The mental health field is constantly struggling with the question of pathology or rather, what makes something a pathology or pathological. We can even pathologize a client’s behavior when it comes to the lack of progress they are making in treatment. We tend to attach labels to clients who appear unmotivated or unwilling to change; feeling at times that there is almost a willfulness to maintaining the status quo. Some of these labels include “resistant”, “defiant” and “in-denial”. The behaviors attached to these labels frustrate therapists because, despite our training, we end up either blaming ourselves or the client for the “failure”. At best, this may come across as self-serving. At its worst, this can act as a convenient excuse not to re-evaluate our own work or avoid work that may feel uncomfortable.
Part of the issue has to do with managed care’s more prominent influence in mental health over the last 20+ years. Like everything else, managed care has a downside and an upside. It’s presence has pushed clinicians and clients to be more clear and accountable for the work being done. This increased accountability also has the potential to push clinicians and clients into a success-failure dichotomy in evaluating therapy. Clinicians and clients can shoot themselves in the foot when thinking and talking about outcomes from this perspective because it can influence both into assigning responsibility for the “failure” onto the other vs. a more thoughtful and considered evaluation around expectations and strategy.
When we use behaviors as evidence in justifying the use of labels, it creates missed opportunities in evaluating and speaking to the fears clients may have in letting go of the behaviors and beliefs that appear to be so problematic for them. It can also invalidate how they dealt with significant historical issues in a way that can create a great deal of damage. This is particularly true of clients who are in treatment as a result of having experienced trauma.
Initiate Dream Sequence…..
So imagine yourself suspended a gazillion feet in the air and the only thing stopping your fall is a rope you have been holding onto for the last, say….thirty years. It’s sort of comfortable because you’re in one of those saddle things you find on swing sets for little kids-you know the one that has holes for your legs to go through.
Hanging onto a rope for 30 years kind of sucks. It’s rather time consuming and you’d like to do something more productive with yourself.
Like get to a phone and order a pizza with extra toppings.
So you finally call out for help.
A helper arrives and asks you to sign all sorts of forms, asks a bunch of questions and then recommends that you take up hang gliding. He tells you that early on, hang gliding will feel different and scarier because it’s new. He also discusses the benefits- more freedom, mobility and the potential to look really cool at parties when someone asks you about your hobbies.
You’re freaking out because being up this high doesn’t really afford one the luxury of making a mistake. You feel hopeful because it sounds like the answer to a problem.
Terminate Dream Sequence
I don’t know about you but letting go of a rope with a nice fitting seat that’s kept me alive for thirty years to fly around on something that looks like a kite isn’t exactly a no-brainer. It may be more productive, it may be what is “better” or “good for me” but my fear and the hesitancy around hang gliding is not pathological (at least not fully). In theory hang gliding seems great but how do I know I’ll do it right? What if I make a mistake that will actually make things worse? How do I know the people who built the glider knew what they were doing? Why should I have faith in the instructor? Is hang gliding the only solution to my problem?
What is driving the fear and reluctance may actually be healthy and reasonable- it’s a survival instinct. Being attentive to this instinct, to hold onto what I think will keep me alive despite the problems “holding on” creates can actually be viewed as resilience.
Many times, as “crazy” or destructive as the behavior or thinking may seem, the only thing that makes it so is context. What may be viewed as due diligence in a combat situation or protective in a house hold where physical or sexual abuse may be occurring becomes hyper vigilance in a civilian setting or healthy household. When we ask folks to give up what isn’t working for them (and we should) we need to be mindful of the meaning associated with what it is we are asking them to give up. We should keep in mind that the difference between “resistance” and “resilience” might actually be negligible. Feeling safe in letting go of something that has allowed you to survive horrific environments isn’t easy and refusing to do so can be a sign of health not pathology.
I am more concerned about clients who did everything that was asked of them with little question or push back than those working and fighting me tooth and nail in the interest of self-preservation.
The point here is that resistance is something clinicians should be careful to avoid tearing down or dismissing. We should do our best to understand the need it is meeting. On some level, we should acknowledge the role that the behaviors we think should change have had in helping the person in front of us survive difficult situations. Clients will usually change if they remain open to therapy. This change may not be evident in their work with you. You may be one step in a long line of therapists or episodes- be careful in what you try to take away and how you go about doing it.