“You Can’t Make Me Do it!” Defiance

“Is defiance always a sign of a transference resistance building up or high resistance? How would you address it? Is it part of a wall?” Thanks to Peter for these great questions!

How we understand defiance depends upon its context. Let’s take a common form of defiance we encounter with fragile patients. You ask what the patient would like to work on. In response to this invitation to form a more intimate relationship, the patient experiences a rise of feelings and anxiety. As a defense, the patient projects his will to explore his inner life onto the therapist.

Now the patient has ‘forgotten’ that it was his will to come to therapy, to talk, to explore his inner life. Now he believes the therapist wants to explore his inner life. Now the patient says things like, “I’m afraid of the questions you want to ask. He is not really afraid of you. He is afraid of the projection he has placed on you (his will to explore). Now he fears your wish to explore.

In response to this projection, the patient may defy you. This is very important to remember. A patient never defies you. He defies the projection he has placed upon you. Defiance is always based upon projection. Thus, to deactivate defiance, we have to deactivate the projection upon which defiance is based.

In this case, the therapist blocks the projection and reminds the patient of his will to deactivate the projection.

Th: “Was it your will to come here to day?” “Was there a problem you want to overcome?” “Do you want to know what is going on inside you so you have better information about yourself?” “Do you want better information about yourself, so you can make better decisions for yourself?”

Notice how each question reminds the patient of his will. Each time he accepts a part of his will, that part is no longer projected onto the therapist. Thus, step by step, the therapist can deactivate the projection of will. Once the patient accepts his will and does not project it onto the therapist, he no longer defies the therapist.

A patient can defy other projections onto the therapist. For instance, a patient who judges himself may project that the therapist is judging him.

Pt: “What are you looking at?”

Th: “It sounds like you are afraid I am looking for something. Is there any evidence for that?” [Help the patient differentiate the therapist from her fantasy.]

The patient who believes the therapist is judging him may defy the supposedly “judging” therapist.

Or the patient may project that the therapist wants her to depend on the therapist.

Pt: “I don’t want to f***ing depend on you!”

Th: “I have no right to ask you to depend on me if that is not something you want to do.” [Deactivate the patient’s projection.]

The patient defies the therapist who supposedly wants her to depend.

In each case the therapist deactivates the projection upon which the defiance is based.

In these examples, we have seen how defiance can result from a single projection and can be relatively easily restructured. Thus, defiance, although quite provocative, is not always a sign of high resistance.

In contrast, we can see a defiant transference resistance that does not deactivate so rapidly. Why? In contrast to the previous examples of defiance (based on a single projection), the transference resistance is a pathological mode of relating where a bunch of defenses work together as a system. For example, you might have an oppositional patient. Remember the line of James Dean:

Man: “What are you against?”

James Dean: “What do you got?”

In the oppositional transference resistance, the patient enacts a relationship from his past. He enacts, for instance, the role of a domineering, questioning, doubting, critical father and you are in the role of a dominated, questioned, doubted, criticized child whose every initiative is opposed by the father. This is the enactment of an internalized object relation, that is, a memory of a past, pathological relationship. You can see that here the enactment is not based on a single defense, but that a large variety of defenses work together to create this enactment.

To deactivate the oppositional transference resistance, therefore, you will need to deactivate the patient’s identification with the oppositional father and deactivate the projection of his healthy desires onto you. Therefore, we psychodiagnose each patient response to see which of the four elements of the transference resistance is in the forefront.

For instance, the patient may be identified with his oppositional parent.

Pt: “I don’t want to look at that.”

Th: “Why look at it if you are fine with how things are going?” [Deactivate the patient’s identification with his father by hinting at the price of the defense.]

Or the patient may be proposing an omnipotent transference for the therapist.

Pt: “I’m not going to look at it.” [Encouraging the therapist to take on the sole responsibility for looking at an issue.]

Th: “Ok. If you don’t want to look at it, we won’t be able to.” [Pointing out reality to deactivate the omnipotent responsibility he proposes for the therapist.]

Or the patient may propose a regressive wish.

Pt: “So how am I supposed to get better?” [I want to get better even though I refuse to collaborate with you.]

Th: “You can’t. If you don’t want to look at this issue, we simply have to agree that we won’t be able to help you with it.” [Point out reality to deactivate the patient’s regressive wish.]

Or the patient may project his healthy wishes onto the therapist.

Pt: “You seem to think I ought to look at this.”

Th: “Why look at something you don’t want to look at?” [Deactivate the projection of the healthy wish onto the therapist.]

These interventions facilitate a “head-on collision” between the patient and his resistance. Up to this point, the patient identifies with his resistance and tries to have a conflict with you, the embodiment of his healthy wishes. When you deactivate the projection of his healthy wishes, his resistance becomes in conflict with his healthy wishes rather than with you. Thus, we try to convert his interpersonal conflict between him and the therapist into an intrapsychic conflict between him and his resistance.

This pathological relationship, the transference resistance, is the “wall” between the patient and therapist. The issue here is not a single defense but an entire enacted relationship. We no longer focus on an isolated defense but on the enacted pathological relationship.

Sometimes the patient will enact this relationship by arguing with everything you say. The only way that can continue is if you argue with the patient. Here is a little secret: the patient’s resistance can work only if YOU resist it. His arguing works ONLY if you argue with him. In other words, the resistance takes two. When there is a tug of war, drop the rope.

Pt: “I don’t believe you.”

Th: “Ok.” [Deactivate the omnipotent transference: you are supposed to make me believe you.]

Pt: “Aren’t you supposed to convince me?”

Th: “No. That’s not my job. If you don’t believe me, why should you believe someone you don’t believe?”

Pt: “I want to argue with you.”

Th: “It’s good you notice that.”

Take home point: defiance is always based on a projection. In a fragile patient, defiance will be based on defying a projection of will, desire, superego, or feeling. Deactivate the projection and the defiance will disappear. In a moderately resistant patient, deactivate the projection upon which defiance is based and feeling will rapidly rise. In a highly resistant patient, defiance enacts a pathological relationship, the transference resistance. Here, deactivating one projection will not make the defiance fall. Instead, the therapist must deactivate all the projections upon which the transference resistance is based. The therapist must assess each patient response to see which element of the transference resistance is being enacted in that moment (identification with the resistance, omnipotent transference, regressive wish, or projection of healthy wishes). The therapist deactivates that element repetitively until the transference resistance drops and feelings finally break through. When the defiance continues, examine the videotape carefully to see what you might be doing to defy his defiance!!

 

 

 

 

 

2 thoughts on ““You Can’t Make Me Do it!” Defiance

  1. Claire

    How do you know when assisting a fragile patient that what you think is her projecting a past relationship, isnt that she has picked up counter transference feelings of anger from the therapist and how do you deal with that?

    Reply
  2. Jon Frederickson

    This is an extremely important question. Framed differently: how do we know that the patient’s reaction is transference (a reaction based on a past relationship) or a rational response to a therapist error or countertransference issue? Robert Langs has written much on this very issue. It can be so easy to assume that all patient reactions are based on the patient’s inner problems. In fact, no therapist has been “purified” by therapy. Thus, it is always possible that a therapist’s reactions will trigger perceptions from the patient that are critical and accurate.
    One way to assess this problem is to examine the process, i.e., the sequence of the patient’s associations. When did the reaction occur? What was the stimulus? If the stimulus was something the therapist said, was his statement an attempt to identify or clarify a defense, which would encourage closeness? Or was his statement a premature confrontation or a projection on his part, a stimulus that would trigger objective anger within the patient?
    Another way to assess this problem is to examine the pathway of anxiety discharge. If the patient’s statement serves as a defense, anxiety will not rise. If the patient’s anger is objective, anxiety may well rise since it will be connected to anger in other situations.
    Another way to assess this problem is to examine what happens if the therapist tries to repair the rupture. If the repair triggers a release of feelings, then the act of moving closer to patient has healed the relationship. If the repair triggers more anger and suspicion, then the patient’s reaction may very well be serving as a defense.
    Another way to assess this problem is to examine the latent content of the patient’s associations. If the patient refers to other people who are critical and attacking, this will show that the patient unconsciously perceives the therapist’s interventions as critical and attacking. If the therapist makes an attempt at repair and the patient later talks about an uncle who is able to see better now that he went to the eye doctor, we can assume that the patient unconsciously perceives that the therapist’s ability to see her has markedly improved.

    Reply

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