Mo i a ion Science
Implica ions o Psychological Reac ance o Clinical P ac ice in Psychia y
Including a Sys ema ic Re iew
Ca los De Las Cue as and Jose de Leon
Online Fi s Publica ion, July 18, 2024. h ps://dx.doi.o g/10.1037/mo 0000321
CITATION
De Las Cue as, C., & de Leon, J. (2024). Implica ions o psychological eac ance o clinical p ac ice in
psychia y including a sys ema ic e iew.. Mo i a ion Science. Ad ance online publica ion. h ps://
dx.doi.o g/10.1037/mo 0000321
SPECIAL ISSUE ARTICLE
Implica ions o Psychological Reac ance o Clinical P ac ice in
Psychia y Including a Sys ema ic Re iew
Ca los De Las Cue as
1, 2
and Jose de Leon
3, 4
1
Depa men o In e nal Medicine, De ma ology and Psychia y, Facul y o Medicine, Uni e sidad de La Laguna
2
Ins i u o Uni e si a io de Neu ociencia (IUNE), Uni e sidad de La Laguna
3
Men al Heal h Resea ch Cen e , Eas e n S a e Hospi al, Lexing on, Ken ucky, Uni ed S a es
4
Biomedical Resea ch Cen e in Men al Heal h Ne (CIBERSAM), San iago Após ol Hospi al, Uni e si y o he Basque Coun y
Psychia ic ea men s can be pe cei ed as a h ea o es ic ion o pa ien s’au onomy, especially when pa ien s
eel coe ced in o ea men o ha e limi ed say in ea men decisions. This a icle explo es he ele ance o
psychological eac ance in clinical psychia ic p ac ice. The fi s sec ion explains ha his concep was de el-
oped in he psychological li e a u e. The second sec ion explains ha he psychia ic li e a u e is no open
owa d ecei ing new psychological concep s bu ypically uses he biomedical and biopsychosocial models.
Ad ances in clinical psychology such as psychological eac ance ha e, un o una ely, had limi ed impac on
he p ac ice o clinical psychia y. The hi d sec ion sys ema ically e iews he limi ed numbe o a icles
on psychological eac ance published in psychia ic jou nals. Only 22 a icles we e ound, including 15
c oss-sec ional s udies and 15 a icles on medica ion adhe ence. Tha he concep o psychological eac ance
is no used by psychia is s does no mean some concep s used in psychia ic li e a u e do no o e lap and a e
closely ela ed. These concep s a e e iewed in he ou h sec ion. The fi h sec ion p oposes ha using a model
o psychological eac ance can educe ha ms and inc ease benefi s when in e ac ing wi h psychia ic pa ien s.
The six h sec ion uses he li e a u e o p o ide ips on p ac ical in e en ions in how psychological eac ance
can be used o clinical p ac ice in psychia y. The a icle concludes ha he unde s anding and applica ion o
psychological eac ance is essen ial o p o iding e ec i e and app op ia e men al heal h ca e, and ha u he
esea ch is needed o explo e he implica ions o psychological eac ance in clinical psychia ic p ac ice.
Keywo ds: psychological eac ance, psychia y, physicians’p ac ice pa e ns
This a icle e iews he implica ions o psychological eac ance o
clinical p ac ice in psychia y. The fi s sec ion explains he concep
ha was de eloped in he psychological li e a u e. The psychia ic li -
e a u e is no pa icula ly open o ecei ing new psychological con-
cep s; his is explained in he second sec ion which explains he
models ypically used in psychia y. The hi d sec ion p o ides a sys-
ema ic e iew o he limi ed numbe o a icles abou psychological
eac ance published in psychia ic jou nals. Tha he concep psycho-
logical eac ance is no used by psychia is s does no mean some con-
cep s used in psychia ic li e a u e do no o e lap and a e closely
ela ed. These concep s a e e iewed in he ou h sec ion. The fi h
sec ion p oposes a model showing how he concep o psychological
eac ance can educe ha ms and inc ease benefi s when in e ac ing
wi h psychia ic pa ien s. The six h sec ion uses he li e a u e o
p o ide ips on p ac ical in e en ions in how psychological eac ance
can be used o clinical p ac ice in psychia y.
The O igin and His o ical De elopmen o he Concep o
Psychological Reac ance
One impo an psychological concep ha has gained conside -
able a en ion in ecen yea s is psychological eac ance.
Psychological eac ance is a phenomenon ha occu s when indi id-
uals eel ha hei eedom o au onomy is being h ea ened o
es ic ed, leading hem o eac de ensi ely in o de o es o e
hei sense o con ol (J. W. B ehm, 1966). The concep o eac ance
has i s oo s in ea ly psychological esea ch on mo i a ion and deci-
sion making, bu i wasn’ un il he 1960s and 1970s ha i began o
be mo e widely s udied and unde s ood (J. W. B ehm, 1972).
One o he ea lies esea che s o explo e he concep o eac ance
was Jack B ehm, who published a seminal book on he opic in 1966
(J. W. B ehm, 1966). B ehm a gued ha when indi iduals pe cei e
ha hei eedom is being h ea ened, hey expe ience a s a e o
“psychological discom o ” ha mo i a es hem o easse hei
independence. He also sugges ed ha eac ance could occu no
only in esponse o explici a emp s o es ic beha io , bu also
in esponse o mo e sub le o ms o influence o pe suasion.
In he decades ha ollowed, nume ous s udies we e conduc ed o
u he explo e he phenomenon o psychological eac ance.
Resea che s looked a a wide ange o ac o s ha could influence
Ca los De Las Cue as h ps://o cid.o g/0000-0001-5742-905X
Jose de Leon h ps://o cid.o g/0000-0002-7756-2314
The au ho s acknowledge Lo aine Maw a he Men al Heal h Resea ch
Cen e a Eas e n S a e Hospi al, Lexing on, Ken ucky, Uni ed S a es, who
helped in edi ing his a icle. The au ho s a e g a e ul o he e iewe s and
edi o s who p o ided impo an sugges ions o imp o ing he a icle.
Co espondence conce ning his a icle should be add essed o Ca los De
Las Cue as, Depa men o In e nal Medicine, De ma ology and Psychia y,
Facul y o Medicine, Uni e si y o La Laguna, San C is óbal de La Laguna
38071, Cana y Islands, Spain. Email: [email p o ec ed]
Mo i a ion Science
© 2024 Ame ican Psychological Associa ion
ISSN: 2333-8113 h ps://doi.o g/10.1037/mo 0000321
1
This documen is copy igh ed by he Ame ican Psychological Associa ion o one o i s allied publishe s.
This a icle is in ended solely o he pe sonal use o he indi idual use and is no o be dissemina ed b oadly.
he s eng h o eac ance, including he pe cei ed impo ance o he
h ea ened eedom, he pe cei ed legi imacy o he au ho i y mak-
ing he es ic ion, and he deg ee o which he es ic ion was pe -
cei ed as unjus o un ai (S eindl e al., 2015).
One no able applica ion o he concep o eac ance has been in
he field o heal h communica ion, whe e esea che s ha e sough
o unde s and how messages designed o p omo e heal hy beha io s
can inad e en ly igge eac ance and ac ually backfi e. Fo exam-
ple, a message ha says “Don’ smoke!”may ac ually inc ease he
likelihood ha someone will smoke, as i may be pe cei ed as a
h ea o hei au onomy (Dilla d & Shen, 2005).
O e all, he concep o psychological eac ance has played an
impo an ole in ou unde s anding o how indi iduals espond o
h ea s o hei au onomy and eedom, and has been applied in a
wide ange o se ings, om consume beha io o poli ical messaging.
O he no able e e ences on he opic include Bu goon and Bu goon’s
(2002) chap e on eac ance in The Pe suasion Handbook (Bu goon &
Bu goon, 2002), Sil ia’s (2005) s udy on inc easing compliance and
educing esis ance h ough simila i y (Sil ia, 2005), and Wicklund
and B ehm’s (1976) book Pe spec i es on Cogni i e Dissonance.In
a me a-analysis, Rains (2013) p oposed ha psychological eac ance
is a complex phenomenon ha can be influenced by mul iple ac o s.
Al hough his e iew p ima ily ocuses on he applica ion o psycho-
logical eac ance in psychia y, i is impo an o acknowledge pa allel
de elopmen s in he field o clinical psychology. No able con ibu ions
in his a ea ha e been made by Beu le e al. (2002,2011), S. S. B ehm
and B ehm (1981),andShoham e al. (2004), who ha e explo ed psy-
chological eac ance om a clinical psychological pe spec i e.
S. S. B ehm and B ehm’s (1981) seminal wo k, Psychological
Reac ance: A Theo y o F eedom and Con ol, del es in o he nuances
o eac ance as a undamen al human esponse, o e ing a comp ehen-
si e heo e ical amewo k ha has influenced subsequen esea ch in
clinical se ings. This wo k p o ides a ounda ional unde s anding o
how eac ance can mani es in he apeu ic ela ionships and he impo -
ance o ecognizing and add essing i in clinical p ac ice.
Fu he mo e, he esea ch by Beu le e al. (2002,2011)and
Shoham e al. (2004) o e s aluable insigh s in o he dynamics o
esis ance in psycho he apy, emphasizing he ole o eac ance in
pa ien – he apis in e ac ions. Beu le and colleagues in es iga e he
ac o s con ibu ing o esis ance in he apy, highligh ing he signifi-
cance o ailo ing he apeu ic app oaches o indi idual clien needs.
Shoham e al. (2004), in hei chap e in Mo i a ional Analyses o
Social Beha io , ex end his discussion by examining he ans o ma-
ion o eac ance om a s a e o a ai and i s implica ions in clinical
p ac ice. While hese con ibu ions ocus mo e on he he apeu ic p o-
cess and clien – he apis dynamics, hey in e sec wi h ou e iew in
psychia y, o e ing complemen a y pe spec i es on he applica ion
and unde s anding o psychological eac ance. These wo ks collec-
i ely unde sco e he b oade ele ance o psychological eac ance
ac oss di e en domains o men al heal h p ac ice.
Psychological Reac ance in he Con ex o Psychia ic
Models
Psychia ic p ac ice has adi ionally been domina ed by wha is
usually called he biomedical model, which is summa ized in Box 1
(And easen, 1985,2001;B acken e al., 2012;Deacon, 2013;Guze,
1989;Kup e & Regie , 2011;Rich e & Dixon, 2023;Wade &
Halligan, 2004). Psychia ic a icles equen ly men ion ha Engel
(1977) p oposed he biopsychosocial model, which is desc ibed in
Box 2 (Bo ell-Ca ió e al., 2004;Deacon, 2013;Fa a & Sonino,
2008,2017;Papadimi iou, 2017) bu his model has been c i icized
by some au ho s (Benning, 2015;Deacon, 2013;Ghaemi, 2009)
and i is no clea ha i has significan ly modified clinical p ac ice
o mos psychia is s, who ha e limi ed ime o in e ac wi h pa ien s.
Gi en he limi a ions o he biomedical model and he con ibu ions o
clinical psychology, he e has been a g owing ecogni ion o he impo -
ance o inco po a ing psychological concep s in o psychia ic clinical
p ac ice (De Las Cue as & de Leon, 2017). This includes concep s
such as mo i a ion, emo ion egula ion, and cogni i e biases, which
can influence he pa ien ’s expe ience o hei diso de and hei
Box 1. The Biomedical Model o Psychia ic Clinical P ac ice
Concep
•The biomedical model o psychia ic clinical p ac ice is a widely used
app oach ha emphasizes he ole o biology and physiology in he
de elopmen and ea men o men al illness (And easen, 1985).
•This app oach ocuses on he gene ic, biochemical, and
neu oana omical ac o s ha a e hough o con ibu e o men al
heal h diso de s.
•The biomedical model also uses a se o s anda dized diagnos ic
c i e ia o iden i y men al heal h diso de s, which a e based on
obse able symp oms and beha io s, as well as physiological
ma ke s such as b ain imaging o biochemical es s (And easen,
2001;Guze, 1989;Rich e & Dixon, 2023).
C i ical e iew
•While he biomedical model has been he dominan pa adigm in
psychia ic clinical p ac ice, his o ically he e has been a g owing
ecogni ion o he limi a ions o his model and he need o a mo e
comp ehensi e and in eg a ed app oach o men al heal h ca e
(B acken e al., 2012;Deacon, 2013;Wade & Halligan, 2004).
Specific limi a ions
•The ea men ocus o he biomedical model is on ea ing men al
illness wi h medica ions and o he biological in e en ions, such as
elec ocon ulsi e he apy o ansc anial magne ic s imula ion. While
hese ea men s can be e ec i e o many indi iduals, he
biomedical model ends o educe complex men al heal h issues o
simple biological explana ions, which can some imes o e simpli y
he causes o men al heal h diso de s and igno e social, cul u al, and
en i onmen al ac o s ha may con ibu e o hem.
•Ano he limi a ion o he biomedical model is i s na ow ocus on
ea ing symp oms a he han add essing he unde lying causes o
men al heal h diso de s. This may no ully accoun o he complex
in e play be ween biological, psychological, social, and
en i onmen al ac o s ha con ibu e o men al heal h issues. In
addi ion, he biomedical model can con ibu e o he s igma iza ion o
men al illness by implying ha people wi h men al heal h diso de s
a e somehow de ec i e o abno mal because o hei biology, leading
o shame and disc imina ion agains indi iduals wi h men al illness.
•I s o e eliance on medica ion o ea men al illness is ano he
limi a ion. While medica ions can be e ec i e o many indi iduals,
hey can also ha e side e ec s and may no be e ec i e o all
indi iduals. This can also con ibu e o a lack o emphasis on
psycho he apeu ic o o he nonbiological in e en ions, which may
be mo e app op ia e o some indi iduals.
•Finally, he biomedical model may no accoun o indi idual
di e ences in gene ics, biology, o o he ac o s ha may influence
he de elopmen and ea men o men al heal h diso de s. As a esul ,
i may no p o ide he mos e ec i e ea men o all indi iduals.
Despi e hese limi a ions, he biomedical model emains a widely
used app oach in psychia ic clinical p ac ice, and ongoing esea ch
and ad ances in echnology may con inue o efining and imp o ing
i s e ec i eness (Kup e & Regie , 2011).
DE LAS CUEVAS AND DE LEON
2
This documen is copy igh ed by he Ame ican Psychological Associa ion o one o i s allied publishe s.
This a icle is in ended solely o he pe sonal use o he indi idual use and is no o be dissemina ed b oadly.
esponse o ea men (Villalobos e al., 2021). This iew is elabo a ed
in Box 3 (Al hobai i e al., 2020;Ame ican Psychological Associa ion,
1996;Benjamin, 2005;Campbell e al., 2013;De Las Cue as, Peña e,
& de Ri e a, 2014;Fa a & Sonino, 2005;Fa a, Tomba, & Bech,
2017;Hunsley e al., 2014;Kameno e al., 2017;Ola unji e al.,
2010;Ol son & Ma cus, 2010;Tadmon & Ol son, 2022). The nex
sec ion desc ibes he small numbe o a icles explo ing and/o measu -
ing psychological eac ance in clinical p ac ice in psychia y.
A Sys ema ic A icle Re iew o Psychological Reac ance
o Clinical P ac ice in Psychia y
Table 1 shows he limi ed esul s o an a icle sea ch abou psy-
chological eac ance in clinical psychia ic p ac ice. On Oc obe
Box 2 The Biopsychosocial Model o Psychia ic Clinical P ac ice
Concep
•On he o he hand, he biopsychosocial model p oposed by Engel
(Engel, 1977;Fa a & Sonino, 2008,2017;Papadimi iou, 2017) akes
in o accoun he complex in e play o biological, psychological, and
social ac o s ha con ibu e o men al heal h p oblems, and ecognizes
he impo ance o en i onmen al and social ac o s in shaping an
indi idual’s men al heal h and well-being. This model acknowledges
he ole o psychological and social in e en ions alongside medica ion
in he ea men o men al illness, and has led o he de elopmen o a
ange o inno a i e and e ec i e in e en ions ha add ess he mul iple
ac o s ha con ibu e o men al heal h p oblems.
C i ical e iew
•The biopsychosocial model in psychia y has been widely used as an
al e na i e o he biomedical model. Ne e heless, no model is pe ec
and he biopsychosocial model has also been subjec o c i icism om
some qua e s, who a gue ha i has i s own limi a ions and
sho comings (Benning, 2015;Deacon, 2013;Ghaemi, 2009).
Specific limi a ions
•Fi s . A key c i icism o he biopsychosocial model is he lack o
cla i y and p ecision in i s app oach. Some c i ics a gue ha he
model is oo b oad and imp ecise, and ha i ails o p o ide clea
guidance on how o in eg a e biological, psychological, and social
ac o s in o clinical p ac ice. This can make i di ficul o
p ac i ione s o e ec i ely apply he model o hei pa ien s.
•Ano he c i icism o he biopsychosocial model is i s o e emphasis
on he medical model. Some c i ics a gue ha he model s ill elies oo
hea ily on a medical model, which p io i izes biological ac o s o e
psychological and social ac o s. This can lead o o e eliance on
medica ion and o he medical ea men s, a he han add essing he
unde lying psychological and social ac o s ha may con ibu e o
men al heal h p oblems.
•A hi d c i icism o he biopsychosocial model is he di ficul y in
measu ing and assessing social and psychological ac o s. While
he e a e many ools a ailable o measu e biological ac o s, such as
b ain scans and blood es s, he e is less cla i y on how o accu a ely
measu e and assess psychological and social ac o s. This can make i
di ficul o in eg a e hese ac o s in o clinical p ac ice, and o
e ec i ely apply he model o pa ien s.
•Ano he c i icism o he biopsychosocial model is he lack o a en ion
o cul u al ac o s. The model has been c i icized o no adequa ely
add essing he impac o cul u al ac o s on men al heal h, which can
lead o a one-size-fi s-all app oach ha ails o ake in o accoun he
unique cul u al expe iences o pa ien s.
•Finally, some c i ics a gue ha he biopsychosocial model has a limi ed
ocus on p e en ion, and is p ima ily ocused on ea men . This can
lead o a eac i e app oach o men al heal h, a he han a p oac i e
app oach ha seeks o p e en men al heal h p oblems be o e hey
occu . Add essing his limi a ion would equi e mo e emphasis on
p e en ion-o ien ed in e en ions in he biopsychosocial model.
Conclusion
•Despi e hese c i icisms, he biopsychosocial model emains an
impo an app oach in psychia y, and ongoing esea ch and
efinemen may help o add ess some o hese limi a ions and imp o e
i s e ec i eness (Fa a & Sonino, 2008,2017). Fu he esea ch is
needed o be e unde s and he complex in e play be ween
biological, psychological, social, and cul u al ac o s in he
de elopmen and ea men o men al illness, and o de elop mo e
e ec i e in e en ions ha ake hese ac o s in o accoun .
Box 3 The Role o Clinical Psychology in Add essing Limi a ions o
he Biomedical Model
Role o clinical psychology
•Clinical psychology has a long his o y o add essing he limi a ions o
he biomedical model o psychia ic clinical p ac ice (Benjamin,
2005). Clinical psychology emphasizes he impo ance o
unde s anding he pa ien ’s subjec i e expe ience, including hei
hough s, eelings, and beha io s, and how hese ela e o hei
symp oms. This app oach ecognizes ha psychia ic diso de s a e
no pu ely biological in na u e bu a e also influenced by
psychological and social ac o s (Ame ican Psychological
Associa ion, 1996;Fa a & Sonino, 2005).
De elopmen o psycho he apeu ic in e en ions
•One impo an con ibu ion o clinical psychology o psychia ic
clinical p ac ice is he de elopmen o psycho he apeu ic
in e en ions. Psycho he apy ocuses on add essing he unde lying
causes o he diso de a he han simply educing symp oms. I is
based on he p inciples o he biopsychosocial model, which
emphasizes he in e ac ion o biological, psychological, and social
ac o s in he de elopmen and main enance o psychia ic diso de s
(Campbell e al., 2013). Psycho he apy has been shown o be
e ec i e in ea ing a a ie y o psychia ic diso de s, including
dep ession (Kameno e al., 2017), anxie y (Ola unji e al., 2010),
and pos auma ic s ess diso de (Al hobai i e al., 2020).
Pha macology in he con ex o psycho he apeu ic in e en ions
•Al hough bo h pha macological and psycho he apeu ic ea men s ha e
been shown o be e ec i e in he ea men o psychia ic diso de s
(Hunsley e al., 2014), acco ding o a U.S. su ey
psychopha maceu icals a e cu en ly he main app oach used in clinical
p ac ice, wi h abou hal o psychia is s p ac icing no psycho he apy a
all (Tadmon & Ol son, 2022). Among U.S. ou pa ien s ecei ing
men al heal h ca e, he majo i y (57.4%) use only psycho opic
medica ion, while only 10.5% u ilize only psycho he apy. A significan
p opo ion (32.1%) ecei es a combina ion o psycho he apy and
psycho opic medica ion (Ol son & Ma cus, 2010). One eason o his
is ha medica ion can o en p o ide mo e immedia e elie o
symp oms, which can be c i ical in cases whe e a pa ien is
expe iencing se e e dis ess o is a isk o ha m. Addi ionally,
medica ion can be mo e easily and consis en ly adminis e ed han
psycho he apy, which ypically equi es ongoing sessions wi h a
men al heal h p o essional. Howe e , i is impo an o no e ha
medica ion is no always he bes app oach o all pa ien s o all men al
heal h diso de s, and ha psycho he apyand o he nonpha macological
ea men s can also be highly e ec i e, especially in cases whe e
unde lying psychological o social ac o s con ibu e o he
de elopmen o he diso de . I is essen ial o men al heal h
p o essionals o conside he indi idual needs and p e e ences o each
pa ien when de eloping a ea men plan, and o ake a holis ic
app oach ha add esses all aspec s o he pa ien ’s men al and physical
heal h (De Las Cue as, Peña e, & de Ri e a, 2014).
Psychological eac ance in he con ex o clinical pha macopsychology
•Table 1 indica es ha mos o ou s udies on psychological eac ance
ha e ocused on i as a a iable ha may con ibu e o medica ion
adhe ence. The subdiscipline o clinical psychology ha s udies he
psychological aspec s o pha macology has been called clinical
pha macopsychology (Fa a, Tomba, & Bech, 2017).
IMPLICATIONS OF PSYCHOLOGICAL REACTANCE 3
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Table 1
Sys ema ic Re iew Using a PubMed A icle Sea ch
a
o PR in Psychia ic Diso de s Leading o he Inclusion o 32 A icles
Au ho
b,c
( om mos ecen o oldes ) Sample PR Scale Topic
d
A icle ype Summa y
De Las Cue as (2023)
b
——T ea men adhe ence Re iew Pe cei ed heal h con ol and PR in e ac o influence
medica ion adhe ence
Pogany e al. (2022) 85 psychia ic ou pa ien s HBQPT Pa ien s’a i ude owa d
d ug ea men
C oss-sec ional su ey O he a iables besides PR had a nega i e influence
on he a i ude owa d ea men
De Las Cue as, Bap is a, e al. (2021)
c
212 schizoph enic ou pa ien s HBQPT T ea men adhe ence C oss-sec ional su ey In pa ien s wi h schizoph enia, poo adhe ence was
associa ed wi h o he a iables bu no wi h PR
e
De Las Cue as, Mo uca, e al. (2021)
c
521 dep essi e ou pa ien s HBQPT T ea men adhe ence C oss-sec ional su ey In pa ien s wi h dep essi e diso de s, poo adhe ence
is influenced by many a iables including PR
e
Laza y e al. (2021) 875 psychia ic ou pa ien s HBQPT T ea men adhe ence C oss-sec ional su ey High PR was associa ed wi h dec eased adhe ence o
an idep essan medica ions ac oss diagnoses (by
g ouping h ee samples
e
)
De Las Cue as, Villasan e-Tezanos, e al. (2021)
c
142 ou pa ien s wi h bipola
diso de
HBQPT T ea men adhe ence C oss-sec ional su ey In pa ien s wi h bipola diso de , poo adhe ence was
influenced by many a iables including PR
De Las Cue as, Laza y, e al. (2021)
c
HBQPT Re iew Th ee i ems o HPRS we e included in he HBQPT o
measu e PR
Pogany e al. (2021)
b
295 psychia ic inpa ien s HBQPT Pa ien s’a i ude owa d
d ug ea men
C oss-sec ional su ey Highe PR sco es we e associa ed wi h lowe
dep essi e symp oma ology bu highe anxie y
Pogany and Laza y (2021) 148 psychia ic ou pa ien s
and 41 medical pa ien s
HBQPT Pa ien s’a i ude owa d
d ug ea men
C oss-sec ional su ey Pa ien s wi h addic ion showed significan ly highe
PR
Mundal e al. (2021)
b
224 psychia ic ou pa ien s HBQPT P e e ences o
pa icipa ion in
decision-making
C oss-sec ional su ey PR did no ha e a di ec e ec on p e e ences o
pa icipa ion in decision making.
De Las Cue as and de Leon (2020)
c
——T ea men adhe ence Re iew PR has consis en , s ong e ec s and a p edic i e ole
o ea men adhe ence in some psychia ic
pa ien s
La a-Cab e a e al. (2020)
b
191 psychia ic ou pa ien s HBQPT Pa ien - epo ed
well-being
C oss-sec ional su ey Psychia ic ou pa ien sel - epo ed well-being was
nega i ely co ela ed wi h pa ien s’PR
De Las Cue as and de Leon (2019)
c
588 psychia ic ou pa ien s HBQPT T ea men adhe ence Valida ion s udy A ques ionnai e including PR help in p edic ing
adequa e adhe ence, al hough he a ious
subscales beha e di e en ly in di e en analyses
De Las Cue as e al. (2017)
c
966 psychia ic ou pa ien s HPRS T ea men adhe ence C oss-sec ional su ey Adhe ence was nega i ely associa ed wi h cogni i e
PR
De Las Cue as and de Leon (2017)
c
——T ea men adhe ence Re iew Poo adhe ence was associa ed wi h se e al cogni i e
s yles o psychia ic pa ien s, including highe PR.
De Las Cue as e al. (2016)
b
966 psychia ic ou pa ien s HPRS T ea men adhe ence C oss-sec ional su ey Adhe ence o p esc ibed psychia ic ea men was
linked o bo h low a ec i e and cogni i e PR
De Las Cue as and Peña e (2015a)
b
966 psychia ic ou pa ien s HPRS Sel -e ficacy o
psychia ic ou pa ien s
Valida ion s udy Low co ela ion coe ficien s we e ound among
gene al sel -e ficacy and PR dimensions
De Las Cue as and Peña e (2015b)
b
949 psychia ic ou pa ien s HPRS T ea men adhe ence C oss-sec ional su ey PR was associa ed wi h pha macophobia, making
inadequa e adhe ence o p esc ibed ea men
mo e likely
Jaege (2015) ———Commen Commen on De Las Cue as, Peña e, and Sanz
(2014)
De Las Cue as, Peña e, and Sanz (2014)
b
119 psychia ic ou pa ien s
wi h dep ession
HPRS T ea men adhe ence C oss-sec ional su ey Medica ion adhe ence was nega i ely associa ed
wi h bo h cogni i e and a ec i e PR
McNiel e al. (2013) 198 psychia ic ou pa ien s TRS T ea men adhe ence and
sa is ac ion
C oss-sec ional su ey Highe sa is ac ion wi h ea men was associa ed
wi h se e al a iables including lowe le els o PR
Moo e e al. (2000) 39 schizoph enic pa ien s and
h ee wi h schizoa ec i e
diso de
HPRS T ea men adhe ence C oss-sec ional su ey PR was associa ed wi h adhe ence especially when
pa ien s pe cei e ea men o be a h ea o
eedom o choice
DE LAS CUEVAS AND DE LEON4
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23, 2023, we conduc ed a PubMed sea ch using he ollowing s a -
egy “Psychological eac ance AND psychia y”which p oduced 32
a icles. A missing a icle om 2000 known by he au ho s (Moo e e
al., 2000) was added making a o al o 33 a icles. As desc ibed in
oo no e a o Table 1, 10 o he 32 a icles we e excluded (Allen
e al., 1994;Cho e al., 2016;Cunningham e al., 2020;Ho e al.,
2005;Lee e al., 2021;Longsho e & Te uya, 2006;So e i e al.,
2020;Taboada-Vázquez e al., 2021;Taylo & Asmundson, 2021;
Zimb es e al., 2020). The 22 included a icles we e fi e w i en
by o he au ho s (Jaege , 2015;McNiel e al., 2013;Moo e e al.,
2000;Pogany & Laza y, 2021;Pogany e al., 2022) and 17 w i en
by a leas one o he wo au ho s o his a icle (De Las Cue as,
2023;De Las Cue as & de Leon, 2017,2019,2020;De Las
Cue as & Peña e, 2015a,2015b;De Las Cue as, Bap is a, e al.,
2021;De Las Cue as e al., 2016,2017;De Las Cue as, Laza y,
e al., 2021;De Las Cue as, Mo uca, e al., 2021;De Las Cue as,
Peña e, & Sanz, 2014;De Las Cue as, Villasan e-Tezanos, e al.,
2021;La a-Cab e a e al., 2020;Laza y e al., 2021;Mundal e al.,
2021;Pogany e al., 2021). Th ee scales we e used o measu e psy-
chological eac ance (De Las Cue as & de Leon, 2020;Dowd e al.,
1991;Hong, 1992). The 22 a icles included: one commen , wo al-
ida ion s udies o scales, ou e iews, and 15 c oss-sec ional s udies
o a ious psychia ic pa ien s. One a icle included wo opics bu
he es ocused on only one. The e was one a icle each on sa is ac-
ion, sel -e ficacy, and well-being. The e we e wo a icles on deci-
sion making, h ee on a i ude owa d ea men , and 15 on ea men
adhe ence. Table 1 also p o ides a sho summa y o he esul s o
each a icle.
In summa y, he li e a u e on psychological eac ance in psychia -
ic pa ien s is s ill ela i ely limi ed. These s udies ha e consis en ly
ound ha eac ance is a common phenomenon among psychia ic
pa ien s and in some s udies, i can ha e a nega i e impac on ea -
men ou comes.
Concep s in Clinical Psychia ic P ac ice Rele an o
Psychological Reac ance
The e m psychological eac ance is no used in psychia ic li e -
a u e bu we hink ha his concep has impo an implica ions o
men al heal h ea men and o e laps wi h o he concep s no mally
used in he psychia ic li e a u e. The e o e, some o he mos impo -
an e ms used by psychia is s o explain he clinical p ac ice o psy-
chia y a e e iewed since hey a e ele an in unde s anding ou
model o using he concep o psychological eac ance in psychia -
ic p ac ice, which is p oposed in he nex sec ion.
Pe cei ed Th ea o Au onomy o he Pa ien
One o he mos ele an ac o s o e lapping wi h psychological
eac ance is wha psychia is s and o he physicians call pe cei ed
h ea s o he au onomy o he pa ien . Pa ien s may expe ience psy-
chological eac ance when hey eel ha hei au onomy and con ol
o e hei ea men a e being h ea ened (Pa ey & Spa ks, 2009).
In olun a y hospi aliza ion and o ced medica ion a e examples o
si ua ions whe e pa ien s may eel ha hei au onomy is being
h ea ened. Addi ionally, lack o inpu in ea men decisions, coe -
ci e language o beha io s, and lack o espec o pa ien p e e -
ences can also lead o he pa ien s’ eelings o us a ion and
disengagemen (Mundal e al., 2021).
Eigh including Ca los De Las Cue as
b
Nine including Ca los De Las Cue as and Jose
de Leon
c
Fi e o he au ho s
11 HBQPT
six
HPRS
one TRS
15 on ea men
adhe ence
Th ee on a i ude
owa d ea men
Th ee on decision
making
One on sa is ac ion
One on sel -e ficacy
One on well-being
15 c oss-sec ional s udies
Fou e iews
Two alida ion s udies
One commen
No e. PR =psychological eac ance; HBQPT =Heal h Belie Ques ionnai e on Psychia ic T ea men ( h ee i ems aken om HPRS); HPRS =Hong Psychological Reac ance Scale (14 i ems); TRS =
The apeu ic Reac ance Scale (28 i ems) by Dowd e al. (1991).
a
We used he ollowing s a egy Psychological Reac ance and Psychia y which p oduced 31 a icles. F om ou eco ds we added ano he a icle no iden ified by he sea ch (Moo e e al., 2000), making a o al
o 32 a icles. O he 32 a icles, 10 we e excluded due o be ela ed o: (a) legal ma e s and no psychia y (Allen e al., 1994;Ho e al., 2005); (b) ma ke ing: ma ke ing o obacco (Cho e al., 2016), ma ke ing
e ec s on s igma iza ion (Zimb es e al., 2020) and ma ke ing o cance p e en ion (Lee e al., 2021); (c) educa ion (Cunningham e al., 2020); (d) public heal h including COVID-19 accina ion (So e i e al.,
2020) o mask use du ing COVID-19 pandemic (Taylo & Asmundson, 2021) and heal h se ices use (Taboada-Vázquez e al., 2021); and (e) men ion heo y o psychological eac ance bu he e is no measu e
(Longsho e & Te uya, 2006).
b
Pa icipa ion o Ca los De Las Cue as.
c
Pa icipa ion o Ca los De Las Cue as and Jose de Leon.
d
Mo e han one opic can be p esen in he same a icle.
e
The la ge
sample combines he samples o pa ien s wi h schizoph enia, bipola , and dep essi e diso de s.
IMPLICATIONS OF PSYCHOLOGICAL REACTANCE 5
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Communica ion S yle
Psychological eac ance is an impo an a iable o be conside ed in
he communica ion s yle in heal hca e (Reynolds-Tylus, 2019).
Pa ien s who eel ha hei heal h ca e p o ide s a e lis ening o
hei conce ns, espec ing hei opinions, and collabo a ing wi h
hem on ea men decisions a e mo e likely o eel engaged and
in es ed in hei ea men . Howe e , when heal hca e p o ide s use
an au ho i a ian o pa e nalis ic communica ion s yle, pa ien s may
eel ha hei au onomy and con ol a e being h ea ened. This can
lead o esis ance and less likelihood o complying wi h ea men ec-
ommenda ions. In con as , a mo e collabo a i e communica ion s yle
can help pa ien s eel ha hei au onomy is being espec ed and hey
may be mo e likely o comply wi h ea men ecommenda ions.
S igma
S igma and disc imina ion a e o he ac o s ha can con ibu e o
psychological eac ance. Pa ien s wi h men al heal h condi ions o en
ace s igma and disc imina ion, which can make hem eel de alued
and powe less (Co igan & Wa son, 2002). When pa ien s pe cei e
ha hey a e being disc imina ed agains o judged based on hei men-
al heal h s a us, hey may expe ience psychological eac ance.
P io Expe ience Wi h Men al Heal h T ea men
Finally, p e ious expe iences wi h men al heal h ea men can
also influence psychological eac ance. Pa ien s who ha e had neg-
a i e expe iences wi h men al heal h ea men in he pas may be
mo e likely o expe ience psychological eac ance (De Las
Cue as, Peña e, e al., 2014). Fo example, i pa ien s ha e expe i-
enced mis ea men o abuse by heal hca e p o ide s, hey may be
mo e esis an o ea men in he u u e. Simila ly, i pa ien s ha e
had nega i e expe iences wi h specific ea men s o medica ions,
hey may be mo e likely o esis hose ea men s in he u u e.
A P oposed Model o Using Psychological Reac ance in
Psychia ic P ac ice
Psychological Reac ance and A oiding Nega i e
Ou comes
When an indi idual pe cei es ha hei eedom o make choices
o beha e in a ce ain way is h ea ened o es ic ed, his can esul in
a s ong emo ional esponse ha mo i a es he indi idual o esis o
push back agains he pe cei ed es ic ion, which can mani es in
a ious ways such as inc eased defiance, a gumen a i eness, o
e en wi hd awal (Rosenbe g & Siegel, 2018).
In a he apeu ic con ex , psychological eac ance can be pa icu-
la ly de imen al o he he apeu ic ela ionship and he achie emen
o posi i e ou comes (Seemann e al., 2004). I a pa ien eels ha
hei au onomy o choices a e being h ea ened, hey may become
esis an o he he apeu ic p ocess o he he apis ’s sugges ions,
which can impede p og ess and e en lead o p ema u e e mina ion
o he apy. By p o iding choice, using mo i a ional in e iewing,
emphasizing he pa ien ’s au onomy, collabo a ing wi h he pa ien ,
p o iding educa ion and in o ma ion, alida ing he pa ien ’s eel-
ings, and moni o ing and adjus ing he ea men plan, clinicians
can educe eac ance and inc ease ea men adhe ence while
espec ing he pa ien ’s au onomy.
Ano he impo an benefi o ecognizing and add essing psycho-
logical eac ance is ha i can educe esis ance and de ensi eness
om he pa ien . When pa ien s eel ha hei au onomy is being
h ea ened, hey may become de ensi e and esis an o he he apeu-
ic p ocess. By ecognizing and add essing psychological eac ance,
he apis s can educe he likelihood o hese nega i e esponses and
c ea e a mo e open and ecep i e he apeu ic en i onmen .
Mo eo e , in psychia ic p ac ice, ce ain ypes o pa ien s seem o
an agonize d ug e ec s as a consequence o hei psychological
eac ance (Fa a e al., 2017,2020,2023); such clinical phenomena
can easily be ound in he se ing o pe sonali y dis u bances,
al hough hey do no in a iably occu in e e y pa ien wi h such
cha ac e is ics, because hey depend on he in e ac ion be ween
pa ien and doc o (Fa a, 2021).
Psychological Reac ance and Inc easing Posi i e
Ou comes
In a clinical con ex , unde s anding psychological eac ance can
help clinicians de elop in e en ions ha a e mo e e ec i e in p o-
mo ing posi i e ou comes and add essing ea men esis ance (De
Las Cue as, Peña e, e al., 2014;Reynolds-Tylus, 2019). He e a e
some a gumen s ha suppo his claim.
One benefi o ecognizing psychological eac ance is ha i
enables clinicians o iden i y and add ess sou ces o eac ance. By
unde s anding wha igge s eac ance in hei pa ien s, clinicians
can de elop in e en ions ha a e less likely o be pe cei ed as
h ea ening o es ic i e, ul ima ely educing he likelihood o eac-
ance and inc easing he e ec i eness o ea men .
Recognizing and add essing psychological eac ance can be a
help ul s a egy o he apis s in he c ea ion o a suppo i e and col-
labo a i e he apeu ic en i onmen . This app oach can os e a sense
o empowe men and au onomy among pa ien s, which can inc ease
hei mo i a ion o engage in he apy and wo k owa d hei goals
(Fa a, 2016). By acknowledging and espec ing he pa ien ’s need
o au onomy, he apis s can help pa ien s eel mo e in con ol o
hei he apeu ic jou ney.
Mo eo e , ecognizing and add essing psychological eac ance
can acili a e a collabo a i e app oach be ween he he apis and
pa ien . This collabo a i e app oach can help bo h pa ies wo k
oge he o find solu ions and make p og ess owa d he pa ien ’s
he apeu ic goals. When he he apeu ic ela ionship is collabo a i e
and espec ul, i can inc ease he likelihood o posi i e ou comes.
By acknowledging and espec ing he pa ien ’s need o au onomy
and wo king collabo a i ely owa d solu ions, he apis s can educe
esis ance, enhance mo i a ion, and inc ease he likelihood o suc-
cess ul he apeu ic ou comes.
Recognizing and add essing psychological eac ance can enhance
ea men adhe ence. Pa ien s who eel ha hei au onomy is being
espec ed and ha hey a e collabo a o s in he he apeu ic p ocess
a e mo e likely o adhe e o ea men ecommenda ions and engage
in he apeu ic ac i i ies. This can enhance he e ec i eness o he -
apy and p omo e posi i e ou comes. By c ea ing a suppo i e and
collabo a i e he apeu ic en i onmen , he apis s can help hei
pa ien s eel mo e engaged and mo i a ed o wo k owa d hei goals.
Ano he ad an age is ha i helps clinicians ailo hei in e en-
ions o he indi idual (Fa a, 2022). Di e en pa ien s may expe i-
ence eac ance in esponse o di e en s imuli, so unde s anding
psychological eac ance can help clinicians ailo hei in e en ions
DE LAS CUEVAS AND DE LEON6
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o he indi idual. This can inc ease he e ec i eness o ea men and
educe ea men esis ance.
In addi ion, ecognizing and add essing psychological eac ance
can enhance pa ien mo i a ion and engagemen . Pa ien s who eel
ha hei au onomy is being espec ed and ha hey a e collabo a o s
in he he apeu ic p ocess a e mo e likely o be mo i a ed and
engaged in ea men (Fa a, 2023). This can inc ease he e ec i e-
ness o in e en ions and p omo e posi i e ou comes.
Finally, ecognizing and add essing psychological eac ance can
imp o e he o e all quali y o ca e. By de eloping in e en ions
ha a e mo e e ec i e in p omo ing posi i e ou comes and add ess-
ing ea men esis ance, clinicians can imp o e he o e all quali y o
ca e o hei pa ien s. This can enhance pa ien sa is ac ion and
educe he likelihood o p ema u e e mina ion o ea men .
P ac ical S a egies F om he Li e a u e o Implemen
Ou Model o Psychological Reac ance
In he ealm o psychia ic p ac ice, na iga ing he delica e bal-
ance o pa ien ecep i i y and psychological coope a ion is an a
o m. Fo psychia is s, unde s anding he nuances o human beha -
io is pa amoun , especially when i comes o a oiding igge ing
psychological eac ance in pa ien s. D awing om a weal h o psy-
chological esea ch, we p opose se e al key s a egies ha e eme ged,
o ming a oadmap o enhancing pa ien engagemen and
coope a ion.
Explain he Ra ionale o T ea men
Fi s and o emos , anspa ency becomes a linchpin in his p o-
cess. Psychia is s a e encou aged o me iculously elucida e he
a ionale behind he p oposed ea men . S udies by Ho a h and
Lubo sky (1993) and Beck (2020) unde sco e ha pa ien s a e con-
side ably mo e ecep i e when hey comp ehend he unde lying ea-
sons o he apeu ic in e en ions. By a icula ing he benefi s and
elucida ing how he ea men can e ec i ely manage hei symp-
oms, psychia is s pa e he way o unde s anding and accep ance.
In ol e he Pa ien in he T ea men Planning
Empowe men eme ges as ano he c ucial ace . In ol ing he
pa ien in he ea men planning, as ad oca ed by Ba low (2010)
and Mille and Rollnick (2013), lends a sense o con ol. When
pa ien s ac i ely pa icipa e in decision-making p ocesses, hey pe -
cei e a g ea e deg ee o au onomy o e hei ea men . This inclu-
sion no only diminishes psychological eac ance bu also kindles
mo i a ion, os e ing a collabo a i e a mosphe e be ween he psychi-
a is and he pa ien .
P o ide Op ions
A co ne s one o pa ien coope a ion lies in he eedom o choice.
Deci and Ryan (2000) and Mille and Rollnick (2013) posi ha p o-
iding pa ien s wi h op ions diminishes esis ance. Whe he i
in ol es o e ing a ious ea men app oaches o allowing pa ien s
o de e mine he sequence o add essing ea men goals, his ele-
men o choice nu u es a eeling o con ol, significan ly educing
eac ance.
Use Language Tha Respec s he Pa ien ’s Au onomy
C ucially, language wields immense powe in psychia ic in e ac-
ions. By espec ing he pa ien ’s au onomy and a oiding coe ci e
exp essions, as sugges ed by Kolden e al. (2011), psychia is s
can c ea e a non h ea ening en i onmen . U ilizing ph ases such as
“I ecommend”o “we could y”ins ead o dic a o ial language mi -
iga es esis ance, os e ing a sense o collabo a ion.
Valida e he Pa ien ’s Feelings and Conce ns
Acknowledgmen o ms he bed ock o pa ien –psychia is ela-
ionships. Acco ding o Roge s (1957) and Linehan (1993), alida -
ing he pa ien ’s eelings and conce ns, e en when hey di e ge om
p o essional opinions, is pi o al. Demons a ing unde s anding and
espec engende s us , dissipa ing eac ance and acili a ing a
mo e open dialog.
Build Rappo and T us
Finally, he i al ole o appo and us canno be o e s a ed. As
highligh ed by Ho a h and G eenbe g (1989) and Lambe and
Ba ley (2001), pa ien s a e mo e amenable o ea men when hey
us hei men al heal h p o essionals. Building his appo
demands ime, pa ience, and genuine empa hy. Howe e , he di i-
dends in e ms o pa ien coope a ion and posi i e ou comes a e
immeasu able.
In conclusion, by emb acing hese s a egies oo ed in psycholog-
ical esea ch, psychia is s can c ea e an en i onmen whe e pa ien s
eel hea d, espec ed, and empowe ed. This syne gy o unde s and-
ing, choice, espec ul communica ion, alida ion, and us o ms
he bed ock o e ec i e psychia ic p ac ice, os e ing coope a ion
and mu ual espec be ween men al heal h p o essionals and hei
pa ien s.
Conclusion
In conclusion, psychological eac ance is a significan challenge
in psychia ic ea men , pa icula ly among pa ien s who eel hei
au onomy is being h ea ened. Howe e , by adop ing a pa ien -
cen e ed app oach ha in ol es pa ien s in hei ea men decisions
and p o ides hem wi h educa ion and in o ma ion abou hei ca e,
clinicians can educe he impac o psychological eac ance and
imp o e ea men ou comes. By empowe ing pa ien s and os e ing
a collabo a i e he apeu ic ela ionship, clinicians can c ea e a mo e
e ec i e and sa is ying ea men en i onmen . Ul ima ely, ecog-
nizing he impo ance o pa ien au onomy and empowe men is c u-
cial o success ul psychia ic ea men and should be a p io i y in
clinical p ac ice.
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IMPLICATIONS OF PSYCHOLOGICAL REACTANCE 7
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