Process: The Path to Change

Last week I mentioned David Burns’ argument that one of the main causes of treatment failure is the therapist’s overeagerness to help. This leads the clinician to leap into the fray before the client has fully embraced the idea of change, creating an oppositional relationship in which the therapist is pulling for change and the client is backpeddling.

Once both client and therapist are on the same page, however, we still have to figure out how to get to the goals the client has specified. The client may have ideas about how the process will take place.

It’s useful, then, to distinguish between two types of resistance, a topic that Burns is eloquent about.

Outcome resistance is directed, not surprisingly, at the outcome of an intervention. Anyone giving up alcohol, for example, can think of good reasons not to succeed: I’ll give up my best coping strategy, I’ll be more anxious, I’ll have to face what I’ve done to others, and so on. Overcoming a fear of heights will mean that I’ll be in high places more often, and I hate high places. Overcoming my elongated bereavement reaction will mean letting go of someone I loved, which seems like a betrayal of their memory.

Process resistance is directed at the path toward the outcome. Dealing with my public speaking anxiety might involve doing some public speaking as part of the therapy, which I am reluctant to do.  Working on my depression might mean taking up an exercise program, which I have no energy to do.

Once a client has identified a treatment goal, we can feel tempted to race in (yet again) and seize control. We are supposedly the big experts, after all. “Right, so you want to overcome your anorexia.  Great!  Here’s an eating program for you.” The client has bought into the goal but not the path, and again resists.

Process resistance often occurs because the therapy will involve doing distasteful things – like exercise, or public speaking, or challenging long-held ideas, or sniffing alcohol without drinking any. But sometimes it occurs because the client has a clear idea of the path toward the destination that differs from the vision of the clinician.

I once saw a person beset by a hoarding compulsion who had had decades of unsuccessful psychodynamic intervention. S/he had learned the importance of investigating the circumstances of his/her upbringing in order to find the key that would unlock the problem. S/he hadn’t found it yet, but was reluctant to abandon the search.

My suggested approach had little to do with the past, and instead emphasized behavioural rehearsal (bringing in bags of stuff that we would actually throw the contents in the dumpster together) and cognitive work (noting and evaluating the thoughts that occurred when it was decided to save something or contemplated throwing it out). Before s/he could do this, however, we had to explore the therapeutic options and it had to be the client's decision to give this seemingly nonsensical strategy a try. It worked well, but it would never have done anything if s/he hadn’t chosen it.

So once we have an idea of the client’s destination, we should ask the client how he or she envisions reaching that goal. They may or may not have a picture of this. If they have a picture that doesn’t match what we can do effectively, or that is simply more of a strategy that has been tried for years with little result, we can discuss the issue. We can present our own ideas as well. But until we’ve had the discussion and agreed on a course of action, we are on the road to certain treatment failure.