Clementine Miami Pinecrest Clinical Director Bertha Tavarez, PsyD discusses treating an adolescent who is resistant and treatment ambivalent. Dr. Tavarez offers some strategies to help strengthen the therapeutic alliance and build the groundwork necessary for full recovery.
“The sun and the wind were having a dispute as to who was more powerful. They saw a man walking along and they had a bet as to which of them would get him to remove his coat. The wind started first and blew up a huge gale, the coat flapped but the man only fastened the buttons and tightened up his belt. The sun tried next and shone brightly making the man sweat. He took off his coat.” – Anonymous
The metaphor of the sun and the wind is an accurate depiction of the challenges that many clinicians face while working with adolescent patients. Although we may have access to the gravity of our patient’s clinical needs, simply communicating our concerns and providing much needed skills can be met with resistance. Our patients remain “locked in” to their emotional experience while simultaneously feeling “locked out” of the insight and motivation needed to increase their receptivity to much needed skills development. The adolescent, preoccupied with exerting and maintaining control and autonomy, may hold tightly to their coat, rendering our intentions to provide care futile.
So how do we, like the sun, create shifts in awareness and influence change?
The power of reflection
It may be tempting to adopt the roll of cheerleader (“You can do this!”) or problem solver (“Why don’t you try this?”). When an adolescent patient presents with resistant talk (“I don’t want to be here”) or talk that inhibits change (“I got straight A’s with ED, what’s the problem?”). Often the simplest and most effective way of building rapport and loosening the grasp of resistance is to simply reflect the patient’s message in your own words. Often, patients are primed for persuasion and direction. Reflection statements can contribute to feelings of validation and interpersonal trust.
Resistance as an interpersonal process / Resistance as developmentally appropriate
It is important to keep in mind that resistance is both developmentally appropriate for adolescent patients and an interpersonal process that occurs within the therapeutic alliance. Although, we may expect a certain degree of resistance on a developmental level, we can provide corrective experiences around resistance that still promote autonomy. A clinician may benefit from awareness about the resistance that is brewing in a session, abstain from engaging in a power struggle, and promote an alliance with the patients’s desire for autonomy.
Highlight intrinsic control
An effective technique that facilitates a shift from resistance talk to change talk is the clinician’s emphasis on the patient’s access to her personal control. A clinician may reflect the pros and cons experienced by the patient:
Patient: “I got straight A’s with ED, what’s the problem? Gosh! That was so hard!”
Therapist: “It sounds like you did well in school this year, but ED made it more difficult.”
A clinician may also reflect a patient’s choice within the constraints of the treatment environment while having the knowledge of the consequences. For example, the patient may be informed of her choice to select what day an exposure is initiated or asked to reflect on her choice to not participate in a group while being aware of consequence of losing a daily privilege as a result.
If resistant talk persists, the clinician can shift the focus to another closely relevant therapeutic topic that may tie into the overall theme beneath the resistance. For example, if the patient states, “I don’t want to take medications and that’s final!” the clinician can say, “Ok, how about you tell me how you’re feeling about your overall health today?”
Working with patients experiencing resistance and treatment ambivalence can be challenging. However, there are great opportunities at this treatment phase that can strengthen the therapeutic alliance and build the ground work necessary for lasting change. Motivational interviewing and person-centered techniques are an integral component of the clinical work at Clementine adolescent treatment program.