It is common in substance abuse treatment to hear clinicians label clients as resistant, meaning the individual is unmotivated to participate in the treatment process. Over the last year of so, I’ve been thinking a lot about the idea of resistance within teens. The more I think about this, the more I've come to believe that resistance is extremely rare in teens, if not in all client populations.
It seems to me that resistance is an easy answer to explain away non-engagement by clients, providing an easy excuse to not make further efforts at engagement. Selekman wrote, “The traditional psychotherapeutic concept of resistance is an unhelpful idea that has handicapped therapists” (p. 32). Motivational interviewing provides many useful ideas for moving beyond the easy excuse provided by labeling a client as resistant. According to Miller and Rollnick, motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25).
In my experience, most teens are not resistant. They are ambivalent. Indeed, most of the clients I’ve worked with have held as absolute fact two seemingly incongruent thoughts: 1.) I have a problem; and, 2.) I don’t want to do anything about my problem. Its worth noting that my clients rarely define their problems the way I do, at least not initially, but that doesn't mean they believe themselves to be problem-less. It also doesn't mean they are resistant.
From my perspective as a clinician, my clients have problems stemming from drug use, truancy, illegal behavior, mental health challenges, and family dysfunction. Rarely are these the problems my clients initially identify, though. Many of my clients reluctantly enter treatment with only one self-identified problem, being on probation or an at-risk youth petition, and only one self-identified goal, avoiding detention. It would be easy to dismiss these youth as resistant. After all, they don't agree with me, the professional. In fact, though, not agreeing with me probably shouldn’t be considered pathological.
Miller and Rollnick wrote, “Understanding the dynamics of ambivalence… provides an alternative to thinking of people as (and blaming them for being) ‘unmotivated.’ People are always motivated for something” (p. 18). Avoiding detention—the sole initial motivation with many of my clients—is an extremely concrete goal and an excellent place to begin. It is easy to develop discrepancy with these youth, a key principle of motivational interviewing (Miller & Rollnick, p. 37). This principle requires that the helper “create and amplify, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values” (Miller & Rollnick, p. 38).
“If we want to help people learn, we should not worry about how we can motivate them but try to identify what already is motivating them” (Zull, p. 53). For teens on probation or an at-risk youth petition, continued use of alcohol and other drugs will lead to a violation that could send them to detention. Staying out of detention—their self-defined goal—requires clean UAs and attendance at treatment. When I talk about this with a client, I’m not telling him to stop using alcohol and other drugs. Instead, I’m being collaborative and helping him solve his problem as he defined it. Sure, the client is doing what I hoped for, but he's doing he for his reasons, not mine.
The threat of detention may not motivate a youth to change her behavior, but it is usually sufficiently motivating to start the process. Once this process has begun, “the overall goal is to increase intrinsic motivation, so that change arises from within rather than being imposed from without and so that change serves the person’s own goals and values” (Miller & Rollnick, p. 34).
Mental Logjams
Many of my clients are adequately motivated by extrinsic rewards to start the change process. However, for a client who simultaneously hold as true “I have a problem” and “I don’t want to do anything about my problem,” the mental logjam created from these incongruent beliefs can serve to reinforce his maladaptive cognitive scripts, encouraging him to remain stuck. After all, resolving this discrepancy will be hard and brains are lazy. They’d rather continue to use the same ol’ well-rehearsed scripts. Those brains would rather continue to Act Up, Shut Down, or Use.
When lazy brains do what lazy brains do, it may appear to be resistance or a lack of motivation. However, it seems to me that this is really just basic neuroscience in action. What fires together wires together, and then wants to keep firing that way. Getting unstuck requires getting lazy brains to do something different; that requires overcoming an apparent lack of motivation. Miller and Rollnick wrote that lack of motivation “can be thought of as unresolved ambivalence. To explore ambivalence is to work at the heart of the problem of being stuck” (p. 14).
In my experience, professional helpers often do their work only on the “I have a problem” side of ambivalence. I believe this is ineffective for two reasons. First, as discussed above, my clients already know they have a problem. They don’t need me to repeatedly tell them that. If anything, doing so is invalidating and reaffirms their apparent inability to be effective or make change. In fact, it would seem to me that repeatedly telling a client she has a problem contributes to keeping her stuck.
The second reason working on the “I have a problem” side is ineffective is that it is developmentally inappropriate with adolescents. Lectures don’t persuade teens. Neither does forcing compliance to a pre-determined solution they had no input on. Adolescents are supposed to question, rebel against, and ultimately resist the plans authority figures. Most professional helpers may be reluctant to view themselves as authority figures, but our clients never forget it.
“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged” (Miller & Rollnick, p. 18). If I tell my clients to stop using alcohol and other drugs, I may be increasing the likelihood of them continuing their use! That's true for any client, child, adolescent, or adult. However, as an unavoidably authoritarian figure working with adolescents who are supposed to rebel against what I say, this is magnified. So, not only does telling a client he has a problem contributes to keeping him stuck, so does telling him what to do about his problem.
Reframing Resistance
I started this post by stating that resistance meant that the individual is not amiable to treatment. Miller and Rollnick propose a different definition for resistance, “movement away from change” (p.47). Forced compliance doesn’t lead to change, but as we’ve seen above it may lead to movement away from change.
With mandated clients, I could create a pressure cooker situation that forced them into compliance, and I’ve seen counselors, parents, and probation officers take this approach. However, it is vital to avoid this sort of taking sides. “If the counselor argues for one side of the conflict, it is natural for the client to give voice to the other side… Hearing themselves vigorously arguing that they don’t have a problem and don’t need to change, they become convinced” (p. 56-57).
One way to avoid taking sides is to externalize the problem (Selekman, p. 93). This therapeutic strategy involves talking about the problem as if it was a separate being from the client, complete with sentience and decision-making abilities. About two years ago, when I initially read Selekman, I started externalizing ambivalence when working with reluctant clients. Inspired by a treatment-oriented board game, I began talking about Addictive Voices and Rational Voices. I’ve integrated the Voices throughout my groups—including role plays, art activities, the board game, and experiential activities—and I’ve found my clients readily embrace this concept.
In both individual and group sessions, I often assume the role of a client’s Addictive Voice, leaving the Rational Voice to the client. According to Miller and Rollnick, “If taking up one side of the argument causes an ambivalent person to defend the other, then the process ought to work both ways… By the nature of ambivalence, when the counselor raises only one side the client is inclined to explore the other” (p. 107).
In my experience, even the most ambivalent client is able to effectively speak for her Rational Voice. According to Miller and Rollnick, this is exactly the goal of motivational interviewing—for the client to “present the arguments for change” (p. 76). In doing so, the client can begin the process of breaking through the mental logjam caused by ambivalence.
Mandates may bring clients into treatment, but they don’t lead to lasting change. Motivational interviewing “focuses on intrinsic motivation for change, even with those who initially come for counseling as a direct result of extrinsic pressure” (Miller & Rollnick, p. 26). Looking beyond the simple answer of resistance is vital if this process is to occur.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.
