reactance and therapeutic noncompliance

Cognitive Therapy and Research , Vol. 23, No. 4, 1999, pp. 373-379

Reactance and Therapeutic Noncompliance 1

Cynth ia A . Seibel2 and Edmund Thomas Dowd 3

We explored the behavioral correlates of reactance in actual psychotherapy relation-ships. Ninety client± therapist pairs particip ated. Clients completed a well-being im-provement rating and two reactance measures. Therapists rated improvement in clientglobal functioning, medication compliance, 61 client behaviors during therapy, andpremature termination. Reactance was negatively associated with global improvement,positively with premature termination , but not with medication compliance. Reactancewas positively associated with a set of interpersonal distancing behavio rs labeledBoundary Augmentation and weakly with boundary reducing behaviors. Reactancewas not associated with behaviors indicative of a collaborative relationsh ip nor ofdisengagement from therapy. Improvement was positively associated with a collabora-tive relatio nship and negatively with boundary-reducing behaviors.

KEY WOR DS: reactance ; noncompliance ; resistance .

REA CTA NCE A ND THERA PEUTIC NONCOMPLIA NCE

Beutle r (1979) originally propose d that psychologic al reactance is a personality

variable that might mediate therapeutic process and outcome . Subsequent investiga-

tions (Dowd, 1993) indicate d that reactance was associated with a varie ty of opposi-

tional-type behaviors. Therefore , psychological reactance (Brehm, 1966; Brehm &

Brehm, 1981) might be associate d with compliance behaviors in therapy.

Psychologic al reactance has been de ® ned as the motivational force to restore

lost or threatened freedoms (Brehm, 1966) . Brehm and Brehm’s (1981) research

suggests that situational threats to freedom elicit motivation to restore freedoms

across individuals.

In mental health treatment, there are myriad opportunitie s for the arousal of

reactance . Treatment is typically administe red by an ``expert’ ’ or ``authority’ ’ who

1This article is based in part on a dissertation conducted by the ® rst author under the direction of the

second author. An earlie r version was presented at the 1994 Annual Meeting of the Society for theExploration of Psychothe rapy Integration, Buenos Aires, Argentina.

2Portage Path Community Mental Health Center.3Kent State Unive rsity. Correspondence should be addresse d to Thomas Dowd, Departme nt of Psychol-ogy, 118 Kent Hall, Kent State Unive rsity, Kent, Ohio 44242.

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0147-5916/99/0800-0373$1 6.00/0 Ó 1999 Plenum Publishing Corporation

374 Seibe l and Dowd

may be perceived as prohibiting certain behaviors, attitude s, and life style s (e.g.,

smoking, competitive achievement). Such prohibitions , whether implicit or explicit,

may arouse reactance . Even low-pre ssure recommendations to engage in presum-

ably attractive behaviors, such as taking more vacations or viewing oneself more

positive ly, threaten the freedom to engage in other behaviors and may elicit re-

actance .

Psychothe rapy noncompliance has been examined as a function of individual

diffe rences in client reactance to therapist social in¯ uence (Dowd, 1993; Dowd &

Sande rs, 1994; Graybar, Antonnuccio, Boutilie r, & Varble , 1989) . Investigators

have propose d tailoring psychothe rapy inte rventions according to client diffe rences

in reactance . For example , it has been hypothe sized that highly reactant clients

may bene ® t from paradoxical interventions (Rohrbaugh, Tennen, Press, & White ,

1981) . Graybar et al. (1989) found that high-reactant patients exhibited a greater

reduction in smoking after a low amount of negative ly toned advice , whereas for

low-reactant patients, a higher amount of either negative ly or positive ly toned

advice was more effective . Dowd and Sande rs (1994) sugge st those high-re actant

clients whose proble ms are ego-syntonic would be especially dif® cult to treat. Other

inve stigations (Dowd & Wallbrown, 1993; Dowd, Wallbrown, Sande rs, & Yes-

enosky, 1994) found that reactance was positive ly associate d with such personality

variable s as autonomy, dominance , and independence and negative ly associate d

with such variable s as af® liation, tole rance , inte rest in making a favorable impres-

sion, and nurturance Ð variable s with implications for noncompliance .

The purpose of this study was to investigate the relationship between client

psychologic al reactance and speci® c compliance behaviors and general improve ment

(as rated both by clients and therapists) in an actual therapy situation. We hypothe -

sized that measured reactance would be negative ly associate d with compliance and

global improve ment.

Method

Participants

Participants were 90 adult psychothe rapy clients recruited indire ctly through

the ir therapists with opportunity sampling of mental health facilitie s or private

practice s located in the Midwest and Northeast United State s. These 90 clients

represented 51% of those clients approache d. An attempt was made to include

clients in a varie ty of therapy settings and facilitie s. Therapists were also participants

as they completed a questionnaire regarding client diagnose s, history, and in-therapy

behaviors. Both clients and therapists received consent forms emphasizing that the

project was not connected with the agency and that participation was voluntary.

Therapists were requested to randomize selection of clients by soliciting partici-

pation from the next eligible client scheduled for an appointme nt after the therapist

had read the materials. They were instructed to exclude clients according to the

following criteria:

1. Diagnosis of mental retardation

2. Diagnosis of schizophre nia or other psychotic disorder

Reactan ce and The rape utic Noncom pliance 375

3. Diagnosis of mood disorder with psychotic feature s

4. Diagnosis of organic mental disorde r

5. Less than 21 years of age

6. In therapy for fewer than eight sessions

7. In crisis so that a request for research participation would be inappropriat e

The study was limited to clients who had been in therapy for eight or more sessions

to assure that therapists had enough data to comple te the detailed questionnaire

regarding client in-the rapy behaviors.

The majority of participants (59%) were receiving treatment at a community

mental health center or a private ly owned community mental health clinic. An

additional 22% of the sample was be ing seen in a private practice clinic or by

an independent licensed practitione r. Clients at unive rsity counse ling centers or

psychologic al clinics comprised 9% of the sample , and another 7% were incarce rated

clients receiving drug and alcohol counse ling through visiting therapists from a

private community agency. The remaining 3% were being treated in other settings.

Participants ranged in age from 21 to 60 (M 5 37.03; SD 5 8.68) . The sample

consisted of 60 women and 30 men. The majority Ð 91% Ð were Caucasian, with

only two African Americans, two Hispanic Americans, and one Oriental individual

included in the sample . This bias may be partly attributable to the opportunity

sampling of clinics and agencie s located in rural and semirural areas.

Participants had been in treatment for an average of 15.9 months (M 5 9

months, range 5 1 to 127 months; SD 5 18.1 months) . This distribution was highly

skewed, as most subjects (57%) had been in treatment for 12 months or less. Mood

Disorde r was the predominant Axis I diagnosis, with more than a third of the

sample falling in that category. Nearly 30% of the subjects were described as having

no Axis I diagnosis or a diagnosis of V Code or Adjustment Disorde r. Twelve

clients (13.3%) were diagnose d with Substance Use Disorde r, and 10 subje cts (11%)

carried diagnose s of Anxiety Disorder. An additional 10 participants carried ``othe r’ ’

diagnose s, including Dissociative Disorde r, Eating Disorde r, and Post-Traumatic

Stress Disorde r.

The therapists were asked to describe the ir theoretical orientation. A majority

(53.3%) listed cognitive ± behavioral, cognitive , or behavioral, with the remainde r

listing eclectic (15.6%), psychodynam ic (10%), client-centered or humanistic (8.9%),

and other (12.2%).

Instruments

Clients ® rst rated the ir own improve ment in well-be ing on a 5-point Likert scale .

They then completed two pape r-and-pencil measure s of reactance . The Therapeutic

Reactance Scale (TRS; Dowd, Milne , & Wise , 1991) is a 28-ite m Likert scale ranging

from ``strongly agree ’ ’ to `̀ strongly disagree.’ ’ Dowd et al. (1991) factor-analyzed

the scale into two subscale s, Verbal Reactance and Behavioral Reactance . Internal

consistency reliability has been reported as .84 (total scale ), .81 (behavioral) , and

.75 (verbal) . Test ± retest reliability has been reported as .59 (total scale ), .60 (behav-

ioral) , and .57 (verbal) . Validity has been demonstrate d by theoretically expected

correlations with other measure s (Dowd et al., 1991) . A sample item is, ``I resent

authority ® gure s who try to tell me what to do.’ ’


The Fragebogen zur Messung der Psychologisc hen Reactanz (Questionnaire for

the Measurement of Psychologic al Reactance ; QMPR; Merz, 1983) was deve loped in

Germany and translate d by the second author and his colle ague s. It consists of 18

items, rated on a 6-point Likert scale from Completely True to Not at All True .

Split-half reliability has been reported as .88, and test ± retest reliability as .86 (Merz,

1983) . Validity was demonstrate d by theoretically consistent corre lations. A sample

item is, `̀ Suggestions and advice often make me do the opposite .’ ’

The Therapist Questionnaire was devised for this study. In addition to ratings

of global improvement, premature termination, and medication compliance , it con-

sisted of 61 client-in-the rapy behaviors that the therapists rated for frequency of

occurrence on a 5-point Likert scale, from `̀ Never or Hardly Ever’ ’ to ``A lways

or Almost Always.’ ’ Item generation was based on a review of the treatment

noncompliance and resistance lite rature and they were drawn primarily from Otani’ s

(1989) theoretical taxonomy of client resistance . Examination of the sample means,

modes, standard deviations, and skewness measure s indicated that the majority

of the items displaye d good variability with distribution s approaching normality.

However, some items were highly skewed due to high or low incide nces of certain

behaviors (e.g., `̀ Exhibits ¯ irtatiousne ss’ ’ ). Eight psychologist s provided feedback

on item clarity, content validity, and length of time to assist in the development of

the scale .

Procedure

Clients who agreed to participate were given a research packet consisting of

a demographic sheet, the TRS, and the QMPR. They were permitted to complete

these forms in the waiting room or at home. Their therapists, not aware of the

hypothe ses of the study, comple ted the Therapist Questionnaire . In addition to

the rating of global improve ment and the client in-se ssion behaviors described

previously, they brie ¯ y described their own training, theoretical orientation, and

experience , as well as diagnostic information about the client.

Resu lts

Global improvement as rated by the therapist was negative ly correlated with

the QMPR (r 5 2 .23, p , .05) , the TRS± Total (r 5 2 .24, p , .05) , and the

TRS± Behavioral subscale (r 5 2 .33, p , .01) . Client rating of improvement in

well-be ing was positive ly related only to the TRS± Verbal (r 5 .28, p , .01) . None

of the reactance measure s were signi® cantly corre lated with medication compliance .

This study also assessed the relationship of reactance to premature termination.

Participants were divide d into two groups, those who had a history of premature

termination according to records and those who did not. Premature terminators

were signi® cantly more reactant on the TRS ± Total (t 5 2 1.97, p , .05) and the

TRS± Behavioral (t 5 2 1.97, p , .05) . There were no signi® cant diffe rences associ-

ated with premature termination for the TRS± Verbal or the QMPR.

A total of 48% of the 61 client-in-the rapy items on the Therapist Questionnaire 4

4Interested reade rs may obtain this questionnaire from the second author.


was signi® cantly corre lated with one or more of the reactance scale s. The patte rn

of results appeared supportive of the hypothe sis that reactance was associate d with

in-se ssion resistive behaviors. Because of the high intercorre lations between the

client-in-the rapy variable s and the large number of corre lations, a Principal Compo-

nents Factor Analysis was conducte d as a data reduction technique on 59 of the

61 client variable s. Two client variable s were omitted because they were applicable

to only 68% of the subje cts. The initial unrotate d matrix consisted of 15 factors

with eigenvalue s more than 1.0, accounting for 73% of the variance . Plotting of the

eigenvalue s sugge sted that four factors would most parsimoniously describe the

data so the set of items was subje cted to oblique rotation to a four-factor solution.

The four factors accounte d for 43% of the variance and all the client variable s

except one loade d above .30 on at least one factor.

The ® rst factor accounte d for 21% of the variance and was composed of items

that appeared to represent client attempts to control the leve l of therapeutic or

inte rpersonal in¯ uence (e.g., ``Behaves in argumentative manne r’ ’ ). This factor was

labe led ``Boundary Augmentation’ ’ due to the high number of items relevant to

inte rpersonal distancing behaviors. The second factor was labe led ``Boundary Re-

duction’ ’ due to the heavy representation of items denoting client attempts to

af® liate with the therapist or to increase the therapist’ s liking of the client (e.g.,

``Tries to elicit personal favors’ ’ ). Overall, this factor seemed to involve inte rpersonal

dependency. The third factor appeared to represent orientation toward the tasks

of therapy and was therefore labe led `̀ Collaborative Relationship.’ ’ This factor

seemed representative of client leve l of motivation and willingne ss to attempt new

behavior (e.g., `̀ Indicate s you’ ve in¯ uenced change ’ ’ ). The fourth factor5 was labe led

``Behavioral Disengage ment’ ’ and represented such behaviors as coming late to

sessions or changing appointme nt times (e.g., ``Tardy to sessions’ ’ ) .

A ll of the reactance scale s and subscale s corre lated positive ly and signi® cantly

with the ``Boundary Augmentation’ ’ factor. This ® nding indicate s that a common

dimension of reactance may be related to interpersonal distancing behaviors on

the part of clients in therapy. However, the QMPR was also positive ly corre lated

with the ``Boundary Reduction’ ’ factor, which represented client attempts to af® liate

with the therapist, dependency, and more passive forms of treatment nonacceptance

such as externalization of blame. Contrary to expectation, ne ithe r Factor 3 nor

Factor 4 were corre lated with reactance . Both Factor 2 (Boundary Reduction) and

Factor 3 (Collaborativ e Relationship) were corre lated with therapist rating of global

improve ment and client rating of improve ment in well-be ing, the ® rst negative ly

and the second positive ly.

Discussion

Our results indicate that psychological reactance is associate d with a host of

in-se ssion behaviors that may be inimical to the course and outcome of therapy.

These can be summarized as client behaviors that attempt to control and direct

the amount of therapeutic or inte rpersonal in¯ uence . Previous research (Dowd &

5Interested reade rs may obtain the items in each factor from the second author.


Wallbrown, 1993; Dowd et al., 1994) found that reactant individuals tend to be

autonomous and lacking in intimacy, so these results are not surprising. A lthough the

client is engage d in the therapeutic relationship, it may tend to be an argumentative ,

distancing, limit-setting type of engagement. We labe led this set of behaviors as

boundary augmentation.

The QMPR was associate d with boundary-re ducing client behaviors as well.

These behaviors can be seen as attempts to af® liate or ingratiate oneself with

the therapist. Because the QMPR was positive ly corre lated with both ``Boundary

Augmentation’ ’ and ``Boundary Reduction,’ ’ clients who score high on this measure

may have dependence ± independence con¯ icts and may oscillate between distancing

from and af® liating with the therapist.

Interestingly, ne ithe r Factor 3, Collaborative Relationships, nor Factor 4, Be-

havioral Disengage ment, were related to psychologic al reactance . The former ap-

pears to represent a positive orientation toward the tasks of therapy and include s

both af® liative and assertive items. The latter appear to represent a disengage ment

from and an uninvolve ment with therapy, as indicated by missing sessions and

arriving late . Thus, reactance may not be associated with the level of engagement

in the tasks of the therapeutic process.

Consistent with previous research on the importance of the working alliance

in therapy (Horvath & Greenberg, 1989) , client behaviors forming the collaborative

relationship were positive ly associated with both therapist and client ratings of

improve ment. Likewise, the reactant behaviors associate d with Factor 1 were nega-

tive ly associate d with improve ment. The af® liative behaviors represented by Factor

2 were also negative ly related to improvement, sugge sting the counterproductivi ty

of those dependency behaviors.

These data sugge st that, although reactant clients may engage in distancing

behaviors, they are at least engaged at some level in therapy. Furthermore , these

behaviors do not appear to harm improvement, at least in the short run, although

they may be exaspe rating for the therapist. Reactant clients tend not to exhibit

the ultimate disengage ment represented by Factor 4. In that sense , oppositional

engage ment may be better than untherapeutic af® liation or no af® liation at all.

Behavioral reactance was also associated with a history of premature termina-

tion, supporting Morgan’ s (1986) ® ndings. This provide s further evidence that re-

actant clients tend to be more dif® cult to engage in the therapy process. Interestingly,

however, verbal reactance was positive ly related to client-rated improvement in

well-be ing, indicating that the verbal oppositional ism characte rized by this measure

may be healthy. This is supporte d by Pepper (1996) , who found verbal reactance

was positive ly related to measures of psychosocial health, whereas behavioral re-

actance was negative ly related.

This study has a number of limitations . First, participants comprised an opportu-

nity sample of therapist /client pairs who were willing to participate . Clients returned

the ir forms to the therapist, not to us, so it is possible some clients might have been

concerned their therapist would examine the ir forms. Second, only about half of

those approache d agreed to participate ; any diffe rence between participants and

those who declined is unknown. Third, it is like ly that those clients who had a good

relationship with the ir therapist as well as the lower reactant clients chose to


participate . These would have the effect of reducing the range of reactance and

thus reducing the number of signi® cant ® ndings. Fourth, although we took care to

deve lop it according to theoretical rationale and expert opinion, the reliability and

validity of the therapist questionnaire are unknown.

A CKNOWLEDGMENT

The authors thank Dr. Stevan Hobfoll for comments on an earlie r draft.

REFERENCES

Beutler, L. E. (1979) . Toward speci® c psychological therapies for speci® c conditions. Jou rnal of Consulting

and Clinical Psycho logy, 47, 882-897.Brehm, J. W. (1966) . A theory of psych ological reactance. New York: Academic Press.Brehm, S. S., & Brehm, J. W. (1981) . Psycho logical reactan ce: A theory of freedom and con trol. New

York: Academic Press.Dowd, E. T. (1993) . Motivational and personality corre lates of psychological reactance and implications

for cognitive therapy. Psicologia Conductual, 1, 145-156.

Dowd, E. T., Milne, C. R., & Wise , S. L. (1991) . The Therape utic Reactance Scale : A measure ofpsychological reactance . Journal of Counseling and Development, 69, 541-545.

Dowd, E. T., & Sanders, D. (1994) . Resistance , reactance , and the dif® cult client. Canadian Journal ofCounselling, 28, 13-24.

Dowd, E. T., & Wallbrown, F. (1993) . Motivational components of client reactance . Journal of Counseling

and Developm ent, 71, 533-538.Dowd, E. T., Wallbrown, F., Sanders, D., & Yesenosky, J. M. (1994) . Cogn itive Therapy and Research,

18, 601-612.

Graybar, S. R., Antonnuccio, D. O ., Boutilier, L. R., & Varble , D. L. (1989). Psychological reactanceas a factor affecting patient compliance to physician advice . Scandinavian Jou rnal of BehaviorTherap y, 18, 43-51.

Horvath, A . O ., & Greenberg, L. S. (1989) . The deve lopment and validation of the Working AllianceInventory. Journal of Counseling Psych ology, 36, 223-233.

Merz, J. (1983) . Fragebogen zur Messung der Psychologischen Reactanz (Questionnaire for the measure -ment of psychological reactance ). Diagno stica, 29(1) , 75-82.

Morgan, R. D. (1986) . Individual differences in the occurren ce of psych ological reactan ce and therap eu tic

outcome. Unpublished doctoral dissertation, University of Nebraska.Otani, A . (1989) . Client resistance in counse ling: Its theoretical rationale and taxonomic classi® cation.

Jou rnal of Counseling and Developm ent, 67, 458-461.

Pepper, H. F. (1996) . An investigation of psych osocial developm ental precurso rs of psycho logical re-actan ce. Unpublished doctoral dissertation, Kent State Unive rsity.

Rohrbaugh, M., Tennen, H., Press, S. & White, L. (1981) . Compliance, de® ance, and therapeutic paradox:Guidelines for strategic use of paradoxical interventions. American Journ al of Orthopsychiatry,51, 467.

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