This is an introductory to intermediate level course. Upon completion of the course, mental health professionals will be able to:
The course was created from, and is based on, the book, Effective Techniques for Dealing with Highly Resistant Clients. The book addresses additional areas of resistance beyond those included here. Some of these additional areas of study include dealing with silence, responding to challenges from clients, additional linguistic techniques and language nuances, as well as an assortment of additional approaches such as paradox and reframing. If you would like to order the book or view the resistance topics not contained herein, please go to www.CliftonMitchell.com for more information.
One day, after feeling worn out and emotionally "beaten up" by a client, I searched every text I had for information on dealing with resistance. What I discovered is that most texts had nothing, and a few had less than a paragraph addressing the subject. Over the next eight years, I continued to search for material on resistance. I found numerous ideas and approaches scattered throughout the literature as well as a few excellent books that addressed resistance exclusively.
As a result of my own struggles and search, I began leading training seminars on resistance. Immediately, I realized the need for a comprehensive course that succinctly compiled ideas and techniques for the working therapist who does not have time to read lengthy, detailed books and articles that often include a great deal of theoretical discussion and only a small amount of practical how-to. I wrote this course in an effort to fill this void in the literature.
Before studying resistance, my basic skills as a counselor were reasonably well developed. Like most therapists, I could skillfully empathize and build rapport. Conceptualizations of client's problems were readily formulated. I could analyze and present logical reasons for change for any client. Along with these positive skills, I was adept at stressing over my clients. When I did not perceive client movement, I was burdened by the lack of progress. I could carry tension regarding a session with me for days. Moreover, when clients did improve, I did not always know why. This aroused the unsettling question that so many therapists ask themselves – Do I really know what I am doing? I was like many of the therapists I meet at my trainings – stressed out and approaching burnout without a definitive plan to resolve the predicament. The study of resistance is vital to therapists desiring to get out of this state.
There are a few things you need to know before reading this course.
The purpose of this course is to present a compilation of ideas, techniques, and approaches from a host of sources. Some of the ideas will be new to you. Some of what you will read focuses on basic skills that we seem to forget easily when caught up in exceptionally difficult client problems. These basic skills are presented with a focus on resistance. However, this course is by no means complete. As I kept compiling and writing material, I realized that I had to stop writing somewhere, even with many ideas still available about which to write.
This course will not solve all of your resistance problems. It will provide techniques that effectively handle resistance in many instances. It will provide you with a host of approaches that will greatly improve your therapeutic skills and subsequently enhance movement in your clients. However, you will still have some clients who make little progress. In the midst of its shortcomings, there is an important ancillary benefit that comes from the study of this course – it will reduce your stress levels. This, in and of itself, is a meaningful reason to undertake a serious study of resistance. Even if your clients don't get better, you will.
In the sections that follow, you will find an emphasis on practicality. I have tried to write this course in somewhat distinct sections so that the reader might turn to any page and discover a helpful idea or technique. However, in order to fully understand resistance and ways to deal with it, you will have to read all of the sections and bring the material together in your practice.
There is no step-by-step, linear way to present this material. I have rearranged the order of what I want to say many times, and I am never completely satisfied. Thus, there is repetition and there will be references to ideas in some sections that are explained in later sections. You just cannot say it all at once. Those who have attended my workshops have indicated that the order of presentation used is practical, and they have recommended that I retain the order presented here.
Historically, there has been a line drawn between what has been deemed counseling and what has been deemed therapy. However, in the midst of what I see all mental health workers dealing, I view this distinction as archaic. The distinction between the more serious problem that warrants a diagnosis and the less serious problem that is viewed as more developmental is just not that clear. To clients, all problems are serious. The experience of many school counselors is that they are managing small, community mental health agencies in their schools. The elementary school counselors that I supervise have very serious mental health issues in some young children. Even though they may not always be warranted, diagnoses are necessary for services in most community mental health centers and most therapists appear to find ways to accommodate the system with minimum adjustment. Thus, I do not make a distinction between the terms "counseling" and "therapy." I do not know where to draw the line. Further, I do not desire to lessen the significance of the work of any mental health workers by labeling their work as "counseling" and not the more severe "therapy." Therefore, I use the words interchangeably and deliberately alternate their use in discussions.
What you have just read is taken from the foreword to the second edition of my book. Most people never read the foreword. Rather than fight this reality, it is easier to instruct people not to read the foreword. This is how you deal with the resistance against reading the foreword.
The effective management of resistance is the pivotal point of good therapy. Consequently, it is recommended that all mental health professionals take time to develop a personal philosophy for dealing with resistance. Your personal philosophy of resistance should provide you with techniques for dealing with resistance that are built from an understanding of the dynamics of resistance.
Thus, the foundational component of your philosophy should be an understanding of what resistance is – what it represents psychologically. Resistance is not one thing. The word "resistance" is actually a very limiting term utilized by mental health professionals that represents a host of reactions and interactions. In order to deal effectively with resistance, you should have an understanding of its many possible psychological interpretations. One of the purposes of this course is to expound upon this point, and thereby, provide an understanding of the many meanings of what is commonly referred to as resistance.
Your understanding of resistance should then lead you in developing approaches to managing resistance. As a result, your personal philosophy will include a wide variety of approaches and techniques for directly managing resistance. These tactics should equip you with several alternative responses to virtually any client position. Your toolbox of techniques should provide you with approaches that gracefully and eloquently manage client reactions. You should have a balance between responses that are too passive and responses that might appear to be too confrontive. Ideally, you should be able to react in a situationally appropriate, yet decisive, manner when resistance is encountered.
Thus, your personal philosophy should include theories for conceptualizing resistance, and techniques that allow you to maintain your emotional comfort as you deal with resistance. Further, your theories and approaches should aid you in conceptualizing the resistance in a manner that avoids futile battles with your clients. You should easily circumvent being pulled into the stuck state that your clients are experiencing, and you should be able to remain objective as you establish a clear perspective about what is occurring.
Ultimately, your personal philosophy should equip you with the skill to see resistance coming well in advance, so you will not be surprised when it presents in therapy. Interestingly, as your skills develop, your knowledge will help you to remain at ease as you bring to the surface the internal struggles of clients. Because of your increased comfort, you will allow yourself to arrive sooner at critical issues. Thus, you more quickly reach the place in therapy where you can be helpful. Your understanding and comfort with resistance will also decrease treatment time.
In summary, you should have a plan for dealing with resistance before you encounter it in therapy. You should be able to articulate to other professionals your position on resistance and your methods for dealing with it. If you were asked to state your theoretical position on resistance and your approaches and techniques for dealing with it, could you? If not, it is likely that your therapy is not as productive as it could be and that your highly resistant clients are quite frustrating to you.
Here are some indications that resistance may have gotten the better of you:
"Highly resistant clients are experts at winning the client-therapist struggle. They are experts at making us feel incompetent."
"No one's mental health is more important than your own."
Deanna Rote, Seminar Participant
"Resistance feels personal to therapists" (Anderson & Steward, 1983, p. 2) rings true because of two interrelated realities. First, the desire to help others is strong in those who choose to work in mental health. This trait is observed when prospective students are asked why they seek a degree in counseling. The most common response is, "I just want to help people." Second, mental health work is fraught with difficulties. It is understood that most therapists who work in community mental health frequently deal with unmotivated clients with little desire to make serious changes. These clients are treated in a cumbersome bureaucracy that is filled with questionable paperwork and utilizes approaches that often feel as if they are, in part, contributing to the problem.
The strong desire to help others, coupled with the difficulties inherent in promoting client change, can result in resistance feeling personal. We often think it is our fault that our clients do not change. Resistance can result in feelings of insecurity, incompetence, frustration, hopelessness, stress, and burnout. When these feelings are indirectly communicated to clients, additional resistance results and a negative spiral develops. Novice therapists are especially vulnerable to the negative effects of resistance and the downward spiral that can develop.
The reality is that there are hosts of variables over which we have no control that contribute significantly to therapeutic outcomes. Indeed, Hubble, Duncan, and Miller (2006) concluded that approximately 40% of improvement in clients comes from extratherapeutic factors. More recent research estimates the influence from extratherapeutic variables to be as high as 87% (Scott Miller, personal communication, March 12, 2007). Such factors include the client's own personality characteristics as well as social support and chance events. Most likely, you were never taught these particulars. If your coursework included this data, it is unlikely that you will remember it when things are not going well. For some reason, we tend to think that our weekly one-hour conversation is going to override the impact of the 167 hours per week of influence from outside factors. Sounds like a cognitive distortion to me! I should point out that Hubble, Duncan, and Miller's research does indicate that our one hour of therapy is quite significant in its influence. It's those highly resistant clients that burst our bubble and arouse our stress.
Thus, one of the keys to dealing with resistance is to recognize that resistance is not personal. Resistance is a fact of therapy. All therapists experience resistance. All therapists go through periods where resistance gets the best of them. All therapists have to learn to manage resistance. There is nothing personal about resistance, other than that which we allow to be personal.
The mistake is letting yourself get sucked in by the alluring nature of resistance. Most commonly, you may personally take on clients' struggles and try to fight their internal conflicts for them. When you begin fighting clients' internal struggles as if they were your struggles, you allow the resistance to snare you in its trap. You allow clients' resistance to become personal and, in your zeal to help, you become helpless.
An extremely beneficial byproduct of understanding resistance is an accompanying reduction in therapist stress. Stress and burnout among mental health workers is well documented. Much of this stress comes from high therapist expectations coupled with minimal client progress; both of these factors are intimately tied to resistance. A comprehensive understanding of resistance and effective methods for dealing with resistance is essential to controlling therapist stress and burnout. This course was written to teach counselors how to avoid the frustrations of resistance and the accompanying stress. You owe it to yourself to study resistance if for no other reason than to help you deal with the stress inherent in mental health work.
"The first step ... therapists must take to master resistance is to decide for themselves the question of how much responsibility for change they can take realistically."
Anderson & Steward, 1983, p. 36
I do not like the word "resistance." It conjures up precisely the image that I wish to eliminate. Indeed, this course was written in order to overcome the outdated and useless ideas that the word typically conveys. Yet, I am stuck with using the word. This is because "resistance" is so commonly used that it provides a starting point from which to discuss the most serious frustrations encountered by therapists. Moreover, I have no alternative words to adopt in its place for which the meaning is commonly understood among therapists or that does not carry the same pitfalls. Further, given the choice of attending a seminar on "fostering client movement" versus "dealing with resistant clients," the great majority of therapists are much more responsive to the latter. This is because "dealing with resistant clients" carries with it the added appeal of solving therapists' problems as well as those of clients.
Thus, throughout this course and in my trainings I use the very word that I wish to redefine and, ultimately, eliminate from the minds of therapists. Such are the binds in which language places us. In the sections that follow, you will learn some techniques that use similar language binds in ways that greatly benefit the therapeutic process. For now, I am compelled to use "resistance" in order to begin with a common language.
There have been numerous definitions of resistance. Traditional definitions have their roots in Freudian theory. Freud conceptualized resistance from two related perspectives. The primary position of Freud was that resistance represented the client's efforts to repress anxiety-provoking memories and insights (Otani, 1989). In other words, resistance is an attempt to control anxiety. In this sense, resistance protects clients from frightening discoveries about themselves. If we use this understanding to guide us in presenting ideas to clients, there is merit and utility in this definition.
Freudian theory also postulated that clients who do not accept the interpretations of their problems as conceived by their therapists are resistant. The idea that the therapist was wrong, that the therapist presented the issues in an unpalatable manner, or that there may have been other factors that resulted in the client's rejection of the interpretations does not appear to have been considered. Further, Freud also believed that resistance resides in the unconscious. Depending on the client's ability to access and disrupt unconscious processes, this position could make change even more difficult to accomplish. Overall, Freud conceptualized resistance solely as a client problem. It is this aspect of Freudian ideas that renders them outdated and counterproductive. As will be explained, the more we view resistance as a client problem, the less we empower ourselves to do something about it.
The following are representative of outdated definitions found in mental health literature. Such definitions still carry the influence of Freud, and are limiting in that they portray resistance as something that has its origin within clients. Figuratively speaking, resistance is seen as "residing" in clients.
"Any client behavior that exhibits a reluctance, on the part of the client, to participate in the tasks of therapy as set forward by the therapist,"
"... any behavior that indicates covert or overt opposition to the therapist, the counseling process, or the therapist's agenda" (Bischoff & Tracey, 1995, p. 488).
"Resistance refers to the client's unwillingness to change" (Ritchie 1986, p. 516).
"... ways utilized by the client to deter the counselor from his purpose of helping him to change can be called resistance ..." Kell & Mueller, (1966, p. 12). (It should be noted that these authors also discuss the therapist's resistance to the client.)
The next definitions offered have much merit and utility when used to conceptualize and understand clients. When compared with the characterizations above, they expand the perspective and meaning behind resistance. Yet, they are incomplete in that they fail to include the therapist's contributions as a component of the resistance. To varying degrees, each of the following descriptions still tends to view resistance as something that resides within clients. Such perspectives leave therapists lacking control and too much at the mercy of other influences when attempting to foster change.
Cognitive:Typically cognitive therapists view resistance as a result of negative cognitions. Although the source of resistance is still seen as internal to clients, there is some truth in this logic. The therapeutic mistake that arises from viewing resistance as resulting solely from clients' cognitive distortions is that therapists can become overly focused on trying to change clients' thinking, rather than on changing their therapeutic approach. Similar to the above definitions of resistance, recent research examining client “resistance” when using cognitive-behavioral approaches to depression and anxiety still utilize measures of resistance that define it from a perspective of opposition to the therapist’s agenda or the therapist’s conceptualization of problems (see Westra, 2011 and Westra, Aviram, Connors, Kertes, & Ahmed, 2012, for examples). As will be addressed later, some resistance is a result of therapists' cognitive distortions that lead to unproductive approaches.
Behavioral: Some behaviorists see resistance as noncompliance with behavioral assignments. Similarly, resistance may be a result of a failure to find the right contingencies, reinforcements, punishments, etc. Kahn (1999) saw resistance as a good measure of secondary gain inherent to the problem. From this perspective, resistance occurs because of the benefits gained from maintaining the current behavior. These perspectives do have the benefit of taking the source of the resistance out of clients. Unfortunately, they require considerable control over the environment before anything can be done to overcome the resistance, a luxury most therapists do not have.
Typically, resistance conjures up ideas of stubbornness, obstinacy, defiance, hardheadedness, rigidity, and opposition. Even with useful conceptualizations, negative labeling is common. However, there is little benefit from conceptualizing resistance in this way. When you place negative labels on your clients, you move into a position of "stuckness" with your conceptualization. In order to avoid the consequences of negative labeling, you may want to consider other perspectives on resistance. For instance:
Unfortunately, perspectives that view resistance as solely a client problem have lingered in modern counseling literature. New, more insightful perspectives have been presented, but have been slow to emerge as a dominant school of thought. Likewise, these new perspectives still do not appear to be taught in many training programs.
The most insightful and useful definitions of resistance come from the social interaction theorists. From this perspective, resistance occurs as a result of a "... negative interpersonal dynamic between the therapist and the client" (Otani, 1989, p. 459). Or, as Strong and Matross (1973) more specifically state, "Resistance is defined as psychological forces aroused in the client that restrain acceptance of influence (acceptance of the counselor's suggestion) and are generated by the way the suggestion is stated and by the characteristics of the counselor stating it" (p. 26). Here, resistance is seen as something that results from the interactional styles of the counselor and the client. The counselor allows the client to form a mutual communication pattern that hinders counseling and the change process. This view of resistance forces the counselor to remain aware of what he may be doing that actually promotes resistance. The great benefit of this perspective is that changing your interaction style results in changing what has been deemed resistance. This perspective empowers therapists.
This position is primarily what is expounded upon in the Solution-Focused Brief Therapy literature. Solution-Focused approaches never label clients as resistant. The concept of resistance is eliminated from conceptualizations of clients and their problems. No matter how much reluctance may be displayed, all responses are simply viewed as information regarding how clients perceive and proceed with change (Walter & Peller, 1992). Taking a position counter to traditional views, Brief Therapy models replace resistance with the idea of cooperating. Clients are not resistant; they are cooperating in ways that are not always understood by most therapists. Indeed, de Shazer (1982) presented arguments that the terms "resistance" and "cooperation" are really two sides of the same coin, suggesting that their differences are a matter of perspective.
Replacing traditional views of resistance with the idea of client cooperation is a major paradigm shift for the field of therapy. Do we react to clients' responses in a manner that views their behavior as resistant, or do we react in a manner that implies cooperation? This course presents approaches that avoid the trap of interaction styles that interpret client responses as resistance. Such pitfalls are likely to create resistance where none may have existed previously.
There are numerous ways in which the perspectives and interaction styles of therapists foster resistance. A number of these will be addressed later. At this point in the discussion, in order to help shift your perspective to a more therapeutically empowering stance, the following ideas are offered. By seeing the source as the therapist, these points of view take a different approach to resistance. Read through the statements below and notice how resistance is defined around therapist behavior and not as something that resides within clients. As you read, perhaps you will become aware of your own reticence toward what is being suggested. Are you resisting or just conveying that these ideas are a bit difficult to accept at this time? Perhaps the writer should present these ideas in a more palatable manner?
Moursund and Kenny (2002) suggested that there are two types of resistance. The first has to do with what the client is struggling with inside. The second is resistance that results from therapist error. When you closely examine personal struggles, you discover that resistance is a natural, necessary part of every client's problems. It is neither good nor bad, and the knowledgeable counselor does not abandon, rescue, or attack the client because of her resistance. Resistance is the problem at hand.
In the case of therapist error, the counselor is trying to get the client to do what she is not ready to do, or is afraid to do, or does not even understand. In this case, the counselor's own impatience creates resistance and is the counselor's greatest enemy. In many cases, the counselor is trying to proceed in a manner that is not suited to the client. Perhaps the counselor has used language in a way that does not promote movement. Regardless, you cannot push or verbally bludgeon your client into genuine change. Approaches different from the commonplace must be learned and applied in order to promote change.
You cannot change your clients; you can only change how you interact with your clients. Perhaps the key point that emerges from studying the social interaction theory is that change results from interaction style. Hence, we do not and cannot change our clients. Our clients change when they decide to change. To think that we have the power to change anyone is a cognitive distortion. We change how we interact with our clients in the hope that our interactions result in clients making decisions to change. When we view therapy from this perspective, our approach and techniques take on a new purpose and meaning. When we focus on how we are interacting, we empower ourselves to make needed adjustments when resistance is encountered. When you think about, this is the only legitimate way we overcome resistance.
In order to further clarify and expand upon the social interaction theories of resistance, the following model is offered. This model conceptualizes and defines resistance as being a mismatch between the therapist's mode of influence and the client's current willingness to accept that influence. The approaches and techniques presented in this course are based upon this model.
There are many ways to influence people and promote change. If you were to create a rough hierarchical list starting with the least forceful and moving toward the most forceful methods to influence people, it might appear something like this:
|Least forceful:||completely non-directive|
|Most forceful:||punitive force|
Each method of influencing has its benefits and drawbacks. Further, the benefits and drawbacks vary depending on the situation at hand. Effective therapy hinges upon therapists using an appropriate level of influence with regard to the client's current state of mind. With highly resistant clients, it is critical to be on target with the method of influence you use relative to their current degree of acceptance of your approach. Resistance is created when the method of influence is mismatched with the client's current propensity to accept the manner in which the influence is delivered.
For example, although there is definitely a time and place for direct confrontation, it is usually not in the initial stages of counseling. Confrontation delivered early in the process will likely be incongruous with most clients' initial inclinations toward accepting such a forceful method of influence. To be effective, direct confrontation should only be employed after considerable rapport and respect have been established and other approaches exhausted.
This is not to say that therapists are not to influence clients. Indeed, it is impossible not to influence. The key is to understand the benefits of each method of influence and to then maximize the use of diverse methods of influence at various times during the therapeutic process. More specifically, in order to manage resistance, you must incorporate the most fitting method of influence relative to the dynamics that are present in the therapeutic relationship at a particular point in time. Effective therapists are constantly adjusting and matching their method of influence with their client's current state of mind. This is perhaps why research continues to support the idea that the therapeutic relationship is the most critical factor in successful therapeutic outcomes. When the method of influence used is incongruous with the client's current state of mind, what is commonly labeled as "resistance" occurs. If you deal with clients who display much reluctance to change, it is important to understand the relationship dynamics at work.
"Resistant client behavior seems ... to conform to Newton's third law of motion: For every force there is an equal and opposite counterforce. In a model in which overcoming resistance potentially becomes a contest, the client will often win."
Cowan and Presbury, 2000, p. 412
Clients who display what appears to be resistance do not, for some reason, want change in the manner prescribed by their therapist. Here, the method of influence utilized is likely mismatched with the client's current inclination to accept that method. In order to subvert therapist influence, clients must expend energy as they focus on not coming under another's control (i.e., resistance). In reaction to clients' reluctance to accept their influence, most therapists try even harder to influence. As therapists' attempts to influence increase, so do the clients' rationales and inner needs to circumvent this influence. A vicious cycle is formed that is fueled by the escalating attempts of therapists and clients to not be influenced by each other. Often, what originated from an inappropriate method of influencing intensifies into an arduous battle of wits.
In such relationships, it is as if the client and the therapists are in a tug of war with each pulling harder on his end of the rope in order to drag the other across the line into submission. Each is exerting considerable effort to force the other to give in and agree with the opposing perspective. The result is that clients are reinforced by the secondary gain of not having to face their struggles and change, and therapists are exhausted and approaching burnout in their work.
The way out of this cycle is to avoid directly fighting clients' positions. Stop pulling the rope and join clients on their side of the line. Upon doing this, there is no reason for clients to focus on, and expend energy to oppose, therapist influence. This same energy is now free to be used for other pursuits. Once this is accomplished, a more suitable method of influence can be established. Typically, at such junctures, therapeutic influence that is indirectly presented has a much better possibility of shifting perspectives and behavior.
Clients only have so much energy to focus on the difficult struggles before them. Therapists do not need to do anything that diminishes the amount of energy available for the therapeutic work at hand. When therapists apply mismatched methods of influence with clients, they increase resistance and decrease the energy available for change. For those seeking additional study of models of resistance from this general perspective, I suggest you begin by reading Cowan and Presbury (2000).
"An effortless yielding of one's agenda is a major signal to the client's unconscious that here is a person I do not have to resist."
Ron Kurtz, 1990, p. 60
The redefining of resistance has two interrelated components. The first component is to understand resistance from a social interaction perspective. The groundwork for this was presented in the previous discussion. The second element is to learn to replace conceptualizations that inaccurately label client dynamics as resistance with more precise conceptualizations that provide a useful framework from which to proceed.
When you view resistance from the perspective of these two components, you quickly realize that the word "resistance" is frequently used when one of two things is occurring. The first is that we, as therapists, do not have a technique or approach available at the moment to use with a particular client situation. If we had a technique to deal with every interaction, would we need to label clients as resistant? The second is that we use the word when we do not fully understand the world of the client and, thus, we do not understand why the client is responding in the manner in which she is. If we fully understood the world of our clients, would we need to label them as resistant? Or, in such instances, would we simply comprehend and understand their reactions relative to their world? From these perspectives, it becomes apparent that resistance has become a catchword – an excuse, if you will, for our lack of skill in dealing with clients and our lack of understanding of our clients' worlds.
With this understanding, it becomes apparent why therapists are strongly cautioned against labeling any behavior as resistant. Such labeling moves therapists into a position where they stop looking for alternative conceptualizations of client reactions and for alternative approaches. Thus, labeling creates stuckness. Further, as will be discussed later, we create what we talk about. If we talk about clients' reactions as being resistant, we are creating the very thing we want to avoid. The more you study what is commonly labeled as resistance, the more you will recognize that such labeling is of little therapeutic benefit. Indeed, it is most likely harmful. Before any behavior is deemed resistant, the counselor should rule out a host of alternative conceptualizations.
There are a multitude of possible explanations and meanings for what is often labeled resistant behavior. Below are some of my own and some from various sources. These ideas are offered in an effort to be thorough and to add utility to this course by increasing the understanding of the many client dynamics to which therapists must adjust. These ideas are not presented as a definitive list nor are they assumed mutually exclusive. Many have overlapping components. They are presented to stimulate ideas about what may be occurring within clients that may appear as resistance to therapists.
When you find yourself frustrated with a client's lack of progress, read through this list and assess whether any of these ideas may be legitimate conceptualizations of the underlying factors resulting in the lack of movement. Typically, after a client dynamic is understood, it is less likely to be perceived as resistance. Subsequently, you can adjust your approach and deal with the dynamics at hand.
Resistance has a purpose, otherwise, it would not exist. When you understand the many benefits of resistance, you begin to realize that it is essential for mental health. Drawing from the work of Hycner (1988), Cowan and Presbury (2000) remind us that, "... the counselor must be able to appreciate the wisdom of resistance as the client's way of preserving some important aspect of self or identity" (p. 414). To fully understand resistance, we must recognize and study its many positive aspects. The following purposes and benefits of resistance are compiled from the writings of Anderson and Steward (1983) as well as my own analyses.
Food for thought: Would you rather have a client that does everything you suggest, or would you rather have a client that takes time to adjust to new ideas? Which is more frightening?
"Without resistance we would all be out of a job."
Pipes & Davenport, 1990
The purpose of this section is to take a hard look at what might be occurring in the counseling relationship that may inadvertently create resistance. Many of these points stem from the distinction between what we are trying to accomplish in therapy and what we are doing at present with the client. One of the keys to becoming a master therapist is to develop a keen awareness of what we are doing, literally, at the present moment with the client. Too often, mental health professionals know, and focus on, what they are trying to do with clients. However, these same professionals are not always aware of what they are actually doing with clients – what is happening with the relationship as they speak. Understanding this distinction is critical to managing resistance. When the focus is on what you are doing in therapy, the chances of success are increased.
This section examines what we are doing and the potential impact it can have on creating resistance. Although the initial points presented here are highly interrelated, they are presented as separate issues for clarity.
Among other things, when we experience resistance we say that our client is "not going anywhere." The client is not "invested in changing" and is "showing no progress." We feel stuck. Central to these statements are the questions, "where is the client supposed to be going?" and "the client is showing no progress toward what?" One of the primary therapist errors that causes resistance is failure to establish a mutually agreed upon objective.
The key word here is "mutually." Clients – particularly resistant clients – should be active participants in goal establishment. People do not resist what they want; they resist what they do not want and what is imposed upon them. If we start by first seeking what the client wants, we build a foundation for mutually agreed upon goals. Our initial conversation should set an atmosphere of understanding wherein ideas are not imposed upon the client.
Counselors who impose goals on clients without regard for clients' desires are like salespeople who try to sell products that people do not want. We have all experienced the irritation of a pushy salesperson trying to get us to buy something we do not desire or need. When therapists create goals without client input, they often find that they have inadvertently moved into the role of salesperson. In most of these instances, therapists are trying to sell the client on a particular treatment plan. Ironically, most people enter the counseling profession because they do not like sales work. Yet, they frequently experience therapy as trying to sell treatment plans to clients who are not interested in buying. In order to prevent moving into a position where we are trying to convince clients to "buy" our treatment goals, we should strive to stay in a customer service mode where we aid clients in finding what they desire. This mode of interaction is also considerably less stressful to therapists.
"... conflict between the goals of the therapist and those of the client, often implicit and unacknowledged, forms the very fabric of therapy and contributes significantly to resistance."
King, 1992, p. 167
The significance of a mutually agreed upon goal is substantiated in the insightful and informative research of Hubble, Duncan, and Miller (2006). When factors within the therapist's control are examined, the therapeutic relationship/alliance emerges as primary to successful outcomes. This should be of no surprise. When the therapeutic relationship/alliance itself is factored in, it turns out that agreement between the client and the therapist on the basic goal of the therapy is one of the three critical components that make the therapeutic relationship/alliance work. Thus, of the factors we control, a commonly recognized goal is essential to successful outcomes. (One of the other two factors that form a successful relationship is agreement on the therapeutic processes that must be carried out within the sessions. In other words, agreement on the therapeutic work to be done. The final factor is, of course, the presence of Rogerian core conditions. What did you expect?!)
If you and your client are not in agreement about desired outcomes, problems are inevitable. For therapy to be successful, you and your client should be able to clearly state mutually agreed upon objectives. If mutually agreed upon objectives have not been established and a reasonable time has been devoted to establishing rapport and understanding the client's situation, then it is critical to focus session time on the creation of such objectives.
The next time one of your colleagues complains to you about a particularly difficult client who does not want to change, ask, "What is the goal?" If she begins stuttering or goes into a vague, rambling explanation, you will know that a mutually agreed upon goal has not been established. Then inquire, "If the client was asked what the goal is, would the client agree and could he state it?" It is mind-boggling how many times this essential therapeutic component has not been formulated.
Understand this: Most people do not come to therapy to find solutions to their problems. Most people come to therapy, "... because they realized what the solution was and were terrified" (Walter & Peller, 1992, p. 100). Although there may be exceptions to the above statement, more often than not, it is true. Perhaps you have heard the commonly stated axiom that all clients have the solution to their problem inside; the job of therapists is to help them find it. The reason people are unable to come to grips with a possible solution is that the solution is terrifying. Making the changes necessary to resolve issues in their lives scares the hell out of them. Thus, it becomes much easier not to recognize possible solutions at all.
From this perspective, one of the primary jobs of therapists is to normalize the fears surrounding the solutions and support the client's courage to move forward in the midst of the perceived, impending dread. In cases where fear of the solution is great, focusing too strongly on solutions and goals may actually increase fear. To break the impasse, focus on dealing with the fear that accompanies the solution before moving the focus forward toward actions to be taken. The primary point is that therapists may inadvertently create what appears to be resistance because they have focused the discussion on the wrong issue, or on an issue that should not be approached until other issues are addressed and, at least, partially resolved. In such instances, therapists have gotten ahead of clients in problem resolution.
The issue of defining the problem and thus, the solution and goal, is often directly tied to the "horror of the solution." The more terrifying the solution, the more likely clients will be to dance around the real problem. They will discuss a series of seemingly disjointed incidents or never actually present a clear picture of why they are seeking help. In these instances, the problem is not clearly emerging in the dialogue. Generally, such dialogues are unfocused, scattered, inconsistent, contradictory, and just do not add up and make sense. If this occurs, it is likely that the discussed problem is not the primary problem that needs to be addressed.
Clients that dance around the central issue often feel as if they are resistant. The real issue facing such clients is only discerned from the overall impression of what is going on in the session. The therapist must step back and look at the session as almost an abstract work of art. You must look at the big picture and then find the primary underlying theme that prevents clarity in the dialogue. As noted, this is typically an impending fear or dread that is linked to the problem. As a picture of this theme emerges, the therapist's next task is to find a way to present the theme to the client in a supportive, palatable manner. From this discussion, a coherent problem definition can be developed.
In our clinic we once had a woman who talked for four sessions about how much she hated her husband and how badly she wanted a divorce. We were dumbfounded that she was not proceeding with the divorce. As we addressed the issues further, she began discussing her financial dependence on her husband and the fact that she had no marketable skills to use toward getting a job. This was compounded by the fact that she had children to support, and returning to school for training would be costly and scary. At this point, the entire session changed from focusing on the desire to divorce to focusing on the fears that accompanied the divorce. Hence, we began dealing with the real issues.
As will be explained in future sections, clients that greatly fear solutions to problems are typically said to be in the precontemplative stage of change (See the section entitled, Failure to Recognize and Respond to the Client's Stage of Change). With such clients, therapists must learn to focus on the immediate struggles and not on distant goals. This is often challenging because it does not place emphasis on immediate problem resolution and quick action. The ability to recognize that there is much groundwork that must be laid before direct attempts at resolution are implemented requires much skill and patience on the part of therapists. The ability to understand the dynamics of change across time is a must. The ability to be content with small steps will also go a long way toward making meaningful progress.
"The immature therapist has trouble backing off. Frustration comes easily and is usually answered with more technique and method. Stepping back is letting go of doing things and just taking a look at what's going on."
Ron Kurtz, 1990, p. 60
Here is a simple but powerful premise that was taught to me by Dr. David Burns, author of Feeling Good: The New Mood Therapy, at a seminar he conducted. Dr. Burns stated that you can never help your client until the problem is defined around a specific person, place, and time. I have contemplated and tested this assumption numerous times and have yet to disprove it. If your discussion with your client has not reached the point where the problem can be formulated around a specific person, place, and time, then there is clarifying yet to do.
This is a very interesting idea. Sometimes the person, place, and time are obvious. It might be a husband or wife or boss or child. In other instances, the person, place, and time is the client at an earlier age in a traumatic experience with someone. Sometimes it is the client and you at the present moment in the session. This is because what is occurring between you and the client is often a microcosm of what is occurring with others in his life. Thus, there is no need to seek an outside example when the pattern of behavior is occurring right there in the session.
In most instances, something needs to change in the interaction with the particular person, place, and time. Something must be done to interrupt the current modus operandi. At other times, the client needs to "return" to a point in time in her life, and discuss and reframe events and emotions. Regardless of the case specifics, the person, place, and time components are always present in solvable problems. If you and your client cannot readily state the person, place, and time of a problem, then the problem definition is too vague and progress will be hindered.
What actually happens is that clients have a series of problems. These problems have to be sorted through to determine which one the client wants to work on presently. The problem chosen has within it a series of person, place, and time events of significance. Most likely, there are similar patterns of interaction within each of these person, place, and time events. In order to be helpful, one of these person, place, and time events must be selected and processed in great detail in regard to emotions and alternative approaches. It is at this point that we, as therapists, become helpful. Person, place, and time events are the nuclei of most problems. These core components are only reached when the issues are funneled down to a singular person, place, or time event. Until this level of clarity is reached, clients may appear resistant. When clarity is lacking, establishing specificity is the first step to dissipating resistance. However, as will be addressed, there is a time for generating confusion, also.
An interesting paradox occurs with highly resistant clients. The greater the resistance, the greater the likelihood that the client is refusing to consider any of a host of possible solutions. Because there are so many changes that may bring improvement, possible solutions appear abundant from the therapist's perspective. As you become aware of the myriad possible solutions, you become more certain that your knowledge can help. Because of your certainty, you begin talking more and more as an expert regarding the problem at hand.
But here's the catch. The more of an expert you become, the more you provide the client something definitive to resist. Furthermore, the more of an expert you become, the less psychological freedom the client has to explore possibilities on her own. Thus, your expertise results in the client losing the sense of freedom that is necessary to willingly embrace change.
One sure sign that you have become too much of an expert is "Yes, but ..." answers. "Yes but ..." responses most commonly follow advice and suggestions, or questions that are intended to convey alternative behaviors the client might try. The problem with such comments is that they communicate your expert knowledge. With highly resistant clients, the more knowledge you present about solutions, the greater the likelihood of resistance. Conversely, when you present yourself as less knowledgeable, uncertain, and puzzled, the less you provide a position against which to resist. In addition, when you present yourself as unknowledgeable, you give clients more psychological freedom to "move" therapeutically.
Moving to a position of naivete and unknowing is sometimes difficult because you really do think your ideas could help. However, it is not how much you know that matters. It is not how much you want to help that matters. What matters is what is occurring in the relationship between you and your client at any particular moment. If the client is rejecting your suggestions with "Yes, but ..." responses, he is signaling that he is not buying what you are selling. When this occurs, stop selling and return to gathering information about what the client might accept. This is a classic example of a mismatch between our method of delivering influence and the client's current propensity to accept the method by which the influence is delivered.
Hence, the way out of this situation is to reverse the paradox. The more obvious possible solutions become, the more naïve, inexperienced, and uncertain your displayed attitude toward these solutions should be. In other words, your highly resistant clients should experience you as more uncertain when possible solutions are obvious. You want to avoid creating a situation where your knowledge of solutions emerges in such an overbearing, know-it-all manner that you increase the motivation of your highly resistant clients to try to prove you wrong. You can avoid this dilemma entirely by assuming a naïve position toward solutions. The principle at work here is that your clients cannot be resistant if there is nothing to resist.
My students have referred to this approach as the "Columbo technique" because it is very similar to the approach taken by detective Columbo as he fumbled yet cleverly hoodwinked his suspects into revealing key pieces of information necessary to solve the murder. Columbo apprehended his suspect by appearing unable to understand the basic components surrounding the murder and by asking questions that forced the suspect to clarify her actions. Although Columbo always appeared to be two steps behind the murderer, in reality he was two steps ahead.
It should be noted that there are certain pseudo therapeutic statements that convey a knowing attitude without substantiation and invite challenges from clients. To make such statements is a classic error that should be avoided. Gerber (1986) provided examples of two such statements – "I know how you feel" and "I understand." If you suspect you know how clients feel or you understand their situation, then say it explicitly; do not just expound that you know it. (Can anybody really know how another feels?) The problem with such statements is that, if the client challenges your knowledge and you are forced to explain what you think you know, the client can always say you are wrong, and you have no grounds from which to defend your position.
"Where ignorance is bliss, 'Tis folly to be wise."
Thomas Gray (1716-1771), English poet
A long-standing maxim in counseling is, "Clients do not care how much you know until they know how much you care." Yet often, after some therapeutic experience is gained, counselors forget the powerful impact and importance of empathic statements. We become lax in consistently including empathy throughout our sessions. Commonly, sessions become loaded with an excessive quantity of questions without a foundation of understanding. What typically follows is that clients lose the feeling of psychological support necessary to proceed safely. Much of the time, the decreased use of empathy is more of an unconscious than conscious progression on the part of the therapist. You have slowly moved away from the basics as your job has become routine. Subsequently, sessions begin to stagnate. An essential component to breaking through resistance is to maintain a foundation of understanding through a dialogue that consistently includes empathic statements.
In addition, there is an even more important reason to consistently use empathic statements. Many times therapists discount and limit the consistent use of empathy once rapport has been established. The logic here is something like, "Now that I have rapport, I will build a logical case for change." However, people do not change because of logic. People change when they have an emotionally compelling reason to change. The energy and drive for all change is derived from an emotionally charged base. Logic alone is not enough. If people changed because of logic, no one would smoke, no one would drink, everyone would exercise, we would not eat the vast majority of the food in vending machines, we would never try to outrun a yellow light or a train, or engage in a host of other stupid human behaviors. Yet, people continue to do these things on a regular basis.
I am not saying that logic is not present in change; it almost always is. Most of the time, it is presented as the reason for change. However, when you closely examine the underlying forces that actually move people to change, they are not logically based. They are emotionally based. You must look below the surface to understand fully the dynamics of change. Logic provides the socially acceptable, sensible reason to change; emotion provides the underlying motivation to initiate and implement the change.
Compelling reasons are compelling because they arouse strong emotions. Yet, because emotions are often linked to uncomfortable feelings, most clients have blocked awareness of, or are in denial about, their own emotions. It is through the use of empathic statements that therapists get clients in touch with the emotional energy needed to initiate change. Empathy is the tool by which therapists get and keep clients in touch with the emotions that ignite and fan the fires of change.
Highly resistant clients need to experience consistent empathic responses in order to build a compelling emotional foundation on which to motivate their logical reasons to change. For most resistant clients, logic without an underlying emotional charge is just talk. Failure to consistently include empathic statements in counseling dialogue inevitably makes the task of overcoming the client's ambivalence to change much more difficult and will likely be experienced as resistance by therapists. Interestingly, it is the highly motivated client that is less in need of empathy, even though you should use it here, also.
The general rule should be, the more resistant the client, the more empathy is needed in the process; the more motivated the client, the less empathy is needed. For compelling research that substantiates the powerful and pervasive influence that empathy has on therapeutic outcomes, see Burns and Nolen-Hoeksema (1992) and Hubble, Duncan, and Miller (2006).
"Change results from a crystallization of discontent."
A significant amount of resistance comes from poor timing. The most common timing mistakes center on introducing new ideas prior to your client being ready to accept those ideas. Anytime you are experiencing resistance, ask yourself, "Am I getting ahead of my client?" If you find that you are ahead of your client, slow your pace, back up, and take smaller steps. Explaining before the client is ready to accept, confronting too soon, and moving too quickly to an action phase are all common forms of bad timing.
In the movie What About Bob, Richard Dreyfuss plays a psychiatrist who suggests to his client, Bob, played by Bill Murray, that he read his book entitled, Baby Steps. He further instructs Bob to take only baby steps toward solving his host of neuroses. As the movie progresses, Bob develops a highly dependent relationship with his psychiatrist as he begins to take baby steps and solve his problems. Although this movie was a hilarious spoof on therapy, the concept is not to be taken lightly. In many areas of life, you must slow down to go faster. Therapy is clearly one of these areas. Teaching and allowing clients to take smaller steps are vital components of effective therapy. Getting ahead of your clients in the change process is a sure way to experience the frustrations of what appears to be resistance.
In order to not rush your client, I suggest that you constantly ask yourself, "What could I say that might move my client the smallest step possible toward where he needs to be to resolve his problem?" In other words, although your client may have an ultimate goal, your immediate task is to simply move your client closer to that goal using the smallest step possible. Rarely should your immediate task be to reach the ultimate goal.
This approach solves two problems. First, it does not push the client excessively and thereby create resistance. In fact, if you can stay "behind" your client in the process, then you can actually have the client pulling you along toward his solution. Second, this approach takes an enormous amount of pressure off of you. The task at hand becomes manageable, and you are more able to remain balanced in sessions. Therapists also need to learn to take baby steps. This skill is an enormous stress reducer.
Therapeutic Tip: Many therapists use scaling techniques to get a feel for the client's position relative to psychological concepts such as the level of emotion, commitment, tolerance, etcetera. Most therapists use a 1 to 10 scale for such assessments. However, in order to allow movement in even smaller steps, I suggest using a 1 to 100 scale. Moving from a six to a seven may be difficult for your client. However, moving from a 63 to a 65 will likely be perceived as achievable.
"Some therapists, most likely beginning ones, are so eager to form a relationship that they do so on terms that forever destroy any therapeutic potential. Other therapists are so eager to force a client toward maturity that they bring pressures to bear on him that are beyond his ability to withstand; unwittingly they drive the client out of the relationship"
Tate, 1967, as cited in Moursund, 1985, p. 80
People come to counseling because they feel bad. They are worried, stressed, lonely, in conflict, or unresolved, and are bewildered as to the direction to go in order to relieve themselves of their pain. To some extent, all clients want to be relieved of their pain without suffering. They do not want to move through their pain, they want to avoid it altogether. Clients would love for you to just take their pain away without any additional distress. As a result, all clients will – to varying degrees – "invite" you to take their pain. Even though the ultimate objective is for clients to feel better, relieving their pain, in and of itself, should not be the primary objective.
This is not to say that we should not provide an environment where clients can fully experience and ventilate their pain. Indeed, the provision of such an environment is one of the greatest gifts we give clients. However, once the anger and the tears are "dumped," we do not pick them up and take them with us. We do not try to directly repair the wound. Instead, we structure our dialogue to honor clients' pain while recognizing that it is theirs and not ours.
As most have been taught in their training programs, this is the difference between sympathy and empathy. Sympathy tends to drain motivation and can reinforce stuckness and suffering. Empathy recognizes and respects clients' suffering. It may actually increase it. Yet, when expressed appropriately, empathy also increases the motivation to change.
Clients extend the invitation to take their pain in a host of ways. It is often difficult to discern how much of what is being communicated is an invitation to embrace their pain as opposed to a genuine expression of frustration. Undeniably, the message is often mixed. Common ways the invitation is extended include histrionic expressions of problems; asking for advice (that is "yes, but-ted" and rarely accepted); expressing problems while avoiding any serious discussion of alternative actions; failing to do what they have expressed is clearly needed; wanting the therapist to change the behavior of another person not present; and framing problems in a clearly unsolvable manner.
We send the message that we have accepted the pain through our actions, the words we use, and the tone in which they are stated. This is often quite subtle. For example, as will be discussed later, the use of the word "we" in reference to problem ownership conveys that the therapist has taken the task of solving the problem as his own. "We need to see what we can do the resolve this," is an example of such a statement. The fine points of such communications should not be underestimated in the quest to avoid cultivating resistance.
Another common way to communicate that the invitation is accepted is by allowing the therapeutic tension to move to a position between the client and the therapist, and not be kept within the client. As previously discussed, moving too quickly puts pressure on the client and, thus, creates tension between the client and the therapist. At another level, it communicates that the therapist wants a quick resolve because she has taken on the problem as hers. Similarly, it is a mistake to excessively pursue clients and keep them in therapy when they appear unmotivated. If the therapist is working harder than the client to get the client to therapy, the responsibility for wellness is clearly misplaced, and resistance is certain.
Felder and Weiss (1991) argue that the therapist taking excessive responsibility for the client is the most common reason for resistance. They point out that excessive concern by the therapist tends to neutralize client motivation. This is because the more responsibility therapists take for clients, the less responsibility is given to clients for helping themselves. Thus, the level of concern displayed is always a delicate balance between the amount needed to maintain client motivation and being so excessive that the client hands the psychological work to the therapist. Therapists who fall into this trap often complain that they are working hard for their clients and getting nowhere. Yet, they are blind to the resistance they are creating through their excessive hard work. Perhaps the secondary gain of knowing we are "working hard" for our clients is just too significant of a feeling for mental health professionals. As a result, we are extremely reluctant to relinquish it to only the mere chance that clients may work through their problems by themselves.
Felder and Weiss (1991) provide an interesting example of accepting the invitation to take the pain. A colleague, John Warkentin, advised that if a client becomes suicidal, that the therapist should make certain that his fee does not go unpaid. To allow the fee to go unpaid would send a signal to the client that she is defective and cannot be held responsible for her debt. To allow the fee to go unpaid sends the message to the client that she is not responsible for herself by reason of some flaw. It would also be a sure indication that the therapist is attempting to take the pain. To the contrary, the client should remain invested in her own well-being, and the therapist should promote such an investment. One must not forget that the client is likely suicidal because she sees herself as flawed already. To relinquish the fee would only reinforce the self-perception.
"If we become more concerned about the patient than she is, we neutralize their motivation; it becomes our problem. We are then in the same position as the parent who has taken responsibility for the child to practice the piano; love of music is sacrificed to the power struggle."
Felder & Weiss, 1991, p. 56
One of the reasons therapists tend to accept the invitation to take the client's pain is that many therapists feel unproductive unless they perceive that they are making the client feel better. Such therapists have never learned how to be comfortable in the presence of the client's suffering. Such therapists usually have a high need to nurture. Unfortunately, this need to nurture overrides effective technique and they unconsciously send a message that they accept the invitation to take the client's pain.
It is a mistake to put too much of the immediate focus on techniques and responses that result in clients feeling better temporarily. Therapists who do this in excess run the risk of creating a therapeutic relationship that repeatedly band-aids the client's problems with no long-term resolution. You will know if you have done this because you will recognize the patterns that emerge. Clients will come in with their current catastrophes, you will talk with them and get them momentarily relieved of their agony, and they go their way only to return and repeat the pattern. Or, perhaps clients will make statements like, "I just love talking with you. I feel so good for the few days that follow. Then I get down on myself and have to come back to get another boost from our talks. You are a wonderful person. I am so glad you are in my life." Although such comments may be immediately gratifying for counselors, they can be an indication of a classic therapeutic error.
The error is that you have not designed a dialogue that keeps the therapeutic tension with clients. This therapeutic error fosters resistance in a covert manner. The mistake is often unseen because your repeated band-aiding appears to be effective initially; however, the effect is short-lived. Problems arise because the motivation for genuine, lasting change is diminished as a result of clients being able to get quick, temporary relief. You have used your understanding and skills to take away too much of your clients' pain. Subsequently, the motivation for long-term change is reduced as well.
Often, such clients are often the ones that you carry in your mind as you go through your weekend. You hurt while your clients go nowhere. As the pattern repeats, such clients become quite exhausting. After awhile, you wonder if you should stay in this business when you feel so bad and your clients make so little progress. You experience your clients as resistant when, through your style of dialogue, you have removed their motivation to change through an over emphasis on feeling better. You have forgotten the wisdom of Albert Ellis who is fond of pointing out that feeling better does not equal getting better.
It is important to remember that you should not appear to place blame on clients in the slightest way when constructing a dialogue that maintains the therapeutic tension. With highly resistant clients, recognition of the clients' part in creating their pain should emerge from within as a result of their constantly explaining the dynamics of their situation to you. The dialogue styles taught in this course always have this underlying goal.
"Feeling better does not equal getting better."
Although we commonly view change as a momentary or short-term event, it is not. In most instances, change takes place gradually, over time. To help understand the process of change, Prochaska has developed a transtheoretical model of change that conceptualizes change as occurring over time in relative stages (Prochaska, DiClemente, & Norcross, 1992). However, this perspective has appeared to be ignored by many counseling theories. Most counseling theories approach clients as if they were all at the same general point in their struggles. Yet experience teaches us otherwise. The Transtheoretical Model construes change as a process involving progression through a series of five stages. A brief explanation of the five stages follows.
1. Precontemplation is the stage in which people are not intending to take action in the foreseeable future, usually measured as the next six months at least. However, people can spend years in this stage. Although family, friends, or employers may be acutely aware of the problem, people in this stage are typically unaware or under-aware of their problem. Alternatively, they may have tried to change a number of times and may have become demoralized by their inability to do so. Such people tend to avoid reading, talking, or thinking about the negative consequences of not changing. When they show up for therapy, it is often because of pressure or coercion from others.
People who attend therapy because of threats of losing their job, threats of divorce, or threats from parents or principals are often in this stage. People who are court ordered, or people who must attend in order to receive medications often fall into this category also. Those in denial typically fall into this stage. Many times, once pressure to attend is removed, they drop out. They may make statements like, "I guess I have faults, but there's nothing I really need to change," or they may only "wish" to change. Such clients are often characterized in most theories as resistant or unmotivated or as not ready for change. The fact is traditional counseling theories are often not designed for such clients and do not present approaches that are effective in helping and managing them.
Unfortunately, a substantial portion of clients seen at community mental health centers fall into the precontemplation category and are immediately pigeonholed as resistant. For such clients, it is imperative to spend much time building rapport and discussing their situations in a non-threatening manner. Your (covert) goal should be to engage them in a discussion of how the situation is a problem. The least threatening way to do this is to inquire as to how it is a problem for them. Remember, these clients usually do not recognize that a problem exits. Any session in which there is some recognition of a problem should be considered a success. To expect more is unrealistic and a cognitive distortion of the therapist.
Remain puzzled and naïve in the midst of overwhelming evidence of issues. Do the unexpected by not pointing out the obvious and not criticizing them for their lack of movement. Seeking immediate action is most often futile and a therapeutic mistake. They are masters of avoidance and you cannot create movement if they do not allow it. You will likely be defeated in your efforts if you appear coercive. Remember, if you push these clients, all they have to do to sabotage and thwart your efforts is nothing.
2. Contemplation is the stage in which people are aware that a problem exists and are intending to change in the next six months. However, just as in the precontemplation stage, people can spend years in this stage. It is in the contemplation stage that people are deeply struggling with the pros and cons of change. The internal conflict between the sacrifices and benefits of change produces profound ambivalence that keeps people stuck in this stage. Thus, there is awareness that a problem exists, but no commitment to action. They make statements such as, "I have a problem that I think I should work on," with the operative word being "think" and not "work." We often characterize this phenomenon as chronic contemplation or procrastination. Examples of people in this stage may include those considering divorce, changing jobs, losing weight, or starting an exercise program.
These people are not suited for approaches that assume immediate action is forthcoming. The therapeutic focus should be on examining the internal struggles. Any conversation that engages the client in a discussion of the pros and cons of change should be considered a success. Gestalt techniques such as the empty chair may be appropriate but may be experienced as quite threatening. The main point here is that therapists should keep in mind that it is a mistake to measure success in terms of immediate action. With contemplators, if you seek immediate action, you will likely increase resistance.
3. Preparation is the stage in which people are intending to take action in the immediate future, usually measured as the next month. They have typically taken some significant action in the past year. For example, if they are planning to divorce, they may have seen an attorney. If they are beginning their diet, they may have consulted a physician or joined a health club. They may have read a self-help book and scheduled an appointment with you. The preparation stage is a planning phase in which clients are beginning to actively carry out their plans – small behavioral changes have occurred and additional action is planned for the very near future. Thus, the primary focus should be on whatever is needed to sustain a continued commitment toward further action. These are the people best suited for most commonly taught counseling theories.
4. Action is the stage in which people have made specific overt modifications in their lifestyles within the past six months. The major changes for which they have been preparing are occurring. Because they are in the midst of change, they may be encountering unexpected consequences about their choices and motivations. The counselor's job is to provide an environment where all of the issues present can be analyzed. An emphasis on long-term consequences may be important, as doubts are likely to emerge. Or, perhaps there is little doubt about the current course of action, and the client is seeking validation of the decisions that he has made. Regardless, counselors should give emphasis to continued support and encouragement. This is also the point where issues of relapse begin to emerge because of the consequences of change becoming more real. Thus, along with promoting continued movement, the focus should begin including vigilance against relapse.
5. Maintenance is the stage in which major changes have occurred and people are working to prevent relapse. Because the major changes are already in place, people do not apply change processes as frequently as do people in the action stage. Here, clients are less tempted to relapse and increasingly more confident that they can continue their change. However, maintenance should not be viewed as a static stage. Maintenance does not mean completion. It is critical that clients continue to work to nourish implemented changes. The therapist should focus on gathering an understanding of what the client is doing that is working and reinforcing a continuation of such behaviors. Alcohol and drug clients who have been clean for a reasonable period fall into this category. Failure to properly understand and attend to the maintenance stage could result in backsliding into old familiar patterns.
The relationship between Prochaska's model and resistance is self-evident. Too frequently, therapists approach clients as if they were in a later stage of change when they are not. Most commonly, we assume clients come to therapy ready to change (preparation stage) when they are actually in a precontemplative or contemplative stage. Highly resistant clients are almost always in the precontemplation or contemplation stage.
Furthermore, the therapeutic approaches used for each stage vary considerably. What works for a preparation or action stage will likely be ineffective for the precontemplation or contemplation stage. What is effective for someone in the preparation stage will indeed create much resistance for the precontemplator or contemplator.
To effectively manage precontemplators and contemplators, you might suggest that they, "... move cautiously and slowly as they consider alternatives to their problems and move forward with change." Note that this statement continues to suggest that they "consider alternatives" and "move forward with change." It just presents these ideas with the admonition to "move cautiously and slowly." Why do we present it this way for these stages? Because that's what they are going to do anyway! Why fight it? Join with them at their stage of change, and then proceed from there. Give them the freedom to act independently; this is what they want. If you have an extremely oppositional precontemplator, you might go so far as to paradox him by suggesting that he is not ready to change and you are not sure how to proceed. (You could not be more honest and accurate in your assessment.)
Adjusting approaches and goals relative to the client's stage of change results in a much more cooperative relationship. Although what is presented in this course will work to some degree in all stages, most of what is presented is focused on dealing with those in the precontemplative and contemplative stages.
It is also important to be aware that people do not progress through these stages only once. The more common pattern is to cycle through the stages several times. Many times, clients progress nicely, only to reach a point of stagnation where they move back to a former stage. This is not unusual. Be prepared for such recycling and adjust accordingly. Clients may also be at different stages of change relative to different problems and components of problems. Recognizing this, therapists may have to constantly adjust approaches as different problems are addressed. To enhance movement, therapists should learn of past progress and struggles, building a knowledge base of client strengths and resources from which to draw as new issues arise.
After a stage of change is determined, therapists should be careful to set goals appropriate for the current stage or one stage beyond the client's present stage (Littrell, 1998). This approach results in more manageable goals and more motivated clients. Goals that are only appropriate for later stages will appear unfathomable and impossible to those in the beginning stages of change. Such goals are a nice way to create resistance, though.
The following brief assessment questionnaire comes from Littrell (1998) who adapted it from the work of Prochaska, Norcross, and DiClemente. This brief assessment is useful in determining general stages of change.
YES NO 1. I solved my problems more than six months ago.
YES NO 2. I have taken action on my problem within the past six months.
YES NO 3. I am intending to take action in the next month.
YES NO 4. I am intending to take action in the next six months.
Assess the stage of change using the following criteria:
Precontemplation: no to all
Contemplation: yes to #4 and no to all others
Preparation: yes to #3 and #4, but no to the others
Action: yes to #2 and no to #1
Maintenance: yes to #1
It should be noted that Prochaska, DiClemente, and Norcross (1992) argue that the stage of change is the second best predictor of client progress. The most influential factors are centered on therapeutic components such as helping relationships, consciousness raising, and self-liberation (i.e., self-commitment). It follows that correctly identifying a client's stage of change and aiming toward taking small steps that consistently prepare the client for the next stage of change are strategic for utilizing these findings.
Therapeutic Tip: If you have not currently conceptualized your clients by their stages of change, I suggest you do so. Then, before each session, review the stage of change in which you suspect your client to be and acquire a mindset going into each session to respond accordingly. This is yet another technique that will not only reduce resistance and help your clients, but will also greatly reduce your personal stress. As you learn to approach clients with not expecting more than is reasonable relative to their stages of change, you take pressure off yourself to perform therapeutic miracles. Your assessment of what can realistically be expected becomes more grounded in reality. In turn, you will feel better about your work.
"... it is well known among experienced clinicians that rigidly expecting a client to change at the therapist's rate, rather than according to the client's own internal rhythms and personal abilities, is tantamount to setting that person up to fail."
Dolan, 1985, p. 20
Cognitive distortions are most commonly associated with client problems. Yet, some therapists hold internal beliefs that lead to unproductive therapeutic approaches that invite resistance. Many times, we may not be consciously aware of our beliefs and how they lead to the resistance we wish to avoid. Sometimes, one needs to look inward and ask what fundamental beliefs are held about one's self and therapy, and how these beliefs may be encouraging resistant behavior from clients.
There are numerous cognitive distortions that promote what feels like resistant behaviors. Some of these distortions are listed below, along with a brief discussion of the pitfalls inherent in them. I am certain that there are many other cognitive distortions with similar themes; however, a study of these should suffice to exemplify how our own attitudes, no matter how good the intentions, may work against us. Some of the distortions discussed are my own and some are adapted from the writings of Aldo Pucci (2001) and Corey, Corey, & Callanan (2003).
As you read, ask yourself how many of these might apply to you. It is very difficult to be a therapist and not at some time or another have embraced some of these thoughts. Beginning therapists are especially likely to fall victim to these notions. If, as you read, you realize that you are hearing echoes of your own thoughts, consider how you might adjust your thinking in order to reduce resistance.
"My clients want to change."
"My clients do not want to change."
"My clients should not be ambivalent toward changing."
"My clients should be easy to work with."
These statements cloud an accurate perception of the truth – clients are ambivalent about change. That's why they are talking to a counselor. To hope for or assume anything other than ambivalence with regard to change is unrealistic and unproductive. Erroneous beliefs about motivations and conflicts associated with change often lead the dialogue in unrealistic directions. Learn to accept and be at peace with your clients' ambivalence toward change.
"My job is to make my clients feel better."
"It is beneficial to try to remove my clients' distress and discomfort."
As noted previously, the notion that clients come to counseling to feel better does not necessarily mean that we should attempt to alleviate all of their distress. Too much sympathy and distress abatement may lead to a lack of motivation to change on the part of clients. In such instances, you are only "band-aiding" the problem. With resistant clients, counselors should strive to keep prominent the emotional distress that results from repeating unproductive behaviors. This provides an emotional reason to act. Hence, the therapeutic tension should stay with the client, not with the therapist.
"My clients should and will change when they understand the logical flaws of their current behavior and the logical benefits of alternative approaches."
"If I could only present stronger arguments for change, my clients would 'see the light' and begin doing things differently."
These two statements stem from the assumption that change occurs because of logic. Oh, if it were only so easy! As noted elsewhere in this course, people do not change because of logic; they change when they have an emotionally compelling reason. The problem with the cognitive distortions above is that they lead to a dialogue that presents what appear to be logical arguments for change. Rarely will logical arguments, in and of themselves, produce change. More importantly, arguing for change through logic often creates resistance. Change is a much more complex process than mere logic. The fact is that logic plays only a small part in the overall dynamics that foster change. Therapy is the art of getting clients in touch with all of the underlying factors that support the logic.
"The more I put pressure on my clients to change, the faster they will change."
"I go into every session with an agenda to get the client to do something different."
With resistant clients, such cognitions are likely to hinder the therapeutic process. Increased pressure often slows change and promotes resistance. Agendas aimed at getting clients to act immediately are very likely to fail. Approaches that are more paradoxical in nature have a greater chance for success. Therefore, to promote change with resistant clients, remove the pressure to change. For example, you might suggest that your client move slowly at implementing new behaviors.
"My clients should work as hard as I am."
"I have to be successful with all of my clients."
"My job is my life." (Thus, failure at work = failure in life.)
"I am responsible for my clients' behavior."
Such statements will likely put undue pressure on you to promote change in your clients. When this pressure is transferred to clients, resistance may result. The fact is that your work and your client's work are different. You should be working hard to create a dialogue that maximizes the potential for change and avoids the pitfalls of the nonprofessional whose understanding of the change process is limited. Clients should be working hard at facing their inner struggles and at adjusting to the realities of their lives. If you feel you are working harder than your clients toward a resolution of their problems, something is amiss. You are likely working at the wrong thing.
Further, I know of no therapist who has been successful with all of her clients. The truth is that sometimes the therapeutic process just does not work, no matter how hard you try. If you are unrealistically burdening yourself with your clients' lack of progress, then get real and cut yourself some slack.
This section addresses overarching ideas for handling resistance. Some of what is presented here is based on correcting therapist errors presented in the last section. This creates some redundancy in the presentation of some of the material. However, from my experiences in teaching these concepts, I have concluded that it is more practical and effective to divide the "what not to do" and "what to do" components into two separate sections. Besides, redundancy is not necessarily a bad thing. Most learning is a result of spaced repetition – in other words, redundancy.
Please bear in mind that the ideas and techniques presented in this course are intended for use with clients who display considerable resistance in therapy. In general, the more resistant the client, the more you will be required to adjust your approach. Although you could use these techniques with all clients, if clients are highly cooperative, some of these techniques may be unnecessary or even excessively time consuming.
Furthermore, if I am confident of my rapport and of the motivation of the client to implement change, I may respond in a manner quite opposite of what I am suggesting. The bottom line is, do not assume that you must employ certain approaches in all situations. One of the things that make therapy so interesting is that each situation is unique, and there are no set rules on how to approach every situation. What may increase resistance in one situation may be extremely therapeutic in another. Research has repeatedly indicated that the client-therapist relationship is a critical or primary factor that contributes to change. Therapeutic relationships are often quite unique from one client to another.
Indeed, research appears to indicate that therapists’ emotional reactions to clients influence subsequent resistance presented by clients (Westra, Aviram, Connors, Kertes, & Ahmed, 2012). As would be expected, positive reactions toward clients from therapists were associated with lower levels of resistance and greater reduction of resistance present. It appears clients’ awareness of therapist’s reactions toward them diminishes resistance and, subsequently, improves outcomes. These findings only confirm what Carl Rogers observed and discerned more than fifty years ago: The therapeutic relationship is the critical factor in effective therapy.
Similar findings emerged from a study of adolescents diagnosed with depression and therapists’ approaches in the first session (Jungbluth & Shirk, 2009). Therapists who attended more to understanding client experiences and who were less structured in the first session promoted more client involvement in subsequent sessions than therapists who were less focused on client experiences and more structured in the initial session.In light of the above comments, some fundamental guidelines to consider are provided below. Bear in mind that resistance is a complex matter. You cannot effectively resolve your resistance problems with just one or two maxims. Yet, you can have great impact through the application of these principles, as these points are pertinent for the majority of situations.
Before addressing some specific principles, I would like to point out that we frequently can prevent resistance by foreseeing it and circumventing it before it arises. Many times, we can almost predict that certain procedures, questions, and approaches common to mental health practice are likely to arouse resistance. This being the case, it is amazing how often we continue on without making any attempt to thwart the relatively certain resistance we are kindling.
When you know that there is potential resistance on the horizon, it is best to make attempts to avert it before you get there. This is typically done with some dialogue that attempts to lessen the probability that the client will respond in a resistant manner. What follows are two excellent examples of how taking time to address issues in advance can be very effective at circumventing future resistance.
In one of my seminars, a woman who was quite frustrated with the excessive intake interviews she is required to complete in her work with adolescents, told me how she has learned to avoid shutdown to interview questions. Before the intake begins, she says something to the effect:
I am going to ask you a series of questions. To some of these questions you are going to answer, "I don't know." Sometimes you will answer, "I don't know," because you don't know. Sometimes you will say, "I don't know," because you are really saying, "I don't know you well enough to tell you the answer to such a personal question." If this is the case, I want you to know that I understand, and that you do not have to answer such questions. Perhaps some time in the future when you feel more comfortable, you can reveal more about yourself.
Prior to making this introductory statement, "I don't know" responses were common. She recognized that such responses resulted from the intake interview process itself, which is prone to arouse resistance. After implementing her own policy of addressing client feelings with the above statement prior to encountering such feelings, she stated that she has not had any problems with gathering information from adolescents. This is an excellent example of how taking a few moments to recognize the client's position and to address potential resistance areas can go a long way in reducing resistance. Such approaches should be standard practice with the unrealistic, burdensome interviews that mental health professionals must conduct.
A colleague of mine, Dr. Graham Disque, uses a similar approach to everything he says and does in the counseling session. Prior to beginning sessions, he tells clients that if they do not understand why he is asking or doing something, or if they are uncomfortable with anything he asks them to do, they are to stop and ask why he is doing what he is doing and express their discomfort. In other words, he sets a tone where the entire counseling process is wide open to explanation. Nothing is a secret. Nothing is covert. Nothing is done without the client understanding what the counselor is trying to accomplish. The client is not pushed to discuss any topic he does not want to discuss. All discomfort is addressed first, if the client so desires. Dr. Disque refers to this approach as honoring the resistance.
By taking the time to allow the client to understand the process, and by respecting and addressing the client's discomfort with certain topics, resistance is dissolved. This is a beautiful example of creating an atmosphere that continuously allows the client the freedom to address his concerns. The client is given complete control. When this is done, there is nothing to resist! There are only topics to discuss. Every session is designed to deal with each moment of resistance as it arises, and prior to it becoming a major barrier to therapeutic progress.
Approaches similar to these should be implemented whenever experience dictates that resistance is looming on the horizon. By recognizing and honoring the resistance, many problems can be averted.
"Engagement predicts outcome. Your job is to keep the client engaged."
Clients vary considerably in their degree of embarrassment and willingness to discuss problems. Some clients are fearful of discussing their problems. Such clients may feel inadequate or shameful for having problems. Clients reluctant to talk often anticipate responses that include criticism. Other clients, however, talk openly about their diagnoses and problems as if they are proud of them and are challenging the counselor to do something about them. Open clients, who are also resistant, are often prepared for confrontation, and have a packaged set of responses regarding their situations. Regardless of the degree of openness, resistant clients tend to anticipate certain common responses and have well prepared answers that are intended to defend the status quo. These responses usually present arguments for the futility of their situation or contend that the problem lies with someone else.
Clients who have talked to non-mental health professionals (and some professionals) have likely heard the standard "how-to-fix-your-situation" advice commonly dispensed. Most frequently, this advice does not mesh with the client's view of the world. Years of research and experience have taught us that such socially typical responses are of little benefit. If socially typical responses were effective, we would not need trained counselors – clients could talk to anyone and get better!
As therapists, we know that socially typical responses are, by and large, ineffective in creating therapeutic movement. Typical responses beget typical reactions, and typical reactions keep clients stuck in their situations. In such scenarios, what appears to be resistance is fueled by the commonplace. This is one reason why the brief therapists argue that problems are maintained by attempted solutions that are ineffective (Walter & Peller, 1992). Our typical responses and reactions are likely to be incorporated into established, ineffective, attempted solutions. The more we respond in a typical manner, the more likely we are to become part of the system that maintains problems.
In order to avoid the pitfalls of typical responses and the resistance that follows, you must consistently strive to avoid the commonplace. You must avoid typical verbal and non-verbal responses. In doing this, you surprise clients, you confound their anticipation of your response, and you begin disrupting the patterns that are inherent to their problems.
The unexpected does not have to be complex or foreign to counselors. The better techniques taught in training programs are unexpected by most clients. The empathic statement, the avoidance of questions with preordained answers, the lack of criticism, the nonjudgmental posture, or the statement that has the appearance of puzzlement or agreement with the client are all unexpected. Most of what is recommended in this course is unexpected by clients, but known in some manner by counselors.
When resistance is encountered, the prevailing urge is to speed up the session and break through the resistance. Instead, slow the pace. Increase your use of silence. Make sure that each statement by the client is fully addressed and processed in detail. "The devil is in the details," is more than a bit of folk wisdom. By addressing the details, you show genuine concern and respect for the client's issues, and you are more likely to get to the crux of the issue.
Take a moment and review a few of your most successful cases and breakthroughs. You will find that your success was because you took the time to discover and discuss a detail in the client's world that had never been addressed previously. It is my experience that these elements are always present when significant therapeutic impact has occurred. I challenge you to review your own experiences and disprove this idea. Resistance dissipates when details are processed. "First seek details" should be your established rule of thumb. The devil is in the details and so is the solution!
Ferreting out details is also essential to the basic counseling skill of funneling problems into manageable segments. As noted in the last section, manageable segments always include a person, place, and time. The process moves from deciding which problem to address to finding a particular person, place, and time element of the problem to gathering specific details about the observable and psychological dynamics of the person, place, and time elements. When you recognize that details are essential for solutions, you will naturally move through these steps. Thus, recognition of the critical importance of gathering details puts you on the right track.
As you gather details, process the client's feelings relative to meaning. You should constantly seek to determine the specific feelings present as the client discusses situations. Effort should be made to determine the most precise feeling word that accurately fits what the client is experiencing. Once this is established, you should seek to answer the question: What does this situation mean relative to the client and her world? Feelings and meaning should be brought to the forefront and allowed to be present in the room. This is where clients find emotionally compelling reasons to change.
These steps are foundational to the therapeutic process. Most people have never openly explored these dynamics in detail. Lay conversations rarely tolerate this level of emotion and depth. This will have a very different feel for clients and perhaps for some therapists. Through this process, ineffective client logic will begin to slowly dissolve, and genuine reasons for change emerge. That which is processed, changes. A pace that is too quick does not allow time for thorough processing.
One way to slow the pace is to increase your use of silence and the time between speaking your words. Increasing your use of silence does two things – it creates pressure to fill the space and it provides time to think and feel (Gerber, 1986). Most resistant clients avoid both of these tasks. Yet, it is the pressure to fill the space as well as the time to think and feel that leads to clients doing the work. The real therapeutic work is done in the time between the words, during the quiet moments when new perspectives are embraced. If this is the case, then increase your use of silence and increase this therapeutic work time.
Taking this a step further, many therapists often feel as if they are trying to pull or push their clients through the change process. This is not only hard work; it is very stress-producing. To make matters worse, it fuels resistance. The key is to slow your pace to the point that you appear to be "behind" clients in your understanding and awareness. Thus, you keep clients explaining to you in order to pull you along. You create an environment where it appears that you are trying to catch up with them. When this state is achieved, resistance dissolves.
Please note, however, that slowing the pace does not mean to become passive and slow the therapeutic work. To the contrary, you slow the pace to intensify the therapeutic work. You slow the pace in order to focus on and magnify clients' internal struggles, and to search for answers. As noted, the therapeutic tension should not be between therapists and clients as the therapists try to pull their clients along or coerce new perspectives. The therapeutic tension should be within clients as they face their inner struggles.
Speeding up the conversation places the therapeutic tension between you and the client. Take some time to observe the pace of conversations during arguments, notice how the quickened pace increases the tension between the parties involved. This is not where we want the therapeutic tension to be. Slowing the place is one of the easiest ways to keep the therapeutic tension with the client. Another subtle benefit of slowing the pace is that it provides a few extra moments for the client's defenses to dissipate. As noted earlier, when you try to go too fast, you begin doing the work yourself and change takes longer. Always keep in mind that increasing the pace often places the therapeutic tension between clients and therapists. Slowing the pace keeps the therapeutic tension within clients where it should be. In counseling, you will be rewarded if you slow your pace.
I have often noted in my seminars that, "Direction is more important than speed" (Wade Cook, 1996). In the current managed care environment of mental health there is simply too much sacrificing of direction for speed. Therapists and their clients frequently feel as if they are going nowhere fast. (Unfortunately, many are!) Direction is never acquired by going faster. To develop some direction you must first get your bearings. You then assess where you need to go relative to where you are. In order to take these steps you must first slow down. Therapy is a slow-down-to-go-faster business. In therapeutic work, rare is the case where speed trumps direction in usefulness.
Therapeutic Tip: Sometimes clients get nervous and excited as they approach difficult material. Others are slow to take cues that suggest slowing the pace. In such instances, you might directly instruct clients to slow their discussion by making statements such as, "In order for you to help me fully understand your world, let's go over this in slow motion."
"Direction is more important than speed."
Wade Cook, 1996
Much of the time, clients do not appear logical in their behavior and assessments of their situations. Yet, regardless of how foolish, ridiculous, inappropriate, illogical, absurd, dumb, ignorant, weird, bizarre, unreasonable, preposterous, peculiar, strange, or abnormal we think their perceptions are, clients have a perceived need to cling to them. Thus, you should always address clients' perceptions, and the accompanying resistance, with care and respect. We should take time to honor the resistance. As Cowan and Presbury (2000) point out, "... resistance is evoked in the relationship between counselor and client when the client interprets the behavior of the counselor to mean that a repetition of injury may occur" (p. 418).
Disrespecting the client's perceptions and resistance is to reject the client's experience of reality and thus, to reject the client. As Moursund and Kenny (2002) noted, "A client who is stuck is very likely to experience whatever you do as criticism, since he is already criticizing himself for being stuck" (p. 94).
Historically, one of the best predictors of counseling outcomes is the client's experience of the counselor's acceptance. Showing a genuine respect for the client's resistance is typically your first opportunity to do the unexpected. This will be quite surprising to many clients, particularly when they have some awareness of the absurdity of their positions. Therefore, respecting the resistance is one of the first opportunities to do the unexpected and, thus, begin disrupting patterns.
The struggles of anthropologists offer an insightful analogy to what we often encounter in therapy. When anthropologists find a new culture they desire to study, their primary fear is that, by studying the culture, it will change. They approach the new culture with great respect in hopes of not influencing its natural state. Interestingly, regardless of their efforts not to change the culture, merely studying it inevitably changes it. However, if you go into a foreign culture and try to deliberately change it, the culture most often will resist the new ideas. This is similar to what many therapists encounter.
When we approach clients trying to change them, they resist. When we approach clients trying to understand them, they change. My colleague, Dr. Graham Disque, teaches that we should treat each client as a unique culture to be understood. With this approach, change is likely to occur on its own. Through displaying respect for clients' resistance, we gain access to studying their world. When we display respect, the client is more likely to let us into his world and see its inner dynamics. And, just like the anthropologist, the mere study of a person (or culture) results in that person changing. When we study the counseling process, we discover that many times we do one thing in order to accomplish another thing. This is one of the many paradoxical lessons we have to learn in the counseling profession.
The exception to the rule of always respecting the resistance would only come after a lengthy number of sessions when rapport was substantiated, when issues were well formed and processed, and when the justification for the therapist's confrontation has been established. At such junctures, it may well be appropriate to challenge openly the erroneous logic that has been confirmed from prior discussions. However, until such a time, respect all client positions, thereby minimizing the chances of intensifying resistance.
"If the therapist is not being sensitive to something the client needs, something about safety or being understood, then the client will resist. It is a mistake to attempt at the level of method before relationship is firmly established."
Ron Kurtz, 1990, p. 58
As discussed previously, with highly resistant clients the more you become an expert, the greater the likelihood of creating resistance. In order to combat this dilemma, maintain an attitude of naïve curiosity. Constantly exhibit a posture of puzzlement. This, in turn, will keep your clients in a mode of constantly having to explain things to you. The more they are explaining, the more they are working. The more they are working, the less they are resisting. If someone were watching your sessions, it should appear as if the clients are the experts, and you are being taught by clients about their situations.
As noted earlier, you should become like an anthropologist who is completely uninformed about a new culture – your client's life. With this approach, you are constantly learning and observing in an attempt to put the pieces of your client's life together to make sense. Another way to conceptualize this is to imagine you were from another planet and you are completely uninformed of the ways of the planet on which you have just landed. Your client is your guide to life on this new planet. Further, because you do not want to make any social blunders, you want to learn about life in this new world, the rules that people follow, and why people act as they do. You listen intently as your client explains her world as if it is the first time you are learning of these new ways and behaviors.
It's amazing how many headaches you can avoid through being naïve. When the going gets tough, think and act like Columbo. Ignorance is bliss, and the appearance of ignorance may be as close to bliss as it gets when dealing with highly resistant clients. The general rule is something like this:
The more resistant the client, the less you know.
The more motivated the client, the more you know.
If clients are motivated and cooperative, and you have a good idea, then by all means, tell it to them. If they accept your suggestion, move forward. If they are reluctant to accept your suggestion, become naïve.
Directly related to maintaining a position of naïve curiosity is the fact that about 85% of what we communicate is through paralanguage. Paralanguage consists of the voice tones and inflections, facial expressions, and physical gestures we make as we talk. Approximately 50% of paralanguage is communicated through body movements and gestures, and approximately 35% of paralanguage is communicated through voice tone and inflections. Only about 15% of what we convey is through words alone. Thus, most of what we are communicating is received by the listener through paralanguage. As you apply the approaches presented in this course, remember that your paralanguage is critical to successfully dealing with resistance. A well-worded statement delivered with incongruous paralanguage could be extremely detrimental. The art of maintaining a puzzled, naïve position is built largely upon paralanguage. To be convincing in your naïveté, make certain that your voice tone, facial expressions, and body posture convey puzzlement. Keep in mind that you do not know your client's world – that you truly lack understanding of their perspectives. The more you remain cognizant of this fact, the more aligned your paralanguage will be with your words.
The art of therapy may be more in how you say your words, than the words you say.
We create what we talk about. If we discuss negative, resistance-promoting characteristics as if they are a reality, we reinforce their presence and influence. Interestingly, this is true even if the negative characteristic is discussed in an unfavorable manner with the intention of discouraging its presence. How can an undesired characteristic or behavior be pointed out without, to some degree, implying that the undesired characteristic or behavior currently exists? When possible, it is best to avoid labels that create and foster resistant behavior.
It is unfortunate that I have to add the "when possible" comment. However, I am well aware that the procurement of most counseling services is dependent on ascertaining and assigning a diagnostic label. Unfortunately, once a diagnostic label is attached to a person, that label in itself may contribute significantly to resistance.
Yet, as therapists, we do not have to continually add to the negative impact of diagnostic labels with the language and terms we use in sessions. It is a grave mistake to label a client as stubborn, obstinate, hardheaded, resistant, and the like. Such labeling not only belittles the client, it feeds the very characteristics to be overcome. Many uninformed texts teach that therapists should be careful to "criticize the behavior and not the person," or "label the behavior and not the person." Such tactics are presumed to get around the labeling problem. I think this is pure bunk. Most people do not discriminate between themselves and their behavior. Further, most people never take the time to analyze whether a statement was made about something they did as opposed to who they are. To most people, such statements are personal criticisms, period. And, when used in therapy, they promote resistance.
Recognizing that it is virtually impossible to conduct a therapeutic dialogue without some reference to the undesired, what are we to do? How do we discuss the negative characteristic or unwanted behavior without promoting it? It is really quite easy. When discussing the negative, simply refer to the lack of the presence of a desirable characteristic or behavior. For just as a negative behavior cannot be discussed without it being presumed at some level, likewise, a positive behavior cannot be discussed without it being presumed at some level.
Read the four example statements below.
Bad: "You really are stubborn."
Often Taught: "At that point in time, you responded in a rather stubborn manner."
Better Yet: "At that point in time, you responded in a 'less than open' manner."
Even Better: "At that point in time, you struggled to ... be open to other options."(Ellipses [...] are used to indicate a brief pause.)
Notice how the first response directly labels the client as "stubborn," a poor choice of words. The second response attempts to label the behavior and not the client. However, the statement is detrimental in that the implication that the client was stubborn is still present. The third and fourth responses discuss the client's actions in terms of a positive behavior that was not present; there is no mention of a negative behavior or label. In addition, these two statements also bring to mind and, subsequently prime the client for, an alternative, perhaps more helpful, behavior (See the section entitled, The Compelling Power of Priming).
Master therapists are aware of the pitfalls that come with a poor choice of words and consistently edit their dialogue in a manner that avoids unproductive labels while priming the client for alternative responses. Later sections discuss and teach the linguistic techniques presented in this example.
"Humans tend to resist changing enough on their own, without being helped to do so by negatively being labeled for their distressing."
Albert Ellis, 2002, p. xii
Often, when a point of resistance is reached, it is only touched upon briefly. This is followed by the client, and sometimes the therapist, deflecting and changing the subject to lead the conversation away from the point of resistance into a more palatable topic of discussion. Although there may be an array of specific reasons for the client's deflection, it is generally because the conversation is in some way threatening or uncomfortable. The therapist deflects because she senses the resistance and does not know how to proceed effectively. The hope is that some progress may be made with another topic of conversation. Although this tactic may prove effective on occasion, it typically just becomes an endless dance of avoidance. The unfortunate reality is that this is likely one of those times that the therapist feels inadequate and, in turn, labels the client as resistant.
A more effective approach would be to slow the pace, attend to details, become naïve, respect the client's beliefs, and go into the resistance, but not in a direct manner. From the client's perspective, the conversation should feel as if it is a supportive quest for understanding. From the therapist's perspective, the conversation should always have the ultimate goal of dealing with the current point of struggle. There should always be a clandestine focus on the issue on which the client is stuck.
Interestingly, many clients appreciate this approach at some level, particularly those who have a part of them that recognizes the importance of changing. Those who do not appreciate your efforts will, nonetheless, be dealing with their struggles. Remember that the real reason clients are there is to deal with their resistance. Do not disappoint them.
It is also important to note that you should find the place where your clients are stuck. Dr. Graham Disque has often pointed this out. His main premise is that the therapy begins after you get to the stuckness; up until that point, you are just gathering information. After you get to the stuckness, then you work with the client to find a way out of the stuckness. To this end, therapists should develop an appreciation for getting stuck with their clients. Therapists should strive to find the stuck place and remain composed when there. The more you can model composure when faced with the stuckness, the more clients can feel comfortable with their unknowing. This is the first step to helping. This is a significant skill in our work.
It should be noted that the current point of struggle is also the place where clients will attempt to lure therapists into taking on the burden of their problems. Be careful not to take this bait. Do not accept the invitation to take the client's pain. Many resistant clients are masters at sucking you into their world and enveloping you with their issues. While approaching the resistance, it is important to keep the ball in the client's court. Discovering and clarifying the point of stuckness does not mean that you take on the stuckness as your problem. Do not let your clients hand you their problems and manipulate you into accepting their immobilized mindset.
Universally, clients come to sessions and discuss problems from a negative language framework. They rarely use words that express what they want; rather, everything is expressed in terms of what they don't want. They make statements such as, "I don't want to be depressed," "I don't want to feel nervous," "I want to stop fighting with my spouse," "I have got to stop this procrastinating," or "I want to stop obsessing about ...." Statements such as these are only stating what isn't wanted – the desire to remove a negative. Such descriptions say nothing about what is wanted. As long as your clients are talking in the negative, there is no expression of what is desired. There is no direction in which to go. There is no goal.
Further, continuing to discuss what is not wanted actually maintains it. For this reason, always take the time to establish a positive reframe on negatively expressed desires. For example, not wanting to be nervous may be reframed as wanting to be calm, poised, or cool. Not wanting to fight with a spouse may be reframed as cooperating, listening, respecting, or understanding each other. Not wanting to procrastinate may be reframed as "doing it now," "beginning tasks," or "acting immediately." Please note that these are just examples and that the client's own words should be used instead of the therapist's reframe. To do this you simply inquire, for example, "Tell me what would you be feeling or doing if you weren't feeling nervous," or "Give me an idea of what you would be doing if you weren't fighting with your spouse." Once you get the information, from that point forward, make all of your discussion statements from the positively desired perspective. It is a significant therapeutic mistake to allow negative framing of goals and desires to remain the norm of the dialogue. Once the positive frame is established, all future conversations should avoid bringing up what is not wanted. This should be a consistently occurring dialogue style.
Commonly, when the inquiry is made as to an alternative positive behavior, clients cannot respond in the positive. Many times, they state that they do not know. If this is the case, then this is the precise issue that should be focused upon. This is where you want to be working. Refer to the section entitled, Managing "I Don't Know" Responses for details on how to proceed.
The significance of this idea cannot be overstressed. The theory behind this concept is discussed in detail in the section entitled, Words, The Fundamental Tool of Therapists. Ideas and techniques aimed at developing the want or positive side of change are presented throughout this course.
Change rarely occurs when someone feels certain. Change usually occurs as a result of confusion. If your client is not confused, change is not likely. If you try to fight a position of certainty, you will likely create resistance. Certainty is common with teenagers – the age of infinite wisdom – and with adults who are strongly entrenched in their position.
When you encounter people who are quite confident of their positions, listen with great curiosity and keep seeking explanations and details. Eventually clients will corner themselves with their own contradictions. For some clients, it can be quite helpful to make statements that foster confusion. Once confusion is established, the stage is set for change. When their logic fails, the critical window that creates the possibility for change opens.
When a contradiction emerges, it is important that you become puzzled and confused in seeking to understand the contradiction. Empathize with the client's confusion. This, in turn, can be followed by a suggestion that new ideas may emerge to resolve his confusion. For example, "This is really a confusing situation for you. Perhaps you will discover some new perspectives as you work to resolve your confusion and move toward clarity." Of course, this must be done with a paralanguage that conveys genuine puzzlement and concern. If your paralanguage reveals that you think you are clever because you have confounded their logic, you will likely make matters worse. Your apparent lack of understanding and apprehension for the client as he struggles to reach resolve should be founded on a base of genuine concern for the client's growth and well-being.
In summary, for the resistant client who is not confused, it is important to foster confusion before introducing new ideas. It is much easier to germinate change from confusion than certainty. Thus, if a client is not confused, first confuse him, and then promote alternative perspectives and change.
Although there is definitely a place for confrontation in counseling, if you confront too early in the process, it will likely be counterproductive. There are two fundamental reasons to avoid early confrontation. First, with highly resistant clients, confrontation that comes before considerable rapport and a thorough discussion of surrounding issues will usually result in even greater resistance. The right to confront must be earned over time. Confrontation that occurs before a critical level of respect is earned will likely hinder the process. Effective confrontation is always dependent on proper timing.
Second, rarely is the initial issue the "real issue." Likewise, the initial reason for resisting is often just a "surface reason" and deeper reasons that carry more significance have yet to emerge. To effectively deal with resistance, deeper issues need to be discovered and processed. Premature confrontation often precludes the emergence of the more significant issues that are critical to promoting genuine change. Premature confrontation risks losing the client. A client might shut down or artificially acquiesce. Once this happens, deeper reasons for resisting are less likely to be addressed. When more profound reasons for resisting are addressed, surface rationales dissipate.
The rule of thumb is to avoid early confrontation. Confrontation is typically best delivered after respect is well established. Furthermore, excessive, repeated confrontation can also promote resistance. This is because the impact of confrontation is lost due to desensitization from being confronted repeatedly. Confrontation is discussed in detail in Chapter 12 in my book in the section entitled, After Much Time and Consideration, Confront.
This section introduces some fundamental, overarching concepts about language that are critical for effective therapeutic dialogue. Every suggested response in this course incorporates, to some degree, these points. Study these ideas until you have a thorough understanding of their significance. Much resistance can be avoided through the consistent application of these points of language.
The primary point asserted throughout this course is that a considerable amount of resistance is overcome through the meticulous, precise use of words accompanied by congruent paralanguage. This fundamental premise is based on two underlying, rudimentary ideas. The first is that all language is hypnotic – all words and paralanguage influence. Words and paralanguage are the primary vehicles by which influence is transmitted and conveyed. Words are the tool by which our minds are changed. Your indigenous language is the programming language of your mind. Even if not openly acknowledged, anything heard or read by someone impacts that person to some degree. Well-stated comments have a great deal of impact and influence.
Understanding this, the second rudimentary point is that, if you are talking to another person, you cannot avoid manipulation. If you are talking to another, you are manipulating him. And, if you are listening to someone, he is manipulating you. The degree of influence and manipulation varies considerably from one situation to the next. Everyday conversation does not generally result in substantial manipulation or impact. However, each of us can recall a time when an off-the-cuff comment by another individual substantially shifted our perspective. Although most advertisements do not greatly manipulate the average person, there are times when advertisements have struck a chord in each of us and influenced us to buy a product. Some people are more easily influenced by everyday conversations and advertisements, and are often taken advantage of by the endless manipulations present in our world.
The times when a comment or advertisement seem to influence us the most are when the message delivered connects with some internal need or struggle we are currently experiencing. If, at some conscious or unconscious level, we are searching for clues to aid in discovering the solution to an internal struggle, it appears that we are more open to the influence of statements that connect with this struggle. It is as if our need for an answer automatically focuses our attention on things that may lead to it. Thus, if we have a problem with dirty carpets, we are likely to tune into advertisements that proclaim the power of products to clean carpets. The degree of influence by language is directly related to our internal need to hear what is being said. Therapy is, by design, a place where the influence of words is magnified.
"Words are our most precious natural resource."
James Lipton, host, Inside the Actors Studio
In therapy, the client has internal needs. We provide words and language that hopefully tap into those needs and influence the client toward finding her way to fulfilling those needs. The influence of our words is magnified by a number of factors. One such factor is clients' foremost needs, which are usually quite high as is evidenced by their seeking counseling. Another is the physical environment – usually a rather neutral room, in a private setting, with few distractions. In addition, there are the rules and content of the conversation. For example, the conversation is held in strict confidence and is usually very focused on emotionally burdensome issues. Thus, the therapeutic environment is one in which the manipulative power of words is augmented by the nature of issues and the context in which they are discussed. The therapeutic environment is designed to be one of the places where words have greater influence. In therapy, the fact that we cannot avoid manipulating is amplified.
Although it is not conventional to describe therapy as manipulative, it is. The job of the therapist is to acquire an understanding of the client and use this understanding to manipulate the client into doing the difficult task he desires to accomplish. We manipulate the client into accomplishing the goal sought through providing a dialogue that aids the client in resolving the struggles inherent in the goal accomplishment.
The idea of manipulation is frequently not used in conjunction with discussions of therapy because the term often carries negative connotations. This is a result of the term being commonly associated with self-serving agendas. However, we do not manipulate for our benefit; we manipulate for the client's benefit. Not to understand that therapy is manipulative is naïve. Because we cannot avoid manipulation, we must constantly be aware that we are manipulating and learn to actively manipulate for the client's benefit. Thus, the question is not, "Do we manipulate?" The question is, "In what direction and in what manner do we manipulate?"
Some of the most ineffective and dangerous therapists are not cognizant of these points. They go about their craft unaware that they are manipulating constantly, whether they want to or not. Their lack of awareness leads to a haphazard, deleterious use of language that promotes resistance and may even make problems worse. Those who realize that all language is hypnotic and that you cannot not manipulate, understand that language is a primary force that creates realities and moves people in one direction or another. A careful choice of words is the cornerstone of effective therapy.
Aikido (ì'kê-do, ì-kê'do) noun: The Japanese art of self-defense that uses the principles of nonresistance in order to debilitate the strength of opponents.
Aikido is an Asian form of fighting in which all of the moves focus on defending against attack. It is a pure form of self-defense that has no tactics for attacking. The theory behind Aikido is quite sophisticated. The Aikido master is always evading and using the energy created by the attacker against him. One of the fundamental questions the Aikido master asks is, "Where is the one place that I can stand that my attacker cannot hit me?" The answer to this question is, "The place where the attacker is standing when the attack occurs." If I could move to the center of where you are standing, you could not hit me. Your physical center is the point at which the attack begins, all energy moves away from this point. Thus, there is no way to be hit at that point.
Although it is not physically possible to stand exactly where another is standing at the same time, the Aikido master frequently moves in a manner that places him where his attacker just was. The purpose is to move to the position from which the force is coming. At the moment of the attack, this position is unattackable. This is a very different tactic when compared to blocking or defending against an attack. When you block or defend against an attack, you are using force against force.
Fighting force with force is risky business depending on your size and speed. When you use an Aikido style to defend against an attack, you move in a manner that avoids and dissipates the attacking force, rendering it harmless. The issue of size becomes moot. The issue of speed is important but is augmented by direction and the manner of movement.
A similar approach is needed when dealing with resistant clients, except that our defensive movements are not physical; they are built upon the eloquent use of language. To carry the analogy further, size is analogous to authoritarian power in the therapeutic relationship. As noted elsewhere in this course, there is very little true authoritarian power in the therapeutic relationship. (Except perhaps in cases that involve court sanctionings or the withdrawal of monetary benefits, and even then clients have a choice.) We cannot force clients to do anything. As repeatedly noted, all clients have to do to thwart our efforts is nothing. The primary power therapists have arises from their use of words.
Words are analogous to the movement of the Aikido master. Language is the tool by which we evade the resistance (the attack). The primary way that we prevail over the resistance is to not provide a verbally expressed position to resist. Thus, we constantly try to avoid being in a position of opposition to the client. We avoid "us-versus-them" and "give-in-or-dig-in" situations. Instead, we make statements that, even if not in agreement, always appear to carry a degree of understanding.
Ideas contrary to those that are readily acceptable to clients are introduced indirectly, primarily through some form of indirect or embedded suggestion. In this manner, we steadily prime clients for new ideas and alternate responses. While doing this, we maintain a posture that conveys that the responsibility for change lies with the client. Language that directly or indirectly implies that we are responsible for, or are capable of, creating change is avoided. This is because we are aware that, the more we take the responsibility for change, the less likely clients are to implement change. Therefore, we are careful to avoid creating an atmosphere where clients become dependent on the illusion that the therapist will somehow implement some sort of a mystical procedure that will result in change without any effort on their part.
"You do not have to want to stop your current behavior in order to change; you simply have to want something else more."
There are two interrelated reasons for change. The first is that you do not like the status quo, and the second is that you want something else more. Not liking the status quo pushes the client, while desiring something new pulls the client. Clients who don't like the status quo only and who do not have something they desire more, are much more difficult to work with than clients who desire a specific alternate lifestyle. This is because they are only thinking in terms of not wanting rather than desiring. Figuratively speaking, they are only being pushed away from a problem; they have nothing pulling them toward something new. They have no specific direction in which to go. Psychologically, being pulled toward something is more pleasant than being pushed away from something. Although not wanting (pushing) and desiring (pulling) are always linked, most clients have not clearly formulated the "desire side" of the equation – the pull side.
By far, the most difficult clients are those that find comfort and pleasure in their current state, only partially desire to change, and, yet, have a host of problems in their lives. Such clients have little push and no pull. Drug and alcohol clients frequently fall into this category. Those in the precontemplative and contemplative stages of change likely fall into this category, too.
By and large, both therapists and clients conceptualize change from the "fed-up-with-the-status-quo" perspective – the push side. Unfortunately, it is very difficult to change based solely on disliking the status quo. This is because, regardless of the pain of the current state, the status quo is familiar, and a painful "known" is typically less threatening than a new "unknown." This emotional bind is the basis for the old expression, "Better a known devil than an unknown saint." In order for change to be permanent, clients have to discover and define something that they want more than the current state. Once discovered, this realization becomes a powerful force fostering change.
One of the reasons that the development of the desire side is so vital to change is that nature abhors a vacuum. Whenever something is taken away, the void that remains is immediately filled by something else. When change occurs, old behaviors (including cognitions) are stopped. This leaves a void to be filled. It is critical to consciously develop new behaviors to fill this void. When new behaviors are not deliberately created to occupy the void left by the ceasing of old behaviors, backsliding to old behaviors is likely. I personally believe it is inevitable. In some instances, when the void isn't consciously filled, other nonproductive behaviors emerge. The desire side provides new behaviors to fill the gap left by change and, thus, it prevents backsliding. Consequently, the desire side of the change equation has a dual purpose. It motivates by pulling as well as fills voids left by replacing old behaviors.
The more you study the desire side of the change equation, the more you realize that this aspect is more important to change than the "don't want" side. This idea is fundamental to Solution-Focused Brief Therapy approaches that depend almost exclusively on developing the desire side of change. Yet, it is most frequently the "don't want" side of change that brings clients to counseling.
A few examples may help illustrate these ideas:
People do not stop smoking because they do not like cigarettes. Smokers love their cigarettes. They stop smoking because they desire good health, a long life, fresh breath, more money, or to be a good model for their children more than they desire cigarettes.
People do not get off welfare because they want to stop receiving free money from the government. They get off welfare because they desire more money, more possessions, a better self-concept, more for their children, or to be good models for their children more than they desire free money.
People do not stop using drugs because they do not like drugs. They stop using drugs because they want better health, they want to have more money, they want to take care of their children, they want a good job, or they want positive relationships more than they desire drugs.
Much resistance can be overcome by creating and clarifying the desire side of the change equation. Wise therapists take considerable time to establish and crystallize the desire side of client's problems. The next section explains the overarching reason why the specific wording used in therapy is critical to this objective.
Don't think about an elephant. What did you just do? For a brief moment, you likely pictured an elephant in your mind. But the sentence stated to not think about an elephant. However, it is impossible to read that sentence and not think about an elephant. Now read this sentence – Think about an elephant. What did you just do? Again, you thought for a moment about an elephant. It was of no consequence whether you were directed to think about an elephant or not, you still thought about an elephant.
Although this may appear to be a minor point, it is not. To the contrary, it is an enormously significant point when it comes to creating influential therapeutic dialogue that promotes change. The reason this concept is so important is this:
The mind moves you and your listener in the direction of the dominant thought regardless of whether the thought is stated in the positive or the negative.
For statements made in the positive, the dominant thought is simply the content of the statement. However, for statements made in the negative, the dominant thought is the opposite of what is grammatically stated. For example, if you were to say, "Don't procrastinate," the grammatically stated meaning is "get the job done." However, the dominant thought is still "procrastinate" – what is not desired. Other examples that include inappropriate dominant thoughts would be, "Don't worry," "Don't get angry," or "Try not to yell." In each instance, the dominant thought in the statement brings to mind what is not desired.
To quickly discover the dominant thought of negatively worded statements, simply remove the "no's," the "nots," the "shouldn'ts," the "wouldn'ts," the "don'ts," and the "won'ts." What is left is the dominant thought. Statements including these words only convey the "not want" side of change – the push side. They do not convey the desire side of change – the pull side. Such statements ask someone to move away from a behavior but offer no direction or place to move toward. Conversation styles that incorporate the "not want" side of change are only half of the needed dialogue. Further, they are the lesser half of the needed dialogue. The reason they are the lesser half is because they are bringing to mind and, thereby moving clients in, the direction of what is not wanted. This is because the dominant thought is still the "not want" component.
Some might say that this is a trivial point. However, when you study the power of priming and the covert influence of words, you quickly realize that it is not inconsequential. I assert that much therapeutic failure is a result of a lack of understanding of these points. When talking to clients, the message received is not necessarily what you intended to convey. The only way to assure that your responses are not focusing clients on unproductive behaviors is to consistently attend to the dominant thoughts in each statement you make. To decrease resistance, it is critical that therapists learn to always speak to clients using dominant thoughts that lead in the desired direction.
For example, if you say, "Concentrate on not fighting with your spouse," the dominant thought is "fighting with your spouse" (remove the "not" from the statement to reveal the dominant thought). It is very unlikely that the instruction will have much effect toward diminishing fighting. In fact, it may actually increase fighting. On the other hand, if you tell your client, "Listen, respect, and be cooperative with your spouse," you have given a very different instruction that will lead and move your client in a more productive direction. Interestingly, if you tell your client, "Don't listen, respect, and be cooperative with your spouse," and your client remembers your instructions, you may still be leading him in a productive direction. It is doubtful, however, that you would ever make such a statement. On the other hand, you might say, "At this time, you are searching for a way to listen, respect, and cooperate with your spouse." Here, your reflection of the client's struggle also defines and suggests the desired behaviors. Thus, your dominant thoughts lead appropriately.
Clients inevitably present problems in the negative. That is, they tell you what they do not want, instead of what they do want. This is, in part, why they are stuck in their present state. They do not have dominant thoughts that move them away from their current state and lead in a new direction. Most likely, their current dominant thoughts are moving them on a course they do not want to take.
Many times when clients are asked, "Tell me what you want," they will honestly reply that they do not know. This is very significant because, if clients do not have a dominant thought that is leading them in a desired direction, they will inevitably remain in their current state. Similarly, if you instruct, a worrywart client to, "Tell me the opposite of worrying for you," they will most likely say, "Not worrying." As you can readily see, the dominant thought is the same – worry. In both cases, all thoughts remain on the undesired and lead nowhere.
The concept of the dominant thought should be applied at all times in therapeutic dialogue. Whenever clients state concerns or desires in the negative, time should be taken to discover the positively stated opposite of the negative. From then on, you should speak only in terms of the positive side of the concerns and desires. Whenever you establish a goal, it should be stated in the positive in order to deliver a dominant thought that moves clients in a beneficial direction. In your general responses to clients, you should consistently plant seeds of possible actions by using the power inherent in dominant thoughts. In doing so, you are constantly priming clients for future changes.
Effective therapists recognize that their benefit to clients comes from the skilled use of language. All language has inherent power that is either working for or against the speaker and listener. This power comes from the influence of words and is constantly present regardless of whether there is an overt awareness by the communicator or the listener.
One of the language skills that good therapists constantly employ is that of priming. The word "priming" means to prepare for action. As used in this course, priming is a general, overarching term to describe any type of statement that directly or indirectly introduces new ideas to clients and, thus, prepares them for new perspectives and behaviors.
Whenever you incorporate deficit statements, embedded suggestions, suggestions that the current state is temporary, and so forth, you are priming clients for new perspectives and actions. You are introducing new ideas indirectly through the words you choose in your therapeutic dialogue. Whenever you directly suggest or promote a new behavior (e.g., positively worded goals or suggestions about when to implement goals), you are directly priming clients to implement alternative behaviors. Most examples of priming presented here introduce new ideas indirectly. In such instances, we are not arguing with clients about what they should do. Rather, we are using language in a manner that gently suggests and contributes new ideas in indirect ways. All dominant thoughts prime clients for future action.
A simple example of the power of priming can be observed if you first ask someone to say the word spelled by the letters S-H-O-P. Then ask, "What do you do when you come to a green light?" The most common answer is "stop" (Reason, 1992, as cited in Kirsch & Lynn, 1999). In this example, the word "shop" resembles the word "stop" in spelling and sound. Because of this similarity, it influences the listener to respond to the question with the incorrect answer, "stop." Although this an elementary example, the power of the priming influence of language is nonetheless observed. With all priming, the nature of the words that are presented early in the discussion influence the listener in the considerations that follows.
The concept of priming is directly tied to the two basic aforementioned premises: All language is influential and we cannot, not manipulate. It should be clear by now that, whether you are conscious of it or not, you prime your clients. It follows that an understanding of priming is essential for good therapy, and that skill should be developed so that you are priming for the benefit of clients. Even the basic empathic response has priming influence. As is well known, clients are often out of touch with their degree of emotional distress or the deeper meaning of their discomfort. When counselors make empathic responses, clients assess if the words presented accurately describe their world. The words used by counselors prime clients to consider their current emotional state carefully and precisely. Thus, priming leads to greater clarity and self-understanding. Clarity is empowering because it generates more definitive action. Whether we are aware of it or not, we are constantly directing clients' thoughts through the words chosen to describe and understand their worlds.
All priming statements utilize the power of the dominant thought. It follows that the correct use of the dominant thought within priming statements is of paramount importance. This is because all priming components of your responses are, ideally, the building blocks for the desire side of change. Thus, it is critical to word all embedded suggestions, deficit statements, goals, and the link in the positive to plant the seeds that begin creating movement toward specific objectives. If the dominant thought is worded in the negative, it loses significant impact. At the worst, it could be harmful. It also means that we should literally use new and different words in our dialogue. New words disrupt patterns and plant the seeds for new perspectives and behavior. After studying and speaking about this concept for many years, I am convinced that consistently implanting properly worded dominant thoughts in priming statements is a hallmark of successful therapists.
In my seminars, I often ask how many counselors have ever had clients give them credit for some breakthrough statement that, to the counselor's embarrassment and surprise, they never actually made. Usually such statements were perceived by clients as having a major influence in fostering change in their life. It is amazing how many counselors have had this experience! Why are clients crediting the counselor for statements the counselor never made? I believe this phenomenon is a result of the counselor unconsciously (or consciously) priming clients for new perspectives. Clients, in their need to discover reasons for change, assimilate the priming statements and invent a therapeutically impactful statement containing the insights they seek. Clients then credit this never-stated statement to their counselor. I am convinced that this is a process about which we have limited understanding and that contributes significantly to successful therapeutic outcomes.
I cannot emphasize enough the importance of developing an understanding of the concept of priming and the significance of its use in therapy. The research supporting the impact and influence of priming is quite compelling. For those desiring further scientific study of priming, I suggest you start with three articles that review current findings: Bargh and Chartrand, 1999; Gollwitzer, 1999; and Kirsch and Lynn, 1999.
When it comes to therapeutic dialogue, it's not just semantics, it's all semantics.
"... resistance to counseling and to the counselor is not an inevitable part of psychotherapy, nor a desirable part, but it grows primarily out of poor techniques of handling the client's expression of his problems and feelings ... out of unwise attempts on the part of the counselor to short-cut the therapeutic process by bringing into discussion emotionalized attitudes which the client is not yet ready to face."
Carl Rogers, 1951, p. 151
As noted previously, one of the keys to effective therapy is to establish a mutually agreed upon goal with the client. In reviewing principle factors for managing resistance, Haugaard and Sandberg (2008) cited a number of research studies that suggest that establishing clear, accepted goals was a factor. It is astonishing how many times I hear of stories from therapists and clients about therapy that continues for session after session with little or no direction. Often the dialogue just rambles around in circles.
There is an art to creating dialogue that produces meaningful objectives. When such dialogue is done well, clients will experience goal establishment as something that naturally develops as a byproduct of the therapeutic conversation. Clients will not feel in conflict with the goals that emerge. Properly established goals will provide motivation and hope for clients. Subsequently, clients will have a greater sense of meaningful direction.
Timing is critical to goal development. Rushing the process, before issues surrounding the problems are discussed, may foster resistance. This resistance is often a result of failing to address critical barriers to goal accomplishment. In such cases, clients may openly agree to the goal without having any intention of following through. On the other hand, allowing the conversation to ramble excessively without at least an indirect introduction of a goal can be equally unproductive. Clients rarely have clear goals in mind. One of the primary functions of the therapist is to sort through the issues, pain, and confusion, and assist in developing a direction that promotes growth. Many times clients are threatened by the discussion of goals because the underlying implications are that they must face an intimidating task. Thus, great care should be taken in goal creation. When a goal is established, it should have congruence with the client's perceptions of the world and what is possible.
Counselors should be flexible and open with regard to what is deemed a worthwhile goal by clients. A small, seemingly insignificant goal to therapists may be quite significant to clients. The therapist's acceptance of such goals increases rapport, mitigates resistance, and paves the way for future action.
This section discusses specific methods for creating goals. As with much of therapy, goal creation is largely a result of careful wording on the part of therapists. Goals can be gently and subtly introduced into the conversation through the style of responses provided. For example, many times clients will state that they, "just need to talk to someone." Even such vague comments can be politely framed around a goal-oriented empathic statement: "You're experiencing some confusion, and you desire to discuss some of your concerns in order to ventilate, analyze, and sort through issues in your life." Or, "You sound uncomfortable and unclear about some things and want to provide yourself a forum in which you can more clearly determine where you stand in relation to what's going on in your life and what you want." Although the implied goals in these responses are general in nature, the goal oriented conversation style primes clients for future discussions of more specific goals.
Similar to the above example, the approaches below allow goals to emerge as a byproduct of therapists' responses and not so much as a result of direct inquiry. Although direct inquiry can be effective in establishing goals, highly resistant clients may find it threatening and will many times deflect when directly approached. Such deflections often attempt to frame problems in a manner that makes them unsolvable. To this end, resistant clients are masters at constructing a conversation that appears to make problem resolution impossible. We do not want to give them any help.
The first step to effective goal creation is not to focus directly on goals or what the client wants. Rather, the first step is to determine clearly how the problem is a problem from the client's perspective. Once this is accomplished, goal creation builds from a foundation formed by the client's words and meaning. A technique that promotes this process is discussed first, followed by other goal creating techniques.
With all clients, and particularly resistant clients, much can be gained if time is taken to seek a detailed answer to this inquiry – "Tell me how this is a problem for you" (adapted from Walter & Peller, 1992). Unfortunately, many therapists, after hearing a plethora of overwhelming problems, assume why the issues presented are problems for clients. Although such assumptions are likely correct, not taking time to ascertain this information directly limits therapists' capacity to formulate a dialogue that promotes change.
Below are some fundamental reasons why not directly determining this information is detrimental to the therapeutic process.
1. The assumptions about why the issues are problems may be wrong. In my seminars, when I ask participants how many of them have ever proceeded to help a client resolve issues only to later discover that their understanding of the issues was all wrong, most hands go up! When you have such misunderstandings, the motivation for change, the approach for enhancing change, and the desired change may be misconstrued. Subsequently, the therapeutic dialogue may move off course relative to what the client views the problem to be and is willing to do about it. Occurrences of misconstruing the problem components and motivations can be greatly reduced by directly confirming how the problem is a problem for the client.
2. A universal characteristic of clients is that problem definitions are muddy, unclear, and not well-formulated. Most clients are in "vagueville." Many times clients have never fully clarified why their issues are a problem for them. As they clarify the reasons, they often discover new reasons for change as well as possible solutions. Any effort and movement toward clarity is an effort and movement toward resolving resistance. Clarity is always empowering.
In addition, people often come to therapy because they are stuck when weighing reasons for change against fears of change. This is the cardinal characteristic of clients in the contemplative stage. When you take the time to clarify and crystallize the reasons for change, these motives are often amplified and strengthened. As such, they begin outweighing the fears associated with change. At the very least, the reasons for change can be realistically assessed against the fears of change. Sometimes the solution is worse than the problem and clients decide to maintain the status quo.
3. Directly related to number two above is the fact that issues presented initially are often not the primary issues. Typically, below the surface, clients are struggling with deeper issues that are at the root of the problems presented. Thus, as the counseling dialogue progresses, problems often metamorphose and are redefined around new struggles. By taking time to process how the issues presented are problems from the client's perspective, problem metamorphosis is expedited and the issues underlying the presenting problem more quickly emerge. These new issues are what we commonly refer to as "the real problem." Frequently, such issues center on a client fear or internal struggle. This is where the critical work is done because it is here that the real meaning of the problem from the client's perspective is discovered. Often this discovery is just as new to clients as it is to therapists.
4. Through directly seeking why the problem is a problem for the client, therapists and clients are able to construct positive, viable goals building from strengths (as opposed to continuing to discuss negative, "how-do-I-get-rid-of," "how-do-I-stop," or "not-doing" goals that are counterproductive). The conversation format goes from exploring why the situation is a problem for clients, to clarifying what they "don't want," to turning this around and clarifying what they do want. Finally, strategies for attaining what clients do want are ascertained. Note that the change process is founded on clients' reasons for how the situation is a problem for them. When this is clearly established, change is easier to accommodate.
5. When you directly seek an understanding of why the problem is a problem for clients, you are provided reasons for change directly from clients' mouths. These reasons can be referred to when needed to help clients remain motivated. When clients hear their own reasons for change, they are more likely to be motivated. In addition, if clients choose not to change at this point, they are not resisting the therapist's desires; rather, they are resisting their own previously stated motivations. Thus, the struggle (therapeutic tension) remains with clients and not between clients and therapists.
Sometimes counselors are reluctant to attend to this step. This is because it is often quite apparent why problems are problems, and the process appears redundant and time consuming. I agree with both of these points. However, I suggest that the trade-offs are worth it. Keep in mind that we are not doing this merely to establish why problems are problems. There are multiple reasons for directly attending to this step, not the least of which is to have clients work through it and experience the problem definition insights and shifts that result. The primary benefit comes from clients openly stating and, thereby, clarifying to themselves why problems are problems. Of course, counselors' jobs are made easier as they gain access to the deeper motivations for change that emerge.
I have personally concluded that the failure to ascertain directly this information is a fundamental mistake of many therapists. If you cannot explicitly state clients' reasons for an issue being a problem, then perhaps you should consider deliberately taking time to discuss this point in your next session. The greater error is to omit the step.
It should also be noted that this is not a one-time process. Most clients will cycle through – or should be led to cycle through – this process many times; each cycle of discussion leading to greater crystallization of the client's discontent and greater clarity of reasons for change.
With clients in the precontemplative stage, inquiring as to why the problem is a problem for them should be the primary focus and approach. Remember, precontemplative clients have an external locus of control and do not typically see themselves as having a problem or being part of the problem. They often complain about others and the demands placed upon them by others. For precontemplators it is often hard to solidify a problem. Thus, problem solidification is a paramount initial step for this group of individuals. By constantly seeking an understanding of how others and their demands are a bothersome for clients, problems are clarified for clients. Subsequently, the dialogue inevitably moves to discussing clients' actions that might alleviate their concerns. With this approach, the process of exploring what clients are doing to maintain problems is introduced into the conversation by clients themselves as they discuss how to eliminate their perceived problems.
With clients in the precontemplative stage, this approach is much more effective than trying to explain to them why they have a problem. When done in an atmosphere of curiosity and concern, clients build their own case for change. Such dialogue also leads clients to build their own web that captures them in their denial and hypocrisies. Comments that promote this discussion might sound something like this:
"Tell me how this is a problem for you."
"This may sound like a bit of a strange request, but tell me how this is a problem for you."
"Let me confirm that I am on track with you. You have stated that ... and you have stated that this is a problem for you because .... Tell me other reasons how this is a problem for you."
You might also pace and lead as you approach this point:
"As you sit here examining and discussing your situation, and getting in touch with your feelings of ... go inside and, John, assess if there are other reasons how this is a problem for you."
"As you sit here examining and discussing your situation, and getting in touch with your feelings of ... tell me any other reasons that have emerged about how this is a problem for you."
Sometimes it is beneficial to take time to amplify the desire side of change before moving to goal creation. This is because, even though clients might clearly know how the problem is a problem for them, it is sometimes difficult for clients to obtain a clear picture of what they want. When clients are struggling in their conceptualizations of what they want, it is important to slow down and take time to explore ideas and possibilities. As noted, the clearer the reasons for change become, the less resistance occurs. The more clients develop and recognize their own motivations for change, the more likely they are to follow through.
In order to cultivate the desire side of change and to increase motivation, it is useful to explore the benefits of change and the consequences if no change occurs. Statements similar to the examples below can be used to promote this exploration with clients. Those familiar with Brief Therapy approaches will recognize this style of dialogue. It is common to Brief Therapy approaches because they focus almost exclusively on developing future goals. The primary difference in the following examples is that the grammatical structure avoids using questions – a practice common in Brief Therapy texts.
Exploration of benefits:
"Tell me how your life would be different without this problem."
"Tell me how your life would be different if you were resolved on this issue."
Hypothetical exploration of past decisions:
"If you had your life to live over, tell me what one thing you would change relative to this situation."
"Looking back at the beginning of your current situation and knowing what you know now, tell me what you would have done differently."
Looking back from the future:
"If it is a year from now, and you are looking back to this point in time and nothing has changed, tell me what you will wish you would have done differently."
"Imagine it is a year from now, and you still have this problem; tell me what that would feel like."
I suggest that such comments be delivered in a rather slow, thoughtful, philosophical manner as opposed to a brisk, quick, inquisitive manner. The reason for this is that you want to maintain a paralanguage that conveys that you truly do not know what clients will say in response (See the discussion on asking questions with preordained answers in the section entitled, To Ask or Not to Ask, That is the Question). This is much easier to convey with a slow, thoughtful manner of speaking. In addition, the thoughtful, philosophical manner of speaking models for clients that they are to take the time to explore the answer for themselves. Much can be accomplished with the message conveyed through paralanguage. Attending to such details is critical in managing resistant clients.
After the desire side of change is clarified, it is common to move to goal creation. As noted, direct inquiry is always an option for goal creation:
"Tell me what you want."
"Tell me what you want more of in your life."
If direct inquiry results in goal creation, use it. However, highly resistant clients have a knack at avoiding conversations that focus on actually doing something. It is at such junctures that the wise therapist continues to place responsibility for goal creation with clients. This is done through creating a dialogue that focuses on discovering clients' desired outcomes. You do this because you want to avoid creating assumed goals that clients resist. However, you also want to avoid talking in circles with no ultimate objective. The following statements are adapted from the excellent writings of Walter and Peller (1992) and are very powerful tools that aid in avoiding these traps. When clients continue to offer complaints about their circumstances, empathize with their plight and say something like:
"Tell me what about this situation you would like to change, or in what ways you would like to be handling things differently."
"Tell me what about this I can help you with."
"Tell me again what you would like as a result of coming here and discussing your situation."
"I realize that _____ is definitely something you do not want. Help me to understand what you do want."
Such statements should be delivered with candor and genuine inquisitiveness. Be acutely aware of your tone and body language. Uniform inflections across all words generally work well. Do not accent the "I" or the "me." Such subtle shifts in vocal inflections could result in a sarcastic tone that would be extremely counterproductive.
As with all such requests, after you have spoken, model thinking and allow ample time for contemplation on the part of clients. Do not rush this process! You have likely just requested something that clients are not expecting or are prepared to answer. Give them time. If they appear stumped by the request, you might respond with something to the effect of, "This requires some thought." After you make this statement, model thinking. Such statements and actions convey an understanding of the immediate feelings and mindset, imply that clients should be thinking, and acknowledge that they can take even more time to think about it.
Many times clients will avoid the request by changing the subject and returning to their previous dialogue styles. This expression typically has an emphasis on complaints. When this happens, empathize and repeat your request. This may take several attempts. If needed, reconfirm how the complaint is a problem for the client.
Note how clients' responses to the above sample statements begin creating objectives and goals, and place the responsibility for their construction with clients. They also establish a boundary regarding therapists' duties. By using such statements, you distance yourself from taking responsibility for clients' situations and solutions. These statements further establish a position of naivete regarding the therapist's knowledge of a solution. You relieve yourself from feeling as if you have to figure out what clients need or want and thus, you insulate yourself psychologically. I have students who have successfully used these statements with elementary school students.
If clients respond with a "don't want" style of response, empathize, confirm or establish why they do not want what they have expressed, and begin clarifying what they do want. For example, respond, "Tell me what you want more of in your life." If clients respond with "I don't know," refer to the section entitled, Managing "I Don't Know" Responses. Conversely, sometimes clients never openly state that they do not know, they just continue talking around the issue. In such instances, point out what is occurring using an empathic response such as, "As I hear you discuss your situation, I get the feeling you really are stumped as to what you really want." The ability to recognize that clients are not sure of what they want is very important information regarding their mindsets and should be treated as such. Not knowing what you want from your therapist parallels not knowing what you want for yourself. At such junctures, slow down, keep the focus here, and process deeply and precisely. Address meaning. As noted, therapy often requires that you slow down to go faster. This is one of those times.
"... we change when we become aware of what we are as opposed to trying to become what we are not."
Corey, 2001, p.196
Much has been written on the importance of empathy in therapy, and justifiably so. Most graduate programs in mental health spend much time teaching students how to actively listen and make empathic statements. When dealing with highly resistant clients, empathy is paramount. However, empathy alone will not solve all problems. Some well-entrenched clients will respond to basic empathic statements in a manner that attempts to suck the therapist into their stuck world. In such cases, the conversation may simply get mired in the misery of the client without actually creating movement. In order to prevent this problem and to help establish direction and movement in the conversation, deficit statements should accompany empathic statements.
A deficit is defined as that which is lacking. Deficit statements implicitly recognize what clients are lacking and explicitly state what clients need at the moment. By adding deficit statements to empathic statements, therapists bring to the forefront of the conversation what is needed in clients' lives. In this way, the deficit statement primes clients for direction, movement, and goal creation. Yet, when added to the end of an empathic statement, the priming effect goes completely unnoticed by clients. When stated by the therapist with an air of concern, clients never experience the idea as being imposed upon them. Effective therapists understand and take advantage of this feature.
The construction of deficit statements is presented below. Simply attach a phrase similar to those below to the empathic statement and follow this with a statement of what is lacking.
|Empathic statement +||... and what you're looking for ...||+ deficit|
|... and what you need ...|
|... and what you're searching for ...|
|... and what you want is ...|
|... and what you require is ...|
|... and what you desire is ...|
|... and what you wish is ...|
|... and what you crave is ...|
Examples of empathic statements that include a deficit component are:
"You are very distraught over the divorce from your wife. The marriage in which you have invested nine years of your life appears to be coming to an end, and you are searching for a way to make some sense of what has occurred."
"You have tried to have a child for quite some time and are experiencing much grief over the possibility that it may not occur. As you talk about it now, it appears you are looking for a way to begin resolving the enormous dissonance this causes in you."
"You are at your wits end with your children, and are experiencing much anger at your husband for reinforcing their misbehavior. You strongly desire a way to obtain support from you husband and to develop more effective methods of discipline for your children."
If you are correct in your perception of the current deficit, such statements will provide direction and open the door for a discussion of how to go about acquiring what is needed. If you are wrong in your perceptions, clients will likely correct you. When corrected, empathize and clarify the new need, then proceed toward a clarification of goals.
Even though we are labeling this as a "deficit statement," be careful to word in the positive. For example, it would be unproductive to state:
"Your situation is quite irritating to you and you are lacking the guts to speak out."
A much better statement would be:
"Your situation is quite irritating and you're searching for the best words to use in order to have a significant impact."
Although it does recognize a deficit, the first statement above is critical of the client. On the other hand, the second statement gets at the client's struggle to find the right words and to say them in an effective manner. In this statement, there is no mention of a personal shortcoming. In addition, the second statement primes the client to consider making an assertive statement.
Empathic statements are powerful therapeutic tools. The use of empathic statements that include a deficit component is a characteristic that separates the average from the truly skilled.
The miracle question has been presented in numerous Brief Therapy texts as a means of moving the client toward the creation of a solution. When preceded by appropriate therapeutic discussion and delivered at the appropriate time, it is a very useful tool. Its utility stems from its uniqueness and its propensity to move the client toward an examination of possibilities not yet explored. Once these possibilities are developed, it is a simple matter to begin converting them into goals. It is important to remember that this is an unusual question to pose to clients. Provide time and understanding as they work to develop an answer. Your patience as clients work through an answer is key to the question's cultivation of solutions.
Suppose that one night, while you were asleep, there was a miracle, and this problem was solved. However, because this happened while you were sleeping, you have no idea that there was a miracle and the problem is all gone. Disappeared. When you first wake up with the problem gone, how would you know? What specifically would you be doing differently? How would your husband, wife, or children know that the problem was solved without you saying a word about it?
As will be expounded upon, I have a strong bias against over-questioning. Thus, it may be beneficial to convert the miracle question to the miracle statement or, to be grammatically precise, the miracle command delivered with paralanguage that conveys curiosity.
Suppose that one night, while you were asleep, there was a miracle, and this problem was solved. However, because this happened while you were sleeping, you have no idea that there was a miracle and the problem is all gone. Disappeared. When you first wake up with the problem gone, tell me what you would be doing differently. Explain to me how you would know. Give me an idea of how ______ would know the problem was gone.
Littrell (1998) notes that statements that are tailored to the client's world are much more likely to strike a chord and have impact. He suggests that the miracle question can be adapted accordingly. For example, if your client was a person with strong religious beliefs you might say:
"If God changed your life with a miracle tonight, tell me what it would be like tomorrow."
If your client was a young child, you might say:
"If a good fairy was to wave a magic wand tonight, and tomorrow things were different, tell me ...."
Therapists need to assist clients in developing goals that are appropriate and manageable. When goal setting goes astray, goals are not achieved, and clients lose faith in themselves, the goal setting process, and the therapeutic process. There is an art to co-creating effective goals, some of which has been previously discussed. Characteristics of good goals are commonly addressed in texts and at seminars as well. Because many sections of this course address central points to well-created goals, and because the subject is frequently taught, the most common characteristics will not be discussed extensively. However, aspects of goal setting that fall outside of conventional, mainstream teachings will be given additional consideration.
Before reviewing some critical points on goal setting, I would like to point out a rarely taught, little understood aspect of the process – for most people, goals should not be labeled as "goals." Biehl (1995) wrote a very interesting and enlightening book entitled, "Stop Setting Goals If You Would Rather Solve Problems." In his years of work with goal setting, Bobb Biehl discovered that most people do not like setting goals and are turned off by the idea. Most people have a built-in, negative knee-jerk reaction when the topic of goal setting is introduced. However, most people like to solve problems and readily label themselves as "problem solvers." Thus, Biehl separates people into two categories: goal setters and problem solvers. A few general examples of the preferences of goal setters and problem solvers will perhaps further clarify the differences between the two.
Goal setters typically like to create new things while problem solvers like to improve on the status quo. For example, goal setters would rather buy a new house, whereas problems solvers would rather remodel the old house. Goal setters prefer to write a book; problem solvers would prefer to edit a book. Goal setters prefer to score points (offense); problem solvers prefer to keep the opposing team from scoring (defense). Goal setters would rather change their academic curriculum to something new, while problem solvers would rather improve on the current curriculum. Goal setters are concerned with the direction things are going; problem solvers are concerned with what is currently broken and how to fix it. When the boss comes to the meeting and declares next year's goals, the goals setters are excited while the problem solvers are asking when last year's goals are going to be met. Goal setters tend to not see the problems at hand, get bored easily, and fail to attend to details. Problem solvers fail to see the big picture, are leery of the untried, and distrust their instincts in new situations. In the final analysis, goal setters are energized by goals and drained by problems; problem solvers are energized by problems and drained by goals. Say the words "goals" and "problems" to yourself. Perhaps you have an internal sense of which word stimulates and which word burdens.
The benefit of understanding these differences emerge when you recognize that goal setters are much more motivated when they have a goal to accomplish, while problem solvers are much more motivated when they have a problem to solve. Regardless of whether or not you view this as a matter of semantics (which it may well be), the distinction appears to be real in the minds of people and how they perceive themselves. Biehl estimates that between 60 and 90 percent of people prefer problem solving to goal setting.
This being the case, how you frame the task at hand can significantly influence clients' motivations to accomplish it. For most people, instead of talking about goals, simply talk about solving problems. This reframe can be critical and may change the course of therapy. In order to discover whether clients are goal setters or problems solvers, Biehl suggests you ask the following question, "Which would you rather do, define a problem and solve it or set a goal and reach it?" It is interesting how many people are immediately clear as to which they prefer. For those who are not as aware or who may not have a strong preference, a bit more discussion regarding the differences may be warranted. The distinctions presented above can provide a starting point from which to begin such discussions.
Critical Points for Viable Goals/Problem-Solutions
Implementation intentions focus on when, where, and how behaviors that may lead to goal accomplishment should be executed. When focusing on implementation intentions, therapists discuss with clients the specific situations in which alternative responses should be made that would likely lead to goal accomplishment. This discussion clarifies the time, place, and details of what is needed in order to begin moving toward goal accomplishment.
The significance of this differentiation may appear obvious to those therapists who instinctively discuss implementation intentions with clients. However, many therapists do not focus enough time on implementation intentions. Failure to tend to implementation intentions is devastating to goal accomplishment and problem solving. Research has indicated that even a brief mention of implementation intentions can have a significant effect. Further, the more detailed the discussion, the greater the likelihood of client follow-through (Gollwitzer, 1999).
Two primary benefits result from focusing on implementation intentions. The first is that, by detailing when to begin a new behavior, a link is formed between the new behavior and the opportunity to apply it (Gollwitzer, 1999). By discussing implementation intentions, you create the chance for an automatic response or an "instant habit" that overrides the former response style. The second benefit is that this link helps to protect against the influence of distractions and competing responses that may subvert goal attainment. When clients leave your office, they return to their hectic lives filled with automatic patterns and distractions. The real challenge to accomplishing goals is in overriding these patterns and distractions. Detailed discussion of implementation intentions puts the focus on ways to override such automatic responses. The research on implementation intentions is impressive. To review the current research, I suggest you read Gollwitzer.
The more you understand the distinction between goal setting and implementation intentions, the more you realize that the focus should be on the latter. Those who have attended time management seminars have likely been taught that, when trying to accomplish tasks, it is more effective to schedule and commit to blocks of time for doing the work rather than committing to deadlines and overall goals. This distinction is a good example of the difference between focusing on implementation intentions and focusing on goals.
I once observed the Reality Therapist, Dr. R. E. Wubbolding, skillfully demonstrate a Reality Therapy group approach in which he proceeded to ask each group member his level of goal commitment on a 1 to 100 scale. Although most members responded with relatively high numbers, one member responded with a "three." To the surprise of the audience and the group member, Dr. Wubbolding quickly and sincerely responded with, "That's good!" Rather than criticizing the client for a low level of commitment and entering into a discussion with the client aimed at seeking a higher level of commitment, Dr. Wubbolding accepted the level of commitment with glee. He refused to take the bait to enter into a discussion from an openly resistant client. He did not fight the resistance. Imagine the confusion the client experienced as his low level of commitment was embraced. The client who a moment ago was poised to verbally battle, now sat there wondering what had just happened. There was also a slight sense of embarrassment that he had not offered greater commitment in order to balance out the surprising level of acceptance he received. This was an excellent example of not fighting the resistance while, at the same time, doing the unexpected.
When dealing with resistance, it is vital to be vigilant in avoiding typical responses to such obvious invitations for confrontation. As can be gleaned from this example, sometimes-low levels of commitment should be sincerely embraced in order to prevent an escalation of resistance.
"You cannot embrace that which you are not free to reject."
J. Graham Disque
It has been my experience that the use of questions is a very controversial component of therapeutic dialogue. Some approaches – Reality Therapy, Brief Therapy, and Gestalt Therapy, for example – rely heavily on questions. Other approaches, such as Rogerian Therapy, are much less dependent on questions and are often taught with an emphasis on avoiding questions.
One reason there is so much disagreement on the use of questions is that the pitfalls of questions do not readily emerge in the therapeutic process. Much of the time, therapy progresses or appears to progress even if you use questions. This is particularly true with motivated clients. In fact, with highly cooperative clients (those in the preparation or action stage), questions can be effective and save time. Those in private practice who have hurting, paying, motivated clients have likely made considerable progress through questioning and may have difficulty accepting arguments against the excessive use of questions. With highly resistant clients however, the dynamics are different.
Another reason the perils of questions go unnoticed is because questions are such a common part of our language. Your clients are accustomed to them and so are you. This is particularly true when you go to see professionals such as medical doctors or auto mechanics. If your car breaks down, you take it to a mechanic. The mechanic immediately starts asking a series of questions about the problem. If you are like most people, with every question and answer, you are filled with hope that the problem will be fixed and, in a short time, you will have your car back. Because they are seen as an aid to getting your car fixed, such questions provide you with hope and reduce stress. We have a deep appreciation for them and we are disappointed if we are not asked enough of them.
However, taking your car to the mechanic is not analogous to therapy. In the case of the car, you are not going to have to do the work! All you have to do is pay for the service. There is no personal, internal struggle you have to endure when having your car repaired. To the contrary, you are highly motivated because fixing your car is highly desired. It is a win-win situation. Such is not the case with therapy. In therapy, in order to "win," the client must work and struggle.
It should be noted that questions are not readily accepted in some cultures and are considered rude. However, they are quite acceptable in Western cultures. Yet, when dealing with highly resistant clients, questions are likely to impede progress and foster resistance. Therefore, questions deserve attention.
In attempting to create better therapeutic conversation, this section offers some guidelines regarding questions. Please remember that they are only guidelines and that there are always exceptions. I personally would break any rule presented in this course if I believed that it would be of benefit to the client. Nonetheless, the great majority of the time, the guidelines presented offer the better therapeutic approach.
Although it is very difficult to establish hard and fast rules in counseling, there is an overarching principle that should guide therapeutic dialogue – In order for therapeutic dialogue to be effective and of value, there must be something different about how it is conducted when compared to everyday, lay conversation. One of the factors that make therapeutic dialogue unique is that we do not respond in typical ways when clients present information. The asking of questions is extremely common in everyday conversation and, thus, offers little variation from what people receive from talking to untrained laypersons. When you avoid questions, you avoid the commonplace and the problems that questions spawn.
It is important to note from the outset that not all questions are the same. Some questioning styles have greater pitfalls than others do. Some questions are more readily accepted by clients. The therapeutic value of questions is often determined by the context in which they are delivered and the paralanguage skills of the therapist asking them. Nonetheless, anyone involved in counseling should be acutely aware of the influence of questions on the therapeutic relationship, and a detailed analysis of the psychological dynamics of questioning should be an integral part of every therapist's training.
Although all questioning has its potential problems, the primary questioning style that I will be criticizing is that of asking leading questions. That is, questions in which the answer is intended to lead the client toward some insight. With resistant clients, this style of questioning is undoubtedly the worst. Still, the general approach of asking question after question, whether leading or not, can have a devastating effect on the counseling relationship and can increase resistance.
The problems that arise from asking questions are subtle to the untrained practitioner and, most often, go unnoticed. In order to shed light on the underlying complexities of questions, an explanation of some problems that questions generate will first be addressed.
1. Questions have a tendency to put people in a "one-down" defensive position (Ivey & Gluckstern, 1974). The person asking the question has put the ball in the other's court; thus, there is pressure to provide an answer. This one-down positioning occurs because questions are frequently asked with preordained answers in mind. Questions with preordained answers are referred to as leading questions. Here, people are attempting to lead others toward insights or actions with what they think is a clever, indirect approach. However, this approach is so common that it is very transparent and, thereby feels condescending and arrogant to the recipient.
In our culture, people often comment incredulously about the "loaded" question. Leading questions are very frequently loaded. The loaded, leading questioning style is so overused that we have become unconsciously skittish as soon as we are asked anything. We have developed a built-in, knee-jerk reaction to defend as soon as we hear a question being asked. The bottom line is that questions tend to put people on the spot and, as a result, resistant clients will likely "dig in" and defend – the very response we want to avoid.
One of my seminar participants, Greg Kaufman, noted that he had a professor that was fond of stating that a question mark turned upside down is a fishhook. The point being that when we ask our clients questions, we often are trying to hook them in. This is a wonderful visualization to keep in mind when you are feeling the urge to ask a question.
My favorite example of the drawbacks of the leading question came from a seminar participant who worked in an adolescent inpatient facility. At the facility, those claiming to do counseling often asked very obvious leading questions to their adolescent clients. On one occasion a "counselor" asked a young man the very transparent question, "Now, was that a good decision?" The young man seeing through this rather stupid attempt at getting him to admit he was wrong, responded with, "Is that the best you've got?" From this response, it was apparent that the young man readily saw through the feeble attempt at getting him to admit a fault and exposed the "counselor's" weak therapeutic skills. It is important to study such interactions when they occur in order to avoid such blunders in the future.
2. Another problem with questions centers on the fact that, when we have problems, we all dialogue in our mind about our problems. Because the question is such a common part of our language, our mental dialogues include internally asked questions. Because we are usually afraid of the solution to our problems – perhaps more than we are the problems – we tend to develop answers to our internal questions that do not solve our problems, but that keep us stuck in them.
This natural process is greatly enhanced as clients anticipate visiting their counselor. Further, the more resistant the client, the more likely the defensive, unproductive answer will be manufactured and awaiting the unprepared counselor. When therapists ask resistant clients questions, these clients have developed answers that are of little benefit in solving their problems. In responding to the therapist, such clients provide answers that are not helpful and, in the process, lure the therapist into their stuck state in order to validate their belief that little can be done.
When this dialogue pattern is closely examined, it becomes apparent that counselors are asking questions in the hope of leading clients toward some insight. However, what actually happens is that clients are prepared for the questions and answer in a manner that is of no benefit. Consequently, asking questions provides the means by which clients draw therapists into their stuckness. When you ask a question, be careful that you are not setting your own trap!
3. When you ask a series of questions, the implied message the client perceives is something like this: "Once I answer all of these questions, my therapist is going to make her assessment and tell me what to do." This interpretation is particularly common with highly dependent clients. This implied message occurs because it is the commonly occurring dynamic with questions. Similar to the auto mechanic dialogue presented above, people often assume that a therapist's questions ultimately lead to direct instruction and advice. Several problems arise from this underlying message.
The first problem stems from the fact that resistant clients do not respond well to advice. As you ask questions, they are preparing their rebuttals. Some oppositional clients will not follow suggestions simply because you suggested them! On the other hand, dependent clients, who are often seeking advice, end up disappointed because, as good therapists, we do not provide the advice they seek.
Another problem with this questioning dynamic is that it takes responsibility for change away from clients. When you study questioning conversations in most areas of life, you quickly realize that responsibility goes to the questioner, not the receiver. When we ask questions, clients assume that we are homing in on a solution – that we are going to "fix" their problems with our advice. However, our protocol is not that of an auto mechanic, as we do not "fix" any of the client's problems ourselves. Responses that take responsibility for internal struggles away from clients will likely foster resistance.
Remember, many clients come to therapy because they looked at the obvious solutions and were horrified. They are hoping that you will have a solution that avoids the frightening difficulties that they foresee. When you ask questions, you are building the hope of a painless alternative solution. When clients come to the realization that the solution includes personal suffering, you are right back where you started. When analyzed from this perspective, it becomes apparent how the underlying dynamics of questioning often run counter to the therapeutic process.
4. Questions invite "Yes, but ..." responses. Because many questions are typically asked with preordained answers in mind, they open the door for "Yes, but ..." responses. This occurs because clients readily see the assertion being imposed on them through the use of a question and are quick to defend their positions. Remember, they have likely asked themselves the same questions already. They are likely well-armed with a surplus of "Yes, but ..." ammunition. "Yes, but ..." responses generally indicate that you are working too hard and have taken responsibility for finding solutions to clients' problems instead of allowing clients to find their own solutions (Walter & Peller, 1992).
5. The asking of questions often has the built-in assumption that change will occur as a result of logic. As noted, the position presented in this course is that change only occurs when there is an underlying emotionally compelling reason. Thus, we are more effective when we clarify the emotionally compelling reasons for change than when we try to establish logical reasons to change. Many questioning styles have a tendency to lead to a logical analysis of situations. Questions frequently send your clients into their heads to "think" about issues. Although this can be beneficial, excessive logical questioning that is not accompanied by emotionally-based reasons will frequently bog down sessions. Excessive questioning frequently results in an unproductive logical discussion that is void of the emotional fuel for propelling change.
In summary, most people ask questions because they are seeking a known answer and, through that known answer, they are trying to lead the other person toward some conclusion or action. The truth of the matter is that questions suck therapists into the stagnant worlds of clients and trap them in unproductive dialogues. Sometimes clients simply give answers they think will get the therapist off their back. As a result, questions can produce placating answers and artificial acquiescence.
To make matters worse, a question-loaded dialogue may actually feel as if it is making progress. Indeed, you can sit for session after session with a question-laden dialogue and actually sense that a breakthrough is imminent. Yet, after numerous sessions, your client has made no progress. You wonder what is going wrong. The endless stream of questions you asked doesn't even enter your mind as the reason for the stagnation. The subtle pitfalls that questions create are well hidden in the conversation. You have fallen prey to one of the most common linguistic errors therapists make.
"When we indulge ourselves with too many questions, the situation quickly becomes one in which the client feels they are there to be 'worked on,' to wait for questions, to answer them and to wait again, either for another question or to be told what to do next."
Ron Kurtz, 1990, p.154
I am not saying that you cannot have a therapeutic dialogue that includes questions. You certainly can. In fact, questions will be readily accepted by motivated clients who will embrace them as tools to explore their own psychological dilemmas and possibilities. What I am saying is that such dialogues rarely make significant headway with resistant clients. With highly resistant clients, it is a deception that the excessive use of questions will result in any sort of breakthrough. Rather than creating insights in clients, most questions are perilous hazards that should be avoided when possible.
In order to make therapy effective, you should assess clients across a continuum from more motivated to less motivated. Further, you should adjust your techniques and approaches relative to where clients fall on this continuum. Thus, the general rule of thumb for questions would be – the more motivated the client, the more questions can be used; the less motivated the client, the fewer questions should be used.
1. Do not ask questions to ascertain information that is apparent by the client's paralanguage or affect. Typically, this would include asking a question about how the client feels when it is obvious how the client feels from the statements made and paralanguage. This is a common mistake among beginning therapists. An example of such a query would be, "How does that make you feel?" A much better approach would be to respond with an empathic statement that includes a deficit. Even if you are wrong in your perception, your client will likely self-correct and continue without the negative implications inherent in asking questions. In the above example, the negative implication from asking a question is that you are not very perceptive.
2. Do not use a question to grill a client in a way that arouses guilt or ideas of ineptness on the part of the client. Typically, this would be asking, "Why didn't you ...?" or "Why did you ...?" or similar questions with an implied "why." Questions that impose a value such as, "Why did you not use birth control?" also fall into this category. Because of the underlying criticisms such questions convey, they are certain to damage rapport. One of my former colleagues, Doc Whitmore, was often quoted as saying, "When you ask 'why' questions you set your clients up to alibi, justify, deny, and lie." These types of questions should be avoided with all clients and, particularly, with resistant clients.
3. If for some reason you find yourself forced to gather information through questioning, do not ask more than two questions in a sequence without an intervening, empathic statement. In other words, if you have just asked a question, make sure you have fully verified the experience of the client before you proceed with asking another question. However, I would assert that, if you have properly worded your empathic statement and included a deficit component, it is unlikely that you will have to follow with another question.
As a general rule, given the option to communicate with a question as opposed to a statement or command, it is more therapeutic to use the latter. When you make a properly phrased statement or command, you are less likely to create resistance in your client and you are more likely to maintain an atmosphere in which your client is willing to talk openly and explore new perspectives. Of course, as previously noted, this should all be done with paralanguage that communicates naïveté, caring, and genuinely inquisitive curiosity.
The urge to ask questions can be powerful. When you feel this urge growing, the following guidelines are suggested.
1. First, slow down, sit there, and do not ask the question until you further assess the reasoning and need behind the question.
2. Ask yourself, "Is it absolutely necessary to know the information about which I want to inquire?" and "Is it important to know, or am I just curious to know the information?" If you are just curious, do not ask the question.
3. If you think the information is important enough to warrant a question, then ask yourself, "What is happening inside me that makes me want to ask this question?" Many times, you will find a strong emotion within yourself such as fear or concern for the client. Or, you may be aware of an urge to have the client recognize or do something, or an desire to jump ahead because you want to know something about the situation before the client has offered the information. If this is the case, do not ask the question. Instead, make a statement to the client about what you are experiencing. In other words, rather than inquiring about the information, tell the client your motivation or what is happening inside of you that is creating the motivation to ask the question.
Read and compare the feel of each of the questions versus statements examples below. Notice how the statements come across as less threatening and more supportive, yet address the same issue. However, by making a statement you often approach the issue from a different angle. As noted, this skill demonstrates one of the differences between lay conversations and counseling dialogue.
Question: "How much do you want to get over this?"
Statement: "I sense that there is a part of you that is struggling to let go of this and resolve your loss."
Question: "Why haven't you tried talking to her?"
Statement: "I am puzzled as to what your concerns are about having a direct conversation about this"
Question: "Have you tried ..."
Statement: "As I hear you speaking, I am picking up some fear that, if you do not act soon, you will miss an opportunity."
Learning to make statements instead of asking questions is a much more powerful therapeutic practice. By telling clients what is occurring inside of you as you hear them speak, you are providing powerful feedback to clients and modeling the expression of emotions. This feedback raises their awareness of the emotions that they are likely experiencing, but of which they are not fully aware. In this way, you help construct emotionally compelling reasons for change that will enhance therapeutic movement. You are also avoiding the pitfalls intrinsic to questions. Developing this fundamental skill is one of the first steps in moving from a typical conversation style to a therapeutic conversation style.
To circumvent the problems created by questions, therapists should avoid asking them whenever possible. With just a few adjustments in grammatical structure and voice tone, it is possible to avoid questions a great deal of the time. Ordinarily, most questions can be converted to statements or commands by avoiding certain words and phrases at the beginning or ending of sentences.
In the first instance, when you eliminate certain phrases at the beginning of questions, you will change them into commands. Moreover, if your voice tone and paralanguage communicate a genuine concern and curiosity, the commands will not have a commanding feel. I call such statements "curious commands." This is because, when done properly, your response is grammatically a command, but has the feel of a genuinely curious inquiry. The benefit of curious commands comes from the fact that you largely avoid the traps that come with questions yet the information sought is still obtained. Rarely will clients consciously recognize that you are not questioning them. However, they frequently will have a subtle awareness that the conversation feels less threatening. This is because the conversation does not include all of the negative elements that arise from excessive questioning.
Summers (2001) wrote a superb course covering a number of therapeutic issues and skills. This course includes one of the best chapters I have read on asking questions. The following table was adapted from this course. This table was originally developed to provide a formula for asking open-ended questions. I have adapted it to demonstrate the basic structure for converting questions into curious commands.
Converting Open Questions into Curious Commands
|Openers||Directives||Add-ons/Softeners||Object of the Inquiry|
Can you (unnecessary, eliminate)
Could you (unnecessary, eliminate)
help me to understand
|a bit more about
a little about
a little more about
the problems with
something more about
a little more about
some more about
the larger picture
what he/she said
When delivered with the proper paralanguage, curious commands are a power tool for bypassing resistance. This is because they place the therapist in a position of not knowing while, at the same time, subtly directing clients to provide clarifying, detailed information about their current problems. With the curious command, the knee-jerk defensiveness that questions so often provoke is eliminated. Curious commands provide an excellent example of a refinement in talking style that can have significant impact on the client's movement. This eloquent use of language is a component of that for which clients are really paying.
Similar to the opening phrases just discussed, some verbal tags at the end of comments are also unproductive and unnecessary. Such phrases convert perfectly acceptable statements into questions and, thus, bring with them the associated hazards. Furthermore, these tags tend to send the added message that the therapist is right in her assessment. Though subtle, for resistant clients this message may feel arrogant and result in shutdown. The "I am right" component of these statements also conveys a position of knowing that may unconsciously suggest to clients that we (therapists) also know the solution to their problems. When we use such tags, we relinquish our not knowing, naïve, puzzled posture. The result is that such tags tend to foster dependence in some clients by subtly taking responsibility for change. Likewise, these tags create an atmosphere that precludes clients from coming up with their own solutions. Some examples of statements with unnecessary ending tags are provided below.
"You feel quiet annoyed, don't you?"
"You have thought a lot about getting a divorce, haven't you?"
"You wish you had never had kids, don't you?"
"You really let your family down, didn't you?" (This question is bad all around. It implies criticism and interjects a counselor value. In addition, it conveys an "I am right" attitude.)
As with curious commands, it is recommended that therapists examine their style of talking and eliminate ending phrases that convert statements into questions. This is yet another subtle linguistic shift that can have considerable impact on the therapeutic relationship and that can help to eliminate resistance.
Exception: As is so often the case with therapeutic principles, there are exceptions; in certain situations, grammatical tags such as those just described may have utility. Sometimes converting statements into questions is necessary in order to get the non-verbal, unresponsive clients to respond. In this case, the tags provide a verbal cue that a response is needed while triggering an almost reflex-like answer. Thus, the tag can be used to help promote dialogue. If you find it necessary to use the ending tag in order to promote conversation, by all means, do it. However, try to dialogue without the tag initially.
Comments on Brief Therapy's Use of Questions: Most Brief Therapy approaches are couched around asking a series of judiciously designed questions that lead clients toward significant perceptual shifts with regard to problems and, ultimately, solutions. Although such questioning can be very effective with highly motivated clients, it can arouse resistance in unmotivated clients. Fortunately, virtually every Brief Therapy question can be restated as a curious command and lose the interrogating feel of an over-questioning mode of dialogue. I have already noted how the miracle question can be restated as a curious command. Presuppositional questions that assume certain conditions and, therefore, more readily move clients toward a conclusion, can also be converted to commands. Below is an example of a commonly used Brief Therapy question followed by an example of how easy it is to convert such questions into curious commands. This same concept can be applied to virtually any question.
"When the problem is not a problem, how are things different?" This question assumes that there are times when the problem does not exist, and that things are different at those times. Also implicit to asking a question is the idea that clients can describe how these things are different. However, the question may have a leading-the-client feel, may feel a bit like interrogation, and is likely to invite an "I don't know" response.
"When the problem is not a problem, tell me how things are different." This statement assumes that there are times when the problem does not exist, assumes things are different at those times, and explicitly assumes that clients can tell you what these things are. When asked with a paralanguage expressing curiosity, this style is less likely to feel like it is leading or interrogating clients. With this mode of responding, you are less likely to get an "I don't know" type response.
As previously noted, significant resistance can be alleviated with careful attention to paralanguage, particularly voice tone. It is difficult to communicate through the written pages of this course the significant influence that paralanguage has on resolving resistance. You cannot hear the example statements. Suffice it to say, without the proper voice inflection, very little of what is presented will have therapeutic value. The following examples may shed some light on this point. Say each of the questions and statements below with an emphasis on the underlined words. Notice how the underlying message changes with different inflections.
"What did you do?" (Personal sounding, accent on the "you" tends to imply a comparison of "you" to others.)
"What did you do?" (Accent on the "do" tends to maintain a not knowing, information-seeking attitude. This is a much better inflection for a question.)
"Tell me what you did." (A command that still tends to imply a comparison to others.)
"Tell me what you did." (Accent on the "did" conveys curiosity. The better method for gathering information.)
"How do you get along on the job?" (Focus may appear to be on finding a fault in the client.)
"How do you get along on the job?" (Inquires as to methods of "getting along" and not finding faults.)
"What did you do when your husband hit you?" (Possible negative presupposition: You did not do the right thing if there is still a problem.)
"And when your husband hit you, tell me what you did." (Conveys curiosity about the client's response.)
"And when your husband hit you, tell me what happened next." (If spoken with an even tone will result in a much less personal feeling.)
As noted at the beginning of this section, not all questions carry the same implications. Within a suitable context, questions can be used therapeutically. In order to do this, one needs to become acutely aware of the many dynamics that accompany questioning. When studied in depth, the dynamics of questioning is quite complex. Having pointed out the pitfalls of questioning, I would now like to discuss how to use them therapeutically. Questions become therapeutic when the dynamics behind them are understood and when they are used appropriately. The appropriate use of questions, however, requires that they are used sparingly. Excessive questioning is a major factor in creating resistance.
The primary reason that so much presumably "therapeutic" dialogue tends to emanate as questions is that the legitimate reasons for asking questions are also convenient excuses for over-questioning. Recognizing this, the challenge to therapists is to not allow the legitimate rationale for questions to result in excessive questioning that destroys the therapeutic climate. This being said, I am going to present several therapeutically legitimate reasons for asking questions with the understanding that the circumstances for such use should be limited.
1. If not provided an option, it may be necessary to use a question to verify your understanding of information provided by clients. Sometimes clients do not display good paralanguage and do not communicate back to you that your perceptions of their world are accurate. In such cases, you would be better off directly asking clients if you are accurate in your perceptions of their situation than to continue with a dialogue that may be off track.
2. You may also find it useful to use questions to emphasize a point. An example of this would be a question that is intended to normalize an experience. Example: "Who wouldn't be upset if they had that happen to them?"
3. If you need to gather information that is essential to understanding the situation and that is not obvious from what has been said, then ask. The operative word here is "essential." If you do not absolutely need the information, it is better to sit on it for a while and see what develops. Please note, however, that even essential information can also be gathered with gentle commands. Keep in mind that most people who are "trying" to help others often go into a questioning assault mode of conversation. By being careful to avoid such conversation styles, you are automatically doing the unexpected. This will have a foreign feel for clients and, in and of itself, begins to disrupt clients' perspectives on their problems.
4. Another legitimate use of questions arises when you are assessing clients' capabilities for doing some therapeutic task. For example, some techniques require clients to imagine their problem in terms of its color or shape. Not everyone has the ability to do such tasks. It is legitimate to ask, "Can you place your problem on the chair beside you?" "If so, what shape would it be?" and "What color would it be?" Note that such questions are not trying to lead the client to a predetermined answer and, as such, do not have the accompanying pitfalls. Still, when assessing clients' skills at imaginative exercises, be sure to deliver questions with a sense that the answer is truly unknown to you, and with a paralanguage that conveys that not being able to do the task is entirely acceptable. Many clients have difficulty doing imaginative exercises, and you do not want your questions to convey fault. I have a colleague who is a master at presenting such questions. Even before clients answer, he has conveyed through his paralanguage an acceptance if they cannot do the task. When delivered with proper paralanguage, such questions can be quite therapeutic.
5. Finally, questions can be used as tools to lead clients toward exploring new perspectives and possibilities that have not been previously addressed. This is what most people think they are doing when they ask loaded questions with preordained answers. This is also the logic that frequently lures therapists into over-questioning. However, we want to avoid the risks of obvious preordained answers and of over-questioning. We want to approach this use of questions with great forethought and care.
Adding to these points, it should be apparent that many questions are micro-confrontations. These questions put the ball in the client's court. Questions are often asked in an attempt to lead the client toward a preordained answer that is likely threatening to them. Regardless of how non-confrontational you desire to be, the question is a micro-confrontation, at least. Thus, in order to be effective, it should be understood and applied in a similar manner as confrontation. It should be set aside and only asked at well-timed moments within the context of the dialogue (See the section entitled, Resist the Urge to Confront Initially).
The most common mistake is to prematurely ask leading, exploratory questions before the proper atmosphere has been established. A "proper atmosphere" would be one in which you have explored the issues surrounding the answer to the point that clients are ready to provide the answer, or one in which you are certain that clients have the answer in mind and simply need to be gently nudged to embrace it. You will know if you have asked prematurely if clients either evade the question (often perceived as resistance) or are not able to answer. In such cases, you asked before they had begun to form the new possibility in their minds. For the therapeutically leading question to be effective, timing and voice tone are critically important. It may take several sessions before such a question is posed. Use this sparingly! One such question per session may likely be enough for an extremely resistant client.
In order for a therapeutically leading question to work, it must be delivered in the proper manner. Be genuinely puzzled about what you are asking so as to convey a state of true befuddlement on your part and to avoid the appearance of a preordained answer. Your paralanguage must express a state of authentic inquiry and that you are truly not seeking a preordained answer. It is recommended that you incorporate a pace before you lead with a question. For a discussion on pacing, the reader is referred to Chapter 11 in my book.
After you have asked the question, say no more. Do not look at the client. Rather, look off and model pondering the answer. Now wait. Give the client more than ample time to respond. This silence should convey that this is a time for thought, that you are waiting for an answer, and that you will not speak until an answer is given. If the client does not respond after more than ample time, say something to the effect of, "This appears to be a quite difficult issue to ponder," and then process the difficulties. If the client evades, you may have asked too soon. Back off and process the evasion. If the client evades consistently, use immediacy and address this. Consistent evasion is a sign that your client is not yet ready to change and is likely in a precontemplation or contemplation stage. In such cases, back off and adjust your dialogue to accommodate the level of readiness.
Interestingly, if you wait long enough to ask a rather obvious question, the client may begin wondering if you were ever going to ask. In anticipation, the client may tell you the answer in advance. Alternatively, if you wait long enough, the client may be more likely to provide an answer because the waiting has built a special therapeutic tension. The client may even respond with, "I thought you would never ask!" Here, your patience has created an "elephant in the room" effect with regard to the obvious question. You have deliberately created the "elephant in the room" atmosphere in order to prime the client for the impending question. In such instances, you have slowed your pace to the point that the client is pulling you rather than you pushing him. Because of your patience and your understanding of the power of waiting, you have masterfully circumvented the resistance that comes with asking too soon.
I believe that one of the reasons therapists struggle with avoiding excessive questioning is that we are afraid that, if we do not ask, the question will never be addressed. As I have studied the question in therapeutic dialogue, I am convinced that this is an unfounded fear. Let me explain with an example.
I regularly demonstrate counseling theories in my classes. In this process, I also demonstrate that you can have an extended dialogue without questions. In these situations, the clients are always students who have heard my lectures on the pitfalls of questions. Once, after completing a demonstration, the client, who was well aware that I was avoiding a questioning dialogue style, commented about what she recognized was occurring in her own mind. She stated that, because I did not ask her questions, she realized that she was, for the first time, asking and legitimately answering questions about her situation in her mind. Her awareness of this occurred approximately halfway through the session. She was quite surprised and pleased with this insight and revelation to herself and the class. She was also well aware that she had not previously answered the tough questions about her situation. Until this session, she had been avoiding facing the difficult truths about her dilemma.
What I learned from this is that, just because we are not asking questions of our clients, we cannot assume that they are not asking questions in their minds. To the contrary, because we are not asking questions, we free clients to legitimately ask and answer the difficult questions for themselves. Because we are not asking questions, there is no external pressure to fight. Thus, the energy that would have been used to oppose the questioning therapist is now available to deal with the internal struggles.
Because questioning is such a common dialogue style, I doubt it would be possible for most clients not to ask and answer questions in their minds. As therapists, we need to learn to have faith in the process. We need to trust that the real work is occurring with the clients on the inside, even if it is not apparent from their outside demeanor. Perhaps our excessive questioning dialogue is an expression of our lack of patience and faith in the counseling process.
I will note again that these dynamics are much more critical with resistant clients. Motivated clients often welcome the question that allows them to bring the internal struggle into the open. Rarely is this the case with the resistant client. Thus, the dynamics change across the motivated to unmotivated client continuum, and we should adjust accordingly.
There are a number of psychologically significant problems that overquestioning promotes. Conversely, there are a number of benefits to avoiding questions. A summary list of some of the benefits that emerge as you reduce questioning follows.
"I don't know" responses are so common they deserve special attention. In order to maintain your sanity, it is essential that you develop a firm understanding of, and techniques for dealing with, "I don't know" responses. Most likely, your comfort with "I don't know" responses is directly related to your stress level as a therapist. Interestingly, "I don't know" responses are not that difficult to manage, provided you understand the possible meanings behind the statement and have some approaches for addressing them.
It is unfortunate that "I don't know" responses are often frustrating; in virtually all counseling situations, it is imperative to get to the "I don't know" aspect of problems. This is the point where the client is stuck. This is the place you must reach in order to make progress. This is the place where we can be of benefit as therapists. Once you develop skills for handling "I don't know," you will find that you actually promote and like reaching this point. This is because you will know that you are at an important juncture at which you can be genuinely helpful.
Regrettably, counseling texts have neglected to conduct a detailed analysis of the "I don't know" response. This section is an attempt to begin to fill this void in the mental health literature. Later in this section, I will expand on these ideas and discuss how the "I don't know" response is often the doorway into the inner world of clients. I will explain how the proper handling of an "I don't know" response can give the therapist access into the precise struggles that need to be brought to the forefront in therapy.
Meanings behind "I don't know" will first be explored, followed by approaches for managing the response. An analysis suggesting that what lies behind the "I don't know" response is frequently key to therapeutic movement.
"All a client has to do to thwart your efforts is nothing."
Adapted from King, 1992
Unfortunately, “I don’t know” responses from clients are assumed to be associated with resistance in some research (see Westra, 2011, and Westra, Aviram, Connors, Kertes, & Ahmed, 2012, for examples). To make such an assumption is an error. There is much more to the “I don’t know” response than such simplistic views offer.
The first step to managing "I don't know" responses is to recognize that there is a gamut of meanings behind the response. "I don't know" does not mean one thing. When you become acutely aware that it can mean a multitude of things to clients, you have knowledge that motivates you to respond in a more therapeutic manner. You begin to free yourself from the unproductive, redundant patterns into which many therapists fall. Perhaps the most serious mistake a therapist can make is to assume that the response is always oppositional in nature and to engage the clients in a battle of wits in an attempt to secure an answer from them. I can think of no better way to promote resistance. More on this later.
Recognizing that "I don't know" can mean a lot of things, it is perhaps important to explore some of the possible meanings. Below are just few of the multitude of connotations possible. Keep in mind that the list below is seriously incomplete. It is provided here to make a point and to begin to stimulate thinking about meanings.
In my experience, most "I don't know" responses can be responded to with a literal interpretation. That is, your response conveys an understanding of the reality that the client simply does not know or cannot formulate an answer. Even if the client is avoiding the answer, responding literally is the safest way to de-escalate the potential for more resistance. A literal response to "I don't know" would be to reflect and empathize with the client's inability to provide an answer. Examples of such responses are:
"At this moment, you are really stumped as you search for an answer."
"Right now, you are really stumped about what to do."
"It is very difficult for you to see a way to deal with this, currently."
"You really cannot think of a possible approach that you can take that appears better than what you are doing."
If you have acquired a good feel for the situation, it may be helpful to add a deficit statement to your response:
"Currently, it is very difficult for you to see a way to deal with this. You are searching for new ways to approach this quandary."
"It is difficult to sort out these philosophical struggles. You really want some peace of mind and balance in your life."
If you suspect that a client has stated "I don't know" in order to avoid revealing some threatening reality about herself, simply empathize about your suspicion:
"It is difficult and scary to actually say aloud the truth about ..."
"You are really uncomfortable facing this aspect of your life."
If you suspect the "I don't know" is a peacekeeping deflection, then respond similarly with an understanding of this perspective:
"You are concerned that if you provide the answer, it will cause a lot of controversy and conflict among your family."
"You are reluctant to tell me the answer because you worry about how I might feel with regard to your answer. You are worried that I might take it the wrong way."
In order to understand the importance of responding with a respectful, empathic comment, consider the alternative relative to resistance. If you respond in a manner that implies that the client knows and is holding back on the answer, you move into a position of opposition to the client. Once you do this, the client can either "give in" and provide you with an answer, or "dig in" and defend not knowing. The more resistant the client, the more you should strive to avert such situations.
Too often, therapists are convinced that the client does know the information asked and subsequently, focus exclusively on manipulating the client into revealing the answer. Although this may work with motivated, cooperative clients, it can be disastrous with unmotivated, uncooperative clients. This is because it pits you against clients in a game of I-bet-you-do-know-and-I-can-get-it-out-of-you. Such power struggles only fuel resistance.
When you create the power struggle inherent in "give in" or "dig in" situations, you are gambling with your dialogue. You are placing a bet that clients will give in and provide an answer. But what if they don't? You have now created resistance because you have positioned yourself in opposition to your client. So, why take the gamble? With an empathic response, you keep the discussion going. By accepting clients' struggles to answer, you create an atmosphere where they are freer to provide an answer at some later time, after the surrounding issues have been discussed. You have created this freedom because, through your acceptance and understanding, you have created nothing to resist.
Even if the "I don't know" is from an oppositional client who obviously knows, the response should initially be treated respectfully. This is a good example of doing the unexpected. At the least, this will be so unusual and different that it will begin to disrupt her typical pattern of thinking and responding. At best, it may move toward a beneficial discussion. Only after considerable rapport has been established should a counselor confront a client about a clearly unreasonable "I don't know" response.
A universal response with layers of meaning. As discussed in the section entitled, The Compelling Power of Priming, much resistance can be overcome through the precise use of language that is always using the power of the dominant thought to prime clients for new possibilities. An example of a somewhat universal response to "I don't know" that incorporates many of these principles is:
"Right now, it is difficult to imagine saying or doing something different in these situations."
Let's analyze the components of this statement so we can fully appreciate what it is communicating to the client. The first two words, "Right now," convey that the current state of not knowing is only temporary. These words also suggest that, at a future point in time, things could be different. Thus, we suggest that the current stuckness is a momentary state. (See Chapter 11 in my book, Continually Suggest That the Resistance is Temporary, for a more detailed discussion of this concept.) Next note that the dominant thought is to "imagine saying or doing something different." These words prime the client to think of an alternative thing to say or do. Note that the alternative response is broadly described as taking place through actions as well as words. In addition, there is also a recognition that the task is "difficult," thus, empathy is shown regarding the client's struggle. These components alone create a therapeutic response with much utility.
However, there is yet another layer of embedded suggestion that is at work here. Note the italicized words in the statement: "Right now," "imagine," and "different." When voicing the statement, if you accent these words slightly, you are sending a message to the client's subconscious to, "Right now imagine different." This is exactly what you would like the client to do. Thus, movement toward alternatives is further encouraged. All of the above components in combination are what make this response an excellent example of using language for the client's benefit while, at the same time, circumventing resistance.
The overall key to responding to "I don't know" is to react to the meaning behind the response and not the response itself. To respond to the meaning, simply ask yourself, "Why is the client compelled to answer with 'I don't know' at this time?" If you have a moderate knowledge of your client's world, you should have at least a general understanding of the motivation behind the "I don't know." A supportive, empathic comment that demonstrates an understanding of the meaning and motivations behind the response is the safest way to decrease resistance and move forward. Effective therapeutic dialogue is created through such conversation skills.
With all clients, whether resistant or not, I have several suggestions for dealing with "I don't know" answers. The first is to try to avoid statements (i.e., questions) that you are relatively certain will elicit that response. The second is to empathize with the meaning behind the "I don't know" reply. Methods of avoiding "I don't know" responses will be addressed first.
Most "I don't know" responses are a result of the overuse of leading questions. As noted, questions are perilous with highly resistant clients. Moreover, the "I don't know'' response is perhaps the consummate example of what can happen when you utilize a questioning-style dialogue. If you are rather certain that a particular question will result in an "I don't know" response, you would be better off doing one of two things, depending on the client and the situation.
The easiest thing to do to avoid "I don't know" responses is to simply omit the question altogether. Instead, make the empathic statement that you would have made if the client had just answered your question with "I don't know." As a general example, you might say, "I sense that you are stuck as to what to do. You have no idea how to begin doing something about your problems. You are really searching for some new approach that might work." Here, you have avoided eliciting an "I don't know" response because you omitted the question that would have spawned it. If you are correct in what you have said, the client will likely agree and you can proceed. If you are incorrect, the client will likely feel compelled to tell you what she does know about solving the problem. Again, you have therapeutic movement. Similarly, if your client is oppositional, by skipping the question and responding to an assumed "I don't know" answer, the only way to oppose you is to know! Hence, the advantage of this approach is that, regardless of how the client responds, you are likely to promote movement.
If you have already asked a question or are halfway through a question and you anticipate an "I don't know" response, stop what you are doing and regroup. Signal your client not to respond. Assess and cultivate the empathic response you would ideally deliver had the client responded with "I don't know," and say it. There is no need to hide your struggle to adjust your response style. I am personally convinced that clients appreciate experiencing your efforts to respond in an understanding manner. Your open display of your efforts sends a signal to the client's unconscious that you are working hard to move into a position of understanding and away from a position of opposition. It is hard to imagine how such an approach can work against you (Although, I am certain that there is some rare instance out there where it will).
A second approach to avoiding "I don't know" responses is to change your question to something less threatening. For example, rather than asking, "What should you have said to your spouse?" You might instead say, "That must have felt very demeaning to have that said to you; tell me what you wish you would have done." The first approach is a question and, thus, carries the implications of questions. It presupposes that there is an alternate response, and if your client is at a loss for an answer, it may again feel demeaning. Depending on the client, you may be asking for an answer outside of his current insights or capabilities. If the client knew what should have been said, then he might have said it. Further, even if the client knew a better response, this does not necessarily mean it will be provided to you. This is because providing an alternative response to the spouse also carries with it the expectation that the client will possibly have to say it in the future. Such an expectation may be too threatening at this point. Thus, an "I don't know" response is given in order to circumvent the expectation of having to actually say difficult things to his wife.
Although not a perfect statement, the second comment above leads with an empathic expression and follows with a request (grammatically, it is a command) to express the inner feelings at the pretend level. By inquiring as to the client's "wish," you are not looking for a solution, but simply the fantasized response. The client's response to his spouse does not have to be spoken words because you inquired about what "you would have done." Notice that, "... would have done," is less specific than "... would have said." The word "said" suggests that there was an appropriate statement that could have been made. The word "done" is broader and allows for other options, such as walking away. In this instance, the second approach is less threatening and less likely to result in an "I don't know" answer.
If the second statement above results in an "I don't know" answer, this is important information. It may be telling you that the client cannot even imagine an alternate way of dealing with the situation. On the other hand, it could be telling you that every imagined alternative response is too frightening to consider actually doing. This is not resistance. In this client's world, he is truly stuck. For this client, the "I don't know" response is genuinely indicating that he does not know a viable alternative behavior.
In order to avoid creating resistance between the client and yourself, it is important that you slow down and process details, emotions, and meaning. You must learn to be comfortable with the client's not knowing. You must be comfortable with your own not knowing and allow your client to see it. Do not focus excessively on finding a solution. Instead, first engage the client in a detailed discussion of his world and display understanding. Excessively focusing on solutions too early in the process could slow progress.
In summary, if you hear an "I don't know" response coming, stop, assess what you are saying and adjust your statements; you may be able to avoid hearing "I don't know" altogether. With just a bit of practice, action to avoid "I don't know" will become second nature.
Another approach to eliciting answers after an "I don't know" response has been given is to figuratively bring a third person into the room and ascertain what she may say regarding the unknown information. One way to do this is to inquire if the client has friends who are familiar with his situation. Many times clients do have such friends; these friends have opinions and may offer insights. If this is the case, you simply ask what the client hears his friends saying in response to your question. This technique often results in the client providing insights that he may feel reluctant to present were it coming directly from himself. Obviously, the use of this technique is predicated on what you know about clients, their situations, and their friends. Be aware that the friends' responses may not be useful or worthy. If they are not, discuss the benefits and drawbacks.
Another way to introduce information through a third person is to bring an imaginary colleague into the room to express her opinion. You might do this by saying, "I am not sure of my own position on this matter; however, I have colleagues and if they were here right now I could hear her saying ..." You then state an idea as if it were coming from an imaginary colleague in the room. If appropriate, you could even join with your client in opposing the alternate idea presented by your colleague.
By eliciting the response of a third party who is not present, any opposition can be framed as being against her. Thus, the therapeutic tension is between the client and an imaginary person in the room. The advantage of this approach is that it does not place the therapeutic tension between you and the client yet, it creates an environment where ideas are more readily expressed.
Although the following technique has its pitfalls, it is amazing how many times it works. It is presented here because it has a decent record of success and it provides an excellent study of some of the dangers inherent in commonly practiced therapeutic dialogue.
In an attempt to make the answer less real and, in a manner of speaking, trick clients into responding, the approach simply asks clients to pretend they knew the answer. Thus, when clients state that they do not know something, you suggest that the lack of knowledge can be imagined away. Examples include:
"Pretend you weren't confused – what would you be saying if you knew what you wanted?"
"Guess what you think you might say if you did know."
"Imagine what you would say if you did know."
"Make up an answer."
The reason that I do not like this technique is because it can appear disrespectful because it negates clients' realities. If clients state that they do not know something, I would prefer to first recognize and embrace "not knowing" before trying to move clients into a state of knowing. Using the above technique does not recognize that clients may truly not know, which is often the case. It also does not demonstrate your comfort with an unknown. If a highly oppositional client picks up on your discomfort with not knowing, they may attempt to use it to frustrate you by excessively stating, "I don't know," to other questions. Remember, you can always try the approach after you first display empathy for the lack of knowledge. You can also make the response less threatening by leading with phrases such as, "Sometimes it is helpful to just ..." or "Some people find it helpful to just ..."
Problems also arise if clients become aware of what you are attempting to do. In such instances, the tricky feel of the approach may result in a sarcastic response or a loss of rapport. Clients may state that you are trying to use "psychology" on them. Extremely oppositional clients may "call your shot" with much zest as they credit themselves with seeing through your approach. Because of this, the approach has a greater success rate with moderately motivated clients. However, this technique does work a fair amount of the time and, under the right circumstances, it can be very effective.
If you are fully aware of the pitfalls and are prepared to deal with them, try this approach if it appears befitting. With challenging clients, you use what works. Much of the time, if it fails you can simply continue with the discussion and little harm is done. If the approach fails and harms rapport, apologize for attempting such a trite technique and praise the client for her insight. This will once again move you out of the expert position that the client may have perceived you moving toward with this use of this technique.
This discussion reveals a number of noteworthy nuances in relation to this rather commonly practiced approach to dealing with "I don't know" responses. Many therapists fail to have appreciation for these subtleties and the underlying dangers they pose. It is suggested that therapists analyze the impact of other techniques in a similar manner. In this way, therapeutic dialogue is refined and utilized relative to the individual characteristics of clients.
When you directly fight resistance, counseling becomes an act of veiled coercion. To prevent resistance, avoid any agenda that has a coercive component.
Too often, therapists treat "I don't know" responses lightly and without respect. They fail to see the significance and value in the response. When this happens, therapists are missing an opportunity to move into a discussion of core issues.
As I have continued to study the "I don't know" response, I have discovered that the information motivating the "I don't know" is, more often than not, the exact information the therapeutic discussion needs to access. Thus, not only do we, as therapists, need to get to "I don't know," once there, we need to process carefully the client's personal meaning behind the response. Frequently, when the client's personal meaning is revealed, the therapist is led directly into the deeper struggles at hand. This is where the real therapy begins.
Something is happening in the client's world that motivates the client to say, "I don't know." The client is signaling that this is a point where the psychological factors which are at play are of such a nature that she is confused, or troubled, or torn, or scared, or threatened, or in some way psychologically stressed by the question posed. This is a critical juncture. It is important for counselors to fully recognize this and remain respectful. This is what makes therapy, therapy, and therapists, therapists. When you respect the "I don't know" response, you are providing one of the missing pieces that clients are not getting from the lay conversations they have been having.
As noted, there could be a host of possible mental processes occurring that spawn an "I don't know" response. The unskilled therapist assumes defensiveness on the part of the client and changes the subject or engages in a verbal scuffle. The skilled therapist slows the pace and expresses empathy. This is followed by a supportive quest for understanding in which you delve into the client's personal meaning focusing on details and processing feelings. To begin this process you might say something to the effect of:
"Tell me what is occurring in you right now as you hear yourself saying 'I don't know.'"
"Go inside and take a look at what just happened that led you to say, 'I don't know.'"
"Help me to understand your struggle as you search for an answer."
With such statements we can begin to move toward an understanding of the client's meaning behind an "I don't know." This skill is vital to moving beyond what appears to be resistance and to the therapeutic process in general.
I once asked a client to rate the potential of his current relationship enduring on a 1 to 10 scale (1 being no chance of enduring and 10 having a great chance of enduring). The client looked into the distance and said, "I don't know." At the time, I assumed that the question was too threatening and changed the subject. The next week, I referred back to this particular "I don't know" and the client informed me that he knew exactly what was happening in his mind to compel his response. He told me that he saw a meter in his mind and that the pointer on the meter was bouncing between 3 and 7!
There are a couple of lessons to be learned from this example. The first is that I was dead wrong when I assumed that the answer to the question was too threatening. The answer was not threatening; rather, the answer was not clear – the meter would not stabilize on a number! There was no single, solid number with which to answer.
The second lesson is that the information motivating the "I don't know" response was precisely what needed to be discussed! The meter was not fixed or consistent and neither were the factors that were crucial to the relationship continuing. The therapeutic issue to be discussed was what made the meter register 3? What made the meter register 7? What would it take to register 2? What would it take to register 8? The unstable meter was the perfect metaphor for the critical issues to process. Where the therapy needed to get to was just behind the "I don't know."
What I have discovered is that, by and large, we are underestimating the therapeutic potential within an "I don't know" response. The most likely reason we have failed to maximize on the "I don't know" response is that we are often uncomfortable ourselves with not-knowing states. Because of our own discomfort, we try to move quickly when we encounter an "I don't know." In our zeal to immediately fill the void felt to be present, we overlook the treasure of information just beyond our reach. Thus, one of the first steps many counselors have to take in order to deal with "I don't know" is to learn to manage their own discomfort with not having answers. This is often especially difficult for beginning counselors who somehow believe that they must be knowledgeable experts regarding solutions. After studying the "I don't know" response for some time, I now have no problem with responding to an "I don't know" with an "I don't know, either."
I am now convinced that "I don't know" responses can be rich sources of information. Rather than dismiss them, we should treat them as pregnant statements to be explored with great curiosity. Not understanding the complexities of the "I don't know" response results in much wasted time in therapy. As with so many of the approaches to dealing with resistance, we have to learn to slow down to go faster. We must learn to give "I don't know" responses their due process. The more comfortable you are with "I don't know," the more you will allow yourself to milk such responses for the valuable information they hold.
You will not be able to remember and incorporate all of the ideas presented in this course all at once. I recommend that you pick an area on which to work and focus there. Once that area is learned to a satisfactory degree, go to the next area you desire to improve. For example, you might initially focus on reducing and changing your style of questioning. Next, you might study and adjust your responses to "I don't know," or perhaps tune in on your pacing and speed, noting when it would be advantageous to slow down. At another time, you might attend to your sense of where the therapeutic tension resides. Is it within the client? Between you and the client? It is simply too overwhelming to try to do too much too quickly. I suggest that you make adjustments to your therapeutic style in manageable "baby steps," just as you would suggest to your clients with regard to their changes.
As I stated at the beginning, you owe it to yourself to study resistance. You should do this for your clients as well as for your own mental health. This course is a good place to start, but it is not a good place to end. There is an ever-increasing collection of material being written in the field of therapy; much of it offers new and innovative approaches to overcoming resistance. Those desiring more detailed information might refer to the references at the end of this course for sources of additional study.
The course was created from, and is based on, the book, Effective Techniques for Dealing with Highly Resistant Clients. The book addresses additional areas of resistance beyond those included here. Some of these additional areas of study include dealing with silence, responding to challenges from clients, additional linguistic techniques and language nuances, as well as an assortment of additional approaches such as paradox and reframing. If you would like to order the book or view the resistance topics not contained herein, please go to www.CliftonMitchell.com for more information.
It is my sincere hope that the ideas in this course will help those who have chosen to accept the challenges of practicing effective therapy. However, there is nothing like extensively studying and writing about a topic to make one realize the flaws and inadequacies of current knowledge. Upon completing my book, I found myself more aware than ever that all theories and techniques are just approximations of what we are striving to understand and implement. All theories and techniques fall short of accomplishing what we ultimately desire. Those presented here are no exception.
In the midst of the shortcomings, I am confident that, when applied properly, the ideas presented here have much utility and will help many therapists and clients. Yet, there will always be clients whose problems and personalities are of such a nature that little can be accomplished with techniques alone. With such clients, change occurs as a result of the therapeutic relationship, external circumstances, time, and perhaps some luck. I wish you much success in all of your endeavors.
Anderson, C. M., & Steward, S. (1983). Mastering resistance: A practical guide to family therapy. New York: The Guilford Press.
Asay, T. P., & Lambert, M. J. (2006). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.). The heart and soul of change: What works in therapy (pp. 23-55). Washington, D. C.: American Psychological Association.
Baird, B. N. (1996). The internship, practicum, and field placement handbook. Upper Saddle River, New Jersey: Prentice Hall.
Bandler, R, & Grinder, J. (1979). Frogs into princes. Moab, Utah: Real People Press.
Bargh, J. A., & Chartrand, T. L. (1999). The unbearable automaticity of being. American Psychologist, 54(7), 462-479.
Biehl, B. (1995). Stop setting goals if you would rather solve problems. Nashville, Tennessee: Moorings Publishing.
Bischoff, M. M., & Tracey, T. J. G. (1995). Client resistance as predicted by therapist behavior: A study of sequential dependence. Journal of Counseling Psychology, 42(4), 487-495.
Beutler, L. E., Engle, D., Mohr, D., Daldrup, R. J., Bergan, J., Meredith, K., & Merry, W. (1991). Predictors or differential response to cognitive, experiential, and self-directed psychotherapeutic procedures. Journal of Counseling and Clinical Psychology, 59(2), 333-340.
Brodsky, S. L. (2011). Therapy with coerced and reluctant clients. Washington, DC: American Psychological Association.
Brown, L. S. (1994). Subversive dialogues: Theory in feminist therapy. New York: Basic Books
Burns, D. D, & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model. Journal of Consulting and Clinical Psychology, 60(3), 441- 449.
Carnegie, D. (1936). How to win friends and influence people. New York: Simon & Schuster.
Constantine, J. A., Stone Fish, L., & Piercy, F. P. (1984). A systematic procedure for teaching positive connotation. Journal of Marital and Family Therapy, 10(3), 313-316.
Cook, W. B. (1996). Wall street money machine. Kent, Washington: The Lighthouse Publishing Group.
Cooper, J. F. (1995). A primer of brief psychotherapy. New York: W. W. Norton & Co.
Corey, G. (2001). Theory and practice of counseling and psychotherapy (6thed.). Pacific Grove, California: Brooks/Cole.
Corey, G, Corey, M. S. & Callanan, P. (2003). Issues and ethics in the helping professions. Pacific Grove, California: Brooks/Cole.
Cowan, E. W., & Presbury, J. H. (2000). Meeting client resistance and reactance with reverence. Journal of Counseling and Development, 78(4), 411-419.
de Shazer, S. (1982). Patterns of brief family therapy: An ecosystemic approach. New York: The Guilford Press.
Dinkmeyer, D. C., Pew, L. W., & Dinkmeyer, D. C. Jr. (1979). Adlerian counseling and psychotherapy. Monterey, California: Brook/Cole.
Dolan, Y. M. (1985). A path with a heart: Ericksonian utilization with resistant and chronic clients. New York: Brunner/Mazel.
Does Therapy Help? (1995, November). Consumer Reports, pp. 734-739.
Ellis, A. (2002). Overcoming resistance: A rational emotive behavior therapy integrated approach. New York: Springer Publishing.
Felder, R. E., & Weiss, A. G. (1991). Experiential psychotherapy: A symphony of selves. Lanham, Maryland: University Press of America.
Flinton, C. A, &Scholz, R. (2006). Engaging resistance: Creating partnerships for change in sexual offender treatment. Oklahoma City, OK: Wood ‘N’ Barnes.
Gerber, S. K. (1986). Responsive therapy: A systematic approach to counseling skills. New York: Human Sciences Press.
Gladding, S. T. (1995). Family therapy: History, theory, and practice. Englewood Cliffs, New Jersey: Prentice-Hall.
Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54(7), 493-503.
Hammond, C. D., Hepworth, D. H., & Smith, V. G. (1977). Improving Therapeutic Communication. San Francisco, Jossey-Bass.
Haley, J. (1973). Uncommon therapy: The psychiatric technique of Milton A Erickson. New York: W. W. Norton.
Haugaard, C., & Sandberg, K. (2008). Resistance in cognitive therapy: An analysis of paradigm and contemporary practice. Nordic Psychology, 60(1), 24-42.
Hoffman, L. (1981). Foundations of family therapy: A conceptual framework for systems change. New York: Basic Books.
Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999). The heart and soul of change: What works in therapy. Washington, D. C.: American Psychological Association.
Hycner, R. H. (1988). Between person and person: Toward a dialogical psychotherapy. New York: The Gestalt Journal.
Ivey, A. E., & Gluckstern, N. B. (1974). Basic attending skills. North Amherst, Massachusetts: Microtraining Associates.
Jungbluth, N. J., & Shirk, S. R. (2009). Therapist strategies for building involvement in cognitive-behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77(6), 1179-1184.
Kahn, W. J. (1999).The A-B-C's of human experience: An integrative model. Belmont, California: Wadsworth.
Kaplan, E. P. (2001, March). Prescription for motivating the unmotivated client. Training seminar, Knoxville, Tennessee.
Kell, B. L., & Mueller, W. J. (1966). Impact and change: A study of counseling relationships. New York: Appleton-Century-Crofts.
King, S. M. (1992). Therapeutic utilization of client resistance. Individual Psychology, 48(2), 165-174.
Kirsch, I., & Lynn, S. J. (1999). Automaticity in clinical psychology. American Psychologist, 54(7), 504-515.
Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. The Counseling Psychologist, 12(3), 43-55.
Kottler, J. A. (1994). Advanced group leadership. Pacific Grove, California: Brooks/Cole.
Kurtz, R. (1990). The Hakomi Method. Mendocino, California: Life Rhythm.
Littrell, J. M. (1998). Brief counseling in action. New York: W. W. Norton & Co.
Mahalik, J. R. (1994). Development of the client resistance scale. Journal of Counseling Psychology, 41(1), 58-68.
Miller, I. J. (1996). Ethical and liability issues concerning invisible rationing. Professional Psychologist: Research and Practice, 27(6), 583-587.
Moursund, J. (1985). The process of counseling and therapy. New Jersey: Prentice Hall.
Moursund, J. & Kenny, M. C. (2002). The process of counseling and therapy (4th ed.). New Jersey: Prentice Hall.
Murdock, N. L. (2004). Theories of counseling and psychotherapy. Upper Saddle River, New Jersey: Pearson Education.
Murphy, B. C., & Dillon, C. (1998). Interviewing in action: Process and practice. Pacific Grove, California: Brooks/Cole.
Otani, A. (1989). Resistance management techniques of Milton H. Erickson, M.D.: An application to nonhypnotic mental health counseling. Journal of Mental Health Counseling, 11(4), 325-334.
Pipes, R. B., & Davenport, D. S. (1990). Introduction to psychotherapy: Common clinical wisdom. New Jersey: Prentice Hall.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114.
Prochaska, J. O., Norcross, J. C., &DiClemente, C. C. (2005). Stages of change: Prescriptive guidelines. In G. P. Koocher, J. C. Norcross, & S. S Hill (Eds.), Psychologists’ Desk Reference (2nd ed.) (pp. 226-231), New York: Oxford University Press.
Pucci, A. R. (2001). Helping difficult and challenging clients: A cognitive-behavioral approach. Training course that accompanied seminar of same title. Cross Country Seminars, Nashville, Tennessee.
Ritchie, M. (1986). Counseling the involuntary client. Journal of Counseling and Development, 64(8), 516-518.
Reason, J. T. (1992). Cognitive underspecification: Its variety and consequences. In B. J. Baars (Ed.), Experimental slips and human error (pp. 71-91). New York: Plenum.
Rogers, C. R. (1951). Client-centered therapy: Its current practice, implementation and theory. Boston: Houghton Mifflin.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy. American Psychologist, 50, 965-974.
Strong, S. R., & Matross, R. P. (1973). Change process in counseling and psychotherapy. Journal of Counseling Psychology, 20(1), 25-37.
Summers, N. (2001). Fundamentals of case management: Exercises and readings. Belmont, California: Brooks/Cole.
Tate, G. T. (1967). Strategy of therapy. New York: Springer.
Teyber, E. (2000). Interpersonal process in psychotherapy: A relational approach. Belmont, California: Brooks/Cole.
Walter, J. L, & Peller, J. E. (1992). Becoming solution-focused in brief therapy. New York: Brunner/Mazel.
Whitaker, C. A., & Keith, D. V. (1981). Symbolic-experiential family therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy. (pp. 187-225). New York: Brunner/Mazel.
Westra, H. A. (2011). Comparing the predictive capacity of observed in-session resistance to self-reported motivation in cognitive behavioral therapy. Behaviour Research and Therapy, 49, 106-113.Westra, H. A., Aviram, A., Connors, L., Kertes, A., & Ahmed, M. (2012). Therapist emotional reactions and client resistance in cognitive behavioral therapy. Psychotherapy, 49(2), 163-172.
Wubbolding, R. E. (1988). Using reality therapy. New York: Harper & Row.
|© Copyright 2004-2017 by ContinuingEdCourses.Net, Inc. All rights reserved.|