Resistance in psychotherapy

Resistance in Psychotherapy: What ConclusionsAre Supported by Research

Larry E. Beutler, Carla Moleiro, and Hani TalebiUniversity of California

Theoretical literature is contradictory in most areas, but virtually all theo-ries agree on the existence of patient resistance and propose similar impli-cations, meanings, and effects of its manifestation. However, theories differwidely in both the assumed causes of resistance and the methods ofdealing with resistant patients. Common to various theoretical definitionsis an assumption that resistance is both a dispositional trait and an in-therapystate of oppositional, angry, irritable, and suspicious behaviors. Reactanceis a special class of resistance that is manifest in oppositional and unco-operative behavior. Resistance bodes poorly for treatment effectiveness.Nondirective and paradoxical strategies have been found to be quite suc-cessful in overcoming resistant and reactant states, while matching low-directive and self-directed treatments with resistant patients circumventsthe effects of resistance traits. 2002 John Wiley & Sons, Inc. J ClinPsychol/In Session 58: 207217, 2002.

Keywords: prescriptive therapy; resistance; reactance; opposition;psychotherapy

While they disagree with one another in many ways, the 4001 theories of psychotherapythat are practiced in contemporary society converge on the curious observation that somepainfully distressed patients seeking assistance from expensive and highly trained pro-fessionals reject their therapists best advice, fail to act in their own best interests, and donot respond to the most effective interventions that can be mustered on their behalf. Suchpatients have been called oppositional, reactionary, noncompliant, intractable, and unmo-tivated (Dowd, 1989; Kolko & Milan, 1983). While the descriptions offered of resistantbehavior by different theories are similar, they offer dramatically different explanationsand intervention methods.

Classical psychoanalytic theory views resistance as a central process that is mani-fested both as a transient, situation-specific state in psychotherapy, and as an enduring,

Correspondence and requests for reprints should be sent to: Larry E. Beutler, Ph.D., Counseling/Clinical/School Psychology Program, Department of Education, University of California, Santa Barbara, CA 93106;e-mail: [email protected].

JCLP/In Session: Psychotherapy in Practice, Vol. 58(2), 207217 (2002) 2002 John Wiley & Sons, Inc.

trait-like quality to which some individuals are more predisposed than others. Theseexpressions of resistance are assumed to reflect, in a metaphorical or symbolic manner,the unconscious material that the patient is struggling to avoid uncovering. The essentialpsychoanalytic approach to treatment requires that the analyst interpret patient resistancein an attempt to help the patient experience an increased awareness of the various aspectsof his/her own feelings and impulses that are being repressed.

In contrast to psychoanalytic perspectives, in which resistance is both unconsciousand a valuable target of interpretations, cognitive and behavioral theorists view resistanceas simple noncompliance, which in turn is seen as an obstruction to goal achievement.Some social cognitive perspectives differentiate between oppositional behaviorwhichsome refer to under the label reactanceand a less insidious form of noncompliance.

As an enduring trait within these perspectives, such noncompliance arises from ahistory of interactions in which such behavior is reinforced by the environment. In thisform, resistance colors much of ones reaction to relationships with authorities, includinga psychotherapist, and extends beyond the demands of any one situation. As a state-likequality, however, noncompliance arises from a particular situation, usually the actions ofthe therapist or the demands of the therapy situation. In this behavioral tradition, non-compliance is any client behavior that is antitherapeutic (Turkat & Meyer, 1982), andindicates a therapists failure to identify adequately or modify reinforcement contingen-cies within treatment.

Exemplifying a behavioral perspective, Patterson (1984) suggested that effectivetreatment requires two levels of interventionmicroanalytic procedures to modify thecontingencies that exist within the therapy session, and macroanalytic strategies thatfocus on increasing compliance during the time between sessions. It is assumed thatresistance can be avoided or overcome through the identification and alteration of reinforce-ment contingencies at these two levels. Perspectives from cognitive therapy are often abit broader than this, invoking internal states and motivations. From this perspective,resistance is defined in terms of the degree that it interferes with the patients willingnessto consider data that do not confirm the individuals existing views of the world. Intreatment, resistant behaviors are acknowledged as technical problems, countertherapeu-tic beliefs, avoidance behaviors, and passivity in cognitive therapy.

Contemporary attribution theory is an example of a social cognition approach thathas been applied by various researchers to understand resistance in therapy and to suggestways that it may be treated. According to Kirmayer (1990), the therapists attribution canlead to the development of a moral pejorative insofar as it assumes that clients are respon-sible for their own misery. While this assumption may absolve therapists of responsibilityfor failure with highly resistant clients, it also can result in a countertherapeutic experi-ence for the client. In fact, Kirmayer pointed out that clients rarely experience themselvesas actively opposing helpful interventions. Instead, they perceive themselves as lackingpersonal control. This self-attribution exacerbates both their own symptoms and the reac-tive basis of their resistance. In the end, cognitive theory emphasizes the desirability ofredirecting internal self-attributions of trait defects into situational, externalizing directions.

In still another theoretical approach to resistance, Perls (Perls, Hefferline, & Good-man, 1951) conceptualized resistance as avoidance of unpleasant or dangerous feelingsthat then become rigid, leading to permanent blocking of awareness and impairment ofholistic functioning. This framework later was incorporated into Gestalt therapy as aconflict between the needs/desires of the organism and the requirements of the environ-ment that necessitated a creative reorganization of the patients experience. This adjust-ment was thought to consist of blocking self-awareness in order both to accommodate theenvironmental demands and to provide protection from the experience of pain or feeling

208 JCLP/In Session, February 2002

bad. Later, this response could become an automatic reaction that is out of a patientsimmediate awareness.

Although contemporary Gestalt therapy continues to recognize the phenomenon ofresistance, the perspective applied to this phenomenon has come to include those strug-gles that the patient exerts against the therapists interventions. Resistance to ones ownawareness is addressed in Gestalt therapy by magnifying the split between conflictingwishes or fears in order to allow the natural completion of the experience. In contrast,resistance to the therapists efforts is addressed in Gestalt therapy by reframing it as ahealthy function of self-assertion. It is assumed that the effective therapist will decreasethe level of patient resistance by becoming more genuine, spontaneous, and acceptingwith the client.

Family systems theories have added still another level of complexity to perspectivesof resistance. In a comparative analysis of family therapies, Nichols and Schwartz (1991)observed that, in general, resistance to change is expected to emerge as an inevitable partof any family system. Strategic, structural, and Bowenian therapies share the basic prem-ise that resistance reflects an attempt in familieswhether conscious or notto preventdisruption of the systems homeostasis. Paradoxical techniques often are used in systemstherapy, particularly in strategic therapy, as a means of bypassing the familys resistanceto changing patterns of functioning.

Drawing from available empirical literature, this article will summarize a series ofconclusions that can be drawn about the role and management of resistance, in its variousforms. These conclusions will be organized as they apply to four general areas:

1. conceptual issues in defining resistance,2. measuring resistance,3. empirical correlates of resistance, and4. relationships of resistance to treatment outcomes.

Conceptual Issues in Defining Resistance

Conclusion 1. Theoretical Definitions of Resistance Differin the Degree to Which Trait and State Factors Are Implied

Problems of definition plague research on resistance. Many psychological studies areconducted with resistance defined as a situation-induced state, while others are carriedout embracing resistance as an in-dwelling quality of the person. Contemporary explo-ration of resistance has exposed an additional problem that arises: Some theorists andresearchers treat resistance as a dichotomous constructit is either present or absentwhile others maintain that resistance is a variable that ranges from overly compliant tocompletely oppositional.

An important distinction in general behavioral research is between actively opposi-tional behavior and the less-obvious patterns of reluctant compliance and passive non-compliance. Brehm and Brehm (1981) postulated that all individuals possess an inherentintolerance for loss of choice, and that a state of motivation is aroused whenever thisfreedom is threatened. Under these conditions, individuals assert their choice by doingthe opposite of what is requested. Brehm (1966) called this state of oppositional behaviorreactance, a unique and transitory instance of resistance. Ancillary research suggests thepresence of a continuum of resistant behaviors, anchored on its poles by oppositional andcompliant patterns, respectively, with passive noncompliance in the center.

Resistance in Psychotherapy 209

Several authors (e.g., Beutler, 1983; Brehm & Brehm, 1981; Dowd, 1989) haveexpanded the original definition of Reactance to include an in-dwelling level of vigi-lance, a hypersensitivity to loss of freedom, and motivational traits that are assumed tovary from person to person. According to Dowd (1989), while resistance may occur viaspecific client actions in specific situations, reactance is a predilection that exists withina person because of their idiosyncratic histories of relationships with authorities, demands,and loss of freedom. Perceived from this internal motivational state, reactance potentialassumedly can be increased by characteristics of both the situation and the individual.Moreover, while an inept therapist may evoke reactance in almost any patient, even acompetent therapist using an innocuous intervention may trigger a reactant-prone patientsresistance.

Conclusion 2. Resistance Includes Both Interpersonal and IntrapsychicFactors that Must Be Considered in Treatment Decisions.

While resistance classically has been conceptualized as a client-based, intrapsychic vari-able, an interpersonal perspective is gaining favor among theoreticians. With the adventand advancement of social-psychology perspectives, such as reactance theory (e.g., Brehm,1966), many theorists have adopted a view of resistance as a process that occurs ininteractions among people. Brehm and Brehm (1981) suggested that threatened loss ofinterpersonal freedom is more relevant to therapeutic influence than an intrapsychic threat.The magnitude of resultant reactance arousal is thought to be determined by three factors:

1. the importance of the threatened freedom;2. the proportion of freedoms eliminated or threatened with elimination, and3. the magnitude of the threat embodied in the authority and power of the threaten-

ing force or person.

These and other interpersonal views have been incorporated partially by psycho-dynamic theory out of a concern that intrapsychic views permit therapist excesses. Kir-mayer (1990), for example, pointed out that the therapist may use resistance to avoidresponsibility for his/her biases. He suggests that resistance is as much a creation of thetherapists perceptual rigidity as it is a feature of the clients interpersonal style (p. 90).Still other researchers believe that the intrapsychic view espoused by the therapist directlycontribute to the development of an adversarial relationship in therapy, rather than thecollaborative alliance deemed important for therapeutic success. Even contemporary psy-choanalytic theories are adopting an interpersonal view of resistance to supplement orsupplant the intrapsychic views that traditionally have characterized them.

Measuring Resistance

Conclusion 3. While Measures Evoke Both State and Trait Resistance Tendencies,These Dimensions Are Frequently Confounded in MeasurementEmpirical literature contains numerous efforts to measure the constructs of resistance.The several specific measures that have been used to study resistance are of two types:measures of in-session states of resistance and measures of dispositional resistant traits.

Measures of Resistant States. Shoham-Salomon, Avner, and Neeman (1989) usedaudio recordings of voice qualities taking place within an interpersonal interaction, such


as psychotherapy, to predict subsequent client resistance and reactance. This procedureinvolves filtering out speech bands of sound so that only vocal and tonal qualities ofspeech remain. The filtered voice is rated on dimensions that are thought to reflect resis-tance and defensiveness. These dimensions include vocal qualities thought to sound com-plaining, whiny, rebellious, and uncooperative. Ensuing research determined that thesequalities are related to current and subsequent patterns of oppositional behaviors when anauthority makes a request or demand.

Other measures of resistance states are based on ratings of in-therapy behaviors inwhich resistance is defined within a particular, usually psychoanalytic, frameworkadefense against painful insight. One example is the Patient Resistance Scale (PRS; Mor-gan, Luborsky, Crits-Christoph, Curtis, & Solomon, 1982), a seven-item rating of levelsof in-session defensiveness expressed by the patient. The reliability of this measure wasreported to be high, but it failed to demonstrate a relationship with treatment outcome.

The Resistance Scale (TRS; Schuller, Crits-Christoph, & Connolly, 1991) was amodification of the PRS, also based on a psychodynamic concept of resistance. Derivedfrom data acquired during the Penn Psychotherapy Project (Luborsky et al., 1980), thePRS subsequently was expanded into a multidimensional format. It consists of 19 ratingsof the frequency and intensity of in-session behaviors that included vocal, content, andprosaic qualities of speech. Having three clinical judges rate verbatim excerpts fromtherapy sessions established the scales psychometric properties. The PRS identifies fourtypes of resistant behavior: Abrupt/Shifting, Oppositional, Flat/Halting, and Vague/Doubting. Initial results indicated that stable patterns of resistance characterized differentpatients, transcending situations and therapy content and indicating that the resistantbehaviors assessed have inescapable trait, as well as state qualities.

Departing from the psychodynamic traditions of the PRS and TRS, the Client Resis-tance Scale (CRC; Chamberlain, Patterson, Reid, Kavanaugh, & Forgatch; 1984) adopteda behavioral tradition to develop a method of rating resistant behaviors from direct obser-vations of in-session activities. This scale identifies seven varieties of moment-to-moment behavioral states, and one index of the patients level of nonresistant behaviors.Studies using the CRC in treatment indicate that resistance scores covaried with stage oftreatment, probability of completion of treatment, source of referral (i.e., agency vs.self ), and the therapists rating of treatment outcome.

Assessment of Resistant Traits. Because most in-session measures have proven toreflect cross-situational traits, as well as situational states, several researchers have turnedtheir efforts to assessing directly resistance proneness independently of therapy itself.They reason that if resistance levels could be predicted from measures taken before ther-apy begins, those scores could be used more effectively in planning treatment, as opposedto measuring resistance levels only within sessions after treatment begins.

Adopting the viewpoint that resistance in therapy reflects an enduring effort to avoidpainful affect, manifest both situationally within therapy and as a continuing propensityoutside of therapy, the Client Resistance Scale (CRS; Mahalik, 1994) was designed toassess both of these qualities. The CRS yields five separate subscales, each of which wasfound to identify an enduring characteristic. All subscales seem to contribute to a singlecommon construct or disposition for defensiveness. The separate dimensions include

1. opposition to the expression of painful affect,

2. opposition to recollecting past events,

3. opposition to the therapist,


4. opposition to change, and5. opposition to insight.

The various types of resistant behaviors were found to be affected differentially by client,counselor, and process variables, indicating that resistance may be susceptible to changewhen subjected to the right conditions.

The Therapeutic Reactance Scale (TRS; Dowd, Milne, & Wise, 1991) is probablythe best-known measure of resistance traits. It is a self-report measure derived from theReactance Theory of Brehm and Brehm (1981). The Brehms had suggested that disposi-tions to reactance might be embodied in measures of perceived internal locus of control.The TRS yields behavioral and verbal reactance scores, as well as a total reactance score,based upon 28 items scored on a Likert format. Initial results indicate convergence ofscores with measures of defensiveness, aggressiveness, and dominance (Dowd & Wall-brown, 1993), as well as predictive validity on the differential efficacy of directive andnondirective treatment.

The Questionnaire for Measuring Psychological Reactance (QMPR; Merz, 1983)was developed in Germany and translated by Dowd as a predecessor to the TRS. Thescale consists of 18 items that load on a single factor of psychological reactance. Merz(1983) found that the QMPR scale correlated positively with measures of autonomy,dominance, nervousness, emotional liability, insecurity, self-consciousness, depression,and resentment of authoritative questions.

The Systematic Treatment Selection, Clinician Rating Form (STS-CRF; Fisher, Beut-ler, & Williams, 1999) includes a special trait-like resistance rating scale. Based on ahistorical review of the patients relationships with authorities and an inspection of theirbehavior when faced with external demands, the clinician rates the degree to which thepatient obstructs interactions, avoids confrontation, rebels against demand, and behavesin oppositional or passive-noncompliant ways. This scale has been found to be predictiveof patient response and an indicator for fitting level of therapist resistance to the needs ofthe patient (Beutler, Clarkin, & Bongar, 2000).

One of the most frequently employed methods of measuring resistance is through theuse of various subscales and subscale combinations, drawn from different omnibus andmultidimensional personality tests whose content and description suggest that they maymeasure resistant states or traits. Several of these have been used in predictive studies ofpsychotherapy (Beutler, Moleiro, & Talebi, in press).

Empirical Correlates of Resistance

Conclusion 4. Resistance-prone Individuals Are Characterized by a Constellationof Interpersonal Traits and Defensive Styles, Including Anger,Need for Control, Impulsivity, and Direct AvoidanceDowd and Wallbrown (1993) explored the common personality and situational-responsecorrelates of resistance by intercorrelating measures of resistance and personality. Theycompared scores on the TRS, the QMPR, and subscales from the Personality ResearchForm. Results led them to conclude that resistant states and traits are associated with anenduring personality assemblage comprised of defensiveness, aggression, dominance,needs for autonomy, and tendencies to avoid affiliations.

Beutler, Zetzer, and Williams (1994) also inspected interrelationships among MMPIsubscales that reflected various personality qualities that were associated conceptuallywith resistant behaviors [i.e., Dominance (Do), Control (Cn), and Overcontrolled Hos-


tility (O-H)]. Intercorrelations first were computed on normative samples from the MMPI-2standardization group and then replicated on an independent sample of alcoholic men.The pattern of these correlations revealed that resistance was comprised both of interper-sonal and intrapersonal avoidance behaviors, including general measures of coping style.Correlates included indices of acting out, impulsiveness, aggressiveness, and direct avoid-ance. Such findings led Dowd and Wallbrown (1993) to conclude that resistant individ-uals are aggressive, quarrelsome, irritable, hostile, lacking in sympathy and support forothers, ostentatious, and eager for attention. They tend to lack warmth, are uncooperative,lack loyalty, are avoidant of friendships, and devoid of humility. They have difficultytolerating criticism and tend to be unpredictable and insensitive.

Relationships of Resistance to Treatment Outcomes

Conclusion 5. A Negative Relationship Exists between Resistance and Prognosis

Given its nature, one would expect that highly resistant individuals would fail to benefitfrom treatment. However, to the degree that session or treatment outcome is used to helpdefine the level of resistance, there is a danger that measures of this relationship may bespurious (Arkowitz, 1995; Wachtel, 1999). Even when controlling for this potential con-tamination, however, the results are very strong (see review by Beutler, Clarkin, et al.,2000). For example, a box score tabulation of research findings by Beutler, Moleiro, andTalebi (in press) identified 11 studies that had specifically investigated resistance in psy-chotherapy using suitably controlled research designs. Nine (82%) of these studies foundthat patient resistance measures were correlated negatively with outcomes.

Conclusion 6. The Effects of Resistant Traits and States Can Be Circumventedby the Use of Nondirective and Self-Directed Interventions; WhereasLow Resistant Traits and States Serve as Indicators for theUse of Directive and Structured Procedures

More pertinent to the question of treatment planning are research studies that have inspectedresistance traits as indicators and contra-indicators for different types of intervention.Beutler, Moleiro, and Talebi (in press) reviewed 20 studies that inspected the differentialeffects of therapist directiveness as moderated by patient resistance and found that 80%(n 5 16) of these demonstrated that directive interventions worked best among patientswho had relatively low levels of state or trait-like resistance, while nondirective inter-ventions worked best among patients who had relatively high levels of resistance. Suchfindings provide consistent support for the value of resistance level as a predictor oftreatment outcome, as well as a treatment-planning variable.

In most of these studies, however, the use of directive and nondirective interventionshave been inferred through a direct comparison of different models of psychotherapy thatmay have varied in many ways besides level of directiveness. In these studies, cognitiveand behavioral therapies generally are used as the prototypes of directive interventions,while psychodynamic, self-directed, or other relationship-oriented therapies are used asthe prototypes of nondirective or evocative interventions. Nonetheless, those few studiesthat have attempted to control for these potential contaminants continue to find the expectedrelationships. Specifically, that among very resistant patients, self-directed and nondirec-tive therapy regimens surpass directive ones in affecting therapeutic gain. Conversely,patients who are low on resistance tend to do better when directive, cognitive therapy


procedures are used (e.g., Beutler, Clarkin, et al., 2000; Beutler, Moleiro, Malik, & Har-wood, in press).

Conclusion 7. Reactant States Are Responsive to the Useof Paradoxical Therapeutic Interventions

Reactance theorists have suggested that, among patients who are especially resistant,paradoxical interventions (including the use of symptom prescription and reframing)may be effective because they capitalize on the patients tendency to respond in opposi-tional ways. These Defiance-based paradoxical techniques are designed to use patientresistance against their symptoms by encouraging them rather than attempting to elimi-nate them.

An accumulating number of studies have provided support for the relative value ofparadoxical interventions among those with highly resistant behavior. Three meta-analyses have investigated this relationship. Some of these studies (Horvath & Goheen,1990; Shoham-Salomon et al., 1989) specifically have addressed this issue in the contextof the therapeutic relationship, and all found results that supported the position that reac-tant states are responsive to the use of paradoxical interventions.

Limitations of the Research Reviewed

Because resistance traits cannot be assigned randomly to patients, they are not subject toexperimental designs that require random assignment. However, there is a good deal ofconsistency in the available research, and this supports a modestly strong conclusionabout the role of patient resistance traits in mediating treatment effects.

Aside from the correlational nature in studies of treatment effects, the major limita-tion in studying patient resistance is the absence of consensually accepted and recognizedmeasures of trait-like resistance. We have drawn attention to the potential circularity ofdefinitions of resistance, but such a problem would be reduced greatly if there wereaccepted measures of these traits. Although numerous measures have been developed, inall cases these measures suffer because of low or inconsistent intercorrelations. The pres-ence of stable and consistent predictive measures would add greatly to the draw that thisarea has on contemporary researchers.

It is important to note the role played by different theories of psychotherapy insetting the level of therapist direction and structure in their interventions with patients.Therapies that are thought to be variously directive (behavioral and cognitive-behavioral)or nondirective (self-directed or evocative) are assumed to be advantageous for differentpatients. Of course, such demonstrations only are interpretable if it can be assured thatdifferent models of psychotherapy actually differ in level of therapist direction.

Summary and Implications for Therapeutic Practice

Collectively, the studies reviewed here suggest that resistance is a constellation of bothsituation-induced states and enduring character traits. The extent of these reactions varyfrom being oppositional, a quality that is often referred to as reactance, to manifestationsof a slow or reluctant compliance. These varieties of resistance embody descriptive qual-ities and correlates that suggest concepts of defensiveness and anger in the context of thepsychotherapeutic relationships.


Reactance theory is based on several assumptions that may be generalized to themore general case of resistance:

1. freedom (of choice and action) is valued by all human beings;2. human beings will react negatively to perceived or actual threats to their freedoms;3. individuals exhibit stable differences and vulnerabilities to these threats;4. in the therapy context, the therapists directives or suggestions may overcome

these states; and5. the more-stable resistance traits also can be addressed in the therapeutic process,

largely by matching patient patterns to the directive levels of the interventions.

The current review has provided convincing evidence that resistance is an impedi-ment to effective treatment and that it can be influenced by the therapists use of self-directed and nondirective interventions. Both research and practice may benefit from theobservation that directive and nondirective interventions may be most effective whenselectively assigned to low- and high-resistant patients, respectively. Directive and author-itative interventions may be used effectively with nonresistant patients, while nondirec-tive and paradoxical interventions may be recommended effectively for use with patientswho are high in resistant states or traits.

Clinically, therapists first must learn to recognize the manifestations of resistance,both as a state and as a trait. Cues for state-like manifestations of resistance includeexpressed anger at the therapy or therapist ranging from simple dissatisfaction with ther-apeutic progress to overt expressions of resentment and anger. Beutler and Harwood(2000) suggested three responses to these expressions of resistant states:

1. acknowledgement and reflection of the patients concerns and anger;2. discussion of the therapeutic relationship; and3. renegotiation of the therapeutic contract regarding goals and therapeutic roles.

These responses are designed to defuse the immediate consequences of resistance and toinfuse the patient with some sense of control, as suggested in formulations of reactancetheory.

Paradoxical interventions, such as discouraging rapid change, symptom prescription,and symptom exaggeration also are ways of using the patients resistance traits in theservice of making change. That is, paradoxical interventions are designed to encourageviolation of directives.

The Systematic Treatment Selection (STS) model, proposed by the senior author(Beutler & Clarkin, 1990; Beutler, Clarkin, et al., 2000) proposed that specific functionalclasses of interventions (e.g., directive versus nondirective, insight-oriented versussymptom-oriented, abreactive versus supportive) likely are to be more conducive to thetask of tailoring treatments to individual patients than selecting among different globalbrands of treatment or specific techniques. Within this model, Beutler, Clarkin, et al.(2000) have suggested that two principles relating to resistance can be applied to clinicalpractice:

1. Treatment is most effective if the therapist can avoid stimulating the patientslevel of resistance.

2. Therapeutic change is greatest when the directiveness of the intervention is eitherinversely correspondent with the patients current level of resistance, or authori-tatively prescribes a continuation of the symptomatic behavior.


Beutler, Moleiro, and Talebi (in press) concluded that there is strong and consistentsupport for these principles. While a causal chain between patient resistance and outcomecannot be certain, the consistency of the correlational evidence is persuasive, and a strongmajority of studies that investigated resistance as an indicator for the application of eithernondirective or paradoxical interventions found support for these relationships.

Beutler, Clarkin, et al. (2000) added that, in spite of the consistent results supportingthe role of patient resistance in guiding treatment directiveness, this relationship might betempered by other variables. They determined that many variables operate in complexways and that they frequently potentiate or suppress one anothers effects. They identi-fied six variables that might be jointly considered in addressing the questions of system-atic treatment selection for a given patient: resistance, coping style, functional impairment,subjective distress, social support, and problem complexity. Further research on howthese and other variables interact with each other (namely, with patient resistance) andwith the use of directive, nondirective, and paradoxical interventions is needed.

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IntroductionConceptual Issues in Defining ResistanceConclusion 1. Theoretical Definitions of "Resistance" Differ in the Degree to Which Trait and State Factors Are ImpliedConclusion 2. Resistance Includes Both Interpersonal and Interpsychic Factors that Must Be Considered in Treatment DecisionsMeasuring ResistanceConclusion 3. While Measures Evoke Both State and Traits Resistance Tendencies, These Dimensions Are Frequently Confounded . . .Empirical Correlates of ResistanceConclusion 4. Resistance-prone Individuals Are Characterized by a Constellation of Interpersonal Traits and Defensive Styles, . Relationships of Resistance to Treatment OutcomesConclusion 5. A Negative Relationship Exists between Resistance and PrognosisConclusion 6. The Effects of Resistant Traits and States Can Be Circumvented by the Use of . . . Interventions . . .Conclusion 7. Reactant States Are Responsive to the Use of Paradoxical Therapeutic InterventionsLimitations of the Research ReviewedSummary and Implications for Therapeutic PracticeSelect References/Recommended Readings

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