Working with Resistance and Denial

Posted on Friday, December the 28th at 6:57pm

Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

“I don’t want to be here and I don’t understand why my doctor said I had to see you in the first place.” Not the best way to start a therapeutic relationship, yet many therapists are faced with resistant clients and need to know how to work with that resistance. I believe that the root of most clients’ resistance is their automatic and unconscious defense mechanism—denial. This denial system helps protect them from facing their painful reality.

In my training and consultation practice I have discovered that there are three crucial steps that clinicians need to implement in order to obtain positive treatment outcomes with resistant clients who are in denial. The first, and most obvious, step in any therapeutic relationship is developing rapport with the client. This is even more crucial with the resistant client due to their denial system and underdeveloped, or in some cases self-destructive, coping skills.

It is a big mistake to start this therapeutic encounter by confronting the client’s resistance head on. In fact, some clinicians implement what I call a formula for disaster—pre-judgment plus insensitivity plus confrontation. This formula usually leads to a major power struggle that nobody really ever wins.

Therefore, I suggest clinicians implement the formula for success—understanding plus compassion before strength-based positive challenge—this usually leads to collaboration instead of a power struggle. Please see the following diagram and ask yourself; “Which formula do I want to use?”

To gain true understanding, the effective use of respectful active/reflective listening, including frequent accuracy checks is essential. This active listening process must be continued throughout the therapeutic process.

While creating the therapeutic bond, it is also important for the clinician to fully understand the motivational crisis that resulted in the client referral in the first place. It is helpful to get outside just verification of the facts whenever possible, so obtaining releases for the referral source and any other important party is an essential first step. This will lead to creating a more accurate picture of what really brought the client to therapy in the first place.

The next step in the process is to determine which defense mechanisms the client is using to protect themselves from their painful reality. These defense mechanisms can be called denial patterns. It is important to remember that these denial patterns are automatic and unconscious processes. There are twelve common denial patterns and each one has its own cognitive theme, or self-talk, which are listed below.

Once you have noted the cognitive theme and identified the denial patterns, the next treatment objective is helping the clients let go of their self-defeating defense mechanisms. You never want to take away someone’s defenses unless you give them new healthier tools. This can be accomplished using a four-step process.

The first step is to expose the denial pattern the client is using. Of course this means you need to be able to recognize the denial pattern by its cognitive theme. However, caution needs to be used here in order to keep the client from becoming even more resistant. You first expose the denial pattern by naming it and describing the cognitive theme the client used. For example if the client was blaming their doctor for needing to be in therapy you can say “what I’m hearing is you know you have a problem but it’s not your fault. Did I get it right?” The next step is to show the client what he or she is doing and exploring with him or her what role their behavior play in experiencing negative consequences. Once this unconscious game is out in the open its power is diffused.

Unfortunately, most clients will then automatically and unconsciously switch to another denial pattern. In the real world denial works in clusters and most resistant clients have a preferred defensive structure using between two to six denial patterns. Before you can fully diffuse one pattern they rapidly cycle to another. When this happens it is important to stop the process by staying focused on the original denial pattern being used. This is done by switching from an interviewing format to a mini-education mode with the goal to teach the client about the original denial pattern.

This education is the second step in the denial management four-step process. You want to keep the client focused on the denial pattern that was exposed. You need to teach the client to be consciously aware of the denial pattern being acted out, recognize the related cognitive theme or self-talk, and the underlying mistaken belief system on which it is based. This mini-education session is a one or two minute educational overview of the denial pattern.

Once you have completed the education you need to move quickly into the third step, positive challenge. When challenging the denial pattern it is important to show why using the denial pattern is problematic and the negative consequences of staying in denial. This needs to be followed by a therapeutic injunction against continuing to use the denial pattern and positive permission to get out of the problem and into the solution.

Getting into the solution is the fourth step where you teach the client effective denial management strategies. Clients need to learn how to recognize and stop using their denial patterns while at the same time learning new skills to identify and solve their painful reality problems. This is where the collaboration needs to happen. I often ask the question “Are you willing to learn a new way of thinking and behaving that will better get your needs met?” Most of the time the answer is a little tentative but is a “yes I’m willing.”

The alternative to denial is recognition, acceptance, and problem solving. In order to achieve proficiency clients need to learn how to self-monitor their thinking, emotions, urges, and behaviors. This is where cognitive restructuring techniques can be implemented. Only by learning to identify their irrational thinking and challenging it can clients start to manage their uncomfortable feelings that lead to self-defeating impulses and self-destructive behaviors.

Once denial is uncovered and managed the client’s resistance to ongoing treatment is significantly reduced. Working with resistance and denial takes tremendous patience and perseverance. But most of all, it requires developing understanding, empathy, and compassion before offering a strength-based challenge, thus giving people permission to stop using automatic and unconscious defense mechanisms that cause more negative consequences than benefits. I strongly believe that this denial management approach will significantly improve treatment outcomes with resistant clients.