From resistance to resilience working with the anxious client

Presented by Stacey LloydMA(Couns), BA(Psych), Dip Bus (Mgmt), JP(C.Dec), PACFA, MACA(Clin)

What we will cover today..

Working definition of anxiety- anxiety cycle

Theoretical (psychological ) basis of anxiety

Types of anxiety

Causes and symptoms

Psychopharmocologicaltreatment of anxiety

Exploring resistance and the anxious

client

Moving toward client resilience-

coping with change, identity work

Working definition of AnxietyAccording to a standard manual for mental health clinicians, the Diagnostic and Statistical Manual

of Mental Disorders , fourth edition, text revised (also known as the DSM-IV-TR ), the followingdisorders are considered anxiety disorders:

Panic disorder without agoraphobia—A person with this disorder suffers from recurrent panic attacks and worriesabout experiencing more attacks, but agoraphobia is not present. Panic attacks are sudden attacks of intensefear or apprehension during which the sufferer may experience shortness of breath, increased heart rate,choking, and/or a fear of losing control. Agoraphobia is anxiety about places or situations from which escapemight be difficult, or in which help might not be available.

Panic disorder with agoraphobia—A person with this disorder also experiences recurrent panic attacks but also hasagoraphobia. The anxiety about certain places or situations may lead to avoidance of those places or situations.

Agoraphobia without history of panic disorder—The person with this disorder suffers from agoraphobia andexperiences panic-like symptoms but does not experience recurring panic attacks.

Specific phobias —A person diagnosed with a specific phobia suffers from extreme anxiety when he or she isexposed to a particular object or situation. The feared stimuli may include: particular animals (dogs, spiders,snakes, etc.), situations (crossing bridges, driving through tunnels), storms, heights, and many others.

Social phobia—A person with social phobia fears social situations or situations in which the individual is expectedto perform. These situations may include eating in public or speaking in public, for example.

Working a definition of Anxiety cont.Obsessive-compulsive disorder —A person with this disorder feels anxiety in the presence of a certain stimulus or

situation, and feels compelled to perform an act (a compulsion ) to neutralize the anxiety. For example, upontouching a doorknob, a person may feel compelled to wash his or her hands four times, or more.

Post-traumatic stress disorder —This disorder may be diagnosed after a person has experienced a traumaticevent, and long after the event, the person still mentally re-experiences the event along with the same feelingsof anxiety that the original event produced.

Acute stress disorder — Disorder with similar symptoms to post-traumatic stress disorder, but is experiencedimmediately after the traumatic event. If this disorder persists longer than one month, the diagnosis may bechanged to post-traumatic stress disorder.

Generalized anxiety disorder —A person who has experienced six months or more of persistent and excessiveworry and anxiety may receive this diagnosis.

Anxiety due to a general medical condition—Anxiety that the clinician deems is caused by a medical condition.

Substance-induced anxiety disorder—Symptoms of anxiety that are caused by a drug, a medication, or a toxin.

Anxiety disorder not otherwise specified—This diagnosis may be given when a patient's symptoms do not meetthe exact criteria for each of the above disorders as specified by DSM-IV-TR.

DefinitionAnxiety is an unpleasant emotion triggered by anticipation of future events, memories of past events, or ruminations about the self.

Rather than attempting to formulate a strict definition of anxiety, most psychologists simply make the distinction between normal anxiety and neurotic anxiety, or anxiety disorders.

Normal (sometimes called objective) anxiety occurs when people react appropriately to the situation causing the anxiety.

Generalised anxiety Disorder Causes

• The causes of generalised anxiety disorder appear to be a mixture of genetic and environmental factors. Another factor in the development of GAD is social expectations related to gender roles.

• Socioeconomic status may also contribute to generalized anxiety. One additional factor may be the patient's level of muscle tension.

SymptomsThe symptomology of GAD has changed somewhat

over time with redefinitions of the disorder insuccessive editions of DSM.

According to the DSM-IV-TR, the symptoms of GADare:

• excessive anxiety and worry about a number ofevents or activities, occurring more days than notfor at least six months

• worry that cannot be controlled

• worry that is associated with several symptomssuch as restlessness, fatigue , irritability, ormuscle tension

• worry that causes distress or impairment inrelationships, at work, or at school .

Symptoms cont.One categorisation of GAD symptoms that some

psychiatrists use in addition to the DSM frameworkconsists of three symptom clusters:

• symptoms related to high levels of physiological arousal:muscle tension, irritability, fatigue, restlessness,insomnia

• symptoms related to distorted thinking processes: poorconcentration, unrealistic assessment of problems,recurrent worrying

• symptoms associated with poor coping strategies:procrastination, avoidance, inadequate problem-solvingskills

Anxiety does not only consist of physical effects; thereare many emotional ones as well. They include"feelings of apprehension or dread, troubleconcentrating, feeling tense or jumpy, anticipatingthe worst, irritability, restlessness, watching (andwaiting) for signs (and occurrences) or danger, and,feeling like your mind's gone blank"

Cognitive effects of anxiety may include thoughts aboutsuspected dangers, such as fear of dying.

The anxiety cycle, in summary..

Diagnosis Treatment - Psychopharmacology

• Evaluating a patient for generalised anxiety disorder includes the following steps:

1. Patient interview

2. Medical evaluation

3. Substance abuse evaluation

4. Evaluation for other psychiatric disorders.

There are several treatment types that have been found effective in treating GAD. Most patients with the disorder are treated with a combination of medications and psychotherapy

Assessment of Anxiety

Treatment Options

Medications Psychotherapy

• Pharmacologic therapy is usually prescribed forpatients whose anxiety is severe enough tointerfere with daily functioning. Several differentgroups of medications have been used to treatgeneralized anxiety disorder.

• These medications include the following:

Benzodiazepines

Buspirone (BuSpar).

Tricyclic antidepressants

Selective serotonin reuptake inhibitors

• Relaxation techniques

• Proper Breathing techniques

• Cognitive therapy

• Family Therapy:

▫ Art Therapy- experiences

▫ CBT

▫ REBT

▫ SFT

▫ Strengths based

• Behaviour therapy

• Dietary adjustments

• ExerciseAlternative & complementary therapies

• Hypnotherapy

• Yoga

• Meditation

• Biofeedback – acupuncture

Psychopharmacological effect

PrognosisGeneralised anxiety disorder is generally regarded as a long-term condition that may become a lifelong problem. Patients frequently find their symptoms resurfacing or getting worse during stressful periods in their lives. It is rare for patients with GAD to recover spontaneously.

Prevention The best preventive strategy, given the early onset of GAD, is the modelling of realistic assessment of stressful events by parents, and the teaching of effective coping strategies to their children.

Resistance

• The 1940s and 1950s saw the development of the existential and client-centred approaches and subsequently the view of resistance changed. In these humanistic approaches, resistance is conceptualized as the avoidance of unpleasant or dangerous feelings that may become permanent blocks to awareness and impair holistic functioning.

• Modern theories approach client resistance from a systems perspective. The family systems theorists view resistance as an unconscious attempt to protect other family members by avoiding any disturbance to the delicate homeostatic balance of the system in which change and growth have unconsciously become associated with disloyalty, betrayal, and loss. Clients become reluctant to change their beliefs or behaviours for fear that doing so will negatively impact other family members. While these changes might be in their best interests, clients place the family’s welfare ahead of their own.

Resistance

• Early views of resistance focused on its role as an individual defence mechanism. In psychoanalytic terms, resistance is the client’s attempt to block or repress anxiety-provoking memories and insights from entering conscious awareness.

• In contrast to these early approaches, behavioural theorists view resistance simply as client noncompliance.

• (a) lacks the necessary skills or knowledge needed to follow behavioural assignments

• (b) have negative expectations or beliefs regarding their counselling outcomes

• (c) are subject to undesirable environmental conditions (Shelton & Levy, 1981).

• Ultimately, the client’s resistance is seen as an obstruction or obstacle to successful goal attainment.

Resistance• What's resistance?

• Resistance is based on personal automatic ways of reacting in which clients both reveal and keep hidden aspects of themselves from the therapist or another person. These behaviours occur mostly during therapy, in interaction with the therapist. It is a way of avoiding and yet expressing unacceptable drives, feelings, fantasies, and behaviour patterns.

• Examples of causes of resistance: resistance to the recognition of feelings, fantasies, and motives; resistance to revealing feelings toward the therapist; resistance as a way of demonstrating self-sufficiency; resistance as clients' reluctance to change their behaviour outside the therapy room; resistance as a consequence of failure of empathy on the part of the therapist.

State and trait resistance (situational and

characteristic)

• Resistance is an automatic and unconscious process.• According to Van Denburg and Kiesler, it can be

either for a certain period of time (state resistance) but it can also be a manifestation of more longstanding traits or character (trait resistance).

• Outside therapy trait resistance in a client is shown off by distinctive patterns of interpersonal behaviour. Often caused by typical patterns of communication with significant others, like family, friends and partner.

How can therapists handle resistance in

psychotherapy?

• Nowadays many therapists work with resistance as a way to understand the client better. They emphasise the importance to work with the resistance and not against it. This is because working against the resistance of a client can result in a counterproductive relationship with the therapist. You could say that the more resistance is showed, the less productive is the therapy. Working with the resistance provides a positive working relationship and gives the therapist information about the unconscious of the client. A therapist can use counter transference as a tool

to understand the client's resistance. The feelings the client evokes in you (as therapist) with his/her

resistance will give you a hint what the resistance is about. E.g., a very directive client can make the

therapist feel very passive. When the therapist pays attention to their passive feelings, it can make

him/her understand this behaviour of the client as resistance coming from fear of losing control.

Behavioural Models of resistance

• Behaviour analytic and social learning models of resistance focus on the setting events, antecedents, and consequences for resistant behaviour with the goal to understand function of the behaviour.

• For many, the counselling process might seem quite daunting. Unsure of what to expect, clients are asked to enter into a working relationship built on trust and intimacy with an individual they have just met for the first time. They must be ready to explore personal issues they might not have shared previously with even their closest friends and family. For other clients, the choice to seek counselling help might not have been their own. They may have been coerced into treatment, and as a result they are not willing to fully commit themselves to the process.

Addressing Resistance in a session

Client resistance is one of many clinical challenges counsellors regularly face. Counsellors should understand that resistance is a normal client reaction. Its presence in session should be expected and not come as a surprise.

Rather than avoiding the issue, researchers suggest that client resistance should be addressed. Newman (1994) highlights ten strategies proven to be effective in working with resistant clients. These strategies include:

• Educating the client about resistance and how it should look. • Using the Socratic method of questioning to bring out the client. • Allowing the client to have choices and be an active director of the

counselling process. • Fostering collaboration between counsellor and client. • Brainstorming the pros and cons of continuing current behaviour or

changing. • Empathizing with the client and their reason for feeling resistant. • Discussing case conceptualization with the client. • Using a language that mirrors that of the client. • Maximising the use of client self-direction. • Gently persisting when a client either is unable or unwilling to proceed.

Conceptualising Resistant Behaviours

• Response quantity resistance

• Response content resistance

• Response style resistance

• Logistic management resistance

• The client - Clients may be resistant to the counselling process because they have feelings of shame. Counsellors try to move their clients towards an acceptance of responsibility while clients may be more inclined to strive for evasion of responsibility (King, 1992).

• The counsellor - Counsellors, both consciously and unconsciously, contribute to client resistance. Counsellors may have failed to establish rapport with their client. They may have misguided expectations of client behaviour and client roles

• Through the recognition of various forms of client resistance, the understanding of the counsellor’s role in perpetuating resistance, and the working knowledge of various counselling interventions, counsellors can create a therapeutic environment that is inviting to the client and suitable for processing and working through resistance, subsequently reducing their presenting anxiety and enhancing their resilience.

Thank you for…

•listening, its been a pleasure presenting this workshop to you.

References

• Cowan, E. W., & Presbury, J. H. (2000). Meeting client resistance and reactance with reverence. Journal of Counseling and Development, 78, 411-429.

•• King, S. M. (1992). Therapeutic utilization of client

resistance. Individual Psychology: Journal of AdlerianTheory, Research, and Practice, 48, 165-174.

•• Nystul, M. S. (2001). Overcoming resistance through

individual psychology and problem solving. Journal of Individual Psychology, 58, 182-189.