freedom to express what they would do if they impulsively did what they felt like doing at the moment. The therapist's dialogue is typically centered on a series of questions (that can be reworded as curious commands) that compel clients to explore where emotionally fueled fantasies would hypothetically lead. Such dialogues are begun by clients spontaneously stating something to the effect, "I really feel like just…" followed by some action. Or, the counselor could ask, "What do you feel like doing now?" or "What do you really wish you could do now?" Clients' responses are then followed by statements such as, "And what would happen next?" or "Tell me what you would do then," or "And then what would happen?"
Of course, the counselor never passes any judgment on clients' responses. The freedom to express whatever whim or action desired is encouraged. Clients are given nothing against which to resist. The therapeutic benefit comes from being encouraged to follow their inner thoughts and feelings beyond the usual stopping point—to go beyond what is typically imaged in such fantasies. This is not the common pattern for most people.
When struggling with a problem, most people engage in some form of fantasy about what they would "really" like to do. Freud referred to such fantasies as primary process thinking, and they are postulated as emerging from the id's desires. However, most clients have not considered their actions past a certain point in the fantasy. Most likely they have considered their actions up to a certain point and stopped. At that point, they begin the fantasy again. They have not followed through in considering their whims. Thus, they are stuck in a mental loop where actions are considered up to a point and then recycled through.
In order to help clients break out of their mental loops, it is sometimes helpful to encourage them to continue explaining what they would like to do if they had the nerve and the freedom to actually do what they felt. The therapeutic key, however, is to not let clients stop at their usual stopping point in the cycle. When clients stop, continue inquiring what would happen next or what they would do next. This breaks the mental loop and increases awareness of ultimate outcomes and consequences. This is therapeutic because it carries the exploration process beyond the point to which they have become accustomed and into new areas of consideration.
The beauty of this technique is that clients almost inevitably lead themselves to the crux of their problems—back to their own issues. As they follow their energy, they typically go full circle on a path that eventually brings them back to an awareness of their own internal struggles. And of course, this is accomplished by getting out of their way, supporting them as they travel their own path, and giving them nothing against which to resist.
Directly Hand the "Ball" to Them
Counselors as a whole are kind people who truly care for the well being of others. Many times we want to help so much that we forget that the problem is the client’s and not ours. One of the things we rarely do is directly ask clients how they are going to deal with their resistance. Yet, this can be a very effective approach, particularly after rapport is established and the complexities of the situation have been discussed.
The effectiveness of this approach lies in the fact that it clearly places the problem in the hands of clients and, at the same time, gets directly at the heart of the issues that need to be overcome. Even indirect statements regarding how clients propose to address their concerns are important. This is because such statements establish boundaries around problem ownership while addressing the idea that clients have to deal with struggles within themselves. Keep in mind, however, that this approach will be virtually ineffective if a mutually agreed upon goal has not been established and the perplexities of the problem have not been processed. Example statements that directly inquire of clients how they are going to overcome their resistance follow.
"Please provide me with some of your ideas about how you are going to deal with your lack of trust toward others."
"As you sit here discussing your desires, have you thought about how you are going to deal with your own reluctance to discuss your concerns with…?"
"Help me to understand how you are going to overcome your struggles to…"
Related to directly asking clients how they are going to deal with their resistance is the approach of asking them for guidance in how to move forward in the session. Here, we are asking for their facilitation with the task at hand.
"Tell me how we might move forward from here."
"Help me to understand how you might best talk about and approach this issue."
"Give me an idea of how you would like to begin talking about your current reluctance to address …"
Many times such statements are followed with "I don’t know." When this happens, proceed to the approaches to dealing with "I don’t know" presented in Chapter 8.
Explain the Limits of Therapy
Therapy has its limits. It is a good practice to present the limits of therapy to clients that insist on unattainable goals. Although there are a number of ways to present the limits of therapy, I have found that a discussion based on William Glasser's ideas is most effective. Glasser asserts that there are three things that we cannot control: accidents, genetics, and other's behavior. Although I generally agree with this position, there are some alternative perspectives to consider.
We cannot change accidents, yet we can change our reactions to them. Interestingly, modern science has allowed us to change a number of genetic characteristics, particularly with regard to physical appearance. But, by and large the person behind the face lift is the same still. And although we cannot directly change others, we can possibly influence them. However, in attempting to influence others and the way they respond to us, we must genuinely change the way we respond to them. Note the limits of this idea. The first limit is that we must genuinely change how we are acting. Temporary or artificial change is not effective. We can not fake it. It must be real change. The second limit is that, even if we genuinely change, there is still only the possibility of influencing others. There are no guarantees that others will change as a result of our change. These points notwithstanding, Glasser's premises ring true for the most part.
As noted, a common unrealistic goal is for clients to try to change another person without making genuine changes in themselves. Based on this scenario, a dialogue about the limits of therapy may go something like this:
"As I listen to your struggles, it is only fair to you that I take some time to present the limits of therapy. This is because I do not want you thinking that you can accomplish something through working with me that you cannot. I do not want you wasting your time and money.
There are three things that none of us can control: accidents, genetics, and other's behavior. From what you have been telling me, you very much want to change the behavior of another person. However, if another person does not want to change, you cannot make him/her. The good news is that even though you cannot change another's behavior, many times you can influence his/her behavior. In order to do this, though, you must genuinely change your own behavior. When you genuinely change your behavior it has a significant impact on others who must then decide if they want to change in response to your changes. Recognizing these limits, are you willing to genuinely change what you are doing in order to see if it might have an impact on ___________? If so, there are unlimited possibilities of what you might try."
Such a dialogue typically shuts down unproductive complaining by clarifying the rather obvious limits with which we work. It also frees the therapist from feeling overly responsible for client change. In addition, it provides a point of reference that can be referred back to when the client again begins to present unattainable objectives. By referring back to these limits, the therapist refocuses the session on manageable client change.
Similar statements can be constructed around the limits of therapy with regard to accidents and genetics. The major theme being that we cannot change accidents or genetics, only our reactions to them.
Acknowledge Your Contributions to the Lack of Progress
Moursund and Kenny (2002) point out that you can always acknowledge your role in clients' lack of progress. You might openly discuss what you have done that you now recognize as inappropriate relative to clients' personalities and problems. Such a conversation would likely lead into a discussion of the therapeutic relationship and areas that are of concern to clients. All of this in turn would lead to a discussion of better ways to approach resolving problems.
This approach offers several additional benefits. Acknowledging your contribution to a lack of progress will be unexpected. Most likely clients are blaming themselves for a lack of progress and this will remove some pressure. A discussion of the pressure to change may emerge. If you have made errors in your approach, you model discussing things openly as you correct your errors and demonstrate taking responsibility for your actions. This in itself may be of much benefit. If the lack of progress is the result of clients' inaction, such an approach may result in clients feeling uncomfortable that you are taking responsibility for their reluctance to change. This discomfort (likely guilt) may result in clients doing the socially correct thing and claiming responsibility for their inaction. A discussion of yet-to-be-addressed reasons for the inaction might follow, which could then address the newly emerging concerns about change.
The unique benefit of this approach comes from the fact that it is the consummate model of the necessary steps of the change process. You openly state your errors, take responsibility for them, address needed changes, and openly work to implement these changes as you seek feedback as to how they are working. The impact of such modeling on the therapeutic relationship and process can be quite meaningful. Depending on the client and the level of rapport, an open discussion of the above steps of the process of change may be helpful.
After Much Time and Consideration, Confront
Confrontation clearly has its place in counseling. I fully support its use when appropriate. However, with resistant clients, confrontation must be handled with care. The reason that confrontation must be handled with care is that, if done too early and too often, it can promote resistance. This is because confrontation provides clients a powerful stimulus to resist against. Thus, the position taken here is that confrontation should be a last resort approach because, if it backfires, your work is even more difficult.
With most clients, certain elements should be in place before confrontation is employed. Good rapport should be well-established. There must be a level of respect that has been earned. The critical issues should be well processed. The techniques previously suggested in this manual should be exhausted to a large extent. In other words, it should be clearly established, though unspoken, that clients are unreasonable, and that the only alternative left for you is to directly confront them on their unwillingness to make changes. Clients may have even reached a state of wondering why they have not been confronted. When the noted elements are in place, what have you got to lose by confronting? When the right to confront has been well-earned, confronting clients with a well-thought out explanation can be very therapeutic.
In instances where much respect has been earned, clients may secretly desire to be confronted. Indeed, some people will lose respect if they are not confronted about their ambivalence and hypocrisies. With such clients, failure to confront may increase resistance. What an interesting paradox and departure from most of what has been offered here! Yet, such paradoxes are what make the therapy business so complex and interesting. Each client must be considered within his/her own context. However, keep in mind that the level of confrontation that is appropriate in latter sessions is likely not appropriate in initial sessions. The decision to confront is complex and deserves much consideration.
There are two common mistakes that are made with regard to confrontation. The first is to confront too early and the second is to confront too often. Both are errors because effective confrontation is always dependent on careful timing. Although timing is important for virtually every technique, to be meaningful, very few techniques rely on timing to the same degree as confrontation. Poorly timed confrontation runs the risk of severely hindering the therapeutic process.
As noted elsewhere, the problem with confronting too early is that rapport may not have reached a level that includes the earned respect necessary for confrontation to be effective. The right to confront must be earned over time, it is not an inherent right of therapists—no matter how many clients you have seen with similar problems. Another problem that arises from early confrontation is that the initial issue is rarely the "real issue." Likewise, the initial reasons for resisting are often just "surface reasons," and deeper reasons that carry more significance have yet to emerge. Thus, premature confrontation may preclude the emergence of more significant issues that are critical to genuine change. When the real issues emerge and the deeper reasons for resisting are addressed, surface issues typically dissipate. Early confrontation may throw the entire therapeutic process off course.
The problem with excessive confrontation is that the impact diminishes with each reiteration. When repeatedly confronted, clients inevitably desensitize to the potential therapeutic impact. Those who are fond of consistently confronting remind me of parents that yell and threaten their kids every time they attempt to discipline. It is no wonder such children are oblivious to the threats and yelling. Humans tend to desensitize to almost any form of redundant stimulation. This is why people who live by airports eventually do not hear the jets as they come and go. In order to have impact, confrontation is best used sparingly. As such, when it is employed the uniqueness of the interaction, in and of itself, carries significance.
Many times therapists in time-limited settings resort to early confrontation because of perceived or real pressures to make headway quickly. Drug and alcohol treatment programs often fall into this category. Many chemically dependent clients are in a precontemplative stage and have little or no outward recognition of a problem. Further, their level of denial is so great and the lure of alcohol or drugs is so strong, that they have great difficulty developing emotionally compelling reasons to change that are stronger than the addiction. These factors frustrate therapists and result in diminished patience which leads to early and repeated confrontation. The result is that clients often become more deeply embedded in their precontemplative position because of inappropriately timed confrontation.
I do not know the experience of others, but my experience is that people do not genuinely change until they decide to change. Likewise, people do not change until they have an emotionally compelling reason to change that comes from within. Confrontation by their therapist does not singularly constitute a genuine emotionally compelling reason to change. Insight into the problems in one's life and the development of emotionally compelling reasons to change that originate from a well-constructed therapeutic dialog, do promote genuine change. There is a fine line between helpful and harmful confrontation. Be careful with this one.
There is a commonly used technique for confrontation that avoids pitting therapists against clients. What is done instead is to present the confrontation as if it were coming from a third person not present. Thus, the therapist might lead into confrontational material with a statement such as, "I could image if others were listening to this conversation that they might be thinking that…." You could even enlist another hypothetical therapist with a statement such as, "While I am not sure of my position on this, I do know other therapists who at this point would say that…." Many times clients will inform therapists of friends who have confronted them about their behavior. In such cases you might figuratively bring the friends into the room with a lead in comment such as, "You know, if your friends were here listening to this, my suspicion is that they would be saying to you that…." This indirect style of confrontation can be effective at delivering confrontational material. The beauty of it is that it pits the client against a third party who is not present and avoids pitting the client against the therapist. The use of this approach is, of course, dependent on the unique dynamics of the situation at hand.
Sometimes clients are just not ready to do the work of therapy. Perhaps they thought the process would be a magical, painless procedure that would mystically change their life. Regardless of the reason, there is a time to confront clients on their readiness to do the work. A colleague once told me of such a situation. She had been seeing a client for some time. Rapport was established and much had been processed, but little was actually being accomplished. After careful consideration and consultation, she told the client that she did not perceive him as ready to do the work of therapy. She politely explained that she had no evidence that he was ready for the hard work and rigors entailed in the therapeutic explorations necessary for success. The client was instructed to go home and contemplate if he was willing to do the work. No appointment was reserved for the following weeks. If the client wanted an appointment he was to call and schedule it. Approximately two weeks later the client called and made an appointment. Upon seeing the therapist again he said, "You were right, I was not ready to work. I am now, let's get to work."
Therapeutically Surrender to the Client
This idea is comes from Don Durkee, who uses this approach when he has exhausted all of his best approaches and techniques. After his best efforts with highly resistant, frustrating clients, Don openly surrenders. He tells clients that they have exhausted his tool box of ideas and that he gives up. This is all done very frankly and seriously, but without a tone of chastisement or criticism. It should be done more as a statement of fact. You do not, however, tell clients that their sessions are concluded. Instead, you offer to keep working with clients, but explain to them that they have to take the lead and direct the session. Thus, the option to continue and proceed is dependent on clients taking control of how to proceed and the direction to take. You are openly declaring that you are in a powerless position.
Clients now have two choices. The first is to terminate. If they do, it is a sure sign that their desire for change is minimal. If they decide to continue, they must take a more active lead in the direction of the counseling.
In a sense, this is a paradoxical approach. The difference from other paradoxical techniques is that it is not merely a technique, it is a genuine position that you are presenting. The key to the effectiveness of the technique is to not allow clients to suck you back into an active role, and thus, provide them with something against which they can again resist. You must be vigilant in preventing the gradual shift into an overly active role. Remain passive, let clients do the work.
You take people as far as they will go, not as far as you
would like them to go.
If You Have Done Everything in This Manual That is Fitting with No Progress, Fire the Client
Let’s face it, there are people who are masters at using the current mental health system to continue their abuse of the generosity of others. As counselors we often beat our heads against the wall in an attempt to get such individuals help, only to meet with continued frustration. With such clients we tend to forget that, "The essential responsibility for change is the client’s" (Cooper, 1995, p. 63). With so many people in need, it is better to focus our energy on those genuinely desiring help than to have our energy drained by those whose only desire is to maintain the status quo. Although it should be an extreme last resort, there is a time to fire your client.
We have trouble with the concept of resistance. It implies the therapist ought to do something about it.
Whitaker & Keith
Other Issues, Thoughts, and Suggestions
Dealing with Resistance in a Managed Care Environment: Arguments for Thorough, Effective Approaches
A managed care executive dies and goes to heaven. At the pearly gates he comments to St. Peter that he had worked in managed care and was a bit surprised that he was being admitted into heaven. St. Peter responded, "There's no mistake, you can stay three days."
In my seminars someone usually comments on the perceived difficulties of using the approaches presented in this manual within a managed care environment. The difficulty arises because of pressure to achieve results in a limited number of sessions. Ideas presented here such as slowing the counseling pace, not offering obvious suggestions, allowing treatment goals to emerge from dialogue, etc. all appear precarious when therapists are pressured to generate change quickly.
In response to such comments, I point out that the approaches suggested here are for highly resistant clients. If clients are cooperative and motivated, it may be more efficient to use direct approaches that actively lead toward solutions. However, if clients are resistant, then approaches that pressure them to change are likely to increase their resistance even more. If resistance to change is increased, then the insurance company's money is being paid to make clients' problems worse. Thus, pushing clients may result in an even more inefficient use of managed care money. With the approaches presented here, even if no immediate change is realized, you are not likely to increase resistance. Further, you may plant the seeds necessary to foster change when problems are approached again in the future. Sometimes this is all you can do, and it may very well be worth the insurance company's money.
A long-standing ethical principle for all forms of treatment is, "above all, do no harm" (Kitchener, 1984). If pushing clients creates or increases resistance, it could be argued that you have done harm. To honor the "do no harm" ethical guideline, it is imperative that the therapeutic process does not intensify clients' resistance to a level that makes the possibility of improvement less likely.
I have seen little evidence that health insurance companies have an understanding of the complex dynamics that must be maneuvered and finessed in order to promote change when working with mental health problems. However, just because insurance companies are uneducated regarding the dynamics of change, does not mean that we, as therapists, should disregard all that we know in an attempt to appease an overwhelmed system.
I would argue that some managed care environments are harmful relative to the resolving of mental health problems. The arguments for this position are as follows. First, time limited therapy often results in excessive pressure from counselors to push clients toward change that they are not ready to accept. Naturally, clients resist this change and, thus, prolong taking the steps necessary for resolution.
Second, clients are often not allowed more sessions unless they display additional or worse symptoms than initially presented. Once clients (and therapists) recognize that prolonged or more serious symptoms are necessary in order to be granted ample treatment time, such symptoms are likely to appear. Thus, clients are reinforced for getting worse and therapists are reinforced for observing more negative symptoms! To make matters worse, therapists may find that they inadvertently reinforce negative symptoms in order to justify extending treatment time. Systems that function with this logic provide secondary gain for problem continuation. This is a classic example of a system that helps create the problems it was supposedly designed to eliminate.
Third, because treatment time is limited, problems are often band-aided and clients sent on their way, only to return at a later date with the same issues. This continuous band-aiding keeps clients in the system, returning with issues that were never dealt with thoroughly. Band-aiding ultimately results in excessive costs.
Research has demonstrated that psychotherapy can be very effective when properly administered. Proper administration of therapeutic techniques requires individualized schedules of treatment that comprehensively address the issues at hand. Mental health problems have never been responsive to band-aiding. Research that argues these points and supports the efficacy of psychotherapy and the benefits of individualized treatment schedules can be found by reading Miller (1996), Seligman (1995), and Does Therapy
Common Characteristics of Clients
My wife, also a psychologist, and I often take walks and discuss client dynamics. During one of these walks we began discussing the common characteristics that frequently appear across clients. I have included some of these characteristics below. In addition, I have included a brief discussion of common therapeutic processes designed to counteract and remedy the unproductive attributes. The application of approaches and techniques which overcome the characteristics below are what set therapeutic dialogue apart from everyday, lay attempts to resolve issues. Hopefully this discussion will provide knowledge that will help in resolving resistance. Keeping the below points in mind and being a caring person are, to a considerable degree, what good counseling is all about. The techniques in this manual are worthless without an understanding of what follows. These characteristics are presented in no particular order.
1. Clients inevitably present problems in the negative. They tell what is wrong in their life. They state what they don’t want. I have never heard a client initially present his/her problems in the positive—from a position of what is wanted. Good counselors are aware of this actuality and strive to discover and clarify what is desired. We recognize that it is critical for therapists to create discussions that ascertain the want side of presenting problems. All effective therapeutic dialogue, at some point, creates a picture of clients' lives as they would like to be. We understand that you cannot reach a goal you do not have.
2. Clients are frequently in "vagueville." They use vague, general terms to describe their problems. They lack clarity regarding their current dilemma and what they want. Thus, we should constantly strive to clarify what is occurring and what is desired. To do this we use and spend the time discovering the most precise terms possible to describe clients' current worlds and desired worlds. We recognize the power of language and power that comes with well-defined parameters. Once precise terms are discovered, we incorporate them into our dialogue on a regular basis as a means to provide continued clarity. When problems metamorphosize and better terms are discovered, we adapt and use those terms. We are ever cognizant that clients are empowered through clarity.
3. Clients are quite often unsure about their feelings. They do not know or use precise terms to describe how they feel about their situation. Contrary to typical everyday discussions of problems that focus on providing advice, counseling is the place where considerable time and effort is used to clarify feelings and discover precise terms to describe what is felt. We provide a safe environment to recognize and discuss feelings that are not socially acceptable to openly discuss. We recognize that, through a discovery of accurate feelings, emotionally compelling reasons for change emerge. Clarity of feelings provides motivation for and clarity of actions.
4. Clients are ambivalent about change. This is why they are seeking a counselor. If they were not ambivalent, they would likely change on their own without our help. To a large extent, the therapist's job is to help clients resolve ambivalence. Thus, we openly approach and discuss ambivalence. We accept and are comfortable in the midst of contradictory feelings. We allow discussions of topics that are not always socially acceptable and provide a forum to address what is often thought and not said. We provide a unique environment where ambivalence is embraced as a necessary part of life. We understand that ambivalence is not resolved by avoidance, but by experiencing. We provide the safe environment needed for experiencing ambivalence and moving toward resolution.
5. To some degree all clients have lost faith in themselves to resolve problems on their own. Although it is a long-standing maxim that all clients possess the solution to their problems, clients have momentarily lost their ability to discover this inner solution. We are cognizant of the vulnerability of clients as they enter counseling and, therefore, never take advantage of this vulnerability. Thus, we work to create a healthy independence and interdependence in clients and avoid fostering dependence. We strive to build self-confidence. We place the responsibility for change with clients and point out clients' contributions to their growth. We use language that restores faith in self-direction. We provide feedback that reinforces clients' insights and changes. We attribute success to clients' work and not to our own techniques and skills. (Recognition of our skills is reserved for private conversation with our colleagues.)
Related to this concept is the idea that, when one enters into a counseling relationship, there is recognition of the need for another human being to enter into the equation of life as a means of gaining the knowledge necessary for growth. Seeking counseling is, to some extent, the recognition that we are social beings that are only healthy when we allow ourselves to enter into relationships with others. Thus, we are aware that the counseling relationship is the most vital component of the therapeutic process. We take the time needed to build helpful relationships and do not move forward until essential levels of rapport are in place.
6. Clients will inevitably, in some way, invite you to take their pain. Because we understand that we cannot truly take someone else's pain, and that attempts to do so are contraindicated, we respectfully decline the invitation. In lieu of declining this invitation, we provide a supportive environment in which clients are safe to experience their pain. We empathize. We understand that the experience of pain is frequently critical to reach resolve. We do not run from pain, we allow its full expression.
7. Most clients think that others cannot understand their problems. Clients typically see their situations as unique. They see their situations as so unique that they must seek counsel from an expert, and they often doubt that even the expert can understand. Thus, we empathize. We constantly provide feedback that lets clients know that we are attempting to understand their (unique) problem. We normalize when appropriate. We use our expertise to let clients know when they are not alone in their struggles. Even though it has often been said, we remain aware that people do not care how much you know, until they know how much you care.
What you resist, persists.
When You Know You are Not Their First
Perhaps this might be a good place to comment on the need to determine if clients have seen other therapists and the effectiveness of previous approaches.
Frequently, clients will have seen at least one other therapist. Some clients will have seen a host of other therapists. Such information is vital and should always be a component of initial interviews. Much time can be saved and much resistance circumvented by utilizing the information acquired about previous therapists and their approaches.
If clients have been counseled by others, find out how things went with the previous therapist before proceeding with your usual approach. If previous therapy went well, find out what worked. If previous therapy went poorly, find out what did not work. This is a time to listen intently without judgment. Often clients will reveal critical information regarding their view of the world, counseling, and change processes. The lessons learned by clients from previous therapy can be gleaned by you to guide you and clients in creating a viable therapeutic approach. As you learn of previous successes and failures, you can immediately adapt based on what clients have presented.
It goes without saying that the professional should also attempt to obtain a release to speak with former therapists in order to gain any additional information that might by useful. If clients refuse to provide such a release, this in itself may be important, depending on the circumstances.
Knowing that you are not the first, it would be a therapeutic mistake to proceed without a discussion of this part of the client's history. Sometimes much resistance can be avoided by following good professional practice procedures.
It is my sincere hope that the ideas in this book will help those who have chosen to accept the challenges of practicing effective therapy. However, there is nothing like extensively studying and writing about a topic to make one realize the flaws and inadequacies of current knowledge. Upon completing this manual, I find myself more aware than ever that all theories and techniques are just approximations of what we are striving to understand and implement. All theories and techniques fall short of accomplishing what we ultimately desire. Those presented here are no exception.
In the midst of the shortcomings, I am confident that, when applied properly, the ideas presented have much utility and will help many therapists and clients. Yet, there will always be clients whose problems and personality are of such a nature that little can be accomplished with techniques alone. With such clients, change occurs as a result of the therapeutic relationship, external circumstances, time, and perhaps some luck.
As I stated at the beginning, you owe it to yourself to study resistance. You should do this for your clients as well as for your own mental health. This manual is a good place to start, but it is not a good place to end. There is an ever-increasing collection of material being written in the field of therapy much of which offers new and innovative approaches to overcoming resistance. Those desiring more detailed information might refer to the references at the end of this manual for sources of additional study.
References and Suggested Readings
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Bischoff, M. M., & Tracey, T. J. G. (1995). Client resistance as predicted by therapist behavior: A study of sequential dependence. Journal of Counseling Psychology
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. New York: Harper & Row.
Copyright Clifton W. Mitchell, Ph.D.
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