The phenomenon of resistance turns out to be more central and more profoundly embedded in the work of psychotherapy than is sometimes recognized. Freud saw this when he said that psychoanalysis is the analysis of resistance. He also gave a clue as to why it has taken a long time to realize why. In the index of Freud’s collected works, there is but one mention of Darwin, making the point that it takes a very long time for new ideas to be fully incorporated into our thinking.
The key to understanding why resistance is central to clinical work is the somewhat humbling point of view about man that made Darwin controversial. As we explore and accept the radical idea of our evolution from mammalian ancestors, we are led to understand that the human mind is not as radically different as we might wish, and that our own minds and even free will are profoundly impacted by the drive for survival. Furthermore, the threats our brains have evolved to survive are the threats of 200,000 years ago when modern humans had largely attained our present form.
Central to this functionality is emotion. In all of biology, a basic principle of survival is avoiding noxious experiences. In humans, the main embodiment of this principle is avoiding noxious emotions. Emotion is the brain’s way of signaling that it has detected an actual or anticipated threat. In particular, I am referring to what we might call “core emotion,” meaning activation of subcortical emotional circuits, as the culmination of complex calculations located throughout the brain. The (or at least one) function of these deep emotions is to trigger a response calculated to reduce or eliminate the threat, along with motivation to carry out protective measures. For practical purposes, we can say that negative core emotions function as proxies for danger and that protective responses are designed to mitigate the core emotions that triggered them in the first place. When those emotions appear in consciousness in the form of affects (feelings plus bodily changes, experienced or anticipated), we may also choose consciously to avoid them.
When Glen Gabbard, in his classic textbook on Psychodynamic Psychiatry, states that, “all resistance has in common an attempt to avoid unpleasant feelings,” he is stating a truly fundamental principle. However, resistance is only one of many ways the mind avoids uncomfortable affects.
Fundamental Units of Psychopathology
As I stated in TIFT #11, a group within SEPI’s Special Interest Group on Convergence, have settled on the concept of Entrenched Maladaptive Patterns (EMPs) as a way to describe the basic units of pathology that are the primary targets of psychotherapy. There are a great many different kinds of EMP, but one of the clinically important types is resistance.
Psychotherapy seeks to trade old, maladaptive avoidance responses for healthier ones. The mind, following it’s core function of protection, keeps close tabs on the resources it has available at any time to fight threats. Part of its armamentarium of protective responses are just the ones that psychotherapy aims to take away. Naturally, the mind experiences the potential loss of a protective pattern as a new kind of threat, and mobilizes resistance to mitigate the threat.
Recalling from above, that avoidant responses, and EMPs in particular, are designed to avoid negative core emotions, then what makes the loss of protective measures a threat is that the avoided emotion could escape and find its way to consciousness as a painful affect. Of course the mind is skeptical that we therapists really have better coping patterns to replace the ones we want to eliminate.
Down to earth
What is the clinical significance? What this means is that Freud was right, that psychotherapy is basically working with resistance. Psychotherapy starts with the identification of Entrenched Maladaptive Patterns. When we experience resistance to change, then we know that the pattern we are proposing to change is, indeed, regarded by the mind as important. Our job, then, is to work with the patient to develop willingness and courage to trade in or abandon the coping pattern and to face the feeling, knowing that doing so will lead to relief, rather than harm.
There are an infinite number of variations to this simple structure, but this formulation covers essentially all of psychotherapy. Of particular note, is the importance of the relationship. Our presence and calm are among the most important ways that we can support the confidence and courage to risk facing painful or uncomfortable feelings.
Just to tie this formulation into a package, the definition of work is moving an object across a distance against resistance. Psychotherapy is work, too. In psychotherapy it looks like this:
Point A ————R————>Point B
If there isn’t resistance, then we have probably not engaged the problem in a significant way. Maybe we have yet to appreciate how resistance is keeping us away from the tender spots. Or perhaps what we are doing is more counseling than psychotherapy, where adoption of the new pattern is just a matter of learning a new way and realizing its superiority.
There is a saying, “Keep you friends close and your enemies closer.” Perhaps a version for therapists is “Keep your patient close and resistance even closer.”
Jeffery Smith MD
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