Resistance in Psychotherapy: What Conclusions

Are Supported by Research

Larry E. Beutler, Carla Moleiro, and Hani Talebi

University of California

Theoretical literature is contradictory in most areas, but virtually all theories agree on the existence of patient resistance and propose similar implications, meanings, and effects of its manifestation. However, theories differ
widely in both the assumed causes of resistance and the methods of
dealing with resistant patients. Common to various theoretical definitions
is an assumption that resistance is both a dispositional trait and an in-therapy
state of oppositional, angry, irritable, and suspicious behaviors. Reactance
is a special class of resistance that is manifest in oppositional and uncooperative behavior. Resistance bodes poorly for treatment effectiveness.
Nondirective and paradoxical strategies have been found to be quite successful in overcoming resistant and reactant states, while matching lowdirective and self-directed treatments with resistant patients circumvents
the effects of resistance traits. 2002 John Wiley & Sons, Inc. J Clin
Psychol/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 psychotherapy
that are practiced in contemporary society converge on the curious observation that some
painfully distressed patients seeking assistance from expensive and highly trained professionals reject their therapists best advice, fail to act in their own best interests, and do
not respond to the most effective interventions that can be mustered on their behalf. Such
patients have been called oppositional, reactionary, noncompliant, intractable, and unmotivated (Dowd, 1989; Kolko & Milan, 1983). While the descriptions offered of resistant
behavior by different theories are similar, they offer dramatically different explanations
and intervention methods.
Classical psychoanalytic theory views resistance as a central process that is manifested 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: beutler@education.ucsb.edu.

JCLP/In Session: Psychotherapy in Practice, Vol. 58(2), 207217 (2002)

2002 John Wiley & Sons, Inc.

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trait-like quality to which some individuals are more predisposed than others. These
expressions of resistance are assumed to reflect, in a metaphorical or symbolic manner,
the unconscious material that the patient is struggling to avoid uncovering. The essential
psychoanalytic approach to treatment requires that the analyst interpret patient resistance
in an attempt to help the patient experience an increased awareness of the various aspects
of his/her own feelings and impulses that are being repressed.
In contrast to psychoanalytic perspectives, in which resistance is both unconscious
and a valuable target of interpretations, cognitive and behavioral theorists view resistance
as simple noncompliance, which in turn is seen as an obstruction to goal achievement.
Some social cognitive perspectives differentiate between oppositional behaviorwhich
some refer to under the label reactanceand a less insidious form of noncompliance.
As an enduring trait within these perspectives, such noncompliance arises from a
history of interactions in which such behavior is reinforced by the environment. In this
form, resistance colors much of ones reaction to relationships with authorities, including
a psychotherapist, and extends beyond the demands of any one situation. As a state-like
quality, however, noncompliance arises from a particular situation, usually the actions of
the therapist or the demands of the therapy situation. In this behavioral tradition, noncompliance is any client behavior that is antitherapeutic (Turkat & Meyer, 1982), and
indicates a therapists failure to identify adequately or modify reinforcement contingencies within treatment.
Exemplifying a behavioral perspective, Patterson (1984) suggested that effective
treatment requires two levels of interventionmicroanalytic procedures to modify the
contingencies that exist within the therapy session, and macroanalytic strategies that
focus on increasing compliance during the time between sessions. It is assumed that
resistance can be avoided or overcome through the identification and alteration of reinforcement contingencies at these two levels. Perspectives from cognitive therapy are often a
bit 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 willingness
to consider data that do not confirm the individuals existing views of the world. In
treatment, resistant behaviors are acknowledged as technical problems, countertherapeutic beliefs, avoidance behaviors, and passivity in cognitive therapy.
Contemporary attribution theory is an example of a social cognition approach that
has been applied by various researchers to understand resistance in therapy and to suggest
ways that it may be treated. According to Kirmayer (1990), the therapists attribution can
lead to the development of a moral pejorative insofar as it assumes that clients are responsible for their own misery. While this assumption may absolve therapists of responsibility
for failure with highly resistant clients, it also can result in a countertherapeutic experience for the client. In fact, Kirmayer pointed out that clients rarely experience themselves
as actively opposing helpful interventions. Instead, they perceive themselves as lacking
personal control. This self-attribution exacerbates both their own symptoms and the reactive basis of their resistance. In the end, cognitive theory emphasizes the desirability of
redirecting internal self-attributions of trait defects into situational, externalizing directions.
In still another theoretical approach to resistance, Perls (Perls, Hefferline, & Goodman, 1951) conceptualized resistance as avoidance of unpleasant or dangerous feelings
that then become rigid, leading to permanent blocking of awareness and impairment of
holistic functioning. This framework later was incorporated into Gestalt therapy as a
conflict between the needs/desires of the organism and the requirements of the environment that necessitated a creative reorganization of the patients experience. This adjustment was thought to consist of blocking self-awareness in order both to accommodate the
environmental demands and to provide protection from the experience of pain or feeling

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bad. Later, this response could become an automatic reaction that is out of a patients
immediate awareness.
Although contemporary Gestalt therapy continues to recognize the phenomenon of
resistance, the perspective applied to this phenomenon has come to include those struggles that the patient exerts against the therapists interventions. Resistance to ones own
awareness is addressed in Gestalt therapy by magnifying the split between conflicting
wishes 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 a
healthy function of self-assertion. It is assumed that the effective therapist will decrease
the level of patient resistance by becoming more genuine, spontaneous, and accepting
with the client.
Family systems theories have added still another level of complexity to perspectives
of 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 part
of any family system. Strategic, structural, and Bowenian therapies share the basic premise that resistance reflects an attempt in familieswhether conscious or notto prevent
disruption of the systems homeostasis. Paradoxical techniques often are used in systems
therapy, particularly in strategic therapy, as a means of bypassing the familys resistance
to changing patterns of functioning.
Drawing from available empirical literature, this article will summarize a series of
conclusions that can be drawn about the role and management of resistance, in its various
forms. 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, and
4. relationships of resistance to treatment outcomes.
Conceptual Issues in Defining Resistance
Conclusion 1. Theoretical Definitions of Resistance Differ
in the Degree to Which Trait and State Factors Are Implied
Problems of definition plague research on resistance. Many psychological studies are
conducted with resistance defined as a situation-induced state, while others are carried
out embracing resistance as an in-dwelling quality of the person. Contemporary exploration of resistance has exposed an additional problem that arises: Some theorists and
researchers treat resistance as a dichotomous constructit is either present or absent
while others maintain that resistance is a variable that ranges from overly compliant to
completely oppositional.
An important distinction in general behavioral research is between actively oppositional behavior and the less-obvious patterns of reluctant compliance and passive noncompliance. Brehm and Brehm (1981) postulated that all individuals possess an inherent
intolerance for loss of choice, and that a state of motivation is aroused whenever this
freedom is threatened. Under these conditions, individuals assert their choice by doing
the opposite of what is requested. Brehm (1966) called this state of oppositional behavior
reactance, a unique and transitory instance of resistance. Ancillary research suggests the
presence of a continuum of resistant behaviors, anchored on its poles by oppositional and
compliant patterns, respectively, with passive noncompliance in the center.

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Several authors (e.g., Beutler, 1983; Brehm & Brehm, 1981; Dowd, 1989) have
expanded the original definition of Reactance to include an in-dwelling level of vigilance, a hypersensitivity to loss of freedom, and motivational traits that are assumed to
vary from person to person. According to Dowd (1989), while resistance may occur via
specific client actions in specific situations, reactance is a predilection that exists within
a person because of their idiosyncratic histories of relationships with authorities, demands,
and loss of freedom. Perceived from this internal motivational state, reactance potential
assumedly 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 a
competent therapist using an innocuous intervention may trigger a reactant-prone patients
resistance.
Conclusion 2. Resistance Includes Both Interpersonal and Intrapsychic
Factors that Must Be Considered in Treatment Decisions.
While resistance classically has been conceptualized as a client-based, intrapsychic variable, an interpersonal perspective is gaining favor among theoreticians. With the advent
and 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 in
interactions among people. Brehm and Brehm (1981) suggested that threatened loss of
interpersonal 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, and
3. the magnitude of the threat embodied in the authority and power of the threatening force or person.
These and other interpersonal views have been incorporated partially by psychodynamic theory out of a concern that intrapsychic views permit therapist excesses. Kirmayer (1990), for example, pointed out that the therapist may use resistance to avoid
responsibility for his/her biases. He suggests that resistance is as much a creation of the
therapists 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 directly
contribute to the development of an adversarial relationship in therapy, rather than the
collaborative alliance deemed important for therapeutic success. Even contemporary psychoanalytic theories are adopting an interpersonal view of resistance to supplement or
supplant 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 Measurement
Empirical 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) used
audio recordings of voice qualities taking place within an interpersonal interaction, such

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as psychotherapy, to predict subsequent client resistance and reactance. This procedure

involves filtering out speech bands of sound so that only vocal and tonal qualities of
speech remain. The filtered voice is rated on dimensions that are thought to reflect resistance and defensiveness. These dimensions include vocal qualities thought to sound complaining, whiny, rebellious, and uncooperative. Ensuing research determined that these
qualities are related to current and subsequent patterns of oppositional behaviors when an
authority makes a request or demand.
Other measures of resistance states are based on ratings of in-therapy behaviors in
which resistance is defined within a particular, usually psychoanalytic, frameworka
defense against painful insight. One example is the Patient Resistance Scale (PRS; Morgan, Luborsky, Crits-Christoph, Curtis, & Solomon, 1982), a seven-item rating of levels
of in-session defensiveness expressed by the patient. The reliability of this measure was
reported to be high, but it failed to demonstrate a relationship with treatment outcome.
The Resistance Scale (TRS; Schuller, Crits-Christoph, & Connolly, 1991) was a
modification of the PRS, also based on a psychodynamic concept of resistance. Derived
from data acquired during the Penn Psychotherapy Project (Luborsky et al., 1980), the
PRS subsequently was expanded into a multidimensional format. It consists of 19 ratings
of the frequency and intensity of in-session behaviors that included vocal, content, and
prosaic qualities of speech. Having three clinical judges rate verbatim excerpts from
therapy sessions established the scales psychometric properties. The PRS identifies four
types of resistant behavior: Abrupt/Shifting, Oppositional, Flat/Halting, and Vague/
Doubting. Initial results indicated that stable patterns of resistance characterized different
patients, transcending situations and therapy content and indicating that the resistant
behaviors assessed have inescapable trait, as well as state qualities.
Departing from the psychodynamic traditions of the PRS and TRS, the Client Resistance Scale (CRC; Chamberlain, Patterson, Reid, Kavanaugh, & Forgatch; 1984) adopted
a behavioral tradition to develop a method of rating resistant behaviors from direct observations of in-session activities. This scale identifies seven varieties of moment-tomoment 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 of
treatment, 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 to
reflect cross-situational traits, as well as situational states, several researchers have turned
their efforts to assessing directly resistance proneness independently of therapy itself.
They reason that if resistance levels could be predicted from measures taken before therapy begins, those scores could be used more effectively in planning treatment, as opposed
to measuring resistance levels only within sessions after treatment begins.
Adopting the viewpoint that resistance in therapy reflects an enduring effort to avoid
painful affect, manifest both situationally within therapy and as a continuing propensity
outside of therapy, the Client Resistance Scale (CRS; Mahalik, 1994) was designed to
assess both of these qualities. The CRS yields five separate subscales, each of which was
found to identify an enduring characteristic. All subscales seem to contribute to a single
common 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,

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4. opposition to change, and

5. 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 change
when subjected to the right conditions.
The Therapeutic Reactance Scale (TRS; Dowd, Milne, & Wise, 1991) is probably
the best-known measure of resistance traits. It is a self-report measure derived from the
Reactance Theory of Brehm and Brehm (1981). The Brehms had suggested that dispositions 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 of
scores with measures of defensiveness, aggressiveness, and dominance (Dowd & Wallbrown, 1993), as well as predictive validity on the differential efficacy of directive and
nondirective treatment.
The Questionnaire for Measuring Psychological Reactance (QMPR; Merz, 1983)
was developed in Germany and translated by Dowd as a predecessor to the TRS. The
scale 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, Beutler, & Williams, 1999) includes a special trait-like resistance rating scale. Based on a
historical review of the patients relationships with authorities and an inspection of their
behavior when faced with external demands, the clinician rates the degree to which the
patient obstructs interactions, avoids confrontation, rebels against demand, and behaves
in oppositional or passive-noncompliant ways. This scale has been found to be predictive
of patient response and an indicator for fitting level of therapist resistance to the needs of
the patient (Beutler, Clarkin, & Bongar, 2000).
One of the most frequently employed methods of measuring resistance is through the
use of various subscales and subscale combinations, drawn from different omnibus and
multidimensional personality tests whose content and description suggest that they may
measure resistant states or traits. Several of these have been used in predictive studies of
psychotherapy (Beutler, Moleiro, & Talebi, in press).
Empirical Correlates of Resistance
Conclusion 4. Resistance-prone Individuals Are Characterized by a Constellation
of Interpersonal Traits and Defensive Styles, Including Anger,
Need for Control, Impulsivity, and Direct Avoidance
Dowd and Wallbrown (1993) explored the common personality and situational-response
correlates of resistance by intercorrelating measures of resistance and personality. They
compared scores on the TRS, the QMPR, and subscales from the Personality Research
Form. Results led them to conclude that resistant states and traits are associated with an
enduring personality assemblage comprised of defensiveness, aggression, dominance,
needs for autonomy, and tendencies to avoid affiliations.
Beutler, Zetzer, and Williams (1994) also inspected interrelationships among MMPI
subscales that reflected various personality qualities that were associated conceptually
with resistant behaviors [i.e., Dominance (Do), Control (Cn), and Overcontrolled Hos-

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tility (O-H)]. Intercorrelations first were computed on normative samples from the MMPI-2
standardization group and then replicated on an independent sample of alcoholic men.
The pattern of these correlations revealed that resistance was comprised both of interpersonal and intrapersonal avoidance behaviors, including general measures of coping style.
Correlates included indices of acting out, impulsiveness, aggressiveness, and direct avoidance. Such findings led Dowd and Wallbrown (1993) to conclude that resistant individuals are aggressive, quarrelsome, irritable, hostile, lacking in sympathy and support for
others, ostentatious, and eager for attention. They tend to lack warmth, are uncooperative,
lack loyalty, are avoidant of friendships, and devoid of humility. They have difficulty
tolerating 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 benefit
from treatment. However, to the degree that session or treatment outcome is used to help
define the level of resistance, there is a danger that measures of this relationship may be
spurious (Arkowitz, 1995; Wachtel, 1999). Even when controlling for this potential contamination, 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, and
Talebi (in press) identified 11 studies that had specifically investigated resistance in psychotherapy using suitably controlled research designs. Nine (82%) of these studies found
that patient resistance measures were correlated negatively with outcomes.

Conclusion 6. The Effects of Resistant Traits and States Can Be Circumvented

by the Use of Nondirective and Self-Directed Interventions; Whereas
Low Resistant Traits and States Serve as Indicators for the
Use of Directive and Structured Procedures
More pertinent to the question of treatment planning are research studies that have inspected
resistance traits as indicators and contra-indicators for different types of intervention.
Beutler, Moleiro, and Talebi (in press) reviewed 20 studies that inspected the differential
effects of therapist directiveness as moderated by patient resistance and found that 80%
(n 5 16) of these demonstrated that directive interventions worked best among patients
who had relatively low levels of state or trait-like resistance, while nondirective interventions worked best among patients who had relatively high levels of resistance. Such
findings provide consistent support for the value of resistance level as a predictor of
treatment outcome, as well as a treatment-planning variable.
In most of these studies, however, the use of directive and nondirective interventions
have been inferred through a direct comparison of different models of psychotherapy that
may have varied in many ways besides level of directiveness. In these studies, cognitive
and behavioral therapies generally are used as the prototypes of directive interventions,
while psychodynamic, self-directed, or other relationship-oriented therapies are used as
the prototypes of nondirective or evocative interventions. Nonetheless, those few studies
that have attempted to control for these potential contaminants continue to find the expected
relationships. Specifically, that among very resistant patients, self-directed and nondirective therapy regimens surpass directive ones in affecting therapeutic gain. Conversely,
patients who are low on resistance tend to do better when directive, cognitive therapy

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

Conclusion 7. Reactant States Are Responsive to the Use

of 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 oppositional ways. These Defiance-based paradoxical techniques are designed to use patient
resistance against their symptoms by encouraging them rather than attempting to eliminate them.
An accumulating number of studies have provided support for the relative value of
paradoxical interventions among those with highly resistant behavior. Three metaanalyses have investigated this relationship. Some of these studies (Horvath & Goheen,
1990; Shoham-Salomon et al., 1989) specifically have addressed this issue in the context
of the therapeutic relationship, and all found results that supported the position that reactant 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 to
experimental designs that require random assignment. However, there is a good deal of
consistency in the available research, and this supports 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 trait-like resistance. We have drawn attention to the potential circularity of
definitions of resistance, but such a problem would be reduced greatly if there were
accepted measures of these traits. Although numerous measures have been developed, in
all cases these measures suffer because of low or inconsistent intercorrelations. The presence of stable and consistent predictive measures would add greatly to the draw that this
area has on contemporary researchers.
It is important to note the role played by different theories of psychotherapy in
setting 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 different
patients. Of course, such demonstrations only are interpretable if it can be assured that
different 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 both
situation-induced states and enduring character traits. The extent of these reactions vary
from being oppositional, a quality that is often referred to as reactance, to manifestations
of a slow or reluctant compliance. These varieties of resistance embody descriptive qualities and correlates that suggest concepts of defensiveness and anger in the context of the
psychotherapeutic relationships.

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Reactance theory is based on several assumptions that may be generalized to the

more general case of resistance:
1.
2.
3.
4.

freedom (of choice and action) is valued by all human beings;

human beings will react negatively to perceived or actual threats to their freedoms;
individuals exhibit stable differences and vulnerabilities to these threats;
in the therapy context, the therapists directives or suggestions may overcome
these states; and
5. 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 impediment to effective treatment and that it can be influenced by the therapists use of selfdirected and nondirective interventions. Both research and practice may benefit from the
observation that directive and nondirective interventions may be most effective when
selectively assigned to low- and high-resistant patients, respectively. Directive and authoritative interventions may be used effectively with nonresistant patients, while nondirective and paradoxical interventions may be recommended effectively for use with patients
who 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 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:
1. acknowledgement and reflection of the patients concerns and anger;
2. discussion of the therapeutic relationship; and
3. 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 interventions, such as discouraging rapid change, symptom prescription,
and symptom exaggeration also are ways of using the patients resistance traits in the
service of making change. That is, paradoxical interventions are designed to encourage
violation of directives.
The Systematic Treatment Selection (STS) model, proposed by the senior author
(Beutler & Clarkin, 1990; Beutler, Clarkin, et al., 2000) proposed that specific functional
classes of interventions (e.g., directive versus nondirective, insight-oriented versus
symptom-oriented, abreactive versus supportive) likely are to be more conducive to the
task of tailoring treatments to individual patients than selecting among different global
brands 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 clinical
practice:
1. Treatment is most effective if the therapist can avoid stimulating the patients
level of resistance.
2. Therapeutic change is greatest when the directiveness of the intervention is either
inversely correspondent with the patients current level of resistance, or authoritatively prescribes a continuation of the symptomatic behavior.

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Beutler, Moleiro, and Talebi (in press) concluded that there is strong and consistent
support for these principles. While a causal chain between patient resistance and outcome
cannot be certain, the consistency of the correlational evidence is persuasive, and a strong
majority of studies that investigated resistance as an indicator for the application of either
nondirective or paradoxical interventions found support for these relationships.
Beutler, Clarkin, et al. (2000) added that, in spite of the consistent results supporting
the role of patient resistance in guiding treatment directiveness, this relationship might be
tempered by other variables. They determined that many variables operate in complex
ways and that they frequently potentiate or suppress one anothers effects. They identified six variables that might be jointly considered in addressing the questions of systematic treatment selection for a given patient: resistance, coping style, functional impairment,
subjective distress, social support, and problem complexity. Further research on how
these and other variables interact with each other (namely, with patient resistance) and
with the use of directive, nondirective, and paradoxical interventions is needed.

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