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RESEARCH ARTICLE
KEYWORDS
meta‐analysis, psychotherapy outcome, reactance, resistance,
systematic treatment selection, treatment adaptations
1 | INTRODUCTION
Patients who willingly enter psychotherapy typically do so because of a desire to change. At the same time, that
desired change can prove a difficult and frightening process and is often met with what clinicians refer to as
resistance. The clinician is then confronted with the thorny question, “Why is it that one who wants to change then
resists doing so when offered the opportunity?” The role of the clinician is to serve as a facilitator for reconciling
these contradictory inclinations of the patient and to produce change and growth in the process. Psychological
change in psychotherapy has long been considered to result from the persuasiveness and compatibility of the
therapist when addressing an ambivalent patient (Strong & Matross, 1973). Many of these persuasive forces are
mightily tested when the therapist addresses patient resistance.
Resistance in the context of psychotherapy implies a fundamental apprehension and aversion to change
(Firestone, 2015). To a clinician, resistance is an attribute of the person and indicates, as the term suggests, a
pulling back and digging in to prevent change from occurring. It is usually met with either an interpretation or a
confrontation.
Within the frame of social psychology, it is useful to differentiate between resistance to change and reactance to
change. Reactance is an extreme form of resistance and indicates not only the lack of an inclination to change, but
an oppositional reaction to the persuader (Brehm & Brehm, 1981). Moreover, its presence reflects an interpersonal
process that is best met by a reduction in persuasive demand and an analysis of the listener or patient’s immediate
fears and anticipated consequences of the behavior. Brehm and Brehm convincingly argued that the central
motivational theme that stimulates reactance is the fear of losing one’s independence.
In this study, we accept the distinction between resistance and reactance and will view the two terms as a
reflection of two points along a continuum of avoidance. Reactance, even more than the broader term resistance,
will be our point of focus since it appears strongly to be both activated and deactivated by a psychotherapist.
Reactance typically decreases when the therapist avoids challenging or threatening the recipient or patient’s
fear of losing some aspect of personal freedom. And, conversely, reactance may be activated if the therapist is too
confrontive or too uninvolved. The effective therapist, from this perspective, understands that any patient may
directly reassert his or her freedom through oppositional behavior within the therapy room or via premature
termination. Likewise, the patient who declines to engage in therapeutic tasks or homework, or ignores the
therapist’s reflection by interrupting him or her, is engaged in the common task of avoiding the loss of freedom.
Borrowing from social psychology scholars, reactance is responsive to the moderating effects of therapist
directiveness. That is, its destructive impact on psychotherapy outcome can be modified by how much
confrontation and direction the therapist chooses to provide (Beutler et al., 1991). Without the moderating
influence of therapist nondirectiveness and nonconfrontation, the patient’s resistance and reactance are thought to
correlate negatively to treatment outcome.
We begin by providing definitions, measures, and clinical examples of reactance in psychotherapy. We then
present the results of an updated meta‐analysis on the effects of adapting psychotherapy to a patient’s reactance
level. We conclude with limitations of the research, diversity considerations, and therapeutic practices based on
this study evidence.
2 | DEFINITIONS A ND ME ASURES
The psychotherapy objectives when dealing with reactance are to make an environment in which resistance and
reactance are not necessary. While all psychotherapy theories have articulated a variety of techniques with which
to deal with the “problem” of resistance, they seldom consider the possibility offered by Brehm and Brehm (1981)
that resistance in psychotherapy may mark the failure of the therapist to present an environment that does not
challenge the particular patient’s fear of losing freedom. The most likely interpersonal environment for
extinguishing reactance is through the use of nondirective and nondemanding inquiry.
The CRC considers resistance as a set of behaviors embedded in an interpersonal process between the patient
and clinician. A revised version of the CRC measure relies on a similar definition of resistance, but involves an
altered coding process to improve its reliability and validity via providing a rating of variability on a single, global
resistance score. Because the responses from which scores are earned all address the patient’s current activity
within psychotherapy, trait aspects of the measure are lost. Interpretations of any findings are confined to the
singular event of psychotherapy with this particular therapist.
The most widely used self‐report measures of resistance in psychotherapy gauge current situations—states
rather than traits. The Patient Resistance Inventory (PRI; Dowd, Milne, & Wise, 1991) and Therapeutic Reactance
Scale (TRS; Dowd et al., 1991) are related instruments, both of which can be used to measure resistance over time
and either within a specific course of treatment or within psychotherapy generally. These two patient self‐report
measures are similar in design but differ in the response alternatives that are available and what characteristics
they purport to reveal.
The PRI consists of 28 items completed by the patient. The PRI uses a yes–no format and produces one
reliable score indicating level of reactance in the therapy session or to psychotherapy more generally. In contrast,
each item of the TRS is rated on a four‐point Likert‐type scale, anchored from strongly agree to strongly disagree,
in which higher scores suggest greater levels of resistance (Buboltz, Johnson, & Woller, 2003). This measure
produces a total score and two subscores. The Total Score indicates overall level of receptivity to psychotherapy.
The TRS subscores differentiate between verbal reactance and behavioral reactance. Items that load on the
Verbal Reactance Scale scores are reflective of such qualities as verbal negativity and argumentativeness.
Behavioral reactance reflects the presence of oppositional behavior. Elevations on this latter scale include
questions such as “I have a strong desire to maintain personal freedom” and “I find that I often have to question
authority.” In both cases, the items address the patient’s current actions and impulses, not only within their
current psychotherapy but in their daily life. Thus, trait aspects of reactance are obscured and confounded with
more situational events in this scale.
Some measures of trait‐like resistance are available in the scales of omnibus personality tests. Several studies in
the meta‐analysis utilized scales drawn from one of versions of the Minnesota Multiphasic Personality Inventory
versions (MMPI‐1, MMPI‐2; Butcher, Beutler, Harwood, & Blau, 2011). Two general scales and three content
subscales possess content consistent with the trait of resistance (Butcher et al., 2011). These are Pd (psychopathic
deviate), Pa (paranoia), TRT (treatment readiness), CYN (cynicism), and ANG (anger). The general scales are
empirically derived and tap global personality characteristics and are represented in clinical populations whereas
content scales are derived from apparent similarity of items. The general scales are the usual scales that are
administered and graphed when the MMPI‐2 is used in clinical practice. Combinations of the foregoing scores were
successfully used in several studies of resistance levels (e.g., Beutler et al., 1991; Karno, Beutler, & Harwood, 2002).
STS/innerlife (Beutler, Williams, & Norcross, 2008) is a cloud‐based psychological assessment (www.innerlife.
com) that consists of 173 items. STS/innerlife produces an intake narrative and recommended treatment plan along
with graphic and narrative information on six global symptom measures (depression, anxiety, somatic complaints,
chemical abuse, thought disorder, and risk of self‐harm) and up to 16 symptom domain scales. In addition, several
scales from the innerlife yield patient trait qualities based on continuous measures, including patient reactance
level. Patient resistance is conceptualized as an enduring, cross‐situational trait within the innerlife, making it the
only instrument listed in this chapter that explicitly does so. STS/innerlife scales have yielded moderate‐to‐high
reliabilities (mean of α’s = 0.85; Beutler., 2009) and requires from 15 to 35 min to complete on an iPad, iPhone, or
computer.
The most frequently used research design keeps the diagnosis constant across patients and then compares two
or more treatments using a randomized controlled trial (RCT). In this case, the focus of the investigator is on the
effects of a particular brand of psychotherapy, not the role of resistance. The level of fit and the role of reactance
are afterthoughts. No individual‐level measurement of personal traits like resistance is likely to be included and
BEUTLER ET AL. | 5
frequently, neither are individual‐level measures of directiveness. The patient’s diagnosis is used to infer patient
reactance and one’s therapeutic school is used to infer level of directiveness.
For example, suppose investigators conduct an RCT in which two brands of psychotherapy—Cognitive Therapy
(CT) and Motivational Enhancement (ME)—are applied to clients with a diagnosis of alcohol dependence. The
investigators find that the two treatments do produce comparable outcomes. If they want to further investigate the
hypothesis that a poor fit between patient reactance levels and therapist directiveness inhibits improvement, they
are forced to do so retrospectively and most often use an indirect measure of both the major variables. They might
take therapy type as a proxy variable for directiveness—surely this would be justifiable via the distinctive theories
of these two approaches. They might also take the diagnosis itself as a proxy for reactance—Alcoholics are as a
group generally reactant to treatment. They now have two levels of directiveness (high and low) with a highly
reactant group. The investigators might propose that with this highly reactant population, ME would be a better
intervention than CT. But the relative effectiveness of the treatments might be due to the treatments regardless of
the resistance level of the patients.
“Kate,” a 28‐year‐old, Caucasian, heterosexual female presented to psychotherapy after losing custody of her child
in a divorce action. Kate described an extensive history of substance use, as well as a series of traumatic
6 | BEUTLER ET AL.
experiences resulting from an abusive marriage and subsequent homelessness. She also lived a life fraught with
efforts to disengage from and avoid any hint of someone’s directiveness or control over her, portending the
presence of poor interpersonal engagement that probably was linked to her high resistance.
On intake, Kate was administered the STS/innerlife (Beutler et al., 2008), which revealed elevations in
depression and anxiety on the global scales. She also scored in the clinical range on measures of social anxiety,
family‐related distress, and posttraumatic stress disorder on more narrowly defined scales. On treatment planning
scales, she was very high on the Resistance/Reactance scale.
Although Kate was compliant with treatment at the onset of psychotherapy, her high reactance became
increasingly apparent as her treatment progressed. For example, her therapist’s behavior was typically followed by
an oppositional act on Kate’s part. When the therapist leaned forward, Kate consistently moved backward in her
seat. Moreover, she missed several appointments with her therapist, often blaming public transportation or last‐
minute meetings for her tardiness or absence. When the therapist provided homework assignments, Kate found
ample reasons to not complete them, earning high in‐session scores on reactance.
As her history unfolded, the persistence and generalizability of this pattern became apparent and suggested the
presence of an attachment style that varied from avoidant to attached, probably reflecting a lack of readiness for
accepting directive and guided change. Although Kate voiced an interest in engaging in psychotherapy and changing
her behaviors, she demonstrated otherwise when the therapist took a more directive stance, such as assigning
homework and requesting that Kate attend community support groups.
In response to Kate’s high reactance, the therapist decreased her own level of directiveness. Rather than
encouraging the patient to engage in exposure methods for her trauma, the therapist made statements that
supported and even prescribed her withdrawal, such as “I don’t want you to expose yourself to any situation or
person that could be reminiscent of traumatic experience.” The practitioner aimed to build a trusting alliance with
Kate by acknowledging and occasionally advocating for avoidance as a paradoxical intervention.
With regard to Kate’s substance use, the therapist adopted a relatively nondirective, more collaborative
approach to change, but occasionally inserted a more directive procedure as a means of undermining her
resistance. For example, the sessions largely addressed her resistance by incorporating MI techniques, but when
she became particularly oppositional, the therapist met her resistance with a prescription of the symptom or a
directive to avoid changing until she becomes “ready.” These paradoxical injunctions were intended to meet Kate
where she was in readiness for behavioral change. Practicing in this manner allowed Kate both to assume more
control of her behavior and to allow her resistance to sufficiently subside such that psychotherapy eventually
proved successful. Had Kate’s high reactance met with high therapist directiveness, we fear that she would have
terminated treatment prematurely.
The primary aim of the current meta‐analysis was to investigate a causal moderating influence of patient reactance
on psychotherapy outcome. Specifically, we sought to test the hypothesis that high reactant patients would benefit
more in relatively low‐directive treatments whereas low reactant patients would benefit more from relatively more
directive treatments.
criteria: (a) Investigated psychotherapy outcome with actual patients and psychotherapists; (b) used a quantifiable
measure of clinically relevant outcomes; (c) used an RCT or modified RCT design with a sample size of 10 or more;
(d) provided the numerical data needed to calculate effect sizes that indicate the magnitude of effect on treatment
exerted by the match of therapist/therapy directiveness and patient resistance; and (e) was published in a
scientifically recognized and peer‐refereed English‐language journal.
While not identical with the criteria used to select studies in the 2011 meta‐analysis, the criteria overlap and
encompass the previously used criteria. In a practical sense, by insisting on the use of an RCT design, the inclusion
criteria for this meta‐analysis and those for the 2011 study are similar. Both searches used either direct (e.g., the
use of an individual, reliable measure completed by a clinician or patient) or indirect (e.g., assignment based on
group membership) measurement of the targeted variables.
When reviewing the studies, the first question addressed by the coder was whether the study investigated
real psychotherapy with real patients. Second, the coder determined whether each of the three constructs
(outcome, resistance, and directiveness) used individual measurement. The third question addressed whether
any proxy variables could be identified that would substitute for the absence of an individual‐based
assessment of these three variables. If so, the calculation was provided and the range and reliability of the
proxy variable was noted. In most cases, the proxy variables were categorical in nature (e.g., diagnosis or
treatment brand).
Seventeen new studies were identified in a preliminary but thorough literature search of indexed listings,
abstracting services, and primary journals using multiple search terms. Web‐based databases such as, PsycINFO,
MEDLINE, and others were used to search. We used a variety of synonymous terms, such as: “Resistance” and/or
“Reactance,” “Psychotherapy,” “Treatment Outcomes,” “Directiveness,” and “Difficult Patients.” We specifically
searched for studies that analyzed the effect of matching patient resistance and therapy or therapist directiveness.
Fourteen of the 17 new studies did not meet the inclusion criteria for the current meta‐analysis. Most often this
was because the study lacked a quantitative measure for level of directiveness (n = 3; 19%) or lacked a quantifiable
measure of resistance (n = 4; 44%).
sizes were calculated for the main effects of both reactance and directiveness. The numbers of studies
reporting ESs for directiveness (k = 6) alone and for resistance (k = 3) alone were small.
5 | RES U LTS
The results of the meta‐analysis, based on 13 studies and 1,208 patients, are summarized in Table 1. The studies
yielded 14 mean effect sizes that addressed the fit or match between reactance and directiveness in treatment
TABLE 1 (Continued)
outcomes. The aggregate effect size for the fit between reactance and directiveness was a d of 0.78 (SE = 0.1;
p < .001; 95% CI: 0.60–0.97). That ES is considered large in magnitude.
A smaller number of mean effect scores were available to test the independent role of directiveness
(k = 6) and resistance (k = 4). The effect sizes of directivenes and reactance, as independent contributors
to outcome, were (d) 0.40 and 0.54, respectively. These ESs are considered moderate. The effective
therapist may not only adjust her therapeutic stance in response to the patient’s resistance, but keep
patient resistance low and successfully use directive interventions independently of patient resistance
levels.
The effects for the interaction of patient reactance and therapist directiveness were not homogenous
(Q = 52.48 and 0.08; p < 0.001). Thus, between‐study differences accounted for variability of the effects for the fit
between reactance and directiveness.
The weighted average effect size for studies which used direct measures of resistance (k = 12) were compared
to those which used indirect measures of resistance (k = 2). The resulting weighted average effect size for the
studies using direct measures was 0.88 and for those using indirect measures was d = 0.26, which is notably smaller.
The discrepancy between these effect sizes indicate that indirect measures are less sensitive than direct measures,
as was found in the earlier meta‐analysis (Beutler et al., 2011).
The results indicate that if patient reactance is not met with confrontation and control, but with acceptance and
nondefensiveness, good things are more likely to happen in psychotherapy. Not quite as clearly, but suggested by
the linearity and strength of the findings, was the indication that the reverse is also true. These results suggest that
10 | BEUTLER ET AL.
reactant patients have better outcomes in nondirective treatments whereas directive interventions may be
indicated for patients with lower levels of resistance.
6 | L I M I T A T I O N S O F TH E R E S E A R C H
There are several limitations to consider when reviewing the results of the current meta‐analysis. We included only
studies published in the English language and only studies that utilized an RCT methodology. As long as one applies
the findings within an English‐speaking environment, the findings are likely to generalize. We find no immediate
evidence to suggest that international studies published in non‐English journals and studies employing other
research designs may detract from the current results.
Additional limitations concern the types of measures used to quantify the patient and therapy constructs in the
analyzed studies. Table 1 reveals that in 10 of the 13 studies in this meta‐analysis, reactance was measured
indirectly, rather than directly. The analysis demonstrated that these indirect measures are less sensitive and
probably less accurate than direct ones. Use of indirect or proxy measures unnecessarily homogenizes the samples,
since they are group measures of individual differences. Given these limitations, we strongly recommend that
researchers exploring reactance and clinicians applying these principles use direct measures for both therapist
directiveness and patient resistance whenever possible.
Likewise, the use of brand‐name psychotherapies as proxies for therapist directiveness contributes error and
proves less sensitive than a direct measure. These indirect measures may unwittingly lead practitioners to conclude
that the results apply only to those psychotherapies included in reviewed studies. For example, in the current meta‐
analysis, one of the new research studies and three of the older ones used MI as a proxy for low directive therapy.
Thus, our meta‐analytic results might reflect both the effects of low directiveness and some specific strength or
weakness associated with MI, at least in those studies.
In the future, we recommend that researchers ensure that a broad range of therapies and at least two well
defined patient groups are represented in such analyses as presented here. When possible, it would also prove
valuable for research and practice to move away from global brands and toward the use of clusters of like‐
techniques representing the principles that are linked to effective change.
7 | D IV E R S I T Y C O N S I D E R A T I O N S
Despite efforts in the research community to include culturally representative samples, a large proportion of
studies continue to focus on Western populations. The majority of the studies included in the meta‐analysis took
place in a Western culture, mainly the United States. Reactance may appear in a different form or at different levels
among non‐Western cultures than they do in Western cultures. Further, individuals from one of these non‐Western
societies may respond differently than that observed in this review, especially as related to directive and
nondirective approaches. For instance, research shows that Asian Americans regard mental health professionals as
authority figures and welcome a more directive form of psychotherapy (e.g., Sue & Sue, 1999; Wong, Beutler, &
Zane, 2007). That observation may also prove to be the case for patients of other cultural identities, such as gender,
sexual orientation, socioeconomic status, and religious affiliation.
Some cross‐cultural comparisons of patient reactance × therapist directiveness have been explored by
research. While similarity to North American samples is the norm among South American and European studies
(e.g., Beutler et al., 1991; Corbella et al., 2003), there are some indications of differences among Asian and non‐
Asian populations (e.g., Beutler, 2009; Song et al., 2014). To date, the patterns related to reactance seem to
transcend geographic and ethnic boundaries, but some distinctiveness appears also to be present among Asian
groups.
BEUTLER ET AL. | 11
8 | THERAPEUT IC PRACTICES
Based on the cumulative research, now spanning several decades and more than a dozen controlled trials, we close
by offering the following clinical recommendations for improving psychotherapy outcomes:
1. Assess routinely a patient’s reactance level (as a personality trait) and in‐session resistance behaviors (as an
environment‐specific state).
2. Learn to recognize symptoms of state and trait reactance and come to differentiate between them.
3. Consider the possibility that the particular therapeutic approach itself may be creating or magnifying patient
reactance, beyond the ubiquity of the human aversion to change. As evidenced by the meta‐analytic review,
intervention low directiveness is a counter to patient resistance.
4. Maintain or re‐establish a collaborative stance to approach high‐reactance patients. This may involve an
element of transparency—openly naming the patient’s resistance and exploring how the therapist’s methods
fuel such resistance (Ellis, 2004).
5. Respond thoughtfully and sensitively to reactance, including acknowledging the patient’s concerns through
reflecting, speaking candidly about the therapeutic relationship, adjusting the treatment contract to include more
patient control, exploring underlying mechanisms that motivate reactance, and shifting from resistance to change.
6. Follow the research‐supported match: More directive and structured therapy with low reactance patients.
Become more of a guide and an oracle, and even a teacher, but selectively. Doing so will generally bring better
therapeutic results.
7. Emphasize the patient’s self‐control, employ a less directive stance, and consider paradoxical
interventions with highly reactant patients. A therapist may be less of a technician who fixes things
and more of a healer who understands and values things. Doing so will also typically yield better
therapeutic results.
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How to cite this article: Beutler LE, Edwards C, Someah K. Adapting psychotherapy to patient reactance
level: A meta‐analytic review. J. Clin. Psychol. 2018;1–12. https://doi.org/10.1002/jclp.22682