Sacramento Street Psychiatry

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Resistance: "I Have Nothing to Talk About Today"

An apparent block in therapy opens a path to insight.

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about. The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one’s history. In essence, the patient’s conscious agenda for coming to therapy has been exhausted. I tell trainees this often happens around session #7 — truly it’s more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant. The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don’t sit there in awkward silence.

A dynamic therapist typically turns this back on the hapless patient: ”Say anything that comes to mind.” This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration. For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient’s mind. It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy. Speaking “without a script” allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point. Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive. Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful. But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it’s time to dive in and explore the unknown.

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In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day. They exude an uncharacteristic blandness or boredom, as if to signal: “Nothing to see here, just move along.” With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling. In fact, maybe it’s time to talk about wrapping up treatment…

If this presentation stands in contrast to the patient’s usual enthusiasm, I take it as a very good sign. Something emotionally important is going on, and the patient’s Unconscious is trying desperately to throw us off the trail. In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy. Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they “vote with their feet” and leave treatment early in the process. But when a new resistance stands in clear contrast to the patient’s typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.

In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions. Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient’s avoidance that day, it becomes a shared exploration where new discoveries and insights come to light. For reasons I can’t quite explain, the factors motivating such resistance are not deeply buried or inaccessible. They usually become apparent to both of us well within the 50-minute hour. ”Making the unconscious conscious” (in Freud’s famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness. Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings. It turns out there is a lot to talk about.

© 2013 Steven Reidbord MD.  All rights reserved.

Steven Reidbord, M.D., is a psychiatrist and psychiatric educator, and chairs the Continuing Medical Education Committee at California Pacific Medical Center.

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