Just What Is Resistance?

People in the mental health world use the word “resistance” a lot. In fact, they use it so much, and in so many different ways, that it’s hard to know what it means anymore. But there are places where the word is used in a precise manner, and that tells us something about what resistance is and how to use it. The places I’m speaking of aren’t in the mental health or addiction fields, but in the business world, specifically the world of Constraint Theory.

I’ve written before about Goldratt’s Theory of Constraints and how it applies to addiction treatment, but here I want to focus on a more global perspective. I am going to focus on how people change and what makes them resist change. But first, I need to add a bit of a preface.

I work every day with people who treat addiction and have trouble with their patients. In my discussions with counselors and doctors I use a question that seems counterintuitive to them at first. “Why would someone in their right minds act like that?” As you’ve probably guessed the most common answer is, “They aren’t in their right minds, that’s my point!” It’s the only answer I won’t allow. I have my reasons, but here are Goldratt’s.

TOC says that everyone wants to do a good job, that people who have the same goal don’t disagree because they don’t want to work together, but because they have different assumptions about how to meet the goal. Just knowing that alone gives us a leg up. First we need to know do we have the same goal as the patient? If we do but they don’t agree on the plan, we know it isn’t because they want to live in misery or don’t like us; it’s because of a difference between our and their assumptions. So our first task is to get our goals aligned with the patient’s, and after that, to understand what the assumptions are on both our parts that explain why we don’t come up with the same plan.

ChangeIn TOC speak, this comes down to three questions:

1. What to change

2. What to change to

3. How to change

In short, what TOC, and other logical systems, give us is a method of understanding disagreement and conflict as well as a method of resolving that conflict. So far, most of the addiction treatment field resolves conflict by saying, “We’re right; you’re wrong. Do it our way,” and wonder why things aren’t working out. So they see a lot of resistance. So would anyone with that attitude.

So let’s consider the first question, “What to change?” We often think that what the patient needs to change is his drug use, and what the patient thinks needs to change is how bad he feels. Unless we agree on the goal and what to change it’s not likely that we’ll come to agreement on what to change to or how to change.

But let’s say we do agree on what to change. After that there’s often disagreement on what to change to. We often think that complete abstinence should be the the end all, but again, the patients may be looking for a way to feel better. Unless we have agreement on what to change to, we’ll never agree on how to change.

Which brings us to the last point. It’s where most of us focus first, the how to change. We tell patients to go to AA, or go to group, or take their medicine, or live in a half-way house, or whatever other thing we think will do the trick. And they don’t do it, and we call it resistance. But if we look at it from a TOC point of view, we could never expect anyone to accept a plan on how to change if they don’t agree on what to change or what to change to. We have a lot to learn from other fields that approach change from a much healthier point of view. It’s the basis for our DAS score and our understanding of how patients change. It’s the underpinnings of why we get the good results we do.


Author: AddictionDoctor

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  1. Thank you for your always insightful articles. It sounds like we should be cognizant of reaching mutual agreement on the methods and suggestions we give patients, and I fully agree. What do you do with those that do not agree on the first question, what to change? For us, enough time and step work often resolves this problem, but sometimes “resistance”, almost on a sociopathic level persists no matter what we try. AA folks will say “they’re just not ready yet.” Our job is to get them ready, but in some, resistance can be frustrating.

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    • Terrance,
      Working with patients can be frustrating, and an AA principle that helps me when trying to help others is to remember that I’m not in charge of the outcome. I want him to change what I want him to change, but I really don’t know if that’s the best plan for him. He may disagree, or in an AA perspective, his higher power may even disagree with my plan. It’s interesting that the 12th step is the only one that has the word “try” in it. I think that’s because we can’t always carry the message when someone can’t hear it, we can only do our part. Someone once told me that in the department store of life, we work in the efforts department; someone bigger than us is handling outcomes. So that helps a little when I start thinking I’m meeting resistance.

      I’ve come not to believe in resistance, and it seems to help. What I used to call resistance is just information coming from the patient. It helps me align with him if I don’t see it as resistance to something I want, but rather information coming from him about what he wants. I find that I even “get my way” more often if I align with what he wants first and then explore what might happen if we both get our way. In TOC parlance, we face the negative branch together, and often the patient solves it without me having to be the one with the solution. So how I get them to agree on what to change, is that I agree with them on what to change and then we explore together how that will work out for him. He may decide to try, but more often than not, when he’s not busy fighting me because I’m on his side, he figures out himself that something else needs to change to.

      Thanks for the question, and thanks for reading,

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