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Clients: The neglected common factor in psychotherapy

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Abstract

Professional discourse and practice have long privileged the position and point of view of the therapist. The time has come to spotlight the largest yet most neglected factor in treatment outcome: the client. Although experimental studies of client factors are few and far between and most research favors correlational, qualitative, and retrospective designs, a strong case emerges for the potency of the human client in successful psychotherapy. This chapter begins with a short survey of the potential for self-righting and self-healing. We then consider research regarding the client's role as an active contributor to the therapy process. We review data regarding the factors traditionally thought to account for the effectiveness of psychotherapy and offer an alternative account highlighting the importance of the client. The chapter concludes with the assertion that the client offers the best explanation for the dodo verdict as well as a discussion of the implications of a client-centered paradigm for psychotherapy practice, training, and the broader field of mental health. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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CLIENTS:
THE NEGLECTED COMMON
FACTOR IN PSYCHOTHERAPY
ARTHUR C
BOHART
AND
KAREN
TALLMAN
Facts don't
cease
to exist because they are ignored.
—Robert
Louis
Stevenson
Professional discoutse and practice have long ptivileged the position and
point of view ofthe therapist. In the "dtama" of therapy, clinicians restructure
clients' cognitions, extinguish fears, bring forth insight, unlock repressed
affects, help restore brain functioning, and loosen the bonds of familial terror.
Clients, in contrast, have nearly always played Nell Fenwick to the field's
Dudley Do-Rights, bound to the tracks of destruction by weak ego stmctutes,
regressive potential, borderline defenses, lack of skills, and other presumed
deficits. Thus, therapists "intervene," whereas clients "respond," or worse,
"resist" the heroic efforts ofthe helper (cf. Angus, 1992). Told in this way, it
is hard if not impossible to imagine a countemarrative, one in which the con-
sumer of thetapeutic services is more protagonist than
prop,
managing at least
some wotkable accommodations no matter how debilitating his ot het prob-
lems (Rosenbaum, 1996).
Yet the fact is that clients' active involvement in the therapeutic process
is
critical to
success.
Indeed, in a comprehensive review of 50 years of literature
on the subject for the fifth edition ofthe Handbook of Psychotherapy and Behav-
ior Change, Orlinsky, R0nnestad, and Willutzki (2004) stated, "the quality of
the patient's participation . . . [emerges] as the most [italics added] important
83
determinant of
outcome"
(p. 324)—more so than therapist attitudes, behav-
iors,
or techniques. The authors identified 11 additional variables linked to
outcome. These included the following
10:
client suitability, client cooperation
versus resistance, client experience ofthe therapeutic bond, client contribution
to the bond, client interactive collaboration, client expressiveness, client affir-
mation ofthe therapist, client openness versus defensiveness, therapeutic real-
izations (clients' in-session impacts of therapy
events),
and treatment duration.
Note the number of factors that are directly related to the client.
Furthetmore, the client and factors in the client's life account fot more
variance in therapeutic outcome than any othet factor. Asay and Lambert
(1999),
on the basis of their assessment of the literature, portioned 40% of
variance of outcome to the client and to factors in his or her life. Wampold's
(2001) meta-analysis suggests that about 13% of total outcome variance is
explained by treatment (therapist, alliance, model or technique, allegiance,
and placebo), leaving 87% ofthe variance attributed to client or extrathera-
peutic factors as well as unexplained and error variance. It is not unreason-
able to suppose that a substantial portion of the unexplained variance is due
to the client.
Years ago, researchers Bergin and Garfield (1994) called for a reforma-
tion in psychotherapy. Aftet teviewing the evidence, they challenged practi-
tioners and theoreticians to think anew:
Clients are not inert objects upon which techniques are adminis-
tered. ... [Therefore] it is important to rethink the terminology that
assumes
that "effects"
are like
Aristotelian impetus
causality.
As
therapists
have depended more upon the client's resources, more change seems to occur
[italics
added],
(pp. 825-826)
Although this call is finally beginning to be heeded, client contributions to
therapy continue to be neglected in most theoretical models of
change,
with
a few exceptions (cf. Bohart & Tallman, 1999; Duncan, Miller, & Sparks,
2004;
Duncan & Moynihan, 1994). The therapist and his or her techniques
are still seen as the primary curative factors. This emphasis on the primacy of
techniques has unfortunately intensified as the proposition of evidence-based
practice has risen in popularity.
Once more, the time has come to set the story straight, to spotlight the
largest yet most neglected factor in treatment outcome: the client. Although
experimental studies of client factors are few and far between and most research
favors correlational, qualitative, and retrospective
designs,
a
strong
case
emerges
for the potency ofthe human client in successful psychotherapy. This chapter
begins with a short survey ofthe potential fot self-righting and self-healing. We
then consider research regarding the client's role
as
an active contributor to the
therapy process. We review data regarding the factors traditionally thought to
account for the effectiveness of psychotherapy and offer an alternative account
84 BOHART AND TALLMAN
highlighting the importance of the client. The chapter concludes with the
assertion that the client offers the best explanation for the dodo vetdict as
well
as
a discussion ofthe implications of
a
client-centered paradigm for psycho-
therapy practice, training, and the broader field of mental health.
HUMAN POTENTIAL FOR CHANGE
Research on the human potential for self-healing
is
considerable.
It comes
from several sources, including the following: (a) self-generated change and
spontaneous recovery, (b) placebo effects, (c) resilience and posttraumatic
growth, and (d) the corrective effects of self-expression or disclosure.
Self-Generated Change and Spontaneous Recovery
Studies have repeatedly demonstrated that people overcome significant
problems without the benefit of professional intervention. When asked, 90%
of individuals polled report having overcome a significant health, emotional,
addiction, ot lifestyle problem in the prior year (Gurin, 1990). Data provide
support for such self-reports, even for problems most view as extreme. For
instance, many individuals overcome problems considered chronic, such as
antisocial behavior (J. T. Tedeschi & Felson, 1994) and substance abuse.
About the latter, researchers Miller and Carroll (2006) noted, "Most people
who tecovet from drug problems do so on theit own, without fotmal tteat-
ment" (p. 295). Even the coutse fot people who receive personality diagnoses
is more benign than commonly believed. Most individuals diagnosed with
personality disorders improve over time (Perry, 1993; Skodol et al., 2007).
Zanatini, Ftankenbutg, Hennen, Reich, and Silk (2006) found that over a
10-year period, 88% of those diagnosed with borderline personality disorder
achieved remission. These studies are confounded because in many cases the
individuals studied had teceived some kind of treatment. Nonetheless, given
that peisonality disorders are conceived of as engrained, difficult to change
personality characteristics, this is encouraging. In this regard, Fonagy and
Bateman (2006) pointed out that the natural course of borderline personal-
ity disorder is more benign than previously believed and that the treatment
tesistance of people with this diagnosis may have mote to do with the iatro-
genic effects of therapy than with the condition
itself.
Prochaska (1999) studied how individuals overcome problems without
the aid of psychotherapy. People use the same methods and processes used in
therapy. As an illustration, though exposure is a common procedure used for
treating phobias and ttauma, the field of psychotherapy cannot lay exclusive
claim to it. The popularity ofthe old saying "If you are thrown off
a
hotse, get
CLIENTS: THE NEGLECTED COMMON FACTOR 85
back on" indicates that people have long understood the beneficial effects of
the method. Prochaska, Norcross, and DiClemente (1994) have made a com-
pelling case that all change is self-change: Therapy is simply self-change that
is professionally coached.
Additional support for the role ofthe client in the change process
is
pro-
vided by data on spontaneous recovery. Lambert, Shapiro, and Bergin (1986)
estimated that about
40%
of people recover without professional intervention.
Moreover, a strong endorsement of the impact of client resources is found in
the pretreatment change literature. Several studies have shown that 60% or
more of clients reported the occurrence of improvement in the period between
scheduling and attending theit first session (Lawson, 1994; Weiner-Davis,
de Shazer, & Gingerich, 1987). Finally, Miller and C'de Baca (2001) reported
a phenomenon they termed quantum change. This refers to the experience of
a sudden, significant personal transformation. Interviews with 55 individuals
in the Albuquerque, New Mexico, area led the authors to conclude that such
experiences were common—further testament to the human capacity fot
self-change.
Placebo Effects
Placebo effects, or the benefits resulting from the client's expectation that
treatment
will
help,
offet more evidence ofthe significant role that clients play.
In a
review
of 46 meta-analytic
studies,
for
example,
Grissom (1996) found that
the effect
size
(ES) of placebo conditions
was
0.44 compared with no-tteatment
control
groups.
In two ofthe largest
randomized
clinical trials ever conducted
the Treatment of Depression Collaborative Research Project (Elkin, 1994) and
the Collaborative Cocaine Treatment Study (Crits-Christoph et al., 1999)
participants in the placebo and minimal clinical management conditions
achieved outcomes roughly equivalent to those in psychotherapy. The strength
of such
findings
led Honos-Webb (2005) to conclude that placebo control and
minimal clinical management meet the criteria for classification as an empiri-
cally supported treatment.
Similarly, Kirsch et al.'s (2008) massive review of
all
studies about selec-
tive serotonin reuptake inhibitors (SSRIs) submitted to the Federal Drug
Administration reported comparable results of SSRIs and placebos, with diffet-
ences found between SSRIs and placebos only for the most severely depressed
clients, and even these differences were small (Kirsch et al., 2008). The simi-
larity of results between sugar pills and SSRIs suggests that change is far more
about the individual and his or her expectations regarding change than the
treatment provided. One way of undetstanding the placebo phenomena
is
that
the client's expectation for change stimulates innate self-healing capabilities;
in other words, the placebo effect represents the client's personal agency in
86 BOHART AND TALLMAN
action. Considet also that when active placebos, which mimic the side effects
of the experimental drug, are used, no differences between drug and placebo
conditions emerge (see chap. 7, this volume). It
is
thought that side effects sig-
nal that a powerful drug has been ingested, heightening expectations and
releasing client's regenerative processes. Going one step further, techniques in
psychotherapy may be also viewed as active placebos that similarly initiate
client self-healing. The consistency ofthe placebo effect demands that it should
no longer be denigrated. More attention might be paid to understanding its
potency in mobilizing and supporting clients' innate, self-curative processes.
Resilience and Posttraumatic Growth
Evidence regarding human resilience provides extra support for the
human potential for self-healing (Bonanno, 2004). For instance, being exposed
to trauma does not necessarily cause posttraumatic stress disorder. Ozer, Best,
Lipsey, and Weiss (2003) noted that "roughly 50%-60% of the U.S. popu-
lation is exposed to traumatic stress but only 5%-10% develop PTSD [post-
traumatic stress
disorder]"
(p. 54). In theit literature review, Masten, Best, and
Garmazy (1990) concluded, "studies of psychosocial resilience support the
view that human psychological development is highly buffered and
self-
righting" (p. 438). A good example
is
found in a longitudinal study conducted
by Vaillant (1993) of 456 men. Though all were regarded as broken beyond
repair at age 25, most self-righted. Approximately 64% were rated in the top
25%
of mental health by the time they had entered theit 60s. So compelling
are the data that Masten (2001) posited that resilience
is
"a common phenom-
enon ... development is robust even in the face of
severe
adversity" (p. 227).
Petsonal factors do play a
role,
such
as
the person's temperament and dis-
position, intelligence quotient, and level of self-esteem. Environmental fac-
tors such as the presence of a good social support network, a mentor, a role
model, or even a therapist are also important. Yet, even children without good
environmental buffering often show some resilience (Masten, 2001). Similar
results are found in the literature on recovery from traumatic life events. R. G.
Tedeschi, Park, and Calhoun (1998) reported, for instance, that 40%-60% of
people who suffer a trauma recover on their own or report personal growth
following the experience. Such changes include positive self-perception,
improved sense of personal strengths, and better interpersonal relationships
(Calhoun & Tedeschi, 2006).
Corrective Effects of Self-Expression or Disclosure
Added support for human resilience comes from research on the bene-
ficial effects of both self-exptession and disclosure. Several studies have
CLIENTS: THE NEGLECTED COMMON FACTOR 87
shown that writing or discussing a troubling or traumatic event facilitates
healing (Harvey, Orbuch, Chwalisz, & Garwood, 1991; Hemenover,
2003;
Pennebaker, 1997). In one, Segal and Murray (1994) wrote that giving indi-
viduals an opportunity to talk into a tape recorder worked about as well as
cognitive therapy in managing traumatic expetiences.
In
sum,
as this brief survey shows—encompassing spontaneous recovery,
self-generated change, placebo effects, resilience, posttraumatic growth, and
the corrective effects of self-expression and disclosure—humans have a good
deal of potential for righting themselves when struck by adversity.
THE CLIENT'S CONTRIBUTION TO
THE EFFICACY OF PSYCHOTHERAPY
Additional substantiation of the defining role that clients play in ther-
apy is found in research supporting client (a) involvement and patticipation;
(b) perceptions of psychotherapy; (c) agency, activity, reflexivity, and cre-
ativity; (d) integration of therapy experiences into everyday life; and (e) early
change.
Client Involvement and Participation
Recall Orlinsky et al.'s (2004) review of therapeutic process and treat-
ment outcome. They concluded that the quality ofthe client's participation is
"most detetminant of outcome" (p. 324). Client participation encompasses
openness and willingness to engage in the tasks of psychotherapy, cooperative
involvement, and a collaborative versus dependent disposition. In each case,
the majority of studies show a positive relationship with success in therapy.
Client Perception of Psychotherapy
Historically, client perceptions of the therapist and therapy were consid-
ered suspect, distorted by psychopathology. The data show otherwise. As an
example, the client's perception of the therapeutic relationship has been con-
sistently found to correlate more highly with outcome than the therapist's
(Busseri & Tyler, 2004; Zuroff et al., 2000). On a related note, research has
shown that client ratings of therapist empathy and the collaborative nature of
the relationship correlate
as,
or more highly, with outcome than
ratings by
ther-
apists and objective observers (Bohart, Elliott, Greenberg,
&.
Watson, 2002).
Similarly, Levitt and Rennie (2004) reported that when therapists and
clients looked at tapes of their interactions, the perspectives of the therapists
and clients only partially ovetlapped. They noted, "Three stoties may
be
occut-
88 BOHART AND TALLMAN
ring at
once:
the stoty ofthe dialogue between the client and the therapist, the
client's inner story, and the therapist's inner story" (p. 308). Others have also
reported only a modest relationship between the clients' and therapists' views
of the therapy process (Elliott et al., 1994; Rosenbaum & Talmon, 2006).
Combine these two findings—that clients perception ofthe therapy rela-
tionship predicts outcome and that clients perceive therapy differently than
do therapists—and the implication emetges that clients select from therapy
what they need to get better. For instance, Mackrill (2008) had clients keep
diaries on theit experiences both inside and outside of
therapy.
He found that
clients were highly active in integrating their therapy expetiences in their own
ways into their everyday
lives.
As an example, one client focused on the impor-
tance of positive thinking before starting therapy. Later in therapy, the client
interpreted what
was
happening in terms of learning to use positive thinking.
Positive thinking was not one of the therapist's goals. Clients, apparently,
entet thetapy with theit own ideas about what they need (Philips, Werbart,
Wennberg, & Schubert, 2007), and these ideas influence how they construe
and use what therapists offer (Hubble, Duncan, & Miller, 1999). Similarly,
Bohart and Boyd (1997) established that clients perceived empathic responses
from therapists as supportive, if they felt in need of support, and as insightful,
when insight was needed.
Client Agency, Activity, Reflexivity, and Creativity
Clients, therefore, are anything but passive recipients of therapeutic wis-
dom. On the contrary, they continuously evaluate what is happening in ther-
apy and then actively work to arrange events to suit their purposes. Hoemer
(2007) found that clients perceive themselves
as
agentic, valued their own con-
tributions to the process, and attributed the results to their efforts. Consider a
classic study conducted by Garfinkel (1967). Participants posed problems to a
therapist whose responses were limited to a simple yes or no answer. In a wrin-
kle sure to be rejected
by
any modem institutional review board, the therapists'
answers to the queries were entirely random. Despite this less than helpful
experimental condition, participants pieced togethet cohetent accounts of
their experience and derived solutions to their presenting problems.
Since Garfinkel's research, qualitative studies (Levitt, 2004; Levitt &
Rennie, 2004; Rennie, 2000) have shown that clients are highly active, albeit
often at a covert level, during sessions. This literature indicates that clients
often enter therapy with a plan and work to steer
sessions
in directions that they
perceive will be beneficial. They even redirect theit therapist if he or she is off
course. Greaves (2006) found in het study of
13
clients, that
the
clients
exhibited initiative and engaged
in
meaning-making
processes
to make sense
of their difficulties, redefine and remoralize
themselves,
and
CLIENTS: THE NEGLECTED COMMON FACTOR 89
try
out
new ways
of
being.
Not
only did
they act
in
planning and manage-
ment
capacities,
they
also played the role
of truth-seeker, motivator, advo-
cator, and negotiator to further the pursuit and attainment of their
goals.
They blended their own wisdom with their therapist's expertise in idio-
syncratic
ways,
after having prepared their therapist to potentially offer
the
most
appropriate
assistance.
These clients
also
nurtured
a strong
thera-
peutic relationship and utilized learning and healing opportunities within
the context of that relationship, (p. xii)
Research shows, too, that clients tework therapeutic blundets in ways that
enhance therapeutic success (Levitt, 2004; Levitt
&.
Rennie, 2004; Tallman,
Robinson, Kay, Harvey, & Bohart, 1994).
Closely related to agency, activity, and reflexivity is client creativity.
Although tately examined, much of the evidence cited previously supports
the role that client creativity plays in successful outcome. How else can one
explain clients using therapeutic errors to positive effect? It
is
as though clients
give their therapists the benefit of the doubt. In short, they want their thera-
pists to be successful; the therapists' success means their
success.
Most practic-
ing clinicians have also experienced what Talmon (1990) found in interviews
with former clients. He noted that many "reported following suggestions that
I could not remember having made. They created theit own interpretations,
which were sometimes quite different from what I recollected and sometimes
more creative and suitable versions of
my
suggestions" (p. 60). More directly,
Selby's (2004) qualitative analysis showed that half of clients exhibited
creativity ot inventiveness that both altered the direction and facilitated
the success of therapy.
How Clients Relate Therapy to Their Everyday Lives
As Mackrill (2008) observed, we do not know much about how clients
actually integrate their therapy experiences with everyday life. Dreier (2000),
on the basis of his studies of family therapy, concluded that therapy does not
take place primarily in the therapist's office. Clients actively transform what
they have learned in therapy and apply it to their life situations. "Clients con-
figure the meaning of therapy within the structure of their ongoing social prac-
tice"
(Dreier, 2000, p. 253).
For
example,
Moertl (2007) found that clients talked over their
day
treat-
ment experiences with friends and family and reflected on these clinic experi-
ences while at home. Clients also participate in activities such as reading
self-help books, reflecting and self-questioning, thinking about dialogues with
the therapist, or allowing time before or after the session to prepare (Levitt,
Butler, & Hill, 2006). Conversely, Moertl (2007) found that clients also trans-
ferred experiences from everyday life into the day clinic. For instance, they
90 BOHART AND TALLMAN
compared theit relationships at home with relationships at the clinic, using
strategies at the clinic that were effective at home. Mackrill (2008) had
clients keep diaries and found that they actively learned through their own
efforts of integrating information gleaned from their own experiments,
friends, movies, clairvoyants, television, and other outside sources of ideas
with what they were learning in therapy. Finally, Kuhnlein (1999) inter-
viewed 49 clients who had received cognitive-behavior therapy and found
that participants did not blindly adopt what was presented in therapy.
Instead, they took what they found useful and combined it with their own
previously existing schemas.
Early Change
One significant bit of evidence fot the importance of the client's contri-
bution and resources to success in psychotherapy can be found in the emetg-
ing evidence fot early change (e.g., Brown, Burlingame, Lamberg, Jones, &
Vaccaro,
2001;
Howard, Kopta, Krause, & Orlinsky,
1986).
Consider the clas-
sic Howard et al. (1986) article on the dose-effect relationship: First, 30% of
clients, now called early responders, improved by the second session; 60% to
65%
of people experienced significant symptomatic relief within one to seven
visits,
which increased to 70% to 75% after 6 months and to 85% at 1 year.
Now consider, as an example, that in 1986, one of the most prevalent orien-
tations of therapists was psychodynamic, which traditionally views change in
tetms of years rather than weeks. The majority of clients in Howard et al.'s
study achieved change duting the very preliminary stages of therapy, perhaps
even before, according to the model, the transference relationship
was
set and
therapy had really begun. The point, that these eatly changes occutred
before the major mechanisms of
a
theoretical approach had time to become
operative, can also be made about other orientations (Snyder, Michael, &
Cheavens, 1999).
Not all clients are early responders. In fact, different clients follow differ-
ent change trajectories (Stulz, Lutz, Leach, Lucock, & Batkham, 2007). How-
ever, the fact that eatly change is so common reinforces the idea that clients
and their resources frequently are more responsible for change in therapy than
therapists' models, techniques, and theoties. Why not all clients are early
responders and what to do about that is an important issue and awaits fiitthet
investigation.
In a related finding, the best predictor of change appears to be higher
levels of distress at the start of therapy, more so than the client's diagnosis,
chronicity ofthe problem, or the treatment population (Brown et al., 2001).
On the other hand, others have reported that clients who are rated as more
functionally impaired, who are diagnosed with personality disorders, or who
CLIENTS: THE NEGLECTED COMMON FACTOR 91
have had poor early relationships with caregivers do more poorly in therapy
than those without these histories (Castonguay
&.
Beutlet, 2006).
It is not clear what these findings mean or how to reconcile them. Do
diagnoses of functional impairment, personality disorder, and early relationship
issues imply that clients are so impaired that they are robbed of a capacity to
engage in proactive self-healing efforts? Are there clients who lack the capac-
ity for self-healing? Not necessarily. The fact that higher levels of distress are
the best predictot of outcome suggests that being motivated to get involved in
therapy may be more important than hypothesized personal deficits. At the
same time, it may be that long-engrained patterns of behavior may make
change more difficult. It may also be that therapy administered in the studies
of client impairment was not what was needed to support these clients'
self-
healing efforts. Finally, it may also be that some clients elicit negative therapist
relationship behaviors that in turn interfere with their ability to make use of
the therapy environment (see chap. 4, this volume). Further research and
analysis is needed. The fact remains that many clients respond positively very
quickly in therapy, before most models of psychotherapy would predict. This
only makes sense if it is the client who is driving the bus and the therapist and
treatment approach are but passengets on the ride to change.
In
sum,
available evidence shows that clients are not dependent variables
on which the independent variable of therapy operates. Far from it; they are
active, generative agents, working to get what they want and need, protecting
themselves when needed, and even supporting the therapist when they deem
it necessary. Clients modify old concepts and use their revisions, create new
concepts, think of alternatives, and integrate what they learn.
EVALUATION OF THE TRADITIONAL
MODEL OF PSYCHOTHERAPY
The traditional model, patterned after physicians' treatment of physical
diseases, holds that specific interventions are needed for the treatment of spe-
cific
disorders.
In this worldview, the therapist, an expert, diagnoses the client's
problem and then chooses and delivers the appropriate intervention. In com-
bination, therapist expertise and the technique itself
are
considered the forces
behind successful psychotherapy.
Traditional beliefs notwithstanding, the empirical evidence does not
support this view of the factors responsible for the efficacy of psychotherapy.
First, as Wampold argues in chapter 2 of this volume, all bona fide thera-
peutic approaches work about equally well, regardless of diagnosis. Second,
research also challenges the importance of technique. Indeed, estimates
based on meta-analytic studies have shown that specific techniques or models
92 BOHART AND TALLMAN
of therapy contribute little to thetapeutic success. Fot instance, Wampold
(2001) attributed
13%
of variance in outcome to treatment, and of that, only
about 8% is due to techniques; in othet
words,
ofthe total vatiance of change,
model differences account fot but 1% ofthe variance (ot an ES of
0.20).
In a
review for the fifth edition of the Handbook of Psychotherapy and Behavior
Change, Beutler et al. (2004) reported correlations ranging from 0 to .11
between specific techniques and outcome.
These data fit with what clients say about therapy. Even when prompted,
clients rarely mention particular techniques when asked to reflect on the help-
ful aspects of psychotherapy. In an analysis of client interviews, for example,
Levitt (2004) found that clients did not focus on ot even recall specific inter-
ventions. They did attend to the tenot ofthe therapeutic relationship and new
insights they achieved. Instead of procedures, studies have consistently shown
that clients emphasize (a) feeling understood, accepted, and being heard;
(b) having a safe space to explore feelings, thoughts, behaviors, and experi-
ences;
(c) support for dealing with
crises;
(d) support fot trying out new behav-
iors;
and (e) advice (e.g., Cullari, 2000; Elliott &
James,
1989; Kagan, Angus,
&
Pos,
2007;
Levitt et
al.,
2006;
Rodgers,
2003;
Timulak,
2007;
Westra, Angus,
& Stala, 2007). Specific activities such as therapist confrontation ofthe client
(Moertl, 2007; Werbart & Johannson, 2007), doing practical exercises (Levitt
et
al.,
2006;
Von Below & Werbart, 2007), and getting tools and strategies from
their therapists (Carey et al., 2007; Timulak, 2007) are sometimes mentioned,
but they are not emphasized as often as factors such as feeling understood.
Two additional sources of evidence undermine conventional beliefs
regarding the importance of the therapist's expertise and technique. First,
although therapists have been shown to exert significant effects on success,
the field has struggled to provide any consistent evidence that professional
training, experience, discipline, licensure, or certification impacts outcome
(Beutler et al., 2004; Chtistensen & Jacobson, 1994; Horvath & Bedi, 2002;
Najavits & Strupp, 1994; Wampold, 2006). Second, although considerable
research has supported the contribution of the therapeutic relationship to
improvement, there is evidence that neithet a therapist nor thetapeutic rela-
tionship ate necessary for change to occur.
On this score, Norcross (2006) reviewed research on self-help books and
programs, and reported effects as strong as, or almost as strong as, those deliv-
ered
by
a therapist. These results have been supported
by
meta-analyses (Gould
& Clum,
1993;
Gregory, Canning, Lee, & Wise, 2004). For instance, Gregory
et al. (2004) found an ES of 0.77 for bibliotherapy and concluded that that
"compares favorably with data from studies of individual psychotherapy"
(p.
277). In one representative study, Jacobs et al. (2001) found that a simple
form of computer-assisted thetapy produced ovetall outcomes equivalent to
those provided by a therapist, although thete was more clinically significant
CLIENTS: THE NEGLECTED COMMON FACTOR 93
change in the group of clients who saw therapists. The computer program
prompted clients to think about what they wanted and how to obtain it. Clients
in these studies presented with a wide range of problems, including depression,
anxiety, and substance abuse.
However, a recent meta-analysis of studies for depression and anxiety
suggested that therapy with professional therapists does better than self-help.
Menchola, Arkowitz, and Burke (2007) found that compared with control
groups, self-help had an
ES
of 1.0. This
is
a large
ES
and comparable with those
found for psychotherapy in other research reports
(e.g.,
Wampold, 2001). How-
ever, the
ES
fot professionally provided psychotherapy compared with self-help
was
0.31.
This suggests that therapy does provide something over and above
self-help. It is important to note, though, that although the 0.31 difference
between the self-help and psychotherapy ES was statistically significant, it is
small compared with the large effect of self-help. Furthermore, the 0.31 differ-
ence is less than the difference of 0.4 considered necessary to be of clinical sig-
nificance (e.g., Elliott, Greenberg, & Lietaer, 2004). Overall, the data support
the conclusion that self-help
is
as effective or almost
as
effective
as
psychother-
apy for many disorders, again supporting the significant role of the client in
therapeutic change.
THE CLIENT AS ACTIVE SELF-HEALER: CONCLUSIONS
Although the research may appear at times to be a potpourri of findings
from unrelated research areas, it is important to recognize that investigating
client factors is not easy and is hampered by largely ex post facto analysis and
nonexperimental designs. Nevertheless, evidence from multiple sources con-
verges to make a convincing case for client centrality in clinical change, pro-
viding a parsimonious explanation of why all bona fide approaches to therapy
work about equally well and self-help procedures nearly
as
well
as
professional-
provided therapy.
In short, it is the client, more so than the therapist or technique, who
makes therapy
work.
The client's abilities to use whatever
is
offered surpass any
differences that might exist in techniques ot approaches. Clients use and
tailor what each approach provides to address their
problems.
Thus, for exam-
ple,
a client can use cognitive, interpersonal, or antidepressant therapies
(Elkin, 1994); emotional exploration procedures; or empathically based
client-centered therapy (Greenberg & Watson, 1998) to move him- or
herself out of depression.
We have argued (Bohart, 2000; Bohart & Tallman, 1999; Tallman &
Bohart, 1999; cf. also Duncan et al., 2004) that these findings call for a new
paradigm, one that takes as its central assumption that it is clients who make
94 BOHART AND TALLMAN
therapy work. Clients are not submissive recipients of an intervention. They
actively operate on therapists' inputs, transforming bits and pieces of the
process into information and experiences which, in turn, are used to make
change occur. Their effort, involvement, intelligence, and creativity enable
them to accommodate and metabolize different therapeutic approaches and
achieve positive outcomes. In other words, clients are the common factor
across varying forms of psychotherapy. Such a view is not meant to minimize
the importance of therapists. Clearly, clients come to thetapy because they
have not been successful resolving problems with the resources available to
them. Clients need support and, often, some kind of useful structure that they
can use to resolve their problems (see chap. 5, this volume). Instead of tech-
nical know-how, the therapist helps primarily by supporting, nurturing, or
guiding and structuring the client's self-change efforts. This may include the
suggestion of techniques.
IMPLICATIONS
Viewing the client as the common factor has immediate implications
for clinical practice, training, and the field at large.
Implications for Clinical Practice
Therapists should enlist and promote client
strengths,
resources, and personal
agency.
Perhaps the single largest implication of the view of the client as the
active self-healet
is
that therapists should rely more heavily on client resources
and strengths. Consider a study by Gassman and Grawe (2006). They con-
ducted minute-by-minute analyses of 120 sessions involving 30 clients treated
for a range of psychological problems. They found that unsuccessful therapists
focused on problems but neglected client strengths. When the unsuccessful
therapists did focus on clients' strengths, they did so more at the end of a ther-
apy session. Successful therapists focused on their clients' strengths from the
very start of an appointment. Gassman and Grawe (2006) concluded that suc-
cessful therapists "created an environment in which the patient felt he
was
pet-
ceived
as a
well functioning person. As soon
as
this
was
established, productive
work on the patient's problems was more likely" (p. 10).
Strength-based approaches are increasingly becoming a part of many psy-
chotherapies. It has always been a part of
some,
such as Duncan, Solovey, and
Rusk's (1992) client-directed approach, the solution-focused approach (e.g.,
Berg
& Miller, 1992), narrative therapies
(e.g.,
Anderson & Gehart, 2006), and
person-centered therapy (Bohart,
2007).
No matter the therapy, recruiting and
CLIENTS: THE NEGLECTED COMMON FACTOR 95
promoting client strengths means, at times, tapping into resources and abilities
of which clients may not be aware. Therapists can note and then share such dis-
coveries with clients. An aspect of this work is finding strength in seemingly
dysfunctional behaviors (Honos-Webb, 2005,2006; Mosher, Hendrix, & Fort,
2004) and recognizing that clients' identities and innate abilities transcend
descriptions of pathology (Duncan et al., 2004).
Therapists should believe that clients are motivated and capable of proactive
change.
There is no such thing as an unmotivated client. His or her motivations
might not match the therapist's, but clients are indeed driven by personal
desires. Understanding and honoring those motivations is ctitical to client-
centered clinical work. Several authors have suggested that there is even some
underlying sense or positive rationale underlying negative, self-defeating, or
dysfunctional patterns of behavior (Linehan, 1997; Miller & Rollnick, 2002).
This underlying sense or rationale is often implicit. Recognizing that this sense
exists and then helping clients access and unpack the implicit meanings
involved can help them mobilize positive motivation for change. As Cantor
(2003) noted,
What observers of human behavior often lose sight of are the alternative
routes that different individuals take toward personally fulfilling ends. By
focusing on the process of working on
goals,
how individuals
see
their tasks,
what they are trying to do, what kinds of social supports they mobilize in
the process—it is often possible to see meaning and positive purpose in
what may appear to an observer to be at best unnecessary or at worst
self-
defeating behavior, (p. 52)
Moreover, and in concert with embracing the client's motivations fof
change, therapists should also believe in the client's innate ability to change.
Too many pathology-based prognostications about clients pervade the field.
It would seem that a field dedicated to helping people change would believe
that change is not only possible but probable. Believing in the client's propen-
sities for change seems to follow the data presented in this chapter. Given the
amount of variance accounted for by the client relative to models, allegiance
to this belief is pethaps more important that any commitment to a given
approach.
Therapists should promote client involvement: Psychotherapy is a collabora-
tive endeavor.
As Orlinsky et al.'s (2004) review makes clear, psychotherapy is most
effective when it nurtures and supports maximum client involvement and par-
ticipation. Therapists facilitate client involvement by providing an atmos-
phere in which clients can be open, participate, test ideas, and make mistakes.
Bachelor, Laverdiere, Gamache, and Bordeleau (2007) found that the major-
96
BOHART AND
TALLMAN
ity of clients (76%) could be classified as either active or mutual collaborators,
placing the primaty emphasis in treatment on their own efforts or on joint
involvement with the therapist. Thus, therapists are in line with the empiri-
cal evidence when they listen to clients, establish common ground, and work
together to forge solutions. Although some therapeutic models are more didac-
tic in nature than others, all can be pursued collaboratively.
Therapists should listen to clients and
privilege
their experience and ideas.
Therapists must listen in a different way to clients. Instead of hearing
pathology, they must also hear
strengths;
instead of deficits, they need to listen
to clients' experience; instead of seeing what they know, they must know (i.e.,
be aware of) what they
see.
Additionally, therapists must show clients that they
not only understand their experience, view ofthe problem, and potential solu-
tions,
but that they will
also
privilege those perspectives. Easier said than done;
therapists can demonstrate theit ptivilege of clients through careful listening,
attending to feedback (see chap. 8, this volume), and being willing to adjust
services to bettet fit clients' sensibilities. This includes identifying what clients
value and incorporating it into how they proceed.
Listening to clients also entails paying attention to research about what
clients say is important. Fot example, although insight is often maligned as
an insufficient condition for change, clients, the evidence indicates, value
attaining it (Levitt, 2004; Timulak, 2007; Westra et al., 2007). Werbart and
Johansson (2007) found that
people
in therapy viewed increased self-knowledge
as a positive change. Learning about patterns of behavior has also been shown
to be valued by clients (Moertl, 2007).
As
for
emotions,
research
has found that clients value being able to access,
accept, understand, experience, and
express
painful feelings (Kagan et al, 2007;
Werbart & Johansson,
2007;
Westra et
al.,
2007), although this
may be
culture-
specific to Euro-American cultures. Conversely, clients consider being unable
to "reach" their feelings or having trouble expressing them significant hin-
drances (Von Below & Werbart, 2007). Other helpful aspects of therapeutic
process reported by clients include the following: taking risks and trying out
new behaviors, sharing with others (Moertl, 2007; Werbart & Johannson,
2007),
gaining a sense of empowerment (Timulak, 2007), and developing
new strategies fot attaining goals (Moertl, 2007; Timulak, 2007; Werbart &
Johannson, 2007).
Regatding helpful therapist behaviors, research yet again points in the
direction of nonspecific factots. Clients have emphasized being understood,
accepted, and actively supported. These findings were corroborated in a study
(conducted and published by Psychology Today) of more than 2,200 clients
(Hatris Interactive, 2004). Using data gathered online and via telephonic sut-
vey,
researchers
found that clients considered listening skills (63%), peisonal-
ity (52%), personal connection (45%), and activity level (38%) as the most
CLIENTS: THE NEGLECTED COMMON FACTOR 97
essential qualities of a good clinician. Other studies have found that clients'
progress in treatment is hindered when therapists (a) make hurtful remarks;
(b) are authoritarian; (c) do not listen; (d) remain silent, distant, or unrespon-
sive;
(e) refuse to
give
advice, ideas, or practical
exercises;
(0 differ significantly
from the client in personality; and (g) are distant and untrustworthy (Conrad
& Auckenthaler, 2007; Von Below & Werbart, 2007). In all, research about
client preferences suggests that clients want a safe space to talk with someone
who will listen and appreciate what they think is important. Is that too much
to ask?
Implications for Training
Train therapists to value clients: their strengths, resources, ideas, and propen-
sity for self-healing.
Therapists in training should be encouraged to do the following:
Begin with the assumption that clients make therapy work
that clients are both resilient and reasonable, but stuck in a
dif-
ficult situation.
Take seriously the client's perspective on the problem and
honor that petspective. Encourage clients to understand that
there are multiply correct points of view. Certainly no one
point of view offeted by approaches to psychotherapy can be
said to be "the" correct one.
Expect clients will get better, and believe that therapy works
and that the person sitting across from them will change.
Trainees can gain confidence in knowing this by tracking client
progress via outcome measures and making notes of the new
skills,
ideas, goals, and insights clients mention each week.
Support the clients' efforts so they can leave thetapy and be
effective problem solvers on their own. Allow clients to origi-
nate some of the solutions.
Train therapists to listen; listening
is
an art.
Therapists in ttaining should be taught the following:
Be
effective, supportive listeners instead of being diagnosticians
or interventionists. Diagnosis encourages an external petspec-
tive on the client as well as a view of the client as broken ot
damaged. The introduction to pathology and diagnosis should
be delayed until the therapist gains skills in relating to clients.
Instruction in the art of dialogue and the study of communica-
tion should be included before the introduction of models and
98 BOHART AND TALLMAN
techniques. Put models and techniques in their place—not dis-
counting them, but undetstanding their relative importance in
psychotherapeutic change. Use a collaboration metaphot for
therapy rather than the widely accepted advetsarial, often com-
bative, metaphor. It is not "us" against "them" or even "us"
against the problem or pathology. It is both the therapist and
client in partnetship against the obstacles the client views in his
or her life.
Value the power of
listening.
Beginning therapists should prac-
tice their listening skills in triads, acting as the therapist, the
client, and the observer. As conversation unfolds and methods
of exploration ate tiled, trainees learn to evaluate any given
position ot technique from multiple points of view. Fiisthand
experience of varied perspectives encourages flexibility and an
ongoing appreciation of diversity of
views.
Be
comfortable with
silence.
Silence
is
critical when the client is
thinking effectively, engaging in self-reflection, imagining new
possibilities, and consideiing changes.
Include client feedback in their understanding of their listening
and relational
skills.
It is the client's perceptions that make the
difference: You are not listening until the client says you are.
Implications for the Field
Abandon empirically supported treatments: Embrace the American Psycho-
logical Association's evidence-based practice.
The evidence-based practice (EBP) movement has become a central
component of health care policy and research over the past decade. In 1995,
Division 12 (Society of Clinical Psychology) within the American Psycholog-
ical Association (APA) formed the Task Force on the Promotion and Dissem-
ination of Psychological Procedures, with the stated objective of identifying
treatment approaches for which empirical evidence existed (Chambless &
Hollon,
1998;
Task Force on the Promotion and Dissemination of Psycholog-
ical Procedures, 1995). The criteria used by the committee to evaluate exist-
ing research were based on customary ideas about how psychotherapy works.
Thus,
all the approaches designated as empirically validated in the commit-
tee's otiginal report had been tested in a tandomized clinical tt ial using a treat-
ment manual and had focused on specific treatments for specific disorders.
However, if it
is
the client who ultimately (in collaboration with the ther-
apist) makes therapy work
by
how he or
she
uses the procedures and experiences
offered, then the empirically supported treatments approach is misguided
(Bohart,
2006).
The emphasis should be more on helping individual clients use
CLIENTS: THE NEGLECTED COMMON FACTOR 99
their own resources to change rather than on applying standardized treatment
packages. There is some movement in this direction.
In May
2006,
the APA Presidential Task
Force
on
EBP
published
a
revised
definition of
EBP
in psychology. Recognizing that the report ofthe prior Task
Force had been used
by
various government and commercial entities to mandate
the use ofthe approaches labeled
as
empirically supported, the committee moved
beyond
a
simplistic "specific treatments for specific
disorders"
paradigm, to defin-
ing
EBP as
"the integration ofthe best available research with clinical expertise
in the context of patient characteristics, culture, and preferences" (p.
273).
The
role of clients
as
an important factor in clinical decision making
was
recognized.
This definition merits celebration, acknowledging as it does the central role
that clients play in the execution, efficacy, and evaluation of psychotherapy.
EBP is not synonymous with a list of empirically supported treatments
(Norcross, Levant, & Beutler, 2006), although under the APA Task
Force
state-
ment, empirically supported treatments are to be included as one thing for the
clinician to consider. However, in addition, other empirically sound methods
exist fot ensuting that practice is informed by the best evidence (Bohart &
Tallman,
1999;
Duncan et
al.,
2004; Hubble et
al.,
1999;
Orlinsky et
al.,
2004).
Renew interest in person-centered care.
The data reviewed in this chapter, and elsewhere in this volume, provide
strong support for a person-centered orientation to clinical practice. Currently
popular in medicine, this way of working calls for a collaborative, patient-
involved model ofservice delivery. It is an approach in which listening to the
patients' stoties becomes an integral part of what physicians do (Charon, 2006;
Tallman, Janisse, Frankel, Sung, Krupat, & Hsu, 2007).
In mental health
care,
clients not only desire but also demand that treat-
ment be more person centered. Variously called survivors or
consumers,
people,
particularly those who have at some time been diagnosed with schizophrenia
or bipolar disorder, want to take an active role in directing services they receive.
In several states, members of the recovery movement or their advocates sit on
various mental health commissions and have a major say in policy. Cohen
(2005) pointed out those groups often explicitly reject the traditional medical
view of emotional suffering and treatment, choosing instead to embrace a par-
adigm that emphasizes client resources and community activism. An emphasis
on creating or using real-life support networks and opportunities both in work
and in relationships is also seen. Briefly, Cohen's study of 36 survivors, most
diagnosed with schizophrenia, showed that the majority cited self-help, support
of family and friends, social activism, exercise, as well as one-on-one psy-
chotherapy as the most common and helpful methods for facilitating recov-
ety. Only 25% reported the use of
drugs
as helpful. It is unfortunate that the
one movement that explicitly recognizes clients as active, empowered agents
100 BOHART AND TALLMAN
in their own right has been met with mixed feelings by the mental health
establishment.
The person-centered orientation also dovetails with the
field's
increasing
awareness regarding cultural
diversity.
As APA's revised definition of EBP indi-
cates,
therapy needs to be informed by the client's culture and personal prefer-
ences.
Obviously, solutions developed collaboratively, in the context of clients'
cultural experiences, are likely to be more meaningful to the individual, hence
successful. Here again, utilization and mobilization of client resources trump the
application of a specific technique to a specific problem. Finally, the person-
centered perspective fits perfectly with the current Zeitgeist (see chap. 8, this
volume) toward client-based outcome feedback and the privileging of the
client's voice achieved
by
routine assessment and
use
ofthe client's perceptions
ofthe benefit of services. Using client feedback to tailor mental health services
finally makes clients true partners in the therapeutic endeavor.
Changing the goveming paradigm by taking seriously the active, gen-
erative nature of clients leads to fundamental changes in how the process of
therapy is viewed and conducted. This process at once becomes collaborative
in theory and practice, not merely collaborative in the sense that the client
complies with and participates in a predetermined treatment
plan.
From such
a vantage point, each person in the process is an expert in his or her own
right. Togethet, practitioners, researchers, and clients combine their efforts
to ensure that the client is no longer the most neglected common factor in
psychotherapy.
QUESTIONS FROM THE EDITORS
1.
What
has
been the most important
finding
about the client's role
in
psycho-
therapy since the first edition? What research needs to be conducted to establish
further the client's pivotal role?
We would say that the most important finding
is
that the client
is
impor-
tant. In recent years there has been a significant increase in studies on the
client's role in therapy. Writers are now mentioning clients as a critical factor
in how therapy works. As mentioned previously, the recent APA Task Force
on EBP included the client as one of the three major factors to be taken into
account in deciding how best to proceed in therapy.
In terms of
research,
there really is not one particular finding but rather
a convergence of results. Findings continue to accumulate showing that clients
are active interpreters of the therapy environment and that the nature of the
outcomes clients achieve depend in part on their active (and creative) inte-
gration of what therapy has to offer with their own plans, goals, and agendas.
CLIENTS: THE NEGLECTED COMMON FACTOR 101
^SM^BSWS^-Sk,^.,*
Research has also found that focusing on clients' strengths and resources is
important to make therapy work across different approaches.
Conceming future research, there has been almost no work done on
client expertise, although therapists of many different persuasions pay lip
service to the idea that the client is the expert on his or her own life. That
clients apply such expertise to help solve their own problems in therapy is a
major thesis of this chapter. Yet, there is virtually no research on this subject.
Much more also needs to be done to learn how clients actively engage in the
therapeutic process on a session by session basis and how they integrate what
they experience into their lives outside therapy. More research needs to be
done to identify why some clients benefit from care whereas others do not.
What are the causes from the client's point of view? Is it really due to a deficit
in the client? Or is it possible that there is a mismatch between the therapy
provided and the client? Or, finally, is it that the therapy does not sufficiently
address itself to client concerns and perspectives in such a way as to best
involve them? Perhaps the recent efforts, highlighted in this volume, to inte-
grate client feedback and tailor services to client preferences will shed more
light on the issue.
2.
How do you reconcile evidence suggesting that certain clients do less well in
therapy (e.g., clients rated
as more
functionally impaired, diagnosed
with
personality
disorders, and assessed
as
having relationship problems from
childhood) with
other data
showing that client ratings of distress are better predictors of change than diagnosis or
client functional impairment?
These findings on distress suggest that the most important factot in how
well therapy works is, once again, client involvement and participation. Pre-
sumably, more highly distressed clients are more motivated to participate.
That this dwarfs diagnosis, functional impairment, and so forth is significant.
It suggests that the motivated participation ofthe client is the most important
factor.
The data suggesting that clients who are more functionally impaired do
less well in therapy are part of
a
largei picture that shows that different clients
have different healing trajectories in therapy. The traditional interpretation is
to blame the client: It
is
his
or
her psychological impairment that impedes ther-
apy. An alternative possibility is that the typical therapy environment, typical
therapy behavior, and typical therapy solutions do not work equally well in
mobilizing the self-healing capacities of all clients. The traditional model of
therapy—in which the expert therapist
is
the one who decides what the client's
problem is, diagnoses it, and then chooses and prescribes the treatment—may
get in the way of listening to the client to find out what works best for him or
her. This may be particularly important with clients who might not adapt well
to the traditional therapy environment. Ot, the failed therapy itself creates the
noted impairment: Client dysfunction
is
an iatrogenic effect of ineffective ther-
102 BOHART AND TALLMAN
apy. In an interesting project, Duncan, Hubble, and Miller (1997) deliberately
tried to work with clients other therapists had found intractable.
By
working in
a more collaborative way with these clients than they had been worked with in
the past, these clients were able to be successful. More research to understand
how clients approach and work with what
is
offered in therapy
is
needed before
we conclude that their relative lack of
success
is due to their defects.
3.
You talk about the client as active self-healer. We (the editors) have talked
about "heroic clients." Is it possible that such talk could stigmatize individuals who
do
not self-right
in
everyday life and instead need psychotherapy and individuals who
do not get better in therapy?
Fitst, one must keep in mind that the literature on resilience shows that
not everyone
is
equally resilient. Resilience
is
a complex product of individual
peisonality factors interacting with life historical events and the facilitating ot
nonfacilitating aspects of one's cuirent environment. Although 40% to 60%
of individuals who experience traumatic events show signs of posttraumatic
growth, conveisely, 40% to 60%—a substantial number—do not.
Therefore, there is nothing unusual about needing help to self-right.
Indeed, even those who exhibit resilience or posttraumatic growth have usu-
ally had the aid of other
people,
perhaps a mentor, teacher, or supportive fam-
ily member. We believe the evidence supports humans' considerable potential
to self-right. They may need a therapist to help them mobilize it. The evidence
regarding the importance of listening to clients as proactive agents and find-
ing ways to mobilize client's generative capacities is compelling. Unfortu-
nately, we have both experienced too many cases of therapists who "know
what's best for
you"
and impose their view on
clients,
which often implies that
the client
is
damaged in some way and not capable of self-healing. The case of
Molly, presented in Duncan et al. (1997), is a classic example of how thera-
pists repeatedly imposed their perspectives on the client and ignored her voice.
When a therapist finally listened, Molly was able to figure out a solution for
herself.
Why she had not done that in everyday life
is
another question, but it
shows that clients have this potential, and it is not uncommon for them to
need the aid of
a
professional to mobilize it.
Therapy offers at least two things people may not have in their everyday
lives.
First, it offers a supportive interpersonal relationship in which one can
think together with another human
being.
A supportive other can help mobi-
lize hope and renewed effort. In everyday life, many people do not have the
kind of relationship that would help them work through their difficulties. Sec-
ondly, it provides a good workspace. Clients in everyday life may not have the
time,
place, or emotionally safe space to focus productively on their problems.
Although we believe it is ultimately clients' own generative capacities
that lead them to productively use whatever they experience in therapy, it does
not mean those who do not improve should be blamed. As we have previously
CLIENTS: THE NEGLECTED COMMON FACTOR 103
stated, it could be that the therapy did not mobilize theii self-healing capaci-
ties.
Additionally, oui therapy models underestimate the importance of clients'
ecological circumstances. Therapy models focus on fixing factors inside clients,
which presumably allows them to successfully cope with their life spaces. How-
ever, the therapist is never just working with the client but with their life
cir-
cumstances, as well. Robert Elliott's (2002) work with his hermeneutic single
case efficacy design for studying psychotherapy outcome has shown how com-
plex change is and how much it is influenced by clients' circumstances. With-
out stigmatizing clients, therapists need to understand how circumstances both
inside and outside of therapy may be making it difficult for clients to achieve
positive outcomes in therapy.
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