Common Expressions of Ambivalence in Psychotherapy Part 4: The Power Struggle
One of the most uncomfortable feelings I've had in conducting psychotherapy is finding myself in a power struggle with a client. Often when clients are ambivalent, they may voice only one side of their ambivalence at a time. For example, if the client says, “I am never going to get better,” a caring therapist naturally wants to instill hope. However, as the therapist voices hope, she is giving voice to only one side of the ambivalence which often results in the client needing to give voice to the other side. In order to feel completely understood, the client has a need to make sure that both sides are expressed. Consequently, the patient is likely to repeat the "no hope" sentiment and may even state it more strongly. The power struggle develops as the therapist tries harder to win the argument for hope, leaving the patient to struggle to maintain his lack of hope. This can be an exhausting game of tug and war leaving both sides frustrated.Instilling hope is an important therapeutic strategy; however, the timing is vitally important.
I love utilizing Motivational Interviewing and Solution Focused Behavioral Therapy forms of questions and exploring the functions of the behaviors to avoid power struggles and enable the client to resolve the ambivalence from within. Paradoxical interventions were also developed to prevent power struggles and help the client find their own motivation.
Although it may seem strange, since the client sought you out specifically for change of some kind, it is important to remember that all people experience some ambivalence when attempting change of any kind. Furthermore, for people who are suffering with severe ambivalence, there is a part of them that fears change so deeply that it can be very helpful to align with that part by suggesting that the person change very slowly. Although there are some problems which have to be addressed quickly because for instance they have medical consequences, this tactic can be effective with many types of problems.
For example, Christine was struggling with Anorexia Nervosa and had identified many functions that her anorexia was serving. She had been overweight as a child and her anorexia provided her with much relief from being teased for being fat. She knew that focusing on her weight allowed her to avoid the emotions that she felt about herself which generally centered on shame. She also knew that controlling her food intake made her feel strong and competent.
As she talked about these functions, I wanted to point out how her anorexia was also killing her which would have been an accurate, but ineffective, statement at the moment. Instead, I gently said, “I see how important it has been for you and how scary it would be to change it now. Given all that, I wonder what even makes you consider recovery?” I said this with sincerity because I truly wondered this, given how effective the anorexia was in preventing such pain. However, this was not what she expected me to say at the moment and I watched as her resistance melt away. She didn’t need to convince me of how important her anorexia was, since I communicated to her that I understood. She was able then to contemplate, in the same space of time, both why she wanted recovery and why recovery would be difficult.
Asking a client why they want to change, enables them to access their own desire for change rather that resisting your hope for their change. I think it generally works best to "go with the resistance" at a moment when the client is already voicing reasons for not changing. Sometimes therapists are wary of making statements like this for fear that it will romanticize the dysfunction or will slow down the process. But I find the opposite to be true. If I find myself expressing encouragement to a client which is then followed by a 'yes-but' type of statement. I try to change gears.
Another strategy I use when a client is resisting change is to suggest that they are ambivalent in that a part of them feels hopeless while another part must have some hope since they did come to the session. Rather than taking one side, I'll ask if they are aware of both sides and then explore with them the thoughts and feelings of each side.
I want to have the client struggle within themselves rather than with me. Once the client feels completely understood, change can often occur more rapidly. It is as if I jump over to the side of the resistance or join the in the ambivalence temporarily to understand their experience, knowing that I will return to the side of change later. Click here to read an earlier blog also related to staying out of power struggles.
Email me for a free PDF to give clients about dealing with their own ambivalence titled "Understanding Ambivalence: Why is Change so Hard." It can be used as an adjunct to my book A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side which is written to help clinician's re-conceptualize resistance as ambivalence and develop skills to work directly on resolving ambivalence and rewriting old narratives. I would love to hear from you. Please scroll down to the bottom of this page (past the banner of recent posts) to leave a comment.