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.
Of course, many clients do follow our helpful suggestions, and the resulting changes can often be rapid and dramatic. But what about those who seem to do everything in their power, subtly and not so subtly, to undermine our help? We make suggestions, explain proven techniques, reason with them, advise, cajole—to no effect. Regardless of their heartfelt renditions, session after session, of how miserable they are, how much they need our help, some clients simply won’t, or can’t, accept the help we’re offering.
We’ve all dealt with clients like this—the ones who “yes-but” us and consistently “forget” to do their psychotherapy homework. They may insist that we don’t understand, that we’re not helping—and the harder we try, the more adamant they become. Too often, therapy with these clients ends in a stalemate. The client drops out, feeling no better than when he first arrived, and the therapist is left feeling baffled, inadequate, frustrated, even defensive and angry, perhaps blaming the client for being “resistant.”
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 the Beginning was CBT
I left a research career in biological psychiatry in the mid-1970s so I could help develop cognitive behavioral therapy (CBT), an approach I found positively exciting compared to the relatively nondirective psychodynamic approach I’d been taught during my psychiatric residency. With the help of CBT’s array of practical, action-oriented, skill-building tools, many of my clients who’d spent years or even decades in failed treatments for depression quickly, almost magically, seemed to improve—even without medication. I described my conversion experience in Feeling Good, a book published in 1980. In fact, following years of promising research, CBT became one of the most widely practiced forms of psychotherapy ever developed.
Of course, it was great seeing so many clients recover so rapidly, but there were always some who didn’t. Karen, a depressed software developer from New York, was one of them. She was successful in her career, but constantly complained about her life and the men she was dating. I explained that I had many tools to help her overcome her depression and improve her relationships with men, but she just didn’t seem interested. When I encouraged her to pinpoint and challenge the distortions in her negative thoughts, or offered to show her how to improve her relationships, she angrily insisted that she shouldn’t have to change because they were jerks. She added that all I cared about were my Mickey Mouse techniques—not her. Although it may sound uncharitable, I admit that she did frustrate me.
Every week, Karen’s score on the Beck Depression Test remained unchanged, stuck in the extremely severe range. One day, at my wit’s end, I firmly emphasized that using the CBT tools and doing psychotherapy homework between sessions would be mandatory if she wanted to change her life. Bristling with hostility, she said between clenched teeth that if I ever asked her to do psychotherapy homework again, she’d commit suicide, and her body would be found with a copy of my book on her chest and a note that read, “He was my shrink!”
Feeling terrified and ashamed, I told myself that I was pushing too hard, and maybe if I just listened and provided enough warm and empathic support, she’d come around. But after two more years, Karen was still complaining bitterly and refusing homework, and was still just as angry, depressed, and lonely as ever. Eventually, she dropped out of therapy without any real improvement.Over time, I began to see other clients like Karen in my practice, because the ones who followed my suggestions and did their between-sessions work completed therapy after a relatively short time, leaving me with more and more long-term clients who resisted the CBT techniques I was offering. I was puzzled. I had so many treatment tools proven to be effective for so many clients, but some simply didn’t want to use them. What was different about these clients who were fighting me so hard? What was I doing wrong?At about this time, during the mid-1980s, many therapists inspired by CBT in the ’70s were beginning to experience disappointments too. In the early days, we’d expected that about 75 percent of our depressed clients would recover fairly quickly, but a growing number of controlled outcome studies were demonstrating that only about 50 percent of depressed clients improved significantly within 12 to 16 weeks. And the criteria for improvement were sometimes not that stringent. For example, a 50 percent symptom reduction would qualify, but many such individuals were, in fact, still quite depressed. And the other 50 percent of people in most of these studies didn’t even experience 50 percent improvement.
Of course, the authors of these studies didn’t usually spin it this way. Their claim to fame was that the effects of short-term treatment with CBT, like other forms of psychotherapy, were comparable to the effects of antidepressants. But to me this was condemnation through faint praise, because recent research by Irving Kirsch and others suggests that antidepressants are barely better than placebos, if at all. With all the creative proliferation of psychotherapies, both old and new, how could this be the case? And yet the outcome studies, as I read them, have pointed to very few impressive breakthroughs in treatment effectiveness. Now, I don’t believe therapists, regardless of therapeutic orientation, fool ourselves when we see our clients getting better, even transforming their lives; clearly, many of them do. It’s simply that while therapy can work amazingly well when it does, when it doesn’t, we don’t know why or what to do about it.
But far from being discouraged by this apparent logjam, I find it full of exciting potential—because if we can identify the cause of our failure, the blind spots that prevent us from using our own tools and skills to the best advantage, we might dramatically improve our treatment outcomes. So what if by discovering the missing link in treatment, that mysterious something that keeps us from being fully effective, we could help even more clients than we already do?
The Missing Link
As clinicians in private practice, we can’t do formal controlled outcome studies, but we can do process studies pinpointing variables associated with therapeutic success or failure. This type of research can help us understand how therapy actually works, thus leading to new and more effective treatment strategies. Jackie Persons, my former student, got me started with this in the 1980s. Since we were both collecting data on depression severity for every person we treated at every session, we decided to pool and analyze our data using statistical modeling techniques to see what we could learn.
Initially, most of the variables we tested didn’t pan out in any exciting or significant way. In one study of hundreds of patients at my Philadelphia clinic, for example, therapeutic empathy, as rated by patients, seemed to have some positive causal effects on recovery from depression, but the size of the effect was small. I also tested the effects of changes in self-defeating beliefs (SDBs), like perfectionism and dependency, on recovery from depression, but once again, the results were disappointing. While the correlation between clients’ self-defeating beliefs and depression was strong, as was the correlation between the decline of SDBs and mood improvement, no statistical evidence showed that changing their SDBs resulted in their improvement: they were strongly correlated, but not causally connected.
One day, I began to think about Karen, the software developer, and other similarly challenging clients whom I couldn’t seem to help, no matter how many techniques and methods I tried. Wondering again about the common denominator that linked them, I decided to test a proposition so obvious and basic I’d never even considered testing it. In a new study, I asked the question “Does homework compliance have anything to do with recovery from depression?” The answer was a resounding yes. In two separate studies involving hundreds of people treated at my clinic in Philadelphia, homework compliance appeared to have large and robust causal effects on recovery from depression. In fact, nearly all our clients who did reasonably consistent psychotherapy homework recovered or improved substantially during the first 12 weeks of treatment; in contrast, nearly all the clients who refused to do the homework failed to improve. Many of them got worse and dropped out of therapy.
Next, I developed what I called a Willingness Scale to identify the more resistant clients at the initial evaluation, before therapy even got started. I asked clients how likely, or willing, they’d be to engage in various coping activities if they were suggested by a friend or therapist, such as “talking things over with a friend” or “doing something I’ve been putting off.” I predicted that scores on this Willingness scale would reflect each client’s motivation and predict subsequent homework compliance as well as improvement in depression, when controlling for initial depression severity.
And sure enough, scores on the Willingness Scale did predict homework compliance, as well as the outcome of the treatment—and the causal effect was large. People with high willingness scores at intake did more psychotherapy homework and recovered rapidly; those with low scores did little or no homework and improved slowly, if at all. Now replicated in several studies involving outpatients and inpatients in different settings, willingness is, as far as I’m aware, the first variable in the world literature shown to have strong and consistent causal effects on recovery from depression.
Based on this finding, I decided to make some radical changes in the way I practiced. Instead of using more and more tools and techniques to try to help my more noncompliant clients, as I’d been doing, I decided to focus instead on trying to understand why they weren’t willing to engage in coping activities—in short, why they didn’t want to change and were resisting treatment.From my clinical work, I’d determined that there were two major types of resistance: outcome resistance and process resistance. Outcome resistance means that the client doesn’t really want a good treatment outcome, consciously or unconsciously, or at least is ambivalent about recovery. In other words, a depressed client has mixed feelings about recovering from depression; the anxious client isn’t sure he wants to be free of anxiety; the client with a troubled relationship may not want to get close to the person she’s complaining about; and the client with a habit or addiction may not want to give it up. Process resistance, in contrast, means that regardless of how clients feel about the treatment outcome, they definitely don’t want to do what’s required to make it happen. Given that the four most common presenting problems in therapy—depression, anxiety, relationship problems, and habits/addictions—manifest differently with process and outcome resistance, I’ve identified eight types of resistance. (See sidebar on page 24 for details and examples.)
Clinicians who don’t effectively address these types of resistance may find their therapeutic efforts falling short. And the failure to deal with client resistance might explain why so many of the controlled outcome studies show such disappointing results. In these studies, people with a common diagnosis, such as major depression or PTSD, are randomly assigned to one of two treatment packages involving heavily promoted psychotherapies, such as CBT, DBT, ACT, EMDR, or medication, or some combination. The idea is to find the treatment that works the best—which sounds logical. However, the clinicians in these studies must “sell” the treatments to their clients without first exploring the clients’ goals or motivation, and without bringing outcome and/or process resistance into conscious awareness. As a result, many clients will buy in from the beginning, but many others won’t, and I’m convinced those are the 50 percent who fail to improve in these studies.
But here’s the other side of the coin. If we could learn how to bring the client’s resistance to conscious awareness and find ways of melting it away at the very beginning of therapy—before we even try any of our helpful techniques—we might significantly improve treatment effectiveness. And that’s what we’ve done with TEAM-CBT.
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. Some suggest that clients resist because they get some kind of gratification from identifying as victims or that depression has become so central to their sense of identity that they’re afraid of relinquishing it. And then there are all the old psychoanalytic theories linking resistance with transference, or with the need to suppress certain kinds of erotic or aggressive drives, and so forth.
Although these ways of looking at resistance may sometimes contain a grain of truth, they’re not particularly helpful, mainly because they carry a pejorative taint, sounding like put-downs masquerading as therapy-speak. In addition, they implicitly situate the therapist in the role of wise expert trying to fix a broken, dysfunctional client—not a good base for a mutually trusting therapeutic relationship. Also, thinking about resistance this way can allow the therapist to blame the client for treatment failure.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. From a cognitive-therapy perspective, our negative feelings don’t result from what happens to us, but rather from our thoughts about what happened. This idea, originating from the ancient Greek philosopher Epictetus, can be liberating. In Christine case, she can’t change what actually happened—the abuse was real, horrific, and prolonged—but she might be able to change the ways she’s thinking about it, which could help her right now. So 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%
Christine had been carrying most of these thoughts around for decades, and despite all the therapy she’d had, she was still fully convinced they were valid. So where do we begin? I started out by empathizing with her pain, just as I do with all my clients. 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, and posed the following question to find out more about the kind of help she wanted: “If you walked out at the end of the session today feeling like something miraculous had happened, what kind of miracle would you be hoping for?” She answered that she hoped to be free of the relentless negative thoughts and feelings she’d been struggling with unsuccessfully for more than 40 years, and maybe even be able to experience some joy and self-esteem.
“I’m really glad to hear that,” I responded, “but 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. So next on our list was “My sadness and depression are healthy, given what I’ve gone through.” After writing it down, we talked about the idea that sadness and depression usually result from the loss of something we care deeply about; in fact, these feelings sometimes show an intense passion for life and a vivid awareness of what we’ve lost. If Christine weren’t depressed, it would almost be as if she hadn’t cared about all she’d lost and missed in the years during and after the abuse. She grasped this right away, adding to the list of positives “My depression shows my intense passion for life.” She also noted that her depression had given her far more compassion and understanding in her clinical work for her clients who’ve been hurt and abused, so we added “increased compassion.”
One by one, we did positive reframing with all of the negative thoughts and feelings on Christine’s DML. For instance, we decided that the thought I must be defective shows that Christine was honest with herself, because, like all of us, she does have flaws. But more importantly, that negative thought shows that she’s willing to examine her flaws, and to be accountable for them, rather than blaming everyone else for her problems. So we added “honest” plus “self-reflective and accountable” to our list.
Christine’s negative thoughts included numerous self-criticisms, like I victimized myself, I was cowardly, and I lived a lie. We usually think of self-critical thoughts as targets for therapeutic intervention. But Christine could see something positive about her self-criticisms right away: they showed she had high standards, so we added that to the list of positives. I wondered if her high standards had motivated her to work hard and accomplish a great deal, in spite of her horrible circumstances. She enthusiastically said yes, explaining that after she’d gotten divorced, she’d gone back to graduate school, was at the top of her class, and now she had a thriving private practice. So we added “hard work and productivity” to our list of positives.
We also looked at her feelings of hopelessness and discouragement, which she’d rated at 90 percent at the start of the session. How can hopelessness be a positive? This is one of the hardest things for therapists to grasp; even Aaron Beck taught us that hopelessness is the worst aspect of depression, and it’s the feeling that triggers most suicidal urges. But Christine and I discussed some good things about hopelessness. For one thing, it shows a tremendous sense of integrity. After all, Christine had been depressed and anxious for years, and nothing had really helped, except momentarily. So when she feels hopeless, she’s courageously facing the truth as she understands it. So we added “integrity” to our list. Even more, hopelessness can protect us from disappointments. I’d announced in the workshop that I sometimes saw dramatic improvements in a single, two-hour therapy session when using TEAM-CBT. If Christine bought that and got her hopes up, it could trigger yet another crushing disappointment if the session didn’t help. So we added “Hopelessness protects me from disappointment.”
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 and I completed our list of positives in about 20 minutes, and she 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. Her outcome resistance has been honored, so her subconscious mind—the part of her that may not want to change—doesn’t have to lose face. Now, change becomes her agenda, rather than my agenda. And once there’s little or no resistance left, recovery usually unfolds quickly.
For the rest of our two-hour session, we worked with a variety of standard cognitive techniques to help Christine challenge her negative thoughts. That’s the Methods part of TEAM. For example, she wanted to work on the thought I must be defective, so we identified the 10 cognitive distortions in that thought, using a list printed on the DML. These include all-or-nothing thinking (thinking of herself in stark black-or-white categories), overgeneralization (generalizing her abuse to her entire identity as a person), mental filtering (focusing on her flaws and filtering out her good qualities), mind-reading (assuming her husband abused her because he thought she was defective, rather than because he was an exploitative sadist), emotional reasoning (because she feels defective, she thinks she is defective), and so on.
Once Christine identified a distortion, I asked her to teach me why it was distortion. With little trouble, she made strong and persuasive arguments for why the negative thought wasn’t really valid. (In the old days, before I developed PAS, this rarely happened so quickly.) Then, trying a gentle technique called the Paradoxical Double Standard, I asked Christine if she’d ever say to a dear friend or a client who’d been through decades of abuse, “You must be defective.
“Of course not,” she said. When I asked her what she’d say instead, she replied that she’d tell another woman, “You sacrificed enormously for your children, did what you had to do to survive. You’re a beautiful person deserving of love and respect.” I asked if she’d be willing to talk to herself in the same, compassionate way. Smiling, she said yes.
Once a client has smashed one negative thought, it nearly always becomes much easier to do the same with the rest of the negative thoughts. Using some additional CBT methods with Christine, this only took about 20 minutes. Then we got to her last negative thought—that the therapists in the audience would judge her for letting herself be a victim for so many years and wonder how she could help others when she hadn’t been able to help herself. To smash this one, I asked Christine if she could think of a way to test her belief in that thought. “I could ask them,” she floated hesitantly. So we invited the therapists to come up on the stage so Christine could ask them how they felt—an extremely frightening step for her, because she was certain they were looking down on her.
One by one, 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?
Although I used to see this type of super-rapid recovery from time to time when I was first learning and developing CBT, I’m now seeing it regularly using TEAM-CBT. Over the past several years, I’ve treated at least 50 individuals with severe depression and anxiety in live demonstrations, and I’ve seen a complete or near-complete elimination of symptoms in roughly 90 percent of them. If you’d told me this was possible 10 years ago, I’d have written you off as a con artist. But this orbital jump in treatment effectiveness appears to be real, and the results are due, I believe, to the techniques my colleagues and I have created that bring resistance to conscious awareness and melt it away before trying to help with other techniques. Will this level of success generalize to clinicians in practice?
I’m hopeful, but with a few caveats. First, I’m treating pretty highly motivated individuals with depression and anxiety, and most are at least somewhat familiar with my work before coming to the workshop, which probably contributes to the successful outcomes I’m seeing. Second, in a clinical practice, most therapists will see a much broader array of problems, some of which will be more difficult to address and still require much longer treatments. So I definitely don’t want to create false expectations of a miracle cure. Third, although I try to make TEAM-CBT look easy in my teaching and writing, it’s sophisticated and challenging to learn. Further, PAS flies in the face of the therapist’s natural urges to jump in and rescue the client. And finally, while the instruments I’ve developed to assess symptom severity at the start and end of every session, along with the client’s view of therapist empathy and helpfulness, are a vital and promising feature of data-driven psychotherapy, they require regular, dedicated effort and can be threatening to therapists who don’t want to be held accountable.
Still, I’m excited about the new developments in TEAM-CBT because it does seem significantly more effective than traditional CBT and other forms of psychotherapy for depression that have been tested in controlled outcome studies. In a recent informal pilot study I reported at the Brief Therapy Conference in Anaheim in 2015, I noted the rate of symptom reduction per hour of therapy in several hundred sessions conducted by four experienced TEAM-CBT therapists at the Feeling Good Institute in California. The average reduction in the severity of depression and anxiety in my study was approximately 25 percent per hour of therapy. When you consider the fact that most controlled outcome studies of medications or psychotherapy for depression only report roughly 50 percent symptom reduction, on average, in 12 to 16 weeks of treatment, those findings were encouraging. More formal outcome studies are in the works, and we’ll have to be cautious in our claims and hopes until we get the results.
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.
8 Types of Resistance
Process resistance and outcome resistance exhibit themselves in different ways in the four most common presenting problems in therapy, giving us eight distinct types of resistance. Here’s a snapshot of each. Clinicians who don’t bring these to conscious awareness, and work to melt them away, may find their therapeutic efforts falling short.
Depression. Outcome resistance for depression nearly always involves nonacceptance, meaning clients cling to depression because they don’t want to accept some internal flaw or external circumstance. For example, a depressed, perfectionistic college student who’s not doing well in school may not want to give up her depression until she’s getting all A’s. Simply put, she subconsciously feels her depression is a manifestation of her high personal standards, which she’s determined not to give up, lest it lead to mediocrity.
Or in the case of external nonacceptance, there’s some life event or situation that clients believe they must have to feel happy and fulfilled. For example, a severely depressed, successful 40-year-old attorney told me that a husband and a child were the only things that could possibly make her feel fulfilled and happy. So I asked her to imagine there was a magic button on my desk: if she pressed it, her depression would instantly vanish and she’d be flooded with joy. Would she press it? When she enthusiastically said yes, I asked, “Are you sure? If you press it, you’ll be happy by the end of the session, but you still won’t have a husband or a baby.” She quickly reneged, exemplifying how, with outcome resistance, clients may subconsciously believe that giving up their depression means giving up some cherished dream.
With process resistance for depression, clients may want to recover, but they don’t want to engage in what’s required to do so, such as psychotherapy homework between sessions, perhaps because it forces them to focus on difficult aspects of their lives on a daily basis.
Anxiety. Outcome resistance for anxiety always involves magical thinking. Most anxious clients secretly believe that the something terrible they’re anxious about will happen if they recover. So although they’re asking for help, they fear letting go of the anxiety. For example, a mother who worries endlessly about her husband and children may subconsciously believe that her anxiety protects them from danger, or a student with test anxiety may believe that his relentless worrying is the key to his peak performance.
Process resistance for anxiety means that a client may want to recover, but doesn’t want to engage in therapy because it would involve facing his fears via exposure techniques, which is incredibly frightening.
Relationship conflicts. Outcome resistance in this case means that the client doesn’t really want to get close to the person he or she is at odds with. For example, a client may complain about her spouse, or ex, or sister, or colleague during sessions. But it doesn’t follow that she wants help improving that relationship. This is something basic that many therapists overlook. They wrongly conclude that people with troubled relationships want loving, joyous, peaceful ones.
In workshops, I demonstrate this by asking therapists to think of one person they don’t like, now or at any point in their life, and to raise their hands if someone comes to mind. Almost every hand in the room immediately goes up. Then I say, “Now imagine there’s a magic button on your desk, and if you push it, that person will instantly become your best friend, with no effort on your part. How many of you will push that button?” In an audience of 200 therapists, typically only 3 or 4 of them put their hands up. So almost everyone would chose a hostile, troubled relationship over a loving, peaceful one. I’m not saying there’s anything wrong with that, just that it’s an example of a common type of outcome resistance.
Process resistance for a relationship problem is different. To demonstrate, I ask my workshop participants to answer this question honestly, from their hearts: “Who, in your opinion, is more to blame for the conflict in the relationship? You or the other person? Raise your hand if you feel the other person is the bigger jerk?” Nearly all the hands go up. Then I ask, “What’s the prognosis for helping someone who blames others for the problem?” They all say zero. And that’s the main process resistance for relationship problems. If you do want a more loving or satisfying relationship, you’ll probably have to stop blaming and trying to change the other person. Instead, you’ll have examine your own role in the problem and focus all your efforts on changing yourself—but that may be extremely painful.
Habits and addictions. Here, outcome resistance simply means that the person doesn’t want to give up a source of immediate pleasure or gratification. That’s pretty obvious. In contrast, process resistance means that the client doesn’t want to deal with the discipline and deprivation that will be required to achieve a good outcome. For example, many people may want to lose weight, but they probably don’t want to deal with the challenges and inevitable setbacks involved in changing their diets and exercise routines. Let’s face it: for most of us, eating a carrot and going for a run seems a lot harder than watching our favorite TV show and snacking on Doritos.
David Burns, MD, is the author of the bestselling book Feeling Good: The New Mood Therapy, which has sold more than five million copies. He’s the host of the free weekly Feeling Good podcast, and has authored many additional resources for therapists and clients, including the TEAM-CBT psychotherapy training book, Tools, Not Schools, of Therapy. Contact: firstname.lastname@example.org.
Illustration © Steve R. Dininno