Outcome resistance in therapy and coaching.

A colleague asked for my thoughts on why we should help people with challenging emotions of sadness, worry and guilt as they may represent a near spiritual awakening which can be blocked by jumping in to 'save them'.

I had this to say in reply:

Personally, I am directed by the patient in front of me. I ask them the state of goal that they wish to achieve with coaching and explain my personal approach as an option to get there.

TEAM CBT is grounded in rational emotive and cognitive therapy and tends to see things through the lens of dysfunctional thought patterns driving an emotional response. If a patient believes this theory, they are more likely to be motivated to perform the ‘work of therapy’ Ie learning the skills and techniques required to change a thought to achieve the outcome they desire.

If a patient doesn’t share the belief in this cognitive theory, it will be very hard to achieve a result and I will state from the outset that I don’t want to waste their precious time and money on something that I know won’t work.

People have to be motivated and engaged with your message and therapy modality in order to get results. This is true with any therapy from functional medicine to coaching or counselling.

Personally, what resonated with me about TEAM CBT is the idea that a lack of motivation on behalf of the patient to change isn’t seen as a bad thing. Indeed it’s actually seen as a truly positive thing that should be celebrated.

In a hypothetical case, a patient in session may tell me they wish to experience joy, calm and confidence instead of sadness, anxiety and suffering.

We then examine the good reasons why they would want to KEEP hold of sadness, anxiety and suffering.

I often find that people who have deep spiritual or philosophical beliefs about the pursuit of the meaning of life and the self do not want to rid themselves of sadness, worry and suffering when they represent a sort of spiritual asceticism like Gautam Buddha starving himself to find enlightenment. Or perhaps a philosophical realism which deeply respects and does not ignore the harsh qualities of life (which as we can see evidently from world events is brutal and punishing).

Sadness and suffering can often give the advantage of connection to other likeminded people, communities and spiritual groups who feel the same way. As we all know, deep connection is healing.

There are many more examples of positive values and advantages for all seemingly “negative” emotions of sadness, guilt, inadequacy, frustration, anger, even hopelessness and shame. Often we can list 20-30 positive aspects together in one session.

In this example, suffering through existential sadness or worry is then a truly beautiful value with advantages to that patient. Hence they have resistance to the ‘outcome’ of therapy which is contentment, happiness and the ease of suffering.

In the session, we then address this paradox and ask ‘why would you want to put in the work of learning new skills to change your thoughts and beliefs to make you feel happier, calmer, more confident?’

This often allows the patient to bridge the gap and state whilst there is true beauty in the value of these often termed “negative” emotions, the suffering causes limitations that outweigh the benefits of the positive values.

In some cases they are then paradoxically more motivated  to get to work and learn ways to change the thoughts.

This is improved when we present a way to keep hold of the virtues of “negative emotions” but also change them.

We then move in to the Methods section of TEAM which can lead to rapid change in limiting thoughts and beliefs because people are no longer held back by the often hidden desire not to change for a good reason.

Alternatively patients they leave my session with their head held high because they see the core value in their emotions.

Long story short:

1- patients will choose the clinician whose beliefs and training they resonate with

2- we can’t all help everyone

3- patients need to be motivated and engaged with any therapy modality to make a positive difference

4 - there are always hidden good reasons not to change and engage which speak to beautiful and amazing core values of a patient.

5- if these reasons are brought to conscious awareness and you try to convince a patient NOT to change and NOT to work with you, often this leads to more motivation to work.

6- if people still don’t think your therapy is for them, you both leave without animosity and with gratitude and closeness. Often the value of being truly seen, heard and respected is therapeutic in itself.

(Note This is a contrarian take on the topic of “patient resistance” causing therapeutic failure which is often taught as being due to patients malingering, being difficult, have a personality defect or wanting some secondary gain - having these beliefs is a recipe for conflict and complaint IMO)

What are your thoughts about this? I'd love to hear from you.