Client Resistance Research Articles

Logic of Accounting: The Case of Reporting Previous Options in Norwegian Activation Encounters

The article deals with the enactment of client resistance in Norwegian vocational rehabilitation encounters. More specific, a practice here called “reporting previous options” is analyzed by using the resources of ethnomethodological conversation analysis (CA) in five instances as doing some sort of accounting. In response to the counselor's investigative action, an earlier considered option is reported, but in the delivery, this option is also described as unsuitable at the moment of speaking. Across the cases, clients' reports of previous options had a conventional agreement-preface organization as described in the CA research on how dispreferred actions tend to be packaged. This accounting practice surely manages misaligning actions in a diplomatic manner, but a closer inspection reveals that the clients' accountings were also designed to defend the speaker's case and moral identity as an appropriate client. Thus, self-concerns, rather than other-concerns alone, lie at the hearth of this accounting practice.

Responsive management of early resistance in cognitive-behavioral therapy for generalized anxiety disorder.

Client resistance limits the efficacy of cognitive-behavioral therapy (CBT), rendering it an important process marker for clinicians. Yet, little is known about how CBT therapists' responsively navigate resistance. This study examined whether differences in therapists' behavior during moments of early resistance in CBT predict distal (posttreatment worry) and proximal (subsequent resistance) therapy outcomes. We hypothesized that clinicians' use of supportive, motivational interviewing (MI)-consistent strategies versus directive CBT methods during resistance episodes would relate to more favorable outcomes. Clients (N = 30) with severe generalized anxiety disorder (GAD) were treated with CBT (without MI) in the context of a randomized controlled trial. An adapted version of the Client Resistance Code was used to identify moments of client disagreement with therapist direction, and these episodes were rated for therapist behavior using the Motivational Interviewing Treatment Integrity (MITI). Context-specific variations in therapists' MITI ratings during disagreement were compared with variations in ratings during randomly selected moments to examine whether the timing of therapist use of theoretically indicated MI skills differentially impacted outcomes. Clients whose therapists displayed greater MI-consistent responses during disagreement had lower levels of posttreatment worry, t = -2.84, p = .009, and subsequent resistance, t = -2.96, p = .013. Additionally, MI-consistent behavior during disagreement was substantially related to treatment outcomes, but MI-like behavior during randomly selected therapy segments was not (t = -.15, p = .886 for posttreatment worry, and t = -.09, p = .934 for subsequent resistance). Findings support the importance of context-responsivity to resistance markers, suggesting that systematic incorporation of MI for managing resistance holds promise for improving CBT for GAD. (PsycINFO Database Record

Clients’ resistance to therapists’ proposals: Managing epistemic and deontic status

This paper uses conversation analysis (CA) to examine client resistance in Cognitive Behavioural Therapy (CBT) sessions for clients with depression. Analysis focuses on clients’ responses to therapists’ proposals for behavioural change. Typically, clients displayed active resistance to such proposals by drawing on one of three types of ‘inability to comply’ account: (1) appeals to restrictive situational factors; (2) appeals to fixed physical states; (3) assertions of previous effort to do what the therapist was proposing. Each type of account involved clients utilising knowledge from personal experience as their reason for resisting the proposal. In formulating their accounts, clients’ turns were designed in ways that displayed their epistemic stance in relation to the situation under discussion. By indexing their superior epistemic authority in the domain of their experience, clients were able to invoke their ultimate right to reject the therapist's proposed course of action. The implications for CBT practice are discussed.

Interpersonal Factors Are Associated with Lower Therapist Adherence in Cognitive-Behavioural Therapy for Panic Disorder.

The contributions of disorder severity, comorbidity and interpersonal variables to therapists' adherence to a cognitive-behavioural treatment (CBT) manual were tested. Thirty-eight patients received panic control therapy (PCT) for panic disorder. Trained observers watching videotapes of the sixth session of a 24-session protocol rated therapists' adherence to PCT and their use of interventions from outside the CBT model. Different observers rated patients' behavioural resistance to therapy in the same session using the client resistance code. Interview measures obtained before treatment included the Panic Disorder Severity Scale, the anxiety disorders interview schedule for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the structured clinical interview for DSM-IV, Axis II. Questionnaire measures were the anxiety sensitivity index at intake, and, at session 2, the therapist and client versions of the working alliance inventory-short form. The higher the patients' resistance and the more Axis II traits a patient had, the less adherent the therapist. Moreover, the more resistant the client, the more therapists resorted to interventions from outside the CBT model. Stronger therapist and patient alliance was also generally related to better adherence, but these results were somewhat inconsistent across therapists. Pretreatment disorder severity and comorbidity were not related to adherence. Interpersonal variables, particularly behavioural resistance to therapy, are related to therapists' ability to adhere to a treatment manual and to their use of interventions from outside of the CBT model. Copyright © 2015 John Wiley & Sons, Ltd. Patients' behavioural resistance to therapy may make it more difficult for cognitive-behavioural clinicians to adhere to a structured treatment protocol and more likely for them to borrow interventions from outside the CBT model. Patients' Axis II traits may make adherence to treatment CBT protocol more difficult, although whether this is true varies across therapists. Therapists' adherence to a structured protocol and borrowing from outside of the CBT model do not appear to be affected by disorder severity or Axis I comorbidity.

Patient-provider concordance with behavioral change goals drives measures of motivational interviewing consistency

ObjectiveMotivational Interviewing (MI) consistent talk by a counselor is thought to produce “change talk” in clients. However, it is possible that client resistance to behavior change can produce MI inconsistent counselor behavior. MethodsWe applied a coding scheme which identifies all of the behavioral counseling about a given issue during a visit (“episodes”), assesses patient concordance with the behavioral goal, and labels providers’ counseling style as facilitative or directive, to a corpus of routine outpatient visits by people with HIV. Using a different data set of comparable encounters, we applied the concepts of episode and concordance, and coded using the Motivational Interviewing Treatment Integrity system. ResultsPatient concordance/discordance was not observed to change during any episode. Provider directiveness was strongly associated with patient discordance in the first study, and MI inconsistency was strongly associated with discordance in the second. ConclusionObservations that MI-consistent behavior by medical providers is associated with patient change talk or outcomes should be evaluated cautiously, as patient resistance may provoke MI-inconsistency. Practice implicationsCounseling episodes in routine medical visits are typically too brief for client talk to evolve toward change. Providers with limited training may have particular difficulty maintaining MI consistency with resistant clients.

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.

SY21-1 * ARE THERE ANY BENEFITS FROM REDUCING ALCOHOL CONSUMPTION?

Alcohol contributes substantially to the global burden of disease and is the fifth leading disorder of DALYs in 2010 (GBD 2010 study) worldwide, and thus is one of the largest avoidable risk factors. Any reduction in dose of alcohol consumed, as well as in frequency of drinking occasions and the amount drunk on a single occasion will have an immediate impact in reducing alcohol-related injuries, the cardiovascular events and mortality related to heavy episodic drinking. Several examples demonstrate that total alcohol consumption has a significant impact on chronic consequences of excessive drinking. However, many treatment programs promote abstinence as the only/main acceptable treatment goal. Thus, many problem drinkers decline treatment programs aimed at abstinence. Offering both abstinence and no abstinence treatment goals to clients, permits a client-centered approach that contributes to alleviate client's resistance to change. The new DSM-5 introduces a diagnostic shift from the binary diagnostic criteria of alcohol dependence and alcohol abuse, to a single continuum of alcohol use disorders introducing a clear measure of severity such that treatment goals can be modified individually. In conclusion, reduction strategies offer an opportunity to address patient heterogeneity and lower the treatment threshold by bringing new patients into the treatment. Language: en

Teaching psychotherapy skills with a semester-long role play.

One of the most popular types of experiential learning for psychotherapists in training is role play. As a teaching tool, role play has been used in prepracticum (Larson et al., 1999; Woodard, 1999), couples counseling (Shurts et al., 2006), group counseling (Fall & Levitov, 2002), and theories courses (Dollarhide, Smith, & Lemberger, 2007). Further, it is a way for students to learn particular types of skills, such as treatment planning (Osborn, Dean, & Petruzzi, 2004); emotional responsiveness with complex clients (Grant, 2006); assessing crisis scenarios, child maltreatment, and domestic violence (Hodgson, Lamson, & Feldhousen, 2007); broaching sensitive subjects such as culture (Crowe & Villalba, 2012); sexual history and alcohol screening (Haist et al., 2004); and dealing with client resistance (Grossman et al., 2007). Although authors have suggested ways to use role play (Smith, 2009), specific classroom guides have not been offered to those wishing to incorporate this in the classroom. The following brief article offers one model of incorporating a semesterlong role-play assignment for the training of psychotherapy students.

In the Hyphen: Perceptions, Benefits, and Challenges of Social Workers’ Dual Identity as Clinician–Client

This study is the first to directly inquire into the experience of clinical social workers who live “in the hyphen,” having received psychiatric diagnoses and/or been in therapy themselves. Rather than inhabiting these roles sequentially as previous studies suggest, many inhabit them simultaneously. Social workers who took part in this qualitative thematic analysis describe the benefits of living in the hyphen, such as greater understanding of client resistance and opportunity to serve as a model of realistic hope, as well as its challenges, including countertransference, retraumatization, and fear of being “outed.” Overall, the experience of “sitting in the other chair” was more important to participants than having a skillful therapist as a role model or sharing a specific diagnostic history with a client, which they cautioned did not offer a shortcut to authentic understanding or formation of a therapeutic alliance.

P4.108 With Whom Did You Have Sex? Evaluation of a Partner Notification Training For STI Professionals Using Motivational Interviewing

ObjectiveTo enhance partner notification (PN) practises in STI clinics a newly developed PN training based on motivational interviewing (MI) was offered to STI professionals and evaluated.MethodsThe effectiveness of PN training...

Testing use of payers to facilitate evidence-based practice adoption: protocol for a cluster-randomized trial

BackgroundMore effective methods are needed to implement evidence-based findings into practice. The Advancing Recovery Framework offers a multi-level approach to evidence-based practice implementation by aligning purchasing and regulatory policies at the payer level with organizational change strategies at the organizational level.MethodsThe Advancing Recovery Buprenorphine Implementation Study is a cluster-randomized controlled trial designed to increase use of the evidence-based practice buprenorphine medication to treat opiate addiction. Ohio Alcohol, Drug Addiction, and Mental Health Services Boards (ADAMHS), who are payers, and their addiction treatment organizations were recruited for a trial to assess the effects of payer and treatment organization changes (using the Advancing Recovery Framework) versus treatment organization changes alone on the use of buprenorphine. A matched-pair randomization, based on county characteristics, was applied, resulting in seven county ADAMHS boards and twenty-five treatment organizations in each arm. Opioid dependent patients are nested within cluster (treatment organization), and treatment organization clusters are nested within ADAMHS county board. The primary outcome is the percentage of individuals with an opioid dependence diagnosis who use buprenorphine during the 24-month intervention period and the 12-month sustainability period. The trial is currently in the baseline data collection stage.DiscussionAlthough addiction treatment providers are under increasing pressure to implement evidence-based practices that have been proven to improve patient outcomes, adoption of these practices lags, compared to other areas of healthcare. Reasons frequently cited for the slow adoption of EBPs in addiction treatment include, regulatory issues, staff, or client resistance and lack of resources. Yet the way addiction treatment is funded, the payer’s role—has not received a lot of attention in research on EBP adoption.This research is unique because it investigates the role of payers in evidence-based practice implementation using a randomized controlled design instead of case examples. The testing of the Advancing Recovery Framework is designed to broaden the understanding of the impact payers have on evidence-based practice (EBP) adoption.Trial registrationhttp://NCT01702142 (ClinicalTrials.gov registry, USA)

Resistance in couples counselling: Sequences of talk that disrupt progressivity and promote disaffiliation

From the video-recordings of a single complete case of couples counselling, this article examines how repeated occurrences of client opposition and avoidance or resistance is managed over extended sequences of talk and across sessions. By drawing from the methods of conversation analysis, resistance is analyzed in terms of how a client resists the constraints set up by a counsellor's questions and, subsequently, how resistance is oriented to by the next speaker. It was found that the counsellor's orientation to the client's resistance became more disaffiliative and oppositional in the later stages of counselling. This increased disaffiliation was found to facilitate an alliance between the counsellor and client's spouse against the client. This lead to more explicit forms of disengagement from the client and, ultimately, to a breakdown in the progressivity of counselling work. Counsellor practices used to deal with resistance are critically discussed in terms of their effectiveness.

Practical Counseling and Communication Strategies: Tobacco Cessation

OPEN ACCESSJanuary 28, 2013Practical Counseling and Communication Strategies: Tobacco Cessation Laura Romito, DDS, MS, Lorinda Coan, Arden Christen Laura Romito, DDS, MS Indiana University School of Dentistry Google Scholar More articles by this author , Lorinda Coan Indiana University School of Dentistry Google Scholar More articles by this author , Arden Christen Indiana University School of Dentistry Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9324 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractTobacco use is a primary cause of preventable morbidity and mortality worldwide. Therefore, it is critical that health care providers address the issue of tobacco use and dependence with their patients. The purpose of this module is to explain and demonstrate the application of communication techniques for patient tobacco cessation counseling. This presentation contains three formative learning activities and several video clips demonstrating communication techniques involved in tobacco cessation counseling interventions. It also includes a slide script, reference list, and instructor's guide, as well as a sample 10-item assessment based on the content of the module. The content of this module is significant for learners about to enter the clinical setting, or already involved in patient care because they can readily apply the material to a clinical encounter. Health professions students and practitioners are often reticent to discuss tobacco use because they lack the time and skills to do so or are afraid of offending patients. After completion of the module, the student should be better prepared to communicate with patients in a more effective manner when discussing tobacco use and dependence and attempting to encourage a behavior change (tobacco cessation). The module presents evidence-based behavioral and communication strategies and techniques which have been shown to be effective in tobacco counseling. As such, it is anticipated that they may be more likely to engage their tobacco-using patients in education and cessation counseling. Educational Objectives By the end of the module, the learner will be able to: Explain the principles of practical counseling and motivational interviewing as applied in tobacco cessation counseling.Explain the stages of Health Behavior Change and identify a patient's current stage of change.Explain the 5As tobacco dependence intervention and provide examples of patient-practitioner communication for each step of the process.Demonstrate the communication strategies involved in motivational interviewing, and practical counseling for tobacco cessation. ReferencesChamberlain P., Patterson G. R., Reid J. B., Forgatch M. S., & Kavanagh K.Observation of client resistance. Behavior Therapy. 1984;15: 144–155. http://dx.doi.org/10.1016/S0005-7894(84)80016-7Google ScholarFiore MC, Baker TB. Clinical practice. Treating smokers in the health care setting. N Engl J Med.2011. Sep 29;365(13):1222–31. http://dx.doi.org/10.1056/nejmcp1101512Medline, Google ScholarFiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: Department of Health and Human Services, U.S. Public Health Service, 2008.Google ScholarMiller WR, & Rollnick S. Ten Things That Motivational Interviewing Is Not. Behavioural and Cognitive Psychotherapy. 2009; 37(2): 129–140. doi: 10.1017/S1352465809005128. http://dx.doi.org/10.1017/S1352465809005128Medline, Google ScholarMiller WR., Rollnick S., Butler C.Motivational Interviewing in Health Care: Helping Patients Change Behavior (Applications of Motivational Interviewing), 2007. Guilford Press. New York, New York.Google ScholarMiller WR, Rollnick S. Motivational Interviewing: Preparing people to change addictive behaviors. 1991. Guilford Press. New York, New York.Google ScholarProchaska J.O., DiClemente C.C.Toward a Comprehensive Model of Change. In Miller W.R. & Heather N. (Eds.), Treating Addictive Behaviors: Processes of Change 1986. pp. 3–27. New York: Plenum Press. http://dx.doi.org/10.1007/978-1-4613-2191-0_1Google Scholar Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: INSTRUCTOR GUIDE.doc BOHC Toolkit.pdf ASSESSMENT.docx Slide Script.docx Practical Counseling and Communication Strategies — Tobacco Cessation.pptx REFERENCES.docx To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2013 Romito et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsCounselingCommunicationMotivational InterviewingBuilding Oral Health Capacity (BOHC) CollectionEducationTobacco Use Cessation Disclosures None to report. Funding/Support None to report. Loading ...

Applications of Motivational Interviewing in Career Counseling

The Protean and Boundaryless career paradigms are calling for new ways to provide career counseling to clients. Career counselors need methods for facilitating client’s career transition across all stages of career development. This facilitation requires career counselors to be armed with methods for promoting client’s autonomy, responding to client resistance, and addressing client’s self-efficacy. In this article, career counseling is introduced with a Motivational Interviewing (MI) approach. First, an overview of career transition is presented. Then an application of MI as a component of the career counseling process is reviewed along with seven distinct counseling processes: (a) establishing the therapeutic relationship, (b) client assessment, (c) developing discrepancies, (d) rolling with resistance, (e) addressing client self-efficacy, (f) establishing empathy, and (g) transition/termination. Additionally, the article discusses the theoretical tenets, empirical support, and applications of MI for career counselors.

Multiple Pathways of Recovery for African American Men

For decades, tension has existed between addictions counselors and clients based upon a widely held belief by counselors that there is only one way to recover, leading to client resistance to treatment, premature termination, and relapse, as the client's approach to recovery has been commonly ignored. This article outlines multiple pathways of recovery among African American men and also offers clinical recommendations for service providers who work with these men.

Therapist emotional reactions and client resistance in cognitive behavioral therapy.

Although extensively discussed in theoretical papers, empirical studies of therapist emotional reactions to clients are lacking, particularly within the context of client resistance and cognitive-behavioral therapy (CBT). The present study examined the early positive and negative emotional reactions to clients of four therapists, together with observed client in-session resistance, and changes in resistance from early to midtreatment, in a sample of 30 outpatients receiving eight sessions (14 hr) of CBT for generalized anxiety disorder. Findings indicated that greater therapist early positive reactions to clients, especially liking, enjoyment, and attachment, were associated with significantly lower levels of client resistance midtreatment and greater reductions in client resistance from early to midtreatment. These effects were independent of therapist competence in delivering CBT, suggesting a potentially unique and important role for therapist feelings about clients beyond the skillful delivery of treatment techniques. Greater early negative therapist reactions to clients were less consistently related to client resistance but power struggles, and feeling drained, helpless, guilty, and frustrated were associated with higher levels of client subsequent resistance.

The relationship between socially prescribed perfectionism and depression: The mediating role of maladaptive cognitive schemas

Determining the mediating role of maladaptive cognitive schemas in relation between socially prescribed perfectionism and depression was proposed and tested in a model by path analysis among a nonclinical sample of 200 students. Participants completed the Hewitt and Flett Multidimensional Perfectionism Scale, Depression Anxiety Stress Scales, and Young Schema Questionnaire- short form. Results have shown that the initially hypothesized model did not have enough fitness to be confirmed. The findings show that, failure schema, relatively have indirect effect on defectiveness/shame and insufficient self control/selfdiscipline schemas and may play the role of mediator in relationship between socially prescribed perfectionism and depression. According to the findings, therapist should attend to factors that increase client's resistance, especially for perfectionists.

Stigma, Embarrassment and the Use of Mobility Aids

Client resistance in using the white cane is discussed. Fears about stigma and embarrassment are expressed by clients as the...

Identity work and client resistance underneath the canopy of active employment policy

In the Danish employment system social workers have the important institutional task of trying to establish a labour market perspective for each cash benefit recipient, even when the client has other problems in addition to unemployment. The client’s ‘capacity for work’ must be documented and described. In this article we examine the dilemmas that occur in the interaction between clients and social workers. We show how clients try to evade the demands of labour market related identities in their negotiations with social workers. Our analysis focuses on two cases, selected from a vast qualitative material, that represent cases in which the client’s dissatisfaction becomes apparent. The results indicate that clients are active participants who resist, protest against and sometimes even avoid the identities offered by the employment system.

Improving therapeutic use of homework: suggestions from mental health clinicians

Background. The majority of mental health clinicians report the use of homework to support their case management, but practitioner surveys indicate that homework is not routinely used.Aims. To examine barriers that mental health case managers experience in implementing homework and to identify strategies to promote successful homework administration.Method. One hundred thirty-four surveys were completed by mental health case managers. The survey examined their use of homework for individuals diagnosed with a severe mental health problem. It also asked them to identify barriers to regularly implement homework and describe strategies to promote more regular use of homework.Results. On average, homework was used at 50% of clinical contacts. The primary reasons for not using homework included allocating insufficient time at appointments, perceived client resistance for using homework and concerns that the client was too unwell. Strategies used to overcome these difficulties included prioritising the use of homework and ensuring that homework assignments were achievable.Conclusions. Clinicians are able to identify a range of practical strategies to promote the use of homework. Discussion focuses on the application of the suggested strategies to promote regular use of homework. This includes discussion of possible training approaches to enhance systematic homework administration.