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DOI: 10.1002/jclp.

22682

RESEARCH ARTICLE

Adapting psychotherapy to patient reactance


level: A meta‐analytic review

Larry E. Beutler | Christopher Edwards | Kathleen Someah

Clinical Psychology, PhD Program, Palo Alto


University, Palo Alto, California Abstract
Resistance and its extreme variation, reactance, are
Correspondence
Larry E. Beutler, PhD, 2620 Piedra Verde uniformly observed across varieties of psychotherapy.
Court, Placerville 95667, CA. Social psychologists note that reactant individuals prove
Email: larrybeutler@yahoo.com
to be less so when offered a receptive and nondirective
environment. We provide definitions of reactance, review
its frequent measures, and offer a clinical example. A
meta‐analysis of 13 controlled studies (1,208 patients)
examined the degree to which treatment outcomes are
enhanced when therapists offer less directive treatments
to high‐reactance patients. The results revealed a large
effect size (d = .79), confirming that highly reactant
individuals did better in psychotherapy when the thera-
pist assumed a reflective and nondirective stance than a
directive and authoritative one. To a lesser degree, the
opposite was also true. Limitations of the research and
diversity considerations are noted. Practice recommen-
dations are provided to minimize a patient’s reactant
behavior.

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

J. Clin. Psychol. 2018;1–12. wileyonlinelibrary.com/journal/jclp © 2018 Wiley Periodicals, Inc. | 1


2 | BEUTLER ET AL.

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

2.1 | Defining reactance level


Resistance is the tendency of an individual patient to avoid making the changes advocated by the therapist. As we
have noted, reactance is an extreme example wherein the patient not only resists, but changes in a direction away
from that advocated by the therapist. In a practical sense, a therapist intuitively knows that a resistant patient may
not carry out homework or may behave in ways that ensure the maintenance of the symptoms. In contrast, a
reactant patient may do the homework but even the simplest assignments will be wrong. Or the reactant patient
may suddenly have more symptoms and to be highly distressed about things the therapist says or recommends.
As this latter definition suggests, the clinician plays an integral role in the formation of resistance through the
use of demanding and authority‐based directives. In contrast, the therapist could relieve reactance by noting and
changing communication patterns that subsequently initiate reactance on the part of the patient. Strong and
Matross (1973) emphasized that resistance emerges through the therapist’s request for change, not the behavior
change itself. This is an important distinction for a therapist to remember.
BEUTLER ET AL. | 3

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.

2.2 | Measuring reactance level


Patient reactance can either be caused by situational (state) or temperamental (trait) variables. Likewise, their
measurement can be either direct or indirect. Although direct measures both of patient reactance and therapist
directiveness are obviously superior, indirect measures are usually used because typically direct measures are not
available within a particular study.
Few reliable observational tests of patient resistance exist. Moreover, many (or most) relevant studies of the fit
of patient and therapist are not intentionally aimed at this phenomenon and did not use direct measures to
measure a patient’s resistance. When direct measures are not available, it is necessary to use indirect measures. In
the case of patients, these indirect measures usually take the form of diagnoses, under the assumption that people
with certain disorders (e.g., paranoid personality, antisocial personality, etc.) are imbued with a proclivity to be
resistant.
While it is logical that individuals with paranoid personality disorder are likely to be more resistant than groups
of patients with unipolar depression, unfortunately, most treatment studies are designed to test the efficacy of one
or more treatments on a single diagnostic group. Thus, a post hoc measure of resistance via diagnoses assigns all
patients with the same diagnosis to the same “resistance” level. The lack of within group variation in subsequent
scores reduces the sensitivity of the measure. Thus, it is important in reviewing the literature to specify when direct
observations are being used versus the articulation of indirect inferences are based on group level indicators (e.g.,
diagnosis). When identifying the effects of a patient quality, one must remember that studies with indirect
measures are likely to underestimate true effects related to patient resistance.
The most used direct measures of patient resistance in studies in this review are those that look at compliance
with homework or in‐session behavior as continuous indices of resistance. Less direct measures, but ones that
are nonetheless aimed at individual behavior, are drawn from a personality test or an interview where a complex
score for resistance is computed for each individual. Many of these measures focus on a particular point in time or
a particular setting; they are “state” measures rather than “trait” measures. State measures may tell us about a
specific point in time, but do not work if we want to use a knowledge of the patient’s reactance to plan a
therapeutic approach over a period of time. There, trait measures generally prove more useful.
Instructions on a test that ask a patient to rate the current moment or event is a state measure, while a trait
measure usually asks one to rate the “past few” weeks or sessions. This kind of measure (depending in part upon the
number of items included) yields a continuous score that is preferred over single item scales among psychotherapy
researchers because of its relative sensitivity. Such measures also allow for coding patient reactance from their
behaviors, such as missed appointments or repeated failures to complete homework assignments (Karno &
Longabaugh, 2005a; 2005b; Westra, Aviram, Kertes, Ahmed, & Connors, 2009).
The measurement of reactance also can be measured nominally (i.e., categorically). Two such categorical
measures, the Adapted Client Resistance Code (Westra et al., 2009) and the Client Resistance Code (CRC;
Chamberlain, Patterson, Reid, Kavanagh, & Forgatch, 1984), have been used in studies of patient resistance. The
CRC delineates 11 categories of resistance behavior. Patients are identified by which category best fits them.
Resistance is identified as one of the 11 varieties, all of which depict behaviors that interfere with the direction of
psychotherapy. Ratings are made by the therapist based upon verbalizations from the patient. Thus, although these
measures are clearly direct, some of the classifications require an inference.
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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.

2.3 | Defining therapist directiveness


Linking therapist’s behavior (level of directiveness) to the reduction of patient reactance is the nucleus of research
considered in our meta‐analysis. The motivation that produces resistance from this perspective, and the key to its
treatment, has been described as, “a state of mind aroused by threat to one’s perceived legitimate freedom,
motivating the individual to restore the thwarted freedom” (Brehm & Brehm, 1981, p. 4).
Directiveness is defined as the degree to which the therapist uses suggestions, interpretations, and assignments
to guide the patient’s movement through psychotherapy. Directiveness may apply both to the use of techniques
within the therapy session and to the use of homework outside of the session. The clinician can be directive in
making a request or setting topics and leads for the session.

2.4 | Measuring therapist directiveness


Indirect measures of therapist directiveness, based on the type of psychotherapy, are relatively easy to apply and
are frequently the only ones that are available to investigators. Certain treatment orientations are considered more
directive than others. For instance, prior research has used Cognitive Behavioral Therapy (CBT) as a measure of
high directiveness and Motivational Interviewing (MI) as low directiveness (Karno & Longabaugh, 2005a; 2005b).
Traditionally, CBT entails that the therapist adopts an active, structured stance. For instance, a CBT therapist may
guide a patient through interventions such as cognitive restructuring and incorporate the use of homework to be
completed in between sessions. In contrast, MI involves rolling with the patient’s resistance and working with the
patient where they are at in terms of motivation for change.
One of the few direct measures of therapist directiveness is the Therapy Process Rating Scale (TPRS; Fisher,
Karno, Sandowicz, Albanese, & Beutler, 1995), which is rated by trained external observers. The revision of the
scale permits the therapist or supervisor to make ratings as well as an external rater. The measure yields five
scores: (a) Therapist directiveness, (b) facilitating change through insight/awareness, (c) focus on symptom change,
(d) therapist skillfulness, and (e) facilitating change through the induction of arousal.

3 | CLIN IC AL EXAMP LES

“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.

4 | META‐A NAL YT IC REVIEW

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.

4.1 | Literature search


To build on the research from our previous meta‐analysis (Beutler et al., 2011), we undertook an extensive
literature review. Relevant research studies were included in the meta‐analysis if they satisfied the following
BEUTLER ET AL. | 7

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%).

4.2 | Coding and calculating effect sizes


The final sample for the current meta‐analysis consisted of 11 studies from the 2011 meta‐analysis and the
two new studies found in the literature search, for a total of 13 studies. Three effect sizes were extracted
from each of the articles, when possible: (a) The mean effect size of patient resistance/reactance on
treatment outcome; (b) the mean effect size of the level of therapy/treatment directiveness (i.e., more
directive vs. less directive); and (c) the overall effect of matching therapeutic directiveness to patient
reactance level.
The effect size used throughout this study was Cohen’s d, which was calculated by determining the
difference in means between groups and dividing the results by the pooled standard deviation (Borenstein,
Hedges, Higgins, & Rothstein, 2009). When means were not available, the effect size (ES; d) was estimated
directly from significance tests according to the procedures or equations indicated by Lipsey and Wilson (2001)
and then transformed to d. The signs of the ESs in all cases were changed when necessary to ensure that
positive signs indicated support for the hypothesis. Multiple outcomes within studies were aggregated using
the method of Borenstein et al. (2009).
To determine the overall effect of fit between patient reactance and therapist directiveness, we used a
random‐effects meta‐analysis using Wilson’s (2005) SPSS macros. Similar to the previous meta‐analysis,
interaction effects were examined by eliciting ESs as the product of the patient and therapist variables, using
all studies that related to a “fit” of reactance and directiveness. The resulting ESs from each study were used
to calculate a mean ES across studies by weighting each study by the inverse of its variance. As well, effect
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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

T A B L E 1 Summary of Studies in Meta‐Analysis

Measure Measure Number M ES M ES V of


References N Design resistance directiveness of ES (direct) (resist) M ES (fit) fit ESs

Calvert 108 RCT D (FIRO‐B) D (TOQ) 1 0.52 0.019


et al. (1988)
Beutler 62 RCT D (MMPI) I (CBT vs FEP 3 0.34 0.88 0.07
et al. (1991) vs S/Sd)
Beutler 63 RCT D (9 scales) I (BEH vs ND) 9 0.62 0.065
et al. (1991)
Beutler 46 RCT D (MMPI) D (TPRS) 1 0.33 1.4 0.11
et al. (1993)
Piper 98 RCT D (QOR) I (Interp vs 4 0.31 0.43 0.64 0.021
et al. (1999) insight)
Karno 47 RCT D (MMPI) I (FST vs CBT) 1 0.46 0.42 0.65 0.044
et al. (2002)
Karno and 140 RCT D (anger) D (TPRS) 3 1.16 0.017
Longabaugh
(2004)
138 RCT D (anger) I (MET 2 0.43 0.014
vs CBT)
Karno and 169 RCT D (obs) D (obs) 4 1.21 0.014
Longabaugh
(2005a)
Karno and 139 RCT D (self‐re) I (TPRS) 6 1.12 0.017
Longabaugh
(2005b)
Clarkin 62 RCT I (BPD) I (DBT vs Pdyn 3 0.14 0.065
et al. (2007) vs Support)
Gregory 30 RCT I (BPD) I (Pdyn 4 0.52 0.068
et al. (2008) vs TAU)
Westra 76 RCT D (CMOTS) I (MET before 3 0.53 0.92 0.9 0.057
et al. (2009) CBT vs
no MET)
Aviram, Westra, 30 RCT D (VNIS I (MET) 5 0.49 0.75 0.014
et al. (2016) and obs)
Total (N) 1208
ES weighted by 0.4 0.54
sample size
(Continues)
BEUTLER ET AL. | 9

TABLE 1 (Continued)

Measure Measure Number M ES M ES V of


References N Design resistance directiveness of ES (direct) (resist) M ES (fit) fit ESs

ES, random‐ 0.78


effects model (0.6–0.97)*
(CI 95%)
Q (random‐ 52.48
effects (0.086)*
variance
component)

Note. Design = randomized clinical trial


Measures of resistance and directiveness = Measure of resistance and directiveness are either directly measured (D) or
indirectly measured (I). Specifically, D indicates the use of direct observational ratings of directiveness (obs) or a standardized
trait measure (e.g., the MMPI, QOR‐Quality of Object Relationships, FIRO‐B, VNIS, or STS‐Clinician Rating Form) applied to
each individual. I indicates that an indirect measure of resistance was used based upon a grouping variable such as patient
diagnosis — e.g., borderline personality disorder (BPD) or substance abuse disorder (SAD) to indicate resistant groups. Among
measures of Directiveness, D indicates the use of a direct rating of therapist acts in treatment —for example, using an
observational rating like the Therapy Process Rating Form (TPRS), or a simple observational rating (obs). I indicates the use of
an indirect measure of directiveness, based on the general directiveness of the treatment model used. Below are identifiers of
the direct and indirect measures of the directive and nondirective treatments employed.
N ES/Study = Number of effect sizes calculated for this study; M ES (Direct) = the mean effect size attributable to the
directiveness of the treatment—combining all treatments ; M ES (Resist) = the mean effect size attributable to the resistance
variable—combining all varieties; M ES (Fit) = the mean difference between Effect sizes for “good” and “poor” fit, estimated
in MR/Nat studies from correlational data.
TOQ = Therapist Orientation Questionnaire — a measure of therapist directiveness; Pdyn = psychodynamic treatment —
moderately directive; TAU = treatment as usual, nondirective; BEH = Behavioral Tx, directive; ND = nondirective or
reflective, nondirective; CBT = cognitive therapy, directive; FEP = focused expressive therapy, low directive; Interp =
interpretive, highly directive; FST = family systems; NT = narrative therapy; MET = motivational interviewing, nondirective;
DBT = dialectic behavior therapy, directive; Support = supportive therapy, nondirective
All ESs are expressed as d.
*p < .001.

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
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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