As an editor in this field for 20+ years, this is one of the more innovative, insightful (and open) books I’ve worked on.
Elizabeth Budd
A Clinician’s Guide to
Pathological Ambivalence:
How to Be on Your Client’s Side Without Taking a Side
Do you ever feel confused and stuck with your clients?
Are you sometimes surprised that they pay good money for your
help but don’t make the changes that you know would help them?
As a therapist, you have probably worked with patients who spend a lot of money and time coming to therapy just to avoid doing what you suggest. These patients are often labeled resistant, oppositional, or borderline, in part because of the frustration they create in those who want to help them. Similarly, you may label yourself as ineffective or unskilled while working with these patients. When dealing with someone with pathological ambivalence (PA), such labels are unnecessary and often inaccurate. Instead, the client and therapist will benefit by utilizing specific strategies to identify, manage and resolve their ambivalence.
After working for 30 years with people with eating disorders (25 years at the Atlanta Center for Eating Disorders, a partial hospitalization and intensive outpatient program I founded and now with Walden Behavioral Care to whom I sold the business), I learned a great deal about working with treatment resistant or ambivalent patients. Maybe more than in any other client population, ambivalence among those with eating disorders can be pathological. The very thing that makes them believe they can manage their problems in life actually is life threatening. While the patients may be seeking help, they often feel as if they are being forced to give up behaviors that provide them, albeit irrationally, with a sense of safety and ability to cope with life.
Are these clients resistant or ambivalent?
I developed the concept of pathological ambivalence to explain the underlying mechanisms of “resistance” and to inform the strategic interventions best used with this population. The theory encompasses:
How ambivalence develops
Why some people are more susceptible than others to developing PA
How narratives formed early in life create ambivalence
The theory suggests that pathological ambivalence will occur when certain factors converge during a person’s development that create a conflict in core needs. This is not normal ambivalence, such as choosing whether to go out to dinner or stay home. PA occurs when what the person believes about core needs is in conflict with the getting the core needs met. For instance the universal core needs of love and safety can be in conflict when a person has learned that it seems safer to never expect to be loved.
However, the core need for love doesn’t disappear, meaning the person is unable to get the needs for love and safety met at the same time. This conflict of needs can lead to life-crippling dilemmas. Similarly in psychotherapy, the alternating expression of these needs results in behavior often labeled as resistant, such as therapy-interfering behaviors, power struggles, and even suicidal ideation.
Why this book?
A guide to dealing with pathological ambivalence is necessary to enable the clinician to quickly identify when core needs are in conflict, to help the patient become aware of the associated narratives that have developed, and to develop treatment strategies for harnessing and resolving the ambivalence. Dealing directly with this ambivalence is the primary therapeutic strategy to facilitate change. In this book, I provide case examples of how the expression of PA affects therapy, offer strategies to sidestep common therapist pitfalls while also helping clients understand their ambivalence and rewrite their early narratives. The book is divided into three parts:
Part I: Understanding Ambivalence as Resistance to Change. A model is presented for understanding how ambivalence is developed and maintained in a person’s life.
Part II: Recognizing Pathological Ambivalence from a Dialectical Perspective. A dialectical therapeutic frame is introduced for addressing PA while exploring common manifestations of PA, such as power struggles, indirect communication, projection, splitting, avoidance, and denial. Also described are common therapeutic pitfalls to avoid when working with people with PA and how to deal with the projection of the ambivalence or narrative.
Part III: Treatment Strategies for Pathological Ambivalence. Specific strategies are described for working with the various forms of PA, primarily through case examples. The strategies are grouped as follows:
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The first collection of strategies is aimed at decreasing the natural tendency to maintain the status quo of previously held beliefs (such as, “I’m not lovable”) and at enabling the patient to see the impossible state of her ambivalence.
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Another section focuses on integrating the two sides of the dilemma by identifying the truths and fallacies, so that the ambivalence can be resolved and change enabled.
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The final set of strategies is devoted to rewriting the early narrative into a more functional belief set or story about oneself and the world.
I use a variety of techniques from many theoretical orientations, including Gestalt, Cognitive-Behavioral, and Psychodynamic, and from techniques informed by Narrative Therapy, Motivational Interviewing, and Acceptance and Commitment Therapy.
Endorsements
“Dr. Buchanan’s meticulous examination of resistance from the perspective of ambivalence is a welcomed analysis and a must read for therapists. This book takes you from theory to conceptualization to techniques and offers a wealth of strategies and approaches to add to your therapeutic tool box. Her points regarding the management of therapist neutrality alone are worth the price of the book. You will be glad you bought this book and so will your clients!”
Clifton Mitchell, Ph.D., author of Priming: Programming the Mind for Habit Change and Success
"It is apparent that Dr. Buchanan is a sophisticated clinician who understands intimately how to intervene with the most difficult to treat populations who are ambivalent and often considered resistant or untreatable. By keeping a sustained pulse on all aspects of the patient’s experience, she adeptly informs us how to avoid common ruptures to promote growth, integration and healing in the most collaborative manner possible. While the lessons taught are crucial for resistant populations, because the principles are universal, they will be invaluable for the psychotherapeutic treatment of all clients. This book will not only result in more favorable outcomes for clients, but I predict it will also reduce frustration and countertransference for therapists to result in a fulfilling and rewarding sense of clinical efficacy!"
Steven Shapiro, Ph.D. Senior Faculty AEDP Institute
This excellent book is a must-read for clinicians who will learn to harness and resolve their clients’ pathological ambivalence in order to help them achieve a more fruitful enjoyable life.
Mary Anne Cohen, The Eating Disorder Journal (2020)
Book Review by Mary Anne Cohen
The Eating Disorder Journal
(March 2020, Vol. 21, No.3)
Eating disorder patients seek therapy hoping to resolve their destructive eating behaviors, poor body image, or to lose weight. But hidden in every patient is a secret fear and trepidation about giving up those very behaviors that have also provided comfort, safety, security, and a method of coping. Clinicians often find themselves in the role of cheerleader as they encourage their patients to adopt healthier habits and build more supportive caring thoughts. But this encouraging position can often backfire when the clinician does not fully respect the vital meaning of the eating disorder symptom or appreciate the patient’s mixed feelings about getting better. A power struggle may then develop between client and clinician.
This is where Linda Buchanan comes in with her sophisticated yet accessible book to help therapists “be on your client’s side without taking a side.” Buchanan points out that underlying resistances, which she terms “pathological ambivalence,” occur in all therapy – not just with eating disorder patients. On one hand patients desire to get better, but they can also be compelled to sabotage their success due to fear and anxiety. Dr. Buchanan helps therapists identify, manage, and resolve their patients’ ambivalence. She elucidates strategies to help therapists remain neutral while also facilitating progress such as asking clients what percentage of themselves is committed to change and what percentage is fearful, or to help the client arrange a “committee meeting” with different parts of themselves to discuss their confusion, and acknowledging to the client “I see you feel both x and y, so let’s focus on BOTH.” By honoring both sides of the patients’ ambivalence, and exploring through motivational interviewing with its collaborative stance and open ended questions, patients will feel well understood in their dilemma and better able to tackle their resistance.
This excellent book is a must-read for clinicians who will learn to harness and resolve their clients’ pathological ambivalence in order to help them achieve a more fruitful enjoyable life.