Client Resistance Research Articles

A 2-Day Postpartum CBT-Based Training for Nurses.

Public health nurses (PHNs) are often a first point of contact for postpartum individuals seeking mental health support, but report limited training related to mental health. To determine whether a two-day cognitive behavioral therapy (CBT)-based training program focused on postpartum maternal mental health can improve PHN perceptions of their ability to deliver CBT techniques, their confidence working with distressed clients, and with managing client resistance to treatment recommendations. A convenience sample of 45 PHNs working in the Family Health Division of Niagara Region Public Health in Ontario, Canada were assessed before and after they received a two-day CBT-based training program. Before attending training, PHNs reported their current professional position, years of experience working in public health, and any previous mental health training. Their confidence in delivering CBT techniques, working with distressed clients, and with managing client resistance to treatment recommendations was assessed pre- and post-training. Participants also rated their satisfaction with the training. Statistically significant improvements were seen in confidence using CBT techniques, and in supporting and managing distressed or resistant clients. The two-day training was highly rated overall by participants. Medium to large effect sizes were found for changes in confidence-related questions. Providing PHNs with brief CBT-based mental health-related training can increase their confidence in this aspect of their practice, and could potentially improve the quality of care they provide.

Resisting wh-questions in business coaching.

This study investigates clients' resisting practices when reacting to business coaches' wh-questions. Neither the sequential organization of questions nor client resistance to questions have yet been (thoroughly) investigated for this helping professional format. Client resistance is understood as a sequentially structured, locally emerging practice that may be accomplished in more passive or active forms, that in some way withdraw from, oppose, withstand or circumvent various interactional constraints (e.g., topical, epistemic, deontic, affective) set up by the coach's question. Drawing on a corpus of systemic, solution-oriented business coaching processes and applying Conversation Analysis (CA), the following research questions are addressed: How do clients display resistance to answering coaches' wh-questions? How might these resistive actions be positioned along a passive/active, implicit/explicit or withdrawing/opposing continuum? Are certain linguistic/interactional features commonly used to accomplish resistance?. The analysis of four dyadic coaching processes with a total of eleven sessions found various forms of client resistance on the active-passive continuum, though the more explicit, active, and agentive forms are at the center of our analysis. According to the existing resistance 'action terminology' (moving away vs. moving against), moving against or 'opposing' included 'refusing to answer', 'complaining' and 'disagreeing with the question's agenda and presuppositions'. However, alongside this, the analysis evinced clients' refocusing practices to actively (and sometimes productively) transform or deviate the course of action; a category which we have termed moving around.

Exploring stationary and major modular construction challenges in developing countries: a case study of Egypt

Purpose This study aims to identify the most significant barriers and the stationary barrier to modular construction (MC) implementation and promote MC widespread use. By doing so, the construction industry can leverage the benefits of MC, such as faster construction times, improved quality control, reduced waste and increased sustainability. Design/methodology/approach This study uses a Gini’s mean analysis approach to identify the stationary barriers hindering the MC adoption in residential projects. The research focuses on the Egyptian context and uses a questionnaire survey to gather data from professionals in the construction industry. Findings According to the survey findings, the top five significant MC barriers are inability to modify the design; contractors asking for high bidding prices (higher initial cost); scepticism, conservation and resistance of clients to innovation and change; transportation restrictions; and lack of a one-size-fits-all tool for the design. In addition, Gini’s mean of dispersion demonstrated that the stationary barrier that faces MC adoption is the apprehension that architectural creativity will suffer because of MC. Practical implications The identified obstacles could be useful for decision makers in countries that have not yet adopted MC and may aid in the planning process to manage the risks associated with MC projects. The paper stresses the significance of devising techniques to overcome these barriers and proposes several methods to tackle these challenges. Originality/value This study fills the knowledge gap by identifying the stationary barrier and emphasising the potential risks associated with MC barriers. Furthermore, it suggests several strategies for overcoming and reducing these barriers in developing countries residential projects.

Dealing with the Sexual Component of Women's Life Script Through a Fairy Tale Metaphor

This article discusses the basic components of a life script in relation to the sexual sphere of life and proposes an algorithm for writing a fairy tale that reflects a female sexual script, and also pays attention to the most important points for understanding a sexual script when analyzing a client's fairy tale metaphor. Taking into account the specifics of the topic, the author suggests an approach that allows bypassing the client's resistance: integration of art-therapeutic technigues (fairy tale therapy, work with metaphorical associative cards) and transactional-analytical structure. The article offers reflections on working with the sexual sphere through exploring images, as well as on the formation of a fairy-tale metaphor, and provides an algorithm for writing a fairy tale reflecting a female sexual life script, and also pays attention to the most important points for understanding the sexual life script when analyzing a client's fairy-tale metaphor

A test of psychotherapists' and nontherapists' recognition of correct and incorrect process in managing client resistance

AbstractObjectivePsychotherapist management of client resistance (i.e., opposition to change or the therapy process) has a significant impact on therapy outcomes. This study aimed at assessing psychotherapists' and nontherapists' abilities to recognise empirically supported correct and erroneous therapist responses to client resistance.MethodSeventy‐eight therapists and 111 nontherapists completed a rapidly administered novel skills test, Therapist Errors in Resistance Management (TERM), assessing recognition of correct and erroneous resistance management.ResultsParticipants were, on average, less than half as accurate at recognising therapist errors (recognised below chance levels) compared with correct therapist responses to resistance (recognised above chance levels). Therapists outperformed nontherapists in accurate recognition of therapist responding. However, among the therapist group, greater clinical experience did not predict superior recognition of therapist errors.ConclusionThese results indicate that therapists and nontherapists alike may have difficulty detecting erroneous therapist responses to resistance, tending to mistake empirically contraindicated directive responses for correct responding. This may reflect the difficult and unintuitive nature of correct resistance responding and may suggest a need for increased training in process acuity and resistance management in therapist education.

Trainee psychologists’ experiences of learning and conducting psychodynamic therapy via telepsychology

Despite extensive research on telepsychology, less attention has been devoted to psychodynamic therapy (PDT), especially trainee psychologists’ experience of learning and conducting online PDT. Using inductive thematic analysis, this study explored the experiences of student psychologists learning and conducting PDT via video-based web platforms. Semi-structured interviews were conducted with 10 Australian trainee psychologists, all completing the psychodynamic component of their clinical psychology training. Interviews addressed participants’ experiences of online PDT learning and psychotherapy practice, generating five main themes: (1) technological barriers and their impacts, (2) overcoming telepsychology limitations through awareness and adaptation, (3) benefits of telepsychology, (4) effectiveness of psychodynamic telepsychology, and (5) experience of online psychotherapy learning. Participants reported that the paucity of sensory information, client resistance, distraction, problems maintaining therapy boundaries, supervisor opposition, and technological limitations made online PDT difficult to conduct and less effective than in-person treatment. However, some participants noted that the anxiety of commencing PDT delivery was reduced online, and that the ‘layer of separation’ assisted countertransference management. Notwithstanding its inherent limitations, online PDT was perceived to be relatively effective, but this requires specific training in adapting traditional psychodynamic techniques. Furthermore, PDT may be effectively learned online, but is an inferior alternative to in-person training.

Small animal general practitioners discuss nutrition infrequently despite assertion of indication, citing barriers.

To determine what perceived factors prevent small animal general practitioners from discussing pet nutrition with clients during healthy and sick pet appointments. 403 veterinarians in small animal general practice. An online survey was used to gather veterinarians' opinions on perceived barriers, knowledge levels, and confidence regarding pet nutrition discussions. Reported barriers to discussing nutrition during healthy pet appointments included client resistance to changing brand (149/359), time constraints (146/359), misinformation online (138/359), and difficulty keeping up with products (132/359). Reported barriers to discussing nutrition during sick pet appointments included client cost concerns (101/349), pet not accepting new food (99/349), and time constraints (83/349). Veterinarians reported discussing nutrition less during healthy pet appointments, compared to sick pet appointments, and were significantly less confident with their knowledge regarding nontherapeutic food, compared to therapeutic food. Veterinarians also reported that they perceived conversations about therapeutic foods to be more positive than conversations about nontherapeutic foods, and veterinarians with more years in practice more commonly reported that there was nothing that would dissuade them from discussing nutrition. Veterinarians who reported barriers to discussing nutrition described a need for resources and reliable information for health-care teams and clients. Results demonstrated a substantial gap between veterinarians' assertion that nutrition conversations are indicated and the frequency with which they discuss nutrition during appointments. Veterinarians reported that they felt their nutrition conversations were frequently positive; therefore, it is important to overcome barriers to engage with clients about pet nutrition.

Trauma triptych: inviting cross-disciplinary collaboration in art therapy, social work, and psychiatry

Structured Background: Trauma can impact an individual's ability to process memories, develop a healthy identity, express emotions, maintain focus, navigate relationships, and achieve goals. Despite the potential negative impacts of trauma, specific psychotherapeutic interventions and trauma-informed care provide opportunities for recovery and healing. Context: Creative processes can promote trauma recovery. The literature suggests that creativity can support people in non-verbally processing memories, containing internal chaos, and restoring hope. Approaches: Case examples highlight the approaches of an art therapist, social worker, and psychiatrist who introduced arts-based interventions to traumatized clients. The art therapist explores use of an ancient Japanese approach to repairing pottery with a 23-year-old who experienced sexual abuse and neglect. The social worker discusses how Janusian thinking and “creative destruction” inspired collage-making with a 15-year-old who witnessed domestic violence and experienced depressive symptoms. The psychiatrist considers how traumatic memory processing theory informed her structured drawing approach to traumatic grief work with an aggressive 10-year-old. Outcomes: Use of arts-based interventions assisted in overcoming client resistance to “talk therapy” approaches, offering a non-verbal, expressive alternative and supporting client progress toward treatment goals. Implications for Practice: Reflection on three case vignette led to several practice implications: (1) Professionals should use creative approaches carefully and responsibly, operating within their scope of practice, (2) Professionals should consider how arts-based interventions can strengthen trauma treatment, & (3) Increased provider collaboration and cross-disciplinary dialogue can enhance trauma informed care. Implications for Research: More research on the effectiveness of creative approaches in trauma treatment is needed.

Integration in Psychedelic-Assisted Treatments: Recurring Themes in Current Providers’ Definitions, Challenges, and Concerns

Integration therapy, an integral part of psychedelic-assisted treatment, usually includes sessions devoted to making meaning of relevant psychedelic experiences after subjective effects have subsided. As the psychedelic renaissance continues, offers for this integration therapy have proliferated. In the present project, semi-structured interviews with 30 integration therapists focused on definitions of integration as well as challenges and concerns that they associated with the practice. A mixed-methods approach revealed 19 themes that coders identified reliably. Prevalent themes included expressing concern about nonresponsive clients, defining integration as a bridge between the psychedelic experience and daily life, and apprehensions about the commercialization of psychedelic psychotherapy. Interviewees viewed integration as a process that begins prior to the administration of substances, never ends, makes sense of the psychoactive experience, creates behavioral change, is personalized, and makes the individual whole. Most participants also discussed issues related to client resistance, unrealistic expectations of psychedelic psychotherapy, problems associated with power differentials, the importance of an integration therapist’s connection to other service providers, and the need for self-care. These data might help the standardization of integration therapy, inform lay impressions of the process, and help generate hypotheses for continued research on this aspect of psychedelic-assisted treatment. These data also suggest that psychedelic integration practitioners would appreciate regular support from a community of like-minded colleagues.

The Resistance Vignette Task: Validating a rapid measure of therapist skill at managing resistance.

Therapist appropriate responsivity to client ambivalence and resistance is considered an important interpersonal skill to avoid disengagement and ensure a continued collaborative, productive process. The present study examined the predictive validity of the newly developed Resistance Vignette Task (RVT), a 10-item rapidly administered measure of therapist ability to appropriately respond to various presentations of client resistance. Following a resistance management workshop, the concurrent and prospective predictive capacity of RVT scores were examined through test interviews with ambivalent simulators and volunteers. Prospectively, in test interviews with ambivalent interviewees, higher RVT scores immediately postworkshop were associated with significantly greater responsivity (appropriate responsivity and fewer responsivity errors) at 4-month follow-up. RVT scores at the 4-month follow-up point were also concurrently associated with significantly greater therapist responsivity and lower levels of interviewee resistance. These findings provide further validation for the RVT as a measure of therapist responsivity in vivo, in actual interviews by predicting and being concurrently associated with therapist performance in response to client resistance. Thus, the RVT holds promise in advancing therapist training, as well as research on resistance as it represents an efficient measure of this key therapist skill.

Client resistance to hepatitis C treatment initiation in opioid agonist treatment clinics in Sydney, Australia: A qualitative study.

Opioid agonist treatment (OAT) clinics play a key role in achieving elimination of hepatitis C virus (HCV) globally. Previous research has identified barriers to HCV treatment uptake in OAT clinics; however, most studies were conducted prior to the introduction of direct-acting antiviral treatments (DAA). It remains unclear whether progress has been made in responding to barriers and what challenges persist in this setting. Semi-structured in-depth interviews were conducted with staff (n=20) and clients (n=15) in two OAT clinics in Sydney, Australia. Interviews were transcribed verbatim and analysed using constant comparative methods. Despite progress in integrating hepatitis C care in the clinics, competing priorities, concerns about side-effects, distrust of staff, health problems and difficulties accessing testing and medication persisted as key reasons why clients had not initiated treatment. Most clients preferred to postpone treatment and focus on other priorities and some highlighted lack of medical evidence for urgent treatment. Pressure on services to achieve elimination targets within set time frames was a primary driver of repeated offers of treatment by staff and the framing of clients' preferences for postponing treatment, as a barrier. Current timelines for HCV elimination targets may have galvanised services into action but may have also created tensions at the coalface due to disparities between staff and clients' priorities. The involvement of peer workers and mechanisms to ensure continued follow up with clients about DAA treatments is required. Public health timelines for HCV elimination need to be informed by affected communities' priorities.

Therapist affiliation and hostility in cognitive–behavioral therapy with and without motivational interviewing for severe generalized anxiety disorder

ABSTRACT Objective Although therapist supportive, rather than directive, strategies have been particularly indicated during client resistance, little systematic research has examined how therapists responsively navigate resistance in different therapy approaches and how this responsiveness is related to outcome. Method In the context of disagreement episodes in cognitive–behavioral therapy (CBT) for generalized anxiety disorder (GAD; Westra, H. A., Constantino, M. J., & Antony, M. M. Integrating motivational interviewing with cognitive–behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768–782. https://doi.org/10.1037/ccp0000098, 2016), the present study examined (1) the degree to which therapist management of resistance differed between therapists trained in CBT integrated with motivational interviewing (MI-CBT; i.e., training centered on the responsive management of resistance) and therapists trained in CBT-alone, and (2) the impact of specific therapist behaviors during disagreement on client worry outcomes immediately posttreatment and 1-year posttreatment. Episodes of disagreement were rated used the Structural Analysis of Social Behavior (Benjamin, L. S. Structural analysis of social behavior. Psychological Review, 81(5), 392–425. https://doi.org/10.1037/h0037024, 1974). Results Therapists trained in MI-CBT were found to exhibit significantly more affiliative and fewer hostile behaviors during disagreement compared to those trained in CBT-alone; both of these, in turn, were found to mediate client 1-year posttreatment outcomes, such that increased affiliation during disagreement was associated with improved outcomes. Conclusion This study highlights the value of training therapists in the responsive detection and management of resistance, as well as the systematic integration of MI into CBT.

Improving fan inlet conditions to reduce noise

This presentation will review various examples of fan inlet conditions that caused excessive noise in different frequency ranges, and system modifications for noise reduction that involved a few intermediate steps to maximize effectiveness and sometimes to reduce initial client resistance. Examples will include several large air handlers, a healthcare facility exhaust fan, and some informal experiments.

A process-outcome study of school-based art therapy

ABSTRACT Background Only a few studies in the arts therapies in general and in the field of visual art therapy in particular have begun to address process variables and their relationship to outcome variables. Aim The present study thus aimed to contribute to this literature by examining the relationship between process variables and outcome variables in the school-based art therapy setting. Method The process-outcome relationship was examined in a school-based art therapy setting in a sample of 32 art therapists and 44 clients aged 7–13. Hypothesis 1 predicted that over the course of art therapy, client involvement and client productive behaviours would increase whereas resistance would decrease. Hypothesis 2 predicted that increases in client involvement and client productive behaviours and decreases in client resistance would be linked to decreases in behavioural problems. Results Both hypotheses were partially supported in that cognitive–behavioural exploration and emotional exploration differed significantly during therapy. In addition, there was a significant correlation between improvement in client involvement and cognitive–behavioural exploration and improvement in internalising problems. Conclusions The present study provides initial support for the claim that the processes in art therapy with children are more complex than is typically assumed for art therapy. For example, the results showed that an increase in resistance and a decrease in insight were associated with positive outcomes. Implications for practice The findings indicated that in the education system, cognitive–behavioural exploration is an important variable. Models such as the cognitive–behavioural approach thus may be useful in school-based art therapy. Plain-language summary Recent studies have attested to the positive impact of art therapy on children and adolescents. However, little is known about what happens during the process of therapy and how it can lead to a positive outcome. The present study examined the relationship between process variables and outcome variables in the school-based art therapy setting. For this purpose, it focused on two process variables. The first was the art therapist's assessment of the client's degree of involvement in therapy. The second process variable was the therapist's assessment of the client's productive behaviours as well as resistance to therapy. This assessment can shed light on the ways in which the client responds to the therapist's interventions. The outcome variable was Child Behaviour Checklist that is designed to evaluate changes in children's behaviour and functioning over time or before/after therapy. Thirty-two art therapists employed by the Israel Ministry of Education and 44 clients participated in the present study. At the beginning of the school year, each art therapist selected one or two of her clients, who were in grades 1–7. Consent was obtained from both the clients and their parents. Parents and teachers filled out the outcome measure, at the beginning (September) and end of the year (June). The art therapists were asked to fill in the process measures after each treatment session (once a week). The results showed that cognitive–behavioural exploration and emotional exploration differed significantly across time. In addition, an association was found between improvement in client involvement and cognitive–behavioural exploration and improvement in internalising problems. The present study provides initial support for the claim that the processes in art therapy with children in general and within the school setting in particular are more complex than is typically assumed for art therapy.

TAKING UP A SOCIAL WORK IDENTITY: PREPARING UNDERGRADUATE STUDENTS FOR ENTRY-LEVEL GENERALIST PRACTICE

Undergraduate students who are new to the social work profession enter into a complex socialization experience. New to the profession, they are expected to absorb a variety of knowledge and skills learned in separate courses and then integrate these together into an authentic performance as a social worker. Additionally, students are trained to confront personal bias and must learn to socially locate themselves and begin to form their own critical framework for understanding and responding to the influence of oppressive discourses on everyday systems, structures, practices, and experiences. Although the socialization process is essential to the development of a social work identity, there is little description in the social work education literature about students’ experiences of that process. Through using a practice demonstration video as teaching-learning resource for an undergraduate child welfare practice course, this paper presents our effort to examine how students position themselves in relation to practices and skills shown in the social worker-service-user interactions on the video. For the purposes of this pilot study, we used qualitative content analysis to generate a descriptive analysis of students’ written responses to viewing the video interactions. Analyses of these responses revealed that, although students were able to name and discuss the practices they observed through the video demonstration, they were also challenged by the interactions that demonstrated conflict, client resistance, and the overt use of power in the worker-service-user relationship. The results demonstrate the need for greater understanding of how students become socialized into the profession and develop their own unique identities as social workers.

Surveying views of metaphor vs. literal language in psychotherapy

Abstract Five key therapeutic functions of metaphors are often discussed by psychotherapists. They (i) help clients express emotions and experiences, (ii) help therapists and clients explain difficult concepts, (iii) introduce new frames of reference, (iv) help work through client resistance, and (v) build a collaborative relationship between therapists and clients. Research on how these functions are enacted in psychotherapy talk tends to assume that they are indeed perceived as such by clients, and that metaphorical language is preferred to comparable literal language in performing them. This paper reports a survey study (N = 84) to critically interrogate these assumptions. Participants read two constructed therapy dialogues, controlled and counterbalanced for presentation sequence, where therapist and client discuss an issue using metaphorical and literal language respectively. Each dialogue is followed by a 15-item questionnaire to rate how well the presumed functions were performed (e.g. the therapist and client can work effectively together, the therapist is able to explain difficult concepts). A combined Confirmatory (CFA) and Exploratory Factor Analysis (EFA) suggests that, instead of the five distinct functions proposed in the literature, participants discerned three functions which reflect a more holistic view of what metaphors can do. A second EFA conducted on literal responses yielded only two factors. This contrast in factor structure further suggests that (i) literal language is less functionally nuanced, and (ii) metaphors are not simply perceived as an ‘add-on’ to literal language, but are evaluated across an extended narrative in fundamentally different ways. Within-subjects metaphor vs. literal ratings of the items under the emergent three-factor structure were then compared. Metaphor ratings were significantly higher in all factors (p < 0.01), suggesting that metaphorical language is indeed perceived as more effective than literal language when discussing clients’ issues. Implications, limitations, and future directions are discussed.

Symptom. Toxic story

Symptom. Toxic story

Important Factors for Evidence-Based Implementation in Child Welfare Settings: A Systematic Review

ABSTRACT Child welfare agencies are expected to implement research-supported interventions (RSIs) to serve youth and families. However, literature shows that the child welfare system has had less success in implementing RSIs than other fields (i.e., health care, schools, etc.). Purpose This systematic review synthesizes the common barriers and facilitators to implementing research-supported interventions with child welfare agencies using implementation frameworks. Methods For this systematic review, database searches, and quality assessments of relevant literature produced 24 studies that examined the implementation of RSIs in child welfare using an implementation framework. Results The studies were coded for themes and the thematic analysis found several common factors to RSI implementation across child welfare agencies including funding, collaboration with external stakeholders, agency culture, staff burden, leadership support, worker’s buy-in, client resistance, program fit, intervention clarity, supporting staff competency, and implementation teams. Discussion The findings provide important information on the most common barriers and facilitators of implementation in child welfare settings.

Dealing with Resistance: Working with Involuntary Clients in Community-Based Drug Treatment Programs in China

ABSTRACT This study explores strategies for dealing with client resistance that are commonly used by a group of selected counsellors who work closely with illicit drug users in the community-based compulsory treatment programs in China. Through semistructured in-depth interviews with 16 counsellors, this study finds that different forms of client resistance were experienced in their day-to-day practice, encompassing passive and active behaviours. Five typical strategies are used by Chinese counsellors in this study to deal with client resistance: showing respect and caring and expressing empathy; attending to the needs of the clients; making effective use of peer influence; altering clients’ unwillingness to change; and strategically enhancing clients’ self-determination. Considering these strategies can also be seen as general principles for dealing with involuntary clients in other fields of social work services, the findings of this study may have broader impact. IMPLICATIONS Effective ways that can be used by counsellors for reducing illicit drug users’ resistance during treatment include: showing respect and caring, and expressing empathy; attending to the needs of the clients; making effective use of peer influence; altering clients’ unwillingness to change; and strategically enhancing clients’ self-determination. Professional social work training is urgently needed among community-based drug treatment social work practitioners in China, to achieve efficient practices and better outcomes.

Resistance and outcome expectations in cognitive‐behavioural therapy for generalised anxiety disorder

AbstractGreater client resistance has been consistently found to be negatively associated with outcome in psychotherapy. However, the pathways through which resistance impacts such outcomes are underexplored. Given that client outcome expectation (OE) has been identified as an important common factor in psychotherapy, the goals of the present study were to examine: (a) the impact of resistance on subsequent client and therapist OE (COE & TOE, respectively); and (b) whether COE and/or TOE mediate the relationship between resistance and outcome. These relationships were tested among 44 clients with severe generalised anxiety disorder treated with cognitive‐behavioural therapy in the context of a randomised controlled trial (Westra, Constantino, & Antony, 2016). Resistance was measured at a mid‐treatment session, and COE and TOE were assessed at baseline and immediately after the resistance session. Treatment outcome was measured via client‐rated worry severity at post‐treatment. As predicted, higher resistance was associated with lower subsequent COE and TOE; B = −.73, p < .001 and B = −.46, p < .001, respectively. In turn, lower post‐resistance COE predicted higher post‐treatment worry (B = −.5, p < .001), indicating mediation. In contrast, TOE did not mediate the relationship between resistance and outcome (B = −.02, p = .876). These results suggest that resistance can be demoralising to both clients and therapists. However, only lower client morale may be detrimental to therapy outcome. This study contributes to understanding outcome pathways through two common therapy processes.