Book Review
Psychotherapy
Overcoming Resistance in Cognitive Therapy. Robert L Leahy. New York: Guilford Press; 2001. 309 p. CAN$56.95.
Reviewer
rating*: Excellent
Review by: Nancy L Kocovski, MA; Zindel V Segal, PhD, C Psych
Toronto, Ontario
Resistance, plainly spoken, refers to the problems encountered by patients when they attempt to address and master feelings and experiences that had been previously avoided or diminished. It has been central to psychoanalytic and dynamic accounts of treatment for well over a century, both as a means of gauging how the process of treatment is proceeding and as a target of treatment in its own right. More recently, cognitive therapists have considered this topic, partly as a result of finding that the simple application of appropriate interventions does not always turn out to be successful and partly through the expansion of cognitive- behavioural therapy (CBT) principles to patient groups with more complicated clinical pictures. Overcoming Resistance in Cognitive Therapy is therefore both timely and a welcome addition to the sparse CBT literature on this topic.
Leahy recognizes precedence when using terms such as resistance, transference, and countertransference from psychoanalytic and dynamic theory but recasts them within a multidimensional cognitive model of resistance that is informed by basic research in social cognition and cognitive science. The book is divided into 3 parts that detail the theoretical and conceptual foundations of resistance, along with its illustration across 7 domains of clinical practice.
In Part 1, Leahy describes psychoanalytic models of resistance, behavioural models of noncompliance, and then cognitive models of resistance (Ellis, Burns, and Beck). He also discusses resistance to the various procedural aspects of cognitive therapy and possible interventions. There are compelling clinical descriptions of the type of noncompliance that cognitive therapists usually discuss (for example, not getting homework done and not following the agenda). This may be familiar ground to some readers, but Leahy provides enough hints and commentary for the reader to appreciate how his model of resistance adds to these formulations.
The book really hits its stride in Part 2, wherein the author discusses each dimension of resistance in greater detail. A central theme presented in this section is a response to the clinical observation that “many patients in therapy actually struggle as much with themselves as with the therapist in maintaining a losing position” (p 284). What cognitive framework can we use to understand this? Starting from the premise that much of the “patient’s resistance in therapy can be understood in terms of processes that the patient believes protect him or her from further loss or harm” (p 285), Leahy discusses 7 cognitive and affective mechanisms that may bring this about.
Validation resistance (both within the therapy session and self-invalidation) points to the possibility that some patients require validation before they are ready for change. If these patients do not receive validation from the therapist, they may ruminate in session, devalue the therapist, or present in a more intense manner. Self-consistency, the focus of Chapter 5, is the second dimension of resistance discussed in the book. The basic concept is that individuals are generally motivated to maintain consistency in their beliefs and assumptions. Leahy discusses 5 aspects of consistency (cognitive, predictability, self-justification, interactive realities, and sunk-costs). Much of the chapter focuses on sunk-costs. Leahy does an excellent job in describing sunk-cost theory and suggests numerous interventions that the clinician can attempt when sunk-cost is identified as the type of resistance in therapy. Chapter 6 discusses schematic resistance. Leahy recognizes that schemas (and interventions for schema modification) have been largely discussed in recent years. This chapter reviews the literature on schemas, applying it to resistance in therapy.
In Chapter 7, Leahy presents moral resistance—the idea that patients will not change if they perceive that change to a new belief is inconsistent with their personal morality, even if much evidence that supports the new belief exists. Leahy provides clinical illustrations from patients with obsessive–compulsive disorder. Chapter 8 describes victim resistance. Commonly held just beliefs (for example, bad things happen to bad people) can lead to resistance and may have to be addressed before change can take place. Twelve facets of the victim role are outlined, along with strategies for working with this type of resistance.
In Chapter 9, Leahy presents his Investment Model of Resistance and Depression, which posits that individuals with depression focus on avoiding further loss at all costs. In addition, he peppers it with analogies to the stock market that help to convey his points. More structure and summary statements, however, might have been helpful in considering how all the information presented comes together to form the model. One study is presented as support for the model, but it is insufficient. Dr Leahy could have paid more attention to empirical support and to intervention strategies that follow from the model. Chapter 10 describes self-handicapping, the final dimension of resistance that has an interpersonal component.
In the next 2 chapters, Leahy returns to the broader literature on resistance to discuss countertransference, highlighting that patients in treatment respond to a person (that is, the therapist), not just to the cognitive therapy techniques. Leahy states that transference and countertransference exist—regardless of whether they are recognized—and offers guidelines for understanding countertransference within his model.
To conclude, this book is an excellent addition to resident, graduate-level, or postgraduate-level training in cognitive therapy and a useful bridge to practitioners of other psychotherapy forms where the concept of resistance is more dominant.
Dr Robert Leahy is the founder and director of the American Institute for Cognitive Therapy, in New York, and a clinical associate professor in the Department of Psychiatry at Weill-Cornell Medical College. Currently, he is president of the International Association of Cognitive Therapy and a founding fellow of the Academy of Cognitive Therapy.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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