Discerning Clients’ Resistance to Treatment

Multiple elements go into a client’s resistance to change, including major mental illness, physical factors, medication effects, protective denial, lack of skills and knowledge, immaturity, passive-aggressiveness, and oppositional tendencies.

Multiple forces go into a client’s resistance to change.

Many of your clients might belong to the “worried well” and have skills and maturity. They are willing to look at themselves. These attributes make therapy easier. But as excited as clients are about changing, some things may stand in their way.

Imagine you are using your hand to prop up a pencil against a clipboard that is held at a sixty-degree angle. Your hand is just beneath the pencil, and the force of gravity holds the pencil against it. The force you exert upward against the pencil keeps it from sliding downward. Cohesive forces in the pencil keep it from falling apart. Air flows by the pencil. The sum of the forces on it is equal, causing it to stay put. It is stuck. The pencil appears to be inactive, yet many forces are at work. If we ascribe a motive to the pencil, we might say it is a lazy pencil that does not want to move. We might say that the forces on it conflict with one another. The pencil moves when you remove one of those forces by taking your hand away. It is no longer resistant to change.

Clients are aware of some behavioral determinants, but not others.

Multiple forces also affect people’s resistance to change. We describe behavior as “multi-determined.” Clients are unaware of some of these behavioral determinants.

Current research shows that our brains have billions of nerve cells. So, much activity goes on at the same time. We can’t be aware of all the multiple psychological processes in our brains, both waking and sleeping, that affect our behavior.

We cannot be sure what someone is thinking or why they feel what they do. This uncertainty is part of our challenge in trying to understand and help others.

The unconscious is not located in a specific part of the brain. The term refers to that part of the mind that is not accessible. Over the years, people have developed mental constructs to understand what is happening in the unconscious. We call these constructs “psychodynamics,” or “dynamics” for short. We try to understand the client’s dynamics by examining how one thought leads to another. When they repeat behaviors, we look for themes in the patterns. We examine how their view of us recreates past conflictual relationships.

Clients defend against recognizing their dynamics.

Understanding the unconscious dynamics allows us to help the client become aware of them, make better choices, and avoid repeating maladaptive behaviors. Removing resistance is like taking your hand away from the pencil and freeing it up to move. Freed from the effort needed to remain unaware, they develop a more accurate understanding of themselves.

And that leads to change.

The process of becoming aware of dynamics can make a client anxious. Developing an excellent client-therapist relationship is essential because the client needs to feel safe and have a caring, competent, and careful therapist they can talk freely to. Ideally, you will have helped the client develop techniques to deal with the anxiety and contain the generated affect.

“The process of psychotherapy is to strengthen the ego to be able to hear what one does not want to hear—the worst thing one could hear—what one’s defenses were erected to prevent” (Dill 2022).

Clients may feel they are paying a lot to see you and want to get into the heavy stuff right away. They may expect a quick fix. Let them know that you will work with them to develop the skills they need to cope with the resultant anxiety and difficult emotions. Explain the importance of developing skills and a

sense of safety before diving into the more challenging material.

Clients use different defense mechanisms to avoid the anxiety that comes with becoming aware. These defenses include some combination of denial, projection, displacement, regression, rationalization, reaction formation, repression, or sublimation.

Ryan Baily and Jose Pico discuss these and other defense mechanisms in StatPearls at https://www.ncbi.nlm.nih.gov/ books/NBK559106/ (Bailey and Pico 2025).

Resistance is not just a roadblock. It’s also the stuff of therapy and not just the roadblocks. If you have ever played the game Battleship, you know that if you accidentally set off a mine planted by your opponent, you also discover where their battleship is. You know they put their mines near their battleships to protect them. Similarly, when you encounter your client’s resistance, you know that something there is important.

Let’s look at how clients may resist treatment. They may have varying degrees of awareness of their resistance.

Reluctance to change may not be because of psychological resistance.

If your client does not understand what you are saying or misunderstands you, they may have a subtle hearing deficit. Hearing impairment is not always related to age. Hunters, service members, and rock concert fans are at risk. Clients may fill in the gap with assumptions based on what they expect you to say. Sometimes, they may look a little paranoid. Do you often have to repeat what you say?

English may be the client’s second language. When I am in another country and don’t quite understand what a salesclerk is saying, I smile and act like what I missed was not essential. Clients may also misread your behavior and manners.

When a client looks unmotivated, they may have a physical illness that makes them tired. Everything, including therapy, is more challenging when fatigued. Consider whether they may benefit from a workup for long-term COVID-19, anemia, hypothyroidism, diabetes, hepatitis, sleep apnea, mononucleosis, heart disease, poor nutrition, or low testosterone.

Marijuana can cause amotivational syndrome. Anergia (extreme persistent fatigue) can be a symptom of clinical depression and several other diseases. Apathy can be a symptom of several diseases, including neurological disease.

Robert van Reekum et al. have written an excellent article on apathy titled “Apathy: Why Care?” (Reekum 2005). Here is the link: https://psychiatryonline.org/doi/full/10.1176/jnp.17.1.7.

Sometimes, clients feel that if they talk, they risk being rejected by their family. Families may not approve of therapy or medications that affect the brain. They may feel threatened, knowing that secrets about abuse, addiction, infidelity, sexual abuse, or mental illness may come out. Family members may also believe that a client who needs therapy lacks faith in God.

Some people lack opportunities that would lead to a sense of personal agency. It seems life will not work out for them no matter what they do. Because they’re in pain, these clients may try therapy anyway. You may be the first person to believe in them, see their worth, or want to hear what they have to say. They may continue therapy, but it may be more because they like you than because they think they will succeed. They don’t want to let you down because it seems to matter to you how well they do.

Some people are reluctant to do therapy due to realistic, common-sense reasons. You may not know that the things they need to change are monumental and personally costly to change. If that client makes a change, they may be going against their family or culture. In another example, a woman may not want to realize her spouse is unfaithful because that would mean having to leave him and become a single parent.

Too little or too much medication hinders therapy.

If a client is too nervous, they may not do psychotherapy. Conversely, overmedicated clients may lack the motivation to do psychotherapy.

Some clients don’t recognize their maladaptive behaviors.

A client may see smoking or doing drugs as part of who they are and not a problem. They see the behaviors as ego-syntonic. Something that is ego-syntonic is thought to be consistent with the client’s fundamental view of themselves and their beliefs.

Clients may feel that your focus on change implies that they are not good enough as they are. In reality, you are showing them that you accept them as a person, encourage their self-acceptance, and help them change maladaptive ways of thinking and behaving. You want them to see those maladaptive parts of themselves as ego-dystonic, or not consistent with their identity. Your compassion shows them that you accept them as they are. For example, you accept the smoker but not the behavior of smoking.

Your client’s values may be different from yours, and your client may not have a concept of the value of therapy. Instead of being psychologically minded, maybe they have a superficial view of life. Because they see things concretely, they aren’t aware of the psychological process. They don’t consider personal growth an essential value. Clarifying these clients’ goals for treatment may help you see how and where to begin.

Different situations require different approaches to denial.

When a client sees maladaptive behaviors as part of themselves, this is just one form of denial. Denial is an unwillingness to accept reality and acknowledge what others can see as fact. It’s a defense mechanism against anxiety, but it also leads to resistance to change. If a client can’t conceptualize a problem as a problem, they don’t see it and can’t address it.

Their brain may have repressed something by pushing the anxiety-producing thought into their unconscious. The memory is not available to let them put a piece in the puzzle.

Imagine a half-ton pickup truck. How much manure can it haul? The answer is an infinity of manure, but only an average of three thousand pounds at a time. If you pile too much manure on it, it will break down from the load.

Sometimes, a person feels so bad about themselves, their life, and what they have done or not done that they already have three thousand pounds of emotional manure on their pickup truck. You may need to help them remove some of the more reachable emotional manure and reinforce the pickup truck before you consider breaking through their denial.

Prematurely breaking through their denial is like reminding a tightrope walker how high up they are.

When I was working in a senior intensive outpatient program, I met a woman who, as a child, had to wear worn-out, hand-me-down clothes to school. Her lifelong sense of shame manifested as an inability to protect herself from being used by others. When she entered treatment, confrontation was not part of her treatment.

Instead, she took part in group therapy several times weekly with other clients from her community. She discovered similarities with other group members and made strong connections. She witnessed them being cared about and accepted for who they were. In time, she came to feel accepted for herself. It was only then that her denial broke. Then she could see how shame had compromised her ability to set limits on others. Being accepted by others opened the way for her to accept the orphaned parts of herself.

On the other hand, my experiences in inpatient addiction treatment emphasized the need to break through denial more quickly because the denied behaviors were dangerous. These clients were in a supervised, safe setting with supportive staff, and intensive treatment was readily available. Staff carefully monitored the treatment effects. Clients were encouraged to see the big picture, remember their strengths, and be aware of their support network as they examined the consequences of their behaviors.e

Clients may not have developed the personal skill set to do therapy or initially see its value.

Ideally, children learn frustration tolerance by having to tolerate incrementally more difficult, age-appropriate frustration. If their parents do not provide them with opportunities to develop this tolerance, they may lack ego strength. People with ego strength can tolerate frustration, compromise, reflect on themselves, and see the big picture. These are the very skills clients need to do therapy successfully.

Clients who have a dim awareness of their skills gaps prefer to maintain the status quo and avoid taking on responsibilities they cannot manage. Instead, they expect others to change.

Beneath their voiced entitlement is an unrecognized feeling of inadequacy. By providing emotional support and using parent-like therapy techniques, you could gradually empower them by patiently helping them develop the ego strength they need to do the work in small steps.

Clients lacking self-reliance may be reluctant to accept responsibility for themselves.

Some people have a stronger aggressive drive than others. They have agency, take ownership of their therapy, and actively participate in the process. Other people are more passive and feel they are not the hero of their life story. They don’t want to be the alpha dog and prefer being taken care of. They want someone else to be responsible. Their situation growing up may not have supported their incremental growth toward self-reliance.

If you are feeling unusually maternal, ask yourself if the client is encouraging you to take care of them and do the work of therapy. They may think that doing the work themselves will risk you abandoning them, as they will no longer need you.

Passive-aggressive clients express their aggression by withholding progress.

When people are not comfortable expressing their aggression directly, they may express it passively by withholding, like a two-year-old child who withholds pooping in the toilet during toilet training. If a client consistently comes late, forgets their credit card, and requires you to pull teeth to get them to talk, they may be passive-aggressive. They may show subtle contempt by not bothering to bathe or change clothes. (Some depressed clients find activities of daily living to take too much effort. So make sure your client is not depressed.)

Do you feel irritated? Do they seem to get some pleasure from defeating you, the person they see as their opponent in the tug-of-war? Hearing them talk about how their boss or spouse is frustrated with them may make it clear that understanding the passive-aggressive behavior is central to the therapy.

Set limits on your passive-aggressive client so they can’t externalize their conflict by putting their feelings into behavior. When they can’t act out, they will internalize the conflict and make progress. When I worked in a prison setting, I noticed how depressed prisoners became when the acting out was limited and they realized their internal conflicts.

Clients become defensive if they believe you are telling them what to do or think.

Even when you listen carefully, ask open-ended questions, and pose your statements as ideas to consider, the client may feel you are telling them what to do. They resent it. Clients who had controlling parents may believe that you also think you know best and that you want to impose your opinion on them.

Victims of prejudice may expect you to act superior and discount their views. Their reflex opposition may reflect growing self-worth.

To avoid looking pretentious and authoritarian, I dress plainly in clothes that might have come off the rack at Walmart. My standard garb is an old, gray button-up sweater reminiscent of Mr. Rogers. It makes me look kind and nonthreatening. I want my clients to think it is going to be a “wonderful day in the neighborhood” and not a day at the office with a competitive male coworker or sexually abusive boss. I operate from a one-down position to be approachable and encourage emotional comfort.

In other settings, I might wear a suit because upscale clients would consider me unprofessional if I dressed otherwise and discount what I said.

I want my clients to feel safe. I speak softly, move slowly, and sit comfortably back in my chair. My responses to their comments are not rapid and may include a pause that shows I am carefully considering what they just said. I recognize that I might seem threatening, so my verbal and nonverbal behaviors anticipate that.

Oppositional behavior may have several explanations.

Occasionally, a client will loudly object to everything you say, including your recommendations. If they have a history of this exact behavior over time, consider whether they have oppositional defiant disorder (ODD). Clients with ODD tend to be grumpy, argumentative, and even spiteful at times.

Sometimes, clients who are manic can’t listen and are very sure of their own opinions.

Some people with schizophrenia are negativistic, and that negativism can look superficially like ODD.

While autistic clients vary widely, some have pathological demand avoidance, which results in them perceiving requests as a threat to their autonomy. Occasionally, autistic clients think your requests are illogical and should not be followed.

Don’t equate opposition or rigidity with invulnerability. Some rigid clients are fragile.

There is a group of people who come across as very rigid. Because they are so very inflexible, you may at first think they are solid. In fact, behind their rigid defenses, they are fragile. You need to treat them gently and work hard to avoid saying anything that could feel like a slight. They are easily narcissistically wounded. They are like peanut brittle. Brittle things are both rigid and fragile. They break easily.

Involuntary clients may have trouble changing due to serious mental illness.

Your voluntary outpatient client has made some effort to get up, dress, travel to your office, set aside time, and prepare to pay you. These behaviors suggest motivation to change and a desire for something to be different.

On the other hand, involuntary clients may lack the motivation and even partial insight that outpatient clients have. Some involuntary clients are, by definition, a potential danger to themselves or others. They may be psychotic, intoxicated, manic, profoundly depressed, suicidal, or unbearably anxious. Hopefully, medical interventions, medications, close observation, and support will make them more amenable to therapy at some point.

A discussion of serious mental illness (SMI) and inpatient treatment is beyond this book’s scope. Your first exposure to severe mental illness can be overwhelming. Harry Stack Sullivan said, “We are all more simply human than otherwise.”That is a good thing to remember as you see clients who are on the wrong side of the locked door.