All patients desire to preserve their status quo, in spite of expressed claims of wanting to change. Whether one describes patients’ resistances in terms of frustration of drive gratification, maladaptation to reality, irrational cognition, repetition of old internalized relations, or as related to fears of self-cohesion, they are powerful enough to bring the therapist’s attempts to a dead end. This is because the potential change always arouses anxiety, even though discontinuity rather than continuity best characterizes lives over time. Any change inevitably threatens the patient’s stability, no matter how precocious and nonadaptive that stability may seem to outsiders. As H. Strean has put it: Therapists observe a universal paradox in psychotherapy―all clients unconsciously want to preserve the status quo no matter how dysfunctional it is … Those who accept resistance as part of the therapeutic process are accustomed to hearing the impotent man extol the virtues of celibacy, the unhappily married couple insist that fighting and hating are inevitable features of married life, and the alcoholic or drug addict proclaim that dysfunctional ways of coping are superior.
Conceiving of opposite discrete entities simultaneously is demanded from the therapist. He must particularly be a student of this homospatial Janusian process in dealing with negatively engaging patients, insofar as their negativity is a form of cooperation. The patient’s negativity is primarily related to developmental conflicts, especially to the individuation phase. And they’ll not deal with these issues, never mind resolve them, as they are commonly associated with their fears of further selfobject failure.
Compliance in the separation phase of development is a duplicitous act stemming from excessive dependency. Otherwise, in all self-asserting relations, the resistance in treatment is expected to develop as an organic phenomenon. It has nothing to do with the therapist’s or patient’s “failure.” In fact, the emergence of negative reactions (every patient has some latent negative transference) may be an early sign of the beginning of a therapeutic process.
For a long time I dreaded (well, at least didn’t look forward to) opposition on the part of the patient and tended to blame myself. I am not sure whether any therapist really appreciates its appearance, even though Freud alerted us to the fact that resistance is part and parcel of treatment, that the overcoming of resistances is the part of our work that requires the most time and is the greatest trouble. It is worthwhile, however, for it brings about an advantageous alteration of the ego, which will be maintained independently of the outcome of the transference and will hold good in life.
Yes, defiance is necessary for the progress of treatment, and resistance may accomplish it to the extent that the therapist stands for parental authority and the patient behaves as an embattled child. Insofar as the libido serves the process of attachment, aggression serves to ward off individuation. In spite of knowing all that, I couldn’t help seeing resistance as a technical problem until I got away from the negative terminology, itself―the concept of resistance―as R. Schafer advises, and began to view it as an affirmative phenomenon, defined by what it accomplishes. S. B. Messer’s defamiliarizing argument, that the patient’s resistance is not only or not primarily opposition, but paradoxically a kind of cooperation with the therapist, makes the point. But just how much of this kind of cooperation can one take? Apparently a lot.
In fact, according to K. Jaspers, one grows dependent on one’s opponent. Of course, each therapist contributes, in his own idiosyncratic fashion, to precipitating negative reactions on the part of the patient. Even simple efforts of the therapist can be construed in an unpleasant light, naturally causing resistance, of which the most effective ones are offered by the therapist. The resistances manifest as various rationalized forms designed to preserve the status quo, in spite of the patient’s expressed desire to change, and they have to be understood within the context of his psychopathology. For example, superego resistance is geared to maintaining a guilty status, whereas id resistance seeks childhood gratification from the therapist, and ego resistance attempts to contain impending danger. They may also take the shape of resistance to transference, or as intensification of it, or they may take a primordial form of striving to merge with the therapist. The resistances can be obvious, like prolonged silences, or circumstantial; or they can be repetitious, but relatively unobtrusive, as in slips and inattention. In short, no therapeutic relationship is immune from encountering resistances. And no matter how or when these defensive responses are formed, they should be regarded as necessary, even desirable elements in the natural progress of treatment, rather than as obstacles to be overcome.
Follow me on Twitter: www.twitter.com/thedailyshrink
T. Byram Karasu, M.D. is the author of Life Witness: Evolution of the Psychotherapist