How Helpful Is Helpful?
When I made this statement, I became the voice of Sam’s resistance. I call this technique the Externalization of Resistance, because you externalize the patient’s inner voice committed to maintaining the status quo. I also call this Sitting with Open Hands, because you aren’t trying to grab or persuade the patient to work with you. Instead, you verbalize all the reasons not to change, and you’re willing to let the patient go. If you do this skillfully, with warmth, logic, and compassion, patients won’t have to argue for the resistance anymore, because you’ve made the case for them, Instead, most will usually jump to the other side of the argument and suddenly become the voice that argues for change.
That’s what happened here. Sam replied, “Yes, but aren’t we supposed to fill out the Disadvantages column? Isn’t there a downside to the constant panic and rage attacks?”
I asked Sam if he could list some disadvantages in the right-hand column of the CBA. What price was he paying to maintain these symptoms? What was the downside?
Sam came up with one disadvantage right away. He said that he wasn’t convinced that the anxiety really kept him safe. He said that maybe the bad guys can smell it when you’re scared and are even more likely to mug you. By contrast, if you’re confident and alert, you may actually be safer.
I told him to write that down in the Disadvantages column, but continued to play the voice of his resistance. I reminded him that even if the panic attacks didn’t protect him, he still had every right to be angry: his anger showed he was a man and not a mouse.
“Yeah, but I’ve got the right to be happy, too,” he answered immediately. “And those guys don’t even know I’m angry. They’re probably in Florida robbing 7-Elevens by now. I’ll probably never see them again. So I’m the only one who’s suffering. I’m actually punishing myself.”
I asked him to record that in the Disadvantages column as well, but continued in the role of his resistant self, and said, “Yes, that may be true, but if we could make the symptoms go away quickly, wouldn’t that trivialize what happened? After all, it was dreadful, and your feelings of rage and panic are absolutely justified.”
Sam argued, “Yeah, but if I could quickly overcome those feelings, I could get my life back and stop feeling miserable 24 hours a day.” He added this to the Disadvantages column.
Notice that the more I verbalized all the reasons not to change, the more Sam became convinced that he really did want to change. This was the opposite of the “helping” or “rescuing” role that had gotten me into hot water at first. But the helping role was the one I’d been trained for and felt most comfortable inhabiting. The helping or rescuing role may be a role that you occasionally get trapped in as well. When therapists ask me for help with cases they’re stuck with, it’s nearly always a circumstance in which the patient is complaining, but not really asking for help, or the patient is asking for help, but the therapist hasn’t brought the patient’s resistance to conscious awareness and pointed out all the reasons not to change.
Finally, I asked Sam to assess the advantages of feeling constantly angry and panicky against the disadvantages on a hundred-point scale. Were they 50/50? 60/40? 30/70? Sam decided that the disadvantages outweighed the advantages by a significant margin, so he put 35 in the circle under the Advantages column and 65 in the circle under the Disadvantages column at the bottom of the CBA.
At this point, the antagonism disappeared and Sam asked about the tools I’d referred to earlier. Then I just used simple cognitive techniques, such as the Daily Mood Log, Identify the Distortions, Examine the Evidence, Externalization of Voices, and Acceptance Paradox, along with exposure techniques such as Cognitive Flooding and Memory Rescripting, and his symptoms completely disappeared within a few sessions. However, if I hadn’t dealt with Sam’s resistance, I’m pretty sure that all the techniques in the world would have been ineffective, and he probably would have dropped out of treatment.
With time, I began to notice the same phenomenon, in varying degrees, with nearly all of the patients I was treating, so I called this phenomenon Outcome Resistance. In the simple terms, Outcome Resistance means that clients will resist or fight against the therapist’s efforts to help because, on some level, they’re afraid of or don’t even want a good treatment outcome. In most, if not all, cases of anxiety, the Outcome Resistance results from Magical Thinking, the irrational belief that the anxiety, while painful, is protecting clients from something even worse.
You can see Magical Thinking in every type of anxiety disorder, including generalized anxiety disorder (GAD), panic attacks, agoraphobia, crippling shyness, performance anxiety, OCD, PTSD, or even a simple phobia. For example, let’s say you’re treating a woman with GAD. She makes herself miserable with constant worrying about her children or husband. She worries that her children may get into an auto accident and be killed after a party with friends, or she may worry about her husband’s health or job security. Why does she resist treatment that can keep her from tying herself in knots from irrational worry? Here’s one possibility that I’ve seen numerous times: she may secretly believe that her worrying protects her family and keeps them safe, and that if she suddenly stopped worrying, they would get killed. She may also believe that the worrying is what a good wife and mother is supposed to do. It’s an expression of her love.
We typically think of resistance as something pathological. We’re taught that some patients are committed to their symptoms because of a neurotic addiction to misery and self-pity, or because they like being in the victim role, or because of “secondary gain,” such as getting attention from others. Such assumptions are formulaic, applicable to anybody, and not related in any specific or compelling way to the individual patient you’re treating. Worse, they’re condescending, even insulting, suggesting that the patients are shallow, selfish, manipulative, and whiny.
Now I understand resistance as displaying something positive about the patient and his or her values, representing a kind of personal integrity, and consciously try to make my patients proud of their resistance. Paradoxically, this seems to make it easier for them to change and far more motivated to work with me.
In retrospect, this seems obvious to me, but therapists find it extremely hard to assume this perspective, as I did myself at first. We’re trained to think of symptoms as bad, pathological artifacts that need to be eradicated. Because we have such a strong desire to jump in and help—get rid of that bad thing!—we have a hard time imagining that symptoms often serve a real, even honorable, purpose in a patient’s life.
Obviously, most of what we call resistance to therapeutic change, for want of a better word, is to a greater or lesser degree unconscious. Patients aren’t usually slyly manipulating us or engaging in conscious strategies of refusal for some unspecified gain, although occasionally that can happen. For example, many drug addicts are skillful at manipulating doctors so they can get prescriptions for opiates. But most of the time, patients’ initial reluctance to get with our program isn’t from some primordial stubbornness or neurotic desire to suffer, but rather a manifestation of the patient’s core values.
For example, a depressed man may beat up on himself because of his failures in his career and his failures to be the kind of husband and father he wants to be. But in his misery, he’s really saying, “I have high standards, and I don’t want to settle for second best. I intend to hold myself accountable for the failures in my life. I won’t let myself off the hook so easily” So the shame, worthlessness, and relentless self-abuse may actually reveal something admirable and positive about him—a sense of integrity and humility, a desire to do better with his life.
If this is true, then, when we try to override the patient’s resistance, we may undermine therapy. For one thing, many patients will just be pissed off and leave, as Sam almost did, because we haven’t “gotten” them on some deep level: we haven’t comprehended the real reason for their suffering. We’ve failed to recognize that resistance to change may reflect something positive or beautiful about the patient and his or her personal values. By respecting and honoring their refusal, we give breathing room to the resistance, and in doing so, shift their energy from fighting us to fighting for themselves in a far more genuinely therapeutic way.