NATURE OF SPECIFIC THERAPEUTIC VARIABLES:CLIENT’S MOTIVATION

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Clinical Psychology (PSY401)

LESSON 28

NATURE OF SPECIFIC THERAPEUTIC VARIABLES

It would be pleasant if psychotherapy were a simple routine in which the therapist makes a diagnosis,

conveys it to the patient, gives a lecture or two, and presto, the patient is cured. Unfortunately, things do not

work that way. Indeed, it is often necessary to spend considerable time correcting patients' expectations that

they will be given a simple psychological prescription. Because psychotherapy is an active, dynamic

process, passivity and lack of motivation can be obstacles. A number of factors involving the nature of the

patient, the therapist, and the patient-therapist interaction affect the process of therapy in important ways.

Often their effects are felt over and above the specific mode of therapy employed.

THE PATIENT OR THE CLIENT

Are there specific or general patient characteristics that influence the outcomes of therapy? Such a

deceptively simple question really has no answer other than "It depends." The reason is that the outcomes of

therapy are exceedingly complex events that are not shaped by patient characteristics alone. They are also

determined by therapist qualities and skills, the kinds of therapeutic procedures employed, the circum-

stances and environment of patients, and so on. Eventually, the field will have to identify specifically which

kinds of patients benefit from which procedures, under which circumstances, and by which therapists

Now we will discuss some of the more prominent patient's variables that have been related to outcomes in

traditional therapies.

1. The Degree of Patient's Distress

A broad generalization often made by clinicians is that the persons who need therapy the least are the

persons who will receive the greatest benefit from it. A good prognosis may be expected for a patient who

is experiencing distress or anxiety but is functioning well behaviorally.

At best, however, the research data are contradictory and inconsistent (which, again, probably reflects the

impossibility of coming to a simple conclusion without considering many other factors). For example, one

group of studies finds that greater initial distress is associated with greater improvement. Another group of

studies finds exactly the reverse. To complicate matters further, Miller and Gross (1973) contend that the

relationship between improvement and the initial disturbance is curvilinear; that is, patients with little

disturbance or extreme disturbance show poorer outcomes than do moderately disturbed patients.

Summarizing research in this area, Garfield (1994) concludes that, although mixed findings across studies

temper one's degree of confidence in general conclusions, more recent studies seem to find with some

consistency that individuals who are more severely disturbed have poorer outcomes. Intelligence. In

general, psychotherapy requires a reasonable level of intelligence (Garfield, 1994). This is not to say that

persons who suffer from mental retardation do not, under certain conditions, benefit from counseling or

from the opportunity to talk about their difficulties. Nevertheless, other things being equal, brighter indi-

viduals seem better able to handle the demands of psychotherapy. This is so for several reasons.

First, psychotherapy is a verbal process. It requires patients to articulate their problems, to frame them in

words.

Second, psychotherapy requires patients to establish connections among events. Patients must have the

capacity to see relationships between prior events and current problems, and ultimately they must be able to

connect their current feelings with a variety of events whose relationship to those feelings may at first seem

improbable.

Finally, to enable connections among events to be made, psychotherapy requires a degree of introspection.

Since traditional psychotherapy has always emphasized the inner determinants of behavior, it follows that a

patient who finds it difficult to look inward may have problems in adjusting to the process.

However, behavioral forms of therapy have often been used with considerable success with individuals

suffering from cognitive limitations. A variety of behavior modification approaches are quite feasible,

especially when goals involve specific behavioral changes rather than insight. In such populations,

improved social abilities, self-care skills, and other skills can be developed with a focus on behavior rather

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than cognitions. As a generalization, when behavioral deficits are the problem, behavioral techniques are

frequently the preferred ones.

2. CLIENT'S AGE:

Other things being equal, younger patients have long been considered the best bets for therapy. Younger

patients are presumably more flexible or less "set in their ways." Perhaps younger patients are better able to

make the appropriate connections because they are closer to their childhood years, or perhaps they have

been reinforced for negative behaviors less often than their older counterparts. In any event, the notion that

younger persons do better in therapy is quite prevalent among clinicians. Research evidence supporting the

contention that older clients have a poorer prognosis, however, is weak at best.

It is best to consider not age alone, but rather the specific characteristics of the prospective patient. It often

happens that a 55-year-old will be an active, open, introspective person who can really benefit from therapy.

In short, denial of therapy to an elderly person can be construed as a form of ageism in some instances!

Research supports the efficacy of various forms of both cognitive-behavioral and psychodynamic treatment

with older adults.

CLIENT'S MOTIVATION

Psychotherapy is sometimes a lengthy process. It demands much from a patient. It can be fraught with

anxiety, setbacks, and periods of a seeming absence of progress. If psychotherapy is to be successful, it will

force the patient to examine comers of the mind that have long remained unscrutinized. It may demand that

the patient engage in new behaviors that will provoke anxiety. As was noted previously, psychotherapy is

not a passive process in which insights are fed to the patient. Instead, the patient must actively seek insights.

Typically, the search is not easy. For these and other reasons, successful psychotherapy seems to require

motivation.

At some level, the patient must want psychotherapy (though there are times during psychotherapy when

even highly motivated patients want out). It follows, then, that psychotherapy is a voluntary process. One

cannot be forced into it. When people are forced, either openly or subtly, to become patients, they rarely

profit from the experience. Therapy is not likely to be of much benefit to the prisoner who seeks therapy to

impress a parole board; to the college student who, following a marijuana charge, is given the option of

reporting to a counseling center or facing the prospect of jail; or to the person who undergoes therapy to

protect an insurance claim. Despite the conventional wisdom that cites client motivation as a necessary

condition for positive change, research support is mixed (Garfield, 1994).

4. CLIENT'S OPENNESS:

Most therapists intuitively attach a better prognosis to patients who seem to show some respect for and

optimism about the utility of psychotherapy. They are relieved when patients are willing to see their

problems in psychological rather than medical terms. Such per. sons can be more easily "taught to be good

psychotherapy patients," in contrast to patient who view their difficulties as symptoms that can be cured by

an omniscient, authoritative therapist while they passively await the outcome Thus, a kind of "openness" to

the therapeutic process appears to make the patient a better bet for therapy.

5. CLIENT'S GENDER:

In the present climate, there are several prominent issues related to gender. One is the relationship between

the outcomes of therapy and the gender of the patient. Research does not support the view that biological

sex of the client is significantly related to outcome in psychotherapy.

A second, more volatile issue is whether sexism operates in therapy and whether, for example, male

therapists exploit female patients .Stricker (1977) suggests that this issue offers serves as a platform for

extremists on both sides those at the feminist end of the spectrum claim exploitation, and the male

chauvinists deny that it exists. Research into the question of whether therapists and counselors are guilty of

gender bias and stereotyping is highly inconsistent. Many, however, are confident in suggesting that clinical

psychologists should do a better job of educating clinical students regarding gender issues). Good, Gilbert,

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and Scher (1990) have even recommended a brand of psychotherapy called Gender Aware Therapy

(GAT).

GAT integrates feminist psychotherapy and knowledge of gender into a treatment approach for both women

and men. This approach, which focuses on exploring unique gender-related experiences, may be

appropriate for- a variety of issues faced by women (such as career development and eating disorders) and

men (such as depression and sexual dysfunction). Finally, although sex of the client has not been reliably

linked to outcome, it is probably true that sex or gender of the therapist may be especially important to

consider in certain cases. For example, women rape victims may feel much more comfortable talking to

women psychotherapists than to men psychotherapists.

FEMINIST THERAPY:

For many years, therapy was a male-dominated enterprise. The special problems facing women were poorly

addressed and poorly understood by male therapists. New treatment models were needed to deal with the

disorders prevalent among women What was needed, many felt, was a feminist therapy-a therapy that

would recognize the manner in which women have been oppressed by society through the ages.

Feminist therapy grew out of the women's movement and has been quite visible since the early 1970s. It

acknowledges that many of the personal problems of women arise out of the social position women are

forced to adopt. It points to the failure of the psychiatric and psychological establishment to see the

oppression of women as a prime factor in their development of personal distress. The feminist approach

views the relationship between therapist and patient in terms of equality rather than power versus

subordination. Feminists, in short, do not take kindly to the "power of expertise." This form of therapy also

requires a frank admission of the values of both therapist and client and the development of specific

contracts with regard to the therapy process itself.

Feminist therapists tend to be especially attuned to specific emotional problems experienced by women:

anger and its expression, learned helplessness and depression, autonomy and dependency, and sexuality.

Also important are concrete issues such as work, finances, and family choices. Particularly critical are

issues of personal freedom and choice and a willingness to consider life alternatives that depart from tra-

ditional sex-role expectations.

6. Race, Ethnicity and Social Class:

For years, debate has raged over the effectiveness of therapy for ethnic minority patients-especially when

they are treated by white therapists. It does appear that many therapeutic techniques have been designed and

developed for white, middle and upper-class patients. Too few procedures seem to take into account the

particular cultural background and expectations of patients. Banks (1972) has suggested that greater rapport

and self-exploration may occur when both therapist and patient are of the same race. Others have reached

the same conclusion regarding social class, background, values, and experience and have proposed that

conventional therapies be abandoned in favor of more supportive techniques. Still, two decades of research

have seemingly failed to show conclusively that ethnic minorities achieve differential treatment outcomes.

It was Schofield (1964) who described the psychotherapist's belief in the ideal patient as the YAVIS

syndrome (young, attractive, verbal, intelligent, and successful). However, numerous reviews of existing

research have concluded that there appears to be virtually no relationship between social class and outcome

(Garfield, 1994).What has not been examined in great detail is whether patients and therapists should be

matched according to social class or whether some forms of psychotherapy are more effective than others

for patients from lower socioeconomic levels.

When there is a significant difference between the social class or the values of the patient and those of the

therapist, some researchers have found that the patient's willingness to remain in therapy may suffer. Some

have also suggested that traditional forms of therapy are inappropriate for patients from lower

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socioeconomic levels. Others, however, maintain that special efforts to build a therapeutic relationship can

overcome the difficulties encountered when therapist and patient differ in background.

Few would disagree; however, that cultural sensitivity on the part of the therapist is very important. The

field needs to develop culturally sensitive mental health services. Clinicians also need to develop a kind of

cognitive empathy, or what Scott and Borodovsky (1990) have referred to as cultural role taking in their

work with ethnic minorities. In the final analysis, it is imperative that clinical psychology develop culturally

sensitive therapists who can work effectively with culturally diverse populations

THERAPISTS REACTIONS TO PATIENTS:

In the best of all worlds, it would not make any difference whether or not the patient was an engaging

person who elicited positive responses from others. A therapist should be able to work with elegant

effectiveness regardless of her or his positive or negative reactions to the patient. Therapists are far from

perfect creatures; they are indeed affected by the personal qualities of other persons. Fortunately, the un-

derstanding and self-control of therapists in their professional relations with patients exceed the

understanding and self-control of many laypersons in their social and interpersonal relationships.

Nevertheless, there is some evidence to suggest that patients who receive higher global ratings of

attractiveness or to whom the therapist can relate better tend to have better outcomes in therapy (Garfield,

1994). Also, in at least one study, therapists were less inclined to treat hypothetical patients whom they did

not like as compared to those they liked.

THE THERAPIST'S CHARACTERISTICS:

It will hardly come as a shock to learn that certain therapist characteristics may affect the process of

therapy. Having a specific theoretical or therapeutic orientation does not override the role of personality,

warmth, or sensitivity. Freud very early recognized the potential effects of the psychoanalyst's personality

on the process of psychoanalysis. To "prevent" such personal factors from affecting the process, he

recommended that analysts undergo periodic analyses so that they could learn to recognize and control

them. In a sense, Rogers turned to the other side of the same coin and made therapist qualities such as

acceptance and warmth the cornerstones of therapy. Although Freud may have emphasized the negative and

Rogers the positive, they both set the stage for an understanding of the role of therapist variables in the

process of therapy. Unfortunately, although nearly everyone agrees that therapist variables are important,

there is much less agreement on specifics. How therapist characteristics contribute to therapy outcome has

become an important research area.

THERAPIST'S SEX, AGE AND ETHNICITY

In a recent comprehensive review of therapist features that may influence psychotherapy outcome, Beutler

et al. (1994) report that the available research evidence suggests that therapist age is not related to outcome,

that female versus male therapists do not appear to produce significantly better therapeutic effects, and that

patient-therapist similarity with regard to ethnicity does not necessarily result in better outcome. Beutler et

al. acknowledge that these conclusions may run counter to prevailing sociopolitical opinions. At the same

time, they assert that existing research in this area suffers from a number of methodological problems.

These therapist variables may interact with client characteristics, setting for treatment, and modality of

treatment. Again, the solution seems to be for therapists to become more sensitized to age, gender, and

racial identity issues in relation to themselves as well as to the patient.

THERAPIST'S PERSONALITY:

In discussing therapist variables, Strupp and Bergin (1969) made two points worth noting.

First, even though the evidence shows that the therapist's personality is a potent force; other factors in

combination largely determine therapy outcomes.

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Second, research in this area has taken a back seat as behavioral therapies have gained in popularity.

However, as behavior therapists attend increasingly to factors other than techniques or mechanics, it is

likely that they will "rediscover" the importance of therapist characteristics and begin to integrate those

characteristics into their research and practice.

Is there a set of personality traits that the "ideal" therapist should possess? Krasner (1963), with tongue in

cheek, suggested that the research literature would depict the ideal therapist as:

mature, well-adjusted, sympathetic, tolerant, patient, kindly, tactful, nonjudgmental, accepting, permissive,

non-critical, warm, likable, interested in human beings, respectful, cherishing and working for a democratic

kind of interpersonal relationship with all people, free of racial and religious bigotry, having a worthwhile

goal in life, friendly, encouraging, optimistic, strong, intelligent, wise, curious, creative, artistic,

scientifically oriented, competent, trustworthy, a model for the patient to follow, resourceful, emotionally

sensitive. Self-aware, insightful of his own problems. spontaneous, having a sense of humor, feeling

personally secure, growing and maturing with life's experiences, having a high frustration tolerance, self-

confident, relaxed, objective, self-analytic. aware of his own prejudices, humble, consistent, open, honest,

frank, technically sophisticated, professionally dedicated, and charming.

Certainly no human being, let alone a therapist, could possibly possess all of these traits (even allowing for

overlap in terms). Therefore, as Goldstein, Heller, and Sechrest (1966) point out, it is doubtful whether the

concept of the "ideal therapist" is very useful. Any study that is confined to a single trait or a small group of

traits seems to make a great deal of sense. Taking all the traits together makes the message much less

coherent.

EMPATHY, WARMTH AND GENUINENESS:

Swenson (1971) has suggested that a major factor that differentiates successful from unsuccessful therapists

is their interest in people and their commitment to the patient. In a similar vein, Brunink and Schroeder

(1979) found that expert therapists of several different theoretical persuasions were similar in their

communication of empathy.

The attention to empathy, along with the related notions of warmth and genuineness, grew out of Carl

Rogers' (1951) system of client-centered therapy: He described these variables as necessary and sufficient

conditions for 'therapeutic change (Rogers, 1957). Some research evidence has seemed to point to a

relationship between these three qualities and successful outcomes in therapy.

It has also been argued (Beutler et al., 1994; Gunman, 1977) that these three features reflect not only

qualities of the therapist but also qualities of the therapeutic relationship. Viewed this way, these features

can be considered indicators of the quality of the therapeutic alliance. Studies have consistently

demonstrated that the nature and strength of the working relationship between therapist and patient is a

major contributor to positive outcome (Beutler et al., 1994).

FREEDOM FROM PERSONAL PROBLEMS:

Does personal therapy lead to greater effectiveness as a therapist? In a survey of 749 practicing therapists

who were APA member, 44% responded regarding their own personal problems. Of this group, 18%

reported that they had never received any form of personal therapy .But more than 44% reported

experiencing personal distress in the past three years, and almost 37% said that it decreased the quality of

patient care, Further, out of 562 licensed psychologists, more than a third reported high levels of both

emotional exhaustion and depersonalization what is often called "burnout".

Although therapists need not be paragons of adjustment, it is unlikely that a therapist beset with emotional

problems can be as effective as one would like. It is important that therapists recognize areas in their own

lives that are tender. The tendency to become angry or anxious when certain topics arise or the inability to

handle a client's questions without becoming defensive is a signal that something is amiss. In short, self-

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awareness is an important quality in the therapist (I. B. Weiner, 1975). Therapists must be able to look at

their patients with objectivity and not become entangled in their personal dynamics. Nor is the therapy room

a place for the gratification of one's own emotional needs

In some instances, the therapist may find it necessary to undergo personal therapy in order to resolve

emotional problems. However, whether undergoing personal therapy makes the therapist more effective has

long been argued. Unfortunately, the actual research evidence (Beutler et al., 1994) is less than definitive.

This is not surprising when one considers the complexity of the therapy process. Nevertheless, it would not

seem necessary for all therapists to undergo treatment as a qualification for conducting therapy.

SEXUAL EXPLOITATION:

It is noticed in no uncertain terms that sexual intimacies between patient and therapist are to be condemned

unequivocally. Unfortunately, there are still too many examples of victimization of women by their male

therapists, and an increasing number of cases of women being victimized by female therapists. Many

questions about this kind of unnatural conduct, what kinds of behaviors are appropriate on the part of the

therapist, what patients should don in response, and with Whom they can lodge complaints have been dis-

cussed in Committee on Women in Psychology (1989). Too often, women do not complain to the proper

authorities because they lack knowledge about the complaint process. Suggestions are available, however,

to help women file complaints even the act of touching clients or other nonerotic physical contacts are

sensitive issues that need to be addressed in training programs and by ethics committees. One wonders

whose needs are been met by such contact.

THERAPIST'S EXPERIENCE AND PROFESSIONAL IDENTIFICATION:

Conventional wisdom suggests that the more experienced the psychotherapist, the more effective she or he

will be with patients. Although this is intuitively appealing the bulk of research evidence has not supported

this position. Not only does there appear to be a consistent relationship between therapist experience and

positive outcome, but several suggest that paraprofessionals trained specifically to conduct psychotherapy

produce outcomes equivalent to, or even sometimes exceeding those produced by trained psychotherapists.

Does one profession turn out better therapists than others? Over the years, there have been many running

feuds over which profession is best equipped to carry out proper therapy. For a longtime, psychiatrists

actively sought to prevent clinical psychologists from conducting therapy it, the absence of psychiatric

supervision. Their main argument was often reducible to one of medical omniscience and was never based

on solid research, and clinical psychologists gradually freed themselves from this psychiatric domination.

But old animosities and fights over territorial prerogatives fade slowly. Indeed, with, the availability of

federal funds to pay for health costs and with Insurance coverage being broadened to include

psychotherapy, economic competition has once again kindled these territorial fights between psychiatry and

clinical psychology.

In fact, no real evidence supports the argument that one profession boasts superior therapists (be they

clinical psychologists, psychiatric social workers. psychiatrists, or psychoanalysts). In the Consumer

Reports study "Mental Health," (1995), people who saw a mental health professional rather than a family

physician for their psychological problems reported greater progress and more satisfaction with their

treatment. However, psychologists, psychiatrists, and social workers all received similarly high satisfaction

ratings from consumers. Thus, at this point in time, data do not seem to support the superiority of one

mental health profession over others in terms of effectiveness and client satisfaction.

To this point, we have surveyed a variety of patient and therapist variables that are commonly assumed to

be related to outcome in psychotherapy. As noted in our discussion, many of these assumptions are

unsupported by psychotherapy research findings.

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