Resistance Within the Therapeutic Community

by Joan White

Resistance can take many forms. It may be subtle or more apparent. Resistance can be overcome more easily in a group compared with individual therapy. The author outlines some common forms of resistance, presents some basic principles for managing resistance, and provides clinical examples of resistance and its management in a therapeutic community.

esistance functions much like a suit of armor: It protects the patient from possible harm while R simultaneously burdening the person with a

weight that prevents free expression. Resistance appeared in many forms in one intensive,

outpatient, psychotherapy group. This group used selected principles of the therapeutic community (Jones, 1953). One of these was that the staff (doctor, nurse, psychologist, and others) abandoned the traditional hierarchy in favor of an equal partnership. All shared the same role - that of therapist. Also, each patient in the community was assigned a therapeutic function toward every other patient. This meant that the onus of responsibility was on the entire group. All members were expected to cooperate in their own treatment and the treatment of others. Since this particular patient group was ongoing (members entered therapy for a six- week period), it was essential to tackle resistance when

Joan White , R N , M S N , was on the s taff of the Vancouver Day House, Vancouver, BC, Canada when she wrote this article.

it first appeared. If allowed to slide, resistance could strengthen and damage the morale of the entire community.

What is Resistance?

Psychotherapy, by its very nature, threatens to disrupt the delicate balance among the many components of the personality. This threat is the cause of the patient’s anxiety. Despite the sometimes crippling effect a patient’s symptoms may have on his own life, the patient’s instinctual reaction is to cling to the stability that familiarity provides. Psychotherapy exposes the person to the unknown, often increasing anxiety and fear. The patient’s goal in seeking psychotherapy is usually limited to relief of perceived pain (not to a radical change of thought or behavior).

Resistance is the conscious or unconscious behavior used by the patient to avoid anxiety and maintain stability. Both Freud (1936) and Sullivan (1953) were cognizant of the protective, stabilizing function of resistance. Sullivan wrote of the individual’s need for defense mechanisms or “security operations,” which the patient uses to maintain well-being. Menninger (1958, p. 106) elaborated on Freud’s original definition. He

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noted that resistance prevents expression of material “which might upset one’s emotional balance.”

Resistance, therefore, functions to maintain some sense of stability in an individual, thus preventing anxiety. If the status quo is threatened with disruption, the person’s anxiety increases, causing feelings of discomfort. In order to return to a more comfortable state, the individual consciously or unconsciously employs some form of resistance.

Many forms of resistance exist. The most common ones are evident in either speech content or body language. More subtle forms involve ela- borate patterns of speech and behavior, which are not always noticed by the therapist when first exhibited by the patient. Resistance is a dynamic concept, evidenced only in interaction. It is also a dan- gerous concept, subject to abuse by the unskilled. It is very easy for the therapist to tell herself, when therapeutic progress is slow or nonexistent, that the fault lies with the patient’s resistance, rather than with her own ability. The therapist can avoid abuse by being open to examination of

guarded thoughts or feelings. Similar to this form of resistance is the superficial content focus, in which the patient avoids discussion of relevant material, diluting the efficacy of the therapy session.

Many techniques may be labelled distraction devices. Humor is one of these. It alters the mood of the group or dyad and may be successful in preventing any further delving into a subject. A patient may use deflection when he becomes anxious about being the

center of attention. Thus, a patient may direct the discussion away from himself onto more general terms.

Resistance, therefore, functions to maintain some sense of stability in an individual, thus preventing anxiety. I f the status quo is threatened with disruption, the person’s anxiety increases, causing feelings of discomfort. I n order to return to a more comfortable state, the individual consciously or unconsciously employs some form of resistance.

Managing Resistance

The primary principle to keep in mind when dealing with resistance is that the trust of the patient is paramount. If the patient distrusts or is unable to accept the therapist, the patient’s anxiety will increase, intensifying resistance.

Second, make the patient aware of the resisting behavior. Several approaches may be used, depending on the patient’s vulnerability. One, direct confrontation: “It seems that you are avoiding talking

her own thoughts, behaviors, and methods as well as those of her patients.

Apparent Forms of Resistance

A patient may be late for a therapy session or may not come at all. Silence may be used in a general way. For example, when the patient appears for the session, he refuses to speak. Silence also may be used selectively, so that material of importance is withheld from the therapist or the patient refuses to discuss particular subjects.

The patient often shows resistance through body language. He may lean far back in the chair, indicating passivity or retreat from interaction. He may take on a hostile, defiant air by sitting up rigidly with his arms crossed in front of him.

The patient may resort to planned communication during the therapy session, studiously avoiding spontaneity, which may expose some of his well-

about what is really bothering you.” Two, a supportive approach: “I’ve noticed before when you talk like this it means you are anxious.’’ Three, a transactional approach “What is it that you want from me?”

The third step is to help the patient explore the meaning of the resistance. If the patient is unable to offer any ideas, the therapist’s role (or that of a group member) is to offer tentative reasons for the behavior. Here the therapist must assess carefully the neurotic needs of the individual and the degree of vulnerability. It may be more helpful to offer interpretations in terms of universal psychological principles. For example, “Many people find that ...,” or, “It is not unusual for men of your age to ....” This will be less threatening to the patient. The therapist can move from the general to the more specific as the patient displays a readiness to give up some of the resistance.

The final step is to focus on the material that the patient is resisting. Again, this requires careful assessment on the therapist’s part. Knoblock and

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Knoblock (1979) emphasize the subtle balance of often occurs. The individual discovers that he is not rewards and costs for the patient. If the patient is alone; many of his experiences and thoughts are shared expected to do something he would rather avoid (cost), by others. The two processes of mutual support and he must be rewarded with something he values (reward). identification help to break through the natural An example is the @-year old patient who is unable to resistance of the patient. The therapeutic community make any decision, however small, without first also provides a patient with a larger audience than one. consulting his mother. If the patient is able to tolerate It may be easy for a determined patient to resist the the anxiety of arriving at a decision independently, the interpretations of a single therapist, but few can reject intrinsic reward might be self-satisfaction; the extrinsic the repeated reactions of an entire group. Resistance in reward might be praise from the entire group for the form of planned communication, deflection, silence, engaging in more adult-like behavior. If the therapist and monopolizing are more quickly discarded in a group works with too much haste, she may simply reinforce setting for this very reason. the existing resistance or the resistance may take One of the chief disadvantages of target multiplicity another form. An entrenched resistance requires pro- is that a patient may unload hostile or aggressive longed work with repeated feelings on another group explanations. Wolberg (1988) member when the feelings, in

is rarely effective. tackle resistance when it first therapist. This displacement occurs because the patient appears. If left alone, it tends to finds it too threatening to

It is crucial for the therapist to tackle resistance when it first appears. If left alone, it tends to strengthen because it protects the express his hostility directly to strengthen because it protects patient so effectively. the therapist (Slavson, 1969). the patient so effectively. It is important for the therapist Wolberg (1988) believes that to help the patient recognize resistance may bum up all the the purpose of his anger; patient’s energy. The person may concentrate solely on particularly if the fellow group member who received it the behavior he is using to avoid treatment, and cannot tolerate it and/or if direct expression of such therapeutic progress cannot occur. feeling toward a parent figure is necessary.

notes that a single interpretation It i s crucial for the therapist to actuality, are meant for the

Managing Resistance in a Therapeutic Community

The therapeutic community has some advantages over the traditional dyadic relationship in managing resistance. One of the most outstanding of these is that the resistance of a single individual is spread out multilaterally, among all the group members. This occurs because each group member has been assigned an interpretive function toward every other group member. The therapist’s role is that of a catalyst; only in a crisis does the therapist become the authority, if it is necessary. She encourages democracy when she asks for the reactions of other group members before giving her own. This method assures the other members that their interpretations are valued, placing the responsibility on the patients to cooperate in their own treatment.

A second advantage pf the therapeutic community is that the group members offer mutual support to one another, reducing feelings of discomfort and anxiety in regard to sharing feelings. As they share experiences, thoughts, and feelings, the process of identification

Clinical Examples of Resistance

Three in one. An often elusive form of resistance expresses itself as a contempt for normality. This is associated with the patient’s refusal to assume any responsibility for himself. Wolberg (1988) notes that this type of resistance appears most intensely after the patient has gained some insight. This was the case with a 23- year old shift worker, Bob, who had a submissive personality with some masochistic tendencies. After two group therapy sessions, in which he appeared to make good progress, he adopted a whining, “poor me” attitude.

Bob (In response to several group members’ suggestions about .different jobs and various activities he could become involved with in order to establish a social life, and in a whining, plaintive tone): But I can’t do that. I’m no good at it. I’ve tried before and I can’t try again - there isn’t any point. I don’t even know what the point of getting better is (laughs). There’s nothing out there for me anyhow.

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In this example, Bob showed two other forms of resistance: passivity and self-devaluation, while expressing contempt for a more satisfying life. To every suggestion, he steadfastly maintained that it was hopeless, that he was ”too old to change.” Unhappy as he was, he preferred to remain with the life he was familiar with rather than risk involvement in something new. His extreme dependency on the group took on a masochistic flavor as his self-contempt became more obvious. This, coupled with his refusal to accept any responsibility for himself, caused the group members to become angry with him. an attack from which Bob appeared to derive some pleasure. The therapist explained to the group how He invited attack and failure through his self-contemptuous, submissive behavior. The pleasure that Bob took in his repeated failure seemed to assuage guilt feelings about himself, which were firmly rooted in his childhood. It was a crucial time for the therapist, in working through Bob’s resistance, to maintain a neutral, benevolent role. She avoided the harsh, punitive role that he expected her to play, which would have fed into his neurosis, where pleasure and pain were intimately mixed. Bob’s resistance was well- entrenched; only a beginning was made in breaking through

unresolved feelings about her father and Susan behaved in an ambivalent manner toward her estranged husband.

They both expressed their appreciation of the therapy group, how useful it had been to them, etc. - and, in effect, said, “We’re finished. We’re fine now.” Repeated confrontations occurred, initiated by the therapist, but continued by group members regarding their lack of involvement. Evelyn clung to her resistance until the final session when she revealed ambivalent feelings about her father. The therapist was aware that Evelyn may simply have spoken up in order to escape criticism and to leave the group on a good note.

T(herapist): But maybe the group exag-

E(ve1yn): No, I think they were there all the gerated your feelings?

time. (With some hesitation) I didn’t want to look at them because I knew i t would be painful.

T: What else was operating here? What made it difficult for you to explore your feelings?

E: I think I was

A disturbing type of resistance that may be missed by the therapist is a ‘yoreedflight into health.” Here the patient tries to convince both himself and his therapist that he is f i l l y capable and no longer in need of treatment.

over several weeks of therapy. wolberg (1988) cori-ms that the resistance of selfdevaluation is painstaking and long-term.

Flight into health. A disturbing type of resistance that may be missed by the therapist is a “forced flight into health.” Here the patient tries to convince both himself and his therapist that he is fully capable and no longer in need of treatment. It is easy to miss this form of resistance because the patient has usually made real gains in one area. It is found often in well-controlled individuals who have perfectionist tendencies and a wish to maintain tight control over everything around them (Wolberg, 1988).

This was the case with two women, Evelyn and Susan, both in their early forties, who had made a good‘ start in their therapy group. Suddenly, the involvement of both seemed to dry up. Both had a rigidity that was reflected by an aloofness in their facial expressions and a rigidity in their body posture. They became very protective of subjects that the group wished to explore with them, denying that they had any difficulties in those areas. This, even though Evelyn suffered from

afraid. It was easier for me to deal with

my father by pretending there was nothing there. But I’m afraid I might have missed something in my therapy, so I wanted to talk about it now.

It is not unusual for patients to bring up crucial issues at the end of a series of sessions or during the last few minutes of a session. They often bring the issue forth, almost reluctantly, with the revealing statement, “This is my last chance,” expressing the patient’s fear of handling the feelings alone.

Acting out. Acting out provides quick release from tension. It is usually accompanied by an unwillingness or an inability to verbalize one’s thought or feelings. Slavson (1969) notes that it can serve as an escape from self-revelation, and often follows upon the heels of an interpretation that is unacceptable to the patient.

This occurred with Bruce, a 53-year-old depressed man, whose passivity had permitted relatives and business colleagues to take advantage of him repeatedly. His response was to internalize his resentment. Occasionally his feelings exploded into acting-out

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episodes, by which he sought to escape the painful truth. He appeared early one morning for a group therapy session, restless and irritated. After expressing his annoyance, “Why don’t these things ever get started on time!”, he left the room and did not attend the session. At the next session, the therapist and group members confronted Bruce about his previous behavior.

alleviating his anxiety, and thereby reducing the need for unrestrained behavior.

Four in one. The patient with a narcissistic character is often prone to use intellectualization as resistance. He represses any demonstration of feelings. Words replace experiences; they are a defense against feelings (Wolberg, 1988). This was the case with 30- year-old Peter, who skillfully employed many forms of resistance that kept group members at bay. It was only after many sessions, as the pattern of resistance became clear, that group members were able to verbalize their frustration and resentment of him.

Peter began by monopolizing therapy sessions - a technique that plays into the resistance of other group members, as it allows them to be non-participants. This soon irritated and frustrated some of the group

members, who confronted him. Next, Peter, who was an

intelligent man, well-versed in psychological jargon, adopted the role of therapist. He offered perceptive interpretations and suggestions to group members. In this manner, he again avoided any discussion of his

T What made you leave yesterday without telling anyone? (The rules of the group prohibited this action.)

B: (Response unintelligible, voice so soft.) T Speak up, please. B: (Softly, mumbling) I was angry. (In the previous session, several group

members confronted B about his passivity in the group and his ineffec- tual way of dealing with problems.)

T You were angry at the group?

B: (Softly, head bowed) Yes. They had no right to say what they did.

A disturbing type of resistance that may be missed by the therapist is a “forcedflight into health.” Here the patient tries to convince both himself and his therapist that

T: What did they

B: That I didn’t face

he is fully capable and no-longer own difficulties and secon- darily sought special recog- nition from the therapist. in need of treatment. say?

up to my problems, that I was incapable of standing up for myself.

T And these remarks made you angry? (B nods.) What specifically made you angry?

B: (Very softly) That they were true. T What the group said hurt you and made

you angry - and yet you said nothing. B: I know. I wanted to. I wanted to yell at

everyone and tell them how unfair they were. T But instead of talking, you ran away

from the situation. B: (Softly) Yes. just like I run away at home

when things get to me. (With rising voice) I never talk about it, I just get the hell out.

Here the therapist has brought the acting-out behavior to the patient’s attention and suggested reasons (hurt, anger, lack of verbalizing) why the patient felt he had to act as he did. The patient himself has made the connection with the pattern of withdrawal he has used elsewhere in his life. The therapist continued from there to stress the need to use his energy by talking first,

When the group pointed out to him how he was focusing on everyone’s problems but his

own, he seemed somewhat chagrined and showed yet another form of resistance - stereotypy. This is returning to the same topic repetitively, blocking progress (Slavson, 1969). By launching into repeated versions of his difficulties with people, he regained the attention of the group. However, Peter constantly rejected any of the group’s suggestions; they became frustrated and bored with his redundancy. Peter related his troubles with very little effect but with great detail and clarity.

The therapist and group members confronted Peter about his avoidance of talking about his feelings. At first Peter reacted to this criticism and the social disapproval of the group as a whole with denial and disbelief. Then he converted his increased anxiety into a brilliant analysis of himself as reflected by the criticisms of the others. Despite this apparent insight gain, the behavioral change was nil. Peter remained unable to talk about his feelings. He continued to use words as a defense against any feeling.

After many sessions, during which Peter was

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confronted repeatedly about his use of intellectu- alization. he reacted with feelings of depression and discouragement. It was necessary for the therapist to remind Peter that he had employed words successfully for many years, that his skills at articulation protected him from anxious feelings. She explained that such methods are common with intelligent people; foresight and reasons are often used to control mounting anxiety. In Peter’s case it was an abuse of this principle as he allowed no feelings to surface. No significant change was noticeable in Peter after six weeks of intensive Because of its dynamic nature and chameleon-like group work. His resistance, as with most character properties, resistance provides an interesting challenge to disorden, was tenacious. Slavson (1969) noted that an the therapist. The patient may employ any of a variety of integral part of character resistance is the patient’s need maneuvers in order to avoid anxiety and maintain some to challenge and defeat the therapist as an authority. sense of stability. Working through resistance can be This also can occur in transference resistance, which arduous, but ultimately rewarding when the therapist occurs in response to the finally wins the patient’s trust. patient’s relationship with the Within the therapeutic therapist. community, many members

A selected attitude. Sometimes a dependent, confront the patient about the Sometimes a dependent, clinging attitude towards the resistant behavior. This means clinging attitude towards the therapist will be evident. This type the resistance is likely to be therapist will be evident. broken through faster than in wolberg (1988) that this of attitude is seen ofen in a individual therapy because of the type of aetitude is seen often in a patient who is submissive and pressure of social disapproval patient who is submissive and ingratiating by character, One and the process of mutual

support. Despite these advan- tages, it can take years to over-

ingratiating by character, one who adjusts to life by clinging to a more powerful person. This more ~ o w e ~ l person* come wellentrenched resistance. was the case with Bob (the Yet it is essential for the therapist patient in the first example), who to be aware of resistance when invested the therapist with an planning group strategy. If not, almost magical healing power and adopted a passive resistant behavior may fester, blocking growth in other stance towards his own treatment. The therapist repeatedly areas and threatening to halt therapeutic progress entirely. informed Bob that he would only get out of his therapy what he put into it, and that she was incapable of any References quick, magic cure. When Bob finally admitted the truth of this, he became openly hostile and contemptuous of the Freud, S. (1936). The problem ofamiety. New York: Norton. therapist and the entire program. Jones, M. (1953). The therapeutic community. New York:

As noted earlier. it was imperative for the therapist Basic Books. to maintain a neutral role, avoiding the role of the Knoblock, F., & Knoblock, J. (1979). Integrated authoritarian, abusive mother Bob expected her to play. psychotherapy. New York: Jason Aronson. The therapist used the group to defend the program - Menninger, K. (1958). Theory of psychoanalytic technique. asking what the group thought about Bob’s destructive New Yo&: Basic Books. allegations that the therapy was useless and a waste of Slavson, S. (1969). A textbook in analytic group time. Many of the group members voiced a positive psychotherapy. Madison, CT: International Universities

Press. critical behavior and his earlier passivity. Only over Sullivan, H. (1953). Conception of modern psychiatry. New many weeks of group sessions did his treatment begin to York Norton. progress, as Bob’s trust for the therapist increased and Wolberg, L. (1988). Technique of psychotherapy (4th ed). he began to accept her as benevolently neutral. Philadelphia: Saunders.

Depending upon the person’s ability to express aggression, the patient may be critical, defiant, challenging, suspicious, or openly hostile towards the therapist. It is essential that the therapist examine the reasons behind such behavior and avoid any negative countertransference feelings that will interfere with therapeutic progress.

Conclusion

who adjusts to life by clinging to a

belief in the program and confronted Bob about his

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