Psychological resistance is the phenomenon experienced in clinical practice whereby the patient engages in self-sabotaging and oppositional behaviors hindering the success of therapy. Psychoanalysts define resistance as a patient’s attempt to suppress anxiety-provoking memories and insights from entering their conscious awareness and as a self-protective mechanism for holding on to the familiar surroundings, emotions and feelings. Behaviorists on the other hand define patient resistance as the obstructive behaviors that hinder the success of therapy. The resistance negatively affects therapy since the patient’s negative cognitive, affective, and behavioral signs continue despite the bad consequences. As a psychologist working with resistant patients, it is however important to view the phenomenon as a double edged sword so as to best understand the patient. The source of the resistance points to the patient’s ideographic obstacles to change to help them direct the patients on ways of staying in touch with their disavowed feelings, their hidden motives, and their dysfunctional interpersonal patterns. Verbal behavior programs are used to overcome the psychological resistance and are developed with the aim of developing functional skills like communication, self-help skills, play skills, social skills, and instruction compliance. They entail therapy sessions of between two to four hours thrice to five times per week.
There are various forms of psychological resistance experienced during therapy sessions as the client seeks to avoid confronting unpleasant emotions or face truths that will disarrange their life perspective (Alvord & Berghorst, 2017). Patients show resistance when they are on the verge of admitting their fantasies, motives, feelings and their contribution to the self-destructive behaviors that led them into therapy in the first place. The patient can also withhold feelings towards the therapist whereby they may think that they are unqualified, failure to disclose negative feelings towards the therapist for fear of retaliation, and projection of feelings from other relationships on the therapist (Barnes, Mellor, & Rehfeldt, 2014). Patients also express resistance through the enactment of past pent up feelings or reactions during the therapy session with the patients seeing the therapist as their hindrance to getting better (Gould, Dixon, Najdowski, Smith & Tarbox, 2012). The patient can also express resistance through the way they communicate either by being too silent or offering minimal information to work with or by being overly chatty and questioning the therapist instead of answering the therapist’s questions.
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They may try seducing and manipulating the therapist, skipping therapy sessions, becoming obsessed with the past or the future, miss or refuse to pay for appointments and refuse to complete self-help exercises recommended by the therapist (Kearney, 2014). The patient may continue engaging in negative actions that contribute to their problems away from the therapy session and also engage in self-sabotage behaviors as a way of getting the therapist’s attention if they feel that the therapist is not empathetic enough. All these actions hinder the progress of the patient and minimize the benefits of therapy and call for a program to help minimize the effects of the resistance on the patient’s wellness (Alvord & Berghorst, 2017). The resistance stems from the patient’s inability to possess the required skills and competency to follow through with therapy assignments, pessimistic feelings about their therapy sessions and their exposure to negative surroundings which trigger their anxieties and negative behaviors (Romanczyk & McEachin, 2017). Family system theorists posit that patient resistance also stems from the avoidance of confronting issues that may upset the client’s family life balance (Barnes et.al., 2014). They therefore prefer living in the disillusioned state where they believe that everything is okay as opposed to acknowledging the discordance between reality and their beliefs and behaviors.
The patient resistance also exists in situations where the patient feels like the benefits that come from their present state of mind outweigh the benefits they would get if they got better (Gould et.al., 2012). If they also feel that the goals of the therapy do not align with their personal needs they may become resistant and hesitant to participate since they may see therapy as a waste of time (Alvord & Berghorst, 2017). The prospect of change whereby they give up their habitual behaviors and beliefs is also scary to some patients and they may strive to uphold the status quo by sabotaging the therapy sessions (Barnes et.al., 2014). The therapist also contributes to the patient resistance especially if they employ techniques that the client deems unpleasant. The people that interact with the patient in their daily schedules may also discourage the patient or degrade the benefits of therapy if they gain something from the patient’s current state of mind (Kearney, 2014). The peer influence may lead to the development of a negative attitude towards therapy leading to the self-sabotaging behaviors.
Strategies for Working with Resistant Patients and a Plan for Overcoming Barriers to Effective Communication with Parent
Psychologists should expect the occurrence of patient resistance in the therapy sessions and should treat it as an opportunity to learn more about their patients (Alvord & Berghorst, 2017). The psychologist should teach the patient about what resistance is and how it negatively affects their health outcomes during therapy and give them the opportunity to change the behavior (Gould et.al., 2012). The therapist should view at the situation from the client’s perspective in order to understand them more instead of seeing resistance as simply a rebellion towards them (Barnes et.al., 2014). From there they can help the patient to explore the different options available and point them towards the right direction. Counselors should also treat resistance as a two way street so that they can also examine their contribution to the patient’s attitude (Romanczyk & McEachin, 2017). Through the self-examination strategy they can adjust their communication styles and how they interact with the patient to minimize the resistance and align the therapy goals with the patient goals.
The therapist should foster collaboration between themselves and the patient since the extent to which the patient resistance is resolved determines the outcomes of therapy (Kearney, 2014). The counselor-client relationship should be established on trust and a feeling of safety and mutual respect since in such an environment the patient feels safe and secure to share (Schreibman & Stahmer, 2013). The failure to disclose their inner wants, fears, actions and feelings renders therapy ineffective but in a safe place where the patient feels respected and like an active director of the session they are more likely to open up about their issues (Barnes et.al., 2014). Clients are most resistant when they have poor relationships with the counselors and feel undermined or disrespected and lowering their defenses through building a trust based relationship makes the patient more open and honest (Schreibman & Stahmer, 2013). The therapist should also handle the issue head on without trying to work around it. They must tell the patient the hard truth of what is likely to happen if they don’t change their attitudes during therapy (Gould et.al., 2012). They can brainstorm the pros and cons of changing versus continuing with the resistance while appearing most empathetic with the client’s position and embracing it without forcing the opposite choice on them.
The therapist should also use a language that mirrors that of the patient to create an environment where the patient feels understood and in touch with the psychologist (Kearney, 2014). Giving the patient a sense of autonomy and freedom also helps deal with the patient resistance during therapy. The therapist should maximize the use of self-direction techniques but when the patient fails to meet their obligation like complete a homework task the counselor should persist that they do in order to continue with the therapy sessions (Romanczyk & McEachin, 2017). The therapist should however avoid being emotionally involved with the empathy until they find themselves colluding with the patient’ excuses and being manipulated into accepting the resistance as normal behavior (Schreibman & Stahmer, 2013). The feelings of victimization and powerlessness should be discouraged and the patient encouraged to face the tough issues that they are scared might upset their current life (Barnes et.al., 2014). Therefore instead of acting like the expert the therapist should proceed with an attitude of naïve curiosity.
To overcome the barriers to effective communication with parents a plan is necessary (Gould et.al., 2012). Effective communication is hindered by emotional barriers, loss of interest in the message or the communicator, stress and depression, inattentiveness, difference in perspectives, pre assumptions and stereotypes and lack of trust and respect between the parents and their children. As such to enhance the communication process these factors must be taken into consideration (Kearney, 2014). The psychologist can recommend the use of the three C’s plan which includes consistency, clarity and courtesy. Both parties in the communication should be courteous by taking into account the other party’s perspective and being active listeners. They should also be consistent in their communication to avoid delivering contradictory messages leading to misinformation and misinterpretation (Alvord & Berghorst, 2017). Their communication should also be clear with no ambiguity or space for misinterpretation and bring out each party’s point of view and what they desire to achieve from the conversation.
Establishing a Verbal Behavior Program
A verbal behavior program is aimed at imparting functional skills like language/communication, self-help skills, play skills, social skills, and compliance with instruction (Kearney, 2014). The program is based on the assumption that a meaning of a word is found in their functions and the basic verbal parts of language include echoics, mands, tacts, and intraverbals (Romanczyk & McEachin, 2017). The program teaches children to use linguistic devices like signing or speaking to ask for things that they need. The operants involved in the program include manding which is the ability of a kid to ask for things, and tacting which develops the ability of a child to label the things they encounter in their day to day lives (Barnes et.al., 2014). Motor imitation is also an operant that involves training the child to repeat other people’s gross and fine motor control and echoics which involve the repetition of sounds, words or phrases aimed at aiding in speech development (Alvord & Berghorst, 2017). The intraverbals operant impart the ability to answer questions, fill in blank spaces and hold a conversation while the receptive task operant aims at developing the child’s ability to follow instructions.
The verbal behavior would involve the therapist using different tactics to impart the various operants on the child during therapy (Romanczyk & McEachin, 2017). The manding is the most important operant and is taught through motivative operation. The child is taught to express their desires and needs and they verbalize them by signing or speaking (Gould et.al., 2012). The child can be trained using a cookie whereby they are made aware that whenever they desire to eat a cookie they can always say or sign the word and the therapist offers direct reinforcement by giving them the cookie (Schreibman & Stahmer, 2013). The tacting operant would be instilled using the sensory stimuli by showing the child a cookie, making them smell it, taste it, touch it or listen to someone eating a cookie (Barnes et.al., 2014). This way the child will be able to label a cookie when they see, feel, touch or taste it and the therapist offers non-specific reinforcement by congratulating them when they identify the word cookie.
The intraverbal operant is imparted by asking the child what they would like to eat and when they say or sign a cookie the therapist offers nonspecific reinforcement by praising the child (Gould et.al., 2012). The echoic operant is imparted by having someone else mention a cookie and when the child says it back the therapist again offers nonspecific reinforcement by praising the child on getting the verbal stimuli right (Kearney, 2014). The data collection process is informed by observing how the children respond to therapy, the extent to which the treatment is impacting the child’s life and how much of the change can be attributed to the speech therapy (Barker, Pistrang & Elliott, 2016). Aside from the treatment data the therapist also collects generalization probe data which involves assessing the performance of the kid outside therapy sessions and control data which provides for the possibility of other factors other than therapy being responsible for patient’s change in behavior (Barker et.al., 2016). The data collection tools include observation, interviews and field notes as well as the therapist’s notes from the therapy sessions.
The data analysis process is guided by the principles of validity and reliability to ascertain which data best informs the therapist’s practice (Barker et.al., 2016). Quantative data analysis requires the therapist to specify the behaviors to be observed during the objective behavioral measurement process (Romanczyk & McEachin, 2017). In this case it would include the treatment target behaviors, behaviors that are related to the target, and the control behaviors that are unrelated to the target behaviors (Barker et.al., 2016). That way the therapist is able to analyze the effectiveness of the treatment by assessing the impacted behaviors and the extent to which therapy influenced them (Alvord & Berghorst, 2017). Qualitative data analysis involves the therapist taking a subjective measurement approach and analyzing the patient away from the therapy setting. The lack of progress is addressed by seeking alternative therapy techniques and integration of other forms of therapy. The assessment phase of the treatment is done using the Assessment of Basic Language and Learning Skills (ABLLS) (Schreibman & Stahmer, 2013). The child’s capabilities in different areas are assessed including basic language and pre-language learner skills, academic skills, self-help skills, and motor skills (Romanczyk & McEachin, 2017). Some of the activities assessed include ability to visually identify objects, language reception, ability to take and follow instructions, vocal and motor imitations, reading and spelling skills and gross and fine motor capabilities.
The integration of specific naturalistic teaching procedures into parent training is important in ensuring that the child does not regress between the moments they spend with the therapist and at home (Barnes et.al., 2014). Naturalistic teaching procedures are implemented within the home, school or general education environments and aims at teaching the child within naturally happening events as opposed to teaching them within an instructional setting. Incidental teaching is a naturalistic procedure that boosts spontaneous language skills and facilitates the employment of the skills learned in the structured settings (Gould et.al., 2012). The parent can be trained on ways to integrate language learning in their child’s normal playtime activities. Through games the parent can train the child to ask for things which will help in developing their manding and tacting operants (Kearney, 2014). The child can therefore apply the gestures, words and other verbal communication skills learned at therapy and the parent can facilitate the memorization by making the child ask for items repeatedly while in a natural play environment.
The natural language paradigm can also be employed in a naturalistic teaching procedure if the parent is trained on how to use it (Kearney, 2014). It involves the parent picking three different activities or items and asking the child to choose one. The parent then uses the selected activity to teach the child to imitate speech by pronouncing words using the selected items or activities (Schreibman & Stahmer, 2013). The parent gives the child a five seconds allowance to imitate the phrase and thirty seconds to interact with the item or activity while repeating the phrase that the child is supposed to learn (Schreibman & Stahmer, 2013). After the thirty seconds the parent retrieves the item and introduces a new phrase and allows the child access to the item when they correctly identify its name (Barnes et.al., 2014). The parent gives the child nonspecific reinforcement and direct reinforcement by praising and allowing the child to access the item simultaneously (Romanczyk & McEachin, 2017). The therapist can collect data from these naturalistic procedures through participatory observation and interviewing the parent and the child to assess the impact of the naturalistic procedures on the child’s verbal behavior.
Performance management strategies can be employed to support and supervise the program RBTs in running the DTT program and support the parents in implementing the client’s natural environment teaching programs (Gould et.al., 2012). They can also be used in the promotion of a team approach among all participants to facilitate positive outcomes for the client (Romanczyk & McEachin, 2017). Performance management facilitates the development of performance appraisal indicators which are useful to the psychologist and the parent in assessing the impact of the naturalistic procedures (Kearney, 2014). They also act as pointers on the improvement or stagnation of the patient progress by defining the desirable behavioral and cognitive characteristics associated with improved health (Alvord & Berghorst, 2017). They also offer a uniform metric on which the child’s performance can be gauged by the therapist, the parent and any other participant in the therapy process (Barnes et.al., 2014). The management strategies therefore form an important foundation in the measurement and assessment of the patient progression during and after the psychologist supervised sessions.
The verbal behavior program is supposed to adhere to certain ethical, legal, cultural, and social validity factors in compliance to the BACB Professional and Ethical Compliance Code (Barker et.al., 2016). The therapist should only use professionally acknowledged sources in based on science and behavior analysis when treating the patient and making any deductions and assessments. They should also limit their practice to their areas of competence for which they are licensed and trained (Barnes et.al., 2014). The psychologist should therefore not engage in new experiments for which they have no experience when treating the patients in the verbal behavior program without undertaking appropriate study, training, supervision, and/or consultation from persons who are competent in those areas (Kearney, 2014). The practice should also not expose the patient to any harmful consequences and should not violate the social norms upheld by the patient or the community they live in. The therapy activities should also have content related validity, face validity, construct validity, criterion related validity, concurrent validity and predictive validity (Barker et.al., 2016). The adherence to the ethical, legal and social validity ensures that the patients are protected from malpractices and prevents the psychologist from having legal trouble.
References
Alvord, M. K., & Berghorst, L. H. (2017). Social Skills (Social Competence) Training for Children and Adolescents: Oxford Clinical Psychology . Doi: 10.1093/med: psych/9780190272166.003.0068
Barker, C., Pistrang, N., & Elliott, R. (2016). Research methods in clinical psychology: an introduction for students and practitioners . Malden, MA: John Wiley and Sons, Inc.
Barnes, C. S., Mellor, J. R., & Rehfeldt, R. A. (2014). Implementing the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP): Teaching Assessment Techniques. The Analysis of Verbal Behavior, 30 (1), 36-47. Doi: 10.1007/s40616-013- 0004-5
Gould, E., Dixon, D. R., Najdowski, A. C., Smith, M. N., & Tarbox, J. (2012). A review of assessments for determining the content of early intensive behavioral intervention programs for autism spectrum disorders: Research in Autism Spectrum Disorders, 5 (3), 990-1002. doi:10.1016/j.rasd.2011.01.012
Kearney, C. (2014). Abnormal psychology and life mind tap psychology: a dimensional approach . Place of publication not identified: Wadsworth.
Romanczyk, G., & McEachin, J. (2017). Comprehensive Models Of Autism Spectrum Disorder Treatment: Points of . S.L.: Springer International Pu.
Schreibman, L., & Stahmer, A. C. (2013). A Randomized Trial Comparison of the Effects of Verbal and Pictorial Naturalistic Communication Strategies on Spoken Language for Young Children with Autism Journal of Autism and Developmental Disorders, 44 (5), 1244-1251 doi:10.1007/s10803-013-1972-y
