Reluctance to Engage in Psychotherapy and Resistance to Change

The mere beginning of the psychotherapeutic process—considering and then engaging in psychotherapy—is already a part of therapy. Some people may spend years reluctant to engage—contemplating and delaying—before finally making the first contact with a therapist. They may feel hesitant without knowing the source of their reluctance. Others may engage, then disengage, only to return later. However, what is rarely obvious is that reluctance to engage often stems from resistance to change, rooted in the unconscious and not related to the apparent reasons at the time. Pre-therapy resistance refers to these unconscious resistances that occur before one enters the therapy room.

Resistance to Change

Resistances are “a basic reluctance to explore, to understand, to grow, and to change.” (Blatt & Erlich, 1982b, pp. 201-202) They are part of an unconscious effort to depart from one's view of oneself, identity, ways of relating, seeing others, and experiencing the world. Not seeing one's resistances does not mean the resistances are not there. In fact, “the best resistance is the one you do not see.” (Schlesinger, 1982, p. 31)

Resistance can manifest in many forms. It can range from missing sessions, being late, dropping out of treatment entirely or for extended periods of time, or engaging in alternative forms of "healing"—such as psychedelics. It might also involve seeking solutions to problems by changing one's life situation, partner, having a child, or changing a career. Additionally, there are more subtle ways of resisting change, such as the client having nothing to discuss in therapy, remaining silent, or refusing to engage with the therapist's questions and probing.

Pre-therapy Resistance

And what about the resistances that we never get the chance to explore? What about those resistances that sabotage the client’s change even before they have a chance to contact the therapist? Experienced psychotherapists are well aware that resistances—both conscious and unconscious—can be at play even before one decides to engage in psychotherapy.

While pre-therapy resistances can arise even before the client makes initial contact, they most commonly occur during the onboarding stage, such as when the client contacts the psychotherapist and arranges the initial session or during the initial assessment. This is a time of heightened fear, doubt, hesitation, and feelings of pointlessness. It is usually at this stage that fear may lead one to ultimately not engage in treatment.

Those who never engage in the psychotherapeutic process unfortunately miss the chance to explore the unconscious motives behind their ambivalence. Consequently, they lose the opportunity to grow from the insights gained about their reluctance. Others, who despite their hesitation do engage, often discover that their hesitation was merely the tip of the iceberg, with much more lying beneath the surface of consciousness.

Resistance to Identifying as a "Psychotherapy Client"

People usually rationalise their pre-therapy resistance. A person may talk themselves out of therapy, claiming, "This is not for me." This may be accompanied by an experience where the individual, before or after the first visit to the therapist, begins to doubt whether therapy is really suited for them or whether they are suited for it.

Pre-therapy resistance may lead the person to question whether the process will benefit them. They might also start seeing themselves as someone who "is not the kind of person" to engage in therapy. A person may rationalise their reluctance by viewing therapy as not "suitable for their issues," convincing themselves that therapy is for others, not for them. These feelings are usually rooted in one's perception of their identity and often in their attachment to perfection and the need to be seen as strong, powerful, competent, self-sufficient, and independent.

Resistance to Viewing One’s Internal Issues as External

Some people may view their engagement in therapy as something that will not "solve their problems in life." They might begin to see their issues—such as anxiety, depression, or relationship problems—as contextual and dependent on life situations rather than stemming from internal issues.

For instance, a breakup or a death in the family may lead to depression or prolonged grief; however, the person might rationalise this as a normal grieving reaction. A person who sees their internal issues as external and contextual, retains hope of improving their presenting issues by changing the practicalities of their life rather than changing themselves internally.

Resistance in the Form of Escapism and Resorting to Other Forms of “Self-Help” or Positive Psychology

Seasoned psychotherapists often have a long track record of witnessing clients resort to other forms of "treatment" before fully engaging in psychotherapy. This can even occur with individuals who have been in therapy for some time but lack genuine engagement with the process, while they explore other forms of "healing," "personal development," or "self-help." These alternatives often include psychedelics, retreats, mindfulness, and spirituality. Some may seek refuge from their pain in continuously new romantic relationships, searching for new partners, or endlessly hoping that the current one will change. Others may resort to travelling, attempting to find purpose in having children, a family, or pursuing a "fulfilling career."

This also applies to pre-therapy resistance, where some clients engage in psychotherapy only after exhausting all other options to alleviate their distress. Individuals may spend years trying to improve through alternative methods, only to turn to therapy in despair and with a sense of lost time.

Pre-therapy Resistance as a Reflection of Attachment to Trauma

Resistance is a complex and multi-layered phenomenon. However, one way to view it is through the lens of attachment to trauma, abuse, and adverse childhood experiences (ACEs).

When someone experiences adverse childhood experiences (ACEs), trauma, or abuse, they may develop an emotional attachment to these experiences despite the pain they cause. For instance, a person who was controlled as a child and subjected to punitive parenting might become attached to being treated this way. They may develop a sense of incompetence and unworthiness, masked by a narcissistic facade of false self-esteem, self-sufficiency, and competence. Such individuals might seek relationships where they are controlled because any other type of relationship could make them feel confused and lost. So, while they may want to change and stop seeking controlling relationships, their attachment to control, which prevents feelings of being lost and abandoned, often causes resistance to internal change.

Resistances reflect an internal attachment to trauma and a familiar self-perception for the individual. They “protect the patient against conscious awareness of unacknowledged and unpleasurable elements within his own psychic life; and they promote and sustain the continuing search for fulfillment of inappropriate drives, fantasies, and relationships.” (Dewald, 1982, p. 48)

Pre-therapy resistance is a form of unconscious sabotage intended to keep the individual in a familiar world, regardless of the pain they may be experiencing. A familiar life is preferred to a painless one.

Conclusion

When discussing resistance to treatment—specifically, the fundamental resistance to change—we must recognise that these resistances are not nuisances or foreign elements to the psychotherapeutic process. They are integral to the treatment and should be analysed and worked through as part of the treatment. True change can only occur by addressing these resistances and emerging on the other side. Therapy that ignores or suppresses resistances will not lead to lasting change.

As Blatt & Erlich (1982b) vividly put it: “The skill of the therapist in helping the patient become aware of and understand the presence and power of these resistances is an essential aspect of the therapeutic process.” (p. 71)

Unfortunately, unlike other forms of resistance, pre-therapy resistances are difficult to tackle as they may sabotage treatment before it even begins. Nonetheless, clients who attempt to engage in psychotherapy and attend the initial assessment and diagnosis have some chance of avoiding sabotage if the therapist is skilled and experienced enough to identify and address pre-therapy resistances as soon as they appear.

Ales Zivkovic, MSc (TA Psych), CTA(P), PTSTA(P), Psychotherapist, Counsellor, Supervisor

Ales Zivkovic is a psychotherapist, counsellor, and clinical supervisor. He holds an MSc in Transactional Analysis Psychotherapy awarded by Middlesex University in London, UK. He is also a Provisional Teaching and Supervising Transactional Analyst (PTSTA-P) and a Certified Transactional Analyst in the field of Psychotherapy (CTA-P). Ales gained extensive experience during his work with individuals and groups in the UK National Health Service (NHS) and his private psychotherapy, counselling, and clinical supervision practice in central London, UK. He was also a member of the United Kingdom Council for Psychotherapy (UKCP). Ales works with individuals, couples, and groups. In clinical setting, he especially focuses on the treatment of issues of childhood trauma, personality disorders, and relationship issues. A large proportion of his practice involves online psychotherapy as he works with clients from all over the world. Ales developed a distinct psychotherapeutic approach called interpretive dynamic transactional analysis psychotherapy (IDTAP). More about Ales, as well as how to reach him, can be found here.

References:

Blatt, S.J., & Erlich, H.S. (1982a). A Critique of the Concepts of Resistance in Behavior Therapy. In P.L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches (pp. 197-203). Springer. https://doi.org/10.1007/978-1-4899-2163-5_10

Blatt, S.J., & Erlich, H.S. (1982b). Levels of Resistance in the Psychotherapeutic Process. In P.L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches (pp. 69-91). Springer. https://doi.org/10.1007/978-1-4899-2163-5_4

Dewald, P.A. (1982). Psychoanalytic Perspectives on Resistance. In P.L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches (pp. 45-68). Springer. https://doi.org/10.1007/978-1-4899-2163-5_3

Schlesinger, H. J. (1982). Resistance as process. In P.L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches (pp. 25-44). Springer. https://doi.org/10.1007/978-1-4899-2163-5_2

Turkat, I.D., & Meyer, V. (1982). The Behavior-Analytic Approach In P.L. Wachtel (Ed.), Resistance: Psychodynamic and behavioral approaches (pp. 157-184). Springer. https://doi.org/10.1007/978-1-4899-2163-5_8