When therapy is not helping, it is easy to locate the failure inside the client. The person is resistant, unwilling to change or benefiting from the problem. Each description appears to explain the difficulty while leaving the practitioner’s method and assumptions relatively untouched.
I am interested in a different possibility. What looks like attachment to a problem may be an attempt to make life with that problem bearable. What looks like resistance may be a response to the conversation, the proposed intervention or circumstances the practitioner has not yet understood.
From The Rainbow Machine: Tales from a Neurolinguist’s Journal by Andrew T. Austin.
The explanation that arrives before the enquiry
Resistance carries different meanings in different therapeutic models. In a psychoanalytic frame it may concern defences against material experienced as threatening. In everyday clinical conversation, the word is often used more loosely for disagreement, non-participation, missed tasks or failure to improve.
Those are not interchangeable observations. A person who cannot carry out a task faces a different difficulty from someone who does not understand it. Someone who declines an intervention may have different priorities, previous adverse experiences or a reasonable objection. The label “resistant” can flatten these distinctions before they are explored.
It can also make the interpretation difficult to challenge. If the client agrees, the theory appears confirmed. If the client objects, the objection becomes evidence of resistance. An explanation that treats every answer as confirmation is poorly placed to discover its own errors.
Learning to look for hidden benefits
As a student nurse between 1989 and 1992, I was taught to consider the sick role and primary and secondary gains. We were encouraged to look beyond a person’s stated problem for benefits associated with being ill: relief from responsibilities, attention, financial support or exemption from work.
The intention was to think more broadly than the immediate symptom. The effect could also be a habit of suspicion. If someone remained unwell, perhaps the illness was serving them. If they rejected a treatment, perhaps they did not really want recovery. The same lens could be applied to chronic pain, smoking and many other difficulties.
The danger is not in noticing that circumstances have consequences. It is in assuming that a consequence explains why the illness exists or persists. Receiving support while ill does not show that the person is ill in order to receive support.
Comfort within a problem
Suppose a person has lived with a difficult condition for years. They may have reorganised daily routines, found practical assistance and developed small sources of comfort. Without those adaptations, life would be even harder. From outside, the arrangements may look like advantages connected to the problem.
Two very different stories can then be told. In one, the person maintains the condition because the benefits are attractive. In the other, the person has a condition and has had to find ways to survive it. The visible arrangement alone does not determine which story is accurate.
I favour beginning with the second possibility because it is often both more respectful and more productive. It asks what the person has already done to cope and what else might help. It does not require accusing them of secretly preferring their difficulty.
That is a working position, not a claim that incentives can never influence behaviour. Motivation, avoidance and competing needs can all be relevant. They need to be established through careful enquiry, rather than assumed whenever a person has not improved.
How an accusation creates the response it predicts
Imagine telling someone with a long-term problem that the reason they still have it is the benefit it brings them. Anger, withdrawal or argument would be understandable responses. If those responses are then filed as further resistance, the therapist has created a loop in which the person cannot correct the account.
The same observation can be approached differently: “You have had to live with this for a long time. How have you made it more manageable?” That question does not pretend the situation is easy. It acknowledges that the person has been doing something to endure it.
The next enquiry can concern what remains difficult, which adaptations are useful and which have become costly. A strategy may have helped at one stage and now restrict the person. It can be examined without treating it as proof of deceit or a wish to remain ill.
Refusing a treatment does not explain the illness
My own experience of a long-term health problem made these assumptions personal. Some of the treatments offered to me did not seem acceptable or useful. From my position, declining them was a considered response to what was proposed. From a frame organised around secondary gain, the same conduct could look like repeatedly seeking help while refusing to improve.
The practitioner and patient may therefore be describing the same encounter in incompatible ways. The patient says the option does not fit. The practitioner hears unwillingness. Unless that difference can be discussed, the relationship itself becomes another obstacle.
A useful clinical conversation makes room for the reason behind a refusal, the person’s understanding of the options and possible alternatives. It does not require the person to agree with every proposal to demonstrate that their wish for help is sincere. Nor does a disappointing encounter mean that all medical support should be abandoned.
The therapist can be attached to a method
Practitioners can develop a narrow repertoire. One relies on a swish pattern, another on a six-step reframe, another on a familiar script. Whatever comes through the door is translated into the kind of problem that the preferred method is supposed to solve.
When the client does not respond as expected, the attachment to the method can remain invisible. The person is said to be uncooperative while the procedure is protected from scrutiny. Asking what is being resisted should include asking what is being imposed.
The NLP challenge to inflexible therapy is useful here: the practitioner should examine their own contribution when the interaction stalls. But replacing “the client is always responsible” with “the therapist is always responsible” creates another oversimplification. Illness, circumstances, competence, timing and the relationship can all matter.
A practitioner needs enough flexibility to recognise a poor fit, change an approach, seek supervision or refer. Flexibility does not mean endlessly inventing new interventions until the client gives the preferred response. It includes accepting the person’s choice to stop.
The relationship may be the difficulty
Sometimes the client simply does not like or trust the therapist. Sometimes the therapist does not like the client but cannot acknowledge that response. A polished display of concern then sits over irritation, impatience or dislike. The client may notice the mismatch even when neither person names it.
This does not require a personal confession from the practitioner. It requires responsible reflection. Are questions becoming accusatory? Is the practitioner trying to win an argument? Are they continuing because they believe they should be able to help, rather than because the work is useful?
Good boundaries allow a mismatch to be addressed without blaming either person’s identity. The issue may be a different approach, clearer expectations or another practitioner. Continuing an unhelpful relationship solely to avoid admitting its limits serves neither party well.
Looking beyond the consulting room
A person may arrive saying they are depressed while living amid noise, insecurity, poor housing, limited opportunities and threatening behaviour. The presenting label can conceal the everyday conditions in which the distress is maintained. A conversation focused only on motivation may never reach those conditions.
If that person receives financial or practical support, describing the support as a benefit of illness can miss the larger picture. The assistance may make an intolerable situation slightly less intolerable. Taking it away would not necessarily remove the problem; it might remove a means of coping.
Ask what a normal day involves, what happens between appointments and which changes are realistically available. A psychological intervention may help with an aspect of experience while leaving a housing or safety problem untouched. Recognising the distinction makes the work more specific.
Questions that keep the enquiry open
Before calling somebody resistant, describe the actual event. What was proposed? What did the person say or do? What reason did they give? What else might explain it? What information would change your interpretation? These questions prevent a broad label from becoming the whole account.
Then examine what the person is already using to cope. Which arrangements provide relief, stability or dignity? What would need to replace them if circumstances changed? What practical obstacle has been mistaken for unwillingness?
The aim is a conversation in which disagreement supplies information. When the person can say that an explanation is wrong or a method is unhelpful without being diagnosed by the objection, there is more opportunity to discover what the work actually requires.