Engage resistant patients in collaborative treatment
First identify and work on what they really want.
Why has the patient come now? What is his highest priority? Can we help him discover the link between his drinking or anger that affects his work performance?
Therapist: “So you want to get the boss off your back. You want people to leave you alone. You feel people treat you unfairly and want them to stop. But why did you come today and not last week or last month?”
Mr. L: “I came now because yesterday my boss said I could lose my job if I didn’t get some help.”
T: “So what you want most importantly is to keep your job, is that it?”
Mr. L: “Well yeah, but I don’t have a drinking problem or any problem with my temper. They’re just overreacting. It wasn’t as bad as they said.”
T: “OK, I am willing to work on helping you keep your job if that’s what is most important to you. Do you know what you are doing that makes them think you have a drinking or anger problem?
Mr. L: “All I did was come in late a couple of times and got into a little argument with a couple of people.”
T: “If we are going to help you keep your job, we could spend our time talking about how unfair your boss is and how she’s misjudging you. Or we could work to show her that she has you all wrong and that you are a productive worker who does not have a substance or anger problem.
“Let’s think together how we could gather the data that would prove you don’t have a substance problem. If all that data is squeaky clean, then I can write a very supportive letter to your boss and tell her all is well. If, however, we discover you do have a problem, I can still write a very supportive letter. But we’ll have to show her how you are taking care of any problems that interfere with your work performance.”
Reframe the presenting complaint
Few patients present fully ready to work on definitive behavioral health recovery. If patients at least attend sessions or talk with you, they must be motivated to do something. Otherwise, they would not show up.
Our task is help patients such as Mr. L get what they want, not what we think they should want. Eventually you will get to explore the patient’s substance use, impulse or parenting problems, mental health symptoms, or communication problems, but this discussion will be in the service of allying with his or her goals.
Rather than viewing patients as unmotivated or resistant, think of resistance as an interactional process. “If we are going to stop them from locking you up,” you might say, “let’s talk about what you are doing that makes you look like you are dangerous and out of control. And when you were not locked away, let’s think of how you kept ‘them’ off your back.”
Instead of interpreting resistance as pathology, view the behavior as an opportunity to understand and respond to the patient’s stage of readiness to change.
Stages of change
By being “difficult,” patients are often declaring that they are not invested in what you think the problem is or in working on that problem. Resistance thrives when we and the patient have not allied around a common goal and are at different stages of change. Think of the therapeutic alliance in the context of the widely-used and well-researched Transtheoretical Model’s stages of change:3,4
Precontemplation. A person at this stage is not considering the possibility of change, although others are aware of a problem. He or she will seldom appear for treatment without coercion. The person could benefit from nonthreatening information to raise awareness of a possible “problem” and possibilities for change.
Contemplation. The person is ambivalent, undecided, vacillating about whether he has a “problem.” He wants to change, but this desire exists simultaneously with resistance to change. Motivational strategies can be useful, but aggressive or premature confrontation could provoke strong resistance and defensive behaviors. Many persons at this stage have indefinite plans to take action in the next 6 months or so.
Preparation takes the person from the contemplation stage to specific steps to solve the problem in the action stage. He or she develops increasing confidence in the decision to change and takes the first steps on the road to action. Most people at this stage plan to take action within 1 month and are making final adjustments before beginning to change.
