The authors wish to thank Michelle Yep-Martin and Makenna Berry for their assistance in the literature search.
In recent years there has been a shift toward greater recognition of the client's role as an active participant in psychotherapy. In 1994 Bergin and Garfield said, “Another important observation regarding the client variable is that it is the client more than the therapist who implements the change process. If the client does not absorb, utilize, and follow through on the facilitative efforts of the therapist, then nothing happens. Rather than argue over whether or not ‘therapy works,’ we could address ourselves to the question of whether “the client works”! In this regard, there needs to be a reform in our thinking about the efficacy of psychotherapy. Clients are not inert objects on whom techniques are administered. They are not dependent variables upon whom independent variables operate” (pp. 825–826).
There is evidence that clients make the single strongest contribution to outcome. Lambert (1992) places “extratherapeutic factors,” consisting of the client and factors in the client's life, at 40% of the variance in final outcome. This compares to 30% for common factors (such as the therapeutic relationship), 15% for techniques, and 15% for placebos. Wampold (2001) estimates that all therapy factors combined account for about 13% of outcome variance. Wampold (2010) states that most of the remaining 87% is likely due to the client. Norcross and Lambert (2011) suggest that 40% of the variance in outcome is unexplained. Of the remaining 60%, they attribute 30% to the client and 30% to all other factors combined. Orlinsky, Grawe, and Parks (1994) and Orlinsky, Rønnestadt, and Willutski (2004) have documented that various client factors are the best predictors of improvement. Orlinsky et al. (1994) concluded, “the quality of the patient's participation in therapy stands out as the most important determinant of outcome” (p. 361). In keeping with these scholarly conclusions, there is evidence that clients benefit from a wide range of therapy approaches (i.e., the “Dodo bird” verdict, Luborsky, Singer, & Luborsky, 1975; Wampold, 2010). Furthermore, they benefit from self-help (Norcross, 2006) and Internet-provided procedures (Caspar & Berger, 2011) as much or nearly as much as from face-to-face therapy. Bohart and Tallman (1999, 2010) have explained this phenomenon by arguing that clients are at the center of the healing process. They are able to utilize widely differing methods of promoting change in order to grow. Bohart and Tallman have suggested this is the most parsimonious explanation for the Dodo bird verdict, that is, that psychotherapies have equal effects.
In this chapter we highlight the role of the client as an active learner and problem solver who contributes to therapy process and outcome. This continues an evolution in how the client's contribution has been conceptualized. Garfield's earlier reviews in this handbook (1971, 1978, 1986, 1994) emphasized research on specific client variables and their relationship to premature termination and outcome. Results of these studies were generally mixed. This led Clarkin and Levy (2004) to emphasize a more dynamic view of the client-therapy relationship. They suggested that these earlier results were due to the fact that, from the start of therapy, client variables begin to dynamically interact with therapist and treatment variables. Therefore it is unlikely that simple relationships will be found. This was seconded by Beutler and colleagues (2004). They argued that the reason no clear relationship between interventions and outcome has been found is that clients react differently to different interventions.
From a research perspective, we consider a change toward looking at therapy from the client's side of the interaction to be something of a paradigm shift. Most research and theory focuses on therapists' interventions and on how clients receive and respond to them. However, clients are not passive recipients of treatment like patients in surgery. Rather, they actively intersect with what therapists have to offer (even if that “activity” sometimes consists of adopting a passive or resistant stance). How they learn involves their degree of involvement, their resonance with therapists and methods, how much effort they put in, their own creativity, and how they interpret and implement the input they receive.
There is one sense in which it has always been held that clients' perspectives and actions matter. This has usually been interpreted negatively: Clients' distortions, transference relationships, and dysfunctional beliefs get in the way of therapy. Although this happens, research findings support a more proactive view. One finding, for instance, is that clients' perspectives and beliefs correlate positively with outcome, suggesting the possibility that how they construe therapy either contributes to or reflects a positive therapy process.
Viewing the client as an active contributor is compatible with American Psychological Association (2006) policy on evidence-based practice. Clients' preferences, values, and perceptions should be included in therapeutic decision making. The client is also featured in recent efforts to reform the behavioral health care system (Bohanske & Franzcik, 2010). The President's New Freedom Commission on Mental Health (2003) argued that consumers should be placed “at the center of the system of care” (p. 27).
The recovery movement has also emphasized empowering consumers of mental health services. Recovery focuses less on treating pathology and more on supporting client strength (Bohanske & Franzcik, 2010). Compatible with this, Bergin and Garfield (1994) concluded: “As therapists have depended more upon the client's resources, more change seems to occur” (p. 826). Research has begun to substantiate this view. Gassman and Grawe (2006) found, for instance, that successful therapists paid attention to clients' strengths starting in the first session, while unsuccessful therapists focused on problems but neglected strengths.
As in previous editions of this handbook, we focus on research that is linked to outcome. However, we also consider studies of client participation and experience in therapy that have not yet been linked to outcome. Participation and experience are important because of their direct link to psychotherapy and the action of therapists. For instance, we review studies on clients' views of what is helpful. A skeptic could argue that what a client thinks may have nothing to do with what is actually helpful. However, what clients think and want is sometimes discrepant with what professional models of therapy focus on. This may be particularly clear in terms of what clients want out of therapy in contrast to what professionals are measuring (primarily symptom reduction; see our sections on clients' views of good outcome and on goal consensus). It is important to investigate clients' views of what is helpful because they may be picking up things that are being overlooked by researchers and by theories. This may be particularly true because the change processes postulated by theories have so far not been shown to explain very well how therapy works (see Crits-Christoph et al. this volume).
In addition, there is evidence that many clients' perceptions, expectations, and preferences do relate to outcome. It may behoove therapists to be aware of the research on clients' views about therapy so they can anticipate the kinds of things clients are thinking, perceiving, wanting, and needing, in order to (a) strengthen the therapeutic alliance, and (b) to capitalize on ways to mobilize client participation.
There are methodological issues that we do not have space to consider. Several are mentioned in Crits-Christoph et al. (this volume). Of most importance is the issue of correlation not implying causation. Many of the findings we consider are correlational. Therefore conclusions we draw must have this as a caveat. In addition, we have included a number of qualitative research findings. Recent editions of this handbook have included favorable comments on qualitative research (e.g., Hill & Lambert, 2004; Slife, 2004). However, for the most part, qualitative research has not previously been included. We break with this precedent because (a) much of the recent research on the client's role in therapy has been qualitative, and (b) because these qualitative studies offer rich findings that invite future quantitative investigation. We note the limitations of qualitative research: (a) samples are often small and nonrandom so that findings may not be generalizable, (b) functionally the studies are correlational in nature, and (c) there have rarely been attempts to link findings to outcome in a formal way. However, there have been attempts to develop qualitative and/or mixed qualitative/quantitative methods for assessing outcome and its links to process (Bohart, Tallman, Byock, & Mackrill, 2011; Elliott, 2002; R. B. Miller, 2011). We cannot consider them here (but see Elliott et al., Chapter 13, this volume; and McLeod, Chapter 3, this volume).
We have chosen to do a narrative review that incorporates recent research evidence, meta-analytic reviews when available, and past narrative summaries. There are now many available reviews of specific aspects of client functioning but none give a comprehensive picture of the client in therapy. Our goal is to give an overview of what is known about clients' participation in psychotherapy and what it means for effective practice. Too many client variables have been studied for us to consider all of them. We have focused on certain variables that have traditionally been studied, as well as newer ones that seem of importance. One final note: Although we prefer the term “clients,” we use both “clients” and “patients” in this chapter to reflect the terms used in the various studies we review.
Many potential clients never enter into treatment, and many more who do enter, do not stay. Corrigan (2004) suggested that estimates ranged anywhere from 40% to 90% of individuals in need of professional care either received no treatment or had less treatment than needed. In addition to the lack of benefits that clients may receive, this may cause researchers to mis-estimate the effects of treatment because we only know the outcome for those who enter and stay in our care.
Research reviewers have concluded that several variables predict nonattendance and these variables appear to be consistent over time: lower socioeconomic status, ethnic minority status, being older, being male, fear of being stigmatized, and being a person who causes stress to others but has less psychological distress him- or herself (Clarkin & Levy, 2004; Garfield, 1994). However, Zane, Hall, Sue, Young, and Nunez (2004) concluded that studies on utilization of services by ethnic minorities have found conflicting results, with Asian Americans having the only consistent pattern of underutilization.
A variety of variables have been proposed as to why many individuals do not choose to enter psychotherapy. Life circumstances may play a role, particularly with individuals with lower socioeconomic status (e.g., it may be difficult for them to get to the office, find child care). Another factor is the possible discrepancy between clients' ideas about problem etiology and treatment and the ideas of the mental health establishment (Garfield, 1994). Fears of stigmatization may play a role. It was found that those who hold negative stereotypes about mental disorders (Corrigan, 2004) or experience shame over their problems (Leaf, Bruce, & Tischler, 1986) are less likely to seek treatment themselves. Obviously there is a strong need to improve the degree to which those who are not entering treatment do so—based on the assumption that they will benefit despite their negative attitudes.
Premature, or early, termination (ET) can be costly both to clients and service providers. Many clients who drop out early not only fail to improve but may get worse (Reis & Brown, 1999). In addition to its impact on clients, dropping out before a benefit has been realized is a drain on mental health resources (Barrett, Chua, Crits-Christoph, Connolly Gibbons, & Thompson, 2008; Garfield, 1994; Reis & Brown, 1999) and consequently on the quality of care of even those who do attend treatment (through long wait lists and spaced treatment).
Estimates of the dropout rate have varied widely. Wierzbicki and Pekarik (1993) did a meta-analysis of 125 studies and estimated that the mean early terminator rate was about 47%. A more recent comprehensive meta-analysis of a staggering 669 studies found an average dropout rate of 19.7%; however, there was considerable heterogeneity, with rates ranging from 0% to 74% (Swift & Greenberg, 2012). One reason for such heterogeneity may have to do with the definition of an early terminator (Garfield, 1994; Hatchett & Park, 2003). Definitions in individual studies have included those who have an appointment scheduled but fail to return, those who stop therapy yet are rated as premature terminators by therapists, or those who terminate before attending a certain number of sessions. However, failing to return and/or terminating before a certain number of sessions may not necessarily indicate that therapy was a failure. Therapists' ratings depend on personal judgments that vary from therapist to therapist. Recently, Swift, Callahan, and Levine (2009) have suggested using as a definition of ET, those who terminate before reaching a level of clinically significant change. However, as of this writing, there is still no consensus in the literature on how ET is defined. Unless otherwise noted, studies reviewed below typically relied upon multiple criteria, or did not specify the criteria for dropout utilized.
Decades of research has been done to identify client variables and factors associated with dropout. There are now a number of reviews and meta-analyses available. (e.g., Barrett et al., 2008; McMurran, Huband, & Overton, 2010; Reis & Brown, 1999; Swift & Greenberg, 2012). For the most part, results for demographic variables have been inconsistent or weak. This is true for gender (Garfield, 1994; Reis & Brown, 1999; Swift & Greenberg, 2012). On clients' age Garfield (1994) and Reis and Brown (1999) did not find a clear relationship. However, the meta-analysis by Swift and Greenberg (2012) found that younger clients showed a greater tendency to drop out, although the effect size was small (d = .16). Other variables that reviewers have sometimes concluded are important are socioeconomic status (Barrett et al., 2008; Garfield, 1994; Reis & Brown, 1999), education (Barrett et al., 2008; Garfield, 1994), and ethnicity/minority status (Barrett et al., 2008; Garfield, 1994; Reis & Brown, 1999). However, the most recent and comprehensive meta-analysis by Swift and Greenberg (2012) did not find any consistent relationship of these variables and early termination. Zane and colleagues (2004) concluded that the results were inconsistent on whether persons of color drop out of therapy more often.
Overall, as we also see with outcome, the results of correlating demographic variables with ET has not been particularly productive. Clarkin and Levy (2004) have suggested that looking at what these variables mean may be more fruitful. Consider gender. Men appear to be less likely to enter therapy, although it is not clear that they drop out more or have worse outcomes (Bedi & Richards, 2011). Bedi and Richards (2011) have suggested that this may be due to the norms and values some men hold. In particular, men who hold traditional North American values are more likely to question the value of therapy.
Some research suggests that masculine norms may influence how clients construe the therapy experience. Bedi and Richards had men sort statements about what strengthened the therapeutic alliance. They found that the categories men created were different from those women created. For instance, the most important category for men was that the therapist helped them talk about important issues, while for women it was that the therapist provided education and validation. Owen, Wong, and Rodolpha (2010) found that clients who held masculine norms, whether men or women, were more likely to see helpful therapist actions in terms of insight or relationship value provided, while those who did not hold masculine norms focused more on information. These findings were not related to early termination or outcome. Nonetheless, taking a more differentiated look like this may ultimately prove more fruitful than simply focusing on gender per se.
Research reviews have also looked at personal characteristics that impact on early termination. Reviewers have concluded that individuals diagnosed with a personality disorder have increased likelihood of ET (Barrett et al., 2008; McMurran et al., 2010; Swift & Greenberg, 2012), as do those with some other disorders such as eating disorders (Flückiger et al., 2011; Swift & Greenberg, 2012), sexual offending, and psychopathy (Olver & Wong, 2011). A variety of characteristics have been found to relate to dropout. These include low motivation, resistance, and relationship issues in psychopathy (Olver & Wong, 2011); and impulsivity, hostility, and low self-esteem in eating disorders (Flückiger et al., 2011). For clients with personality disorders, having a greater number of and more severe problems, having characteristics that interfered with commitment to treatment (e.g., avoidance), and deficient ego strength all related to premature termination (McMurran et al., 2010).
With regard to expectations, there is evidence that many clients expect that therapy will work more quickly than it actually does (Swift & Callahan, 2008). Garfield (1994) and Barrett et al. (2008) have concluded that such an expectation increases the odds of premature dropout. However, the Constantino, Glass, Arnkoff, Ametrano, and Smith review (2011) found the evidence was unclear. Nonetheless, Swift and Callahan (2011) have shown that educating clients about how long it takes on average for therapy to have its effect led to reduced dropout (d = 0.55). As for expectations regarding treatment rationale, clients who did not believe in the treatment rationale were more likely to drop out (Davis & Addis, 2002; Westmacott, Hunsley, Best, Rumstein-McKean, & Shindlera, 2010). There is not much consistent evidence, but these results on expectations suggest that it may be useful for therapists to initiate regular discussions about expectations for the duration of treatment both at the start and during the course of psychotherapy and also to continuously make sure that the client still buys into the therapist's rationale for treatment as a way of preventing dropout.
When asked about their reasons for dropping out, clients' reasons have included being disappointed in treatment and making less progress (Garfield, 1994; Knox et al., 2011; Westmacott et al., 2010). This fits with evidence from Lambert, Harmon, Slade, Whipple, and Hawkins (2005). These researchers used an outcomes management system in which clients' progress was tracked on a session-by-session basis. They found that clients whose progress was below what was expected (compared to other clients with the same level of disturbance) were more likely to drop out. Similarly, clients who dropped out also often reported dissatisfaction with their therapists and with the alliance (Knox et al., 2011; Westmacott et al., 2010). A meta-analysis by Sharf, Primavera, and Diener (2010) of 11 studies looked at the relationship of the weakness of the alliance to dropout. They found a moderately strong relationship (d = .55). The results on both dissatisfaction with progress, and with the therapist and alliance, suggest that therapists need to monitor client satisfaction. One way to do this is by regularly collecting client feedback (see section on client feedback).
Clients also drop out because of therapy-interfering life circumstances. Kazdin, Holland, Crowley, and Breton (1997) found that life barriers, such as those related to transportation or scheduling issues (which are highly related to socioeconomic level), were associated with dropout. Barrett et al. (2008) concluded that factors such as distance the client has to travel, having to wait to get treatment, difficulty in finding child care, and the like, are associated with higher likelihood of drop out. Limited health care coverage also played a role.
Finally, it may be “therapist-centric” to exclusively look at client dropout as a problem/failure of treatment. Despite what therapists believe about how much treatment clients need, clients may not agree. Westmacott et al. (2010) compared clients who terminated unilaterally with those whose decision to terminate was made mutually with their therapists. These authors found that unilateral terminators were more likely to see their distress as lower when they terminated while their therapists were more likely to see them as unchanged. It is possible that these clients got just what they wanted from the therapy or that an extra-therapeutic factor remitted their distress. Likewise, Barrett et al. (2008) summarized studies that showed that some clients end treatment because in their eyes they have attained sufficient relief, even if professionals' criteria for clinically significant improvement or recovery have not been met. A study by Cahill and colleagues (2003) found that the majority of clients who unilaterally left treatment had achieved at least reliable improvement (70%). However, only 13% of them reached the level of clinically significant change, compared to a rate of 71% of those who remained in treatment for the full length of time. In a study reexamining the dose-effect relationship in psychotherapy, Barkham and colleagues (2006) found that more than 50% of clients who attended only one or two sessions achieved a reliable and clinically significant change in symptoms.
Clients appear to drop out for a variety of reasons. First, personal characteristics, such as demographics, type of disorder, level of motivation, impulsivity, or hostility interfere with connecting with the therapist and treatment. Second, and overlapping with the first, from their perspective clients are not receiving the kind of treatment they believe they need, in terms of progress made, relationship with the therapist, or beliefs and expectations about the nature of treatment. Third, life space issues, such as lack of funds or transportation problems, can get in the way. Fourth, some drop out because they perceive they have gotten the help they need even though therapists may not agree. It is likely that most of these issues can be affected by therapist behaviors and attitudes and are matters for training programs and mental health professionals to address.
In this section we look at the role of clients and their contribution to how therapy works. We first consider individual differences in clients' change trajectories. Then we look at client characteristics. Next we consider clients' perceptions, beliefs, and actions and how they relate to the therapeutic process. Finally we look at client constructive activity in therapy.
It has been found that clients follow different change trajectories. Of particular interest has been the identification of early responders. Early responders show significant positive change within a small number of sessions, and this occurs across diagnoses and therapy approaches (Haas, Hill, Lambert, & Morrell, 2002). Furthermore, they may enter therapy with high levels of impairment (Stulz, Lutz, Leach, Lucock, & Barkham, 2007). There has been no one definition used to identify an early responder. It might be based on clinician ratings, reduction of symptoms, deviations from expected rates of improvement, or other methods (Haas et al., 2002). Early responders have been found to have more positive outcomes, and the outcomes last.
Hansen and Lambert (2003) have speculated about causes. These include the possibility that early responders are more ready to change, that they are clients who achieve a better fit with their therapists, or that they are clients who are more organized and better able to maintain a focus in therapy.
Studies have identified other trajectories (e.g., Brown, Burlingame, Lambert, Jones, & Vaccaro, 2001; Stulz et al., 2007; Vermote et al., 2009). For instance, Stulz et al. (2007) found five different slopes of change. These slopes included those who showed high initial impairment followed by improvement, those who showed low initial impairment and improvement, early responders (early improvement), a group that started out with a medium level of impairment and then showed continuous improvement, and a group that started out with a medium level of impairment and showed discontinuous improvement. This latter pattern consisted of periods of both improvement and regression, although the trajectory overall was upwards. Of the two medium-impaired groups at intake, the discontinuous change group showed more reliable change than the continuous improvement group (44% to 19%). Stulz et al. also found that a discontinuous pattern of change did not necessarily predict poor outcome. However, some members of this group showed greater deterioration than those in the continuous change group.
Findings that different clients have different trajectories of change have implications both for understanding how therapy works and for treatment. Brown et al. (2001) found that different trajectories did not depend on the theoretical orientation of the therapist. They concluded, “the most tenable hypothesis is that the patients themselves are the primary determinant of duration of treatment and that the decision to terminate treatment is based on the rate of improvement…the faster the improvement, the sooner treatment is terminated” (p. 8). Client characteristics, in combination with type of therapy, may make a difference. Vermote et al. (2009) studied hospitalization-based psychoanalytic treatment. They found that two groups of clients, both with moderate symptomatology, one successful and one unsuccessful, differed in pretreatment personality characteristics. The more successful group presented with characteristics similar to that of an introjective style focused on matters of self-definition (Blatt, Quinlan, Pilkonis, & Shea, 1995). Vermote et al. suggest that such a style may match up with an insight-oriented approach better. On the other hand, Lambert (2010), speaking specifically to client deterioration, noted that we can predict deterioration before it occurs by utilizing information about the client's level of distress and disturbance at the start of therapy and the client's response to treatment in early sessions. He also noted that other variables, such as diagnosis, age, sex, ethnicity, type of treatment, and experience of the therapist, added relatively little once level of distress and disturbance were taken into account. Further research is needed to understand how different trajectories of change are generated and what it means for treatment.
Decades of research on the relationship of demographic variables to outcome have replicated the pattern found between demographic variables and premature termination; that is, results are generally inconsistent, although there is evidence of weak trends. Clarkin and Levy (2004) found no relationship between age and outcome other than possibly for substance abuse, where there was evidence that younger adults did less well. Reviews of dysphoric, anxiety, substance abuse, and personality disorders identified an effect only for dysphoric/mood disorders (Castonguay & Beutler, 2006a). Older clients did less well than younger ones. This was supported by a randomized trial of both cognitive therapy and medication for depression (Fournier et al., 2009). However, two meta-analyses of treatment for depression by Cuijpers, van Straten, Smit, and Andersson (2009) and Oxman and Sengupta (2002) did not find evidence that older adults were less responsive.
Prior reviews have not found that gender consistently makes a difference in outcome either (see reviews of client characteristics in Castonguay & Beutler, 2006b; Clarkin & Levy, 2004). Furthermore, reviews of studies on matching therapist to client on gender have led to mixed results (Bowman, Scogin, Floyd, & McKendree-Smith, 2001; Clarkin & Levy, 2004). There are occasional studies where gender has been found to make some difference. For instance, Pertab, Nielsen, and Lambert (in press) studied more than 17,000 students at a university counseling center and found that female clients were more likely to end treatment in the “improved” category. However, by-and-large this study found little difference in outcome regardless of gender matches and mismatches with therapists. Ogrodniczuk (2006) found that men benefited more from interpretative short-term psychodynamic therapy than from supportive short-term psychodynamic therapy, while the reverse was true of women. Thus, there may be something about gender that can play a role in outcome, but consistent findings are yet to emerge than can be used prescriptively.
Garfield (1994) concluded that there was a small positive relationship between client educational level and staying in treatment. He also concluded that there was little evidence of a relationship between socio-economic status (SES) and therapy outcome. If there is a pattern, it is that lower SES predicts less improvement; but once again results are inconsistent. For instance, in a review on treatment of anxiety disorders Newman, Crits-Christoph, Connolly Gibbons, and Erickson (2006) found that in five of eight studies low SES clients were more likely to drop out and to have decreased treatment response. However, the authors concluded that the heterogeneity of definitions and the confounding effects of race and ethnicity prohibited drawing firm conclusions.
Research on clients' social support suggests that it too shows a weak relationship to outcome. There are individual studies that have found a relationship (e.g., Fournier et al., 2009, for cognitive therapy of depression, and Kazdin & Whitley, 2006, for parent management training). Roehrle and Strouse (2008) did a meta-analysis of 27 studies of clients with various problems in various types of therapy. They found a small effect size of r = 0.13. Narrative reviews for dysphoric, anxiety, personality, and substance abuse disorders only found clear evidence of an effect for dysphoric disorders (Castonguay & Beutler, 2006a). Thus, social support makes some difference in some cases. Although the relationships are weak, it may make sense for therapists to systematically measure amount of social support present at the inception of therapy and then use methods to bolster social support with individuals' whose support is especially low.
Cultural diversity has been of major concern in the provision of psychological services. Castonguay and Beutler (2006a) concluded that, for the treatment of depression, “patients representing underserved ethnic or racial groups achieve fewer benefits from conventional psychotherapy than Anglo-American groups” (p. 355). However there were no differential effects for treatment of anxiety disorders, personality disorders, or substance abuse disorders. Other studies have not found differential effects. For instance, Lambert et al. (2006) studied archival data on clients who had come to a university counseling center. Each ethnic minority group member was matched with a Caucasian client based on important variables including initial level of disturbance. There were no differences in outcome between any ethnic group and their Caucasian counterparts.
Although there is no consistent evidence that ethnic-minority clients on average do worse in therapy, there has been interest in the idea of matching clients with therapists of their own ethnicity. Zane et al. (2004) concluded that such matching improved both outcome and staying in therapy, although results were mixed. Beutler and colleagues (2004) reported statistical significance in outcome in favor of matching, but the effect size was near zero (r = .02). Meta-analyses of matching studies found similar small effects sizes of r = .01 (Maramba & Hall, 2002) and d = .09 (Cabral & Smith, 2011). Thus the evidence that ethnic matching has any substantial impact on outcome is minimal. However, Cabral and Smith (2011) did find an effect size of .63 for who clients preferred to work with in terms of their ethnicity (not that this produced better outcomes). Farsimaden, Draghi-Lorenze, and Ellis (2007) studied clients who expressed a preference for matching. Those who got their preference had better outcomes, although the size of this effect was not provided. Possibly matching might work better where clients care about it, but studies of outcomes with this subgroup is limited. Further research is needed in this area, though matching with minority clients and therapists has serious practical limitations with only limited evidence that it would improve outcomes if it could be done.
The provision of culturally adapted treatments has been investigated. Smith, Rodriguez, and Bernal (2011) did a meta-analysis of 65 quasi-experimental and experimental studies where treatments for mental illness, distress, family problems, and problem behaviors were provided in culturally adapted ways. They based their conception of culturally adapted treatments on a schemata of eight criteria provided by Bernal and Sáez-Santiago (2006). Examples include providing treatment in the appropriate language, and using culturally appropriate metaphors. They found a moderate effect size of d = .46. The effects varied by ethnicity. The effect size for Asian Americans was d = 1.18, while it was d = .22 for Native Americans. Interventions designed for specific cultural groups were more effective (d = .51) than interventions delivered to mixed groups (d = .18).
There is a problem of interpretation with these results. Not all of the studies compared culturally adapted treatment with a nonculturally adapted version of the same treatment. In some cases the comparison was to an untreated control group. Thus, while the data can be read as supporting the usefulness of culturally adapted treatment, it is less clear that it supports an interpretation that such treatment is superior to nonculturally adapted treatment. On the other hand, it was found that culturally adapted treatment correlated with outcome r = .28 when studies were rated on their degree of cultural adaptation. Furthermore, using symbols and metaphors that matched clients' cultural worldview also correlated with outcome (b = .37, p = .02). These findings suggest there can be utility in adapting treatment in a culturally sensitive way.
The issue of working with culturally diverse clients merits much more research. Furthermore, we did not review evidence on other kinds of diversity/minority statuses such as that of sexual orientation because we were unable to locate sufficient research.
With the possible exception of culturally adapted treatments there is little evidence that demographic variables significantly moderate psychotherapy outcome. In one sense this is good news. It means that psychotherapy is broadly applicable. In another sense, it suggests that looking for simple relationships between individual demographics and outcome no longer seems fruitful. As Clarkin and Levy (2004) have noted, and as we have previously commented, it is time for research to move on from studying simple correlations between age, gender, and so on, and outcome, and develop more sophisticated hypotheses about the psychological variables that may moderate and mediate treatment effects.
In this section we review evidence on the relationship of the severity of client problems and comorbidity to outcome.
Clarkin and Levy (2004) concluded that severity of symptoms and functional impairment led to poorer prognosis, and that individuals with more severe symptoms needed more sessions to show improvement. In addition, higher functioning before impairment predicted a better prognosis. Recent reviews on anxiety disorders (Newman et al., 2006) and on dysphoric/depressive disorders (Beutler, Blatt, Alimohamed, Levy, & Angtuaco, 2006) have drawn similar conclusions. However greater severity does not always lead to poorer outcome. Two studies of parent management training for children with conduct problems found that greater severity led to better outcomes (Hautmann et al., 2010; Kazdin & Whitley, 2006). It is unclear what about parent management training led to results that contradict the general trend in other studies.
In apparent contradiction to the general findings on severity, there is a evidence that a higher level of distress at the start of therapy is the best predictor of outcome, more so than the client's diagnosis, problem chronicity, or treatment population. Brown et al. (2001) studied clients who had received treatment through a major health care organization. The most severe patients, as rated on the OQ-45, showed the most change. Two other studies (Hansen & Lambert, 2003; Hansen, Lambert, & Forman, 2002) also found that higher pretreatment distress predicted greater change.
A resolution of this inconsistency can be found by considering that, although clients with higher levels of distress may show the most change, they do not necessarily achieve the most positive outcomes in an absolute sense (Michael Lambert, personal communication, October, 2011). For instance, Brown et al. (2001) found that although such clients showed the most change, the most severe patients did not improve to the 50% level of a nontreatment control group. In the context of these findings (based on extremely large patient samples), when discussing the relationship between initial levels of disturbance and outcome it is important to know if outcome means amount of change or final status (return to normal levels of functioning).
Earlier reviews have found that clients with comorbid problems are less likely to do well. Clarkin and Levy (2004) concluded that personality disorder comorbidity has been almost uniformly found to predict poorer outcome, with one exception: Cluster A and C personality disorders did not predict poorer outcome with eating disordered patients. Newman et al. (2006), based on their review of research on treatments for anxiety disorders, concluded that comorbidity for depression, personality disorders, and substance abuse all negatively impacted outcome. Beutler et al. (2006) summarized factors influencing treatment of dyshporic/depressive disorders and found that in 15 of 20 studies personality disorder comorbidity negatively affected outcome. Haaga, Hall, and Haas (2006) concluded that substance abusers with comorbid psychiatric diagnoses had less favorable treatment outcomes.
The results on severity and comorbidity imply that policy makers need to be willing to adjust treatment limits to take into account clients' initial levels on these variables. Since these are variables that the client comes with and treatments are aimed at changing these variables, treatment may need to be prolonged or adjusted to deal with them. This may include providing sessions more than on a once-weekly basis, or utilizing adjunctive treatments.
Personal characteristics have to do with clients' styles and competencies for relating to self and others. In previous reviews, such characteristics as internal locus of control, social competence, learned resourcefulness, ego strength, coping style, and defense style were found to predict outcome in therapy (Clarkin & Levy, 2004; Piper, 1994). Below, we look at motivation, styles of attachment in forming relationships, manner of coping with stressors, degree of psychological mindedness, relating to emotion and inner experiencing in an open manner, and tendencies towards self-criticism.
Research shows that client involvement and engagement are strongly associated with outcome (Orlinsky et al., 1994; Orlinsky et al., 2004). Therefore, it might be expected that client motivation would also be associated with outcome. However, Garfield (1994) concluded that the effects of motivation had not received strong support. On the other hand Orlinsky et al. (2004) concluded that more highly motivated clients, defined as clients who saw themselves as engaged and motivated help seekers, or who were seen that way by their therapists, had better outcomes. Results were stronger when motivation was rated by clients. In their summary of research on anxiety disorders, Newman et al. (2006) concluded that four of five studies that assessed motivation found a positive relationship with treatment outcomes.
In part, the issue may have to do with what kind of motivation we are considering. Donovan and Rosengren (1999) observed that the motivation to enter psychotherapy may be different than the motivation to change. Another possible dimension has to do with whether the motivation is internal or external. Research on personality (e.g., Sheldon, 2004) has found that internal motives, such as those that arise from an individual's intrinsic interests, or those that represent their personally chosen or “identified” values, sustain effort and behavior better than external motives, such as external rewards or punishments, or introjected “shoulds.”
Motivation also overlaps with constructs like expectation and hopefulness. Clients who do not believe they can change, and who feel hopeless, may accordingly feel low motivation to participate. Finally motivation overlaps with why clients are in therapy (e.g., personal choice versus external pressure), their views on the nature of problems, their concerns with stigmatization, and their views on what kind of treatment will benefit them.
In general, it appears that clients who are “ready to change” (i.e., more internally motivated) are more likely to benefit. The stages of change model (Norcross, Krebs, & Prochaska, 2011) takes a systematic look at how clients progress, from being unready to change to ready to actively invest in change. The model's first stage, that of precontemplation, is the stage where clients are not internally motivated because they do not recognize that a problem exists. Clients in the next stage, contemplation, have moved to where they recognize there is a problem, but are not ready to take action. By the next stage, preparation for action, clients are showing readiness to change, that is, more self-generated motivation. This continues through the remaining two stages. In a recent meta-analysis of 39 studies, Norcross et al. (2011) looked at the client's readiness to change prior to therapy and its relationship to therapy outcome. The overall effect size was d = .46, a medium effect size. Effect sizes did vary somewhat by client diagnostic category, but still were in the medium to large range for all.
Zuroff and colleagues (2007) looked at readiness to change in a different way. They studied autonomy motivation, defined as the degree to which clients experienced participation in therapy as freely chosen. Autonomy motivation was a better predictor of outcome than was the therapeutic alliance. However, the degree of perceived autonomy, measured at the third session, was not entirely determined by the client. Therapists who were perceived as supporting autonomy motivation had clients who were higher in it. McBride and colleagues (2010) also found evidence that autonomy motivation related positively to outcome and that “controlled” (external) motivation related negatively.
In contrast to these findings, clients who are mandated to be in treatment, that is, those whose motivation is more likely to be external, often do not fare as well. A meta-analysis of 129 studies of offenders referred for correctional treatment in the criminal justice system found that mandated treatment was ineffective, while voluntary treatment was effective (Parhar, Wormith, Derkzen, & Beauregard, 2008).
Finally, clients will not be ready to change if they are resistant. Resistance is related to poorer outcome in therapy (e.g., Beutler, Moliero, & Talebi, 2002). Beutler, Harwood, Michelson, Song, and Holman (2011) have used the concept of reactance to explain resistance. Highly reactant individuals are those who are particularly sensitive to interpreting external direction as threats to their freedom (Brehm, 1966). Beutler, Harwood, Michelson, and Holman (2011) have argued that clients high in reactance are more likely to show resistance when working with therapists who are directive. In a meta-analysis they located 12 studies that looked at the relationship of the directiveness of the treatment to the level of client reactance. The effect size for matching was d = .82. That is, clients who were high in reactance and got treatments lower in directiveness did better than clients high in reactance who got treatments high in directiveness. The reverse was true for clients low in reactance.
In conclusion, results suggest that when clients' motivation to work comes from within, either in terms of their readiness to change, their autonomy motivation, or therapy not activating their resistance, they are more likely to do well. This suggests that therapists need to find ways of mobilizing clients' internal reasons for change. Approaches such as Motivational Interviewing (e.g., W. R. Miller & Rollnick, 2002) explicitly attempt to do this.
Attachment style has to do with clients' ways of relating to other people, although it also impacts how they relate to themselves. Two attachment constructs—that of the client's relationships with people outside of therapy, and within therapy relationships—are addressed in the research. The impact of attachment style on both outcome and process variables has been investigated. Change to attachment style is also an outcome variable in and of itself.
Bowlby (1969, 1988) saw the importance of an attachment relationship as different from other relationships in the sense that the attachment figure was used as a safe haven from distressing events. The attachment figure also functioned as a secure base from which to explore the environment and express oneself. Attachment patterns are formed in infancy through interactions with the primary caregiver. Four main attachment styles have been identified: secure/autonomous, anxious/preoccupied, avoidant (dismissive or fearful), and disorganized; the first three have received the most research attention. Attachment in adulthood can be understood in terms of one's perception of self and others with securely attached individuals having a positive view of self and others; preoccupied/anxious attached individuals having a negative view of self and a positive view of others; and avoidant (fearful/dismissive) attached individuals have a positive view of self and a negative view of others (Levy, Ellison, Scott, & Bernecker, 2011).
Therapists are more likely to see clients with global attachment styles that are secure or anxious/preoccupied whereas those with avoidant attachment styles are more distrustful and less interested in seeking psychotherapy (Obegi & Berant, 2008). The therapy relationship and therapist offer many components of an attachment figure (someone who is strong, a consistent figure that the client can form an emotional connection with, a secure base for exploration or retreat, and who may trigger separation anxiety). Clients may utilize the relationship as a corrective emotional experience (Mallinckrodt, 2010).
In a recent meta-analysis of 19 data sets, Levy et al. (2011) found a significant positive correlation between global assessments of clients' secure attachment and outcome (r = .182). Additionally, they found a significant negative correlation between global assessments of attachment anxiety and outcome (r = −.224) and a negligible relationship between attachment avoidance and outcome. Likewise, in a group therapy context, secure clients had better outcomes than preoccupied clients (Strauss et al., 2006). Levels of attachment anxiety were significantly correlated with clients' levels of distress at the outset of treatment (Sauer, Anderson, Gormley, Richmond, & Preacco, 2010). Different attachment patterns were correlated with specific symptom patterns, although they were unrelated to personality variables (Bachelor & Meunier, 2010). Sauer et al.'s (2010) findings suggested that secure attachment to the therapist had more predictive value for treatment progress than did global measures of secure attachment.
A recent meta-analysis of 17 studies linking attachment and alliance showed a significant effect size for securely attached clients having better alliances and insecurely attached clients having weaker alliances (Diener & Monroe, 2011). Clients' self-reported global attachment style had a higher correlation with client-rated alliance than therapist-rated alliance. Diener and Monroe postulated that clients may be viewing their attachment and their working relationship with the therapist from a more similar framework than therapists who may distinguish more fully between the two.
Bachelor and Meunier (2010) also found clients' attachment to their therapists was more predictive of alliance than either personality variables or symptomatology. Avoidant-fearful attachment scores were negatively correlated with alliance scores; however, there was no significant relationship between clients' preoccupied attachment scores and alliance. Bachelor and Meunier did find that a significant moderator of the relationship between preoccupied attachment and alliance was the degree of clients' distress.
Attachment also affects clients' in-therapy behavior. Increased self-disclosure and positive feelings about disclosure were associated with clients' secure attachment styles and negatively correlated with fearful attachment styles (Saypol & Farber, 2010). The amount of exploration and session depth was also predicted by clients' secure attachment to their therapist, and therapists' own global attachment style served as a moderator in this association (Romano, Fitzpatrick, & Janzen, 2008).
In conclusion, clients' attachment styles impact how they enter into therapy. Both their global attachment styles and their specific attachments to their therapists impact outcome, as well as the alliances they form and specific therapy behaviors such as self-disclosing and amount of exploration. This suggests that it may help for therapists to understand how clients are construing their relationship to therapy in terms of attachment, and to accordingly find ways to work with that (see Wallin, 2007).
Coping style has to do with how individuals deal with change and/or stress (Beutler, Harwood, Kimpara, Verdirame, & Blau, 2011). Two styles have been identified. According to Beutler, Harwood, Alimohamed, and Malik (2002), externalizers have been defined as, “those who are impulsive, action or task-oriented, gregarious, aggressive, hedonistic, stimulation-seeking, and lacking in insight,” while internalizers are, “shy, retiring, self-critical, withdrawn, constrained, over-controlled, self-reflective, worried, and inhibited” (p. 148). In a “box score” analysis, Beutler et al. 2002) found that internalizers were more likely to benefit from insight-oriented therapy, while externalizers benefitted from symptom-focused, or behavioral-skills approaches. In a recent meta-analysis Beutler, Harwood, Kimpara, Verdirame, and Blau (2011) replicated this finding. Overall, based on 12 studies that had been selected for meeting a variety of research criteria, they found a medium effect size (d = 0.55), when matching coping style with treatment approach. Based on these findings Beutler, Harwood, Kimpara et al. (2011) recommend that therapists assess clients' coping style and then match treatment based on that assessment.
Psychological mindedness (PM) is the tendency of a person to turn inward and to seek psychological explanations of behavior or to try to understand people and problems in psychological terms. Studies have found that PM is positively related to staying in therapy (Barrett et al., 2008). However, results with outcome are mixed. In the previous review, Clarkin and Levy (2004) identified 5 studies. Two found a relationship of PM to outcome, two did not, and one found that it related to outcome in one form of therapy but not in three other forms. McCallum, Piper, Ogrodniczuk, and Joyce (2003) examined both psychological mindedness and alexithymia and their relationship to outcome. The data came from two separate trials comparing interpretive to supportive psychotherapy. Both psychological mindedness and alexithymia were found to predict outcome. Nyklí
ek, Majoor, and Schalken (2010) found that increases in the insight scale of psychological mindedness over the course of therapy predicted increased symptom reduction. On the other hand, Kronström and colleagues (2009) studied the effects of psychological mindedness on outcome in short-term psychodynamic therapy with major depressive disorder. They did not find any relationship between baseline psychological mindedness and outcome.
In conclusion, the mixed findings on psychological mindedness reported in Clarkin and Levy's (2004) review were replicated here. Although there are not enough studies, the roughly 50–50 split in results suggest there may be some relationship to outcome in some cases and further research is needed. There is not as yet enough clarity or consistency in findings in order to use the research to modify the kind of treatment delivered to clients.
Access and awareness of emotions have been postulated to be qualities that foster therapeutic change. Therefore, clients who have difficulties with these ought to have more problems benefitting from therapy. We first look at research on alexithymia.
Alexithymia has to do with difficulty in identifying feelings, difficulty in communicating feelings to others, constricted imagination, and an externally oriented cognitive style in regard to how people understand their experience. Defined as such, alexithymia bears some conceptual similarities to low levels of experiencing (Klein, Mathieu-Coughlan, & Kiesler, 1986), particularly in the focus on difficulties in identifying internal experiencing and in adopting a more distal, intellectual perspective.
Several studies have found that high levels of alexithymia predict poorer outcome, but primarily in psychodynamic and not cognitive-behavior therapy. McCallum and colleagues (2003) found that alexithymia was associated with poorer outcome in both interpretive and supportive brief psychotherapy. Leweke, Bausch, Leichsenring, Walter, and Stingl (2009) studied patients in psychodynamically oriented therapy. They found high initial alexithymia total scores significantly predicted worse treatment outcome, although the predictive values were small. Patients with alexithymia still were able to benefit from therapy. On the other hand Spek, Nyklíek, Cuijpers, and Pop (2008) found that alexithymia at the start of cognitive-behavior therapy for depression did not predict outcome. Instead they found that alexithymia varied as a function of depression, suggesting the possibility that depression may in part impact or cause alexithymia. Rufer and colleagues (2010) studied alexithymia in clients in group cognitive-behavior therapy for panic disorder. They found that initial levels of alexithymia did not predict outcome.
Access to emotion has also been studied by experiential psychotherapists. They typically have utilized ratings of early in-therapy emotional openness. Boritz, Angus, Monette, Hollis-Walker, and Warwar (2011) found that higher proportions of autobiographical memories that contained specific concrete emotions which were shared early in therapy predicted outcome. Pos, Greenberg, and Warwar (2009) found that clients lower in emotional processing at the beginning of experiential therapy had poorer outcomes on a measure of interpersonal skills. Watson, McMullen, Prosser, and Bedard (2011) studied 66 clients who received either cognitive-behavioral therapy or experiential therapy for depression. Their findings suggested that, early in therapy, clients' level of affect regulation, which included level of emotional awareness, had a significant impact on the quality of their in-session processing and on outcome.
Clients who are receptively open to their internal experiencing also have been shown to have better outcomes (Elliott, Greenberg, & Lietaer, 2004; Hendricks, 2002; Orlinsky et al., 2004). Inner experiencing is a broader construct than emotion. It includes thoughts, images, and what Gendlin (1996) has called “bodily felt meanings.” It has been found that this kind of receptive openness is something clients enter therapy with (Gendlin, Beebe, Cassens, Klein, & Oberlander, 1968), although therapy can promote it as well (Goldman, Greenberg, & Pos, 2005). Findings on whether openness to experiencing correlates with outcome in cognitive therapy have been mixed (e.g., Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Rudkin, Llewelyn, Hardy, Stiles, & Barkham, 2007; Watson & Bedard, 2006).
In conclusion clients' openness to emotion and inner experiencing appears to be beneficial, particularly for psychodynamic and experiential approaches, but less consistently so in cognitive-behavior therapy. The findings suggest the possibility of favoring cognitive-behavior therapy for those high in alexithymia.
In contrast to being acceptantly open to emotions and experiencing, clients may have a perfectionistic, critical stance toward the self. If inner openness is important, a critical stance could be expected to be associated with poorer outcome. Hawley, Ho, Zuroff, and Blatt (2006) cite studies that are in accord with this hypothesis. For instance, Blatt et al. (1995) found that high levels of pretreatment perfectionism had a negative impact on psychotherapy outcome. Hawley et al. (2006) tracked the impact of perfectionism across sessions. They found that reduction in perfectionism significantly predicted therapeutic change across sessions.
Along with the findings on openness to inner experiencing and emotion, the research on perfectionism suggests that the manner in which clients relate to themselves can either facilitate or inhibit therapeutic processing. Facilitating more effective processing, therefore, may become a prime focus of intervention, although the methods needed to accomplish this and degree to which it can change await further investigation.
Overall certain client characteristics appear to predispose clients to better outcomes. Some of these are styles and competencies that would be expected to make for more adaptive functioning in general (e.g., secure attachment, high ego strength, lower self-criticism). Others appear to particularly influence the quality of the client's participation in therapy. These include motivation, openness to experiencing and emotion, possibly psychological mindedness, and how certain characteristics such as reactance and coping style match up with the particular therapy approach offered.
As might be expected, there is evidence that clients' perceptions of and beliefs about psychotherapy process and outcome often correlate positively with outcome. Furthermore, their perceptions, such as of the therapeutic alliance, correlate more highly with outcome than do those of therapists. Yet clients' perceptions and beliefs often do not coincide with those of therapists (e.g., Levitt & Rennie, 2004).
This suggests that clients' constructions of therapy may selectively influence how they interact with and process what is going on. An alternative possibility is that their constructions are a consequence of how much they are benefiting from therapy. However, some research has shown that clients' perceptions of the alliance early in therapy are independent of how much benefit they are experiencing (Horvath, Del Re, Flückiger, & Symonds, 2011). In any case, it is important to pay attention to clients' constructions and perhaps to formally measure them during psychotherapy.
The importance of the therapy relationship is not just statistically established; there are more than 100 studies where clients themselves point to the relationship as one of the most helpful aspects of therapy (Norcross, 2010). As previously noted, there can be important differences in how clients and therapists perceive their interactions (Eugster & Wampold, 1996; Levitt & Rennie, 2004). Here we highlight the client's perspective.
Horvath et al.'s (2011) most recent meta-analysis of 190 independent data sets shows a highly reliable (p < .001) relationship between alliance and outcome, independent of how either is measured, by whom, or when. Confirming results of a prior meta-analysis (Horvath & Bedi, 2002), clients' alliance scores were significantly related to outcome (r = .282) and had higher correlations with outcome than therapists' (r = .196), challenging the notion that clients distort the therapy relationship and its impact.
Nonetheless, meta-analytic reviews show there is a moderate amount of reciprocity within client-therapist dyads regarding perceptions of the strength of the working alliance (Marcus, Kashy, & Baldwin, 2009). Clients' degree of disturbance can increase the discrepancy between therapist and client perspectives, although generally speaking clients' ratings of the alliance are higher than those of therapists (Tryon, Blackwell, & Hammel, 2007). Explanations of clients' more generous views of the relationship are not known, although it may serve a purpose in the healing process. In two studies that used multilevel modeling techniques, aggregate client ratings of the alliance were able to predict which therapists would have better than average outcomes for their overall caseload, whereas therapist ratings did not have predictive value even in their own case load (Baldwin, Wampold, & Imel, 2007; Marcus et al., 2009). This lends further support to the idea that clients can be finely tuned into critical aspects of a good working alliance.
Marcus et al. (2009) found that clients of the same therapist differed greatly in rating the strength of the therapeutic alliance. However, if a particular client's alliance ratings were especially stronger than the therapist's other clients, this was predictive of a better outcome for that particular client. This suggests that therapists do not construct the same type of alliance with each client; rather, each unique pairing of therapist and client results in a somewhat unique quality of therapeutic alliance. It also suggests that if a client felt that he or she was able to form an especially strong alliance with his or her therapist, this had a positive impact on treatment progress. As a collective whole, client ratings of the alliance were predictive of which therapists were more proficient than others, which lends further support to the unique vantage point of clients in detecting relevant and helpful therapist stances (Marcus et al., 2009).
As defined by Gelso (2009) the real relationship is “the personal relationship existing between two or more people reflected in the degree to which each is genuine with the other and perceives and experiences the other in ways that befit the other” (pp. 254–255). From a psychodynamic point of view the real relationship is distinguished from transferential and countertransferential aspects of the therapy relationship. Lo Coco, Cullo, Prestano, and Gelso (2011) found that clients' perceptions of the real relationship predicted outcome although therapists' perceptions did not. This was particularly true for the genuineness component. Fuertes and colleagues (2007) found that both clients' and therapists' assessment of the real relationship was associated with clients' view of treatment progress. On the other hand, Marmarosh and colleagues (2009) found that clients' ratings of the real relationship did not have a significant correlation with treatment progress, whereas therapists' perceptions did. But Marmarosh et al. also found that clients' perceptions of the genuine qualities of the real relationship did accurately predict therapists' views of the working alliance, although the reverse was not found. Thus two of three studies found that clients' perceptions of the real relationship correlated with outcome. In addition, their perceptions of the genuineness component appeared to be particularly important.
There is evidence that clients have preferences for the kinds of relationship qualities they receive in psychotherapy. In addition to prizing genuineness and realness from the therapist, clients also prize “therapeutic presence” (Geller, Greenberg, & Watson, 2011). This is defined by Geller and Greenberg (2002) as the therapist being completely in the moment in terms of physical, spiritual, cognitive, and emotional engagement of the whole self. Geller et al. (2011) have found that clients' perceptions of presence correlate with outcome higher than do therapists' perceptions. Clients also reveal preferences about the kind of atmosphere they would like their therapist to create. Martin (2008) found that clients mainly wanted an environment that reduced stigma to talk about difficult things, and that enhanced clients' sense of self-efficacy. This environment was facilitated when therapists' were open, respectful, and worked at earning trust (Beretta et al., 2005; Martin, 2008). Clients noted that they sometimes tested their therapist before opening up about vulnerable things. Therapists' “invitations” in the form of slowing down the pace of therapy, giving the clients their full attention, and making themselves vulnerable in some way all seemed to help therapists “pass the test.” Nilsson, Svensson, Sandell, and Clinton (2007) reported similar findings with clients preferring therapists that were adaptive to clients' needs, accepting, and patient such that clients felt free to take their time. These clients also reported that while they appreciated emotional support, neutrality and some interpersonal distance were also important.
Clients of ethnically diverse backgrounds reported better experiences when therapists were open to seeing the strengths in clients' cultural heritage, discerned clients' unique positioning within their culture, and acted with awareness about the impact of ethnic differences within the therapeutic relationship (Cardemil & Battle, 2003). Clients' perceptions of therapists' multicultural awareness and sensitivity were positively correlated with perceptions of alliance and the real relationship (Owen, Tao, Leach, & Rodolfa, 2011). The alliance was a mediator between perceptions of therapists' multicultural orientation and measures of psychological well-being, indicating that multicultural competence fostered a relationship in which good therapeutic work could occur. Likewise, similarity between therapist and client in religious or spiritual orientation was less important to clients than having a therapist who was trained to address spiritual matters and who was open and nonjudgmental (Knox, Catlin, Casper, & Schlosser, 2005; Pieper & van Uden, 1996).
There are several studies that identify clients' contraindications for their therapists' relational stances. One study found that confrontation proved unhelpful (W. R. Miller, Wilbourne, & Hettema, 2003). Another study found that clients generally were mistrustful of confrontational therapists, unless the client was being manipulative or avoidant in which case it was appreciated (Levitt, Butler, & Hill, 2006). Clients were sensitive to therapists becoming critical or rejecting of them (Constantino et al., 2007). Von Der Lippe, Monsen, Rønnestad, and Eilertsen (2008) found that with clients who showed little change or were worse after treatment, therapists had initiated more disparaging comments and dismissive interactions than with clients who had positive outcomes. Nilsson and colleagues' (2007) reported that clients who were dissatisfied in therapy frequently identified their therapist as treating them more like a “thing” than a person, acted as if being a therapist was “just a job,” and were emotionally absent or hiding something.
Clients have preferences for their experiences in psychotherapy. For example, King and colleagues (2000) gave clients descriptions of cognitive-behavior therapy and person-centered therapy and the option of choosing what they received. Not all patients decided to choose one or the other. Of those who did, 60% chose CBT and 40% chose person-centered counseling. In another study, Swift and Callahan (2010) had clients rate their preferences for treatment by comparing variables such as empirical support for treatment to common factors. It was found that clients were more likely to choose variables such as a satisfactory therapeutic relationship, that their therapist would have a greater level of experience, and that they, the clients, would be able to do more of the talking, over whether interventions had empirical support.
Swift, Callahan, and Vollmer (2011) did a meta-analysis that broke client preferences down into three areas: role preferences, therapist preferences, and treatment preferences. Role preferences had to do with the activities and behaviors that clients preferred for themselves and therapists to engage in. Examples given by Swift et al. (2011) included having the therapist play an active advice-giving role versus adopting more of a listening role, or preferring group therapy over individual therapy. Therapist preferences included things like: therapist years of experience, preferring a therapist of a particular ethnic background or of a particular gender, or preferring therapists who were empathic. Treatment preferences included clients preferring one “brand” of therapy over the other, or preferring to have either psychotherapy or pharmacotherapy.
Swift et al. (2011) found 35 studies that looked at whether clients got their preferences for role, therapist, or treatment; 18 studies looked at premature termination. Using an odds ratio calculation, a significant effect was found at the p < .001 level that clients who received their preferred conditions were less likely to prematurely drop out of therapy. Of the 35 studies, 33 also looked at outcome. The overall effect size for outcome was d = .31, a small but significant effect size. The average effect of psychotherapy versus pharmacotherapy was d = .36; for one therapy against another, d = .21. The only client characteristic that mattered was client diagnosis/problem. Matching client preferences positively influenced treatment outcomes for anxiety, depression, and substance abuse disorders.
There was no difference among the type of preference and its bearing on dropout rates, or on outcome, suggesting that matching clients to their preferred role, therapist, or treatment all had similar effects. Swift et al. (2011) reported that patient preferences themselves have been found to be influenced by a number of other variables, such as demographic characteristics, beliefs about the nature of problems, level of symptom severity, previous experience with therapy, expectations for therapy, and other life experiences.
These findings suggest that therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. It does not mean that a client who does not get his or her therapy preference will not be able to benefit. However, if clients' preferences present obstacles therapists may wish to take appropriate action, such as either referring the client or finding a way of more comfortably coordinating what they are doing with the client's pre-existing beliefs.
The topic of client expectations overlaps with that of client preference, but is conceptually different. Frank (1961) referred to it as a preeminent factor in client outcomes. Further spawning the interest in this variable was Lambert's (1992) estimation that 15% of outcome variance could be tied to client expectations about treatment. There are many different angles from which the topic of client expectations has been investigated—expectations in terms motivation for change, preferences for the type of therapy or therapist, theories explaining human transformation, expectations about how the process of therapy should work, and finally, about the efficacy of therapy and whether it will really work for them. The first three topics related to expectations are addressed in other sections of this chapter; here we focus on the latter two.
There are mixed findings concerning the relationship between role expectations and outcome. Role expectations have to do with how clients expect therapy to operate. Arnkoff, Glass, and Shapiro's (2002) review listed 19 studies finding a positive correlation, 9 studies that showed no correlation, and 12 studies with mixed findings. However, clients' expectations for how both they and their therapists will behave influences how the process of therapy unfolds. For instance, clients in one study who reported expectations that they would work hard and come regularly also reported stronger alliances by the end of the third session (Patterson, Uhlin, & Anderson, 2008). These clients' emphasis on their own role had predictive value whereas there was no correlation between their ratings of alliance and their prior anticipation of a warm, accepting therapist or a therapist with great expertise.
It is useful to catalog the variety as well as predominant trends regarding the specifics of what clients anticipate in the therapy environment. In a qualitative study examining expectations, clients reported surprise that they worked so hard in therapy, both in the case of good and poor outcome (Westra, Aviram, Barnes, & Angus, 2010). Despite their surprise that they worked hard, they had expected “to be ‘grilled,’ ‘rushed,’ ‘pushed,’ ‘restrained,’ and ‘made to do things’ and were pleasantly surprised when the therapist relied on them for direction” (Westra et al., 2010, pp. 439–440). In general, clients with good outcomes did not expect therapy to be so collaborative, to feel so free to direct the process, or feel so comfortable with the therapist. Clients were also surprised that their therapists were nonjudgmental. This was the case in both good and poor outcome cases. Westra et al. (2010) also found support for the idea that if negative expectations about the clients' role were disconfirmed, this could draw clients' attention to positive target behaviors. This made these behaviors more likely and led to better outcomes.
High scores on adaptive perfectionism measures were associated with clients' positive expectations towards the therapeutic process and positive outcomes (Oliver, Hart, Ross, & Katz, 2001). In a similar vein, clients who were high in psychological mindedness did not tend to expect more from their therapist but did expect more from themselves (Beitel et al., 2009). Specifically, they expected themselves to be active in the counseling process by sharing openly, sticking with the process when it became difficult, and taking responsibility for the course of therapy. Beitel and colleagues (2009) found that a general trait of optimism was not significantly related to overall client expectations (Beitel et al., 2009). However, a general measure of client hopelessness did correlate with lower outcome expectations (Goldfarb, 2002).
Diagnostic differences can contribute to differences in expectancy/outcome correlations. Depressed clients reported higher pessimism with regard to improvement and suitability of treatment than those with anxiety or comorbid diagnoses, although this difference disappeared mid-treatment (Schulte, 2008). Clients with more severe symptomatology were more likely to have lower outcome expectations (Safren, Heimberg, & Juster, 1997). Also, clients who had received prior therapy were more likely to have higher expectations about therapy success (MacNair-Semands, 2002).
In a recent statistical meta-analysis using 46 samples, Constantino and colleagues (2011) reported a small (r = .12) but significant effect size for the relationship between clients' expectancy of treatment success and outcome. It also appeared that moderate expectations had the best predictive power. Noble, Douglas, and Newman's (2001) review of studies published prior to 1980 also evidenced a curvilinear relationship between expectations for success and outcome; those with moderate expectations had the best outcome compared with those with very high and very low expectations. Extreme expectations in both directions were also correlated with attrition. In one study, clients were seven times more likely to drop out of therapy if their scores were outside the normative range for expectancy (Aubuchon-Endsley, & Callahan, 2009).
Role-induction protocols have been shown to modify expectations and increase successful outcomes (Constantino et al., 2011; Noble et al., 2001). Less has been done on modifying outcome expectations (Constantino et al., 2011). Constantino et al. (2011) offer a number of suggestions for how therapists can both assess and help clients productively modify expectations. Intuitively, it makes sense to try to help clients to have realistic expectations. However, diminishing expectations that are unrealistically high runs the risk of discouraging some patients. Further understanding of the effects of specific methods of changing outcome expectations on specific kinds of clients is needed.
Clients' views about who/what is responsible for the cause of the problem are important to consider. Studies have shown that when the therapist is aligned with client's attributional theories, it is predictive of client satisfaction and outcome (Hayes & Wall, 1998; Tracey, 1988). Furthermore, therapists who align with clients' attribution of responsibility are deemed more credible and understanding (Worthington & Atkinson, 1996).
This does not mean that clients do not change their theories about causes of problems. Clients in Mackrill's (2008) qualitative study had definite ideas going into therapy about what was the cause of problems and the strategy to resolve them. The cases represented a mixture of clients sticking with their theories and/or modifying their understanding when confronted with an alternate explanation that made sense to them.
Clients' understanding regarding the root of current problems can have an impact on their motivation for the type of treatment offered. When Meyer and Garcia-Roberts (2007) administered the Reasons for Depression and the Motivation for Intervention measures to clients, it was found that clients who saw their depression as rooted in interpersonal issues were more motivated for interventions that were interpersonal in nature. Similar results were found for the categories of characterological issues, childhood issues, biological roots, achievement, and relationship issues. Clients with these reasons were motivated for therapy that was personality changing, past-focused, pharmacological, goal setting, or relationship-focused, respectively. Conversely, clients who endorsed more complex reasons for their depression (as measured by their citing multiple reasons) were less motivated for behavioral approaches, possibly because they did not see their problems as being fixed by simply changing behaviors.
There is also congruence between how clients see themselves and how they see the path of change. Kühnlein (1999) interviewed clients 2 years posttherapy and pulled for a narrative history, what the perceived usefulness of therapy was, and the meaning of recovery. She identified four types of clients' models of change and labeled them: Overburdened, Deviation, Deficit, and Developmental-Disturbance. Clients' narratives about their problem category were congruent with their perceived path of change. For instance, those who fit under the Deficit type described their history primarily in terms of their shortcomings. Therapy was seen as a means for learning self-improvement techniques, a learning process that would be ongoing after therapy ended. Although the therapy approach was cognitive-behavioral, clients' narratives involved themes that went beyond formal CBT learning processes, and explanations went beyond the change narratives offered by their therapists. However, evidence that clients construct or retain their own change narrative independent of the therapy model offered is mixed. Like Kühnlein, some studies have found that clients maintained an independent theory (e.g., Clarke, Rees, & Hardy, 2004; Orford et al., 2009). However, Valkonen, Hänninen, and Lindfors (2011) found that clients' problem etiology and resulting change narrative either happened to match the therapy offered or clients accommodated to the therapist's theory.
In conclusion, clients can have their own theories of what is wrong. These can influence their experience in therapy and may impact outcome. Clients may or may not modify their theories to match the theory of the therapist. However, change may happen even if their theories do not match their therapists' theories.
Numerous studies, especially in the past 25 years, have investigated clients' views of therapeutic processes that lead to change. These studies can be categorized in three ways. One category, “significant events,” refers to investigations into a specific point in time. Clients (and therapists) provide a narrative of processes that had a significant impact on the proceedings of therapy (either positive or negative). These events are usually richly described and sometimes are associated with recordings of the session (e.g., interpersonal process recall methods). Inquiries into significant events often highlight therapeutic micro-processes that can be woven together to construct a view of how change comes about (see Elliott, 1985).
Alternatively, inquiries categorized as “helpful and hindering processes” tend to invite clients to reflect more globally on what occurs during either the course of therapy or during a particular therapy hour, again either positive or negative. Although there can be significant specificity in this type of inquiry, there is not usually a causal weaving together of a sequence of events as is the case with the “significant events” inquiry method. A third inquiry, addressed in the previous section, invites clients to reflect on their “theory of change,” allowing clients to not just reflect on what did help the change process but also to prospectively talk about what processes could facilitate change, thereby adding an element of their philosophy along with specific change processes.
In a qualitative meta-analysis involving seven studies looking at significant events, Timulak (2007) identified nine core categories: personal contact; behavioral change/problem solution; exploring feelings/emotional experiencing; empowerment; relief; feeling understood; client involvement; reassurance/support/safety; and awareness/insight/self-understanding. The last two categories were reported in all seven studies. Timulak (2010) also performed a qualitative meta-analysis of 41 additional studies of significant events. He noted that significant events findings can be complex and that while clients may label a sequence of therapy as being helpful, it may also include elements that are hindering. The “significant event” can really only be understood in the context of the larger picture of the therapy endeavor and clients have vastly different understandings of these events than do their therapists. One difference Timulak (2010) found between therapists and clients' understandings was that clients tended to focus on the emotional and relational factors of a significant event whereas therapists placed value on the cognitive components of an event.
Castonguay and colleagues (2010) similarly found there was little overlap in the types of activities reported as helpful by clients and therapists. In another study, Altimir and colleagues (2010) found that clients who were deemed successful tended to report more numerous change processes than their therapists or observers. However, Altimir and colleagues reported that clients and therapists did agree on the basic content of the change process even if they did not agree on the specific change moments. The fact that clients picked up on more change processes may mean that therapists' preexisting schemas for what counts as helpful are less comprehensive and therapists could stand to benefit from paying closer attention to clients' more nuanced perceptions. These are important findings that suggest what clinicians think, teach, and write about with regard to change processes can be generally and importantly different than what clients believe, leaving therapists in a position of not fully understanding client experience.
Studies of helpful processes have yielded a number of findings. Clients identified internal processes that facilitated change, including self-acceptance (Castonguay et al., 2010; Davidson et al., 2005; Nilsson et al., 2007), reflection and insight about self and others (Castonguay et al., 2010; Orford et al., 2009; Paulson, Truscott, & Stuart, 1999), and learning to reason with self (Svanborg, Åberg, & Svanborg, 2008). Negotiation of the client's role was mentioned in several studies as an important element of the therapy: working through a commitment to therapy (Levitt et al., 2006), feeling free to choose the focus of the therapy (Bowman & Fine, 2000), and feeling comfortable with self-disclosure (Orford et al., 2009). Clients also pointed to helpful processes that occurred outside of therapy: trying something new or transferring skills (Mörtl & Von Wietersheim, 2008), testing things out (Clarke et al., 2004), continued processing between sessions (Bowman & Fine, 2000; Levitt et al., 2006), exerting self-control, utilizing environmental supports, and taking medication (Davidson et al., 2005; Orford et al., 2009). The relationship with the therapist and the therapists' facilitative stance was identified as an important element (Binder, Holgersen, & Neilsen, 2009; Bowman & Fine, 2000; Levitt et al., 2006), including an attachment to the therapist (Svanborg et al., 2008) and particular therapist interventions (Paulson et al., 1999). Variety in the client responses to questions about helpful processes may be due to idiosyncratic elements of the treatment, the nature of the questions asked, the time lapse between therapy and the client's report (ranging from a few minutes to 17 years), or the depth of the information that can be obtained from different assessment methods such as using a one-item questionnaire or doing a 3-hour interview.
To understand more fully what a good therapeutic outcome is, Valkonen and her colleagues (2011) suggested getting the different viewpoints of researchers, therapists, and clients. Arguably, researchers have paid significantly more attention to good outcome as is defined by reduction in symptoms at the expense of other elements of change that are deemed valuable by clients (Connolly & Strupp, 1996). Klein and Elliott (2006) employed both quantitative and qualitative free-response measures in their study of outcome. They found overlap between the quantitative measures with clients' perspectives on the qualitative measure. However, clients also spoke of discreet changes that were not accounted for in the various quantitative measures but were nonetheless significant to them. Klein and Elliott (2006) suggest that pluralistic methods for gathering therapeutic results be utilized to include both client and researcher/therapist constructed outcome data.
In addition to symptom reduction, clients in Binder, Holgersen, and Nielsen's (2010) study focused on healthier relationship patterns, an increase in self-understanding that led to freedom and avoidance of destructive behavior, and a stronger valuing of the self. Others have also noted clients' emphasis on changes in self-concept and other-relatedness (Connolly & Strupp, 1996; Svanborg et al., 2008; Castonguay et al., 2010). Knowing when to take responsibility and when to let go was identified with the concept of a good outcome (Clarke et al., 2004). Klein and Elliott (2006) categorized two types of clients' self-reported outcomes. First were changes within the self, which included affective changes, self-improvement, and experiential awareness of self and others. Second were significant changes in terms of their life functioning, such as changes in interpersonal relationships and life status/role changes (e.g., getting a job or reconciling with a spouse).
This broadening of the view of what constitutes a “good outcome” is reflected in both the academic literature and in mental health consumer advocate groups. A panel of 110 experts published a statement that reflects the transformation of “recovery” defined traditionally as stabilization of symptoms to a definition that includes a focus on clients' abilities to participate fully in relationships, work, learning, and in society (National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation, 2004). Davidson et al.'s (2005) interviews confirmed the importance of this broadened definition of “good outcome”; patients spoke of recovery in terms of reengaging in meaningful work and social roles and a restoration of their sense of self-respect as individuals that are not wholly defined by psychosis.
Research on clients' perspectives supports the idea of the client as someone who plays an active, agentic role in therapy. Where such relationships have been studied, clients' perspectives tend to correlate with outcome, often more highly than those of their therapists. Their views of the nature of their problems, of what they want in therapy, and how those views match up with therapists' interventions can influence both their motivation and outcome. Their views may also influence how they construe change. Furthermore they see themselves as actively contributing through such activities as working hard, learning to reason with themselves, reflecting, and trying something new. Finally, as agents, they value being understood by the therapist and being involved in a genuine, mutual relationship.
In this section we review evidence demonstrating that clients often contribute proactively to the change process. We first look at client agency, then at how clients contribute to the therapeutic alliance. We then consider how clients carry therapy experiences into everyday life. Finally, we consider two models of client processing.
The concept of client agency assumes that clients are not merely “absorbers” of what therapists offer, but generators of change as well. Through a series of interviews using interpersonal process recall (IPR) methods, Rennie documented clients' agency in the form of awareness of themselves and the activities they engaged in to negotiate change (Rennie, 2002). Rennie (2010) has called this self-awareness reflexivity and asserted that clients are also aware of their self-awareness, which he referred to as radical reflexivity. Rennie (1992, 2002, 2010) found that clients actively thought to themselves about what was going on while listening to therapists, gained insights they did not share, sometimes resisted therapists' influence, acted upon therapists' directives, were aware of deferring to therapists' expertise, and provided their own interpretation of the meaning of a specific technique or of relationship factors. Mackrill (2009) recommended psychotherapeutic research take a more contextual approach that accounts for agency both in and outside of the therapy room. He pointed to the qualitative work of Dreier's (2008) cross-contextual approach as evidence of clients' agentic ways of transforming everyday life based on what they learned in therapy. Mackrill's (2007, 2008) diary studies provide additional examples of cross-contextual agency: clients learned from and acted upon their environment both in and out of therapy, made connections between the different contexts, and these connections then influenced how they participated in each context.
Levitt's (2004) interviews with 26 clients revealed that clients idiosyncratically reacted to interventions and managed their therapists' style in order to gain what they personally needed from the session. She noted that manualized interventions that are a one-size-fits-all approach would not be sensitive to the way these clients were agentically interacting with the therapy provided. Greaves and Carl (2009) interviewed group therapy participants using interpersonal process recall methods and found that clients were aware of and able to reflect on their intentions behind their actions in the group. Clients indicated that they facilitated an environment where they could receive specific support, could use others as a foil to understand themselves, and set up situations in group that allowed them to practice new behaviors.
The 11 participants in a qualitative study of individual psychotherapy by Hoener, Stiles, Luka, and Gordon (2012) attributed the change they experienced to their own agentic efforts. They worked within the various therapy approaches they were offered and highlighted ways that a particular approach facilitated their agency. For example, more directive approaches were valued for the responsibility placed on them to do homework whereas less-directive approaches lent them freedom to explore.
Studies that allow for the construct of agency to be measured are a rarity. Research shows that measures of well-being are related to clients' agency-laden thoughts and narratives. For instance, one study coded and then rated clients' narratives for content that reflected a sense of empowerment to overcome rather than be at the mercy of circumstances (Adler, Skalina, & McAdams, 2008). The quantified measure of agency correlated significantly with a composite score of subjective well-being measures (r = .55). In another study, following a five-session pretherapy group addressing the topics of hope and agency, clients were given measures of agency and subjective well-being (Irving et al., 2004). In a hierarchical regression analysis, agency scores were predictive of higher subjective well-being scores.
Often when the therapeutic relationship is discussed in the literature, it is referred to as something that is built by therapists for the “benefit” of clients. Recent publications, though, give rise to the notion of clients that positively contribute to the therapy relationship in unique ways. To be more in tune with clients, it is wise for therapists to understand ways in which the client, too, is building the relationship (Soares, Botella, & Corbella, 2010).
Assessing clients' contribution is tricky. Use of self-report measures to determine clients' views of their impact on the formation of a solid therapy relationship may underestimate the client's role, especially if clients see the relationship similar to a parent–child relationship (e.g., Fitzpatrick, Janzen, Chamodraka, & Park, 2006) or a doctor-patient relationship. For instance, Bachelor's (1995) study with open-ended questions inviting clients to talk about what made up a good therapy relationship resulted in clients predominantly talking about therapists' contributions to the alliance. However, in an in-depth transcript-analysis of nearly 100 sessions where the focus was solely on client initiated sequences of alliance building, it was found that clients played a role in fostering healing qualities in the therapist (Greaves, 2006). This study found that by being “present” themselves and engaging with the therapist in a “real” way, above and beyond their role as a client, they appeared to influence similar responses in the therapist. It was also found that clients' vulnerable expressions of pain fostered empathy in their therapists and alternatively, clients' expressions of hope and optimism about treatment progress seemed to inspire a reciprocal hope in the therapists' responses.
Clients have reported being aware of a “state of readiness” and making conscious decisions to become vulnerable and to open up about difficult material (Knox & Cooper, 2011). Clients also noted seemingly reciprocal openness from their therapists as they were able to become vulnerable. It may be assumed that clients' perceived impact on their therapists' vulnerability may be tied with increases in the “bond” of the relationship (e.g., liking, trust, safety, comfort). Fitzpatrick and colleagues (2006) found that as the bond increased, so did clients' “expressive openness.” And clients' gradual reduction of self-concealment was found to be a unique predictor of distress reduction (Wild, 2005). Clients also paid tribute to their own openness to the interventions of the therapist. Fitzpatrick et al. (2006) called this “receptive openness.” As clients attributed positive meaning to their therapists' responses, this also contributed to more positive emotions or more exploration. This kind of receptive openness was found in a qualitative study with patients treated for psychosis (McGowan, Lavender, & Garety, 2005). As these patients were able to move into the frame of reference of their therapists, they were able to progress in the treatment. Both receptive and expressive openness seem to be important activities that move the client along in the therapeutic process and are in part facilitated by clients' capacity to experience positive feelings of liking or being liked by their therapist.
Greaves (2006) found that clients were active in building this rapport with their therapists through prosocial behaviors like being appreciative of their therapist or being accommodative of therapists' schedule changes. Clients cultivated mutuality with their therapist by responding to the humor or “realness” of the therapist, building upon a common language base, or creating shared stories about the therapy experience which were referred to time and again. Further impacting the therapeutic bond, clients also took the initiative to make process comments about relationship dynamics. It is clear from Krupnick et al.'s (1996) study examining the relative impact of clients' versus therapists' contributions to the alliance that clients' contributions had more impact on outcome. In this study, external ratings of Patient Exploration, Patient Participation, and Patient Hostility on the Vanderbilt Therapeutic Alliance Scale were significantly correlated with outcome whereas none of the therapists' contributions related to outcome and for each unit of increase in client alliance contributions, there was a threefold increase in odds of remission.
Ablon and Jones (1999) found an inverse relationship between negative patient interpersonal behaviors and improvement in therapy. Items that were significantly correlated in the reverse were: Patient rejects therapist's comments, is suspicious, verbalizes negative feelings, is shy and provocative. There was only one item on the Psychotherapy Process Q-Set that measured a positive interpersonal process initiated by the patient: Patient seeks greater intimacy with the therapist. This item was positively correlated with outcome. Thus it may be inferred that in the absence of these negative behaviors, patients were accepting, trusting, affirming, assertive, and tactful. Once again, the clear importance of client relationship-building behaviors highlights the need to have process and alliance measures that explicitly query for positive and active client contributions.
Research has supported the usefulness of therapists attending to and helping repair ruptures in the alliance (Safran, Muran, & Eubanks-Carter, 2011). However clients, too, contribute to rupture repairs. Often clients do not attempt to repair ruptures and instead choose to resolve the matter by terminating therapy, perhaps because they see no need to waste time in repairing a mismatched relationship. It makes sense that clients themselves would take on the burden of repairing a salvageable relationship since they have invested both time and money in it and face a setback if they were to switch to another therapist or give up.
Rhodes, Hill, Thompson, and Elliott (1994) found that a differentiating quality between good and poor therapy outcomes was the way that misunderstandings were handled. Good outcome cases involved having a previously established good relationship combined with clients' assertiveness about negative feelings and therapists' flexible and accepting attitude. Williams and Levitt (2008) found that some clients were equipped to manage these differences. One client-therapist dyad had a cue that acknowledged when they were at odds. Another client made special allowances for the therapist based on the fact that the therapist was in training. Resolving disagreements enhanced another client's sense of efficacy when the client was able to get the therapist to see an alternate viewpoint.
There is no shortage of errors that therapists make including inaccurate interpretations, mixing up clients' stories, showing lack of interest, cutting clients off, and misunderstanding cultural differences (Williams & Levitt, 2008). Greaves (2006) found that some clients not only confronted therapists' errors but queried therapists' intentions in order to understand the root of the mistake. One client overlooked the mistake, then addressed it later by asking for something opposite of the therapist's original response. The work of forgiveness was evident on both the part of clients and therapists. These clients both worked to offer forgiveness and renewed faith in the relationship after ruptures as well as offer their own apologies and promises to change when they were the offending party. It should be noted, though, that clients may not reveal negative feelings and this may be due to an assumption that their feelings are irrational or that they would lose the approval of the therapist (Rennie, 1992). It has been shown that when clients do not assert themselves and bring up negative reactions or if they do and therapists do not discuss or acknowledge them, it may lead to poor outcomes or early termination (Rhodes et al., 1994). Westra et al. (2011) found that clients dropped their expectations for improvement by 25% following alliance rupture situations and that expectations were a key moderator on the impact of ruptures on outcome.
Clients, not just therapists, can play a role in actively coping with and managing the therapeutic relationship. When they do not, this fact needs to become a serious topic of discussion.
The construct of the therapeutic alliance is deeply rooted in concepts related to goal consensus: agreeing on the direction of healthy change for the clients, agreeing on the path and goals that lead there, and actively structuring the treatment to be in line with those goals with client buy-in regarding expectations of therapy (Bordin, 1979; Tryon & Winograd, 2011). Goal consensus has been identified as an important ingredient in effective psychotherapy (Steering Committee, 2002). The most recent meta-analysis of the relationship between goal consensus and therapy outcome found an effect size of .34 (Tryon & Winograd, 2011).
Mackrill (2011) identified four different sets of goals: those for life (e.g., repairing a significant relationship) and those for the psychotherapy endeavor (e.g., emotional expression), with therapists and clients each having their own perspectives on each. When addressing the goals for life, diagnosis is not all that therapists need in order to make a treatment plan. Collaboration with clients around treatment goals is an important step in tailoring the treatment plan to meet clients' wishes, not just to remit certain symptoms. For instance, Rajkarnikar (as cited in Cooper & McLeod, 2010) found that for the diagnosis of social anxiety, only a little more than half of the clients were wanting to work on issues of social avoidance or performance anxiety and many instead wanted to focus on other issues like sexuality, work problems, or, the largest category—self-esteem/confidence.
Consensus also needs to be reached for goals regarding the process of psychotherapy (e.g., the quality of therapeutic relationship to be built, degree of emotional expressiveness, insight to be gained). Wampold and colleagues (2006) cited mounting empirical data that better outcomes were associated with therapists explaining the rationale behind the proposed treatment plan and how it fit with clients' presenting concerns, while making room for discussion and negotiation. If clients and therapists agree about the in-session goals and how they relate to the clients' life goals as well as to the in-session tasks, the process of therapy will most likely make more sense to clients and this will mobilize their active participation.
Client cooperation and particularly collaborative participation, has often been cited as one of the primary factors contributing to change (Orlinsky et al., 2004; Lambert, 1992). In a recent meta-analysis, Tryon and Winograd (2011) confirmed a correlation (r = .33) between clients' cooperative behaviors and successful outcomes. But collaboration implies more than just cooperation and much more than compliance. However, of the 19 studies included in the meta-analysis, 13 measured “collaboration” via some form of homework compliance (11) and/or treatment adherence (2). Even the value of homework compliance has changed in light of recent research showing that homework links to better outcome if clients can “buy in” to the rationale behind it (Scheel, Hanson, & Razzhavaikina, 2004) or if clients are explicitly involved in the creation of the homework assignments (Kazantzis, Deane, & Ronan, 2000). Furthermore, evidence suggests that clients may not follow the homework as prescribed and instead mold their therapists' requests into what fits for them (Greaves, 2006; Mackrill, 2008; Rennie, 1992).
Most of the remaining six studies in Tryon and Winograd's (2011) meta-analysis used an alliance measure as a means of determining collaboration. For instance, the California Psychotherapy Alliance Scale (Gaston, 1991) defines the client's involvement with two separate scales: Patient Commitment (e.g., trust, willingness to make sacrifices and experience painful moments) and Patient Working Capacity (e.g., disclosure, introspection, and experience emotion). Although this scale is classified as an Alliance scale, it has significant overlap with much of what is considered collaboration. On the other hand, scales that have been explicitly designed to measure collaboration do not properly elucidate the clients' involvement in comparison to the therapist's. This deficit is important since collaboration and its relative impact on outcome can only be studied as thoroughly as it is operationally defined. Bachelor, Laverdière, Gamache, and Bordeleau (2007) point out that some measures of collaboration are simply one item or are only vaguely related to the construct. For instance, the Psychotherapy Process Q-Set is a 100-item measure that contains both positive and negative statements about client and therapist activities (Jones, 2000). Of the 100 statements, there are only nine that are positively worded statements about clients' active rather than passive involvement. In an NIMH depression study, of the 11 Q-Set items that were linked to outcome, nine of them were these same active client processes (Ablon & Jones, 1999). It would seem then that there are disproportionately fewer positive client activities being measured despite these having the most elucidating power to predict what works in therapy.
Other scales tend to have more favorable constructs for the therapist than for the client. One example of this imbalance is the Collaborative Interaction Scale (Colli & Lingiardi, 2009). In this scale, therapists are rated on 12 Positive Interventions and 8 Negative Interventions with regard to collaboration; however for the client, there are only 3 “positive” items ascribed to the Client Collaborative Processes and the remaining 18 items are either Direct or Indirect Rupture Markers. Conceivably, many of the positive behaviors that therapists are rated on could also apply to the client but are left out.
In an effort to enrich the construct of collaboration, Bachelor et al. (2007) invited clients to share details of a “good experience of collaboration in your therapy” (p. 178). Through a qualitative analysis of their answers, three categories of client collaboration were constructed: Active Collaboration Mode (26.7% of clients), where clients see themselves as primarily responsible for the change process; Mutual Collaboration Mode (36.7%), where there is a shared sense of responsibility and activity, and Dependent Collaboration Mode (33.3%), where clients highlighted the importance of the therapists' collaborative efforts. An interesting finding was the restricted range of collaborative actions clients reported about themselves in this qualitative study in comparison to those that clients were able to articulate about their therapist (Bachelor et al., 2007). One possibility for this disproportion is that therapists are collaborating more; another possibility is that clients take for granted what they are contributing to the therapy process and instead focus on the strengths of their therapy partner.
As an alternative to self-report, session transcript analysis revealed that clients did intervene in the therapy in a myriad of ways, although these were not explicit strategies that they announced one day in session or that were formalized in treatment planning (Greaves, 2006). Greaves pointed to a similar finding in sociological studies of groups where those who were the underdog often appeared to defer on the surface, leaving the strategic moves to those in power, and instead exerted their influence in the grit of the interactions through tactical means (see Certeau, 1984).
Although it is clear that collaboration as it is currently defined has a significant impact on measures of process and outcome, more elaboration is needed both in terms of client actual processes as well as the intricate combining of client and therapist activities for the formation of a true collaborative effort.
An influential development has been that of utilizing ongoing client feedback to enhance the effectiveness of therapy (e.g., Lambert & Shimokawa, 2011). Client feedback can also be seen as a form of collaboration since it adds the client's voice to the practice of therapy management.
Lambert and Shimokawa (2011) pointed out that an estimated 5% to 10% of adult clients participating in clinical trials left therapy worse off than they began. To improve outcome, it has been shown to be useful to regularly monitor and track client responses to therapy and to provide therapists with this information. This is particularly important because therapists often overestimate client performance. Tracking is done by having clients regularly fill out measures of progress, typically on a session-by-session basis.
There are two major approaches to the use of client feedback. The first is that of Lambert and his colleagues (e.g., Lambert & Shimokawa, 2011). Here, collecting client feedback is primarily used to help therapists improve performance. The focus is on cases where clients are not making sufficient progress. This is measured by comparing the client's progress to normed data on clients with similar symptom patterns. Therapists receive feedback on how clients are doing and may use this to make adjustments. In addition, they may also be given tools to help them improve performance if clients are lagging behind. Research has shown that this significantly improves outcomes (g = .70; Shimokawa, Lambert, & Smart, 2010).
In one variant of the Lambert approach, clients who were at-risk were also given information as to their progress. The effect size for studies in which clients were given progress information was g =.55 (Shimokawa et al., 2010). This was similar to the effect size for the therapist-only feedback group (g = .53). Thus there was no clear evidence that giving clients information enhanced outcomes. However, a closer look revealed that giving clients progress information appeared to have a polarizing effect; 15% of clients deteriorated when both themselves and their therapists were given feedback. This compared to 9% deteriorating when only therapists where given feedback. On the other hand, more clients achieved clinically significant change (45% to 38%) when both therapists and clients were given feedback. This suggests that feedback can be beneficial for some clients, and harmful to others. Further research is needed to unpack these results, although it makes intuitive sense that learning you are not progressing as rapidly as most clients could have a motivating effect on some and a discouraging effect on others.
The Partners for Change Outcome Management Systems (PCOMS; S. D. Miller, Duncan, Sorrell, & Brown, 2005) focuses on utilizing client feedback for the purposes of therapists collaborating with clients in the therapy session. Clients fill out a short (four-item) outcome rating scale (the ORS) at the start of each session, which purports to measure subjective well-being, interpersonal relations, social functioning, and overall sense of well-being. At the end of the session clients fill out a four-item session rating scale (the SRS), which basically is a measure of the alliance. The scales are then utilized by the therapist to engage the client in dialogue.
With regard to the PCOMS approach, three studies have supported its effectiveness (Anker, Duncan, & Sparks, 2009; Reese, Norsworthy, & Rowlands, 2009). For example, Reese and colleagues (2009) conducted two studies comparing treatment outcome of clients receiving PCOMS feedback and those receiving no feedback. Patients were randomly assigned to either a feedback or treatment-as-usual (TAU) condition. In the first study they reported that 80% of clients in the feedback group experienced reliable change, while 54% of clients in TAU experienced reliable change. Deterioration was lower in the feedback group (4% to 13%). Lambert and Shimokawa (2011) aggregated these three studies and did a meta-analysis. The combined effect size was g = 0.48, which is a moderate effect size favoring the client feedback condition.
It is difficult to know how much the effects of collecting client feedback are due to an increase in including clients as active agents in therapy or due to increased therapist effectiveness. In the Lambert system the focus is on the therapist who is given a choice about sharing the feedback with the client. However, when clients are given feedback it is clear that it has an impact, with some improving and others deteriorating. In the PCOMS system, clients routinely discuss their ratings of progress with their therapists. In either case, including client feedback makes therapy more of an interactive, responsive process (Stiles, Honos-Webb, & Zurko, 1998). Further research is needed to see just how these methods work.
Studies have shown that how clients relate to therapy experiences between sessions, specifically in terms of internalizing therapist and therapy experience, can have either a positive or negative effect on outcome. Hartmann, Orlinsky, Weber, Sandholz, and Zeeck (2010) concluded, “it appears that differences in the way patients ‘absorb’ and ‘metabolize’ their therapy may emerge more clearly between sessions, when patients are not actually in contact with their therapists, than in the therapeutic process observed during therapy sessions” (p. 357). Research with eating-disordered clients has found that therapy-related intersession experiences were related to client outcome (Hartmann, 1997; Zeeck, 2004; Zeeck & Hartmann, 2005). In one study of bulimic clients, 86% of successful clients and 68% of unsuccessful clients could be identified from their intersession experience. Zeeck (2004) found that positive therapy-related intersession experiences predicted good outcome while negative intersession experiences predicted poor outcome. Different aspects were important in different phases of therapy. In the beginning of therapy clients who had positive experiences thinking about their therapist and therapy between sessions had better outcomes. Hartmann et al. (2010) found that clients who thought more about the therapist and therapy had a lower risk of failure. On the other hand, clients who specifically recreated therapeutic dialogues involving negative emotions such as feeling hurt, rejected, or misunderstood between sessions were more likely to have a heightened risk of failure at 3-month follow-up. However, Nichols (2009) found that while greater negative internalizations were associated with greater negative change, greater positive internalizations were not associated with greater positive change.
There is evidence that different clients internalize in different ways. Knox (2000) reported that some internalized more than others. They were the ones who were more likely to use their representations of the therapist to soothe or support themselves. Farber and Geller (1994) found that women were more likely to use representations of their therapists when working on problems outside of therapy. Bender (1996) found that avoidant, dependent, passive-aggressive, self-defeating, and schizotypal character styles were less likely to benignly internalize the therapist. As noted, a failure to benignly internalize the therapist was associated with less successful outcomes. Zeeck, Hartmann, and Orlinsky (2006) found that clients who received borderline personality diagnoses were more likely to experience their therapists between sessions as offensive or as making them insecure.
Three studies have recently addressed other aspects of client intersession experience. Mörtl and Von Wietersheim (2008) did a qualitative study of clients in a day treatment program. Day treatment experiences became a resource in the home environment. Clients used day treatment experiences as homework at home. They reflected on experiences at the day treatment center with relatives at home, involved people at home in the development of what they had been learning, and used what they had been learning to confront problems at home. Conversely, they compared and contrasted relationships at home with relationships in the day treatment program and learned from that. Overall, they saw the day treatment program as a kind of “practice field” for everyday life.
Mackrill (2008) studied four clients in a program for adult children of alcoholics. Both therapists and clients kept diaries of their experiences. In addition, sessions were taped and qualitatively analyzed. Clients participated on the average for ten sessions. He found that clients were therapeutically active outside the session. For instance, they created their own experiments and other healing experiences without necessarily having them suggested or even implied by the therapist. In addition, clients used their own ideas of what was helpful to structure their experience of therapy, which allowed for a kind of “seamless” translation between therapy and the natural environment. Clients also compared what they were learning from their therapists with what others were telling them in their everyday lives, such as romantic partners or talk show hosts. They were more likely to use what the therapist said if it fit with what someone else had told them.
Finally, Khurgin-Bott and Farber (2011) studied 135 clients in individual psychotherapy and how much they disclosed about their therapy to confidants in everyday life. On average, most clients moderately self-disclosed. They reported having positive feelings about doing so, and the amount of their self-disclosure correlated with the benefit from psychotherapy.
In conclusion, clients work with their therapy experiences outside of therapy. This can either enhance or detract from outcome, depending on how it is done.
Next we consider two models of how clients process information to help get them “out of the box” of the problems in which they have previously been trapped.
Stiles' (2002) Assimilation of Problematic Experiences approach models how clients gradually acquire insight and move beyond it to process problematic experiences. It has been studied with psychodynamic-interpersonal, cognitive-behavioral, and experiential therapy approaches. The model construes the self as a community of voices. The goal of therapy is to build communicative bridges among the voices. It describes a series of steps. In the first stage, the problematic experience is warded off or dissociated. In the second stage, it emerges as an unwanted thought and is avoided. In the third stage the client acknowledges there is a problem but cannot formulate it clearly. In the next stage there is now clarity about the nature of the problem. However, the experience is still one of being stuck. In the fifth stage, the client gains understanding and insight. Understanding is construed as a “meaning bridge” between conflicting internal “voices” or perspectives. In the sixth stage clients use the understanding to work on the problem. In the seventh stage, there is problem resolution. In the eighth stage, there is mastery and integration. The client uses the problem resolution as a new resource for solving future problems.
The method of Stiles and colleagues for validating the model has been to utilize a series of case histories. As one example, Detert, Llewelyn, Hardy, Barkham, and Stiles (2006) contrasted four good outcome cases with four poor outcome cases. These were drawn from a research project where depressed clients received two sessions of either cognitive-behavioral or interpersonal-psychodynamic therapy one week apart, followed by a third session 3 months later. There were no differences in mean assimilation ratings between the two approaches. However, good outcome cases had significantly higher mean ratings on the assimilation scale than did poor outcome cases. Insight was associated with symptom reduction.
The concept of innovative moments (IMs; Gonçalves, Ribiero, et al., 2010) is derived from narrative therapy theory although it has been used to study other approaches. The theory holds that psychopathology is the result of a rigid dominant self-narrative. It is assumed that this self-narrative wards off minority “voices” that might change it in more productive directions. IMs are thoughts, feelings, intentions, projects, or other things that periodically emerge to challenge the dominant self-narrative. However, the question is: Does the client ward them off or does the client integrate them in, thereby changing the dominant self-narrative?
There are five different types of innovative moments: the emergence of a new action, a moment of new thinking or feeling, a moment of actively challenging the problem, a moment of reconceptualizing the problem, and a moment of performing change, which consists of anticipating or planning new experiences or projects. Studies of brief psychotherapy have shown that poor- and good-outcome cases have different profiles of IMs. “Reconceptualization” IMs are more frequent in good outcome cases while rarely being found in poor outcome cases. Performing change IMs, in which new aims, experiences, activities, or projects emerge, also are found more in good outcome cases (Gonçalves, Mendes, Ribiero, Angus, & Greenberg, 2010; Matos, Santos, Gonçalves, & Martins, 2009; Mendes, Ribierto, Angus, & Gonçalves, 2010).
What processes block the path of change in poor-outcome cases? According to a study by Gonçalves, Ribiero, et al. (2010), one process involves what they call mutual in-feeding, in which clients resolve the threat to the dominant self narrative by quickly returning to it, thereby not giving the person the chance to integrate the IM in. This minimizes the threat to the dominant self-narrative and preserves its stability.
Research on the assimilation of problematic experiences, and on the integration of innovative moments, is still in formative stages. Nonetheless, it illustrates the possibility that achieving a better understanding of clients' active processing can help therapists intervene more effectively. For instance, familiarity with the assimilation research has helped therapists sensitively identify where a client was in the process of change in order to choose how to more effectively proceed (Carol Humphreys, personal communication, February 10, 2012).
Overall the research demonstrates that clients can take an active role in mining and managing their therapy experiences. Clients are “co-authors” of therapy. They may silently work to themselves while simultaneously participating in activities with their therapists; they may help manage the therapeutic relationship; most of them are interested in collaboration, and collaboration correlates with outcome; and many of them work between sessions and such work relates to outcome. Furthermore, actively involving them by seeking their feedback impacts on outcome. Finally, clients progress by assimilating problematic material and by attending to innovative moments.
In our introductory section, we cited Orlinsky et al.'s (1994) conclusion that the quality of clients' participation played the most important role in making psychotherapy work. The findings of this review are compatible with this. A number of client characteristics as well as the degree of psychological dysfunction correlate with both early termination and with outcome. However, more so than these, the best predictors of outcome appear to be how distressed clients are when they enter therapy, and their actual in-therapy behavior. This is suggested by research on early responders, trajectories of change, and on predicting deterioration.
Research also shows that clients are as much independent variables operating on therapy as they are “dependent variables” influenced by therapist operations. Findings on early responders demonstrate that many clients do well regardless of the type of therapy they are in. Clients' preferences, beliefs, motivations, and expectations have been found to influence outcome. Their perceptions correlate with outcome. Yet their perceptions may differ from those of their therapists, while correlating with outcome more highly than those of their therapists. This suggests the possibility that how they construe therapy influences what they get out of it.
Findings also show that clients view themselves, and operate, as active agents. They see themselves as working hard and as playing an integral role in producing outcome. They process information and achieve their own insights. They work to develop, maintain, and repair the therapeutic alliance. They may build bridges between their in-session experiences and their between-session everyday lives. They interpret what they are learning in terms of their individual beliefs, schemas, and goals. Some of this research is of a qualitative nature on small client samples. Furthermore, not all of the research has been related to outcome. Nonetheless the research illustrates the existence of client agentic activity.
The most important implication of our review for psychotherapy practice has to do with the potential usefulness of the information for individualizing treatment. There are two general ways to do this. One is to use aptitude-by-treatment interaction information to match clients to a therapy practice based on preexisting client characteristics. We have reviewed evidence that suggests that client reactance, coping style, ethnicity, and preference for different therapy practices might differentially match up better with different ways of providing therapy such as, in the case of ethnicity, the utilization of culturally adapted treatments.
Studies on matching continue to be done. For instance, Conrod and colleagues (2000) have studied the match between client personality traits and variations in substance abuse treatment. Shoham and Insel (2011) have advocated exploring theory-derived mechanisms of problem-formation or problem maintenance and matching intervention to clients on the basis of that exploration. However, there has been controversy over the value of matching (Shoham & Insel, 2011), and not all of the results we have cited are strong.
The other way to use the information is to enhance therapists' capacities for effective responsiveness (Stiles et al., 1998). Responsiveness has to do with therapists' ability to be aware of and adjust to the evolving context. Therapists can utilize the evidence presented here to heighten their empathic awareness. They may be reminded that clients, in some sense, are in many ways the mirror images of themselves in the relationship. As are therapists, clients are thinking to themselves, trying to understand what is going on, trying to decide what to do next, try to figure out how best to connect with or deal with the other person, how best to deal with frustration when things are not going well, and how best to make the situation work. Using this awareness, therapists may be in a better position to sensitively tailor the emerging context to help the client. For instance, knowing that clients often interpret what is going on differently than therapists do might help therapists become aware of such moments when they are occurring. They then can make appropriate adjustments, or, through listening to the client, learn how the client's interpretation may even be helping the client progress at that point.
In terms of responsiveness, we support the recent focus on gathering session-by-session client feedback. Not only does the evidence support its usefulness, but it is another way of heightening therapists' sensitivity to the emerging treatment context.
If clients really do play a central role in therapy outcome, then more research needs to focus on how clients do this. We have previously mentioned that simply correlating client characteristics with early termination and with outcome frequently has not proved to be fruitful. It seems more useful to investigate what these characteristics mean, and then study how they might facilitate or detract from the degree and quality of clients' participation. For instance, given a negative relationship of client impulsiveness to outcome, what does that mean from the client's side of the coin? Does impulsiveness detract because clients are unable to stay involved in the process? Or does it in some way negatively impact on their information processing? Or is it possible that our current therapies do not offer the kinds of affordances that would help such clients successfully involve themselves? These are the kinds of questions that would be fruitful to ask.
In terms of understanding how clients process information, a research direction that has not been extensively pursued so far, but is likely to be in the future is to look at neuropsychological underpinnings of psychotherapy and behavior change (e.g., Wampold, Hollon, & Hill, 2011). There is now considerable research devoted to the neuropsychological correlates of both psychopathology and social behavior (e.g., De Haan & Gunnar, 2009). Such research has demonstrated, for instance, that there are many ways in which social interaction directly affects the physiology and brain functioning of individuals. This kind of research may help clarify perennial issues of debate in psychotherapy such as how much change is based on insight and how much it may be based on direct “reprogramming” of the brain as a result of relational interaction.
Much of the recent research on clients has been qualitative in nature. However, as we noted in the introduction, qualitative studies often have small n. Furthermore they are often based on nonrandom samples. This makes it difficult to generalize results. Nevertheless, qualitative studies are of value in demonstrating the existence of phenomena. They can show that something is possible. This has been true for studies we have considered. Furthermore, qualitative studies can add a richness of understanding often lacking in quantitative studies. The next step will be to see how widespread some of the phenomena we have considered are and to assess their relative impact on outcome.
From our perspective, we encourage more research from a stance of looking at therapy from the client's vantage point. Current attempts to maximize outcomes place enormous amounts of time and energy in treatment protocols, while comparatively neglecting clients' contributions. Typically therapy research has focused on what therapists do and how it impacts on clients. However, when one looks at therapy from the client's side, either through interpersonal process recall methods (e.g., Rennie, 2002), or by analyzing transcripts by focusing on the client as an active agent (e.g., Greaves, 2006), one gets a different picture. Imagine as a thought experiment that therapy is a co-constructive activity of two creative learners. Furthermore, assume that it is clients who ultimately are the ones to take what happens and to use it to change. Then ask: How do they do it? We still know relatively little about this.
In this regard, many previous studies on clients experiences have focused on their retrospective accounts. Although these have been useful, we believe that looking at therapy from the client's side of the coin means more than asking about his or her experience. Some qualitative studies, for instance those of Rennie (1992), Greaves (2006), and Mackrill (2008), have utilized other methods such as tape-assisted recall, ongoing diaries, or intensive analyses of therapy transcripts to get closer to how clients are actually processing and utilizing therapy. Models of how clients process information can also be utilized to explore how they contribute to change. Examples include Stiles and colleagues' assimilation of problematic experiences approach (e.g., Stiles, 2002), the “innovative moments” approach (e.g., Gonçalves, Ribeiro, et al., 2010), and the task analytic approach of Greenberg, Elliott, and colleagues (e.g., Greenberg, Rice, & Elliott, 1993).
Traditionally psychotherapy theory has focused on the idea of the client as someone whose dysfunctionality gets in the way of therapy. Certainly there is evidence for this. However, the assumption that clients are active co-constructors of a positive process may lead to new insights. For instance, one of us (Amy Wade) has observed that many clients seem to have an order and purpose in the material they present. Just at the time where the therapist feels stuck about what to do next, clients may volunteer information that is relevant and that helps the therapy move along in the proper direction. Some clients seem to have this intuitiveness, whereas others do not. Insight processes can be dependent on clients volunteering just the right information that allows clinicians to make connections so that they can offer up a brilliant insight. Observations such as these, if validated by research, may help therapists find new ways of helping.
A key way that therapists therefore can be responsive to clients' therapy-enhancing activities is to first become aware of what these processes look like. The more the research literature identifies specific client contributions in facilitating the change process, in response to and in interaction with what therapists are doing, and the more these contributions find their way into process measures, the more they can then be distinctly connected to successful (or unsuccessful) outcome. This can then find its way into the training of novice therapists.
The creation of precise and thorough conceptualizations of the change process will not evolve as long as researchers are focused on unidirectional theories of influence (i.e., therapist to client; Dorn, 1984) or easily observable but unimportant therapeutic phenomena (Hill & Corbett, 1993). However, slowly building a database that captures the variety of client processes, intentions, and experiences of therapy would serve as a reference point for the possibilities of productive therapeutic endeavors. Clinicians, clients, and researchers alike could refer to this database of “lived knowledge” as a way to recognize or even anticipate the potential influence the client is having on the therapy endeavor and respond accordingly (Polkinghorne, 1999). As the client's contribution is understood, then paired with the therapist's contribution, the truly dialogic aspects of therapy can be better accounted for.
There is an abundance of data that points to the crucial nature of client contributions to therapy outcome and yet it may be easier to return to researching what we know and what we can most readily control, that of technique, interventions, and therapist relational stances. We believe this would be a mistake. We urge researchers and clinicians alike to expand the comprehensiveness and complexity of research and theories linking process and outcome so as to include the dialogic interplay of client, therapist, theory, and technique.
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