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Compendium 2000 on Effective Correctional Programming

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CHAPTER 8

Addressing Treatment Resistence in Corrections

DENISE L. PRESTON1


Treatment resistance, while ubiquitous, has a negative impact on treatment outcome, in terms of poorer compliance regarding attendance and performance and reduced treatment gains. Given that the primary outcome anticipated from correctional intervention is the protection of the public, efforts to reduce treatment resistance are paramount.

This chapter reviews the history and evolution of the concept of resistance, describes various reasons for and manifestations of resistance, discusses assessment issues pertinent to resistance, and suggest strategies to reduce resistance.2 This chapter also describes treatment engagement strategies employed in a specific Correctional Service of Canada intervention, the Persistently Violent Offender treatment program (Serin, 1995).

I will use the terms, clinician and client, as opposed to therapist and patient throughout the chapter. These terms, while not ideal, are more encompassing of the multitude of disciplines and professional relationships that are affected by treatment resistance.

HISTORY OF RESISTANCE

Resistance to behaviour change is not a new concept. It has been evident in virtually every healing process since the earliest human cultures. Shamans and priests, who acted as healers in earlier times, recognized the importance of inducing people into the healing process. Ancient philosophers also observed various forms of resistance.

Although it has been observed throughout the ages, Freud originated the term resistance as it applies to modern psycho-therapy. He viewed it as an unconscious or intra-psychic event that was manifested in a variety of defence mechanisms intended to protect clients from becoming aware of unacceptable thoughts and impulses. Behaviour change was not thought to be possible until clients were freed from their pathological conflicts through the elimination of resistance. Thus the elimination of resistance became the cornerstone of psychoanalytic therapies and psychoanalysts addressed resistance directly.

Phenomenological theorists also postulated that resistance serves a self-protective function for clients. In contrast, however, they believed that resistance could best be eliminated through the development of a strong, positive therapeutic relationship and that such a relationship was best fostered by clinicians maintaining an attitude of unconditional positive regard toward clients. Thus, while the elimination of resistance was an important goal, it was addressed indirectly.

Behaviourists view resistance as evidence of counter-control or non-compliance. While they do not make assumptions about the purpose that the counter-control serves or the client's motives for engaging in it, they attempt to reduce it by changing the contingencies that maintain it.

Cognitive theorists propose that resistance occurs due to distorted thinking on the part of clients. For example, it stems from clients' cognitive rejection of explanations of self that are inconsistent with their pre-existing schema. Although they advocate the use of cognitive-restructuring techniques such as Rational Emotive Therapy (Ellis, 1985) to reduce resistance, they note that the degree of resistance and the reasons for it are constantly changing, necessitating varied approaches.

Each of the theories presented so far views resistance as residing within the client. In contrast, systems theorists view resistance as an interaction of the components in the system being treated. Depending on the type of treatment, whether individual, couples, family, or group, and the location of treatment, whether in-patient or out-patient, there could be numerous components contributing to resistance. This includes the identified client, the client's spouse or family, peers, and environment. It also includes the clinician. To reduce resistance, systems theorists propose a number of strategies, after first identifying the source(s) of the resistance.

Several things are evident from the foregoing review. First, no single psychotherapeutic theory fully explains and addresses resistance. Each one presents a different definition of resistance and offers different approaches to its reduction. Second, despite their differences, the theories all recognize the occurrence of resistance as normal, natural, and predictable. Third, all the theories recognize the reduction of resistance as likely the most important problem of psychotherapy. Finally, the definition of resistance has evolved over time from a static, uni-dimensional, intra-psychic force to a dynamic, multi-dimensional, interactive process. While various definitions have been put forth, the most commonly accepted one seems to be the one proposed by Greenson (1967). He defined resistance as “all those conscious or unconscious emotions, attitudes, ideas, thoughts or actions which operate against the progress of therapy”. This definition encompasses all the components of the multi-dimensional view of resistance.

This shift in perspective from considering resistance to be a static, uni-dimensional concept residing within clients to a dynamic, multi-dimensional concept is mirrored in contemporary thinking about motivation, the converse of resistance. Motivation has traditionally been viewed in a static way as a relatively fixed personality trait. Clients are viewed as either resistant or motivated and clinicians are reluctant to work with them until and unless they somehow become motivated. More recently, motivation has come to be viewed in a dynamic way as a state of readiness to change. Conceptualized this way, the purpose of therapy is to move clients from one state to another by reducing defensiveness and resistance at every stage. Evidently, what clinicians do to facilitate movement between states depends on the client's state of readiness at the start of treatment. Similarly, the amount of progress demonstrated in moving clients from one state to another depends on the client's state when treatment begins (Prochaska, DiClemente, & Norcross, 1992).

TYPES OF RESISTANCE

Given the frequency with which resistance is observed in all forms of psychotherapy, it is not surprising that many clinicians and researchers have attempted to categorize it along several dimensions. Some of these dimensions are the stage at which the resistance occurs, the form it takes, and the reason(s) for it. Related to timing, for example, one classification scheme identifies four types of resistance: initial resistance, halfway resistance, inertia resistance, and resistance to termination.

Initial resistance often takes the form of attendance problems, testing of limits, and challenges to clinician credentials. It is possibly the most important type of resistance to handle both quickly and effectively as statistics indicate that up to 50% of clients drop out of treatment after the first session.

Halfway resistance occurs during the action phase of treatment when clients are being most challenged to implement behavioural changes. This is also the “storming” stage of treatment (Goldstein, 1988) where clients typically begin to become frustrated with the process of treatment, with fellow clients in a group setting, and with clinicians. Halfway resistance takes many forms, including a recurrence of attendance problems, reduced compliance with homework, frustration, and expressing the desire to quit.

Inertia resistance occurs after about six months of treatment. It is described as the client's attempt to preserve the status quo by resisting further intervention and change. Because inertia resistance takes many forms similar to halfway resistance, it appears to be difficult to separate the two types. As well, it may be difficult to separate it from the fact that clients may legitimately have arrived at a treatment plateau, given statistics suggesting little therapeutic gain for most clients after about 25 sessions.

Resistance to termination is manifested in clients suddenly becoming “sick” again, or relapsing to earlier dysfunctional behaviours in an effort to maintain contact with clinicians.

Another classification scheme related to timing looks specifically at on-going forms of resistance. Two types of resistance are noted: resistance to progress or to change and resistance to co-operation. These would likely be subsumed under all but resistance to termination in the foregoing scheme.

Related to the form resistance takes, the most encompassing scheme identifies two broad forms: behavioural and communication. Behavioural resistance can be demonstrated by a myriad of examples such as attendance and punctuality problems, non-compliance with homework, frequent client requests for favours, intimidating actions, and, in some cases, “model” behaviour demonstrated by unobtrusively resistant clients. Communication resistance affects response quantity, content, and style. Response quantity refers to the amount of information clients reveal while response content refers to the nature of what clients reveal. Resistant clients often reveal very little or very little of any relevance. Response style refers to the way in which clients communicate. It includes being silent, a monopolist, argumentative, and unwilling to talk. It also includes interrupting, ignoring, and denying.

While these classification attempts are useful, none of them have been empirically developed or validated. This is likely due to difficulty in operationally defining concepts such as resistance and motivation. This, in turn, makes the measurement of such concepts difficult. Various measurement strategies have been employed to-date, including self-reports, self-monitoring, behavioural observations, and measures of treatment outcome, but none is ideal. Clearly, the development of theoretically relevant, empirically sound, and clinically useful measures of both resistance and motivation would be important. This would also enable an examination of issues related to motivation such as the relative importance of the degree of change in motivation during treatment as compared to the attainment of a minimum “threshold” level of motivation either prior to or during treatment. Related to the difficulty in operationally defining resistance is that each scheme conceptualizes resistance in a slightly different way. This is not surprising given different theoretical perspectives of researchers and different definitions of resistance, however operationalized. This suggests that each one would recommend different strategies to reduce resistance.

Another limitation of these attempts is that the categories suggested by the schemes related to timing do not appear to be mutually exclusive. Inertia resistance seems quite similar to halfway resistance and on-going resistance could be subsumed by all but resistance to termination. Nor do the same schemes appear to be exhaustive, given the numerous types of resistance suggested by the scheme related to form. Related to this, none of the schemes include a category of “legitimate” resistance, alluded to by the possibility that inertia resistance could simply indicate a treatment plateau. Also included in this category would be clients' legitimate rejection of poor advice or treatment techniques inconsistent with their personal or cultural backgrounds.

Finally, although the classification scheme related to form encompasses a broad range of client behaviours and communications, it does not address the underlying reasons for these forms of resistance. A further complication is that in many cases it is difficult to separate the form from the reason. All of this suggests that a classification scheme that incorporates both the form of and the reason for the resistance would be important if subsequent efforts to reduce resistance are to be effective.

REASONS FOR RESISTANCE

Resistance can stem from the following five sources: the client, the treatment or techniques employed, the environment, the clinician, and the client-clinician relationship.

Clients variables

Scores of client variables have been related to resistance. Some are legitimate in that they naturally and predictably occur, while others occur as deliberate attempts to subvert therapy. They can be classified into the following subgroups:

  • disorder;
  • personality;
  • behavioural;
  • client fears; and
  • client self-serving.

However, there is considerable overlap between subgroups in that some client behaviours may stem from personality variables which, in turn, stem from particular disorders.

Disorder variables -- The very nature of certain disorders often predisposes clients to be resistant to treatment efforts. Most often, this is related to how the disorder affects clients' abilities to trust. These disorders include borderline, anti-social, narcissistic, and paranoid personality disorders, psychopathy, schizophrenia, organic or neurological disorders, intellectual deficits, and substance abuse.

Personality variables -- Clients who are hostile, defensive, demanding, and rebellious are resistant to intervention. So are those who reject authority, have an extreme sense of entitlement, and an excessive need for control. Finally, those with an eternal locus of control such that they deny, minimize, or externalize blame are also resistant to intervention.

Behavioural variables -- Numerous client behaviours contribute to resistance. These include lack of motivation to change and failure to see personal problems as serious. These also include various skills deficits, anger, aggression, and violence, and being suicidal.

Client fears variables -- A variety of client fears are related to resistance. Some reflect a lack of understanding of the nature of therapy while some serve a self-protective function. For example, clients may fear a lack of confidentiality in the therapeutic relationship. They may also fear being expected to do something they do not want to do or learning something about themselves that they would rather not learn. They may also fear change itself or have a fear of success. Related to fears serving a self-protective function, clients may fear intervention as they feel considerable anxiety, guilt, or shame about the behaviour in question. Or, they may feel hope-less about their ability to change.

Clients self-serving variables -- Clients may be resistant for various self-serving reasons. For example, they may experience secondary gains from the dysfunctional behaviour that is being targeted in treatment. Or, they may have other hidden agendas to justify continuing to behave the way they do.

Treatment variables

Although evidence seems to suggest that, to clients, the process of therapy is more important in inducing change than the technique, treatment variables can have an impact on resistance. Most obviously, a poor match between type of treatment or treatment techniques and clients does not bode well for behaviour change. For example, verbal therapies, abstract concepts, and written homework would likely lead to resistance on the part of low functioning, illiterate, inarticulate clients. Related to this, client dissatisfaction with treatment is related to resistance, although there is only a moderate relationship between client satisfaction and outcome.

Group size can also affect client resistance and treatment out-come. Smaller groups result in clients communicating only to the clinician as opposed to each other, effectively eliminating the potential benefits of group treatment. Larger groups result in quiet members blending in, loud or aggressive members dominating, reduced consensus, and increased client dissatisfaction. On-going conflict in the group also tends to increase client resistance.

Treatments of shorter duration tend to result in less client resistance and, although there is no significant difference in the amount of resistance encountered by various types of therapies, behavioural therapies seem to engender slightly less resistance than others.

Environment variables

Various environment variables maintain or promote client resistance. Cultural disparities between clients and clinicians can have a negative impact on resistance as can clinicians' failure to understand culturally defined client behaviours. Low socio-economic status can also have a negative effect on client resistance, primarily due to lowered client expectations of their need for and ability to change. As well, poor social support systems can serve to maintain client resistance. The setting in which treatment is provided can also engender client resistance. This is particularly true if the setting is a negative one or if clients are institutionalized and possibly attending treatment involuntarily.

Clinician variables

There has been little systematic research looking at the impact of clinician qualities on the therapeutic process, and on client resistance. As with attempts to measure the concepts of resistance and motivation, the lack of research may be related to difficulties defining and operationalizing seemingly relevant clinician qualities. It may also be related to difficulties measuring clinician qualities due to the controversial and potentially threatening nature of such a task. It may also reflect a fundamental attribution error. That is, clinicians may be more likely to take credit for treatment successes, as indicated by successful reduction or elimination of resistance, than treatment failures, indicated by continued resistance. Lack of research notwithstanding, several clinician qualities have been suggested to contribute to client resistance. These can be divided into the following two sets.

The first set of clinician qualities contributing to resistance is independent of the existence of client resistance. That is, in such cases, clients may or may not demonstrate resistance, but clinicians may erroneously conclude that they are due to their own cognitive or perceptual distortions. First, clinicians may fall prey to a confirmation bias. They may believe that resistance is an inevitable part of all therapeutic interventions, therefore they may be inclined to over-interpret some client behaviours as examples of resistance. Second, clinicians may impose various roles upon clients such as the role of “sick” person. If clients disagree with the imposition of any roles or of particular roles, they may be viewed as being resistant. Third, clinicians may impose their values on clients and may then view clients who disagree as being resistant. Fourth, clinicians may have other expectations or demands of clients that, if legitimately resisted by clients, may be viewed as resistance. This is particularly true if clinicians and clients disagree on treatment goals and techniques.

The second set of clinician qualities has a negative impact on client resistance. In these cases, client resistance is evident, but clinicians respond in ways that exacerbate the situation. First, clinicians that are confrontational in their approach to clients are often met with increased resistance (Murphy & Baxter, 1997). So are those who fail to moderate their feedback to clients with poor self-concepts. Second, clinicians that criticize or blame clients, even subtly, have a negative effect on therapeutic out-come. Third, clinicians that provide little guidance to clients early in sessions fail to reduce client resistance. So do those that prematurely label clients' unconscious motivations rather than gather information or reflect feelings (Murphy & Baxter, 1997). Finally, clinicians with poor relationship skills fail to effectively reduce client resistance.

Client-clinician relationship

In some respects, it is difficult to separate the client-clinician relationship variables from client variables and clinician variables as, ultimately, both sets of factors have their impact on the client-clinician relationship. Nevertheless this relationship, here-after referred to as the therapeutic alliance, and variables affecting it are considered separately because of the importance of the therapeutic alliance to client resistance and therapeutic outcome.

Clinical researchers have written extensively about the therapeutic alliance. They have noted that the therapeutic alliance is likely to be the most important factor related to compliance with treatment. It accounts for most of the variance in treatment out-come, and is the strongest predictor of outcome in brief dynamic and client-centred therapies.3

The development of a therapeutic alliance is contingent upon both client and clinician variables. Related to clients, therapeutic alliance depends upon clients' commitment to treatment, working capacity, and ability to establish healthy interpersonal relationships. Obviously, factors described in the client variables section, including hostility, defensiveness, and mistrust, impair clients' interpersonal functioning. Client perceptions and opinions are also important. These include their perceptions of the openness and friendliness of the clinician, of being treated with respect, and the degree to which they feel they can trust the clinician. These also include perceptions of being actively involved in the treatment plan, feeling that their expectations are being met, and being satisfied with both the clinician and treatment.

Related to clinicians, therapeutic alliance depends upon qualities such as competence, empathy, sincerity, and acceptance of clients. It also depends upon the degree to which clinicians can motivate clients and the type and quality of communication with clients. Also important are negative clinician attributes such as highly moralistic and judgmental attitudes toward clients, clinician interpersonal or relationship problems, erroneous clinician perceptions of clients as resistant, and counter-transference issues. In particular, difficult and resistant clients tend to make clinicians feel rejected, threatened, frustrated, and angry. These feelings can impair clinicians' abilities to develop a therapeutic relationship.

STRATEGIES TO REDUCE RESISTANCE

Clinicians should select intervention strategies only after careful analysis of the form of resistance clients are demonstrating, the likely reasons for the resistance, their relationship with clients, and when in the therapeutic relationship the resistance is manifested. Due to the sheer number of combinations this level of analysis can potentially yield, it is impossible to prescribe specific techniques for every possible manifestation of resistance. Instead, this section will list various strategies to try for any given form of and reason for client resistance. Often, it will be necessary to employ several techniques, either concurrently or successively. In all cases, however, two things should be kept in mind. First, the ultimate goal of the selected strategy is to reduce resistance, enhance motivation, and facilitate treatment gains. Second, it is important to work with rather than against resistance.

Prochaska, DiClemente, and Norcross (1992) conceptualize motivation as a four-stage process. In the precontemplation stage, clients do not see themselves as having any problems requiring attention or, if they do, they have no immediate intention of making any changes. Those who enter treatment at this stage typically do so under duress, are less open, and put forth little effort. They are also typically quick to relapse to maladaptive behaviours. In the second stage, contemplation, clients are aware that they have problems requiring attention, but waver between taking no immediate action and expressing and/or demonstrating some commitment to change. In the action stage, clients have made a commitment to change and actively begin modifying their behaviour, experiences, and environments. Finally, in maintenance, clients have made significant behavioural changes and are actively working to prevent relapse. This model implies clinicians should expend both time and effort prior to and early in treatment motivating clients to move from precontemplation to contemplation to action, if necessary.

Strategies for reducing client-related resistance

Given the relationship of resistance to dropout rates, it is important to effectively address it early on. One possibility is to provide treatment priming or pre-therapy sessions prior to the commencement of a particular course of treatment. This could be provided on an individual or group basis. Advantages of the former are that clients might feel more comfortable in a one-on-one situation and therapeutic alliances would likely develop more readily. Advantages of the latter are that clients would have an opportunity to become familiar with fellow clients prior to the commencement of the formal group, clinicians would have an opportunity to assess group dynamics to take such observations into consideration in delivering the treatment program, and cost-effectiveness. In addition to the advantages of each of these formats, providing priming sessions would orient clients to the expectations of treatment and should facilitate more rapid and extensive treatment gain.

If priming sessions are not a possibility or if they are not completely successful, resistance will have to be addressed early in treatment. It is best not to address resistance directly in the first session, as that should be a non-threatening opportunity for clients and clinicians to formulate initial, hopefully positive, impressions of each other. Following this, however, numerous strategies could prove beneficial depending on the nature of and reason for the resistance. If clients are resisting due to particular fears, normalizing their fears and anxieties could provide some relief. Positive re-framing of uncertainty as a sign that some of their coping strategies are no longer adequate could also provide relief. Similarly, positive re-framing of treatment as an opportunity to change and grow may reassure them. If these tactics do not work, relaxation training may be advisable. Reducing hopelessness and demoralization through the provision of unconditional positive regard may help. So might identifying and reinforcing their use of positive coping strategies. Making initial demands as simple as possible will maximize the likelihood of both compliance and success, both of which should encourage clients. Subsequent demands can be made progressively more difficult as clients progress. Assisting them to consider the costs and benefits of changing versus maintaining the status quo could help. Clinicians can do this by inviting clients to consider alternative perspectives and information. They should provide information and feedback about clients' current situations and the consequences of maintaining their current behaviour. They should also provide information about the likely advantages of changing. In providing such information, clinicians are, in effect, attempting to develop a discrepancy between clients' current behaviour and important personal goals such that clients begin to shift their “motivational balance” in favour of the pros of changing versus those of the status quo.

If clients are resisting for reasons other than fear, other strategies are possible. For example, removing practical obstacles to treatment, such as scheduling appointments or groups at convenient times can help. Clinicians should, however, maintain a balance between active helping and having clients assume responsibility for behaviour change. Limit-setting with respect to attendance, participation, and behaviour is typically both warranted and useful. Sometimes, behavioural contracting may be necessary to enforce limits. Medication may be helpful if resistance is occur-ring because of a mental disorder. Moral reconation therapy, a form of moral reasoning (Little & Robinson, 1988), may also be helpful when resistance is occurring due to deficits in clients' moral reasoning. If resistance is occurring at particular stages of treatment, such as during the “storming stage”, it may help to explain the stages of treatment to normalize its occurrence.

When resistance is ongoing, as in repeated statements challenging clinician credibility or program integrity, clinicians have several options as to how to address it, either individually or in-group sessions. They can attempt to respond specifically to the content of what clients are saying. While this may be helpful in certain circumstances, it can also exacerbate the situation as clients may then resist what the clinician has said. In effect, the specific content of clients' challenges is a red herring. They can respond to the process of the challenge either directly or indirectly. In the former case, clinicians can label clients' behaviour as resistance and use this as a forum for further discussion. However, clients may resist such a direct approach. In the latter case, clinicians can make an observation such as “I've noticed that when we discuss X, you do Y” and then ask clients for an explanation. This is most often the least threatening means of addressing resistance. Third, they can sidetrack on-going resistant behaviours by deflecting challenges or changing topics. This can be an effective way of defusing resistance in a specific situation, but it may not have the effect of eliminating resistance over the long-term. In attempting to address on-going resistance in a group format, it may help to enlist other clients in the group in the discussion. This is because resistant clients may be less defensive with their peers than with clinicians.

Finally, if resistance is ongoing and repeated attempts have failed to reduce it, it may be necessary to terminate clients from treatment. This is particularly true if the ongoing resistance is interfering with the progress of other clients. Termination from treatment should be carefully considered, however, as it may serve to reinforce clients' use of resistant behaviours to avoid taking responsibility for other problematic behaviours. It may also reinforce their notions of power in relationships either because they have successfully used intimidation to get what they want or clinicians may use their authority to control clients. As well, clients may feel further misunderstood and rejected.

Strategies for reducing treatment-related resistance

Clinicians should strive to achieve the best match between clients and treatment. This includes careful consideration of client characteristics such as intelligence, learning style, and symptom severity. This also includes careful consideration of treatment specifics such as its form (individual or group), group size (8 to 12 is ideal), type (behavioural or psychodynamic, for example), intensity, and duration. Wherever possible, client preferences should be taken into consideration.

Clients should be actively involved in developing their treatment plan, setting treatment goals, and selecting treatment techniques to achieve their goals. Plans, goals, and techniques imposed by clinicians will likely engender client resistance with the end result of limiting treatment outcome. The agreed-upon goals must be reasonable, attainable, and pro-social and clinicians should provide regular feedback concerning clients' attempts to achieve their goals.

On-going conflict in the group can be handled in a couple of ways. Clinicians can conduct a process-oriented group in which they address the conflict directly. Alternatively, they can meet individually with the clients who seem to be in conflict to ascertain the reasons for the conflict and to develop some conflict resolution strategies. Or, they can discharge one or more clients from the group.

Strategies for reducing environment-related resistance

Some environmental factors, such as cultural background and socio-economic status, are beyond the control of clients and clinicians. However, their impact on resistance can be minimized. For example, clinicians must endeavour to be culturally sensitive. They can attain this through continuing education efforts and by open communication with clients. Clinicians should ask clients directly about the impact of their cultural background on their beliefs, attitudes, and behaviours and they should take these factors into consideration in treatment planning. With respect to socio-economic status, clinicians should strive to encourage clients about their potential for and ability to change. As with cultural factors, they should take socio-economic status into account in treatment planning.

Resistance due to the setting in which treatment is offered may have to be addressed similarly to cultural and socio-economic factors. That is, in many cases clients and clinicians may not be able to control where treatment is delivered. This is particularly true if treatment is delivered in an institutional setting. Where possible, selecting the best possible location to foster a therapeutic atmosphere within the institutional setting can be helpful. So can reminding clients that, despite the negative atmosphere, they can maintain a positive attitude and change their behaviour for the better. As well, motivational interviewing techniques to encourage clients to see the benefits of treatment may help those involuntary clients who are resistant because they believe they are being forced to take treatment. More indirectly, staff training efforts may have a positive effect on the institutional atmosphere that can then, in turn, have a positive effect on client resistance.

Where clients are resistant due to the negative impact of their social support system, clinicians should use motivational inter-viewing techniques. In doing so, they should lead clients to see the negative impact of their peers on their stated treatment goals. They should also encourage clients to develop potential strategies to minimize negative peer influences. In contrast, telling them that their peers are a bad influence and instructing them to stop associating with their peers will likely be counter-productive.

Strategies for reducing clinician-related resistance

It is incumbent on clinicians to determine their contribution to client resistance and to modify their behaviour accordingly (Mahrer, Murphy, Gagnon, & Gingras, 1994). In addition to accurately assessing client resistance and skillfully employing the strategies above, the following qualities seem essential. Clinicians should be perceptive, sensitive, empathic, friendly, and trust-worthy. They should also be flexible and tolerant. They should demonstrate acceptance of clients, despite their behaviour, good communication skills, and a sense of humour.

Clinicians should also possess the following interpersonal characteristics. They should be supportive of and encouraging to clients, at all times emphasizing client readiness and willingness to make behaviour changes. This is consistent with motivational inter-viewing techniques suggested by Miller and Rollnick (1991). They should use self-disclosure carefully as the utility of clinician self-disclosure depends on the type of therapy, the purpose of the self-disclosure, the particular client, and the amount that is disclosed. Moreover, the relationship between clinician self-disclosure and treatment outcome is unclear.4 They should minimize their use of confrontational approaches as these only serve to increase resistance and attrition rates. They also serve to reinforce power dynamics in relationships that may be counter-therapeutic for clients for whom power issues in relationships are a problem. As well, aggressive confrontation exemplifies clinicians taking responsibility for bringing about behaviour change in clients (Jenkins, 1990).

Finally, clinicians should critically evaluate the source of any counter-transference reactions they may have to clients. For example, in the event that they feel anger toward clients, they should try to discern whether or not their anger stems from provocative client behaviours or from their own frustration with recalcitrant clients. After having identified the source of their counter-transference reactions, clinicians must then manage them appropriately otherwise their reactions could serve to increase client resistance. In some cases, it may be necessary to increase their use of supervision or peer support. In others, they may need to refer clients elsewhere.

Strategies for reducing client-clinician relationship resistance

Utilizing strategies suggested in the sections related to both client and clinician resistance should facilitate the reduction of client-clinician resistance, thereby enhancing the therapeutic alliance. Some other strategies are also of note.

Just as ensuring a good match between clients and treatment is important to reduce treatment-related resistance, so too is ensuring a good match between clients and clinicians. This entails consideration of factors such as cultural background and sensitivity, gender, personality, and interpersonal style.

Clinicians should attempt to maintain an empathic and consistently positive attitude towards resistant clients. This is not the same as unconditional positive regard; effective clinicians are able to support and motivate clients and effectively disapprove of certain behaviours. Related to this, clinicians working with any clients, but particularly those considered treatment-resistant, should avoid judging, denigrating, labelling, or otherwise blaming them. Clinicians can encourage them to take responsibility for their behaviour without attributing blame.

Clinicians must establish and maintain clear professional roles and boundaries from the outset. This is distinct from clinicians making a deep personal commitment to clients as is often implied in client-centred therapies.

FORENSIC POPULATIONS AND SETTINGS

Thus far, this chapter has focused on resistance as it applies to non-specific client populations. While many of the issues and suggestions likely apply to forensic populations, some issues are particularly germane while other additional ones must be considered.

Just as resistance was identified as ubiquitous and predictable in all forms of psychotherapy, it is inevitable with forensic populations. Numerous client-related reasons for resistance were identified; forensic clients demonstrate most, if not all of these factors simultaneously and in greater severity than non-forensic clients. That is, the majority of forensic clients are diagnosed with one or more disorders that seriously impair their ability to effectively engage in treatment, demonstrate hostile, defensive, and aggressive personalities, skills deficits, lack of motivation, a number of fears and insecurities, and numerous self-serving behaviours. Moreover, forensic populations tend to be less motivated for treatment, more resistant or non-compliant while in treatment, have higher attrition rates, demonstrate fewer positive behavioural changes while in treatment, and, possibly, demonstrate higher recidivism rates after participating in treatment (Gerstley, McLellan, Alterman, Woody, Luborsky, & Prout, 1989; Ogloff, Wong, & Greenwood, 1990; Rice, Harris, & Cormier, 1992. Many of these characteristics are understandable given that all forensic clients are being involuntarily detained through some legal mechanism and are participating in treatment under some level of duress. As well, forensic settings are typically less than optimal for inducing or maintaining motivation for treatment and behaviour change.

In addition to the strategies suggested for non-specific client populations, clinicians working with forensic populations must take the clients' legal dilemmas into account. For example, forensic clients may appear resistant when they are actually trying to protect themselves from further legal consequences. This occurs when they would like to disclose information in treatment, but fear being charged for additional offences or are instructed not to disclose any information while their offences are under appeal. Clinicians working with forensic populations must also take safety and security factors into account. For example, they must ensure that they meet with clients in locations that are physically safe and they must carefully consider how to deal with potentially aggressive clients. As well, they must make determinations of a clients' risk for violence based upon the resistance, motivation, and treatment gains demonstrated in treatment.

Andrews and Bonta (1994) state that correctional treatment should be delivered to higher risk offenders, target criminogenic needs, be based upon cognitive-behavioural or social learning theories as opposed to non-directive, insight-oriented, or evocative approaches, and take into consideration the principles of risk, need, and responsivity. Relating to the process of treatment, they specify several clinician and therapy variables such as the relationship and contingency principles. The relationship principle posits that a positive therapeutic alliance between clinicians and clients has the potential to facilitate learning. Clinician qualities that contribute to a positive interpersonal relation-ship include being open, enthusiastic, and flexible, attentive and understanding, and demonstrating mutual liking, respect, and caring for offenders. The contingency principle holds that clinicians must, as part of their relationship with clients, set and enforce agreed upon limits to physical and emotional intimacy as well as clear anti-criminal contingencies. The latter includes effective reinforcement for pro-social behaviour and effective disapproval for anti-social behaviour.

This indicates, then, that the development of a therapeutic alliance or a positive interpersonal relationship between clinicians and clients is of primary importance with both non-forensic and forensic populations. This may not be the case, however, for psychopaths.

STRATEGIES FOR REDUCTION OF RESISTANCE WITH PSYCHOPATHS

Although many of the techniques for therapeutic engagement with forensic clients likely apply to psychopaths, perhaps the most resistant of clients, some may be contraindicated (Preston & Murphy, 1997). As noted by several researchers and clinicians, psychopaths possess a unique cluster of personality characteristics (Cleckley, 1982; Hare, 1993; Meloy, 1995). Most notably, they have a diminished capacity to form meaningful interpersonal relationships although they can effectively mimic such a capacity. This suggests that treatments placing heavy emphasis on the development of a therapeutic alliance between clinicians and clients are likely to fail with psychopathic clients. Moreover, such treatments may be risky to clinicians because psychopathic clients lack the empathy required to inhibit their aggressive responses.

Psychopaths typically experience less anxiety and worry than non-psychopaths, a characteristic which mitigates against behaviour change. First, lack of anxiety causes them to be unconcerned about both the effect of their behaviour on others and the effect of incarceration on themselves. Second, lack of anxiety causes them to be less responsive to negative feedback from clinicians.

Psychopaths are also grandiose and tend to relate based on power more than affection. These qualities are sometimes manifested in demands to be dealt with by the most senior avail-able staff. For example, during police investigations they may request to be interviewed by the most senior investigating officer and in treatment they may expect to be treated by the most senior clinician (Hazelwood, 1995). Their grandiosity also means that they may express over-confidence in their skills and abilities, including those they intend to use to reduce their risk to society. Clinicians must not uncritically accept such verbal declarations; they should always look for behavioural evidence that clients have the requisite skills.

In addition to being grandiose, psychopathic clients can be manipulative. This underscores the need for clinicians to be persistent in setting and enforcing limits on their relationships with psychopaths. Clinicians must not protect them from the legal and social consequences of their behaviour (Cleckley, 1982) and they must repeatedly reinforce to them that they will be convinced by actions rather than words when it comes to behaviour change. Manipulativeness also indicates that clinicians must be wary of giving psychopathic clients the benefit of the doubt even in seemingly innocuous situations. This is because psychopaths may perceive clinicians as gullible and therefore legitimate targets for future manipulations if they can be conned in any given situation.

Finally, clinicians who work with psychopathic clients often experience a number of counter-transference reactions such as condemnation of psychopathic clients as untreatable and a wish to destroy or cause harm to seemingly intractible psychopaths. These have been well described by Meloy (1995). Clinicians must be cognizant of their counter-transference reactions in order to deal with them most appropriately.

PERSISTENTLY VIOLENT OFFENDER TREATMENT PROGRAM

The Persistently Violent Offender Treatment Program is a demonstration project developed and funded by the Research Branch of the Correctional Service of Canada. It was a multi-year, multi-site non-residential treatment program currently offered in two medium-security institutions in Canada. The program targeted persistently violent offenders, defined as those having at least three convictions for violent (non-sexual) offences. It was based upon a social problem-solving theoretical frame-work and was delivered according to cognitive-behavioural principles. It involves 16 weeks of half-time participation (Preston, Murphy, Serin, & Bettman, 1999).

Given the population in question, most were treatment-resistant. For this reason, the first section of the program was a motivational module designed to facilitate participant interaction, commitment, and trust. The module began with two weeks of individual therapy as a form of priming. This allowed clients and clinicians a non-threatening opportunity to begin to get to know each other. Clinicians addressed any concerns clients may have had and began to explore clients' goals for the treatment program. At all times, clinicians were respectful, empathic, and supportive. As well, they employed motivational interviewing techniques.

The motivational module also included one week of group sessions. During this week, violence was rarely discussed. Instead, clients and clinicians generated group rules, discussed obstacles to treatment such as on-going substance use, impulsivity, and aggressive beliefs and how to minimize their impact on treatment outcome, and completed a cost-benefit analysis of program completion. In all of these exercises, the short-term and long-term positive and negative impact of various behaviours on clients and others were considered.

The second and third sections of the program were the problem-definition and skills-building modules, respectively. While specific resistance-reducing strategies were not incorporated into these modules as they were in the motivational module, other factors facilitated the reduction of resistance. As already stated, at all times clinicians treated clients with respect and they required clients to act respectfully toward them and others. Clinicians enlisted the group's help in dealing with resistant clients as clients were more likely to internalize their peers' feed-back. On occasion, a peer tutor was hired to serve as a positive role model for resistant clients. As well, clinicians encouraged the use of problem-solving and conflict resolution skills in each group such that clients felt more empowered and took more ownership over how the group progressed.

In terms of client responsivity factors, clients should optimally have attained a grade eight academic level in order to be admitted. However, clients who had not attained this level were been admitted. In such cases, weekly individual sessions allowed an opportunity for clinicians to monitor and assist with progress, the peer tutor provided some assistance, and student volunteers were of considerable utility. Basically, clinicians had license to utilize whatever mechanism best assisted clients to learn group material. Also related to client responsivity is that program content were presented in a simplified fashion, both in group and in homework assignments. Wherever possible, diagrams and analogies were used.

Finally, clinicians selected for the program were screened for personal suitability factors. Preferably, they were competent, confident, sensitive individuals who ascribed to a “firm but fair” approach in dealing with clients. The perception of self-confidence is particularly important with this population as they have a tendency to prey upon staff who appear to be lacking in confidence. They had to have a strong sense of their professional identities and boundaries and be intrinsically motivated. The former helped them to avoid having strong negative counter-transference reactions to clients that could have potentially interfered with their professional judgements while the latter assisted them in maintaining their enthusiasm with this population despite their recalcitrant nature. They also had to work together co-operatively and supportively, to model appropriate behaviours to clients, to reduce potential manipulation by clients, and to sustain each other through inevitable difficulties.

MEASUREMENT OF MOTIVATION IN THE PERSISTENT VIOLENT OFFENDER PROGRAM

Clients who participated in the Persistently Violent Offender treatment program completed a comprehensive assessment battery before and after the treatment program. Self-report measures of responsivity and motivation for treatment were included in the assessment battery (Serin & Kennedy, 1997). Given the lack of correlation between offender self-reports of motivation and behaviour change and outcome, clinicians also completed weekly behavioural ratings of client motivation and behaviour change, as indicated by attendance, participation, behaviour, and attitude. Future analyses will examine the correlation between the two methods of assessment and the relationship of each one to treatment outcome.

CONCLUSION

As was evident from this chapter, given the number of reasons for and forms of treatment resistance, it is impossible to prescribe exactly what to do with any client in any given situation. Careful analysis by clinicians is a prerequisite to employing the most efficacious means to reduce treatment resistance. These efforts are essential given that treatment outcome is contingent upon the reduction of treatment resistance and that the primary anticipated treatment outcome of correctional interventions is the protection of public safety.


1 Correctional Service of Canada

2 Interested readers are referred to Anderson & Stewart (1983), & Cullari (1996) for comprehensive coverage of resistance and strategies for the reduction of resistance.

3 See Horvath, & Symonds (1991) for a meta-analysis of the relationship between therapeutic alliance and treatment outcome.

4 See Chapter 3 of Cullari (1996) for an in-depth consideration of client and clinician self-disclosure.


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