Get Unstuck! Overcoming Resistance in Therapy

Richard Lam, LMFT, presents "Get Unstuck! Overcoming Resistance in Therapy " hosted by Jill Levitt, PhD, where he unpacks powerful strategies to transform resistance into a path toward genuine change.

 

Explore CBT-proven methods to overcome client resistance in therapy

 

In this video, Richard Lam and Sarah Chickering provide methods to overcome client resistance. Therapy resistance occurs when a client resists or pushes away change in psychotherapy. Some examples of client resistance in therapy include when a client is not progressing or completing homework.

 

Addressing resistance in clients is crucial for working well with them and helping them feel better. It is also important for therapists, as less resistance leads to less burnout. Therefore, overcoming resistance is essential when dealing with demanding clients.

 

Further, therapy activities for resistant clients are discussed within the TEAM-CBT model. These include tools for outcome resistance and process resistance. Outcome resistance is when clients have good reasons for not wanting change. Process resistance is when the client may not wish to engage in the hard work required for change.

 

Let's look at the key techniques discussed in the video:

 

Magic Button: Asking the client if they want to eliminate the emotion instantly.

 

Positive Reframing: To explore hidden benefits associated with the problem emotion with the client.

 

Externalization of Resistance: A role-play where the client argues for change against the therapist playing resistance.

 

Magic Dial: Finding a desired, reduced level of that emotion.

 

Acid Test: Visualizing life without that emotion, but with facts remaining unchanged.

 

This webinar focuses on the effective methods to overcome client resistance and increase their motivation for change. Watch the full webinar today.

 

IN THIS VIDEO:

 

Jill Levitt: So welcome everyone to this month's Feeling Good Institute webinar. We'll be presenting this month on the topic of getting unstuck, overcoming resistance in therapy. And I'm excited to introduce to you this month's presenters, Richard Lam and Sarah Chickering. And as is often the case, our work today is largely based on the work of Dr. David Burns. So let me tell you a little bit about this month's presenters. If you can go back to the slide before that. So Richard Lam is a licensed marriage and family therapist, a TEAM-CBT ambassador, and educational speaker with the Feeling Good Institute. And his clinical specialties include treating patients with OCD, panic disorder and relationship problems. And Richard also teaches TEAM-CBT to therapists worldwide and hosts the Feeling Good Therapist on YouTube, which provides helpful descriptions and roleplay demonstrations of TEAM-CBT techniques. And I'm excited for you all to learn from Richard today. And Richard is joined by Sarah and Dr. Sarah Chickering is a clinical psychologist and she's been in the field for 15 years and she enjoys working with patients who struggle with anxiety, depression and profound loss. She has a passion for excellence in therapy and continues to hone her skills trying to provide the best client care possible. Sarah has a telehealth practice in Washington state and enjoys the outdoors, spending time with her family and loving on her pets. Okay, so let's go to the next slide. I'm just going to tell you guys just a little bit about Feeling Good Institute and then I'm going to turn the reins over to Richard and Sarah to present today.

 

Just briefly to give you a little snapshot of what we're all about here at Feeling Good Institute. Our mission is to make a difference in people's lives through elevating the practice of therapy and our story really started with one big goal, which is to make therapy better and to help people who are going through tough times. And we achieve this by training and certifying therapists in effective therapy techniques. We have a comprehensive kind of five level TEAM-CBT certification system that really provides people with kind of a road map to mastering TEAM-CBT. And we're really proud of what we do, especially all the therapists that practice TEAM-CBT really around the world, we have treatment available in over 35 states across the US and Canada and we offer therapy both online and in person. And finally, we have an intensive one on one therapy program, which is where people can come in from out of town or do it virtually as well and really kind of speed up recovery by having extended or more frequent therapy sessions. And we also have a program to offer lower fee options supervised by advanced clinicians so that more people have access to higher quality care. Okay, next slide. So the boring stuff, just briefly if you're wanting to get your continuing education credit, please make sure that you stay till the end of the hour and just five minutes before the end of the hour we'll drop the CE survey in the chat box. So you do have to be present for the whole hour. You have to complete the CE survey and then you'll receive your certificate of completion via email within a week. So please don't email asking where it is tomorrow or today, just be patient and as long as you fill out the survey today, you'll get your CE certificate of completion via email within about a week. Okay, and now I'm going to turn it over to your awesome presenters.

 

Richard Lam: Great, thank you Jill. Well first of all, hi everyone. I just wanted to share a really quick story just to better understand our topic for today and I also like to embarrass myself so I put this picture of my younger self here when I was a young and aspiring therapist and a big part of this is when I was a therapist in grad school I got very curious about this model called TEAM-CBT and I got the opportunity to join a group at Stanford to learn more about it. And when I got there I found out that every member there is a licensed therapist and immediately I fell out of place. I was thinking what am I doing here? Everyone's so much more experienced than I am. I felt really anxious and inadequate and regardless of how I felt, I just continued going every week. And in this group they always like to ask for volunteers to practice in the whole group. My initial thoughts, no way am I doing that. I didn't want to make a mistake and or make a fool myself and I was really worried about embarrassing myself in front of everyone.

 

One day we got this homework assignment to explore our resistance and to kind of understand more about why we feel stuck and I was looking at maybe some of the advantages of feeling anxious and in the practice groups and I realized by feeling anxious it helped me protect myself from embarrassment because I wouldn't be volunteering and kind of taking action there and it also helped me maintain my high standards of kind of making sure I understood completely before volunteering. And lastly I kind of realized it really protects me from judgment from others because my anxiety wouldn't let me essentially know how like other people know how inexperienced I am especially being a pre-licensed clinician. And it was really amazing because after noticing these wonderful things about my anxiety, it really helped me to a tremendous degree because the beautiful and wonderful things it says about me. And I realized at this point I really want to change. So the next class I raised my hand to volunteer, one of the scariest moments ever. And the reason why I share this story with you today is because I really want to highlight the importance of addressing our resistance to change because there are so so many good reasons to keep my anxiety and the more I shine light on all these good things I realize that I really wanted to overcome my anxiety and it really gets me fighting for change. Something that I want to teach all of you not only for your patients but potentially for yourselves as well because by addressing resistance we can understand ourselves more and decide whether or not we want the change or not. And if we do decide we want the change comes with tremendous amounts of motivation. So that being said, I'll pass it over to Sarah to introduce a little bit more about our plan for today.

 

Sarah Chickering: Thanks Richard, that was a wonderful story and I'm sure that we can all hear ourselves in your story. So this is the road map for today. We're going to go through what we mean by resistance and then this presentation is going to be chalked full of interventions and methods that you'll be able to use with your clients and then towards the end of the hour, we'll have time for questions and comments. So our learning objectives today is that you'll be able to describe at the end of our time together what we mean by outcome resistance in TEAM-CBT and also to be able to use positive reframing as an intervention with your clients. So let's start out first talking about what is resistance. I'm so glad we're doing this topic because I think all of us can relate to it. Resistance is any time we have a client who is resisting or pushing away against change in psychotherapy and this can take a lot of different forms. Sometimes it's when a client just isn't progressing, they feel stuck and we feel stuck and maybe they're not completing homework or they're responding to any intervention or suggestion that we have with yes but. So why do we look at resistance in therapy? Well, first of all I think a lot of us could relate to having a resistant client and it's so important to look at this together today because resistance really impedes psychotherapy overall. It makes it harder to work with clients and they don't feel better. Also, it's really important as clinicians to work on resistance with clients. The less resistance we have in therapy with our own clients, the less burnout that we have. So working on resistance is both a protective factor, not only for our clients and how they're doing, but how we do professionally and personally in our work. So in TEAM-CBT, we talk about two different levels or types of resistance. The first we call outcome resistance and this is really the good reasons that a client may not want to change. For example, if I have a client with OCD or obsessive compulsive disorder and she is a very caring mom who, for example, washes her hands over and over several times a day, she may not want to change because she would risk the potential protection of her kids. So her outcome resistance may be she doesn't want to change. There's good reasons not to change. She wants to protect her family through her symptoms. That's what we call outcome resistance. Process resistance is that there are good reasons the client may not want to engage in the hard work. This is necessary for change in therapy. For example, if I have a depressed client, he may not want to get out of bed every day, work on psychotherapy homework, do pleasurable activities that are required for him to change. He may have what we call process resistance.

 

Richard Lam: Great, thank you Sarah. Thank you for the descriptions of the different types of resistances and today we'll be mostly covering outcome resistance. There's a lot of different outcome resistance tools that I wanted to share with everyone. The first one is going to be magic button but before I explain what it is, I want to explain why I start using something like this to begin with. So I I worked with someone a long time ago who was like a very anxious person. He was really worried about what people thought. He was so worried about health things, just worried about everything and he came to me and he said please just get rid of all my anxiety and I was definitely on board. I was like, oh my god, this guy he's he's suffering so much, he's having tremendous distress to the point where he's feeling depressed because his anxiety is not allowing him to do the things that he wants to do. So I agreed. I'm like, let's do it. And I was like, but at first I was thinking like, do you want to get rid of all of it? And he's like, yes please, just get rid of everything. I'm like, okay. So that's what we did. And a week later he came back and he was really upset with me. He's like, why did you get rid of all my anxiety? And I was like, well, that's that's what you asked for. And I was like, what what happened? And he said, my wife is really upset with me and she's considering divorce now. And and he was basically saying because I don't feel anxious anymore, I actually don't really monitor like what I say. I just say things really unfiltered and I've been hurting her feelings and she's been getting really upset with me and she doesn't really like the person that I've become. And that point I realized one of the most important things to do, one thing that I do with every patient is I offer them this magic button question to really get them thinking because a big part of it is maybe they don't want to get rid of all their emotions and maybe there's something good about it. So how I would present this question is had this magic button and you were to push this button, suddenly all your anxiety would just disappear, disappear with no effort on your part at all. Would you push that button?

 

I usually get two responses. Someone who says yes, I want to get rid of it. I get it, it's so distressing, of course they would want to get rid of it or they say no, I don't want to get rid of all of it. That's interesting and it makes me want to inquire more. So, but regardless of either of these questions, I'm going to explore a little bit more. For example, if they say no, no, I don't want to get rid of it, I'm like great, tell me more. Why, why wouldn't you want to get rid of it? And I'm just going to really jot down everything and something that I'll describe later called PA or reframing or if they say yes, I want to get rid of it, I'm going to find truth and what they were saying and disagree. Like, of course you want to get rid of it, it's so distressing and I want to help you get rid of it too. But at the same time, I feel a little bit concerned and worried because if we got rid of it, we would not only lose all the bad things about it, but we'd lose any of the potential good things that come with it too if there were any. And is this something that you'd be willing to explore with me before deciding to get rid of all of it? And 100% of the time, people usually say yes because they're curious and I wouldn't blame them. And a big part of what we would do next is I'd hand them a piece of paper and what that would be is we go through an exercise called positive reframing. And this is one of my favorite parts of therapy and the reason why is it really helps me understand someone to a greater degree.

 

It helps me understand why they're feeling stuck as they do with these emotions and how they've been how these emotions have been helping them in some way in the person that they are and their value system because each and every person that I meet through this whole therapy process, I get to understand their value system and how they live their lives and what crafts them as a person, which is totally different than the person that I am and this is my favorite learning process. So just to kind of understand a little bit more about this positive reframing is after I asked them that magic button question, I hand them this piece of paper and I'll ask them these questions. One of the questions might be, what are the good reasons they can feel they continue feeling let's say hopeless? Let imagine someone's feeling hopeless about getting a job after an interview. They just did this interview and they're like, I'm not going to get this job and they're feeling really less about it. One of the good things, good reasons to continue feeling hopeless for someone like that is it really protects them from disappointment because if they got this interview and right after they felt really hopeful, like I'm going to get this job no matter what, 100% sure I'll get this job and they don't get it, they're going to feel very disappointed. But if they're going in and they're thinking I don't really think I got this job and then they didn't, then they're like yep, I knew it. So a big part of this is often times people tell me that hopelessness protects them from this like really great disappointment.

 

Another question I would ask people, how does feeling blank help you? So how does feeling anxious help you? For example, I know a lot of students they feel really anxious about like exams coming up and usually when I ask people like how does feeling anxious help you for for exams and they usually say it really motivates them to study because they're so concerned about failing that they're like I got to study as much as I can, which helps them quite a bit. Alternatively, another question I like to ask is what good things does it say about you that you feel whatever emotion? For example, maybe feeling depressed about working too much and not having time for anything else. And I think one of the really wonderful things that says someone that says about someone who feels depressed about working too much, they really value their personal time or the time that they spend with friends and family because they're kind of feeling depressed that they're spending all their time doing work rather than spending time with their family or spending time for their personal time. So a big part of this is this helps people understand themselves more in terms of their value system and also how these emotions have helped them in the past or current. And I think this is a really beautiful thing to explore with our patients to help them understand to a greater degree as well.

 

So that being said, I just want to kind of go through an example with everyone. And you don't have to do it now but something to think about is let me just explain the situation and then those of you who have the answers to these questions on the bottom, send it over to Jill and Jill will let me know all your beautiful responses. So let's imagine there's this 30 year old female who's feeling really tired after work and because of that she's kind of allowing her daughter to watch hours of YouTube so that way she can just relax. But even though she's trying to relax, she's also feeling really guilty because she's kind of thinking, oh, I shouldn't be allowing my daughter so much screen time or and she thinks I'm selfish for prioritizing relaxing over my daughter. So there's a few questions I want you to ask yourselves here and then send the answers over to Jill is what are the good reasons to continue feeling guilty about allowing her daughter to have so much screen time and just feeling guilty help this woman and what good things does it say about her that she feels guilty about allowing for so much screen time? So I just want to take a moment and I often have a hard time just being quiet but I'm just going to pause for a moment while people collect their thoughts and send it over to Jill and we'll be able to read some of the responses in a little bit here.

 

Jill Levitt: I've already got some great ones to share with you Richard, so.

 

Richard Lam: Wonderful. Tell me about it.

 

Jill Levitt: Quick crowd. Okay, so her guilt, her guilt helps her to see herself as a good mother who really cares about her daughter.

 

Richard Lam: I love that one. Yeah, a big part of it is the guilt really shows that she's very cautious and conscious of her daughter and it really shows that I want to be a better mom. I want to be the best mom for my daughter, so I love that. Yeah.

 

Jill Levitt: Yeah. Guilt shows that she cares about the wellbeing of her daughter. Her guilt might motivate her to change or limit the screen time.

 

Richard Lam: Oh, I love that one. That's kind of like the one that's like how does it help her and it helps her by the giving her that motivation to kind of change her behaviors as well.

 

Jill Levitt: It can make her a more conscientious or attentive mother. Shows that she value, well someone said lots of screen time is not good for development. So then we would state that as it shows that she values her daughter's development, right?

 

Richard Lam: Yeah, we've got some other you're rephrasing that something that's going to be helpful through this process too, right? Where sometimes patients do kind of throw out different advantages and we just have to frame them in a more advantageous way.

 

Jill Levitt: Exactly. Yeah, she right, people are stating things like it shows that she cares about her daughter, that she has a moral compass, that it helps her to recognize the need for her daughter to have time away from the screen. Guilt helps her to take action towards that. So anyway, I think we yeah, we've got lots of lots of on target good answers. She loves her daughter, she's concerned about her daughter, etc.

 

Richard Lam: That's lovely. We definitely have a really good crowd of therapists here throwing out really wonderful responses. And I think as anyone can tell, this woman is a really lovely mom who really wants the best for her daughter and the guilt really helps so much in that respect. And I think this is one of the really beautiful things about understanding positive reframing and often times what happens is I feel really convinced where I'm like, oh my god, this is so good, these emotions are really helpful, which kind of oftentimes lead me to the pivot question. So after I come up with all these positive reframing in terms of why is this good and how does it help you and I understand to a greater degree, often times I like to ask this question of given all these good reasons to continue feeling guilty, why would you want to get rid of it? And usually there's two things that usually happen. Patients decide actually this is really good and I want to hold on to it and at this point in time, I'm going to say with open hands and like, well, if you want to hold on to it, wonderful. If not, that's okay too and I'll help you either way, whichever path you want to go. And the reason for that is I respect them too much to change them against their will and part of this too is I'm not here to craft everyone to have similar values as me. We definitely don't need more Richards in this world, so I want them to be their individual self where they can hold on to their values to a certain degree that they want to and at the same time hold on to the things that have been helping them because if I take away all the things that have been helping them then they're they might struggle even more and they're their best judge in terms of what helps them and what they can let go of and also their value system and what they want to hold on to too.

 

Like getting rid of all these emotions, I feel a little bit worried that they might lose themselves in the process and that's not something that I'm going to force upon them and it's their choice at the end of the day. Alternatively, if argue back against me after I asked this question, given all these good reasons to continue feeling guilty, why would you want to get rid of it? And then they fight back with me and they say, well, actually I do experience a lot of good things but there's actually a lot of bad things too. Then they start finding back and I love this moment because now it kind of gives them that tremendous amount of motivation to melt away the resistance to change and gets them fighting for for change and it's not this like me pulling them for change anymore. This is them like, hey, I want to take action. I want this and suddenly therapy is just so much more effective at this point. So at this point, we go into something as you see here something called externalization resistance. Often times people are like, what is that? So I'll tell you and our next slide here, it's a roleplay technique. And this is one of my favorite roleplay techniques and the reason why is this gets them fighting even more for change. So let me describe a little bit about the roleplay and then I want to do a demo of this so that everyone kind of see how this works. So, and this is a roleplay technique where there's two roles. The therapist will be playing the role of trying to convince their patient to stay the same, who may be trying to convince them to continue feeling guilty using all the good reasons that you two came up with in the positive reframing earlier. And another role that's in here that the patient will be playing is the role of trying to argue back against the therapist if they can and the big reason why is they want to see if you can fight back against your resistance to change, which is essentially what the positive reframing is. Let me just kind of go back a few slides here. So if you look at these questions here, these are actually when you ask these questions, not only is it like the advantages but also the values, but these are also reasons to stay the same and if they can argue against change and argue for change rather, so they argue for change then essentially you're melting away the resistance to change. So just kind of going back to externalization of resistance is there's one thing I like to do within the role play and this is all makes sense once we start doing the Mo is I often like to ask this question of who won this exchange? And the reason why is you want to see if they can defeat the reasons to stay the same. So that being said, Sarah, I wonder if you can help me out with a demonstration really quickly and we'll just do the I just want you to play the role of maybe a 30 year old female feeling tired after work and then you can play the role of this this example here. What do you think?

 

Sarah Chickering: Great, let's do it.

 

Richard Lam; So let me just set it up a little bit before we kind of jump in. So this is going to be the person that you are here and I'm just going to call you Sarah just to make it a little simple. And what we're going to do is we're going to maybe start off with let's imagine you and I, we just did some pause reframing. So we did some of these pause of reframing here and then you came up with a lot of good reasons like it kind of shows that you want to be a good mother, it shows that you value mental health for your daughter and of course it kind of motivates you to become a better mother as well, right? So you have all these good reasons to continue feeling guilty and what let's imagine that we just came up with all these and I'm going to start with the pivot question and then we'll kind of go into externalization of resistance so if people can kind of see that flow. What do you think?

 

Sarah Chickering: Great, let's jump into the demonstration now.

 

Richard Lam: So Sarah, you just shared with me and we just came up together with a lot of good reasons to continue feeling guilty about giving your daughter too much screen time and I wonder given that we have all these wonderful reasons to continue feeling guilty, why would you want to get rid of it?

 

Sarah Chickering: Yeah, I mean it is different for me to see my guilt as something positive. That's been really helpful in of itself, but I don't know, it just seems like it's so much of it. It's so overwhelming, it's almost like getting in the way of my parenting because I'm feeling so badly about myself. I almost have too much guilt.

 

Richard Lam: Yeah, kind of sounds like the tremendous amount of guilt is really making things really difficult for you. It's hard to function even though there are good there's a lot also a lot of bad, right?

 

Sarah Chickering: Yeah.

 

Richard Lam: So that being said, I think one thing that might be helpful a little bit for us Sarah is a technique called externalization of resistance and let me tell you a little bit about it as to why this might be helpful. So this is going to be a role play technique between you and I and there'll be two roles. For me, I'll be playing the role of I'm going to try to convince you to continue feeling guilty using the reasons that we came up with together and then your job is see if you can argue back against me. And the reason why we want to do this role play is it'll help you kind of fight back for change but not only that is it'll kind of help you understand what you want to let go of and which one you're able to hold on to as well if any. And a big part of this is going to be a technique that will allow you to kind of choose like what you want to hold on to in the future or not, whether it's guilt or another emotion. So this is something that I want you to learn and practice so that way when we're done with therapy too, that you can continue using this on your own. Does that make sense?

 

Sarah Chickering: Yeah, wonderful. Is this something you want to try with me?

 

Richard Lam: Yeah, I'll give it a shot. Well, let me actually start by asking you just to kind of clarify what is my role in the role play?

 

Sarah Chickering: You're going to convince me not to change and to keep the guilt.

 

Richard Lam: And what's your role?

 

Sarah Chickering: And I'm going to argue of why I want to dial that guilt down, why I don't want so much of it anymore.

 

Richard Lam: You got it. You ready?

 

Sarah Chickering: Yes.

 

Richard Lam: Well Sarah, I I want you to hold on to the skill because I think it's it really shows how good of a mother you are.

 

Sarah Chickering: Yeah, I don't think that's true at all. I think that being a good mother is being cognizant of what's good for my kid and sometimes having a little bit of screen time is is good for her but having too much is kind of getting her way. So the guilt motivates me to be a better mom, but I don't need to to be a good mom to have it being guilty doesn't make me a better mom.

 

Richard Lam: Well, who won that one? You or me?

 

Sarah Chickering: I won.

 

Richard Lam: I think so too. You ready for the next one? Okay. You know Sarah, you should continue feeling guilty because it's really the only and best way to kind of motivate yourself to be a better mom.

 

Sarah Chickering: That's not true at all. I can motivate myself because I love my kid and I can work with her to you know, manage her time better, develop better study habits and just time after school. What makes me good mom is my love for her and I love her very much.

 

Richard Lam: I love that one. Who won that one?

 

Sarah Chickering: Me.

 

Richard Lam: I thought so too. Let's try one more. You ready? Okay. Well, you know Sarah, you should continue feeling guilty because a big part of this is it's really the only way to show that you care about your daughter's mental health.

 

Sarah Chickering: That is totally not true. I have many ways that I show that I love her. I provide for her financially, I cook meals for her, we spend time together. My guilt is not a measure of my role as a parent or mom. I have many other data points to say that I'm really doing a good job of being a good mom to her.

 

Richard Lam: Well and I'll just check in with you how do you or who won that one?

 

Sarah Chickering: I won that one as well.

 

Richard Lam: I thought so too. Sounds like you're doing a really awesome job of kind of defeating a lot of these advantages and values here and I wonder what's this like for you to kind of go through this externalization of resistance exercise?

 

Sarah Chickering: You know, it's funny, it's so much more powerful when I'm arguing those thoughts out. Like I I am realizing the fallacy in the way that I was talking to myself about that guilt, but I feel good about winning against you because those are really my beliefs. That's really what matters to me.

 

Richard Lam: You're kind of feeling more aligned with what's important to you, is that right?

 

Sarah Chickering: Yeah.

 

Richard Lam: Let's pause there. Thank you Sarah for the demonstration here with me and as everyone can see, this can be a really powerful technique to help people understand themselves more to a greater degree and which kind of Leads me to the next thing that I want to talk about is often times people ask me what do I do after externalization resistance? Well, that's when we kind of go into something called the magic dial because right now there are going to be some exchanges that they won. Luckily Sarah won all of them, so that's wonderful. However, there are some that people might not be able to win against, which is totally fine. It just means that there's a part of it they want to hold on to. So if you kind of think about it is earlier I offer kind of like this magic button question and if they pushed it suddenly all their, let's say guilt just disappeared with no effort on their part at all. Sarah might not want that and a big part of it is maybe there's a little bit of it that they want to hold on to. And a big part of it too is where's that magic number where they have enough guilt where they can still get all these wonderful positive things and hold on to some of the really important values they have but not so much of the disadvantages that come with it. So rather than pushing that button and getting rid of all of it, like all or nothing, maybe we can dial it down. Like in this moment, maybe anxiety or guilt is dialed all the way up to 100 and what if you can dial it down to a number where you still can benefit from all the advantages of these negative emotions because I know we label these emotions as negative but at the end of the day, these are just emotions and the emotions help us in one way or another and to get rid of all of it that can be a little bit scary. So maybe there's a little bit that they want to hold on to so we can really adjust our goals and really aim towards reducing the negative symptoms and really maintaining the positives as well. So how this would sound like and feel free to answer here Sarah, I'm going to just kind of jump in and just offer you a magic dial question is Sarah, I'm imagining that there's a lot of negatives to feeling guilty but also some positives that we looked into as well. And I know you mentioned earlier that your guilt in the situation was at 100% and I wonder instead of kind of pushing that button and getting rid of all of it, what if we had the magic dial instead? Right now that diaL is up 100%. You can dial it down to somewhere more comfortable where you got exactly what you wanted, all the benefits from the guilt but not so much of the negatives. What do you think you want to dial that down too?

 

Sarah Chickering: Yeah, it's it's so helpful to think about it that way instead of a button, a dial of getting it like in the right range for me. Honestly, I want to keep some of it, which I'm surprised to say but I want to keep some of it and I I think maybe 40%. It's enough to kind of keep me focused on caring for our daughter, but not too much. 40 sounds like a good range for me.

 

Richard Lam: I love that. So 40% might be a good range for you, right? Where you have enough of the advantages but not so much of the disadvantages. So that's something I want you to write down Sarah and that's the the goal that we'll aim for. And the beauty behind this is we'll aim for that goal and if you're kind of realizing once you achieve it, you want a little bit less, then we can always adjust. But if we kind of overshoot it, you're like, oh actually I want to feel 45%, then we can also make you feel a little more guilty somehow as well, right? Just to kind of get it in the right place for you. So this is specific to you and tailored this therapy will be tailored to you and something that you'll be able to do continuously as well. So this is how we do the magic dial question. And one of the things I want to teach is I'm just going to throw so many techniques at you guys today when it comes to outcome resistance. And one of the other techniques is called the acid test. And the acid test, sometimes I like to use it in replace of the magic button question. Very similar, however, it does kind of create this dynamic where they kind of gets them thinking a little bit more about like, do I really want to let go with these emotions? So really I try to paint a picture of where they imagine their life with essentially all these negative emotions that are gone, but at the end of the day, the facts remain the same because as therapists, we help people with their emotions.

 

We can't really change the facts of their life. So that's exactly what I'm going to paint out to them in terms of, hey, I'll get help you get rid of his emotions but everything stays the same. Is this still still something you want? So to give an example is imagine there was a student who was very anxious and they have an exam tomorrow. So they're very anxious but they actually haven't studied all week and they haven't put any time in studying. So how it frame this to a student is, so are you telling me you would want to get rid of all your anxiety? You have zero anxiety, you feel a lot of peace and calm, but everything remains the same though. You still have your exam tomorrow, you haven't studied but you feel good about it. Is that what you're telling me? Often times what people say is they argue back against me like, no, I need that like I don't want to feel less anxious. I was like, oh, why? And they would say, I I need it so I can feel motivated to study. Then suddenly we kind of get into the talk about the positive reframing and that's when I hand out a piece of paper and like let's write some of this stuff down and get down the pause reframing. But if they still say yes, I'll be like, but I feel a little bit worried. I'm wondering if it helps you in some way or another, do you mind if we explore it? And I still hand them a pause of reframing. And the reason why I like to use this one is I want them to start thinking a little bit about this so it becomes a pattern of do I really want to let go of these emotions because when they're not therapy anymore and they're doing this stuff on their own, I want them to constantly do this like acid test to themselves of like, does it make sense to get rid of all these emotions or not? So this is something that I want to teach them as well. And that being said, I'm really excited for these next slides because Sarah is going to be sharing a really wonderful vignette to really consolidate all the skills and tools that I wanted to lead you today. Take it away, Sarah.

 

Sarah Chickering: Alright, thanks Richard. Okay, so I want to bring this to life a little bit about how we really welcome and work with a client in their resistance. It's integral to the TEAM-CBT model. So I want you to tell you about Niru. She was a client of mine who came to me really in a great amount of distress. She had been working with a client for a long time and just never made any headway. It was like every intervention she tried just kind of fell flat and sadly she she was describing to me this moment that was so upsetting to her where she had gone through a full session with a client and the client had given her and after survey evaluating the session and and sharing how her mood was and how she was feeling afterward and she felt worse after the session with Niru. So she just felt so distraught. Like I'm not sure she was telling me, I'm not sure what to do. I just feel so overwhelmed. So she was having feelings like of inferiority, inadequacy, incompetence and just embarrassed. She was really stuck of what to do next with this person and she was telling herself thoughts such as you know, I'm a bad therapist, maybe others would have helped this person by now and nothing that I'm doing is working or helping. And this was a real point of contention for her because she's a professional woman and it just really struggling with this person and my heart went out to her because I know I felt that way with clients sometimes too. So I asked her very similar to what Richard was teaching us about the magic button. I said Niru, if I had a button here at the end of my desk and I said if you pressed it, all of that inferiority would go away. You wouldn't feel embarrassed, you wouldn't feel inadequate, you wouldn't be telling yourself these things like you weren't doing a good job with this client at all. Would you press it? Without any change, all of the sudden everything that was bothering you would just disappear. And at first she said, well, yeah. And she kind of stopped herself. She said, yeah, well, wait a minute, no I wouldn't. And so I asked her like, well, why wouldn't you want to push the button? And she said, well, you know, I guess that I wouldn't want to feel completely okay if my client wasn't doing well and that was that was kind of a natural segue for us to go to the positive reframing part. And and I'd love for you to just think about this through with me. What do you think some of the benefits are of Niru's thoughts or or her feelings of inferiority? How could they help her? Go ahead and send those to Jill in the chat. What are the good things that her negative thoughts and feelings could say about her? Let's just brainstorm that a little bit.

 

Jill Levitt: Right, so I'm starting to get some rolling in here. It shows and by the way, someone asks if they're not seeing what participants are posting, that's correct because we have the chat box locked because people get very confused. So I will share with you what I'm seeing. So it shows that she cares for her clients. It keeps her motivated to be a better therapist. A more of the the value, she cares about the success of her clients and again we got values and then we got benefits, right? Motivates her to get consolidation or additional training. Motivates her to learn additional techniques to help. Shows her quality of care and professionalism. So yes, we're seeing lots of shows how much she cares as a value and a benefit being that it keeps her learning and training and growing and getting consultation, high standards, that's another one, shows her high standards.

 

Sarah Chickering: Yeah, I'm just making this list because it's such a good list. Thank you for sharing those with us. Yeah, I I think that she came up with a very similar list of it it's it shows her professional integrity that she cares that she really wants to see her clients move forward and just changing and growing as her own professional. So after we did that positive reframing and and we made quite a list and I encourage you when you do this intervention with your client that you really go all the way out. What else does it say about you and allow them to generate that. So we had a great list and then what I did very similar to what Richard modeled for us earlier is I said, you know, goodness, given this list of beautiful things about you, you know, do you really want to give up this feeling of inferiority? I mean, you've got some good arguments to kind of keep it in my mind. So I asked her the pivot question. And and she said, you know, she said, I really love that I want to be so committed to treatment with my clients, but it's almost backfiring. Like I'm I'm spending a lot of time worrying about sessions when I drive home and I'm feeling just about my esteem. She said, I just, I feel like I really want to work on reducing this. And and this pivot question is Richard outline is so imperative that the client is is pushing that change forward.

 

So I'm kind of tossing that power in her lap and saying what do you want to do given all these things, do you want to move forward? She says, yeah, I really do. So what we did is an externalization of resistance role play like Richard and I demonstrated earlier and I said, okay, now Niru, I'm going to try and convince you to stay the same to just stay in that inferiority and and telling yourself that you're incompetent and I want you to fight against me and I really hope that you win and win and win strongly. And she she knocked it out of the park and how I did that was I took each of the thoughts from her mood log that she was telling herself that were negative thoughts, like Richard did and I just kind of hit her one at a time. Well, you know, this really shows that you're not doing a good job. And she just defeated me actually pretty quickly. It's very powerful to see. And so then after the externalization of resistance and she won pretty big and we wrote down those thoughts, it's really important when we do the role play of externalization resistance, the client wins really largely. We want to document what thoughts were were powerful in that. So I asked her to write them down and then we went to the magic dial together and I said, okay, so we don't really want to push the button. She she said, I don't want to press that magic button and have this all disappear. But where do we want that inferiority to be? Kind of how Richard asked me earlier is the the mom with the guilt. I said, where would you like to dial that down? And she said, you know, I honestly want to keep some of it and it was It was kind of interesting to see her almost have a sense of pride in that. And and this this is just a side note that when we're working with clients, we want them to have a really balanced view of their symptoms, right? We want them to kind of walk away going that says something good about me because it does. So she said, yeah, I really want to keep it, maybe I'll reduce it to about 30%. So we reduced her goal to 30% instead of 100% inferiority or telling herself she was a competent, maybe she reduced that to about 30%. So this was the the vignette of what resistance looks like with Niru, her outcome resistance, right? Process resistance and and we worked it through.

 

Richard Lam: Wonderful, thank you Sarah. I think this was really good exampleof how this can work out with a patient and I really like this vignette because it really highlights the skills that we've learned today, which kind of brings me back to or next to or to our next slide here where there's definitely a lot of research that really supports resistance in therapy and one of the things is by addressing resistance, we can have the clients or patients fighting back very strongly and really improve our our treatment outcomes. And I've shared a little bit of different skills and tools that we can use for outcome resistance and if you're wanting to learn more, of course you can continue to attend all of our trainings or another really great resource is the Feeling Great book by Dr. David Burns and it talks about not only outcome resistance but process resistance as well. So that being said, I just wanted to open it up for some quick Q&A.

 

Q&A Session