A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side*
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), I have 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. Order on Amazon here
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 do narratives formed early in life create ambivalence
The theory posits that pathological ambivalence will occur when certain factors converge during a person’s development and create a conflict in core needs. This is not so-called normal ambivalence, such as choosing whether to go out to dinner or stay home. PA occurs when what has been learned about core needs is in conflict with the necessity of having the core needs met. The narratives which are then developed are ruled by these conflicting needs.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, resulting in an inability to attempt to meet the needs for love and safety simultaneously. 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 maladaptive 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 and guide the reader in ways 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 including theoretical concepts and risk factors.
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:
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.
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.
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.* (This book is being published by TPI press and expected to be available by the end of 2018. Please contact me for more information.