How can we tell if a patient is compliant? First of all, compliance is a defense. The patient is complying with “your” will rather than acting on the basis of her own will and desire. Thus, compliance is something we always try to avoid.
To determine if the patient is merely complying with you rather than exploring a feeling based on her own will, notice her unconscious signaling. If the patient says she wants to look at something, that is an act of increased emotional closeness. That should trigger unconscious anxiety signaled by sighing or slight body tensing. If we see no unconscious signaling when the patient says she wants to explore a feeling, that is a sign the patient is complying. Remember, since compliance is a defense, it will not trigger unconscious anxiety. “I want to” following by unconscious anxiety is an expression of the patient’s will. “I want to” followed by no unconscious signaling is likely an expression of the patient’s compliance—just going along with the therapist.
Interestingly, compliance and defiance are two sides of the same coin: projection of will. If I project my will onto you, I can defy “your” will or I can comply with “your” will. Either way, I will be responding to my projection of will onto you. Thus, the key to deactivating compliance and defiance is deactivating the projection of will onto the therapist.
Signs of compliance include statements such as, “I know you think this is something I should look at.” In response, you might say, “Only you can know if this is something you should look at for your benefit.” Block the patient’s projection and do not explore until the patient declares it is his wish to explore.
Signs of compliance can also include non-verbal tactical defenses.
Th: “Would you like to take a look at this problem?”
Pt: “Sure.” [Said diffidently while sitting slouched in the chair.]
Here the lyrics don’t match the music. The patient says the right word but in the wrong way: diffidently with detachment and uninvolvement. If we listen only to what the patient says but not how he says it, we will end up working with a compliant patient in a stuck therapy. When there is a contrast between what the patient says and how he says it, always pay attention to how he says it. You might respond, “You say ‘sure’, but you don’t sound sure and you don’t look sure. You look and sound detached. Do you notice that?”
Sometimes compliance will manifest in a subtle way.
Th: “What is the problem you would like me to help you with today?”
Pt: “Last time you mentioned the rage toward my sister. Do you think that would be a good place to start?” [Projection of will onto the therapist.]
Th: “I have no idea. Only you can know what would be the best place for us to start today.” [Block the projection onto the therapist.]
Another way to address compliance is to ask about feeling. A highly resistant patient might claim that it is his will to look at a problem but do so in a very detached manner. Since the patient is not yet aware of his defenses, challenging them would be premature. Instead, the therapist can ask, “How do you experience that inside, that you know this is what you want?” After asking several times, the patient will share that he feels nothing inside. Then you can respond, “So we still don’t know if this is what you want to explore. I have no right to explore anything unless it is your will to do so. So I wonder what is the problem you would like me to help you with?” His absence of feeling and activation is the evidence that his will is not online. He is merely complying. Since you are not pursuing his pseudo-will further, his defense has failed, and feeling should rise.
You’ll have a chance to read much more about defiance and compliance and projection of will in my forthcoming book, Co-Creating Change: Effective Dynamic Therapy Techniques.