Strive to understand

Although the therapist may believe that change is a good thing, clients may have misgivings.

Many patients, especially those with serious, longstanding disorders, cling tenaciously to the status quo in their lives, because to some extent it is familiar and safe (Beck et al.1990; Layden et al. 1993; Newman 1994a; Young 1990). For many patients, it is frightening and disorienting to change patterns of cognition, affect, and behavior that they have long associated with their very identity. Additionally, many patients believe that significant change is untenable, due to further difficulties that they expect would arise.

For example, Ed and his therapist agreed that prostitutes were a high risk stimulus for him. Whenever he would encounter a prostitute who liked to get high, he was vulnerable to seeking out drugs with which to pay the woman. Then, they would have sex and smoke crack cocaine together. In spite of this understanding, Ed still frequented prostitutes and used drugs.

At first, this exasperated the therapist, who thought that Ed was deliberately sabotaging therapy because of an opposition to change. However, when the therapist probed for Ed's fears about giving up this maladaptive pattern, Ed was able to articulate that he felt he had nothing to offer a straight woman. He believed that because he was unemployed and not very handsome, his only means of finding female companionship would be in the context of drug use with a prostitute. In other words, underlying Ed's apparent resistance was a fear of being alone.

This understanding helped the therapist to express empathy, and to encourage Ed to actively challenge the belief that he would be alone if he gave up drugs.

When patients become overtly angry in session, therapists can cope with this situation best by trying to provide empathy, and by reminding themselves that no matter how aversive this situation is for therapists, the patients almost always feel worse. This stance helps therapists to decatastrophize the situation, and to keep the therapists' attention squarely on the patients' needs.

Three examples:

IV. The Therapeutic Relationship and the Case Formulation
1. Strive To Understand the Pain and Fear Behind the Patient's Hostility and Resistance
Although the therapist may believe that change is a good thing, clients may have misgivings. Many patients, especially those with serious, longstanding disorders, cling tenaciously to the status quo in their lives, because to some extent it is familiar and safe (Beck et al.1990; Layden et al. 1993; Newman 1994a; Young 1990). For many patients, it is frightening and disorienting to change patterns of cognition, affect, and behavior that they have long associated with their very identity. Additionally, many patients believe that significant change is untenable, due to further difficulties that they expect would arise. For example, Ed and his therapist agreed that prostitutes were a high risk stimulus for him. Whenever he would encounter a prostitute who liked to get high, he was vulnerable to seeking out drugs with which to pay the woman. Then, they would have sex and smoke crack cocaine together. In spite of this understanding, Ed still frequented prostitutes and used drugs. At first, this exasperated the therapist, who thought that Ed was deliberately sabotaging therapy because of an opposition to change. However, when the therapist probed for Ed's fears about giving up this maladaptive pattern, Ed was able to articulate that he felt he had nothing to offer a straight woman. He believed that because he was unemployed and not very handsome, his only means of finding female companionship would be in the context of drug use with a prostitute. In other words, underlying Ed's apparent resistance was a fear of being alone. This understanding helped the therapist to express empathy, and to encourage Ed to actively challenge the belief that he would be alone if he gave up drugs. When patients become overtly angry in session, therapists can cope with this situation best by trying to provide empathy, and by reminding themselves that no matter how aversive this situation is for therapists, the patients almost always feel worse. This stance helps therapists to decatastrophize the situation, and to keep the therapists' attention squarely on the patients' needs. Three examples: one therapist defused a patient's hostile outburst by asking, "Do you feel I've let you down in some way?" another therapist achieved the same end by saying, "I'm sorry if what I've said or done has upset you. That wasn't my intention. How did what I said hurt your feelings?" the therapist who" normalized" his patient's angry refusal to answer the therapist's questions by stating, "I can see that you're only trying to protect yourself. That's okay. Everybody has the right to do that."
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