OVERCOMING RESISTANCE IN COGNITIVE THERAPY.

Overcoming Resistance in Cognitive Therapy. Leahy, Robert L. New York: Guilford Publications, 2001. x + 309 pp. $53.00. Within the past two decades cognitive therapy has been shown to be effective for the spectrum of psychiatric disorders. The early manual-based interventions for depression and anxiety have been adapted and proven effective in the treatment of severe psychopathology such as personality disorders, bipolar disorder, and schizophrenia. Notwithstanding this success and the inherent adaptability of cognitive therapy strategies, there continue to be patients who terminate treatment prematurely, complete treatment with only minimal benefits, or respond favorably to treatment but then later relapse. Robert Leahy, a leading cognitive therapist, has written a superb book that outlines clinical strategies for the detection and amelioration of the barriers, or resistances, to engagement in cognitive therapy in order to reach those patients who are otherwise unlikely to fully benefit from standardized interventions. The timing of this book corresponds to the field’s growing awareness and interest in the hard-to-reach patient, which also happens to be the theme of this year’s annual conference of the Association for the Advancement of Behavior Therapy (AABT). The use of the term resistance in the title of a book about cognitive therapy is curious. Cognitive therapists often speak of noncompliance or noncollaboration as roadblocks to successful outcome. So, why the borrowing, or what Leahy refers to as the “downright stealing” of the term from the psychoanalytic lexicon? In the first part of the book, Leahy makes explicit his attempt to integrate psychoanalytic and cognitive theories of therapeutic process and change. The resulting integrated social-cognitive model of resistance acknowledges the importance of emotional dysregulation, childhood experiences, unconscious processes, and defense mechanisms in the production of therapeutic barriers. Notwithstanding the eclectic range of distal and proximal factors identified, Leahy ultimately presents a cognitive model: “resistance is expressed in different dimensions, where each dimension is a relatively self-contained style of thinking. . .that need to be addressed in therapy within its own rules and logic” (p. 21). Prior to outlining the unique dimensions of resistance and their treatment in the second part of the book, there is an excellent chapter titled “Resistance to Procedure” that articulates very useful tips for addressing barriers that come up during agenda setting, homework setting and review, and other standard aspects of the cognitive therapy session. Suggestions are captured through case illustrations. The second part of the book outlines seven fundamental dimensions of resistance and treatment strategies for their reduction. These chapters are extremely rich and are replete with illustrative case material. In a chapter on validation resistance, Leahy reminds us that if we focus too quickly on solving our patient’s problems without first appreciating the importance of the problem to the patient, therapists are likely to come across as dismissing and myopically demanding of change. Leahy describes strategies to enhance validation including becoming aware of moments when targeting negative automatic thoughts will only serve to alienate the patient. Leahy outlines a framework for understanding the interplay of the patient’s past and current invalidating environments and their expectancies/needs for (in)validation in therapy. Leahy describes in another chapter how the patient’s need for self-consistency may override his/her needs for change and improvement. Particular attention is given to the cognitive distortions that perpetuate this pattern, including the distortion of “sunk-costs,” the idea that people are more likely to continue in a course of behavior because of great prior sacrifice or cost (e.g., “I can’t just walk away now.”) Strategies to help people out of the “trap” of sunk-costs are enumerated through detailed case vignettes. The decision to use the term resistance in the title of the book was chosen, in part, to reflect the sense of “struggle” that patients have within themselves. The chapters on validation and self-consistency get at the essence of the struggle that some patients have in letting go of dysfunctional beliefs and behaviors because of their perceived security and protection from further harm or loss. Other dimensions of resistance described in the text may be more familiar to (cognitive) therapists as they build on previously identified targets of therapy, including the role of intrapersonal and interpersonal schemas (schematic resistance), the problems associated with inflated responsibility (moral resistance), and the consequences of risk aversion. The latter two chapters offer fresh ideas for the understanding and treatment of resistances in the therapy of obsessive-compulsive disorder and depression, respectively. To the extent that Leahy uses numerous financial investment terms and models to understand risk-aversive behavior, the reader may find this chapter to be as informative for their therapeutic work as for their choice of stock options. Remaining chapters in the second section identify the resistance with seeing oneself as a victim (victim resistance) and the role of self-handicapping attributions for the lack of personal progress. Overall, the layout of these chapters is excellent; they are consistently structured so that the first part of the chapter describes in detail the nature of the resistances while the second half outlines clinical approaches with case vignettes and actual transcripts. Summary tables of the information are interspersed throughout each chapter thus making it very easy to move back and forth between the details and the “big picture.” The third and final part of the book comprises two chapters on therapist resistances titled “Cognitive Therapy and Countertransference.” Therapists influence the process of therapy through their automatic and distorted responses to in-session events (i.e., “this patient is never going to get better”) and self (e.g., perfectionism), other (e.g., dependency) and world (e.g., disappointing) dysfunctional beliefs. Leahy provides helpful and practical tips for identifying and using our cognitive and emotional responses in therapy sessions, especially when they serve to activate schematic responses in our patients. This text contains a wealth of ideas and illustrative case material to help the (cognitive) therapist navigate patient and therapist-patient resistances. It is destined to be a standard reference within the case conceptualization approach and is relevant for everyone practicing cognitive therapy.

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