Notes on Resistance in Addiction Counseling

Disclaimer:  nothing in this content should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

This post consists of the Overview and Introduction of a monograph I wrote on the subject of resistance in addiction counseling. For those that are interested, the entire monograph, including both the Overview and Introduction that are immediately below, is attached at the bottom of this post.

Overview

In this work I will present the current state of my thinking about resistance in the context of addiction counseling.  I’ll also share my thoughts about the status of resistance as a concept across the current professional addiction counseling arena. 

Very recently, new arrivals in the addiction counseling profession have replied, when I have asked them what is said of resistance in their graduate education, that they were literally told, “Resistance doesn’t exist.  Don’t use the idea of resistance.” 

By contrast, my handling of this topic will be relatively broad.  After the Introduction, the body of this document consists of separate areas of content, labeled Parts 1-12.  Each of those sections begin with a key reference or major source upon which each respective portion of the paper is based.  These are presented chronologically.  The writing concludes with a Consolidation of the work with reflections, two Appendices (each from a different perspective), additional references, and then a list of suggested resources.  

Some of the topics I address include:

• Transference
• The proof that resistance does not exist
• Improper perspectives, methods, relational systems, and language that evoke resistance
• How the idea of resistance has practical use even if resistance doesn’t technically “exist”
• The impacts of ASAM and Motivational Interviewing
• Checking on therapeutic alliance as a remedy and as preventative maintenance
• How psychopathology, personality, and cognitive flexibility relate to this topic
• Psychodynamic considerations
• Stigma against stigma
• Factors in decision making
• What we can gain about resistance via analogy of physical materials and physics

My hope is that the reader discovers something new, and also something old. 

Introduction

It seems to me we have now raised a generation of addiction counselors that know nothing of resistance.   

• I can’t remember the last time I heard resistance featured as a topic of a continuing education presentation.
• I can’t remember the last time I heard a graduate intern mention resistance as a point of discussion or inquiry from a degree program-required checklist of competency or skill.

I’ll say we’ve eliminated the word and idea of “resistance” so fully I can’t remember the last time I heard a professional addiction counselor mention it – neither as an old-fashioned point of deviation from new best-practice thinking or method, nor as a point of complaining or of bragging given its lack.

From what I’ve seen over the last 20 years or so, the fight against the idea of resistance seems to be complete, and it has been driven from our profession.  Even if I’m wrong about the extent of this banishment, the general abolition of resistance leaves me concerned.   

Resistance during psychotherapy can be thought of as nothing more, or nothing more complex, than the old status-quo.  It might take the form of a certain way of making meaning. Or it might take the form of a behavioral strategy to cope.  In any case, resistance is likely to be, or embody, one’s tried and true way of surviving and getting along in the world.  And in its various forms it can be hard to detect.  What might constitute resistance in the clinical instance?   

• Example 1:  Sometimes in the therapeutic process the clinician notices that the work has taken the form of a relatively continuous suspended animation.  And this status has been avoiding detection for quite some time.
• Example 2:  At a key point or juncture in the therapy, the old status quo suddenly asserts itself (with or without the awareness of the patient) in a way that is large and full.
• Example 3:  Active compliance and cooperation that eventually prove to not be change-work, but a means of avoidance.  

The world view found in the school of psychology known as radical behaviorism would argue there is no such thing as “resistance”.  It gets this view by arguing all behavior is goal directed.  And so, by definition, there is no such thing as “resistance” per se. 

But there is a view different from the view of behaviorism. 

One could view any behavior as wholistically containing everything about the patient – as a hologram.  In this way, any behavior is always seen to contain elements of both change-work and resistance.   Thus, from this perspective, the claim that resistance does not exist depends upon the essential strategy of splitting apart and categorizing the concepts of “goal-directed” and “resistance”, and then putting them in artificial conflict. 

In this way, the mental gymnastics (splitting, categorizing, re-defining, etc.) required to claim resistance does not exist could itself be seen as resistance – of the idea of resistance.  But I digress.   

Rather than being any or all of objectively correct, exhaustively comprehensive, or sufficiently authoritative, this work will present the current condition of my thinking about resistance in an addiction counseling context.  My hope is that the reader’s resistance to the concept and reality of resistance will diminish, or that the reader will literally discover something old.

The other day I talked over the framework of this monograph, and some of the content, with a working master’s level addiction counselor at my workplace.  A new graduate, this person calmly remarked, “We were told resistance doesn’t exist, and to not use the idea of resistance.”  And then they gladly started reading the 70% or so of this manuscript that I had completed by that point – with keen interest.

The framework of material in the attached monograph is seated in chronological order of publications and major initiatives.

After the Overview and Introduction (that are shown up above in this post), the first section concerns early clinical observations. 

I encourage the reader to try to be open, and to consider the material in that way during the reading.