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Presented by Rebecca Brumm, Chief Clinical Officer, Within Health
Working on mental health is an important aspect of overall well-being, especially when someone is struggling with complex conditions like eating disorders. But, confronting unhealthy thoughts and behaviors and facing change can be a daunting prospect.
It’s not unusual for practitioners to encounter resistance from clients when trying to help them make necessary changes. But that kind of attitude can potentially derail progress for patients and bring even seasoned practitioners into a similarly hopeless or oppositional mindset.
“Resistance is why therapists have jobs,” says Rebecca Brumm, a trained therapist, certified eating disorder specialist, and Chief Clinical Officer at Within Health. “But it’s important to pay attention to resistance not just in patients, but ourselves.”
Still, Brumm says, the situation is not as hopeless as it may feel. There are several tools and strategies to help practitioners recognize and work past resistance, both in their patients and in themselves.
What is resistance?
Resistance can have several different meanings in a therapeutic setting, but it primarily refers to some form of opposition a patient takes against the practitioner or the process. The unwillingness to show up fully during sessions or hesitation to enact change can be conscious, subconscious, or from a combination of internal and external forces.
Some of the most common causes behind patient resistance include:
Resistance to treatment or change can be strongly expressed or more subtly experienced, but in most cases, Brumm says, patients experience at least some form of the feeling. Otherwise, they wouldn’t need the help of a therapist.
“It’s not a client’s job to know what to do; that’s our job,” Brumm says. “They feel the resistance, and we need to help them figure out where that opposition is coming from.”
Practitioners can also experience resistance, especially when dealing with a particularly difficult case. This can similarly be conscious or subconscious and impact a practitioner’s ability to show up fully for the patient or remain hopeful that recovery is possible.
In practitioners, resistance may be caused by:
“Resistance is one of the biggest struggles a patient can have,” Brumm says. “The struggle to move forward or progress can be heartbreaking to witness. You think, ‘What is preventing this person from taking the next step?’ These are the cases that keep us up at night.”
She also says these cases can build up a sense of resistance in a practitioner.
The key to confronting resistance is the ability to recognize it, both in patients and, as a practitioner, in oneself.
For patients, the emotional reaction to change or difficult situations can take on many forms, including:
Dealing with this type of behavior from patients or an otherwise difficult case can also lead to resistance in practitioners, which can be just as disruptive to the therapeutic process. Again, this can manifest in a number of ways, but some common expressions of resistance in a practitioner include:
To help combat the problem of resistance, Brumm recommends keeping several critical concepts in mind.
Collaborative care is especially effective and important when treating patients with eating disorders, with the approach being linked to higher motivation to change, greater treatment satisfaction and adherence, and greater patient outcomes.
But as a practitioner, a number of issues can interfere with the willingness to take this approach, including:
Brumm recommends practicing self-compassion and compassion for others as an antidote to these potential complications. She says self-compassion can be particularly helpful to fight against personal triggers that may come up during treatment, with Brumm recommending staying present, staying focused, and renewing commitment to a non-directive approach to combat feelings of personal stress.
Practicing compassion for others can help therapists re-attune to the needs of their patients, which can help them give better advice in times of difficulty, validate their clients, and come up with more tailored approaches and solutions rather than relying on more standard courses of action.
Along with collaborative care, feedback-informed care is consistently among the most effective approaches for treating eating disorders and other mental health conditions.
Brumm recommends not only regularly asking for feedback but also having a system for it. The idea is not just to assess whether a patient feels the therapy process is working for them but to continue building and working on the relationship between patient and practitioner to help create the most conducive environment for healing.
“When we elicit feedback, we have to create a culture where it’s understood that feedback is an important element of the care,” Brumm says. “We want clients to understand that they’re the magic ingredient of the treatment. We have some knowledge, they bring their own knowledge, and together, we form the care tailored to their uniqueness.”
Still, she recommends this step be taken formally, with a framework of data gathering, to help ensure feedback can be consistently understood and measured against reliable controls.
Even the most effective practitioners may face resistance from their patients or themselves. When the issue does come up, Brumm recommends a number of tools to proactively work on reducing or working through this unhelpful emotional state.
The idea behind parts work is that humans are comprised of different “parts,” all formed for different purposes, which may work in concert or against one another.
It’s important to remember that there are no inherently “bad” parts. Each part was developed out of a need—generally, a need for protection—even if it results in unhelpful thoughts or behavior. But if a patient (or practitioner) is having a strong reaction to something, Brumm says, it’s likely because something is activating a part.
When combating resistance, this framework helps to acknowledge that peoples’ reactions are not the sum total of themselves, encouraging a path for awareness, compassion, and healing between the ‘self’ and the ‘part.’ To flesh out that concept, a therapist can ask questions like:
Helping someone meet this activated part with compassion and an understanding of the work it’s doing and why can help both patients and practitioners work through resistance.
The general concept of schema therapy is to figure out how one is feeling with the help of measured, data-driven questions instead of open-ended discussions and emotional evaluations. This generally involves answering a range of questions on a sliding scale to help identify persistent feelings and themes that may be coming up in both a patient's and practitioner’s experience of therapy.
There are many ways to practice schema therapy, though Brumm recommends using the YSQL-3, or young schema questionnaire long form. Though lengthy, it can help determine potentially hidden feelings that can drive resistance, such as:
The idea of validation sequencing is somewhat formulaic. It starts with making a “perhaps” statement, which helps set up the concept of the speaker “imagining” the situation from the other person’s point of view, Brumm says. This can be something like:
The next step is validating the emotion the person is showcasing from that person’s point of view and giving three examples. Brumm gave the example of her son showing resistance to doing chores, which she would meet with a statement like, “I imagine that you really don’t want to do the dishes before you go to school today because you had to get up early already, you already feel rushed, and you feel tired.”
At that point, you see how the person responds and either work out a compromise (e.g., “Why don’t we set a timer for 5 minutes and see how many dishes you can get done?”), or respond accordingly. If the person answers with something like, “Yeah, I’m mad that you won’t listen to me,” Brumm says, you can use that statement as a foundation to repeat the exercise.
The concept is great for:
Brumm also recommends teaching this practice to parents or caretakers in family therapy as a helpful tool to foster healthy discussions at home.
Precursors model of change
This concept is similar to schema therapy in that it utilizes more data-focused tools to mine for helpful insight and information. It goes by the framework that seven components are necessary for change to happen:
Each data point is entered into a grid and graded on a scale of 0-28, with 0 being “most unlikely to change” and 28 representing “change easily occurring.” Once grided out, these factors can be graded, giving practitioners a big-picture idea of what’s working and what’s not.
Brumm recommends incorporating this method regularly into sessions as part of feedback-informed therapy. She also says it can be used on practitioners who are facing feelings of resistance.
How to resist resistance
Resistance is challenging to deal with but practically inevitable in lines of work like therapy. Brumm says a key to working through it, at least in oneself, is cultivating greater self-awareness.
She recommends journaling or using other methods, such as the precursors model of change, to judge one’s reactions and feelings or to help determine when one is not feeling “in their self” but instead being pulled away or triggered.
Social support is another helpful tool, she says. “We are humans who show up in very human work – we need places where we don’t have to be therapists, where our personal hearts are nurtured, to work with a team of professionals for our own needs.”
But what’s most important for practitioners, as with clients, is effort, consistency, and patience.
“You can think of it directionally,” Brumm says. “‘East’ is not a singular place, but a direction we can always move toward.”