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Co-Occurring Schizophrenia and Substance Dependence/Abuse

Applying MI: Roll With Resistance
Substance Dependence
Substance Abuse
Assessment of Co-occurring Disorders
Motivational Interviewing
Applying MI: Express Empathy
Applying MI: Develop Discrepancy
Applying MI: Avoid Argument
Applying MI: Roll With Resistance
Applying MI: Support Self-Efficacy
Evidence Based for Motivational Interviewing
Future Research and Barriers to Service
Web sites of Interest

Adjust to client resistance rather than opposing it directly:

Resistance is a predictive of poor treatment outcomes and lack of involvement in the therapeutic process.  One view of resistance is that the client is behaving defiantly.  Another is that resistance is a signal that the client views the situation differently.  This requires that the therapist understand the client’s perspective.  This is usually a signal for the therapist to change direction or to listen more carefully.


Adjusting to resistance is similar to avoiding argument in that it offers another chance for the therapist to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and to stay involved.  The therapist should avoid evoking resistance whenever possible, and divert or deflect the energy the client is investing in resistance toward positive change.

Examples of resistance and how a therapist could avoiding arguing and adapt to resistance:


           Simple reflection: The simplest approach to responding to resistance is with nonresistance, by repeating the client’s statement in a neutral form.  This acknowledges and validates what the client has said and can elicit an opposing response.


Client: I don’t plan to quit drinking anytime soon.

Clinician: You don’t think that abstinence would work for you right now.


           Amplified reflection: Another strategy is to reflect the client’s statement in an exaggerated form—to state it in a more extreme way but without sarcasm.  This can move the client toward positive change rather than resistance.


Client: I don’t know why my wife is worried about this.  I don’t drink

Clinician: So your wife is worrying needlessly.


           Double-sided reflection: A third strategy entails acknowledging what the client has said but then also stating contrary things she has said in the past.  This requires the use of information that the client has offered previously, although perhaps not in the same session.


Client: I know you want me to give up drinking completely, but I’m not going to do that!

Clinician: You can see that there are some real problems here, but you’re not will to think about quitting altogether.


           Shifting focus: You can defuse resistance by helping the client shift focus away from obstacles and barriers.  This method offers an opportunity to affirm your client’s personal choice regarding the conduct of his own life.


Client: I can’t stop smoking pot when all my friends are doing it.

Clinician: You’re way ahead of me.  We’re still exploring your concerns about whether you can get into college.  We’re not ready yet to decide how marijuana fits into your goals.


           Agreement with a twist: A subtle strategy is to agree with the client, but with a  slight twist or change of direction that propels the discussion forward.


Client: Why are you and my wife so stuck on my drinking? What about all her problems?  You’d drink, too, if your family were nagging you all the time.

Clinician: You’ve got a good point there, and that’s important.  There is a bigger picture here, and maybe I haven’t been paying enough attention to that.  It’s not as simple as one person’s drinking.  I agree with you that we shouldn’t be trying to place blame here.  Drinking problems like these do involve the whole family.


           Reframing: A good strategy to use when a client denies personal problems is reframing—offering a new and positive interpretation of negative information provided by the client.


Client: My husband is always nagging me about my drinking—always calling me an alcoholic.  It really bugs me.

Clinician: It sounds like he really cares about you and is concerned, although he expresses it in a way that makes you angry.  Maybe we can help him learn how to tell you he loves you and is worried about you in a more positive and acceptable way.


           Siding with the negative: One more strategy for adapting to client resistance is to take the negative voice in the discussion.  This is not “reverse psychology,” nor does it involve the ethical quandaries of prescribing more of the symptom, as in a “therapeutic paradox.”  Siding with the negative is stating what the client has already said while arguing against changes, perhaps as an amplified reflection.  The therapist should be cautious in using this too early in treatment or with depressed clients.


Client: Well, I know some people think I drink too much, and I may be damaging my liver, but I still don’t believe I’m an alcoholic or in need of treatment.

Clinician: We’ve spent considerable time now going over your positive feelings and concerns about your drinking, but you still don’t think you are ready or want to change your drinking patterns.  Maybe changing would be too difficult for you, especially if you really want to stay the same.  Anyway, I’m not sure you believe you could change even if you really wanted to.


Nicole & Colleen