Psychotherapy

Volume 38/Winter 2001/Number 4

RESISTANCE
LARRY E. BEUTLER
FRANCISCO ROCCO
CARLA M. MOLEIRO
HANI TALEBI
University of California, Santa Barbara
This article reviews extant literature on
how patient resistance has been defined
and its effects on psychotherapy.
Resistance has been considered as both a
patient-in-treatment state and as an
enduring trait. In either form, patient
resistance seems to interfere with treatment
outcome. Resistance also Junctions as a
moderating variable in determining the
effectiveness of different levels of therapist
directiveness. The evidence that patients
who enter treatment with high levels of
traitlike resistance will benefit most from
nondirective interventions is moderately
strong. Conversely, those who enter
treatment with low levels of traitlike
resistance benefit most from therapist
directed interventions. Therapeutic
practices associated with the research
evidence are advanced.
While some experts (e.g., Lambert, 1992;
Wampold, 2001) assert that specific techniques
offer little advantage over the experience of being
understood and affirmed in an environment of
safety, in the past decade, evidence has begun to
accumulate that there are specific factors that affect psychotherapy (Chambless & Ollendick,
2001; Nathan & Gorman, 1998). Thus, while
many authors conclude that highly specialized

Portions of this chapter were supported by research grant,

No. RO1 DA09394 to the first author.
Correspondence regarding this article should be addressed
to Larry E. Beutler, Ph.D., Counseling/Clinical/School Psychology Program, Department of Education, University of
California, Santa Barbara, CA 92106. E-mail: beutler@educ
ation.ucsb.edu

psychotherapies add significantly to the effects of

a caring and supportive psychotherapy relationship, others believe that only nontechnical factors
are of any real importance in producing psychotherapy effects. These contrasting and contradictory conclusions have led many contemporary
researchers to begin looking for patient moderatorsvariables that temper and alter the effectiveness of various treatment methods and relationship stances. These authors criticize diagnosis
as the primary means of ensuring that patients
are homogeneous and appropriate for different
treatments. They observe that, while it is certainly
advantageous to cluster patients into homogeneous groups in order to better observe treatment
effects, sharing a diagnostic label is probably a
poor indicator of how similar or different patients
are from one another, especially as pertains to
predicting the effects of psychological treatments
(e.g., Beutler & Malik, 2002). They propose research on aptitude by treatment interactions
(ATIs) as an alternative to the randomized clinical
trials (RCT) methodologies.
This article reviews available research on patient resistance traits as aptitudes or qualities that
affect the influence and efficacy of different psychotherapy models and relationship stances.
Definitions
The concept of "resistance" began to take shape
in psychology with the development of psychoanalytic theory. Classical psychoanalytic theory
characterized resistance as the patient's unconscious avoidance of or distraction from the analytic work (Arlow, 2000). This theoretical perspective assumed that resistance was an effort to
repress intrapsychic impulses that conflicted with
social expectations and self-perceptions. Resistance was an inherent, unconscious striving to
avoid thoughts and feelings that caused discomfort. This concept of resistance has been incorporated into much of contemporary literature and
even common parlance.

431

Larry E. Beutler et al.

Outside of psychotherapy and particularly, outside of psychoanalytic thought, the concept of
resistance has achieved its greatest recognition
within social psychology. In 1966, J. W. Brehm
proposed a theory of "psychological reactance"
defining this term as a ". . . state of mind aroused
by a threat to one's perceived legitimate freedom,
motivating the individual to restore the thwarted
freedom" (Brehm & Brehm, 1981, p. 4). Thus,
reactance is often considered to be a prototypic,
albeit extreme, example of resistance.
The term resistance, as applied to a client's behavior, implies the refusal to cooperate or change
and is a form of active opposition to the therapist's
influence. Most often in this perspective, patient
resistance is viewed as a variable that mediates
or moderates the effects of therapist level of directiveness. That is, the effectiveness of therapists'
directives and guidance are considered to be directly dependent on the patient's proneness to resist external control.

as little resistance as possible while still moving

the patient toward his or her goals.
Patient resistance, irrespective of its theory of
origination, has consistently affected how and
what subsequent interventions should be implemented. From the standpoint of tailoring treatment to individual patients, for example, clinical
researchers have focused on the proposition that
the degree of structure and directiveness embodied in treatment can advantageously be adjusted
to fit a specific client's level of resistance. This
would allow a clinician to selectively use interventions that vary in such things as the level of
therapist control, structure, and directiveness. By
examining how patient resistance may affect specific outcomes when treatments are varied, researchers may be able to clarify patient-treatment
relationships and to develop effective models of
treatment planning.

Social Influence Theory

Acting in opposition to what one is asked to
do is only one expression of resistance. Depending upon the client's attributions of causality
and control, resistance may be manifest in cognitive dissonance, emotional exacerbation, reactance, or helpless withdrawal. That is, some patients may comply but do so with resentment;
others may resist passively rather than actively
doing the opposite of what is suggested; still others may simply become angry and drop out of
therapy. According to social influence theory,
change on the part of the client is considered to
be a product of activating and restraining forces
that act on the client. The activating forces are
direct products of the client's perception of the
therapist's influence power. Thus, the patient's
resistance represents an internal conflict between
the patient's desire to accept the therapist's influence and the patient's reluctance to do so because
of the perceived illegitimacy of the therapist's
influence.

Patient Contributions
Overcoming and reducing patient resistance are
major objectives of any treatment. Resistant patients experience less benefit and are more prone
to prematurely terminate from treatment than
those who are cooperative (see reviews by Beutler, Clarkin, & Bongar, 2000; Beutler, Goodrich, Fisher, & Williams, 1999). This evidence
seems clear; however, it may be partially artifactual. Resistance is often defined solely on the
basis of the client's failure to improve (Wachtel,
1999). Thus, resistance is both defined by and
defines improvement (Arkowitz, 1995). To escape such circularity, it is important to separately
identify levels of patient resistance and their treatment outcome.

Applications to Psychotherapy
As a general rule, research suggests that patient
resistance impedes the achievement of therapeutic
goals (e.g., Beutler, Clarkin, & Bongar, 2000;
Beutler, Goodrich, Fisher, & Williams, 1999).
The effectiveness of psychotherapy is correlated
with relative absence of resistance, suggesting
that psychotherapists may be advised to induce

432

Research Review

Mediators and Moderators

True to the ATI view of psychotherapy, research has begun to investigate the differential or
mediating effects of resistance on different forms
of psychotherapy. Table 1 provides a summary
of empirical research studies that have explored
the effects of resistance and outcome as well as
the joint interaction of patient resistance and intervention with outcomes. The table separates the
studies by the type of relationship observed and
notes the way mat resistance was measured.
Although a large number of studies have addressed various aspects of resistance, we were
able to identify 35 different studies that have spe-

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433

Larry E. Beutler et al.

cifically addressed patient resistance as a factor
that either correlated with outcome directly, or
correlated with the differential value of directive
versus nondirective, or paradoxical and nonparadoxical treatments. Eleven of these studies addressed the prognostic value of patient resistance,
of which 9 (82%) found a negative impact on
treatment outcome.
More pertinent to the current review are the
studies that inspected resistance by treatment interaction effects. These studies inspected both
trait and state aspects of resistance, finding similar patterns for both. Twenty studies inspected
the differential effects of therapist directiveness
as moderated by patient resistance. Sixteen of
these studies (80%) found that directive interventions worked best among patients who had relatively low levels of state or traitlike resistance,
while nondirective interventions worked best
among patients who had relatively high levels of
resistance (e.g., Beutler & Clarkin, 1990; Brehm
& Brehm, 1981; Dowd, Wallbrown, Sanders, &
Yesenosky, 1994).
In most studies, directive and nondirective
interventions have been compared through an
inspection of different models of psychotherapy. Cognitive and behavioral therapies are
generally used as the prototypes of directive
interventions, while psychodynamic, selfdirected, or other relationship-oriented therapies are used as the prototypes of nondirective
interventions. In such studies, among very resistant patients, a self-directed therapy regimen
surpassed a directive one in affecting therapeutic gain. Conversely, patients who were low
on resistance did best with directive, cognitive
therapy procedures (Beutler, Mohr, Grawe, Engle, & McDonald, 1991).
Reactance theorists have also suggested that,
among patients who are especially resistant, paradoxical interventions may be effective since they
capitalize on the patient's tendency to respond in
oppositional ways. As noted in Table 1, four studies have specifically addressed this issue in psychotherapy, and all found results that support
this position.
Limitations of the Research Reviewed
Because resistance traits cannot be randomly
assigned to patients, they are not subject to experimental designs that require random assignment. However, there is a good deal of consistency in the available research, and this supports

434

a modestly strong conclusion about the role of

patient resistance traits in mediating treatment
effects.
Aside from the correlational nature in studies of
treatment effects, the major limitation in studying
patient resistance is the absence of consensually
accepted and recognized measures of traitlike resistance. We have already drawn attention to the
potential circularity of definitions of resistance,
but such a problem would be greatly reduced if
there were accepted measures of these traits.
It is also important to note the role played by
different theories of psychotherapy in setting the
level of therapist direction. Therapies that are
thought to be, variously, directive (behavioral and
cognitive-behavioral) or nondirective (self-directed
or evocative) are assumed to be advantageous for
different patients. Of course, such demonstrations
are only interpretable if it can be assured that different models of psychotherapy actually differ in level
of therapist direction.
Therapeutic Practices
Collectively, the foregoing results provide convincing evidence that low traitlike resistance
makes patients especially susceptible to benefit
from directive interventions. Conversely, high
resistant-like traits seem to make patients vulnerable to authoritative and directive styles, evoking
states of resistance that interfere with progress,
increasing the likelihood of dropout, and reducing
effectiveness of treatment.
Clinically, therapists must first learn to recognize the manifestations of resistance both as a
state and as a trait. Cues for state-like manifestations of resistance include expressed anger at the
therapy or therapist, ranging from simple dissatisfaction with therapeutic progress to overt expressions of resentment and anger. Beutler and Harwood (2000) suggested three responses to these
expressions of resistant states: (a) acknowledgment and reflection of the patient's concerns and
anger, (b) discussion of the therapeutic relationship, and (c) renegotiation of the therapeutic contract regarding goals and therapeutic roles. These
responses are designed to defuse the immediate
consequences of resistance and to infuse the patient with some sense of control, as suggested in
formulations of reactance theory.
Paradoxical interventionssuch as discouraging
rapid change, symptom prescription, and symptom
exaggerationare also ways of using the patient's
resistance traits in the service of making change.

Resistance
That is, paradoxical interventions are designed to
encourage violation of directives.
Specific functional classes of interventions (e.g.,
directive versus nondirective, insight-oriented versus symptom-oriented) are likely to be more conducive to the task of tailoring treatments to individual
patients than selecting among different, global
brands of treatment or specific techniques.
In sum, two principles relating to resistance can
be applied to clinical practice (Beutler, Clarion, &
Bongar, 2000). First, treatment is most effective
if the therapist can avoid stimulating the patient's
level of resistance. Based on the current review,
we conclude that there is strong and consistent
support for the negative relationship between raising patient resistance and therapeutic outcome.
While a causal chain cannot be certain, the consistency of the correlational evidence is persuasive. Second, therapeutic change is greatest when
the directiveness of the intervention is either inversely correspondent with the patient's current
level of resistance, or authoritatively prescribes a
continuation of the symptomatic behavior. This
principle is also consistently supported in the
current review. A strong majority of studies
(83%) that investigated resistance as an indicator for the application of either nondirective or
paradoxical interventions found the proposed
relationship.
Beutler, Clarkin, and Bongar (2000) concluded
that in spite of the consistent results supporting
the role of patient resistance in directing treatment
directiveness, this relationship might be tempered
by other variables. They determined that many
variables operate in complex ways and, frequently,
they potentiate or suppress one another's effects.
Further research on how these and other variables
interact with patient resistance and with the use
of directive, nondirective, and paradoxical interventions is needed.
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