Psychological resistance

Psychological resistance is the phenomenon often encountered in clinical practice in which patients either directly or indirectly oppose changing their behavior or refuse to discuss, remember, or think about presumably clinically relevant experiences.

Psychoanalytic origins
“There is, however, another point of view which you may take up in order to understand the psychoanalytic method. The discovery of the unconscious and the introduction of it into consciousness is performed in the face of a continuous resistance (Widerstände) on the part of the patient. The process of bringing this unconscious material to light is associated with pain (Unlust), and because of this pain the patient again and again rejects it. It is for you then to interpose in this conflict in the patient’s mental life. If you succeed in persuading him to accept, by virtue of a better understanding, something that up to now, in consequence of this automatic regulation by pain, he has rejected (repressed), you will then have accomplished something towards his education. For it is an education even to induce a person who dislikes leaving his bed early in the morning to do so all the same. Psychoanalytic treatment may in general be conceived of as such a re-education in overcoming internal resistances.” (Sigmund Freud, 1959/1904, pp. 261-262)

Secondary gain
Although the term resistance as we know it today in psychotherapy is largely associated with Sigmund Freud, the idea that some patients “cling to their disease” (S. Freud, 1959/1904, p. 254) was a popular one in medicine in the nineteenth century and referred to patients whose maladies did not improve due, presumably, to the ‘secondary gains’ of social, physical, and financial benefits associated with illness (Leahy, 2001). Freud’s only contribution to that initial notion of resistance came as a side-effect from his larger, more revolutionary contribution to the field of psychology: The dissemination and popularization of the influence of the unconscious on human behavior (Hergenhan & Olson, 2003). Accordingly, although Freud was trained in and familiar with the notion of secondary gain popular at the time (Freud, 1959/1926a, pp. 97-100), he came to see it as an unconscious phenomenon.

Primary gain
Freud’s more specific contribution to the treatment of the mentally dis-eased was a model of human psychological functioning that offered an explanation of the primary gains that patients derive from their psychiatric symptoms (Fenichel, 1945; Wolitzky, 2003). This model explains that the symptoms represent an unconscious tradeoff in exchange for the sufferer being spared other, experientially worse, psychological displeasures (Unlusten). This conceptualization of primary gain is what Freud (1959/1896) labeled a “compromise formation,” (Kompromisslösung; p. 163). And while the distinction between primary gain (internal benefits) and secondary gain (external benefits) was not directly articulated by Freud, it was alluded to, for example: “In civil life illness can be used as a screen to gloss over incompetence in one’s profession or in competition with other people; while in the family it can serve as a means for sacrificing the other members and extorting proofs of their love or for imposing one’s will upon them….we sum it up in the term ‘gain from illness’….But there are other motives, that lie still deeper, for holding on to being ill…[b]ut these cannot be understood without a fresh journey into psychological theory” (1959/1926b, pp. 222-223).

Resistance as conflicting agencies
So to Freud resistance was really an intrapsychic compromise arranged in order to avoid losing more. But with whom was the arrangement established? —And by whom? As the word’s definition suggests, a compromise is reached between two or more conflicting agencies. In this case one of the agencies desires to not experience discomfort. Freud (1959/1896) called this psychic agency “the repressing” (p. 163), or, later, “the pleasure-pain (Lust-Unlust) principle” (1959/1911; p. 14), which eventually came to be referred to as the “id” (Freud, 1959/1937a; Wyss, 1973). The other agency works to maintain contact with worldly experiences. Freud (1959/1896) called that psychic agency “the repressed” (p. 163), or, later, “the reality principle” (1959/1911; p. 14), which eventually came to be referred to as the “ego” (Freud, 1959/1937a; Wyss, 1973). The compromise they strive for is to achieve maximum drive satisfaction (“cathexis” or attachment) with minimum resultant pain (negative reactions from within and without). Freud (1959/1911) theorized that psychopathology was due to unsuccessful compromises: “We have long observed that every neurosis has the result, and therefore probably the purpose, of forcing the patient out of real life, of alienating him from actuality” (p. 13).

Patient resistance as pathogenic in practice
However, it is crucial to note that compromise formations reached by these two agencies were not theorized by Freud to be inherently pathogenic. They were seen as being inherently human. That is, the compromise formation leading to psychiatric symptoms was seen as pathological only because it led to psychiatric symptoms. The pathology was not understood as the act of compromise per se—because compromise between the different agencies of the mind (later named the id or unconscious sex and destruction drives, ego or reality principle, and superego or conscience) represented to Freud (1959/1937a) the fundamental human condition (Wyss, 1973)—but from the results of the specific compromise that led to undesirable symptoms. Similarly, a compromise solution was seen as resulting in “successful defense” (S. Freud, 1959/1896, p. 163)—against displeasure—as long as it resulted in “apparent health” (p. 163), understood as a lack of symptoms. But that was not the case for people who sought treatment: Their compromises were by definition not successful—otherwise they would not be distressed and seeking help. Thus, practically speaking, among people seeking treatment, the compromises they had previously reached were ipso facto pathogenic.

The key players in Freud’s theory of resistance
The key players in this Kompromisslösung theory of symptom production and maintenance present the core kernel of Freud’s theory of resistance. They are: Repression (often used interchangeably with the term anticathexis, to describe the force which counters cathexis, or drive satisfaction), defense, displeasure, anxiety, danger, compromise, symptom, and experience (either external or internal). Three of the terms occasionally were used interchangeably by Freud—resistance, repression, and defense—with subtle differences in meaning: Resistance often was used to refer to the behavioral manifestations of avoiding direct contact with distressing ideas (inclusive of affects), while defense was the higher order construct which explained the behavioral manifestations, and repression was the general act of denying awareness (Strachey, 1959). As Freud (1959/1926) wrote, “The action undertaken to protect repression is observable in analytic treatment as resistance. Resistance presupposes the existence of what I have called anticathexis” (p. 157). And, “The task of defense against a dangerous perception is, incidentally, common to all neuroses” (p. 159). Similarly, the terms anxiety, displeasure, and danger often were used indistinguishably, having the general meaning of negative affect, while occasionally having more specific meanings. The more specific meanings can be summarized as either experiences of helplessness and loss of object (also referred to as fear), or “signal anxiety” acting to warn of potential impending loss or helplessness (Freud, 1959/1926, pp. 169-172; Strachey, 1959; Wyss, 1973).

The sea change in Freud’s theory of resistance
Although Freud (1959/1896) originally theorized anxiety as resulting from the process of repression (a theory which stemmed from his observations of hysterias, phobias and obsessions—entailing pathological manifestations of anxiety—and his striving towards an energy conservation model of the psyche; Strachey, 1959; Wyss, 1973), by 1926 he publicly abandoned that notion and assigned the role of anxiety to the ego, explaining repression as resulting from anxiety experienced by the ego (Freud, 1959/1926; p. 161; Strachey, 1959; Wyss, 1973). The “defense neuro-psychoses” (viz., hysteria, obsessions, and phobias; Freud, 1959/1894) then came to be understood as compromise formations negotiated by the ego, albeit still unconsciously (Freud, 1959/1937a; p. 341), to defend against the anxiety of becoming aware of distressing repressed material (Strachey, 1959; Wyss, 1973). This sea change is interesting because it hints toward initial movement by Freud from a strictly objectivist model of knowledge to a constructivist one, as the ego is transmuted from reporting on reality to arbitrating it.

Similarly, in some ways Freud’s classic psychoanalytic conceptualization of resistance as defense against painful ‘realities’ exemplifies the modernist pursuit of veridical knowledge—including the metaphor of psychoanalysis as surgery or an archaeological excavation (1959/1937b, p. 360). In other ways Freud (1959/1904) seems to hint towards an appreciation of the constructive nature of experience—viewing resistance as part of a process of “the play of mental forces…which alone makes it possible to comprehend behavior in daily life” (p. 254) and demonstrating the human tendency to construct meaning based on past experiences and to interpret the past based on current experience. Freud (1959/1912) called this tendency “Übertragen” (p. 312), translatable as “carried over” or “carried forward” (Universität München, n.d.), but better known as transference. Freud (1959/1912) accordingly referred to transference manifestations as “stereotypes,” “prototypes,” or “clichés” (p. 313) people use to increase satisfaction of their wishes in their encounters with the world. Not surprisingly, Freud (1959/1925) came to understand resistance and transference to be circularly tied to each other, as resistance works to maintain transference while transference shapes resistance. Their occurrence in psychoanalysis was unmistakable to Freud, and important and frequent enough that they became the foundation of the entire psychoanalytic endeavor: "It may thus be said that the theory of psycho-analysis is an attempt to account for two observed facts that strike one conspicuously and unexpectedly whenever an attempt is made to trace the symptoms of a neurotic back to their source in his past life: the facts of transference and resistance. Any line of investigation, no matter what its direction, which recognizes these two facts and takes them as the starting-point of its work may call itself psychoanalysis, though it arrives at results other than my own" (S. Freud, 1959/1914b, p.298). Indeed, to this day most major schools of psychotherapeutic thought continue to at least recognize—if not ‘take as the starting-point’—the two phenomena of transference and resistance (e.g., Beutler, et al., 2002; Leahy, 2001; Anderson & Stewart, 1983; Wachtel, 1982).

Freud's five types of resistance
Having conceded libido (and its inherent motivation and agency) to the ego as well as to the id, and through the ego to the superego, Freud (1959/1926, pp. 157-160) then delineated “five kinds of resistances that are met with in analysis” (while stressing that the list is not exhaustive), three by the ego, one by the id, and one by the superego, listed respectively:
 * 1) Repression, e.g. reaction-formation, obsession, phobia (i.e. denial or avoidance)
 * 2) Transference, (i.e. projection)
 * 3) Gain from illness, (i.e. secondary gain)
 * 4) Compulsion to repeat, (i.e. acting out)
 * 5) Sense of guilt or need for punishment, (i.e. self-sabotage)

All of them serve the explicit purpose of defending the ego against feelings of discomfort, for, as Freud (1959/1926) wrote: "'It is hard for the ego to direct its attention to perceptions and ideas which it has up till now made a rule of avoiding, or to acknowledge as belonging to itself impulses that are the complete opposite of those which it knows as its own' (p. 159)."

The first two forms of resistance work to prevent material from reaching awareness, while the last three work to keep material that was previously avoided out of awareness.

Freud's treatment of resistance
Freud viewed all five categories of resistance as requiring more than just intellectual insight or understanding to overcome. He characterized psychoanalysis as comprising three processes of overcoming pathogenic resistances, "recollection, repetition, and working through" (1959/1914a, p. 366), and emphasized the crucial component of ‘working through’ in the change process: "This condition of present illness is shifted bit by bit within the range and field of operation of the treatment, and while the patient lives it through as something real and actual, we have to accomplish the therapeutic task, which consists chiefly in translating it back again into terms of the past" (p. 371). Working through thus allows patients "to get to know this resistance" and "discover the repressed instinctual trends which are feeding the resistance" (p. 375) and it is this experientially convincing process which "distinguishes analytic treatment from every kind of suggestive treatment" (p. 376). For this reason Freud (1959/1913) insisted that therapists remain neutral, saying only as much as "is absolutely necessary to keep him [the patient] talking" (p. 343), so that resistance could be seen as clearly as possible in patients’ transference, and become obvious to the patients themselves. The importance to Freud of working through in successful psychoanalytic treatment—and its requirement that the resistance be acknowledged and reassessed with the renewed recognition of past events—thus reiterates the inextricable link suggested by Freud between transference and resistance ("transference-resistance," Freud, 1959/1912; Fenichel, 1945; see also empirical support in Patton, Kivlighan, Jr., & Multon, 1997), and perhaps encapsulates his legacy to psychotherapy.

What’s resistance?
Resistance is based on personal automatic ways of reacting in which clients both reveal and keep hidden aspects of themselves from the therapist or another person. These behaviors occur mostly during therapy, in interaction with the therapist. It is a way of avoiding and yet expressing unacceptable drives, feelings, fantasies, and behavior patterns.

Examples of causes of resistance: resistance to the recognition of feelings, fantasies, and motives; resistance to revealing feelings toward the therapist; resistance as a way of demonstrating self-sufficiency; resistance as clients’ reluctance to change their behavior outside the therapy room; resistance as a consequence of failure of empathy on the part of the therapist.

Examples of the expression of resistance are canceling or rescheduling appointments, avoiding consideration of identified themes, forgetting to complete homework assignments and the like. This will make it more difficult for therapist to work with the client, but it will also provide him with information about the client.

State and trait resistance (situational and characteristic)
Resistance is an automatic and unconscious process. According to Van Denburg and Kiesler, it can be either for a certain period of time (state resistance) but it can also be a manifestation of more longstanding traits or character (trait resistance).

In psychotherapy ‘state resistance’ can occur at a certain moment, when an anxiety provoking experience is triggered. ‘Trait resistance’ on the other hand occurs repeatedly during sessions and interferes with the task of therapy. The client shows a pattern of off-task behaviors which makes the therapist experience some level of negative emotion and cognition against the client. Therefore the maladaptive pattern of interpersonal behavior and the therapist’s response interfere with the task or process of therapy.. This ‘state resistance’ is cumulative during sessions and can best be stopped to develop through empathic interventions from the therapist’s part.

Outside therapy ‘trait resistance’ in a client is shown off by distinctive patterns of interpersonal behavior. Often caused by typical patterns of communication with significant others, like family, friends and partner.

How do therapists handle resistance in psychotherapy?
Nowadays many therapists work with resistance as a way to understand the client better. They emphasize the importance to work with the resistance and not against it. This is because working against the resistance of a client can result in a counterproductive relationship with the therapist. You could say that the more resistance is showed, the less productive is the therapy. Working with the resistance provides a positive working relationship and gives the therapist information about the unconscious of the client.

A therapist can use countertransference as a tool to understand the clients resistance. The feelings the client evokes in you (as therapist) with his/her resistance will give you a hint what the resistance is about. E.g. A very directive client can make the therapist feel very passive. When the therapist pays attention to it’s passive feelings, it can make him/her understand this behavior of the client as resistance coming from fear of losing control.

Important to the question of treatment planning are research studies that have looked at resistance traits as indicators and contra-indicators for different types of interventions. Beutler, Moleiro and Talebi (in press, as described in ) reviewed 20 studies that inspected the differential effects of therapist directiveness as moderated by client resistance and found that 80% (n=16) of the demonstrated that directive interventions were most productive among clients who had relatively low levels of state or trait-like resistance, while nondirective interventions worked best among clients who had relatively high levels of resistance. These findings provide strong support for the value of resistance level as a predictor of treatment outcome, as well as treatment-planning. In these studies cognitive behavioral therapy has been used as a prototype for directive therapy and psychodynamic, self-directed, or other relation oriented therapy have been used as a prototype for non-directive therapy.