Challenging, Resistance, and Transference

Transtheoretical Model of Change

• precontemplation

  • no perceived need for change

• contemplation

  • awareness of problem, lack of commitment to act

• preparation

  • decision to make change as evidenced by small actions

• action

  • overt behavior change, moving toward desired outcome

• maintenance

  • continuation of actions necessary to maintain change

Cycle - precontemplation → contemplation → preparation → action → maintenance → recovery or relapse → precontemplation

Client Change Scale (CCS)

• denial

  • denies existence of incongruity or conflict

• partial examination

  • partially recognizes and understand conflict

• acceptance and recognition

  • recognizes situation for what it is and begins to feel congruent emotions, but no significant change

• generation of a new solution

  • generates new thoughts, feelings, behaviors

• transcendence

  • major changes in thoughts, feelings, behaviors

  • new sense of “being”, moving past issues

Challenging your Client

• listen and identify conflict in client communication

  • what are the internal conflicts?

    • incongruity in

      • verbal and nonverbal behavior

      • affect and content

      • conflicting statements

  • what are the external conflicts?

    • conflicts between

      • client & important others

      • client & counselor

      • client & expectations

      • client & religious/cultural norms or figures

• clarify and clearly point out issues of incongruity

  • clearly identify the incongruity or conflicts

    • present evidence - nonverbal, verbal, behavioral

    • useful language

      • on one hand.. on the other hand…

      • and yet…

      • but at the same time…

      • how do you put those two together?

      • what do you make of that?

  • draw out and clarify all aspects of the conflict

    • using observation, active listening, reflection of feeling, etc.

  • periodically summarize those aspects

    • follow up with a check out

  • encourage and support through positive asset search

  • provide feedback is necessary

    • if client cannot see discrepancy on their own, use of advanced influencing skills may be needed (particularly in working with adolescents)

• all of these tones are okay! it depends on the client & your comfortability

• listen, observe, and evaluate

  • effectiveness i measured by client response

    • does the client display change in the here and now?

    • does the client display change outside of session?

Client Resistance

• what is resistance?

  • traditional psychoanalytic definition - any and all behaviors that interfere with the therapeutic alliance or therapeutic process

  • what are some alternative conceptualizations?

  • a joint responsibility for a difficult situation

• how is it manifested?

  • indirectly

    • talking excessively

    • talking very little

    • arriving late or early

    • being unprepared or overprepared

    • too much or too little emotional control during session

  • directly

    • expressing ambivalence or unwillingness to come to counseling

    • interacting in a confrontational manner with counselor

Addressing Client Resistance

• indirect:

  

• direct:

  • emotional validation

    • I get it. I don’t blame you for feeling pissed about having to come to see me

    • I hear you saying you don’t trust men. That makes sense to me. I’m a stranger… why should you trust me before you get to know me?

  • radical acceptance

    • wow. thanks for being so honest… lots of people don’t really like school counselors, but they just sit here and pretend. So I really appreciate you telling me exactly what you’re thinking.

  • paradox

    • based on what’s happened in the past, it’s pretty likely that you won’t be able to have a good relationship with your mom - you won’t be any better off. so why try at all?

Promoting change in “resistant” adolescents

• are adolescents really “resistant” and “difficult”

  • developmentally appropriate conceptualization

    • counselors may encourage adolescents to be assertive, direct, autonomous

    • may be adaptive, especially in girls

• adolescents resist making “contact”

“Resistant” adolescents

• what are some strategies that may work well in breaking through with adolescents?

  • person-centered

  • motivational interviewing

  • solution-focused

  • developmental, multicultural, and feminist considerations

  • choice theory (the only person’s behavior you can control is your own)

  • cognitive-behavioral problem solving

  • playful interventions - movement, games, what are their interests?

Transference

• the displacement of feelings, attitudes, or impulses experienced toward previous figures in a person’s life onto current figures who do not realistically apply

• can be an idealized image or negative

  • seen as both useful and as an impediment

  • early relationships act as templates

    • what are some common transference reactions?

• all clients come to therapy with interpersonal dispositions determined by previous experience, which in turn get reenacted in session

  • fear or resentment of authority figures

  • dependence or avoidance

  • trust or mistrust of motives

  • reluctance or readiness to divulge intimacies

• often stem from familial relationships since they are likely to be involved in initial psychological conflicts

• discussing transference can help

  • progress the treatment

  • alleviate resistance

  • identify aspects of patients’ interpersonal relationships that would otherwise go unnoticed

Client Profile

• a client who, in the midst of recalling an event, suddenly gets angry and states “are you even listening to me”

• likely transference reaction happening here?

• consider

  • distorted perception/misattribution not grounded in reality

  • why is the client bringing it up now?

  • how would you address it?

Issues in the Real Relationship

• not every reaction is transference

  • it can be very frustrating if you behave as thought it is

• clients can react to “real” frustrating aspects of care

  • frequent cancellations by counselor

  • counselor regularly being late

  • counselor traveling for extended periods of time

  • counselor going on leave

• real relationship is distinct from the working alliance

  • clients may at times respond to the “realness” of the counselor, and this can be taken at face value and responded to as such

Related Skills

• counselor tracked the client and responded to underlying emotion when it presented itself

• counselor empathically confronted the client with a discrepancy in the client’s communication

• the counselor verbally acknowledged non-verbal affect cues