The Concept of Resistance In Therapy: A Reexamination During the COVID-19 Pandemic

Posted by on Apr 4, 2020

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The blog below is drawn from an article I published in 2010, along with concepts from my online course, Overcoming Resistance: Engaging Parents in Play Therapy (2007, 2020). It has been updated a little to reflect current circumstances with the pandemic. This blog is written for therapists engaged in mental health, allied health,  and other human behavior interventions.

Current Context

The events of 2020, and most especially the coronavirus pandemic, have drastically changed the face of therapeutic intervention, at least temporarily. Faced with Stay-at-Home orders and social distancing requirements to help stave off COVID-19, therapists have had to shift from the typical face-to-face meetings with clients to using more remote methods, such as telemedicine, also known as telehealth. The client and the therapist meet online through a secure app where they can discuss matters and engage in interventions online. Therapists who use more action-oriented methods, such as expressive therapies, play therapy, adventure-or-nature-based therapies, some forms of behavior therapy,and others, are faced with a challenge. How can they adapt what is most readily conducted in person to the two-dimensional screen? There are a number of excellent telehealth training programs and discussion groups available as therapists seek ways to continue serving their clients.

There is another challenge to this sudden shift in the therapy world, and this pertains to the willingness and ability of clients to make this shift with them. While online meetings and experiences are quite familiar to children, teens and youth, parents and older adults may or may not have experience or comfort with it. Impoverished families might not have the latest equipment and might not have more than a telephone. It is not a “given” that clients will embrace this change.

In the past month, I have seen a large number of therapists lamenting that their clients have not followed through with the therapists’ hard-earned telehealth skills. (I do not diminish the vast amount of learning required to do telehealth well, and it is new for many therapists). I have seen clients and parents of child clients called “resistant” and “avoidant” and other terms that imply that they are balking at the idea of engaging in telehealth therapy. I’ve even seen where therapists, in their own frustration, have described clients as being irresponsible or neglectful due to their slowness in embracing this change. In most cases, I’ve seen and heard these labels within the first three weeks of the social distancing mandates and of therapists scrambling to get their telehealth systems set up. I applaud those who have worked hard and fast to try to meet the needs of their clients, but I have to urge caution. Given what everyone is going through, we need to be careful about using labels to describe our clients that imply negative motives or inadequacies. Fortunately, the numbers of therapists who are showing their frustrations in these ways are very small.

While people might define “resistance” in different ways, the term is most commonly used to suggest that there’s something about the client that is amiss–that the client should be doing something but they lack the motivation or proper desire to do it. In essence, when many of us label someone as resistant, it implies that we think we know what they need to do, and they are not doing it. This line of thinking is problematic to me because therapy is supposed to reflect a collaboration between client and therapist, and a process through which together the client and therapist decide on goals, methods, timeframes, and much more. For those who work with children, it is easy to slip into the mindset that the client is the child and to leave the parents and the rest of the family out of the picture. While there are times that this is necessary, in most cases, we need parents to work with us, too, as they are such key players in children’s lives and form the most influential aspects of the environment that is sometimes part of the interventions. Personally, I prefer to think of the entire family as my client whenever possible, and certainly the parents or caregivers are part of the therapeutic process one way or another.

All of these recent events and comments reminded me of a number of articles I wrote about resistance in child/family therapy spanning from 1986 through 2019. I’ll share a short one below, and follow that with more detailed thoughts about why our clients might be “resistant” to the idea of telehealth right now.

Thoughts on Parent/Client Resistance in General: Therapist Attitudes and Beliefs

Client resistance to therapy can pose serious challenges for the mental health professional.  One step, among many, that we can take involves examination of our own attitudes about resistance. Reprinted below is a brief article which can help us redefine resistance in a way which increases our likelihood of handling it effectively.

Psychological research and common sense suggest that it’s important for people to feel in control of their lives.  When control isn’t possible, predictability is a characteristic that helps people cope with and adapt to situations.  When families encounter problems with their children and/or their relationships with each other, they often feel as though they have little or no control over their home lives.  Furthermore, American culture emphasizes the value of independence and the ability to handle one’s own problems.  Some families may perceive attendance at therapy as a very visible reminder that they are unable to handle their own problems as they “should,” and that there is something “wrong” with them.  This creates an atmosphere where resistance is possible, and the negativity of this climate can be compounded by misrepresentations of therapy in the media and even by some therapists.

The purpose of therapy is to help individuals and families change.  Although families might dislike the problems which have brought them to therapy, there are at least some elements of predictability to the problems (e.g., although Freddie may misbehave, which may seem out of the family’s control, at least his misbehavior is somewhat predictable for them).  The changes suggested by a therapist sometimes seem like a leap into the unknown, which has no predictability at all for the family.  If therapy helps Freddie change, he may no longer be as predictable, and if therapy focuses on the need for parents to change, parents may feel lost in foreign territory.  In essence, the predictable nature of the problem may be preferable to the positive, but unpredictable offerings of therapy.  Regardless of the situation, clients often resist change in order to restore their home life to its former, more predictable state. They want the problem situation to change, but the need for homeostasis can be stronger.

Considering these dynamics, resistance can be seen as a natural outgrowth of the change process.  Expecting resistance as a natural part of the therapeutic process can help practitioners to handle it more effectively.

Therapists and change agents often become frustrated with the resistance they encounter, sometimes assuming that parents or family members are deliberately trying to sabotage therapeutic efforts.  While this can be the case, it is rare.  When therapists view resistance as something that needs to be eradicated, they may unintentionally set up antagonistic relationships that are inconsistent with the changes they are trying to facilitate.  Instead, it can be helpful for therapists to alter their expectations:  to think of resistance as a natural part of the change process and as an expression of parents’ or other clients’ unmet needs.  This view of resistive behavior is more likely to help therapists select helpful interventions.

Family members who seem reluctant to embrace therapeutic changes may be expressing their need for a greater sense of control or predictability, fears about losing control or independence or status, anxiety about adopting new roles or behaviors which are not yet clearly defined for them, doubts about their own ability to carry out changes, concern that the changes might result in a weaker rather than a stronger family, and other reactions.  If therapists can determine and understand the needs that are being expressed through the resistance, they are in a better position to help families overcome their reluctance to make changes.

Frank discussion of family members’ concerns should be encouraged.  It is important for therapists to listen carefully without judging family members’ reactions in order to maintain open communication.  Patience is also essential.  A climate of understanding can set the stage for more collaborative working relationships with even quite challenging clients.

What Does This Mean During the COVID-19 Pandemic?

Let me return now to the current situation as therapists try to ramp up to conduct telehealth services. We need to think about our own feelings and then think about what might be happening for our clients.

We all have lots of feelings about what is happening. There are existential fears, deep concern for people we love who might be at risk for complications, the potentially devastating effects of lost income and jobs, and the myriad unknowns about this very sneaky virus and where it is and where it is going. Having been involved in disaster work for many years, the feelings of helplessness and anxiety are common. COVID-19 has the added challenge of being a disaster that has no clear ending. Earthquakes can have aftershocks for a long time, but we can feel them when they are happening. That’s no consolation, but COVID-19 is invisible and undetectable so we have even less information about it. It is quite unlike what most have experienced before unless they have been involved in other pandemics.

When we therapists are feeling stressed, we need to evaluate our own needs first. We need to determine how intense our reactions are, cognitively, emotionally, behaviorally, and socially. We might live alone or we might have families to support and organize. There is no right or wrong to our feelings–they are likely our own unique reaction to the situation. If we are going to try to be in the right place within ourselves to offer help to others, we need to surround ourselves with whatever supports and sustains us. That might be regular contact with colleagues or supervisors, walks in nature, having fun with our companion animals, journaling, facing our fears, escaping our fears for a while, doing some sandtrays of our own, making music, and many other options. The key is to take care of ourselves first, even though we might feel the urge to dash in and get back to work. Without that, our stress might “leak out” in unexpected ways, perhaps even in ways we don’t realize as they are happening. We might not be able to see our clients clearly until we ourselves are grounded.

After we feel more centered and at peace with the situation (as much as that is possible), it’s time to get the training we might need to develop our competencies in telehealth, disaster/traumatic events, helping vulnerable people, suicide, domestic violence, ethics and telehealth, and local resources that might help our clients. The American Psychological Association has made a number of its excellent articles and series available at no charge to all therapists. Information is on its page on facebook and on the APA website. In addition, we need to figure out or find resources on how we might adapt our particular form of therapy to telehealth, or if that is even feasible. We also need to think clearly about which clients might benefit, and which might not.

After we are well on our way with these tasks, we approach our clients with our newfound excitement and sense of purpose (mixed in with a bit of trepidation if we’ve never done this before, perhaps). This is when our clients might respond with relief or convey that they really just can’t do it now. It is at this point that I’ve seen the words of discouragement from therapists who might express that in terms of “client resistance” or “parental neglect” or some other form of frustration with the client. At this juncture, it is good to stop and think about the source of our feelings — is it really the client, or is it some of our own stress and worry? The answer to that question might lead to different paths of action.

Understanding usually helps temper any feelings of frustration we have directed at our clients. While it is normal for therapists to get frustrated once in a while, it is part of our work to recognize it and work it through so we can be unbiased and fully attentive to our clients’ needs. There are many reasons that clients might not jump at the opportunity to continue their therapy. Just as we might be in a bit of shock about the sudden changes in our lives, they might be reeling from the changes in their own. Parents might have their children at home, spouse at home, and all the schedules to coordinate with schoolwork that is now done at home. The household routines are likely to be upended and require an adjustment period and new routines to establish. These are massive adaptations to make. Clients need some time to get their heads around how everyday processes are now completely different. They are likely to have their own emotional reactions that would benefit from contact with their therapists, but they can’t summon the energy to fit that in. Clients may have lost their jobs or been laid off, and they might have lost their insurance coverage. Their financial worries are likely to outweigh their need for therapy. They might not want a therapist to see parts of their home. They might not have the equipment needed. There are many reasons they might hesitate, even when we, as therapists, know that it could help them. When it comes to disasters, I always say “think Maslow.” His hierarchy of needs applies really well to disaster situations, and as we talk with clients about their needs, we can think about where they are in that hierarchy.

from internet; source unknown

As our empathy reemerges from this frenzied period of adjustment, we begin to see that the our clients have their own struggles that might need our patience. We can hear them out, explain what we would like to offer them, and answer whatever questions they have. If we hear reluctance or hesitation, we can reflect our understanding of that. If they tell us they are not interested right now, we need to accept that. We cannot push or trick them into it (most readers will know this, of course, but I have seen a few comments on social media where therapists have admitted to doing just that). As therapists we are committed to the empowerment of our clients, to honoring their agency and self-efficacy. That means we need to do that in these circumstances as well. Even when children are involved, all we can do is listen to parents’ concerns, explain how we can help them with the challenges they are facing with their children, and have patience. If we do that and let them know that we’d like to check in with them in a couple weeks if that is okay, they are likely to agree to that demonstration of caring. If they do not, our best message is to let them know that we will be there for them at any time in the future that they feel ready.

I have heard many interviews on television where people refer to this as the “new normal.” I agree that it’s new, but not that it’s normal! We are in a holding pattern of sorts. Things will change again in a matter of weeks or months, and we can hope that it’ll be for the better. Then they will change again. Most experts suggest that we will be making changes for 12 to 18 months. THEN maybe we’ll find the “new normal” until something else rolls around. This is a time to find and practice our self-awareness, our flexibility, and our empathy.

Today the musical great Bill Withers passed away. One of his best known songs was released in April 1972. In June/July 1972, as I drove back and forth from helping out in my first disaster, Hurricane Agnes, I listened to this song over and over. Today as we face the much more far-reaching disaster of this pandemic, it resonates once again. We ARE in this together, and our skills and knowledge in our therapeutic field will be needed, if not now, definitely into the future. Have a listen:

 

Click here: Lean on Me

 

 

 

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This information is brought to you by Risë VanFleet, PhD, RPT-S, CDBC,  who has over 45 years of experience in the mental health and play therapy fields. She is well known for her work in furthering the Guerneys’ original form of Filial Therapy and co-developing the field of Animal Assisted Play Therapy® (AAPT) with Tracie Faa-Thompson of the UK. She has written dozens of books, manuals, chapters, and articles on play therapy, Filial Therapy, AAPT, disaster mental health, and has received 14 national and international awards for her training programs and her writing. She administers a number of groups on facebook related to play therapy, Filial Therapy, AAPT, and human-animal relations. She is an acclaimed speaker and workshop leader who has trained tens of thousands of people throughout the world. She can be reached at info@iiaapt.org.