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Beutler L.E., Harwood M.T., Michelson A. et al.
Journal of Clinical Psychology: 2011, 67(2), p. 133–142.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Beutler at email@example.com.
Meta-analytic review commissioned by a US task force concludes that psychotherapy patients who characteristically exhibit low levels of resistance or reactance respond better to directive types of treatment, while reactive patients prone to resist direction respond best to non-directive approaches.
Summary Psychotherapists from all professions and perspectives periodically struggle to effectively manage a patient's resistance to change. This article provides definitions and examples of patient-treatment matching applied to patient resistance or reactance. Resistance was originally seen as an inherent striving to avoid, repress, or control conflicted thoughts and feelings. Reactance is now usually the preferred term and has been defined as a "state of mind aroused by a threat to one's perceived legitimate freedom, motivating the individual to restore the thwarted freedom". Reactance implies that the psychotherapy environment, including the psychotherapist, plays a role in inducing noncompliance. We report the results from an original meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. of 12 select studies involving 1102 clients on matching therapist directiveness Therapist directiveness refers to the extent to which a therapist dictates the pace and direction of therapy and communicates a direction of needed change, as well as the overall predominance of control established by the therapist to elicit change. That is, directiveness refers to the degree to which the therapist is the primary agent of therapeutic process or change through the selection of specific techniques and/or the adoption of a specific interpersonal demeanour. Directiveness imposes a constraint on the client's available options, or his or her freedom – the very conditions which elicit reactance. to patient reactance. It was expected that reactive clients would do relatively poorly if assigned to therapists or therapies characterised by a directive therapeutic style, and relatively un-reactive clients would benefit from a directive style. Studies were selected which maintained a relatively uniform methodology and adequate description to ensure consistency in the calculation of the strength of the relationship (expressed by the effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. metric) between outcomes and the fit between client reactance and therapy directiveness. We believe these represent the best available evidence on this issue. All but one of the selected studies employed a manual-driven therapy and randomly assigned clients to different therapy conditions. Several derived from the Project MATCH trial of matching alcohol-dependent patients to three different types of therapies.
There was some evidence that (as expected) reactive patients tend to benefit least from therapy overall, which itself suggests that therapists would do well to avoid inciting reactance. This implication seemed confirmed by the main analysis, which assessed the fit of therapist directiveness to patient reactance through direct measures of the individual patient's resistance, the therapist's directiveness, or both. Again as expected, the better the fit between client reactance and therapy directiveness (more reactance less directiveness), the better the outcomes. This relationship was quite strong, equating across all relevant studies to an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of 0.82, indicating that about 15% of the variation in outcomes may reflect the fit between directiveness and patient reactance. However, the range of effect sizes was relatively wide, suggesting that other influences affect the strength of the relationship.
These results support the hypothesis that patients who characteristically exhibit low levels of resistance or reactance respond better to directive types of treatment, while patients prone to be reactive or resistant respond best to non-directive treatments. Practice recommendations based on these findings include matching therapist directiveness to patient reactance. High reactance indicates a treatment which de-emphasises the therapist's authority and guidance, employs tasks designed to bolster patient control and self-direction, and de-emphasises the use of rigid homework assignments. Self-directed work and reading may replace the usual instructional activities of the therapist. In general, therapists should avoid counterproductively stimulating the patient's level of resistance.
commentary This article was in a special issue of the Journal of Clinical Psychology devoted to adapting psychotherapy to the individual patient. For other Findings entries from this issue see:
What works for whom: tailoring psychotherapy to the person
Adapting psychotherapy to the individual patient: Stages of change
Adapting psychotherapy to the individual patient: Preferences
Adapting psychotherapy to the individual patient: Culture
Adapting psychotherapy to the individual patient: Coping style
Adapting psychotherapy to the individual patient: Expectations
Adapting psychotherapy to the individual patient: Attachment style
Adapting psychotherapy to the individual patient: Religion and spirituality
A Findings review has specifically analysed the relationship between client reactance and therapist directiveness among addiction patients and whether this can be used to improve treatment outcomes. Since that review and since the featured review other studies will have been published. Among them is a study (free source at time of writing) of 12 weeks of telephone aftercare for people treated for their methamphetamine use problems. At random patients were allocated to this delivered in a non-directive style versus a directive style. Patients allocated to the non-directive option responded about equally well in terms of their stimulant use during the aftercare delivery period whether or not before treatment they had scored as high on reactance. However, the more directive approach was reacted to differently. High reactance patients did worse than the average with non-directive option, low reactance patients better – the expected result if reactive patients respond badly to being ‘told what to do’ while more compliant patients welcome direction. However, another nine months later there was no such interaction; high reactance patients were doing worse than less reactant patients regardless of whether they had been allocated to directive or non-directive counselling.
Last revised 14 November 2018. First uploaded 09 March 2011
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REVIEW 2018 Psychotherapy relationships that work III