As therapists, we want nothing more than to help people who are suffering—help them feel better as soon as possible and help them, after therapy, live more emotionally satisfying lives. But that usually requires helping them change—change their dysfunctional patterns of thinking, self-destructive behaviors, and self-defeating ways of relating to others. Since just sitting with them and commiserating with their misery, week after week, month after month, may not result in any tangible change, most of us naturally want to engage in more active forms of helping. So we try to persuade our clients—compassionately, gently, kindly, patiently—to engage in this and that tool, technique, exercise, or homework assignment, which we know would help, if only they’d just try it.
Ah, resistance! Haven’t we all, at times, blamed our clients for it, suggesting that they secretly don’t want to get better and are, in some way, purposely sabotaging us? But what if the problem is really with us, that we’ve become so single-minded in our attempts to be helpful, that we tend to ignore the aspects of our clients’ inner ecology triggering the resistance? And what if the negative thinking patterns, feelings, and behaviors that keep them stuck have powerful, unconscious advantages serving vital, even life-preserving purposes? Finally, what if their resistance to change reveals something positive, beautiful, and even healthy about them—something that we’ve overlooked? If so, we might want to view resistance from a radically different perspective.
How would this work? Consider a client who’s struggling with extreme anxiety, depression, hopelessness, and rage after experiencing a severe trauma, such as being abused. If the client is still suffering from those symptoms after years of therapies and therapists, we may feel the client is resistant to our help; yet, as we know, holding onto her anxiety and hypervigilance makes perfect sense as the best way to avoid being abused again. In addition, feelings of depression and rage are quite appropriate after going through that experience. And her hopelessness about recovery may reflect her past treatment failures and protect her from further disappointments if our efforts also fall short. If we don’t bring this unconscious resistance to conscious awareness, we’re risking clinical failure.
This should immediately ring true for most therapists. But what many may not realize is that if we can learn to put this unconscious resistance front and center in our clinical work—even before revealing our fabulous toolkit of change-oriented techniques—we can lessen or even eliminate our clients’ resistance to help, making their collaboration with us far more enthusiastic, thus speeding up complete recovery.
In workshops, I frequently ask therapists what they’ve been taught about therapeutic resistance in graduate school or in textbooks. Many therapists say that clients cling to their symptoms because of secondary gains, like support from others or disability income. Others say that clients resist help because they’re afraid of change; after all, the devil you know may seem better than the devil you don’t.
Although these ways of looking at resistance may sometimes contain a grain of truth, they’re not particularly helpful. But what if we could reframe the client’s resistance as something positive, healthy, and helpful, revealing something honorable about his or her core values? If so, then my first goal as a therapist might be to explore the many good reasons a client might have for not changing. This shift in therapeutic tactics has required a massive internal change in how I think and function as a clinician, but it’s revolutionized my therapeutic experience—and I’m now seeing recovery at rates I’d have thought impossible as recently as 10 years ago.
I call this new approach TEAM-CBT. TEAM stands for Testing, Empathy, Agenda setting (paradoxical), and Methods—the four most important keys to all psychotherapy, regardless of the approach you might endorse. I’ll explain these elements as I applied them in a live demonstration I did recently at a workshop on the treatment of trauma.
The volunteer from the audience, an Asian American mental health professional in her late 50’s named Christine, had been the victim of three decades of violent abuse at the hands of her ex-husband, a San Francisco real estate developer. Early on in the marriage, she’d desperately wanted to take her twin daughters and leave, but he’d threatened to murder all three of them if she ever tried. It was horrifying to hear her describe trying to muffle her screams during the beatings so her daughters wouldn’t hear. By the time her children had grown, she’d felt too frightened and demoralized to save herself. Eventually, he decided he wanted a divorce and left her. Years later, even as she was telling her story to the audience, she said she still felt so humiliated and afraid that she simply wanted to run from the stage and hide.
At the time of our session, she’d been divorced for over a decade, but was still severely depressed, anxious, and angry—in spite of more than a decade of psychotherapy involving a vast array of approaches from numerous clinicians. Over the years, she said, therapy sessions, no matter what their clinical orientation, usually made her feel better for a short time, but the effects never lasted, and she rarely experienced much progress.
Before our session began, I’d asked Christine to record her negative thoughts and feelings on a form called the Daily Mood Log (DML), a CBT tool that helps clients pinpoint their negative thoughts and feelings at one specific moment when they were upset. I reference the DML during therapy sessions, and encourage clients to work with it between sessions as part of their psychotherapy homework.
At the top of her DML, Christine briefly described her upsetting event as “sitting in this workshop thinking about my decades of sexual abuse by my husband.” Next, she circled and rated all her negative feelings—such as sad, anxious, guilty, worthless, lonely, hopeless, angry—on a scale from 0 (not at all) to 100 (extremely severe). Almost all of Christine’s ratings were at either 90 or 100. I also had Christine record her negative thoughts on the DML and indicate how strongly she believed each one on a scale from 0 (not at all) to 100 (completely). Here are a few examples:
- I’m not safe. – 100%
- I can’t trust men. – 95%
- I should’ve stopped the abuse. – 90%
- I victimized myself. – 100%
- I must be defective. – 90%
- I lived a lie and shouldn’t have. – 100%
- The therapists in the audience will judge me and think, How can she be a therapist and help others when she can’t help herself? – 100%
Earlier in my career, however, I’d then have encouraged her to challenge her negative thoughts, using a variety of powerful CBT techniques. Often that works, but sometimes we run into resistance, rendering all our efforts ineffective. In fact, I’ve learned over and over that it’s easy to overlook hidden sources of resistance precisely in clients who outwardly seem as motivated as Christine. So instead of rushing in to help, it’s often better to take a different route: focus on some really good reasons not to change.
This is called paradoxical agenda setting (PAS), and as the A of TEAM-CBT, it’s the intermediate step between the empathy phase of the session, when the therapist compassionately listens to the client’s venting, and the methods phase at the end, when you work toward change together. In PAS, you bring the outcome and process resistance to conscious awareness and work to reduce them. If you do a god job of it, the methods phase can be remarkably fast and easy. So after empathizing with Christine as she told her story, I asked her if she wanted some help beyond my listening and providing support; and if so, if this would be a good time to roll up our sleeves and get to work. She said yes to both.
“Great,” I said. “I want to check something out before we get to work. Let’s imagine that there’s a magic button right here on the desk. If you press it, you’ll be instantly cured, with no effort, and all your negative thoughts and feelings will completely disappear. You’ll be flooded with feelings of joy. Would you press that button?”
Like nearly all my clients, she responded to this question with an enthusiastic yes. Then I explained that while I didn’t have a magic button, I did have some pretty powerful techniques we could use. And while I couldn’t promise any specific outcome or miracle, there was an excellent chance she could experience great improvement tonight. However, I told her, I was reluctant to use those techniques.
“Why?” she asked, taken aback. I said it was because her negative thoughts and feelings might reveal some really positive things about her, and might even be helpful to her, so maybe we should think twice before making them all disappear, lest we throw the baby out with the bathwater. I suggested instead that we make a list of the positive aspects about her negative thoughts and feelings. This is called positive reframing; it’s a gentle, nonthreatening way to bring outcome resistance to conscious awareness. Positive reframing of negative thoughts and feelings is baffling to most clients at first, because they’ve been trained to think of their negative thoughts and feelings as “symptoms” of this or that “mental disorder.” Indeed, many therapists initially have trouble grasping it as well, since we’ve all been kind of brainwashed into thinking that psychiatric symptoms are bad, abnormal, or unhealthy. But once therapists get the hang of it, their clients catch on easily too.
In Christine’s case, I suggested that we start with her anxiety, reminding her that one of the negative thoughts triggering her anxiety was I’m not safe. “Let’s assume that you press the magic button and walk out at the end of this session feeling completely free of anxiety and safe,” I said. “Do you really want that? Can you think of some reasons why you might not want that to happen? Are there any benefits to your intense anxiety?”
Christine paused, looking puzzled. Earlier in the session, she’d mentioned that she’d recently flirted on several occasions with an attractive man and sensed there was some chemistry between them. But if she pressed the magic button and her anxiety suddenly disappeared, I suggested, she might let down her defenses prematurely and end up in another abusive relationship. After a moment, she responded, “So perhaps my anxiety keeps me vigilant.”
“You’re absolutely right. Write that down as number one on our list of positives,” I said, adding that her anxiety could even be thought of as an expression of self-love, since she’s protecting herself from being hurt again. She seemed to resonate with this and brightened up a bit right away.
I then asked Christine if there was anything positive about her intense sadness and depression, reminding her that if she pressed the magic button, these feelings, too, would disappear. Could she think of any reasons why that might not be a good idea? She drew a blank. “Why would I want to feel sad and depressed?” she wondered, especially since she’d been struggling for decades to make those feelings go away?
“Well,” I responded, “if you press the magic button, you’ll instantly feel flooded with feelings of joy and happiness. Do you want to feel happy and joyful about decades of horrific abuse?” With a little start, Christine suddenly understood what I meant. Yes, she agreed, maybe under the circumstances, feelings of sadness and depression were understandable and appropriate, even healthy. One by one, we did positive reframing with all of the negative thoughts and feelings on Christine’s DML.
Once we got on a roll, the positive reframing was pretty easy. We even addressed her fear of being judged by the therapists in the audience, suggesting that those thoughts showed her strong desire for good relationships and respect from her colleagues. With PAS, we see genuinely helpful and even healthy aspects to all of our negative thoughts and feelings. But here’s the main, unexpected point: once the therapist clearly conveys his or her understanding of why the client should not change, the resistance typically vanishes, and the client suddenly develops a tremendous desire to change! This is a paradox, for sure, but it has a powerful and predictable effect.
Christine seemed surprised by how much she resonated with what we came up with. She also seemed more relaxed and trusting. At this point, I said, “Christine, maybe it’s not such a good idea to press that magic button and make all of this negativity disappear. Let’s imagine, instead, that we had a magic dial, and we could dial down your negative feelings to a healthier level, instead of making them disappear completely. You could still have the benefits of them, but without being so totally overwhelmed and defeated.” Christine looked intrigued. “Let’s start with the anxiety,” I continued. “At the start of tonight’s session, you said you were 100 percent anxious. If we could dial it down to some lower level, just enough to keep you vigilant and protect you from doing something dangerous, how much anxiety would you need?”
She said she wanted to dial the anxiety down to 2 percent, which would be enough to keep her safe. I tried to persuade her to keep it at some higher level, like 30 percent, but she insisted that 2 percent was plenty. Notice how the paradox is continuing: I, the therapist, am arguing for more anxiety, and she’s arguing for less! When I use the magic dial, I’m making a deal with Christine’s subconscious mind, telling her that we’ll only lower each negative feeling to a level that she chooses and is comfortable with. That way, she’s in control, and I’m not doing something to her. She’s the one calling the shots, and I’ll be working for and with her.
Toward the end of our session, several therapists came up with tears flowing down their cheeks as they told Christine how grateful they felt to her for telling her story, how much the session had meant to them, and how strongly they admired her. Some described abuse they’d endured when they were growing up, or in their own marriages, and said her courageous work on stage made it possible for them to open up as well. After the session, many more of them sent her deeply moving emails. The next morning, Christine reported that she felt euphoric, almost giddy.
These changes were real and obvious to those who watched the session live. After all, she’d been in tears during the first half of the session, when she recounted the abuse, and was laughing and seemed overjoyed during the last half of the session. But that was more than six months ago. I contacted Christine recently to see how she was doing. Here’s what she wrote: “Dr. Burns, I’m a changed woman! I can easily form laser arguments against the negative thoughts that are more and more afraid to speak up. I’m doing well, as are many of my clients, thanks to our work!”
The Next New Thing?
Even as we march forward, it’s worth remembering that in the old days, psychoanalytically trained therapists tended to accept resistance not only as natural and inevitable, but also as a sign of progress, a signifier that therapy was on track. While few of us would care to revisit the days of analysis interminable, I think those old guys were onto something when they showed respect for the role of resistance. Of course, we now realize that many forms of resistance—as we saw with Christine—may be deeply embedded in a client’s moral and ethical system. To give them up for the sake of “feeling better” can seem like a betrayal of the truths we find noblest and most worthwhile.
Our field has had a bewildering proliferation of new therapies—a trend that will likely continue—and many of the methods that have been developed do work. But rather than jumping in to help our clients with this or that new or old technique, our mission in TEAM-CBT is first to cultivate a deep empathy for our clients’ fears and hesitations—and to help them celebrate and honor their “resistance,” so they can feel proud of their symptoms. Once we do that, we find that the resistance almost magically fades away, and the real therapy for change can begin.
This blog is excerpted from "When Helping Doesn't Help" by David Burns. The full version is available in the March/April 2017 issue, Round Hole, Square Peg: If It Doesn't Fit, Don't Force It.
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Illustration © Steve R. Dininno
Tags: 2017 | Anxiety | cbt | Challenging Cases & Treatment Populations | challenging clients | clinical hypnosis | cognitive behavior therapy | cognitive behavioral | cognitive behavioral therapist | cognitive behavioral therapy cbt | David Burns | Depression & Grief | Feeling Good | hypnosis | oppositional children | paradoxical agenda setting | resistance | resistance to anxiety treatment | resistance to counseling | resistance to therapy | resistance to treatment | Resistant Client | treatment resistant