“It soon became apparent that client openness versus defensiveness, change talk versus sustain talk, is very much a product of the therapeutic relationship. 'Resistance' and motivation occur in an interpersonal context.”
― William R. Miller, Motivational Interviewing: Helping People Change
How do you respond when a session is not going the way you had planned? When a client argues, minimizes, interrupts and ignores, how do you get the therapeutic relationship and treatment plan back on track?
A first step is to reframe the way we understand so-called “resistant clients.” After all, resistance is not a solo activity. No one stands alone on a street corner and resists. There has to be someone to push against. This means both the client and the counselor can influence this dynamic. The way you respond to such behavior makes all the difference.
Reframing Resistance
In Motivational Interviewing, Miller and Rollnick describe how labeling individuals as “resistant” was used to justify unhelpful approaches in the past — like confronting, labeling, judging and commanding. Rather than helping people move toward positive change, these approaches actually serve to evoke more resistance — turning the label into a self-fulfilling prophecy.
When you understand that resistance is not a problem with the client, you can see it as an opportunity to use therapeutic skills. As Miller, Zweben and Forcehimes explain in Treating Addiction, “Resistance is not a challenge to try to win the argument but an immediate in-session feedback from your client to try something different.”
To adjust your approach effectively, it can be helpful to understand “resistance” as two separate concepts: ambivalence and discord. Each of these dynamics is normal and expected at times. With thoughtful use of your clinical skills, you can respond in ways that diminish defensiveness and strengthen positive motivation.
Responding to Ambivalence
People in the process of change are often ambivalent. They can see both reasons to change and reasons to maintain the status quo. You can think of ambivalence as a balanced scale. Participants may recognize benefits of changing, but these don’t yet outweigh their reasons for keeping things the same. If you tell participants why they should change, they are likely to resist and maintain balance by emphasizing arguments against change. This is known as sustain talk.
When participants use sustain talk, it can be tempting to share facts, recommend strategies and remind them of the reasons they “should” or “must” make a change. But remember, participants will listen to themselves more than they will listen to you. If you are presenting arguments and evoking sustain talk, participants are more likely to talk themselves out of change. Instead, you will want to allow individuals to decide for themselves if they are ready to make a change.
A person-centered approach involves a focus on listening and practicing accurate empathy. When you acknowledge that you hear and understand what the person is saying, there is no need for them to resist you. Keep in mind, reflecting their thoughts doesn’t mean you have to agree or approve — it’s just good listening. The more a person seems to be resistant, the more you need to listen well.
You also can respond to sustain talk by acknowledging the person’s autonomy and choice. You might say, “And that really is up to you. No one can decide that for you.” People have the right and ability to make their own choices.
The good news is, you can help participants to increase their self-talk in favor of change — also known as change talk — through motivational interviewing techniques. This approach is included in all Interactive Journals. You also can find supporting strategies in each Facilitator Guide for working with participants individually and in groups.
Responding to Discord
In addition to sustain talk, you may encounter resistance in the form of discord. While sustain talk focuses on a person’s ambivalence to change, discord is about the person’s relationship with you.
For example, discord might sound like, “You don’t know me. You don’t know what I need,” or “I know for a fact this is not going to help me.” If you hear statements like these, you will want to focus on strengthening the therapeutic relationship. Consider how the strategies below might be helpful for you:
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Engage the client’s own problem solving skills. In the examples above, you might say, “You’re right. Please, tell me more,” or “If that won’t work for you, what would you suggest given what you know about yourself?” Remember, it’s important to keep your tone free from sarcasm.
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Be willing to take partial responsibility or even apologize for your contribution to this dynamic. You might say, “I’m sorry — obviously I wasn’t listening well enough to you. Tell me what concerns you.”
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Work with the participant to adjust goals. If the person balks at the size of a task or goal, work together to identify one simple step they could take.
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Consider whether literacy is a challenge. This could be one reason for apparent “resistance” when it comes to writing in a Journal and participating in discussions.
Keep in mind, the therapeutic alliance is the most important factor in predicting treatment success. The client’s perception of your therapeutic alliance depends on questions like:
Do I feel respected by this person?
Does this person listen to me and try to understand me?
Do I trust this person?
Do I have a say in what happens?
Is this one size fits all or do I have options?
Is this a collaborative relationship or am I dictated to?
After all, people get to make their own choices about how they will live their lives. Accepting and honoring this autonomy can help you maintain your professional resilience and have effective, collaborative conversations about change.