D. Engle and H. Arkowitz: Ambivalence in Psychotherapy

Irrespective of theoretical orientation and technique, we all encounter clients who seem resistant to change. How many clients tend to move from therapist to therapist, rotating from psychodynamic forms of therapy to cognitive behavioral to more humanistic oriented or constructivist models, seeking help individually or in groups? Yet change sometimes does not occur. Old patterns of familiar behavior persist and the client, often angry and frustrated, terminates the therapeutic process until a new crisis or opportunity for a new therapeutic encounter urges another attempt. Therapists often feel powerless and negative toward the client who seems to keep coming while refusing help. Engle and Arkowitz provide a volume that will be of practical help to clinicians of all disciplines in breaking the cycle of starts and stops to treatment. The book begins with the development of an integrative model of resistant ambivalence, followed by a chapter which surveys several measures of resistance and ambivalence. This chapter includes an example of a self-administered questionnaire which helps the client articulate the changes they wish to make, the self that they would like to be. The remaining chapters are filled with practical applications of the authors’ work on ambivalence. The authors use case examples to illustrate how these techniques may be used to work with ambivalence. The author’s differentiate between the terms of ambivalence versus resistance. They define resistance as behaviors which interfere with progress toward desired change. They contrast the ways in which resistance is viewed across several theoretical perspectives. These include psychodynamic, cognitive behavioral, humanistic/experiential, family systems and constructivist approaches. For instance, client may demonstrate resistance in cognitive behavioral therapy by incompletion of homework assignment. Similarly, clients may demonstrate resistance in psychodynamic psychotherapy through refusal to share uncomfortable transference towards the therapist. This book is organized around four basic questions. These include: What changes are resisted? What behaviors define the presence of resistance? Why is resistance occurring? Who does theoretically based work with resistance in clinical practice? A synthesis of the main themes that depict the commonalities and differences between the theoretical approaches on resistance sets the stage for the authors’ presentation of their integrative model of resistant ambivalence. Engle and Arkowitz define their integrative model as a unique focus on ambivalence as a subset of resistance. They state that in resistant ambivalence, ‘‘there are movements toward change as well as movements away from change’’ (Engle and Arkowitz 2006, p. 52). The authors provide the example of people who want to lose weight and yet have difficulty making the life style changes required to accomplish this goal. The authors are certainly not the first to reframe resistance as being more complex than the traditional view of it as a defense against uncomfortable feelings and thoughts (Brandell 2004). An example is found in the pivotal work of Gilligan et al. (1991). They reframe resistance as a strength in a relational context. They authors suggest that girls and women resist expression of feelings that will create a disconnection in the relationship. Uniquely, Engle and Arkowitz suggest that there is an ambivalent quality to much of the behavior we have previously characterized as resistance. Rather than focus on the obstacles created by M. Spira (&) Loyola University Chicago School of Social Work, Chicago, IL, USA e-mail: mspira@luc.edu