Implications of psychological reactance for clinical practice in psychiatry including a systematic review

Motivation Science Implications of Psychological Reactance for Clinical Practice in Psychiatry Including a Systematic Review Carlos De Las Cuevas and Jose de Leon Online First Publication, July 18, 2024. https://dx.doi.org/10.1037/mot0000321 CITATION De Las Cuevas, C., & de Leon, J. (2024). Implications of psychological reactance for clinical practice in psychiatry including a systematic review.. Motivation Science. Advance online publication. https:// dx.doi.org/10.1037/mot0000321 SPECIAL ISSUE ARTICLE Implications of Psychological Reactance for Clinical Practice in Psychiatry Including a Systematic Review Carlos De Las Cuevas 1, 2 and Jose de Leon 3, 4 1 Department of Internal Medicine, Dermatology and Psychiatry, Faculty of Medicine, Universidad de La Laguna 2 Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna 3 Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, United States 4 Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country Psychiatric treatments can be perceived as a threat or restriction of patients’autonomy, especially when patients feel coerced into treatment or have limited say in treatment decisions. This article explores the relevance of psychological reactance in clinical psychiatric practice. The first section explains that this concept was developed in the psychological literature. The second section explains that the psychiatric literature is not open toward receiving new psychological concepts but typically uses the biomedical and biopsychosocial models. Advances in clinical psychology such as psychological reactance have, unfortunately, had limited impact on the practice of clinical psychiatry. The third section systematically reviews the limited number of articles on psychological reactance published in psychiatric journals. Only 22 articles were found, including 15 cross-sectional studies and 15 articles on medication adherence. That the concept of psychological reactance is not used by psychiatrists does not mean some concepts used in psychiatric literature do not overlap and are closely related. These concepts are reviewed in the fourth section. The fifth section proposes that using a model of psychological reactance can reduce harms and increase benefits when interacting with psychiatric patients. The sixth section uses the literature to provide tips on practical interventions in how psychological reactance can be used for clinical practice in psychiatry. The article concludes that the understanding and application of psychological reactance is essential to providing effective and appropriate mental health care, and that further research is needed to explore the implications of psychological reactance in clinical psychiatric practice. Keywords: psychological reactance, psychiatry, physicians’practice patterns This article reviews the implications of psychological reactance for clinical practice in psychiatry. The first section explains the concept that was developed in the psychological literature. The psychiatric literature is not particularly open to receiving new psychological concepts; this is explained in the second section which explains the models typically used in psychiatry. The third section provides a systematic review of the limited number of articles about psychological reactance published in psychiatric journals. That the concept psychological reactance is not used by psychiatrists does not mean some concepts used in psychiatric literature do not overlap and are closely related. These concepts are reviewed in the fourth section. The fifth section proposes a model showing how the concept of psychological reactance can reduce harms and increase benefits when interacting with psychiatric patients. The sixth section uses the literature to provide tips on practical interventions in how psychological reactance can be used for clinical practice in psychiatry. The Origin and Historical Development of the Concept of Psychological Reactance One important psychological concept that has gained considerable attention in recent years is psychological reactance. Psychological reactance is a phenomenon that occurs when individuals feel that their freedom or autonomy is being threatened or restricted, leading them to react defensively in order to restore their sense of control (J. W. Brehm, 1966). The concept of reactance has its roots in early psychological research on motivation and decision making, but it wasn’t until the 1960s and 1970s that it began to be more widely studied and understood (J. W. Brehm, 1972). One of the earliest researchers to explore the concept of reactance was Jack Brehm, who published a seminal book on the topic in 1966 (J. W. Brehm, 1966). Brehm argued that when individuals perceive that their freedom is being threatened, they experience a state of “psychological discomfort”that motivates them to reassert their independence. He also suggested that reactance could occur not only in response to explicit attempts to restrict behavior, but also in response to more subtle forms of influence or persuasion. In the decades that followed, numerous studies were conducted to further explore the phenomenon of psychological reactance. Researchers looked at a wide range of factors that could influence Carlos De Las Cuevas https://orcid.org/0000-0001-5742-905X Jose de Leon https://orcid.org/0000-0002-7756-2314 The authors acknowledge Lorraine Maw at the Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, United States, who helped in editing this article. The authors are grateful to the reviewers and editors who provided important suggestions for improving the article. Correspondence concerning this article should be addressed to Carlos De Las Cuevas, Department of Internal Medicine, Dermatology and Psychiatry, Faculty of Medicine, University of La Laguna, San Cristóbal de La Laguna 38071, Canary Islands, Spain. Email: [email protected] Motivation Science © 2024 American Psychological Association ISSN: 2333-8113 https://doi.org/10.1037/mot0000321 1 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. the strength of reactance, including the perceived importance of the threatened freedom, the perceived legitimacy of the authority making the restriction, and the degree to which the restriction was perceived as unjust or unfair (Steindl et al., 2015). One notable application of the concept of reactance has been in the field of health communication, where researchers have sought to understand how messages designed to promote healthy behaviors can inadvertently trigger reactance and actually backfire. For example, a message that says “Don’t smoke!”may actually increase the likelihood that someone will smoke, as it may be perceived as a threat to their autonomy (Dillard & Shen, 2005). Overall, the concept of psychological reactance has played an important role in our understanding of how individuals respond to threats to their autonomy and freedom, and has been applied in a wide range of settings, from consumer behavior to political messaging. Other notable references on the topic include Burgoon and Burgoon’s (2002) chapter on reactance in The Persuasion Handbook (Burgoon & Burgoon, 2002), Silvia’s (2005) study on increasing compliance and reducing resistance through similarity (Silvia, 2005), and Wicklund and Brehm’s (1976) book Perspectives on Cognitive Dissonance.In a meta-analysis, Rains (2013) proposed that psychological reactance is a complex phenomenon that can be influenced by multiple factors. Although this review primarily focuses on the application of psychological reactance in psychiatry, it is important to acknowledge parallel developments in the field of clinical psychology. Notable contributions in this area have been made by Beutler et al. (2002,2011), S. S. Brehm and Brehm (1981),andShoham et al. (2004), who have explored psychological reactance from a clinical psychological perspective. S. S. Brehm and Brehm’s (1981) seminal work, Psychological Reactance: A Theory of Freedom and Control, delves into the nuances of reactance as a fundamental human response, offering a comprehensive theoretical framework that has influenced subsequent research in clinical settings. This work provides a foundational understanding of how reactance can manifest in therapeutic relationships and the importance of recognizing and addressing it in clinical practice. Furthermore, the research by Beutler et al. (2002,2011)and Shoham et al. (2004) offers valuable insights into the dynamics of resistance in psychotherapy, emphasizing the role of reactance in patient–therapist interactions. Beutler and colleagues investigate the factors contributing to resistance in therapy, highlighting the significance of tailoring therapeutic approaches to individual client needs. Shoham et al. (2004), in their chapter in Motivational Analyses of Social Behavior, extend this discussion by examining the transformation of reactance from a state to a trait and its implications in clinical practice. While these contributions focus more on the therapeutic process and client–therapist dynamics, they intersect with our review in psychiatry, offering complementary perspectives on the application and understanding of psychological reactance. These works collectively underscore the broader relevance of psychological reactance across different domains of mental health practice. Psychological Reactance in the Context of Psychiatric Models Psychiatric practice has traditionally been dominated by what is usually called the biomedical model, which is summarized in Box 1 (Andreasen, 1985,2001;Bracken et al., 2012;Deacon, 2013;Guze, 1989;Kupfer & Regier, 2011;Richter & Dixon, 2023;Wade & Halligan, 2004). Psychiatric articles frequently mention that Engel (1977) proposed the biopsychosocial model, which is described in Box 2 (Borrell-Carrió et al., 2004;Deacon, 2013;Fava & Sonino, 2008,2017;Papadimitriou, 2017) but this model has been criticized by some authors (Benning, 2015;Deacon, 2013;Ghaemi, 2009) and it is not clear that it has significantly modified clinical practice for most psychiatrists, who have limited time to interact with patients. Given the limitations of the biomedical model and the contributions of clinical psychology, there has been a growing recognition of the importance of incorporating psychological concepts into psychiatric clinical practice (De Las Cuevas & de Leon, 2017). This includes concepts such as motivation, emotion regulation, and cognitive biases, which can influence the patient’s experience of their disorder and their Box 1. The Biomedical Model of Psychiatric Clinical Practice Concept •The biomedical model of psychiatric clinical practice is a widely used approach that emphasizes the role of biology and physiology in the development and treatment of mental illness (Andreasen, 1985). •This approach focuses on the genetic, biochemical, and neuroanatomical factors that are thought to contribute to mental health disorders. •The biomedical model also uses a set of standardized diagnostic criteria to identify mental health disorders, which are based on observable symptoms and behaviors, as well as physiological markers such as brain imaging or biochemical tests (Andreasen, 2001;Guze, 1989;Richter & Dixon, 2023). Critical review •While the biomedical model has been the dominant paradigm in psychiatric clinical practice, historically there has been a growing recognition of the limitations of this model and the need for a more comprehensive and integrated approach to mental health care (Bracken et al., 2012;Deacon, 2013;Wade & Halligan, 2004). Specific limitations •The treatment focus of the biomedical model is on treating mental illness with medications and other biological interventions, such as electroconvulsive therapy or transcranial magnetic stimulation. While these treatments can be effective for many individuals, the biomedical model tends to reduce complex mental health issues to simple biological explanations, which can sometimes oversimplify the causes of mental health disorders and ignore social, cultural, and environmental factors that may contribute to them. •Another limitation of the biomedical model is its narrow focus on treating symptoms rather than addressing the underlying causes of mental health disorders. This may not fully account for the complex interplay between biological, psychological, social, and environmental factors that contribute to mental health issues. In addition, the biomedical model can contribute to the stigmatization of mental illness by implying that people with mental health disorders are somehow defective or abnormal because of their biology, leading to shame and discrimination against individuals with mental illness. •Its overreliance on medication to treat mental illness is another limitation. While medications can be effective for many individuals, they can also have side effects and may not be effective for all individuals. This can also contribute to a lack of emphasis on psychotherapeutic or other nonbiological interventions, which may be more appropriate for some individuals. •Finally, the biomedical model may not account for individual differences in genetics, biology, or other factors that may influence the development and treatment of mental health disorders. As a result, it may not provide the most effective treatment for all individuals. Despite these limitations, the biomedical model remains a widely used approach in psychiatric clinical practice, and ongoing research and advances in technology may continue to refining and improving its effectiveness (Kupfer & Regier, 2011). DE LAS CUEVAS AND DE LEON 2 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. response to treatment (Villalobos et al., 2021). This view is elaborated in Box 3 (Althobaiti et al., 2020;American Psychological Association, 1996;Benjamin, 2005;Campbell et al., 2013;De Las Cuevas, Peñate, & de Rivera, 2014;Fava & Sonino, 2005;Fava, Tomba, & Bech, 2017;Hunsley et al., 2014;Kamenov et al., 2017;Olatunji et al., 2010;Olfson & Marcus, 2010;Tadmon & Olfson, 2022). The next section describes the small number of articles exploring and/or measuring psychological reactance in clinical practice in psychiatry. A Systematic Article Review of Psychological Reactance for Clinical Practice in Psychiatry Table 1 shows the limited results of an article search about psychological reactance in clinical psychiatric practice. On October Box 2 The Biopsychosocial Model of Psychiatric Clinical Practice Concept •On the other hand, the biopsychosocial model proposed by Engel (Engel, 1977;Fava & Sonino, 2008,2017;Papadimitriou, 2017) takes into account the complex interplay of biological, psychological, and social factors that contribute to mental health problems, and recognizes the importance of environmental and social factors in shaping an individual’s mental health and well-being. This model acknowledges the role of psychological and social interventions alongside medication in the treatment of mental illness, and has led to the development of a range of innovative and effective interventions that address the multiple factors that contribute to mental health problems. Critical review •The biopsychosocial model in psychiatry has been widely used as an alternative to the biomedical model. Nevertheless, no model is perfect and the biopsychosocial model has also been subject to criticism from some quarters, who argue that it has its own limitations and shortcomings (Benning, 2015;Deacon, 2013;Ghaemi, 2009). Specific limitations •First. A key criticism of the biopsychosocial model is the lack of clarity and precision in its approach. Some critics argue that the model is too broad and imprecise, and that it fails to provide clear guidance on how to integrate biological, psychological, and social factors into clinical practice. This can make it difficult for practitioners to effectively apply the model to their patients. •Another criticism of the biopsychosocial model is its overemphasis on the medical model. Some critics argue that the model still relies too heavily on a medical model, which prioritizes biological factors over psychological and social factors. This can lead to overreliance on medication and other medical treatments, rather than addressing the underlying psychological and social factors that may contribute to mental health problems. •A third criticism of the biopsychosocial model is the difficulty in measuring and assessing social and psychological factors. While there are many tools available to measure biological factors, such as brain scans and blood tests, there is less clarity on how to accurately measure and assess psychological and social factors. This can make it difficult to integrate these factors into clinical practice, and to effectively apply the model to patients. •Another criticism of the biopsychosocial model is the lack of attention to cultural factors. The model has been criticized for not adequately addressing the impact of cultural factors on mental health, which can lead to a one-size-fits-all approach that fails to take into account the unique cultural experiences of patients. •Finally, some critics argue that the biopsychosocial model has a limited focus on prevention, and is primarily focused on treatment. This can lead to a reactive approach to mental health, rather than a proactive approach that seeks to prevent mental health problems before they occur. Addressing this limitation would require more emphasis on prevention-oriented interventions in the biopsychosocial model. Conclusion •Despite these criticisms, the biopsychosocial model remains an important approach in psychiatry, and ongoing research and refinement may help to address some of these limitations and improve its effectiveness (Fava & Sonino, 2008,2017). Further research is needed to better understand the complex interplay between biological, psychological, social, and cultural factors in the development and treatment of mental illness, and to develop more effective interventions that take these factors into account. Box 3 The Role of Clinical Psychology in Addressing Limitations of the Biomedical Model Role of clinical psychology •Clinical psychology has a long history of addressing the limitations of the biomedical model of psychiatric clinical practice (Benjamin, 2005). Clinical psychology emphasizes the importance of understanding the patient’s subjective experience, including their thoughts, feelings, and behaviors, and how these relate to their symptoms. This approach recognizes that psychiatric disorders are not purely biological in nature but are also influenced by psychological and social factors (American Psychological Association, 1996;Fava & Sonino, 2005). Development of psychotherapeutic interventions •One important contribution of clinical psychology to psychiatric clinical practice is the development of psychotherapeutic interventions. Psychotherapy focuses on addressing the underlying causes of the disorder rather than simply reducing symptoms. It is based on the principles of the biopsychosocial model, which emphasizes the interaction of biological, psychological, and social factors in the development and maintenance of psychiatric disorders (Campbell et al., 2013). Psychotherapy has been shown to be effective in treating a variety of psychiatric disorders, including depression (Kamenov et al., 2017), anxiety (Olatunji et al., 2010), and posttraumatic stress disorder (Althobaiti et al., 2020). Pharmacology in the context of psychotherapeutic interventions •Although both pharmacological and psychotherapeutic treatments have been shown to be effective in the treatment of psychiatric disorders (Hunsley et al., 2014), according to a U.S. survey psychopharmaceuticals are currently the main approach used in clinical practice, with about half of psychiatrists practicing no psychotherapy at all (Tadmon & Olfson, 2022). Among U.S. outpatients receiving mental health care, the majority (57.4%) use only psychotropic medication, while only 10.5% utilize only psychotherapy. A significant proportion (32.1%) receives a combination of psychotherapy and psychotropic medication (Olfson & Marcus, 2010). One reason for this is that medication can often provide more immediate relief of symptoms, which can be critical in cases where a patient is experiencing severe distress or is at risk of harm. Additionally, medication can be more easily and consistently administered than psychotherapy, which typically requires ongoing sessions with a mental health professional. However, it is important to note that medication is not always the best approach for all patients or all mental health disorders, and that psychotherapyand other nonpharmacological treatments can also be highly effective, especially in cases where underlying psychological or social factors contribute to the development of the disorder. It is essential for mental health professionals to consider the individual needs and preferences of each patient when developing a treatment plan, and to take a holistic approach that addresses all aspects of the patient’s mental and physical health (De Las Cuevas, Peñate, & de Rivera, 2014). Psychological reactance in the context of clinical pharmacopsychology •Table 1 indicates that most of our studies on psychological reactance have focused on it as a variable that may contribute to medication adherence. The subdiscipline of clinical psychology that studies the psychological aspects of pharmacology has been called clinical pharmacopsychology (Fava, Tomba, & Bech, 2017). IMPLICATIONS OF PSYCHOLOGICAL REACTANCE 3 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 1 Systematic Review Using a PubMed Article Search a for PR in Psychiatric Disorders Leading to the Inclusion of 32 Articles Author b,c (from most recent to oldest) Sample PR Scale Topic d Article type Summary De Las Cuevas (2023) b ——Treatment adherence Review Perceived health control and PR interact to influence medication adherence Pogany et al. (2022) 85 psychiatric outpatients HBQPT Patients’attitude toward drug treatment Cross-sectional survey Other variables besides PR had a negative influence on the attitude toward treatment De Las Cuevas, Baptista, et al. (2021) c 212 schizophrenic outpatients HBQPT Treatment adherence Cross-sectional survey In patients with schizophrenia, poor adherence was associated with other variables but not with PR e De Las Cuevas, Motuca, et al. (2021) c 521 depressive outpatients HBQPT Treatment adherence Cross-sectional survey In patients with depressive disorders, poor adherence is influenced by many variables including PR e Lazary et al. (2021) 875 psychiatric outpatients HBQPT Treatment adherence Cross-sectional survey High PR was associated with decreased adherence to antidepressant medications across diagnoses (by grouping three samples e ) De Las Cuevas, Villasante-Tezanos, et al. (2021) c 142 outpatients with bipolar disorder HBQPT Treatment adherence Cross-sectional survey In patients with bipolar disorder, poor adherence was influenced by many variables including PR De Las Cuevas, Lazary, et al. (2021) c HBQPT Review Three items of HPRS were included in the HBQPT to measure PR Pogany et al. (2021) b 295 psychiatric inpatients HBQPT Patients’attitude toward drug treatment Cross-sectional survey Higher PR scores were associated with lower depressive symptomatology but higher anxiety Pogany and Lazary (2021) 148 psychiatric outpatients and 41 medical patients HBQPT Patients’attitude toward drug treatment Cross-sectional survey Patients with addiction showed significantly higher PR Mundal et al. (2021) b 224 psychiatric outpatients HBQPT Preferences of participation in decision-making Cross-sectional survey PR did not have a direct effect on preferences of participation in decision making. De Las Cuevas and de Leon (2020) c ——Treatment adherence Review PR has consistent, strong effects and a predictive role of treatment adherence in some psychiatric patients Lara-Cabrera et al. (2020) b 191 psychiatric outpatients HBQPT Patient-reported well-being Cross-sectional survey Psychiatric outpatient self-reported well-being was negatively correlated with patients’PR De Las Cuevas and de Leon (2019) c 588 psychiatric outpatients HBQPT Treatment adherence Validation study A questionnaire including PR help in predicting adequate adherence, although the various subscales behave differently in different analyses De Las Cuevas et al. (2017) c 966 psychiatric outpatients HPRS Treatment adherence Cross-sectional survey Adherence was negatively associated with cognitive PR De Las Cuevas and de Leon (2017) c ——Treatment adherence Review Poor adherence was associated with several cognitive styles of psychiatric patients, including higher PR. De Las Cuevas et al. (2016) b 966 psychiatric outpatients HPRS Treatment adherence Cross-sectional survey Adherence to prescribed psychiatric treatment was linked to both low affective and cognitive PR De Las Cuevas and Peñate (2015a) b 966 psychiatric outpatients HPRS Self-efficacy of psychiatric outpatients Validation study Low correlation coefficients were found among general self-efficacy and PR dimensions De Las Cuevas and Peñate (2015b) b 949 psychiatric outpatients HPRS Treatment adherence Cross-sectional survey PR was associated with pharmacophobia, making inadequate adherence to prescribed treatment more likely Jaeger (2015) ———Comment Comment on De Las Cuevas, Peñate, and Sanz (2014) De Las Cuevas, Peñate, and Sanz (2014) b 119 psychiatric outpatients with depression HPRS Treatment adherence Cross-sectional survey Medication adherence was negatively associated with both cognitive and affective PR McNiel et al. (2013) 198 psychiatric outpatients TRS Treatment adherence and satisfaction Cross-sectional survey Higher satisfaction with treatment was associated with several variables including lower levels of PR Moore et al. (2000) 39 schizophrenic patients and three with schizoaffective disorder HPRS Treatment adherence Cross-sectional survey PR was associated with adherence especially when patients perceive treatment to be a threat to freedom of choice DE LAS CUEVAS AND DE LEON4 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 23, 2023, we conducted a PubMed search using the following strategy “Psychological reactance AND psychiatry”which produced 32 articles. A missing article from 2000 known by the authors (Moore et al., 2000) was added making a total of 33 articles. As described in footnote a of Table 1, 10 of the 32 articles were excluded (Allen et al., 1994;Cho et al., 2016;Cunningham et al., 2020;Ho et al., 2005;Lee et al., 2021;Longshore & Teruya, 2006;Soveri et al., 2020;Taboada-Vázquez et al., 2021;Taylor & Asmundson, 2021; Zimbres et al., 2020). The 22 included articles were five written by other authors (Jaeger, 2015;McNiel et al., 2013;Moore et al., 2000;Pogany & Lazary, 2021;Pogany et al., 2022) and 17 written by at least one of the two authors of this article (De Las Cuevas, 2023;De Las Cuevas & de Leon, 2017,2019,2020;De Las Cuevas & Peñate, 2015a,2015b;De Las Cuevas, Baptista, et al., 2021;De Las Cuevas et al., 2016,2017;De Las Cuevas, Lazary, et al., 2021;De Las Cuevas, Motuca, et al., 2021;De Las Cuevas, Peñate, & Sanz, 2014;De Las Cuevas, Villasante-Tezanos, et al., 2021;Lara-Cabrera et al., 2020;Lazary et al., 2021;Mundal et al., 2021;Pogany et al., 2021). Three scales were used to measure psychological reactance (De Las Cuevas & de Leon, 2020;Dowd et al., 1991;Hong, 1992). The 22 articles included: one comment, two validation studies of scales, four reviews, and 15 cross-sectional studies of various psychiatric patients. One article included two topics but the rest focused on only one. There was one article each on satisfaction, self-efficacy, and well-being. There were two articles on decision making, three on attitude toward treatment, and 15 on treatment adherence. Table 1 also provides a short summary of the results of each article. In summary, the literature on psychological reactance in psychiatric patients is still relatively limited. These studies have consistently found that reactance is a common phenomenon among psychiatric patients and in some studies, it can have a negative impact on treatment outcomes. Concepts in Clinical Psychiatric Practice Relevant for Psychological Reactance The term psychological reactance is not used in psychiatric literature but we think that this concept has important implications for mental health treatment and overlaps with other concepts normally used in the psychiatric literature. Therefore, some of the most important terms used by psychiatrists to explain the clinical practice of psychiatry are reviewed since they are relevant in understanding our model for using the concept of psychological reactance in psychiatric practice, which is proposed in the next section. Perceived Threat to Autonomy of the Patient One of the most relevant factors overlapping with psychological reactance is what psychiatrists and other physicians call perceived threats to the autonomy of the patient. Patients may experience psychological reactance when they feel that their autonomy and control over their treatment are being threatened (Pavey & Sparks, 2009). Involuntary hospitalization and forced medication are examples of situations where patients may feel that their autonomy is being threatened. Additionally, lack of input in treatment decisions, coercive language or behaviors, and lack of respect for patient preferences can also lead to the patients’feelings of frustration and disengagement (Mundal et al., 2021). Eight including Carlos De Las Cuevas b Nine including Carlos De Las Cuevas and Jose de Leon c Five other authors 11 HBQPT six HPRS one TRS 15 on treatment adherence Three on attitude toward treatment Three on decision making One on satisfaction One on self-efficacy One on well-being 15 cross-sectional studies Four reviews Two validation studies One comment Note. PR =psychological reactance; HBQPT =Health Belief Questionnaire on Psychiatric Treatment (three items taken from HPRS); HPRS =Hong Psychological Reactance Scale (14 items); TRS = Therapeutic Reactance Scale (28 items) by Dowd et al. (1991). a We used the following strategy Psychological Reactance and Psychiatry which produced 31 articles. From our records we added another article not identified by the search (Moore et al., 2000), making a total of 32 articles. Of the 32 articles, 10 were excluded due to be related to: (a) legal matters and no psychiatry (Allen et al., 1994;Ho et al., 2005); (b) marketing: marketing of tobacco (Cho et al., 2016), marketing effects on stigmatization (Zimbres et al., 2020) and marketing of cancer prevention (Lee et al., 2021); (c) education (Cunningham et al., 2020); (d) public health including COVID-19 vaccination (Soveri et al., 2020) or mask use during COVID-19 pandemic (Taylor & Asmundson, 2021) and health services use (Taboada-Vázquez et al., 2021); and (e) mention theory of psychological reactance but there is no measure (Longshore & Teruya, 2006). b Participation of Carlos De Las Cuevas. c Participation of Carlos De Las Cuevas and Jose de Leon. d More than one topic can be present in the same article. e The large sample combines the samples of patients with schizophrenia, bipolar, and depressive disorders. IMPLICATIONS OF PSYCHOLOGICAL REACTANCE 5 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Communication Style Psychological reactance is an important variable to be considered in the communication style in healthcare (Reynolds-Tylus, 2019). Patients who feel that their health care providers are listening to their concerns, respecting their opinions, and collaborating with them on treatment decisions are more likely to feel engaged and invested in their treatment. However, when healthcare providers use an authoritarian or paternalistic communication style, patients may feel that their autonomy and control are being threatened. This can lead to resistance and less likelihood of complying with treatment recommendations. In contrast, a more collaborative communication style can help patients feel that their autonomy is being respected and they may be more likely to comply with treatment recommendations. Stigma Stigma and discrimination are other factors that can contribute to psychological reactance. Patients with mental health conditions often face stigma and discrimination, which can make them feel devalued and powerless (Corrigan & Watson, 2002). When patients perceive that they are being discriminated against or judged based on their mental health status, they may experience psychological reactance. Prior Experience With Mental Health Treatment Finally, previous experiences with mental health treatment can also influence psychological reactance. Patients who have had negative experiences with mental health treatment in the past may be more likely to experience psychological reactance (De Las Cuevas, Peñate, et al., 2014). For example, if patients have experienced mistreatment or abuse by healthcare providers, they may be more resistant to treatment in the future. Similarly, if patients have had negative experiences with specific treatments or medications, they may be more likely to resist those treatments in the future. A Proposed Model for Using Psychological Reactance in Psychiatric Practice Psychological Reactance and Avoiding Negative Outcomes When an individual perceives that their freedom to make choices or behave in a certain way is threatened or restricted, this can result in a strong emotional response that motivates the individual to resist or push back against the perceived restriction, which can manifest in various ways such as increased defiance, argumentativeness, or even withdrawal (Rosenberg & Siegel, 2018). In a therapeutic context, psychological reactance can be particularly detrimental to the therapeutic relationship and the achievement of positive outcomes (Seemann et al., 2004). If a patient feels that their autonomy or choices are being threatened, they may become resistant to the therapeutic process or the therapist’s suggestions, which can impede progress and even lead to premature termination of therapy. By providing choice, using motivational interviewing, emphasizing the patient’s autonomy, collaborating with the patient, providing education and information, validating the patient’s feelings, and monitoring and adjusting the treatment plan, clinicians can reduce reactance and increase treatment adherence while respecting the patient’s autonomy. Another important benefit of recognizing and addressing psychological reactance is that it can reduce resistance and defensiveness from the patient. When patients feel that their autonomy is being threatened, they may become defensive and resistant to the therapeutic process. By recognizing and addressing psychological reactance, therapists can reduce the likelihood of these negative responses and create a more open and receptive therapeutic environment. Moreover, in psychiatric practice, certain types of patients seem to antagonize drug effects as a consequence of their psychological reactance (Fava et al., 2017,2020,2023); such clinical phenomena can easily be found in the setting of personality disturbances, although they do not invariably occur in every patient with such characteristics, because they depend on the interaction between patient and doctor (Fava, 2021). Psychological Reactance and Increasing Positive Outcomes In a clinical context, understanding psychological reactance can help clinicians develop interventions that are more effective in promoting positive outcomes and addressing treatment resistance (De Las Cuevas, Peñate, et al., 2014;Reynolds-Tylus, 2019). Here are some arguments that support this claim. One benefit of recognizing psychological reactance is that it enables clinicians to identify and address sources of reactance. By understanding what triggers reactance in their patients, clinicians can develop interventions that are less likely to be perceived as threatening or restrictive, ultimately reducing the likelihood of reactance and increasing the effectiveness of treatment. Recognizing and addressing psychological reactance can be a helpful strategy for therapists in the creation of a supportive and collaborative therapeutic environment. This approach can foster a sense of empowerment and autonomy among patients, which can increase their motivation to engage in therapy and work toward their goals (Fava, 2016). By acknowledging and respecting the patient’s need for autonomy, therapists can help patients feel more in control of their therapeutic journey. Moreover, recognizing and addressing psychological reactance can facilitate a collaborative approach between the therapist and patient. This collaborative approach can help both parties work together to find solutions and make progress toward the patient’s therapeutic goals. When the therapeutic relationship is collaborative and respectful, it can increase the likelihood of positive outcomes. By acknowledging and respecting the patient’s need for autonomy and working collaboratively toward solutions, therapists can reduce resistance, enhance motivation, and increase the likelihood of successful therapeutic outcomes. Recognizing and addressing psychological reactance can enhance treatment adherence. Patients who feel that their autonomy is being respected and that they are collaborators in the therapeutic process are more likely to adhere to treatment recommendations and engage in therapeutic activities. This can enhance the effectiveness of therapy and promote positive outcomes. By creating a supportive and collaborative therapeutic environment, therapists can help their patients feel more engaged and motivated to work toward their goals. Another advantage is that it helps clinicians tailor their interventions to the individual (Fava, 2022). Different patients may experience reactance in response to different stimuli, so understanding psychological reactance can help clinicians tailor their interventions DE LAS CUEVAS AND DE LEON6 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. to the individual. This can increase the effectiveness of treatment and reduce treatment resistance. In addition, recognizing and addressing psychological reactance can enhance patient motivation and engagement. Patients who feel that their autonomy is being respected and that they are collaborators in the therapeutic process are more likely to be motivated and engaged in treatment (Fava, 2023). This can increase the effectiveness of interventions and promote positive outcomes. Finally, recognizing and addressing psychological reactance can improve the overall quality of care. By developing interventions that are more effective in promoting positive outcomes and addressing treatment resistance, clinicians can improve the overall quality of care for their patients. This can enhance patient satisfaction and reduce the likelihood of premature termination of treatment. Practical Strategies From the Literature to Implement Our Model of Psychological Reactance In the realm of psychiatric practice, navigating the delicate balance of patient receptivity and psychological cooperation is an art form. For psychiatrists, understanding the nuances of human behavior is paramount, especially when it comes to avoiding triggering psychological reactance in patients. Drawing from a wealth of psychological research, we propose several key strategies have emerged, forming a roadmap for enhancing patient engagement and cooperation. Explain the Rationale for Treatment First and foremost, transparency becomes a linchpin in this process. Psychiatrists are encouraged to meticulously elucidate the rationale behind the proposed treatment. Studies by Horvath and Luborsky (1993) and Beck (2020) underscore that patients are considerably more receptive when they comprehend the underlying reasons for therapeutic interventions. By articulating the benefits and elucidating how the treatment can effectively manage their symptoms, psychiatrists pave the way for understanding and acceptance. Involve the Patient in the Treatment Planning Empowerment emerges as another crucial facet. Involving the patient in the treatment planning, as advocated by Barlow (2010) and Miller and Rollnick (2013), lends a sense of control. When patients actively participate in decision-making processes, they perceive a greater degree of autonomy over their treatment. This inclusion not only diminishes psychological reactance but also kindles motivation, fostering a collaborative atmosphere between the psychiatrist and the patient. Provide Options A cornerstone of patient cooperation lies in the freedom of choice. Deci and Ryan (2000) and Miller and Rollnick (2013) posit that providing patients with options diminishes resistance. Whether it involves offering various treatment approaches or allowing patients to determine the sequence of addressing treatment goals, this element of choice nurtures a feeling of control, significantly reducing reactance. Use Language That Respects the Patient’s Autonomy Crucially, language wields immense power in psychiatric interactions. By respecting the patient’s autonomy and avoiding coercive expressions, as suggested by Kolden et al. (2011), psychiatrists can create a nonthreatening environment. Utilizing phrases such as “I recommend”or “we could try”instead of dictatorial language mitigates resistance, fostering a sense of collaboration. Validate the Patient’s Feelings and Concerns Acknowledgment forms the bedrock of patient–psychiatrist relationships. According to Rogers (1957) and Linehan (1993), validating the patient’s feelings and concerns, even when they diverge from professional opinions, is pivotal. Demonstrating understanding and respect engenders trust, dissipating reactance and facilitating a more open dialog. Build Rapport and Trust Finally, the vital role of rapport and trust cannot be overstated. As highlighted by Horvath and Greenberg (1989) and Lambert and Barley (2001), patients are more amenable to treatment when they trust their mental health professionals. Building this rapport demands time, patience, and genuine empathy. However, the dividends in terms of patient cooperation and positive outcomes are immeasurable. In conclusion, by embracing these strategies rooted in psychological research, psychiatrists can create an environment where patients feel heard, respected, and empowered. This synergy of understanding, choice, respectful communication, validation, and trust forms the bedrock of effective psychiatric practice, fostering cooperation and mutual respect between mental health professionals and their patients. Conclusion In conclusion, psychological reactance is a significant challenge in psychiatric treatment, particularly among patients who feel their autonomy is being threatened. 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Poor adherence to oral psychiatric medication in adults with bipolar disorder: The psychiatrist may DE LAS CUEVAS AND DE LEON 8 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.