Freud (1912) first used the term “resistance” and was defined by Eidelberg (1968) as the “dynamic power which interferes with the progress of analysis. ” The behavior is seen as an unconscious attempt of a person to lessen or evade apprehension connected with unconscious desires. This is the outlook to which the variety of divisions of psychiatric therapy, dynamic psychoanalysis, and their branches commonly stick on. Both behavior and cognitive therapy theorists in general rebuff the principle of unconscious stimulus.
In its place, they have inclined themselves to look into resistance as a phenomenon of an aware person and not of the unconscious. They believe that it depends on the management of the individual. It is therefore a term used to describe nonconforming behaviors (Fensterheim & Glazer, 1983). Most psychoanalytic conjectures acknowledge the conception that the psychoanalyst, throughout incompetent or inopportune intercessions can incite or amplify resistance. In psychotherapy, as well as in psychodynamic therapies, these would take account of such behaviors as early or pre-mature analysis, contravene or remedial objectivity, and counsel giving.
In the case of cognitive or behavior therapies, the psychotherapist may inexactly evaluate the predicament or erroneously stipulate behaviors. In typical rationalizations of the subject of resistance, the locus is contained by the person, and mirrors unfortunate knowledge, or more customarily, divergence over a subdued desire of the particular challenged individual. Considering this representation, one can consider resistance as a result of the therapist’s fault (impulsive or erroneous interpretations), variation from the conjectural structure or his/her deficiency in understanding.
In recent years, particularly after the civil rights movement of the sixties, some effort has been made to address racial and ethnic differences between therapist and patient. However, no clear understanding of how to deal with such differences has emerged other than the vague admonition that the therapist should “be sensitive” to them. In no instance of which I am aware has concern about differences been viewed in the context of therapy theory. A review of the literature pertaining to the impact on psychotherapy of attitudes and values reveals confusion.
There is a long-held tradition stemming from psychoanalysis that therapists need to be aware of their values so that they do not inadvertently influence their patients. That admonition is confounded by the fact that successful therapy seems to result in a convergence of patient and therapist attitudes. However, in the literature review conducted by Beutler and Bergan (1990), disagreement exists about the role of initia differences in values between patient and therapist. Three studies (Beutler, 1981; Kelly, 1990; Tjclvcit, 1986) found that initial differences in values were predictive of good outcome.
Three other studies (Atkinson ; Schein, 1987; Beutler et al. , 1986; Kelly, 1990) found that initial similarities led to successful outcome. The entire field is further mired by the lack of agreement as to what values have significance in establishing a therapeutic relationship, affect the course of therapy, and create a positive outcome in therapy. One possible solution to the puzzle about the impact of attitudes and values on resistance lies in the focus of examination. Perhaps, resistance is not always due to a particular patient’s unconscious wishes or therapist’s error.
The purpose of this article is to demonstrate that unconscious cultural values are an unrecognized source of resistance. In this view, resistance may be result of conflict in a patient between unconscious cultural values and the values consciously espoused, or may result from conflicting (unconscious) cultural values held by therapist and patient. These sources of resistance may operate in situations in which therapist and patient share such parameters as race and class. [Ried] Phases of Treatment to Overcome Resistance INITIAL PHASE OF TREATMENT The impact of previous help and first-time clients
Previous experiences of help have repercussions which inevitably affect the new contact for therapy. These need to be acknowledged. The client may come with high hopes – especially if the new therapist has been recommended – or it may feel like a last desperate hope, or there may be no hope at all. Depending on the nature of these earlier encounters, a wide spectrum of feelings is evident. Other clients may seek therapy without having seen helpers previously. They may themselves have decided to come, or it may have been suggested to them. For this group it can be the first time they have ever told anyone this story.
They may be desperate and wary of doing so. Setting boundaries Making clear the boundaries can help to make therapy a safer place. Knowing that they will be seen regularly, and how long a session lasts, gives the client some security. Helpers need to be clear about their own boundaries and to communicate these to clients. External boundaries that are safe, that do not collapse when challenged and that are clearly understood on both sides begin to act as a counterbalance to the chaos, as well as reflecting an alternative model of behavior. Controlling the process
Control lies with the therapist when it comes to decisions about frequency of meetings and lengths of sessions. However the clients can take charge of the use, progress and content of the time offered to them. The client is assured that they can proceed at a pace that is comfortable, and that there will be no pressure to disclose anything. The counselor needs to listen carefully, to acknowledge what they have heard, and to indicate that they have taken serious notice. The abuse of children is the abuse of power, and it is crucial that this is no way reflected in the therapeutic process.
The development of trust The development of trust is not simple, yet is central to the process. The guarantee of confidentiality is important. If trust is to develop, clients need to feel they are taken seriously, and that what they say is accepted and believed. Most importantly the client needs to feel that they won’t be judged. A new client is likely to be extremely cautious, and will be on the lookout for signs of untrustworthiness. Telling the therapist about the abuse During the first few weeks, clients begin to tell their stories.
Some underplay the seriousness of events, whilst others who carry the burden for so long can feel overwhelmed by the outpouring. Some describe the abuse as if it happened to another person, or as if it was of no consequence. The duration of therapy Clients require different lengths of therapy and a time-limited contract is not appropriate. Reassurance needs to be made that, although therapy cannot go on forever, it will not be withdrawn suddenly and an ending will be negotiated MIDDLE PHASE OF TREATMENT Facing the abuse As trust in the therapist develops, more details of the abuse are likely to be remembered and reported.
It is common for adults abused in childhood to have only a few, vague memories. If memories have been repressed, their return can induce painful and unpredictable feelings. Some memories occur as flashbacks which are terrifying in their immediacy. The client’s agony at these times, and the complexity of their feelings, has to be addressed. If client states that they can’t cope and that it is all too much, this should be taken seriously. It is important that the therapist can cope with what is happening. It is supportive and helpful to acknowledge the clients feelings and that they are entirely appropriate.
Clients may ask what they can do to help themselves. Coping strategies need to be planned with the client, not for them. The person with most knowledge of what is helpful is the client. The role of the therapist is to facilitate exploration and to empower, not to dictate. Issues of dependency Working with an adult survivor involves both the adult in the present, who is remembering, and the child of the past. Clients are most likely to have difficulties moving from the dependency to independence if they have a therapist who has difficulty in encouraging autonomy or in dealing with endings.
Generally, clients move towards greater autonomy when they are ready to do so, and when they have allowed a safe experience of dependency on the therapist. As clients gradually begin to rely more on themselves and on those around them, encouragement can be given. It is helpful to explore safe ways of making these changes. Relationships with others can be tried and tested carefully, so that risks are minimized. Loss, depression and anger There are many losses endured by an adult survivor, and much that cannot be replaced. There is never sufficient compensation for a destroyed childhood.
To move on and develop as a person involves facing, grieving and accepting the losses. Trying to make sense of the abuse, of why it occurred, inevitably evokes feelings of anger and depression. It is essential to stress that abuse is never the child’s fault; it is always the responsibility of the perpetrator. Challenging boundaries While boundaries exist to hold the client psychologically, and to provide predictable containment for their confusing experience, it is equally important to be aware of the appropriateness of moving or changing a boundary. Working with the child in the adult
When dealing with an adult survivor therapists are also dealing with an abused child. Pressure should never be placed on a client to enter their child self and any such development should arise only from the client’s needs. Great sensitivity needs to be shown during regression, not to act in any way that is abusive or invasive. Facing the abusers One question that frequently arises is whether the victim should confront the abuser(s). The decision varies from person to person, however it is important that clients recognize that they have both the right and the power to decide their own course of action.
The therapist’s role is to assist the process: possible implications need to be discussed and examined, and clients need to be encouraged to consider whether they feel strong enough to deal with the possible consequences. LAST PHASE Who decides the ending? The timing of termination should be decided with the client and should be agreed upon. Some clients will know for themselves when they are ready to terminate the treatment. Others however are unable to make such a decisive move on their own and need help to do so.
There should be no pressure to terminate quickly. Knowing when to end Various factors can be taken into account by the therapist and client in deciding a date to finish. The client’s level of self-esteem is important as is the level of depression. It is unrealistic to expect depression to dissapear entirely however it should be manageable. Reasonable autonomy needs to have been established, and the client should have some ability to be appropriately dependent on others. Uncertainties and doubts
Sometimes the decision to finish therapy can throw a client into doubt and confusion, anxieties can surface even when the ending has been mutually agreed. The prospect of ending often helps both the client and the therapist to focus on outstanding issues. Reviewing the course of therapy Most clients will have entered therapy with considerable mixed feelings, leaving will produce similar feelings however for different reasons. The client has shared and explored feelings and events that were previously untouchable and unspeakable. Reviewing the course of therapy is important.
Clients who are helped to say goodbye gain an overall perspective of the work they have undertaken; they recognize that risks have been taken, that obstacles have been overcome, and that mistakes have been made, but most importantly they have survived. Styles of ending It is better for the therapist and client to decide together whether to end once and for all or whether to arrange an opportunity for a later review session. Some clients wish to make clean breaks whilst others prefer to gradually reduce the meetings. Whatever the decision, it should not obscure the reality of ending, which must be clearly stated and understood.
The ending needs to be approached honestly, carefully and supportively. References: Baer, J. (2001). Evaluating Practice: Assessment of the Therapeutic Process. Journal of Social Work Education, 37 (1), pp. 127, pp. 127. Bernhardt, J. M. (2004). Communication at the core of effective public health. American Journal of Public Health, 94 (12), pp. 2051-3. Canadian Interprofessional Health Collaborative [CIHC]. (2007). Interprofessional education and core competencies. Vancouver, BC. Retrieved May 10, 2009, from http://www. cihc. ca/resources-files/CIHC_IPE-LitReview_May07.
pdf. Holmes, C. A. (1998). There Is No Such Thing as a Therapist: An Introduction to the Therapeutic Process. London: Karnac Books Horvath, A. O. (2001). The Therapeutic Alliance: Concepts, Research and Training. Australian Psychologist, 36(2), 170-176. Henneman, E. , Lee, J. , & Cohen, J. (1995). Collaboration: A concept analysis. Journal of Advanced Nursing, 21, 103–109. Lee, et al. (2002). Enhancing physician-patient communication. Retrieved May 9, 2009, from at http://asheducationbook. hematologylibrary. org/cgi/content/abstract/2002/1/464. Orchard, C. , Curran, V.
, & Kabene, S. (2005). Creating a culture for interdisciplinary collaborative professional practice. Medical Education Online, 10(11). Retrieved May 9, 2009, from http://www. med-ed-online. org/pdf/T0000063. pdf. Roter, D. L. & Hall, J. A. (1993). Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits. Westport, CT: Auburn House. Traveline, John M. , Ruchinskas, Robert and Gilbert E. D’Alonzo Jr. Patient-Physician Communication: Why and How. Journal of the American Osteopathic Association, 105(1), January 2005.