Navigating resistance in the therapeutic relationship

Resistance in the therapeutic relationship can be challenging for both clients and therapists. And, resistance is a two-way street: Therapists can have resistance to clients just like clients can have resistance to therapists.   Here are the most important takeaways:

• Therapists sometimes personalize resistance by believing that the client is doing something to them, such as vying for power or trying to frustrate them, but the reality is that resistance to change is a normal reaction. 
• There are various types of resistance — such as realistic, collusive, outcome, and process — and understanding each type is key to the relationship with a client.
• Rula offers advice for addressing resistance in the relationship, such as remaining calm, expressing empathy, cultivating patience, and knowing when it’s time to end the client relationship.

Understanding therapeutic resistance

Resistance presents in the therapeutic relationship in a variety of ways. It can manifest in behaviors such as:

• Arguing
• Interrupting
• Denying (blaming others, making excuses, being unwilling to change)
• Ignoring a suggestion or question
• Missed or canceled appointment

Both therapists and clients can experience different types of resistance. Understanding how different types of resistance can present in the therapeutic relationship is an important place to start. Here are some of the most common types:  

Realistic resistance

Realistic resistance is when a client has a conscious or deliberate opposition to therapeutic initiatives that they don’t understand or accept. This might be resistance to a therapist’s particular approach, their words and phrases, or the therapist themself (an issue with their gender, ethnicity, or age). This type of resistance is often subtle and can be easy to miss.

Collusive resistance

Collusive resistance is when a therapist avoids painful topics due to their own countertransference reactions or belief systems. It may be appropriate at times to validate the client’s experience, but if you relate too closely to what a client shares (for example, if you’ve experienced a similar trauma) this type of resistance can affect treatment.

Process resistance

Process resistance occurs when the client is resistant to making the necessary changes to achieve their desired outcomes. Maybe someone wants to fix their relationship or make a career change, but they aren’t willing to put in the necessary work to get there. 

Outcome resistance

Outcome resistance occurs when the client doesn’t actually want to change — whether consciously or unconsciously. One example is when a person is depressed but that depression is a core part of their identity. Another example is when a person struggles with alcohol misuse but views themself as the life of the party. 

Understanding the difference between resistance and ambivalence 

It’s very common to have ambivalence about any sort of change, including the types of changes your clients may be working towards in therapy. And, the very thing that brought a client to therapy can also often be the thing they are most reluctant to change. This can manifest as resistance from the client. All people have parts, and different parts of the same person can have different needs or willingness to change. This dissonance creates ambivalence. We all experience ambivalence, which is a normal part of the change process. As a therapist, working with ambivalence is key to inspiring real change with a client. Instead of personalizing a client’s resistance to change, remember that this ambivalence is part of their journey and not something that the client is doing to frustrate or reject their therapist. 

Rethinking resistance

When resistance goes unaddressed, it can cause problems in the therapeutic relationship. However, resistance is also an opportunity to deepen the therapeutic bond and promote growth. Here are three ways to rethink resistance. 

Mouse in the room

Having a “mouse in the room” is when something goes unnoticed by the therapist, usually when working with clients who tend to internalize their emotions and agree with the therapist without actually taking the next steps. By taking control of the narrative (and pointing out the “mouse” you should be hearing and feeling in the room), you can reframe therapeutic ambivalence during the therapy journey.

Repair ruptured relationships

Sometimes, the client-therapist relationship has a rocky start or takes a wrong turn. Ruptures can occur when a technique doesn’t resonate with a client or client has expectations about therapy that aren’t met. By putting in the work to mend the relationship, you’re giving the client a chance to be seen and heard in a way that they might not have been before.

Identify good reasons not to change

There’s value in being able to discuss the reasons a client might not want to change. In fact, the client might appreciate that you’re willing to listen, understand, and not push for change before they’re ready.

Five tips for addressing resistance in the relationship

The following recommendations can help you better address resistance and more effectively  connect with your client. 

1. Calm yourself.

The first tip for addressing resistance is to stay mindful of your physical reactions. When a therapist models acknowledging how an objection made them feel, it can help clients understand the link between their emotions and physical state. Being able to stay calm, especially when there’s tension or resistance, is an incredibly valuable skill for both you and your clients.

2. Express empathy. 

Although expressing empathy may be challenging in certain situations, it’s an opportunity to allow the client to feel heard and understood. By saying something like “I’m sorry that the way I asked that question made you angry” or “I’m sorry that the strategies we discussed don’t feel helpful. Can we discuss alternative methods?” you’re offering a genuine and authentic apology for the tension. Expressing empathy can also help to avoid further escalation and allow you and the client to reset. 

3. Cultivate patience. 

Modeling patience for a client is a useful skill when they become frustrated or aren’t sure how to move forward. There’s great value in recognizing that even when a situation or circumstance is tough, you can work together to resolve it over time. Of course, therapists should be mindful about not projecting their own angst or discomfort onto the client when progress has slowed down.

4. Treat resistance with respect. 

Resistance can be complicated. But it’s often part of the treatment process, and treating it with respect can help you tap into its use in therapy. By asking yourself the following questions, you’re better prepared to respect both the process and the relationship with your client. 

• What type of resistance are we experiencing? 
• Why is the client ambivalent to change? 
• What are my triggers for wanting the client to change? 
• Why am I resistant to the client? 

5. Consider ending the relationship.  

If a client continues to resist therapy or believes that you’re not the right fit for them, it might be time to end the relationship and refer them to another provider.

How Rula supports therapists 

When resistance comes up in the therapeutic relationship, it can be very beneficial for therapists to turn to their clinical support networks and engage in case consultations.  At Rula, a behavioral health organization that leverages technology to help therapists deliver individual, couples, and family therapy via telehealth, therapists can join case consultations offered twice a week and work with our clinical team to brainstorm new approaches to resistance. Therapists can also post a clinical question in Rula’s private online therapist community.  Rula puts clinical quality first and provides end-to-end support so therapists can do their best work with clients. Whether it’s growing your practice by connecting you with more clients or providing best practices and advice to hone your skills, Rula is here to help.  Interested in learning more about navigating resistance in the therapeutic relationship? Check out our webinar on “Navigating resistance in the therapeutic relationship.” Learn more about joining Rula