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Section 12
Overcoming Resistance to Treatment

Question 12 | Test | Table of Contents

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In this section, we will discuss resistance to treatment.  We’ll examine manifestations of resistance as fugues, trances and depersonalizations, acting out, internal uproar and acute regressions, flights into health, and techniques for overcoming resistance. 

As you already know, in the case of dissociative identity disorder, dissociated memories and affects may create resistance to therapeutic interventions.  Clearly, resistances occur in all psychotherapies, and treating multiples is no exception.  In DID clients, however, resistances are most frequently expressed around uncovering work.  

Would you agree that resistances may also be important manifestations and indices of therapist error?  Putnam states that incorrect or inadequate therapeutic interventions may heighten current manifestations of resistance or elicit new forms.  A therapist must always bear in mind his or her possible contribution to a client’s suddenly increased resistance following a "therapeutic" intervention.  Not all expressions of resistance threaten the therapeutic alliance, but all disruptions of the therapeutic alliance are major expres­sions of resistance.

♦ Manifestations of Resistance
First, let’s discuss manifestations of resistance.  Manifestations of resistance are determined by a number of factors, including the relationship between the client and therapist, the point in the course of the therapy such as early or late in treatment, the traumatic material that the resistance is concealing, the client’s personality system, and the circumstances of the treatment, whether the treatment is inpatient or outpatient, to name only a few influences.  

A number of typical resistances seen early in treatment with DID clients may include blaming others, mistrusting or having paranoid feelings, acting out, using a significant other to oppose treatment, denying emotional problems, having financial or time problems, or fearing treatment and the therapist. Think of your DID client.  Does he or she exhibit any of these classical manifestations of resistance?  What unique manifestations of resistance does your client exhibit?

♦ Fugues, Trances, and Depersonalizations
Let’s examine fugues, trances and depersonalizations.  Dissociation is a multiple’s primary defense against trauma. Not too surprisingly, it also becomes a major form of resistance to treatment. Outside of the treatment setting, fugue episodes are a frequent manifestation of resistance.  

Selma, age 41, often left treatment sessions and then wandered in a dissociated state for several hours until she finally "came to" in an unfamiliar place and called her therapist in a panic.  During sessions, Selma sometimes bolted for the door in a panicked or dissociated state.  These experiences, which usually produce significant discomfort for both Selma and her therapist, often dampened the active uncovering of traumatic material.  Do you have a Selma who experiences manifestations of resistance through fugues such as dissociative wandering or fleeing?

In the treatment setting, Selma’s resistance was also sometimes manifested in trance-like states or profound depersonalization.  During trance-like states, Selma became minimally or completely unresponsive and stared off into space.  Selma’s therapist reported having great difficulty making contact or communicating with her. Things often reached a crisis point when the hour ended and Selma’s therapist had another client waiting. Alternatively, have you treated clients who experienced profound depersonalization and responded with a floating detachment to all interactions? 

♦ Acting Out
In addition to fugues, trances and depersonalizations, another manifestation of resistance is acting out.  As a manifestation of resistance, acting out takes a myriad of forms.  But would you agree that the manifestations that are most troubling to the therapist are suicide gestures, externally directed violence, and self-mutilation?  Research shows that suicide gestures or self-mutilation may directly follow sessions in which attempts have been made at uncovering traumatic material.  
Persecutor personalities, with their mandate of guarding secrecy, are often responsible for these actions.  Therefore, you might consider taking steps to end sessions in which attempts have been made at uncovering traumatic material in a way that provides your DID client with the following.  First, try to foster a sense of blamelessness regarding the trauma.  Second, you might consider helping your client acknowledge that the trauma is in the past.  Think of your DID client.  What other ways can you minimize acting out as a manifestation of resistance?

♦ Internal Uproar and Acute Regressions
A third type of manifestation of resistance you may encounter with your DID clients is internal uproar and acute regressions.  Selma had both child and infant personalities.  Selma was capable of acute and profound behavioral regression.  During moments of extreme anxiety, Selma collapsed into a thumb-sucking, preverbal state as her infant personality emerged.  A tyrannical 2-year-olds with disturbed reality testing also emerged, keeping Selma’s therapist preoccupied with "babysitting" rather than psychotherapeutic work.  

He stated, "In many instances, these infant or child personalities seem to be sent out by the personality system to thwart uncovering work.  If a personality cannot talk, he or she also cannot disclose highly charged material.  Such a regressed state would be disturbing to the therapist who perceives this as a deterioration in the client’s condition."  A mistake I have made is to respond to acute regressions with "supportive" interventions or medication.  Would you agree that responding to these regressions with ‘supportive’ interventions only reinforces the efficiency of the child or infant personality as a smokescreen to thwart uncovering work?

Internal uproars, in which the personality system degenerates into a screaming mob within the client’s (usually the host’s) head, often pre­vent further work by overwhelming the client with internal stimuli.  Have you treated a client whose personality system becomes entirely active at once?  How do you respond?  As you know, internal uproars in DID clients are usually highly symbolic of the mate­rial they conceal.  Perhaps you can find the origin of the material your client is concealing by paying close attention to displays of internal uproars.

♦ Flights into Health
A final manifestation of resistance that we will discuss is flights into health.  What I mean by flights into health are essentially a denial of DID by the client after having accepted the diagnosis and prior to unification and integration of the personality system.  These flights into health are common and often occur as the therapy begins to get down to serious uncovering work.  Following a difficult session with her therapist, Selma presented on the next occasion stating that she was fused.  Selma appeared calm and confident.  

Selma’s therapist stated, " I thought I should be cautious in accepting such good news.  Spontaneous total fusion may rarely occur in DID patients, but is highly unlikely to occur in the middle of a turbulent therapy that is beginning to work with unrevealed trauma."  Selma’s therapist instead carefully sought the reasons why this "fusion" has occurred.  In particular, he asked about how the "fusion" had occurred: the circumstances, the reports of other person­alities, and the mechanism of final decision making.  Selma’s therapist found that she  may have been acting out her unconscious wish to be rid of the other personalities.

Alternatively, a DID client may "admit" that he or she "made it all up."  Frequently, however, this denial is immediately preceded or followed by some clear demonstration of the client’s multiplicity as one or more alters break through the internal suppression to demonstrate their continued existence.  Would you agree that neither "spontaneous fusion" nor denial of DID constitutes grounds for discontinuation of treatment.  Even if the client has truly fused, there remains the important post-resolution stage that is necessary to successfully conclude the client’s treatment. 

♦ 4-Step Overcoming Resistance Technique
Although focusing on resistances should not become the central work of psychotherapy with DID clients, we at the Healthcare Training Institute thought it would be beneficial to include a technique on this course for overcoming resistance to treatment.  I believe that the core therapeutic work with DID is to first stabilize the client, develop increased communication and then uncover and reintegrate dissociated memories and affects.  However, if resistance to therapy becomes to obstruct core work, I have found that the following technique can be useful.  As I describe the overcoming resistance technique, you might compare it to you method for overcoming resistance. 

a. The first step in overcoming resistance is for the therapist to recognize that there is a resistance and that it is interfering with the core work of therapy.  For example, is your client acting out, presenting with acute regression, or experiencing internal uproars? 
b. The second step in overcoming resistance requires the therapist to clarify the nature of the resistance and what may be driving it.  You might consider discussing the resistance with your client in plain and simple language.  I find that by discussing resistance plainly with a client, I can make the personality system aware that there is an obstruction to core therapeutic work. 
c. Third, in addition to recognizing and clarifying resistance, therapists can identify the therapeutic context in which the resistance is expressed.  When identifying this expression of resistance to your client, you might consider making it clear how the resistance is blocking the therapeutic work. 
d. Finally, the fourth step to overcoming resistance is making a statement to the client about the ‘cost’ of resistance to the client.  In what ways will resistance negatively impact your client’s treatment progress?

In this section, we discussed resistance to treatment.  We examined manifestations of resistance as fugues, trances and depersonalizations, acting out, internal uproar and acute regressions, flights into health, and techniques for overcoming resistance. 

In the next section, we will discuss mapping the personality system.  Three steps to mapping the personality system are choosing a form of map, identifying useful information, and using maps as final integration tools. 
Reviewed 2023

Peer-Reviewed Journal Article References:
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., Pain, C., & Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 490–500.

Boyd, J. E., O'Connor, C., Protopopescu, A., Jetly, R., Lanius, R. A., & McKinnon, M. C. (2020). The contributions of emotion regulation difficulties and dissociative symptoms to functional impairment among civilian inpatients with posttraumatic stress symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 12(7), 739–749.

Brand, B. L., Webermann, A. R., Snyder, B. L., & Kaliush, P. R. (2019). Detecting clinical and simulated dissociative identity disorder with the Test of Memory Malingering. Psychological Trauma: Theory, Research, Practice, and Policy, 11(5), 513–520. 

Buer Christensen, T., Eikenaes, I., Hummelen, B., Pedersen, G., Nysæter, T.-E., Bender, D. S., Skodol, A. E., & Selvik, S. G. (2020). Level of personality functioning as a predictor of psychosocial functioning—Concurrent validity of criterion A. Personality Disorders: Theory, Research, and Treatment, 11(2), 79–90.

Lentz, J. S. (2016). Reconsidering resistance. Psychoanalytic Psychology, 33(4), 599–609. 

Westra, H. A., Aviram, A., Connors, L., Kertes, A., & Ahmed, M. (2012). Therapist emotional reactions and client resistance in cognitive behavioral therapy. Psychotherapy, 49(2), 163–172. 

QUESTION 12
What are four steps to overcoming resistance? To select and enter your answer go to Test.

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