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Dealing With Resistance in Psychotherapy
Am J Psychiatry 2007;164:176-176.
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by Althea J. Horner. Lanham, Md., Rowman & Littlefield Publishers, Inc., 2005, 216 pp., $40.00.

Dealing with Resistance in Psychotherapy by Althea Horner is an old-fashioned book in the psychoanalytic tradition. It could as easily have been written in 1940 as 2005 and uses psychoanalytic jargon that will be daunting to the uninitiated. Dr. Horner has prepared a thoroughgoing analysis of resistance in therapy that catalogues its many different manifestations, from transference resistance to character resistance.

One of the main distinctions between psychoanalytic psychotherapy and cognitive behavior therapy (CBT) is the emphasis placed on resistance and analysis of defense in analytic work, which is given short shrift in behavioral approaches. Advocates of CBT take a didactic posture on the assumption that patients are motivated to change, but lack the skills or knowledge to do so, and that they will work collaboratively with the therapist/coach. In contrast, psychoanalytic types are convinced that patients will resist change, sometimes in subtle ways, even while appearing to be motivated and compliant. The concept of resistance is the key to a depth psychology.

Dr. Horner is highly critical of what she calls “simplistic” approaches that understate the complexity of human psychology. She feels that the medical model has devalued psychology, and that nonpsychological views are signs of counter-transference resistance in the therapist.

Dr. Horner identifies many different forms of resistance, initially focusing on transference and character resistances in general, subdivided according to developmental “fixation points.” She describes transference resistance as the enactment of a core relationship problem and character resistance as a defense against the enactment of transference resistance. Dr. Horner also delineates specific patterns of resistance (e.g., good boy/girl, sexualization), specific motivations (e.g., wish for power, envy, vengeance, specialness, shame), specific attitudes (e.g., entitlement, injustice), specific defenses (e.g., rationalization, constructed self), and specific symptoms (e.g., eating disorders). She even ascribes resistance to the mood swings of the bipolar patient.

While Dr. Horner presents an interesting list of resistances, her recommendations on how to handle them are not as systematic. After a long career as a supervisor and clinician, Dr. Horner has many anecdotes with suggestions related to the given clinical situation. But her recommendations are not generalizable. Finally, in the last chapter, Dr. Horner presents an extended case history of a “brief” (i.e., 40-session) treatment. This is the most clinically relevant chapter, since Dr. Horner explains how and why she intervenes in very clear terms (as well as where she failed to intervene). It is only in this chapter that the book loses the dense psychoanalytic jargon and it becomes clear how the author deals with the important challenge of resistance in psychotherapy.




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