Definition of Resistance

Resistance is often expressed, whether directly or indirectly, as behaving contrary to the therapist's recommendations and/or the patient's well-being. In fact, even patients with the best intentions may become ambivalent about changing, thus failing to carry out those changes actively. Despite the many definitions and conceptualizations, a patient’s resistance to change is widely accepted as one of the more demanding challenges psychotherapists face (Beutler, et.al, 2011). The term Resistance was initially coined by the Psychoanalytic theory, which defined it as "the patient’s unconscious avoidance of unconscious threatening material that might be disclosed and threatened in analytic work" (Arlow, 2000 in Beutler, et.al, 2011). According to this definition, any objection the patient might express to the therapist's interpretations would be defined as Resistance. This traditional model was criticized on several occasions (de Shazer, 1984; Leahy, 2001), particularly by Rogers (1969) who claimed the contrary:"…it is the client who knows what hurts, what directions to go in, what problems are crucial" (Rogers, 1969, p.11–12). Following Rogers’ view were feminist and constructive theorists, who claim as well that clients are the real experts on their personal experiences (Duncan and Miller, 2000; Worell and Remer, 2003). Within the Solution-focused approach, it was suggested that therapists who look for resistance in their client's behavior would be unable to see their cooperation (De Shazer, 1989). In addition, refusal to cooperate with the therapist could hardly be defined as negative if the patients resist because the therapist's suggestions seem irrelevant to them (Murphy 2008). In such cases, their responses would be more of a "discontent regarding the agenda" rather than Resistance (Furman and Ahola, 1992; Sommers-Flanagan, Richardson & SommersFlanagan, 2011). Another significant point, is that even a trained and experienced therapist could be wrong (Gilhooley, 2011), and if the adolescent response with an objection it may be the result of mistake or misinterpreting of the situation made by the therapist. Recognizing one's mistakes, being aware and sincere about them and openly taking responsibility for them in session, is a core factor in bonding and trust building in therapy, especially with adolescents. Definitions that are more recent suggest that patient resistance is not at all pathological, nor is it even located within the patient's character. Furthermore, they note that the responsibility for resistance may be placed “on the therapists” themselves (Sommers-Flanagan and SommersFlanagan, 2004a). The Motivational Interviewing approach conceptualizes resistance as resulting from the interaction between the patient and the therapist and is most likely to occur when the patient feels a potential loss of freedom (Moyers & Rollnick, 2002). Goffman (1974) made a distinction between "natural" or "unguided" events and "unnatural" or "guided" events. A natural event is defined as an event occurring as part of the expected sequence of occurrences, whereas a guided event is a direct intervention that deflects the occurrences from their natural path. According to this distinction, since striving for individuality and autonomy is inevitable during adolescence, it is normal for adolescents to resist when encountering repression. Their rebellious, uncompromising response could be in fact described as an unguided, instinctive reaction to the oppressive restrictions they face from the surrounding environment while wishing to realize their right to self-expression. In fact, some researchers argue that acts of rebellion have a positive impact on the adolescent's development (Cooper, 1988; Steinberg and Silk, 2002). According to Brehm and Brehm (1981), who called this response “Reactance,” such a situation unavoidably creates in the patient desire to counteract and refuse the therapist's view. They defined it as a "state of mind aroused by a threat to one’s perceived legitimate freedom, motivating the individual to restore the thwarted freedom" (Brehm & Brehm, 1981 in Beutler, et.al, 2011; Moyers & Rollnick, 2002). Though similar in definition, the terms Resistance and Reactance each possess some unique qualities. Defining a patient's behavior as Reactance is relating it exclusively to the situation. Thus suggests the surrounding environment is the source to the relevant acting out. Therefore, by definition, it can occur as well in normal personality. By defining the patient's behavior as Resistance, an inner problem of the patient is implied, which is considered pathological and has different treatment implications. Furthermore, reactance is expressed as directly oppositional behavior while resistance can also include a failure to act (e.g., stubbornness, obstructionism, and rebellion in Beutler, et.al, 2011). It is important to mention that the suspicion (fear) of psychotherapy presented by adolescents is natural, and sometimes well earned. In fact, one can hardly expect an adolescent, stepping into a clinic with an unfamiliar adult for the first time, to present an unnatural trust towards them. So, the beginning of a therapeutic process with an adolescent might seem like as another example of the classic "Strange Situation" presented by Ainsworth (1969). The following situation, during which adolescents are sent to therapy by their parents, then left alone and expected to relax and share intimate stories with a stranger, is likely to cause discomfort and challenges (Sommers-Flanagan, Richardson & Sommers-Flanagan, 2011). This starting point to the therapeutic process makes it rather uninviting for the adolescent to engage in a therapeutic alliance. Establishing a Therapeutic Alliance The therapeutic alliance could be defined as "collaborative nature of the patient-therapist interaction, their agreement on goals, and the personal bond that emerges in treatment" (Horvath & Bedi, 2002; Orlinsky et al., 2004 in Kazdin, 2009). According to studies evaluating therapeutic alliance, a positive alliance can predict improvement in symptoms at the end of the treatment process. That should serve as a guideline for the therapist in forming an intervention strategy and deciding therapy goals (Kazdin, 2009). Establishing a therapeutic alliance early in treatment helps reduce possible resistance. It is aimed to engage the patient and maintain them in treatment, as well as to encourage the adolescent to cooperate with various treatment techniques (Stewart & Birdsall, 2001 in Truneckova & Viney, 2008). Research indicates that a positive therapeutic alliance is both seen as desirable by adolescents and associated with improved therapy outcomes, and that the strength of the alliance increases the therapeutic change (Creed and Kendall, 2005; Eyrich-Garg 2008; Kazdin et al. 2006 in Sommers-Flanagan, Richardson & Sommers-Flanagan, 2011; Horvath & Bedi, 2002; Orlinsky et al., 2004 in Kazdin, 2009). Since the treatment had been shown to improve the outcomes significantly for young people (Lyons and Rawal, 2005), establishing the meaning of the treatment in the eyes of the adolescent and assuring continued attendance is crucial. That requires forming a meaningful therapeutic alliance (Carey and Oxman, 2007) and creating a trusting, safe environment (Prochaska, DiClemente, and Norcross, 1992 in Truneckova & Viney, 2008). The first and critical step would be reaching an understanding and agreement between the therapist and the adolescent about therapy goals, delicately considering the adolescent's problems, as well as their abilities, resources, and expectations. In order to reach those objectives, the therapist should be able to engage the adolescent in his “safe zone”, motivating them to make the required changes (Bordin, 1979; Haynes, 1993; Horvath & Luborsky, 1993; Karoly, 1993; Liddle, 1995; Nezu & Nezu, 1993 in Hawley & Weisz, 2003, Horvath et.al, 2011). If, however, an agreement is not reached, and the therapist does not show a willingness to compromise, the cooperation of the adolescent may be reduced, and the commitment and efforts the patient invests in the treatment substantially decreased (Horvath & Luborsky, 1993; Liddle, 1995). When the patients have come to therapy by their choice in order to achieve individual goals, it is the professional's obligation to work in order to reach consensus among treatment participants, before beginning the process (Hawley & Weisz, 2003). Since adolescents rarely refer themselves and are even commonly coerced into treatment, achieving goal consensus in adolescent therapy tends to be more complicated. The main reason is the involvement of the referring adults, usually the parents, which requires the therapist to bridge different agendas, outlooks, opinions, and perspectives, sometimes even entirely opposite to the adolescents (Shirk & Karver, 2011; Yeh & Weisz, 2001). Forming alliance with both parents and adolescent is imperative for reaching treatment goals since the alliance with the parent would be crucial for treatment continuation, and the alliance with the youth ensures their cooperation (Shirk & Karver, 2011). Achieving both is a challenge, not present when treating adults who refer themselves for therapy. It has been shown that there are major differences in perception and agenda between adolescents and their parents (Shirk & Karver, 2011). In a study conducted by Yeh & Weisz (2001), an agreement between parent and adolescent was not achieved, even regarding one problematic issue that required attention, in over 60% of the pairs. Moreover, there was no parent-child consensus in more than a third of the cases even when requested to select a broad category, one general treatment area. It is clear that failing to agree on treatment goals on such a level could compromise each of the parties' cooperation and even harm the entire treatment process (Yeh & Weisz 2001). In these cases when therapists are required to consider both the youth and the parent's perspectives, considering one side of the other's point of view might create a deformed perception of the situation and establish partial treatment goals (Horvath, et.al, 2011). The most common solution would be combining the main issues of each party though the therapist, in many cases, as an adult is instinctively more inclined to agree with the parent. Yeh & Weisz (2001) found that for most problem types (Attention, Withdrawn, Anxious/Depressed, Self-Destructive/ Identity and Social), treatment goals as determined by the therapist were significantly related to what has been reported by the parent rather than the child. That implies that therapists were "following the strategy of focusing on parent" (Hawley & Weisz, 2003). The importance of the alliance with the adolescent increases, to a critical level, when concerning issues of more direct involvement, which require collaborating actively in (day-to-day situations) therapy tasks. The challenge here is not only reaching active attention and participation, and creating in the adolescent the motivation to attend the sessions but also to achieve the adolescent's willingness and ability applying the acquired skills, gained in the sessions, outside of the sessions. Adolescent-Therapist alliance has also been directly associated with a decrease in severity of symptoms (e.g., Shirk & Saiz, 1992; Stark et al., 1991; 1992 in Hawley & Weisz, 2003). It is important to emphasize that forming an alliance with the adolescent is not merely a task to be undertaken at the beginning of the treatment process, but rather that the alliance should be maintained throughout the process (Shirk & Karver, 2011). In adult therapy, the training, credentials, and experience of the therapist are sufficient for most adults to grant, instantly, the therapist with initial trust. Adults are usually more willing to share details of the problem, even before a therapeutic alliance has been formed. In contrast, adolescents are not likely to open up to a therapist early in the process of treatment. Adolescents, who are in most cases referred to therapy during a time of disagreement with their parents, start by perceiving the therapist as their parents sent anther adult to influence them in that disagreement. In fact, the therapist's efforts to communicate might be perceived by the adolescent as a threat, serving that same purpose of influence and "manipulation." Therefore, adolescents will usually not willingly share with the therapist any information that may assist in diverting them from their chosen position, until making sure the therapist is accepting and supportive of their view. Ultimately, the adolescent's interests and well-being direct the therapist's actions. Only when this understanding has been reached, and trust and alliance between adolescent and therapist are established, will they agree to share details that could be used by the therapist to initiate a process of change and progress. Hence, combining trust building and forming a solid therapeutic alliance with the adolescent are not only a significant advantage in the treatment but are a preliminary condition to the mere existence of the therapeutic process. One of the fundamental principles of establishing a therapeutic alliance with adolescents is recognizing their individuality and unique identity, as reflected in the cross-cultural approach.