Resistance Meets Motivation
Even armed with the Hidden Emotion Technique and a wide variety of powerful CBT approaches, I still couldn’t reach some depressed and anxious patients. That began to make me wonder whether we might be missing something fundamental about our clients, even about human nature. Was it possible that our single-minded desire to help our patients might be blinding us to some incredibly important paradox of human nature? For example, in today’s problem-oriented, solution-focused atmosphere, we assume that clients come to us for relief of their suffering. At least, that’s what they tell us: “I want to stop having panic attacks every time I go out in public. Please help me!” “I want to stop obsessing and having nightmares about the bad thing that happened to me years ago. Please help me!” “I want to stop feeling hopeless and worthless all the time. Please help me!”
So that’s what we earnestly set out to do: we try to give them what they say they want, and while some of our patients play ball and appreciate our efforts, others respond quite differently. They begin to “yes-but” us, or put up a wall, or simply “forget” to do their psychotherapy homework week after week. Pretty soon, we end up doing all the pushing, while the patient does all the resisting, and everyone becomes frustrated or even angry at each other about the situation.
I sometimes think that, for all our supposed expertise in human psychology, we can sometimes be a little naïve about a hidden antipathy to change that exists as an undercurrent beneath our clients’ stated and genuine desire for change. Anthony de Mello, a Jesuit mystic, once said that we yearn for change, but cling to the familiar. What if our clients have mixed feelings about receiving the help they want and seem to need? What if their reasons to resist change actually reflect something positive, or even flattering, about their values and goals in life? Could it be that humans are sometimes far more complicated than even our newer, presumably smarter, models of therapy have taken into account?
As therapists, we’re influenced by the medical model. We assume that, just as any rational person with a broken arm, inflamed appendix, or bacterial infection would be a willing and eager customer for medical care, surely a person suffering from severe anxiety or depression would be equally motivated to receive the healing that we offer. But what if this isn’t the case? Over and over again, I’ve treated patients in genuine pain, sincerely hoping I can provide relief, who turn on a dime, so to speak, when I assure them that they can recover, usually much sooner than they think. Sometimes, they suddenly react, not with feelings of gratitude and relief, but rather with muted enthusiasm or even open opposition and hostility.
Their unwillingness to continue doesn’t look to me like covert or unconscious resistance, but something else. Faced with the real possibility of cure, some patients seem to back off in a kind of horror, almost as if the disappearance of the symptoms would result in the loss of something vitally important to them, or might even force them to confront something even worse than their symptoms. My work with a young man named Sam is a good example.
He came to me for treatment after struggling with severe PTSD. Six months earlier, he’d been working in a Burger King near Temple University in Philadelphia. One night, just before he closed up, two gunmen robbed the place. Before they left, they threw him into a walk-in freezer and left him there to die, laughing on the way out about the clever thing they’d done.
The next morning, the manager came in early and was alarmed to see the doors open and the lights still on. When he opened the freezer, he found Sam huddled in a corner and shivering, but still alive. Although he’d survived, he was badly traumatized. The gunmen never were captured.
Sam soon developed panic and rage attacks, and spent most of his waking hours haunted by vivid memories of the incident. He constantly worried that it would happen again, and woke up at night from terrible nightmares. When he wasn’t struggling with flashbacks or worrying about getting mugged again, he imagined finding the men and taking revenge on them. He said the anger and panic had totally consumed his life. All he wanted, he told me, was to get his life back, if that was possible, though he doubted it was.
In our first session, I told Sam that the prognosis was actually quite positive. I said his symptoms didn’t actually result from the traumatic event, but from the constant stream of negative thoughts and vivid, frightening images that crossed his mind. I explained that we had many new techniques to help him modify those thoughts and images, and briefly described some of them. I then added that, although I couldn’t make any promises or guarantees, there was a good chance we could reduce his anxiety and rage significantly, and perhaps eliminate his symptoms entirely.
He asked how long the treatment would take, given how severe his symptoms were—probably a long time, he supposed, years even. I said that these things were difficult to predict and that the treatment might take not years, but several months or more. However, if we worked hard together, I told him, there was a good chance we might be able to eliminate his symptoms more quickly, maybe in just a few sessions.
Sam looked at me for a moment without expression and then, to my astonishment, flushed and began barking angry questions and “yes-butting” me, as if I’d suggested we try a course of voodoo or animal sacrifice. How was it possible that the techniques I’d described could make the least difference to what he was going through? Didn’t I realize just how horrible what he’d experienced had been? Sure, such simpleminded stuff might work for somebody with really dumb, little problems, but did I not understand that he felt like absolute shit 24 hours a day? I was supposed to be a doctor, who was trained to recognize and treat serious problems, wasn’t I? What kind of crap was I peddling, anyway, with my talk about all this CBT baloney?
I was taken aback. Here I was offering a message of hope and glad tidings, which I thought would relieve Sam immensely, and he was responding with anger, clearly on the verge of getting up and walking out. I realized I was failing with an anxious patient once again. In fact, this time, I was failing before we’d even gotten started. Why was Sam so forcefully resisting my efforts? Could it be that he that, in some way, he really didn’t want to get better?
In near desperation, I decided to try another tack. One of the first CBT techniques I developed wasn’t even a cognitive technique at all, but a Cost-Benefit Analysis (CBA), to deal with motivational problems, particularly with patients with borderline personality disorder. The analysis assesses motivation—whether the patient really wants to change.
You draw a line down the middle of a piece of paper from top to bottom and label the two columns Advantages and Disadvantages. At the top of the sheet, you define the problem; it can be any negative thought, feeling, habit, or belief that the patient is struggling with. Then you and the patient list the advantages and disadvantages of that problem and, afterward, you ask the patient to balance the advantages against the disadvantages on a 100-point scale. That’s called a Straightforward CBA. Alternatively, if the patient is oppositional, you can simply list the advantages of the dysfunctional thought, feeling, or belief, and then agree that the patient would probably be better off not changing. That’s called a Paradoxical CBA, and it’s the approach I decided to try with Sam.
I told him that since what I’d been saying about our chances for rapid recovery seemed to be upsetting him, maybe I’d been overlooking some important advantages of the rage and panic. Perhaps, we should list the advantages of feeling that way in the left-hand column of a CBA. I always say this with genuine respect, sincerity, and curiosity, which I truly feel. If patients think it’s one more clever CBT intervention or manipulation, it won’t work. My fundamental stance is that, at this point, I don’t really know what’s important to my patient, and there might be some really good reasons for him or her to resist getting symptom relief.
Sam perked up and immediately pointed out one rather obvious advantage of his PTSD: the anxiety and constant vigilance protected him from danger and kept him safe. If he let his guard down, he might get robbed again, or even killed. I agreed that the area where he lived and worked—near Temple University in Philadelphia—was extremely dangerous, and said that he had a darn good point, and he should list that in the Advantages column of his CBA. I asked if there might be some additional advantages to the anxiety and anger he was constantly feeling.
He went on to point out that the anger showed that he wasn’t going to just passively accept having thugs abuse and nearly kill him, as though he were some weak doormat, whom anybody could push around. He said that if he suddenly began to feel happy again, it would make him look like a wimp. Driving the point home, Sam added, “Hell, no, Dr. Burns, I have every right to be angry. I’m not going to let those guys walk all over me and then feel happy about it!”
I told him that was a great point, and that his anger showed that he intended to stick up for himself and not put up with any abuse from anybody. His anger, in fact, was an expression of his self-esteem, so he should add that to the Advantages column as well.
Then he came up with a third advantage of keeping his symptoms. He said that if he could be cured in just a few sessions, as I’d suggested, and all his feelings of anger and panic suddenly vanished, it would imply that what had happened to him was trivial. But it wasn’t trivial. It was a horrible, traumatic event that almost killed him and practically ruined his life. So I asked him to add that to the plus side, too.
Now I could see my initial error. I’d jumped in to help Sam without taking time to empathize with his suffering, and without taking into account all the reasons he might have not to change. I still make this mistake at times, and in my opinion, it’s the most common cause of therapeutic failure. Let me repeat that. The compulsive need to help, which usually results from therapist codependency or narcissism, is the cause of nearly all therapeutic failure. We jump in and try to help because that’s our role, and we can’t bear the bad feelings we might experience if we were unable to help, or if our patients didn’t want our help. Although most therapists will say they understand this intellectually, few can avoid this error.
Once I realized what I’d been doing wrong, I said something like this:
“Sam, I can see that I’ve been barking up the wrong tree, and I owe you an apology. What you’re saying makes a lot of sense. It would be foolish to let down your guard, because it is dangerous where you live and you have every right to be enraged. What those guys did was sadistic and awful. You’ve been through a living hell. If you could recover in just a few sessions, which might actually be possible, it would be like saying the trauma was insignificant and didn’t count for much. It would be insulting to you.
“To be honest,” I went on, “I’ve changed my thinking. You’ve convinced me that we probably shouldn’t try to eliminate the rage and panic attacks. Your feelings make perfect sense: they show that you have a sense of dignity and self-respect, and don’t want to put yourself in harm’s way again. Now I can see where you’re coming from.”