Reactance theory and patient noncompliance

Soc. Sci. Med. Vol. 45, No. 8, pp. 1277-1288, 1997

Pergamon

PII: S0277-9536(97)00055-5

© 1997ElsevierScienceLtd. All rights reserved Printed in Great Britain 0277-9536/97 $17.00 + 0.00

REACTANCE THEORY AND PATIENT NONCOMPLIANCE J E A N N E S. F O G A R T Y P.O. Box 6063, Lafayette, IN 47903, U.S.A.

Abstract--With surprising frequency, and to the considerable dismay of health care professionals, patients both subtly and overtly refuse to cooperate with medical treatment. Despite considerable empirical and theoretical attention, and an abundance of interventions designed to combat it, noncompliance continues. Its persistence is accompanied by considerable costs borne by patients and society alike. The theory of psychological reactance sheds new light on the phenomenon. Reactance theory proposes that a perceived threat to an individual's freedom generates a motivational state aimed at recapturing the affected freedom and preventing the loss of others. In a medical context, patients' perceptions of threats to their freedom or control may induce noncompliance. This theory permits integration of many of the seemingly disparate and/or contradictory findings, and may afford professionals new opportunities for improving patient compliance. © 1997 Elsevier Science Ltd Key words--patient noncompliance, patient cc,mpliance, psychological reactance, reactance theory

INTRODUCTION

With surprising frequency, and to the considerable dismay of health care professionals, patients both subtly and overtly refuse to cooperate with medical treatment. While noncompliance may be a fitting response under certain circumstances (for example, changing conditions which legitimately bring into question the appropriateness of particular physician advice), it frequently results in considerable detriment to individual and society alike. Failures in patient adherence may result in, among other things: physician or researcher mistakenly judging treatments to be ineffectual; inappropriate alteration of dosages or prescription of additional medications; unnecessary modifications in courses of treatment; superfluous diagnostic tests; lost work days due to illness or hospitalization; progressive complications, and, in many instances, death (Trick, 1993; Bame et al., 1993). In addition to hindering or preventing recovery, such cortsequences obviously entail substantial monetary waste. Yet just as noncompliance may have an adverse impact on an individual's life, so too may medical intervention itself. Health care demands may disrupt familiar routines, impose restrictions on valued freedoms, and/or generate a sense of loss of personal control. Individually or in concert, such effects could be perceived by the patient as more troublesome than the illness itself, thus prompting some patients to react negatively to the disruptive threat, rather than positively to the potential therapeutic benefit, of health care intervention. It seems reasonable, therefore, to anticipate that compliance would improve in those instances wherein medical recommendations generate a minimum of such

threat. Toward that end, the theory of psychological reactance may offer some guidance. Reactance theory offers at least partial explanation for the significant number of patients who, despite the time, effort and monetary cost involved in seeking professional attention, walk away from a physician's office and do not have prescriptions filled, do not report for diagnostic or screening tests, and do not keep follow-up or referral appointments made for them by the physician. Each of these behaviors is commonplace and has been reported by numerous physicians and researchers alike (e.g. Sackett and Snow, 1979; Bachman et al., 1993; Gurwitz et al., 1993; Zoega et al., 1991; Garr et al., 1993). This paper explores the theory and makes suggestions concerning its relevance and potential for application to the issue of patient noncompliance.

THE THEORY OF PSYCHOLOGICAL REACTANCE

In an effort to explain why people often do the opposite of what they are asked to do, and why efforts to persuade are often ineffectual, Jack Brehm proposed and later elaborated the theory of psychological reactance (Brehm, 1966; Brehm and Brehm, 1981). It arose from "an attempt to understand certain phenomena of interpersonal relations", and is concerned with "the multifarious freedoms of daily living and how the individual responds when these freedoms are threatened or eliminated" (Brehm, 1966, p. 1). Integral to the theory is the idea that each person believes him/herself possessed of a set of "free behaviors" in which s/he could realistically engage, either at present or in the future. Brehm (1966) pro-

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posed that a threat to any of these free behaviors would generate a motivational state aimed at recapturing the freedom(s) affected and preventing the loss of others. The intensity of this reactance state would be a direct function of the magnitude of the threat, the number of free behaviors jeopardized, and the value placed on them by the individual. Freedoms could either be directly removed or threatened, or their peril implied in what happens to other freedoms. In addition, a threat may be implied in what befalls the freedom of another person. " . . . i f the [threat to or] loss of a free behavior to an observed person could just as well happen to oneself, then one's own free behavior is threatened" (Brehm, 1966, p. 7). An important enhancement of the theory accompanied Brehm and Brehm's (Brehm and Brehm, 1981) clarification of the relationship between reactance theory and the concept of control. Control, by their definition, is "the ability to affect the probability of occurrence of a potential outcome. To the extent that one has this ability, one has a freedom...[this] definition of 'control' is equivalent to that of 'freedom' as used in reactance theory. [And] this conception of control...like the definition of freedom...is specific in regard to a particular outcome" (Brehm and Brehm, 1981, p. 6). Thus, if something constrains (or deprives one of) control, freedom is threatened or eliminated. Furthermore, reactance is believed to play a role in augmenting the attractiveness of a threatened or eliminated freedom, and this effect is not diminished by the comparative appeal of other freedoms. Therefore, a threat to freedom will stimulate reactance, and both an increased desire for the endangered freedom and attempts to exercise it will ensue. It is also possible that reactance will generate attempts to protect the capacity to elect n o t to do something. This is one of the reasons why attempts to coax or persuade are often met with resistance. Encouraging a person to do something which s/he may already feel free to do may actually result in the individual "digging in" and refusing to comply. This reactance effect may occur not only with regard to behaviors, but also in the arena of opinions and attitudes. A compelling or convincing effort at attitude change may meet with resistance, even if the recipient of the effort agrees in essence with the communication. ...to the extent that it is perceived by the individual that the communicator is trying to make him change, his freedom to decide for himself will be threatened and he will experience reactance...Information and arguments can be quite helpful to the individual and may result in positive influence, but the perception that the communicator is attempting to influence will tend to be seen as a threat to one's freedom to decide for oneself (Brehm, 1966, p. 94).

REACTANCEAND PATIENTNONCOMPLIANCE The theory of psychological reactance has received considerable attention within the field of mental health. It has been widely tested and applied, and reactance has been shown to play a useful role in boosting the efficacy of psychotherapy and in dealing with client resistance to it (e.g. see Horvath and Goheen, 1990; Dowd, 1990, 1993; Carver, 1991). For reasons which remain unclear, the concept of reactance has not been similarly received or widely applied in the sphere of physical medicine. While psychiatric and physical medicine are in many ways disparate, reactance theory is able to make contributions to both. Even a cursory reading of the Brehms' work (Brehm, 1966; Brehm and Brehm, 1981) reveals its potential for enhancing the understanding of the phenomenon of patient noncompliance in physical medicine. A wide range of impersonal events and social influences-inherent to the manner in which medicine is currently practiced, the nature of many prescribed regimens, and certain techniques for patient educ a t i o n - m a y be capable of triggering reactance. Thus, despite the potential health risks, it is possible that many patients sidestep compliance in an endeavor to retain control over their illness careers and/ or to protect or reassert valued freedoms. By working toward an increase in patient control, as well as a reduction in the threats to freedom posed by doctor-patient, patient-regimen, and patient-education interactions, the medical profession may be able to reduce health care's potential for negative impact on the life experiences of its clientele. The development of techniques for precluding, defusing, or using a reactance response in diverse health care settings may provide professionals with a number of opportunities for achieving these ends and improving patient compliance.

NONCOMPLIANCE:DEFINITIONAND SCOPE Medical noncompliance has been defined as "the failure of a patient to follow precisely the recommendations of the physician or other health care professional" (DiMatteo and Friedman, 1982, p. 37). An extremely broad range of behaviors qualifies as "noncompliance". Patients may exceed, fall short of, or refuse to take the prescribed dosages of medications; cheat on restricted diets; refuse to exercise or cease smoking; decline to submit to screening or diagnostic tests deemed necessary by a physician; and/or fail to keep follow-up or referral appointments. In brief, to qualify as a noncomplier, a patient must "purposely or not, ignore, forget, misunderstand or refuse the clinical prescription" (DiNicola and DiMatteo, 1984, p. 57). In addition, nonadherence flourishes wherever medical recommendations are generated. It is found among all socioeconomic groups in both private

Reactance theory and patient noncompliance and public health care settings, takes a wide variety of forms, and transcends disease category and patient age group (DiNicola and DiMatteo, 1984; Tebbi, 1993; Sackett and Snow, 1979). The phenomenon has proven difficult to operationalize and measure. The often covert mode of such behavior may keep its consequences from being readily appreciable. Estimates of the overall rate of noncompliance range from 30% (DiNicola and DiMatteo, 1984) to 50% (Wright, 1993; Rand, 1993), with the proportion found to run even higher in a number of studies involving specific conditions (e.g. see Davis, 1966; Bachman et al., 1993; Cohn and Pizzi, 1993; Lower et al., 1993). And these nonadherence rates may, in fact, be conservative, due in part to the frequent use of such subjective measures as self-reporting questionnaires and interviews. These tools have been shown to be significantly biased and may overestimate compliance when assessed against objective measures such as pill counts, urinalysis, or microelectronic monitoring systems (Gordis et al., 1969; Cureton et al., 1993; Dunbar, 1993; Waterhouse et al., 1993). In addition, the literature to date provides little theoretical guidance for integrating the variety of explanations and often contradictory findings on noncompliance. This paper addresses this deficiency. MACRO-LEVELNONCOMPLIANCEPATTERNS Three distinct "macro-level" noncompliance patterns have been identified. While there are some notable exceptions to each, the broad patterns clearly emerge upon thorough inspection of the literature. Specifically, the length, complexity, and type of regimen have all been shown by various researchers to directly affect adherence levels. The impact of each of these factors is predictable from the perspective of psychological reactance. The literature on each will be reviewed, followed by a reexamination in light of reactance theory. Length o f regimen

When remedies are prescribed for relatively short periods of time (i.e. 10 days or less), adherence is greater than is that accorded protracted treatments (DiMatteo and Friedman, 1982; DiNicola and DiMatteo, 1984; Rand, 1993; Fincham, 1988). Initial compliance during acute medical events, for which treatment course does not exceed 10 days, may be as high as 80% but falls off rapidly after three to five days of therapy. Those asked to adhere to long-term regimens initially comply at an even lower rate (approximately 50%), with a steady decline thereafter (Trick, 1993; DiNicola and DiMatteo, 1984; Sackett and Snow, 1979; Carmody et al., 1980). This pattern is not confined to illnesses which are painless or asymptomatic. Numerous studies have

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revealed the characteristic in connection with treatment for conditions which involve intense discomfort and/or debilitating symptoms. For instance, failure to follow instructions for contact lens care may produce considerable eye irritation and visual difficulties over time. Yet such noncompliance "was a conspicuous finding among both symptomatic and asymptomatic patients" (Turner et al., 1993, p. 108). Curbow et al. (1993) found that patients whose vision was poor and steadily worsening as the result of cataract formation declined or delayed surgery for extended time periods, despite physician urgings. Hemodialysis patients' adherence to medication requirements and dietary/fluid restrictions hovered around 50% notwithstanding the severe symptoms and consequences associated with noncompliance (Bame et aL, 1993; Rand, 1993; Boyer et al., 1990). In addition, an 18 month follow-up study of 105 renal allograft (kidney transplant) recipients revealed that only 25 persisted in overall compliance with diet/medication requirements. Twenty-nine of the remaining organ recipients became totally noncompliant, while the balance were compliant only with selected portions of the regimen (Kiley et al., 1993). Despite considerable discomfort and moderate to severe restrictions caused by attacks, a substantial number of the asthmatics studied by Byrne et al. (1993) failed over time to comply with physician recommendations for controlling the frequency and severity of episodes. Similarly, a considerable proportion of patients who suffered extreme allergic reactions in connection with allergic rhinitis and/or allergic asthma gradually dropped out of allergen immunotherapy. Compliance was not increased by the number of allergens to which a patient was allergic (Cohn and Pizzi, 1993; Lower et aL, 1993). Steady declines in compliance have also been reported among those suffering from hemophilia, Type I (insulin dependent) diabetes, and symptomatic tuberculosis as the treatment regimens continued for lengthy periods of time (Rand, 1993; Menzies et aL, 1993). Complexity o f regimen

The second pattern of noncompliance which is evident across disease categories is tied to the complexity of the therapeutic regimen. "The more complicated the treatment, the less likely it is that the patient will follow the regimen precisely as prescribed" (DiMatteo and Friedman, 1982, p. 45). For example, among patients with diabetes or congestive heart failure, compliance declined as the number of medications increased. Patients demonstrated an initial compliance rate of 85% when required to take one drug, 75% when two were recommended, and less than 60% when three medications were prescribed (Hulka et al., 1976). Fincham's (Fincham, 1988) extensive review of the

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literature found a similar pattern in a number of studies. Compliance rates have also been shown to drop as the number of times medication(s) must be taken increases. Glaucoma patients' adherence declined steadily as the frequency of daily eyedrop administrations climbed (Gurwitz et al., 1993). Women utilizing fertility drugs were shown to be more compliant with twice per day than with four times per day dosages (Kruse et al., 1993). Frisham (1993) suggested that compliance with hypertension medication increases when a patient is required to take only one controlled release dose of medication per day. Furthermore, reducing or simplifying the behaviors required of patients results in increased compliance (DiMatteo and Friedman, 1982). For instance, periodontal patients who complained of the cumbersome and time-consuming nature of oral care showed increased adherence (and decreased periodontal disease) when supportive treatment was simplified (Wilson et al., 1993; Hellstadius et al., 1993). Thus, regardless of the physiological condition involved, the more a patient must restructure routine or modify behavior, the lower will be compliance (DiMatteo and Friedman, 1982). And, as with the length of treatment element discussed previously, the complexity of treatment pattern is evident whether or not symptoms are present. Janis (1984) reported that even when patients suffer from acute, painful symptoms (e.g. those associated with streptococcal pharyngitis or ulcers), and are hospitalized in connection therewith, complex medication and dietary requirements are often met with only partial compliance. Type o f regimen

The third widely observed pattern in noncompliance is a distinct difference in the rates of cooperation with prophylactic and curative regimens. Physicians find it extremely difficult to stimulate adherence to treatments for subclinical conditions or compliance with recommendations for preventive inoculations and screenings (Trick, 1993; DiMatteo and Friedman, 1982; Janis, 1984). Even when patients have been advised and understand that there is a hidden or potential threat to their health or survival, a relative few comply with medical recommendations (Janis, 1984). As with the duration and complexity patterns, failure to adhere to prophylactic recommendations or regimens is evident across disease categories. For example, SaUeras et al. (1993) reported very low compliance with chemo-prophylaxis against tuberculosis; Swinker et al. (1993) documented difficulties involved in securing compliance with mammography cancer screening, and Myers et al. (1993) found low compliance with continuous screening for colorectal tumors. In addition, Bachman et al. (1993) revealed refusals by members of a prepaid health

program to submit to cholesterol screening; Blinkhorn (1993) reported widespread noncompliance with preventive dental regimens, and Sugarman et al. (1993) disclosed significant failure to complete treatment for diabetic retinopathy. While any aspect of noncompliance may be detrimental to the patient and frustrating to the health care provider, the failure to take advantage of prevention and early cure opportunities is particularly irksome to the latter. Janis (1984) reported that consistently high rates of nonadherence among patients with conditions such as hypertension may actually lead some health care professionals to try not to get involved with them in an effort to avoid facing the frustration of nonadherence. A reactance theory interpretation

The high rates of noncompliance in connection with complex and/or lengthy regimens may be at least partially explained by reactance theory. It is evident that increasing the number of prescriptions or proscriptions would increase the likelihood that more highly valued freedoms are affected. In addition, Brehm and Brehm (1981) suggested that each person may in fact have a threshold point for the perception of threat. Thus, "the perceived difficulty of exercising a freedom can increase from zero up to a certain point without creating the perception of a threat to freedom" (Brehm and Brehm, 1981, p. 393). A patient may therefore comply with a particular regimen for a certain time without sensing a menace. As the number and duration of prescriptions and/or proscriptions climb, however, so too may the apprehension of threat. Furthermore, the arousal of reactance may serve to sensitize an individual to additional threats, both to the same and other freedoms. Complex, lengthy regimens may lead to a hypersensitive state which does not allow the individual adequate opportunity to deal with the arousal generated by one threat before having to deal with another. There may also be an additive effect on reactance from two or more threats to the same freedom. Likewise, independent events, each of which is "subthreshold", may coalesce to shape a threat (Brehm and Brehm, 1981). With regard to preventive regimens, it is possible that the absence of symptoms, which themselves may pose threats to freedoms, may lower the threshold point at which an individual perceives threat in connection with the regimen itself. In addition, most prophylactic programs involve permanent and substantial lifestyle changes which could impact on a considerable number of freedoms and produce the additive, sensitizing and coalescing effects referred to above. Certain prescriptions, such as preventive screenings or diagnostic testing, may carry with them implied threats which generate reactance and efforts to avoid them. A number of studies have demonstrated, for instance, that patients who receive

Reactance theory and patient noncompliance reports of abnormal test results are less likely to comply with further testing or recommended health care regimens (Bachman et al., 1993; Myers et al., 1993; Funke and Nicholson, 1993). Here again the patient could perceive threat directly in the regimen typically imposed to treat the particular subclinical condition, could infer threats in connection with the effects known to be associated with the disease itself, or could detect implied threat from observation of the impact of a similar disease, or its therapeutic regimen, on the freedoms of another person.

REACTANCEAND INDIVIDUALCOMPLIANCE VARIATION In addition to macro-level patterns to noncompliance, there appear also to be patterns at the microlevel. While some patients may be totally noncompliant upon leaving the clinician's office, it is more common for patients to partially comply in one of several distinct ways. Several studies suggest tha! an individual may have a tendency to fall into a particular noncompliance pattern and to persist therein throughout a course of treatment. Sumartojo (1993) proposed that a patient's previous history of adherence is one of the best forecasters of compliance during a specific medical event. In addition, DiMatteo et al. (1993) found, in a longitudinal study of patients with hypertension, diabetes and heart disease, that adherence at the outset of therapy was associated with compliance rates two years later. Similar findings were reported by Menzies et al. (1993) in an investigation of compliance with tuberculosis treatment. The individual variations in compliance may be described as follows.

Slipping from total compliance The first of the identifiable individual variations involves an initial total compliance which is gradually replaced with only partial compliance. The patient may then remain partially adherent, or may later slide into total noncompliance (e.g. see Bergman and Werner, 1963; Donovan and Blake, 1992).

Consistent partial compliance A number of studies include reference to another pattern of individual noncompliance which consists of only partial adherence from the outset and throughout the entire treatment. Such noncompliance involves the patient's compliance with certain proscribed or prescribed behaviors or medications and the disregard of others (e.g. see Bame et al., 1993; Kiley et al., 1993; Paynter et al., 1993).

Redesigning the treatment regimen Yet another form of noncompliance is demonstrated by patients who create their own treatment

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programs rather than adhere to those specifically prescribed by clinicians. Such behavior may include combining a prescribed medical regimen (or portions thereof) with alternative therapies, adding nonprescription remedies to those ordered by the physician, or increasing certain behaviors or medications beyond recommended levels (Trostle et al., 1983; Haynes, 1979; Saekett, 1976).

Outright noncompliance Finally, there are some patients who forthrightly indicate to the clinician that they do not intend to comply with medical recommendations, as was the case in the Swinker et al. (1993) study of patients encouraged to have breast cancer screening mammography. Donovan and Blake (1992) investigation of patient compliance neatly presented an example of several of these individual patterns in just one sample of patients suffering from rheumatoid arthritis: Nearly one half of the patients (25) could be considered to be non-compliant in that they admitted to failing to take drugs according to their prescriptions...10 patients no longer took the drugs they had been prescribed. Three of these had taken the drugs on a lower dose for a while before giving them up; the others gave them up after a period of time at the prescribed dose. The most common level of non-compliance (by 13 patients), was to take fewer tablets than prescribed, usually by reducing doses by an arbitrary amount (often by one half) or taking tablets fewer times per day. A much less common type of noncompliance involved taking more tablets than prescribed-one woman took two or three Bufren tablets when she needed them rather than the one, three times per day, prescribed; and another woman took Co-Proxamol prescribed for her husband (Donovan and Blake, 1992, p. 509).

A reactance theory interpretation Brehm and Brehm (1981) presentation of reactance theory provides a number of potential explanations for these individual variations. First, no two persons possess identical sets of free behaviors. Likewise, individuals differ from one another and vary over time in terms of the intensity of their needs and desires and the frequency and ways in which they employ freedoms to satisfy them. And, while there exist individual variations in the acquisition and exercise of freedoms, any number of persons could feel themselves possessed of the same freedom and yet attach very different values to it. Finally, "a freedom has the status of an expectancy and can be held with more or less strength" (Brehm and Brehm, 1981, p. 35). Hence, identical circumstances may produce markedly different perceptions of threat and magnitudes of reactance in different people, as well as within the same person at different times. A patient who values, and exercises, the freedom to eat bacon and eggs six times a week might be expected to be more reactant to a physician's proscription of these foodstuffs than would a patient who feels free to

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enjoy them once a month but could easily do without them. Similarly, when a physician's recommendation involves prescribed behaviors, whether or not a patient will experience reactance is in part determined by how firmly the patient holds and values the belief that s/he has the freedom to not perform any or all of the behaviors. Thus, reactance-generated noncompliance would occur at a point, or points, unique to the individual. It could involve (1) perception of direct or implied threats to one or more freedoms, (2) efforts to preserve the right to elect not to do certain things, (3) attempts to engage in eliminated or threatened freedoms/behaviors, or (4) any combination of these. Once again, the source of the perceived threat(s) could be the provider, the regimen, the experience of another patient, or any combination thereof. In addition, the patient may be fully aware of reactance. This would include a heightened sense of self-direction with regard to the threatened freedoms and, depending upon the intensity of the state, could even entail hostile or aggressive feelings (Brehm, 1966). The marked constraints upon a patient's power in a medical setting may limit the expression of such increased self-direction to a "veto power" over the prescription--i.e, to the power only to choose not to comply with the physician's recommendations.

REACTANCE THEORY AND MEDICAL PRACTICE: IMPLICATIONS

Reactance and the doctor-patient encounter The encounter between doctor and patient has been described as a "struggle between the voice of medicine and the voice of the lifeworld" (Mishler, 1994, p. 288). In roughly eight minutes, the physician attempts to "establish rapport, discover the reason for a patient's visit, verbally and physically examine the patient, discuss the patient's condition, establish a treatment plan, and terminate the exchange" (Paget, 1993, p. 26). In order to accomplish this, the doctor must clearly establish him/herself as the more powerful of the two and constantly maintain, or when necessary recapture, control of the encounter. The first of these is often at least partially achieved before the physician even enters the examination room. By that time, through the efforts of a nurse or other assistant, the patient has already been: interrogated with regard to history and symptoms, weighed, relieved of a specimen of bodily fluid, invaded with a thermometer, squeezed to ascertain blood pressure, asked to disrobe, draped in a gown, and left perched on an examination table to await the doctor's arrival. While these procedures may provide an assist to diagnosis, they serve also to clearly define for the patient the extent of his/her power in relation to the physician.

The second requirement, control of the direct encounter, is captured by the physician through close management of the verbal exchange which occurs between the two (Mishler, 1994). This is accomplished primarily by asking closed-ended questions which insure that the biomedical model serves as the sole context within which the patient's statements are entertained and translated. The physician's questioning technique permits containment or exclusion of the patient's personal, "lifeworld" accounts and is designed to reduce all information into narrower, medically related terms. In addition, such questioning gives the physician "control of the turn-taking system and, consequently, of the structure and organization of the interview" (Mishler, 1994, p. 290). Procedure and discourse contribute to, and continuously reinforce, the power imbalance which exists in the typical provider-patient interaction. As pointed out by Brehm (1966), however, "those who have...greater amounts of social power than oneself can issue threats of relatively great magnitude to one's own free behaviors..." (p. 6). Thus, intensifying the patient's awareness of the power/control "gap" may also add to the possibility of arousing reactance and, as a result, noncompliance. In contrast, it has been suggested that one of the greatest positive influences that the physician can have on compliant health behavior is the "formation of a social unit with the patient" (DiMatteo and Friedman, 1982, p. 49). A social unit implies a sharing of power, control, and responsibility for outcomes. By continuously inviting patient participation and cooperation, and by allowing the introduction of a socioemotional component into the verbal exchange which occurs between the two, the physician may draw the patient into a mutual interdependence wherein the latter's "dignity and respect are maintained...practitioner and patient have equal power.., and the patient maintains freedom of control over his life and the decisions that are made concerning his body" (DiMatteo and Friedman, 1982, p. 52). While many physicians are reluctant to consider themselves in equal power positions with their patients, mutual participation is clearly less likely to stimulate reactance and, by so doing, increase the likelihood of compliance. Altering the provider-patient encounter A few relatively simple alterations in providerpatient interaction may serve to foster patient involvement and thereby obviate or diminish a reactance response to practitioner and/or prescribed therapy. First, it is essential to provide the patient with opportunities to retain a sense of self-direction and control over the outcome(s) of the encounter. This may be accomplished in part by simply asking for the patient's cooperation before initiating the procedures which accompany office visits. While one might realistically expect few, if any, patients to

Reactance theory and patient noncompliance decline such a request, the psychosocial impact of the query may be substantial--particularly for the more reactant patient. There is evidence that a request for compliance generates considerably less resistance than does compulsion or the perception thereof (Cialdini, 1993). The nurse, aid or technician who first engages the patient might spend a few moments discussing nonmedical issues, outlining forthcoming procedures, and inviting or requesting the patient's cooperation. While this may occur in a few physicians' office,;, it is far more common for the patient to respond to the announcement of his/her name, be led directly to a scale, handed a specimen bottle, directed to a restroom, and then steered into an examination room. Verbal exchanges which occur between nurse and patient are generally perfunctory and are controlled "on the run" by the nurse, with patient in tow. Similarly, the physician may preserve the patient's sense of freedom and control by spending time with him/her prior to the actual examination. This period need not be lengthy, but should be dedicated to soliciting and answering patient questions, familiarizing the patient with examination procedure(s), listening to patient comments and concerns of a personal, nonmedical nature, and again, eliciting a response concerning the patient's willingness to proceed. In addition to acknowledging patient autonomy, reducing the likelihood of resistance, and providing the patient the opportunity to "own" a portion of the control of the proceedings, the process of procuring his/her cooperation may also have the potential, with some patients, to provide the added benefit of increasing the likelihood of future compliance. Freedman and Fraser (1966) found that those who comply with initial small requests are later more inclined to comply with larger ones, even when such compliance has greater impact or consequence for the individual. In addition, a number of studies have clearly demonstrated increased compliance when nurses or other practitioners have invited patients to enter into negotiation and actual "contracts" in which the patient is asked, and agrees to assume, greater responsibility for self-care (Armstrong, 1989; Haynes et al., 1987; Windsor et al., 1980). Second, the physician should work to avoid employing a negative tone or dealing with a patient in a directive or confrontational manner. These may be perceived by the patient as freedom-threatening, and a number of studies have clearly linked such practice styles to lower levels of compliance (Burgoon et al., 1987; Miller et al., 1993; Bartsch et al., 1993; Graybar et al., 1989). Third, it is important that the physician make an effort to discuss with, and counsel patients on, techniques for fitting prescribed regimens into ):he patients' and their families' lifestyles. Such efforts

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are rare on the part of physicians, but may help preclude or reduce the impact of health care demands on patients' daily routines, thereby reducing the potential for reactant noncompliance. Finally, the health care provider should remain cognizant of the fact that the patient's introduction to the therapeutic regimen occurs within the context of the doctor-patient encounter. Keeping the reactance potential of that encounter to a minimum may impact not only on the patient's immediate response to the physician and their exchange, but also on the patient's adherence to the physician's advice or prescription upon leaving the office. Once aroused, reactance may serve to further sensitize an individual to additional threats to freedom or control (Brehm and Brehm, 1981). Thus, in addition to responding to any immediate constraints experienced during the visit to the doctor's office, a more reactant patient may more readily infer the existence of additional threats to freedom in the procedures or treatment recommended by the physician. Such patients may be motivated to reinstate their freedom by dressing and exiting the clinical environment as quickly as possible, and to prevent further intrusion by refusing to comply with all or part of the prescription. Altering the patient-regimen encounter

The manner in which the clinician presents the regimen, and the degree to which the patient is incorporated in that process, may significantly reduce the degree to which therapy itself arouses reactance. If the physician has succeeded in creating an atmosphere of mutual interdependence, s/he should be able to engage the patient in a forthright discussion which results in a "negotiated" regimen which is least threatening and with which the patient is most likely to comply. An initial objective should be to keep treatment as simple as possible. Simplicity, however, should not be defined solely by the practitioner. In outlining desired prescriptions or proscriptions, the doctor should encourage continuous feedback with regard to the impact of such proposals on the patient's daily activities. It should generally be possible to alter, or make substitutions for, various proposals without reducing therapeutic efficacy. The physician should demonstrate a willingness to eliminate any proposal which is not absolutely essential to convalescence and to work with the patient to arrive at the shortest possible course of therapy. In addition, reactance theory suggests that the likelihood of sustained therapeutic involvement is enhanced by maximizing an individual's perception of free choice (Brehm and Brehm, 1981). Thus, whenever possible, the physician should offer a patient more than one effective alternative and allow him/her to select therefrom. For example, rather than automatically prescribing an antibiotic which must be taken four times a day for two

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weeks, the physician might offer the patient a choice between that particular antibiotic and another which may be taken in fewer doses and for a shorter time. In addition to providing the patient with alternatives, this process affords him/her an opportunity to view the physician as an individual who is willing to make concessions. When one is perceived as making a concession, a nearly universal norm of social behavior dictates that the recipient respond with a matching or greater concession (Cialdini, 1993). Gouldner (1960) found that noncompliance was more likely with less reciprocal interaction between patient and physician. The physician's willingness to relent in one area is therefore likely to prompt the patient to be willing to concede with compliance in another. Compliance choices thus made should be perceived as having been made freely, and the affected features of the regimen should be less likely to generate reactance. Each of the foregoing suggestions requires increased personal flexibility and creativity on the part of the physician, along with a modest increase in the amount of time invested with each patient. Potential benefits, however, include a greater sense of involvement, choice, freedom and responsibility on the part of the patient; improved rapport between patient and physician; a simpler regimen; a reduction in the likelihood of a reactance response; and a greater probability that the patient will comply with therapy. The foregoing, however, may not be effective with regard to noncompliance linked to duration of treatment or prophylactic care. In many instances, particularly where chronic conditions are involved, alterations in the term of treatment would simply not be possible. Similarly, extensive changes in lifestyle may be essential for preventing death or damage from chronic or subclinical conditions. Patient education may be the best tool for addressing noncompliance in these areas. REACTANCEAND PATIENTEDUCATION Although education is one of the most commonly used techniques for combating nonadherence, there is ample empirical evidence that it does not always bring about dramatic improvements in compliance, and, in some instances, it may actually lower compliance rate (Byrne et al., 1993; Myers et al., 1993; Tettersel, 1993; Birrer et al., 1993). The theory of psychological reactance may provide some explanation for such findings. First, attempts at educating a patient may produce the "boomerang" effect believed to be generated by reactance in response to efforts to alter opinion, attitude, or behavior through persuasive communication. In addition, the higher the level of threat conveyed through education ("you must do this for your own good"), the greater the likelihood

that it will produce the opposite of the desired result in a more reactant recipient. Furthermore, Brehm and Brehm (1981) proposed that pure information may itself provide a source of threat. The more knowledge an individual possesses concerning something, the greater may be the perception of threat in connection therewith, and the less likely it becomes that one will elect to do it. Finally, as was highlighted at the outset of this discussion, freedom and control are intertwined in terms of reactance theory. It has been known for some time that patients differ in terms of desired control. The Health Locus of Control and the Multidimensional Health Locus of Control scales were, in fact, specifically designed to identify such variations and their potential link to health behavior (Wallston et al., 1976). A number of researchers have attempted to utilize these measures as "independent variables for predicting health behavior" (Clymer et al., 1984, p. 160). For those patients who seek control (and the number may be substantial), many education programs may simply fall flat by failing to meet that need. Despite evidence that training programs which encourage greater control on the part of the patient result in improved compliance (DiNicola and DiMatteo, 1984; Dunbar et al., 1979; Katon and Kleinman, 1981), very few instructional programs are actually designed to enhance actual or perceived control for patients who desire it. In fact, as mentioned above, many educational efforts may have the opposite affect by inducing reactance through enhancement of patients' awareness of the impact of compliance on daily living and the degree to which a therapeutic regimen may threaten to "take control" of their lives and the freedoms they value. However, even for the patient who does not possess a high level of desire for control with regard to health care, prescriptions, proscriptions or education programs which pose, or induce recognition of, substantial threats to valued freedom(s) may still generate reactance, although perhaps at a threshold higher than that of a more control-oriented patient. Altering the patient-education encounter

The core role of the health care professional has been identified as being, in part, educator, persuader or attitude changer (DiNicola and DiMatteo, 1984; Twaddle, 1981; Hingson et al., 1981). Health education may be essential to bringing about the behavioral changes necessary for controlling morbidity and mortality. Yet physicians frequently find it difficult to get patients involved in health education programs, or to put into practice those things conveyed to them therein (DiMatteo and Friedman, 1982). It is evident that the physician's effort to encourage participation, or an educational program itself, may be perceived as an attempt to influence or persuade, and reactance may induce a patient's resist-

Reactance theory and patient noncompliance ance or refusal. To the extent that a// education involves varying degrees of persuasion, it would no doubt be impossible to completely eliminate its ability to generate a state of reactance in some persons. It might be possible, however, to improve health education's efficacy and increase compliance by intentionally stimulating, rather than reducing, n,~actance. For example, one method for prompting patient participation in an instructional program may be to indicate to the patient that enrollment is limited to only a few individuals, and that s/he would have to make a commitment in a relatively short time :ifs/ he desires to be included. Scarcity increases the subjective attractiveness of something by imposing a limit on the freedom to do or acquire i t - - a n d reactance, in turn, generates an increased attempt to obtain it (Freedman and Fraser, 1966; Brehm and Brehm, 1981). Imposing a modest fee on an instructional program may also prompt participation. Wickhmd (1970) found that those who initially rated an alternative as unattractive and expressed little or no desire to obtain it reversed that decision and attempted to secure the alternative when they became aware that a fee was attached to it. The health educator may also be able to employ reactance in an instructional program to trigger increased compliance with a therapeutic regimen. Increasing a patient's awareness of the threat which an illness itself poses to valued freedoms may motivate the individual to more closely adhere to therapy. This might be accomplished by focus:ing health instruction on the disease process and its overt and latent effects on physiology, along with their impact on present and future performance and functional ability. Regimen requirements would be presented as mechanisms whereby the patient n~tay take control of the disease process and short-circuit its ability to threaten freedoms. This technigtue might prove particularly effective with those patients whose conditions are subclinical and lacking overt symptoms, and those who lack motivation to maintain adherence over a protracted period of time. Educating a patient on the existence of psychological reactance, and its potential for interfering with recovery or survival, may also prove beneficial in some instances. By familiarizing patients with reactance, it may be possible to assist them in ":revaluing" those freedoms which they feel are threatened by the therapeutic regimen. Making a patient aware of the degree to which attachments to certain freedoms may threaten or eliminate opportunities to acquire (or defend) other desirable alternatives may assist the individual in altering his/her evaluations.

1285 CONCLUSION

Well before the patient-clinician encounter occurs, many of today's health care consumers have come to believe that they have not only access to a wide range of professional diagnostic and therapeutic options, but also that the individual is capable of making a number of sound decisions with regard to personal health. A variety of influences enhances this perception, including the proliferation of nonprescription remedies and medications, medical "self-help" books, and a steady stream of abbreviated "medical updates" provided by the several media. In varying degrees, people have come to possess an elevated awareness of medical issues and an increased sense of responsibility and choice with regard to their own health. In addition, many health care professionals have made an effort to increase the patient's level of responsibility for his or her own care, lifestyle choices, and preventive behaviors. Thus a variety of health behaviors may gradually accrete to individuals' sets of perceived freedoms. Many see the physician as but one of several options available for dealing with sickness. Most patients, in fact, will have exercised several of these freedoms and tried a number of options for treating an illness prior to seeking professional attention, and many do not feel obligated to follow the physician's advice exclusively (Zola, 1981). Thus, the patient-provider encounter may be fraught with impersonal events and social influences which are capable of triggering reactance. This paper has addressed only a few of the settings in which noncompliance is regarded as a problem. It also permeates hospitals, extended care facilities, and rehabilitation programs. The pervasiveness and persistence of the phenomenon are sending clear signals to the health care profession. While patients fail to comply with medical recommendations for reasons unique to the individual, reactance may be a contributing factor in many instances. In fact, one might reasonably anticipate a reactance response by every patient--regardless of the individual's personal need for control in health care--when a threat of sufficient magnitude is apprehended in connection with highly valued freedom. There will no doubt always be patients who will simply never follow the advice of a health care professional. Yet reducing the potential for reactance may result in marked compliance improvement for many others. The medical profession may be able to accomplish this by restructuring the delivery of care. To effectuate this, however, may require a paradigm shift. As Trostle (1988) pointed out, the present concern with compliance rests on an ideology which presupposes and justifies physician authority, with the problem of compliance lying primarily in the behavior of the patient. This ideol-

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ogy helps "to transform power (potential influence) into authority (legitimate control)" and defines "patient behavior in terms of professional expectations... [which] ignore health-related behavior that contradicts the profession's view of its own centrality to health care" (Trostle, 1988, p. 1300). As was mentioned above, patients do not view the professional as the sole repository of health. "Labeling patients as 'non-compliant' because they follow their own ideas about their own care misses the point that this is what people have done since medicines were first used" (Trostle, 1988, p. 1301). As long as providers seek to maintain the present distribution of power, they will continue to run headlong into what patients perceive to be their freedom with regard to health management and the door to reactance-induced noncompliance will remain open. The rote of psychological reactance in patient noncompliance clearly merits further study. In so doing, the medical profession may move toward a fresh perspective on compliance, and an opportunity to adjust its own ideology and practice in ways which would benefit professional and patient alike. Although the theory is grounded on the assumption that reactance is a motivational state (Brehm, 1966; Brehm and Brehm, 1981; Brehm, 1976), it has been demonstrated that it may be a function of individual differences as well (Graybar et al., 1989; Dowd et al., 1984). To the extent that state and trait may commingle, scales developed for the purpose of detecting such differences could prove beneficial for use in working with patients (Graybar et al., 1989). Due to individual differences, reactance-based strategies might be expected to prove more effective with some patients than with others. In addition, there will be certain patients for whom no strate g y - d e r i v e d from reactance or otherwise--will work to improve compliance. Along with empirical evidence establishing the involvement of reactance in noncompliance, research would be needed to identify the extent to which such strategies would or would not work, and with whom. This paper is exploratory in nature, and the reader is cautioned against generalizations in the absence of direct empirical evidence of the reactance--compliance link. When that link is confirmed, however, the modest expenditure of time and effort which would be required to address reactance proactively--and perhaps even employ it as an ally--should be more than offset by the gains achieved through reducing the cost of the present efforts to deal with it reactively.

Acknowledgement--I am indebted to Dr. George A. Youngs, Jr., North Dakota State University, for his invaluable guidance throughout the preparation of this manuscript.

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