The therapeutic process holds both majesty and mystery for its participants. Client knowledge about the process ranges from total unfamiliarity with and/or misinformation about therapy—and what to expect of it—to the unique sophistication of the client who has entered into episodic therapy with several therapists. Given that individuals bring the sum of their past experiences as well as their current state into the therapeutic process, it is appropriate to assume that client expectations, behaviors, and outcomes vary due to these and many other factors, such as temperament, early learning about relationships, capacity to trust, experience of trauma, current stress level, and cultural mores.
How, then, do therapists proceed to create a therapeutic alliance that allows the maximum gain for their clients? What client attitudes and behaviors mediate the outcome of successful therapy? How does the therapist accommodate these issues when inviting a relationship, determining a course of therapeutic action, or approaching a problem area? The American Psychological Association Division 29 Task Force on Empirically Supported Therapy Relationships has compiled information on client characteristics within the therapy relationship that have been shown to enhance therapeutic outcome. This entry addresses some of these factors.
Meaning-Making and Attribution
The term first impression generally denotes an individual’s immediate sense and understanding of an encounter with a specific person or situation. Individuals may use many different pieces of information as evidence for making quick judgments about others that may become lasting beliefs. Researchers have suggested that humans have a unique ability to judge personality traits and complex social characteristics—such as dominance, hierarchy, warmth, fear, and threat—from their first impression of individuals they meet or see in a photograph.
The client’s assessment of the personal character of the therapist, including the therapist’s physical appearance and dress, professional reputation, assumed ethnicity, and gender, is influenced by the innumerable experiences the client has synthesized over his or her lifetime. Such impressions often lead to permanent judgments and emotional reactions to others, particularly those perceived to be in positions of authority or power. There is little a therapist can do to change clients’ past experiences and how these experiences affect their relationships to the therapist and the experience of counseling. Therapists accept that some issues may be projected onto the therapist and create a distorted view of the interactions between client and therapist. Therapists then work to provide a way in which clients may be able to recognize their distortions when the distortions are pointed out by the therapist in a respectful, well-timed, and appropriate manner.
Different schools of therapy have different labels for these projective phenomena: transference and countertransference, products of early learning, personal schemas, or projective identification. The client’s attribution of specific positive and negative qualities to the therapist and therapeutic process allows the therapist to understand how the client views the world and to provide corrective emotional experiences through addressing the appropriateness and validity of the client’s ascriptions. It also provides a platform for therapists to evaluate themselves and their own attributions and biases through self-reflection, supervision, or their own psychotherapy.
Clients may reenact in therapy their prior experiences in order to determine if there is truth to their beliefs or to verify that their past course of action was valid. Examples of this are clients who continually check that their therapists have scheduled the standing appointment that has been attended for months or those who will tell their therapists about others who have committed an error and then intently gauge their therapists’ reactions in order to see how faults and/or past behavior may be accepted. Obviously, therapists’ attention to language and the meanings of verbal and nonverbal interactions are essential for a positive therapeutic outcome.
Once therapists sense the distortions and biases of the client, they may modify their own behavior and dialogue in unique and distinctive ways. The ability to engage in conscious self-regulation varies among therapists and in different situations; clients appear to have inconsistent levels of awareness of personal schemas, scripts, value systems, cultural biases, and clinical expectations as well. An awareness of habitual ways of interpreting personal information is one of the significant benefits clients may derive from therapy. What appeared to the client to be an adaptive response to a prior problematic situation may now be seen as an irrational action or thought that is within the client’s control to change if necessary.
Adam Horvath emphasized that a client’s first impression and early therapeutic alliance or relationship may predict the outcome of psychotherapy. The therapeutic relationship is conceptualized as the quality and strength of the collaborative relationship between client and therapist in therapy and the positive affective bonds between client and therapist— mutual trust, liking, respect, and caring. It also includes the active establishment of and allegiance to the goals of therapy and the means by which these goals will be attained. The therapeutic alliance creates a sense of shared responsibility in therapy in which each participant is actively committed to his or her specific responsibilities in therapy, and believes the other is equally committed to and invested in the process.
Clara Hill envisioned the therapeutic relationship as evolving over time as the result of the intersection of therapist techniques and client involvement. The therapist is able to employ theoretically appropriate techniques that lead to more intense client engagement and increasing therapist influence, strengthening the therapeutic relationship as it changes during the course of therapy. She viewed supportive and engaging therapist techniques as venues that permit the client to become involved in the therapy process.
Empathy is defined as the therapist’s perceptive and sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. In a meta-analysis of empathy and psychotherapy outcome conducted by Leslie Greenberg, Jeanne Watson, Robert Elliott, and Arthur Bohart, four theoretical factors were identified as potential mediators linking empathy and therapeutic outcome. Three of the factors comprise the processes of empathy as a relationship condition, as a corrective emotional experience, and as a cognitive-affective processing condition. The fourth factor is associated with the role of the client as an active self-healer.
Relationally, empathy provides a positive bonding function. Empathy (i.e., feeling understood) increases client satisfaction with therapy and thereby increases compliance with therapist suggestions and/or homework (most often utilized in cognitive-behavioral therapy). Feeling understood has been related to increased feelings of safety in the relationship and comfort when self-disclosure occurred. In addition, clients who felt understood also felt safer when approaching difficult topic areas and appeared to stay longer in therapy rather than prematurely terminating it. Empathy offers a specific learning or corrective emotional or relational experience. Hypothetically, an empathic relationship may help strengthen the self, diminish isolation, and facilitate clients’ experiences of personal value, including the possibility that they are worthy of respect and of being attended to and heard. Perceived empathy may validate the veracity of clients’ feelings and behaviors. This empathic reflection and validation might eventually lead clients’ to develop the ability to express their feelings and needs in relationships. Empathy may also promote exploration and creation of meaning. It helps clients think more productively, raises levels of constructive experiencing, facilitates emotional reprocessing and decreases emotional angst due to anxiety and depression, as well as providing learning experiences.
Arthur Bohart and Karen Tallman suggested that therapy works fundamentally by supporting and encouraging clients’ active self-healing efforts. Clients are seen as having innate capacities for growth and change, and therapy becomes the educational process that helps clients mobilize their resources. The therapist’s empathy contributes to this process by furthering client involvement and openness to the process. In addition, it provides an “empathic workspace” where clients can draw on their capacities for self-healing. This perspective of client as “self-healer” differs from more medical views of psychotherapy wherein the therapist is viewed as the expert healer.
Deference is commonly defined as individuals’ submission of thoughts, opinion, and projected course of action to another person, who is recognized as superior in knowledge, skill, judgment, and so forth. In the therapy dyad, the therapist is generally considered more expert than the client—a situation that could be expected to exacerbate the client’s deference to perceived therapist directives. This phenomenon has been overlooked in the literature on the counseling relationship. David Rennie noted that attention has been directed more to concepts presumed to relate to the process of improvement in therapy, particularly transference, resistance, empowerment, and the working alliance. Rennie postulated that clients’ deference to the therapist consists of eight categories: concern about the therapist’s approach, fear of criticizing the therapist, understanding the therapist’s frame of reference, meeting the perceived expectations of the therapist, accepting the therapist’s limitations, client’s metacommunication, threatening the therapist’s self-esteem, and indebtedness to the therapist.
The most direct effect of clients’ deference appears to be on the establishment of a positive working alliance and, in a tangential way, the client’s resistance. Being deferential to the therapist is seen as the client’s way of protecting and fostering the alliance. However, deference may at times be costly for clients, sapping their energy and thereby creating difficulty with their commitment to the therapist’s strategies and expectations. Nonetheless, whether clients would appreciate a request to express dissatisfaction may be determined by the degree to which the discontent disturbs the clients’ ability to focus constructively on their own processes. The awareness that many clients are extremely disposed to be deferential might increase therapists’ awareness and influence their clinical judgment, and help them avoid the conflict that comes from a client’s inner feelings of not being good enough, smart enough, or worthy of positive outcomes.
Stages of Change
In the transtheoretical model of therapeutic change developed by James O. Prochaska and John Norcross, behavior change is seen as a process that unfolds over time and involves movement through a series of six stages: precontemplation, contemplation, preparation, action, maintenance, and termination. Each stage represents a period of time and a series of tasks that must be completed before movement to the next stage is possible. Although the amount of time an individual spends in each stage will vary, the tasks to be accomplished during each stage are assumed to be the same. The stages of change model provides a way of thinking about client readiness to change.
In the precontemplation stage, individuals do not intend to change their behavior in the near future. Most individuals in this stage are unaware or under-aware of their problems, although their intimates— family, friends, neighbors, and coworkers—are often aware of the precontemplator’s problems. When precontemplators present for psychotherapy, they are likely to do so because of pressure from others. Precontemplators can wish or hope to change, but do not seriously intend or earnestly consider changing.
Contemplation is the stage where individuals are aware that a problem exists and are sincerely thinking about overcoming it, but have not yet committed to a course of action. Individuals often are in this stage for long periods of time. Those who state that they are seriously considering changing the problem behavior in the next 6 months are classified as contemplators. The preparation stage combines intention and behavioral criteria. Individuals in this stage intend to take action in the next month or so, as their past actions surrounding change have not been successful. Individuals in this stage have experienced a slight decrease in their problem, but have not yet reached a level of effective action such as the absence of anger or a decrease in their symptoms of anxiety.
During the action stage individuals transform their behavior, experiences, and environment in order to surmount their problems. Action involves explicit behavioral changes and requires a serious commitment of time and energy. Modifications of the problem behavior occurring during the action stage tend to be readily visible. Individuals are classified as in the action stage if they have successfully changed or seriously modified the dysfunctional behavior for a period from 1 day to 6 months.
Maintenance is the stage where individuals work to prevent relapse and consolidate their current gains. Remaining free of the problem behavior and consistently engaging in a positive incompatible behavior for more than 6 months are the criteria for considering someone to be in the maintenance stage. The final stage is termination. Termination means that individuals have completed the change process and no longer have to work consciously to prevent relapse. Termination is defined as total confidence or self-efficacy across all high-risk situations and no temptation to relapse.
At each stage of change, different processes of change generate progress. Formulating change processes to facilitate optimal change within the different stages necessitates that the therapeutic relationship correspond to the client’s stage of change. As clients progress from one stage to the next, the therapeutic relationship also progresses. There is an increasing body of research evidence on how tailoring the therapy relationship to the stage of change can enhance outcome, since the various change processes are not equally effective in each stage of change.
The research by Prochaska and Norcross noted that therapists who tailored their interventions to the client’s stage had clients with an increased completion rate for a course of therapy and who continued to implement and maintain change. Prochaska and Norcross’s work suggested that change processes associated with experiential, cognitive, and psychoanalytic orientations appear to be most valuable during the earlier precontemplation and contemplation stages. Change processes traditionally associated with the existential and behavioral traditions, by contrast, are most useful during action and maintenance. Prochaska and Norcross recommended that therapists consider the following:
- Assess the client’s stage of change; tailor therapy relationships and interventions accordingly.
- Beware of treating all clients as though they are in an action phase, as the majority of clients are not. An estimated 10% to 20% are prepared for action, about 30% to 40% are in the contemplation stage, and 50% to 60% in the precontemplation stage.
- Set realistic goals; move one stage at a time and celebrate success as appropriate for the current stage. Helping clients move beyond the stuck phase of pre-contemplation is a therapeutic success. This likely doubles the chances of clients taking effective action in the next 6 months.
- Engage in interpersonal behaviors that tailor the therapeutic relationship to the client’s change stage and use techniques that are consistent with the change processes that are most effective at that stage.
- Avoid mismatching stages and processes. Modifying behavior without awareness of the client’s stage of change and prescribing overt action without insight into the change process and the client’s stage most often engenders only temporary change.
Talking to others about difficult parts of themselves is a challenge for most individuals; nevertheless, it is important within the therapeutic relationship for clients to allow their therapist to know the hidden, misunderstood, even shameful parts of themselves. In general, research has shown that clients who are in moderate to long-term psychotherapy state that they view therapy as a safe place to disclose, particularly if they perceive the therapeutic relationship as good. For the most part, active participants in psychotherapy describe the disclosure process as principally generating shame and anxiety at the outset, but eventually as evoking feelings of safety, pride, and genuineness. They also note that keeping secrets inhibits their progress in therapy and disclosing produces a sense of liberation from physical and emotional tension. It is generally held that initial disclosures in therapy smooth the progress of subsequent disclosures to clients’ family members and friends and the continued disclosure of difficult parts of themselves to their therapist. The consensus is that therapists should gently pursue material that is difficult to disclose.
It should be noted that therapists’ self-disclosures to their clients might engender positive or negative results. The sharing of the therapists’ personal and private experiences must be in the service of client understanding and comfort rather than for the therapists’ self-aggrandizement. When the focus remains on the client and the disclosures (often in the form of stories) remain pertinent to the issues at hand, they usually have positive effects in therapy, frequently helping clients feel understood and allowing clients to move on to other significant issues. When clients’ issues are not addressed, however, a breach in the relationship occurs and may lead to negative outcomes such as premature termination or clients testing the relationship through various modes, which may include missing appointments or failing to invest in positive change.
Clients’ reactions to therapist disclosure have been studied in laboratory settings using videotapes of client-therapist interaction. Research has shown that as long as the therapeutic alliance was positive, study participants rated sessions as more meaningful and the therapist as more expert when the therapist made general disclosures versus no disclosures at all. When the alliance was negative, clients rated the sessions where therapist disclosure occurred as more superficial and the therapist as less skilled when the therapist made either general or countertransference disclosures as opposed to no disclosures.
There are a number of factors that influence clients’ willingness to disclose. The research of Barry Farber, Kathryn Berano, and Joseph Capobianco indicated that about half of clients keep secrets from their therapists. This occurs mostly in the areas of relationship issues, sexual problems, and perceived personal failures. The subjects of clients’ parents and despised personal characteristics are the topics most addressed within the therapy session. Women and men seem to disclose equally. The longer a client is in therapy and the stronger the clients consider their therapeutic alliance, the more willing clients are to disclose to their therapist.
Client Self-Observation as a Precursor to Change
The activation of self-observation is a collaborative feature of all psychotherapies. It differs from self-awareness and relies upon consciousness to provide context and reality. Self-awareness is the capacity to know one’s self and one’s self-in-context. Self-observation is the act of examining one’s inner landscape (intentions, expectations, emotions, thoughts, and behaviors), processing this information, and exploring the ideas in other people’s minds, as well as what others think of the self.
Clients become aware of and learn about their own functioning in order to change maladaptive responses and generate new responses for the future. In helping clients focus attention on their own distinctive patterns, psychotherapists assist clients in activating their self-observation. This process is an implicit and multifaceted thread that runs through the different psychotherapies. It gives the client permanent tools to use during the process of change that is the object of psychotherapy.
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