ApplyingOutcomeResearch

Psychotherapy Volume 31/Summer 1994/Number 2 APPLYING OUTCOME RESEARCH: INTENTIONAL UTILIZATION OF THE CLIENT'S FRAME OF REFERENCE BARRY L. DUNCAN DOROTHY W. MOYNIHAN Dayton Institute for Family Therapy Centerville, Ohio The percentage of outcome variance the client and his/her environment that aid in re- attributable to extratherapeutic and covery) (Lambert et al., 1986). Lambert (1992) suggests that most of the suc- common factors, and the superiority of cess gleaned from intervention can be attributed client's predictions of outcome, to the common factors. Common factors have challenges an emphasis on theoretical been conceptualized in a variety of ways. A recent frames of reference and offers a analysis of the common factors literature (Gren- compelling argument for allowing the cavage & Norcross, 1990) revealed that the most frequently addressed commonality was the devel- client to direct the psychotherapeutic opment of a collaborative therapeutic relation- process. This article suggests that ship/alliance. therapists intentionally utilize the client's Supportive of the Lambert et al. (1986) review frame of reference for the explicit is Patterson's (1984) report that empathy, respect, purpose of influencing successful and genuineness account for from 25% to 40% outcome. A proposal for a client-directed of outcome variance. Patterson (1989) concludes process is offered that de-emphasizes that the outcome research undercuts the view that expertise in methods and techniques is the critical theory and seeks deliberate enhancement factor in promoting change; rather, the evidence of common factor effects and maximum suggests that therapists' influence lies in provid- collaboration with the client through all ing the conditions under which the client engages phases of intervention. in change (Patterson, 1989). The outcome literature challenges the inherent and invariant validity of a specific orientation, A review of the outcome research (Lambert, given that specific technique seems largely insig- Shapiro & Bergin, 1986) suggests that 30% of nificant when compared with common factors and outcome variance is accounted for by the common extratherapeutic variables. Another empirical factors (variables found in a variety of therapies challenge to the therapist's frame of reference is regardless of the therapist's theoretical orienta- provided by research demonstrating that client tion). Techniques (factors unique to specific ther- perceptions of therapist-provided variables are the apies) account for 15% of the variance, as do most consistent predictor of improvement (Gur- expectancy/placebo effects (improvement re- man, 1977; Horowitz et al., 1984). More re- sulting from the client's knowledge of being in cently, the therapist-provided variables have been treatment) (Lambert, 1992). Accounting for the studied in terms of the therapeutic alliance, which remaining 40% of the variance are the extrathera- includes both therapist and client contributions to peutic change variables (factors that are part of the therapeutic climate, and emphasizes collaboration between therapist and client in achieving the goals of therapy (Marmar et al., 1986). A recent study by Bachelor (1991) explored Correspondence regarding this article should be addressed the contribution to improvement of three alliance to Barry L. Duncan, 747 Hidden River Drive, Port St. Lucie, measures and focused on the perceptions of the FL 34983. client and therapist. Confirming and adding em- 294

Applying Outcome Research phasis to many previous findings regarding com- as nurturant. Bachelor concluded that empathy mon factors and the client's perceptions, Bachelor has different meanings to different clients and (1991) found that client perceptions yield stronger should not be viewed or practiced as a univer- predictions of outcome than therapists, and that sal construct. from the client's view, the most salient factors The potential for positive enhancement of com- are therapist-provided help, warmth, caring, mon factor effects will not occur in those situa- emotional involvement, and efforts to explore rel- tions in which the therapist's empathic response evant material. does not fit the empathic needs of the individual The significance of client (extratherapeutic) client. Regardless of how empathic a therapist and common factors as well as the superiority of may be by the standards of a chosen theoretical clients' perceptions in predicting outcomes offer orientation, an empathic response may have little a compelling argument for more attention to the or no positive impact on certain clients, or may client's resources and experience of the psycho- be interpreted by some clients as having negative therapeutic process (Rogers, 1957). As an attempt impact. The therapist's reliance on stand-by re- to further apply outcome research, this article pro- sponses to convey empathy will not be equally poses an intentional utilization of the client's productive in terms of the client's perception of frame of reference for the explicit purpose of in- being understood (Bachelor, 1988). fluencing successful outcome. The client's frame Empathy, then, is not an invariant, specific of reference is discussed in terms of: 1) the cli- therapist behavior or attitude (e.g., reflection of ent's perceptions and experience of the therapeu- feeling is inherently empathic), nor is it a means tic relationship; and 2) the client's perceptions to gain a relationship so that the therapist may and experience of the presenting complaint, its promote a particular orientation or personal value, causes, and how therapy may best address the nor a way of teaching clients what a relationship client's goals, i.e., the client's informal theory should be. Rather, empathy is therapist attitudes (Held, 1991). A client-directed process in psy- and behaviors that place the client's perceptions chotherapy is presented that de-emphasizes theo- and experiences above theoretical content and retical frames of reference and seeks deliberate personal values (Duncan, Solovey & Rusk, enhancement of common factor effects and maxi- 1992); empathy is manifested by therapist at- mum collaboration with the client through all tempts to work within the frame of reference of phases of intervention. the client. When the therapist acts in a way that demonstrates consistency with the client's frame The Client's Frame of Reference: of reference, then empathy may be perceived, The Therapeutic Relationship and common factor effects enhanced. Empathy, One way of enhancing common factor effects therefore, is a function of the client's unique per- is to extend the definitions of therapist-provided ceptions and experience and requires that thera- variables to include the client's perception of the pists respond flexibly to clients' needs, rather than therapist's behavior. Another way is to examine from a particular theoretical frame of reference therapist assumptions critically and eliminate or behavioral set. those that may undermine the client's positive perceptions of the relationship. Consider the ther- Respect apist behavior of empathy, which is defined by Respect, according to Rogers (1957), is the Carkhuff (1971, p. 266) as "the ability to recog- ability to prize or value the client as a person with nize, sense, and understand the feelings that an- worth and dignity. Central to conveying respect other person has associated with his behavior and is a nonjudgmental attitude, the avoidance of con- verbal expressions, and to accurately communi- demnation of the client's actions or motives, and cate this understanding to him." While this defi- acceptance of the client's experience (Rogers, nition describes the therapist's expressed empa- 1957). Demonstrating respect may entail embrac- thy, it does not address the client's idiosyncratic ing a nonpathological and nonpejorative perspec- interpretation of the therapist's behavior. tive of people that assumes that all clients can In a recent study examining client perceptions make more satisfying lives for themselves and of empathy, Bachelor (1988) found that 44% of have the inherent capacity to do so. Diagnostic clients perceived their therapist's empathy as cog- categories or attributions of pathology that con- nitive, 30% as affective, 18% as sharing, and 7% note a poor prognosis are perhaps disrespectful 295

B. L. Duncan & D. W. Moynihan and discount the complexity and beauty of human hopefully offer productive input. The therapist, variation, masking the idiosyncratic strengths that therefore, is not an expert who champions an individuals may utilize to live more satisfying objective truth about the etiology and treatment lives. Such diagnoses may also undermine two of client problems or the way life should be lived. other common factors identified by the Gren- Rather, the client is the expert from a perspective cavage & Norcross' (1990) review, i.e., the cli- that places the client's frame of reference and ent's positive expectations and therapist qualities the client's input in a superior position to the that cultivate hope. therapist's orientation or input. Challenging pathology-oriented, diagnostic Phoniness may be exemplified by the position frames of reference and advocating an abiding that equates theories of psychotherapy with faith in client resources seems unpopular, but "truth", rather than empirical/conceptual approxi- well-founded. Client contribution to outcome mations of reality. Being genuine with clients may (extratherapeutic factors), regardless of diagno- necessitate a humbling acceptance of the nonde- sis, is the single most important factor to success- finitive nature of psychotherapy theory and appli- ful outcome (Lambert, 1992). cation, as well as the inherent complexity of hu- Respect is also conveyed by therapists' flexi- man beings. While theories of psychotherapy are bility regarding their interpretations or views of obviously of great value to clinicians and clients, clients or their circumstances. Interpretations there has been no demonstrated superiority of one made to clients, or therapist views imposed on over another. This equivalence of outcome find- clients despite the clients' lack of acceptance, are ings has been documented in several reviews (Ber- disrespectful and may undermine common factor gin & Lambert, 1978; Klein et al., 1983; Orlinsky effects. Kuehl, Newfield & Joanning (1990) & Howard, 1986; Luborsky, Singer & Luborsky, found that clients who viewed their therapist as 1975; Sloane et al., 1975; Smith, Glass & Miller, not rigidly adhering to a particular point of view 1980), and more recently in the NIMH multisite were more likely to be satisfied with therapeutic study of depression (Elkin et al., 1989). Perhaps experiences. Kuehl et al. (1990) conclude that it is time to reflect such findings in the way clients therapists should proceed cautiously when trying are approached. to convince a client of the utility of an approach The failure to find differential outcomes in the client does not readily accept. Perceived re- studies comparing therapies that use highly diver- spect may be assured when therapists discard their gent techniques also supports the importance of approaches if the client views them as unhelpful. common factors to positive outcome (Arkowitz, Respect is demonstrated in therapist attitudes 1992; Lambert, 1992). These findings, however, and behaviors that place the value of the client may be interpreted in other ways (Beutler, 1991; as a person with worth and dignity above patho- Butler & Strupp, 1986; Stiles, Shapiro & Elliott, logical, theoretical, or pejorative perspectives; re- 1986). For example, the apparent equivalence of spect is manifested by therapist sensitivity to the outcome may reflect that different therapies can acceptability of any therapist behavior to the cli- achieve similar goals through different processes, ent's frame of reference (Duncan et al., 1992). or that different outcomes do occur but are not detected by past methodological designs and strat- Genuineness egies (Arkowitz, 1992; Kazdin & Bass, 1989; Genuineness means being oneself without be- Lambert, 1992). The common factors explanation ing "phony" (Rogers, 1957). Therapists who do has received the most attention, and is supported not overemphasize their role, authority, or status by other research aimed at discovering the active are more likely to be perceived as more genuine ingredients of psychotherapy (Lambert, 1992). by clients (Cormier & Cormier, 1991). Genuine- ness may be further operationalized by the thera- Validation pist's cautiousness and tentativeness about ap- Common factors may also be expressed proaching the client, conceptualizing his or her through a therapist's verbal behavior called vali- concerns, and intervening to address those con- dation. Validation is a therapist-initiated process cerns. Tentativeness conveys to the client that the in which the client's thoughts, feelings, and be- therapist claims no corner on reality and is not haviors are accepted, believed, and considered the deliverer of truth, but rather is a collaborator completely understandable, given the client's who, because of training and experience, can subjective experience of the world. Validation 296

Applying Outcome Research represents a combined expression of empathy, re- Those constructs provide the content, which be- spect, and genuineness that is individually tai- come the invariant explanations of the problems lored to the idiosyncracies of the client's ex- that bring clients to therapy. perience. Although variation exists in the degree to The therapist genuinely accepts the client's pre- which content is emphasized and elaborated sentation at face value and holds the belief that (Held, 1991), most therapies tend to fall to the the client is doing the best that he or she can. content-oriented pole of the content-process The therapist respects the client's experience of continuum. The client presents with a com- the problem by emphasizing its importance, and plaint, and the therapist will overtly or covertly empathically offers total justification of the cli- recast the complaint within the language of the ent's experience. The therapist, therefore, ver- therapist's formal theory. The therapist's re- bally legitimizes the client's frame of reference formulation of the complaint into a specific pre- and in the process may replace the invalidation conceived theoretical content will enable treat- that may be a part of it (Duncan et al., 1992). ment to proceed down a particular path flowing Validation represents a logical application of from the formal theory. common factors research as well as studies docu- In content-oriented approaches to psychother- menting the significance of client perceptions to apy, the formal theoretical reality oftitletherapist outcome. exists in a hierarchically superior position to the frame of reference of the client. This formal the- Client's Frame of Reference: Informal Theory ory necessarily structures problem definition as Another dimension of the client's frame of ref- well as outcome criteria. The more content-ori- erence encompasses the client's thoughts, beliefs, ented the approach, the more content-directed the attitudes, and feelings about the nature of what goals become. Conversely, intentionally utilizing served as the impetus for therapy (the problem or the client's frame of reference requires that the situation), its causes, and how therapy may best content focus of the therapeutic conversation address the client's goals for treatment. Held's emerge from the informal theory of the client. (1991) elaboration of the content/process distinc- Informal theory involves the specific notions tion provides a framework for understanding held by clients about the nature and causes of their this dimension. particular problems and situations (Held, 1991). Informal theory is revealed through clients' artic- Content versus Process ulations and elaborations of their concerns and is Held (1991), building on the work of Prochaska necessarily highly idiosyncratic. Recall the Bach- & DiClemente (1982), defines process as the ac- elor (1991) study, which indicated the importance tivities of the therapist that promote change or of not only the therapist-provided variables, but develop coping solutions (i.e., methods, tech- also the therapist's efforts to explore material that niques, interventions, strategies). Process embod- the client perceived as relevant. Clients seem to ies one's theory of how change occurs (Held, want therapists to explore their informal theories. 1991). Content is the object of the change involv- Rather than reformulating the informal theory ing the aspects of the client and his or her behav- into the language of the therapist's formal theory, ior, upon which the therapist decides to focus the it is suggested that therapists accommodate their interventions (Held, 1991). formal theories to the client's informal theory by Content is defined at both formal and informal elevating the client's perceptions and experiences theoretical levels (Held, 1991). Formal theory above theoretical conceptualizations, thereby consists of either general notions regarding the allowing the client's informal theory to dictate cause of problems (e.g., symptoms are surface therapeutic choices. Understanding the client's manifestations of intrapsychic conflict; symptoms subjective experience and phenomenological rep- are homeostatic mechanisms regulating a dys- resentation of the presenting problem, and placing functional subsystem) or predetermined and spe- that experience above the theoretical predilection cific explanatory schemes (e.g., fixated psy- of the therapist seems consistent with the notion chosexual development; triangulation), which of enhancing common factor effects. Adopting must be addressed across cases to solve problems. the client's informal theory also provides a sig- Cause and effect are either specific or implied by nificant step in securing a strong therapeutic way of theoretical constructs of formal theory. alliance. 297

B. L. Duncan & D. W. Moynihan The Informal Theory and the Therapeutic planatory and predictive validity for the client's Alliance specific circumstance. Such an accommodation to the client's informal theory appears warranted given the impor- Intervention and Common Factor Effects tance of client perceptions to outcome (Gurman, Although it is useful to examine common fac- 1977; Bachelor, 1991; Horowitz et al., 1984) and tors separate from specific technique, relationship the large body of evidence demonstrating that the and intervention factors are interdependent as- therapeutic alliance, as rated by client, therapist, pects of the same process. Butler and Strupp and third-party perspectives, is the best predictor (1986) argue: of psychotherapy outcome (Alexander & Lubor- The complexity and subtlety of psychotherapeutic process sky, 1986; Marmar et al., 1986; Marziali, 1984; cannot be reduced to a set of disembodied techniques, because Suh, Strupp & O'Malley, 1986). the techniques gain their meaning, and in turn, their effectiveness, from the particular interaction of the individuals Bordin (1979) formulated three interacting involved (p. 33). components of the alliance: 1) agreement on the goals of psychotherapy; 2) agreement on the tasks The interactional context that creates meaning of psychotherapy (specific techniques, topics of for intervention are the characteristics, attitudes, conversation, interview procedures, frequency of and behaviors of the therapist that provide the meeting); and 3) the development of a relationship core conditions as perceived by the client. Com- bond between the therapist and client. While the mon factors may be enhanced by specific inter- bonding dimension reiterates the importance of ventions that convey or implement the therapist's the relationship and the therapist-provided vari- understanding and acceptance of, as well as re- ables, the agreement on goals and tasks refers spect for, the client's frame of reference. Inter- to the congruence between the client's and the vention, then, becomes another behavioral mani- therapist's beliefs about how people change in festation of the relationship. Intervention in the therapy (Gaston, 1990). form of tasks or assignments extends the interper- Adopting the client's informal theory may en- sonal context defined in session to the client's sure the development of a strong therapeutic alli- social environment and offers another opportunity ance. By allowing the client's idiosyncratic con- to enhance common factor effects and maximize tent focus to direct the therapeutic process, there a positive therapeutic alliance. is necessarily an agreement regarding goals and The expert therapist role is therefore de-empha- tasks because the therapist always accommodates sized in the current proposal. From an expert posi- formal theory(s) to the informal theory of the tion, the therapeutic search is for interventions client. The therapist attends to what the client reflecting objective truths that promote change via thinks is important, addresses what the client indi- the process of validating the therapist's theoretical cates as significant, and accommodates both in- point of view. The therapeutic search, from a and out-of-session intervention to accomplish position seeking to deliberately influence success- goals specified by the client. ful outcome, is for interventions reflecting subjec- Each client, therefore, presents the therapist tive truths that promote change via the process of with a new theory to learn and a different thera- validating the client's frame of reference. Three peutic course to pursue. Emerging from the pro- general steps extend the common factors and cess of unfolding the client's frame of refer- strong alliance context to the intervention process. ence, the therapist, an active participant, draws upon theoretical frames of reference and adds Dependence on the Client's Resources input, leading to the evolution of a new theory People who enter therapy, except in certain or frame of reference. Clients reconceptualize compulsory situations, do so because the experi- their informal theories by combining aspects of ence of their lives or some specific circumstance their experience with alternative views that has become so painful that a change of some kind arise from therapeutic dialogues. The alterna- is perceived as necessary. Clients may initially tive views are only perspectives that the client appear frustrated and helpless, creative energies achieves in the process. Psychotherapy can be may be at a low ebb, and the perception may conceptualized as an idiosyncratic, process-de- exist that they have tried everything possible only termined synthesis of ideas, formulated by the to have experience failure time after time. The client, that culminates in a new theory with ex- client's frustration and helplessness should be re- 298

Applying Outcome Research spected by the therapist and not considered as a or her description of, and dialogue about, the reflection of any deficits or psychopathology. problem experience. The therapist continuously Such a perspective is critical because the thera- evaluates the multiple options and begins to rule pist is counting on the existent resources and out choices that are obviously antithetical to the strengths of the client. Interventions offer oppor- client's informal theory. Differential therapeutics tunities for change that promote clients' utiliza- gleaned from the literature serve as a guide to tion of their own inherent capacities for growth. the intervention process. However, the therapist A pathology perspective may undermine the ther- depends upon the client's receptivity to ideas gen- apist's confidence in the resources of clients and, erated regarding views and actions about the cli- therefore, limit the range of interventions from ent's concerns. Interventions evolving from col- which to choose. An initial step, then, is the rec- laborative exploration demonstrate the therapist's ognition that interventions depend upon the re- acceptance and validation of the client's frame of sources of clients for success. Therapist depen- reference each time the client enacts the interven- dence may perhaps hierarchically align the tion. The common factors context of the relation- therapeutic relationship in a way that promotes ship is therefore extended outside the session to the alliance and enhances relationship effects. the client's social environment. Out-of-session validation may encourage clients to utilize their What the Client Wants resources to resolve problems. The next general step is that intervention must address what the client defines as problematic and Discussion and Conclusion what the client indicates as the goal for therapy. Recall the percentages of outcome variance at- Rather than an imposition of the therapist's theo- tributable to four therapeutic factors: extrathera- retical (or personal) frame of reference, the inter- peutic change accounts for 40% of outcome vari- vention is a response to the client's formulation ance, common factors account for 30%, while of the problem experience. The client's desires, placebo and specific technique each contribute to therefore, set the focus and structure of the inter- 15% of the variance (Lambert et al., 1986). The vention process. differential percentages of the four factors reflect Intervention begins by accepting the client's their differential emphasis in the current proposal. presentation at face value, without any reformula- Client-specific variables that result in change tion, and then accommodating the intervention to speak to clients' inherent resources, as well as their that general presentation of the problem situation ability to utilize out-of-therapy events (e.g., social via rationales and treatment options available to support, fortuitous events) as opportunities for the therapist. This aspect of intervention is limited change. Given that this factor is percentage-wise only by the therapist's resources and knowledge the most powerful, the therapeutic process may be base. The second step, then, is characterized by viewed as empowering a context that enables clients an explicit therapist acceptance of what the client to access their own capacities for growth. From this wants and a start of a general search for interven- perspective, intervention attempts to create opportu- tion options that directly address the client's nities for extratherapeutic change. desires. This article proposed to maximize the effects of therapist-provided variables by intentionally Collaborative Exploration utilizing the client's frame of reference (experi- The final step involves the recognition that in- ence of the relationship and informal theory) and tervention is a collaborative exploration process extending a strong alliance into the intervention that emerges from the therapist-client conversa- process by depending on the client's resources, tion and the clients' articulation of their content- addressing what the client wants, and collabora- rich frame of reference. As clients tell their prob- tively exploring intervention options. It was sug- lem stories, they elaborate the idiosyncracies of gested that intervention represents another behav- their experiences, their views of the problem itself ioral manifestation of the therapeutic relationship and perhaps how it may be best approached, and that offers the opportunity for clients to experi- what they have tried to do previously to solve ence validation of their frame of reference each the problem. time they enact the intervention. The client, then, collaborates in the interven- Last place in terms of significance to outcome tion process during the interview by virtue of his is shared by placebo and specific technique fac- 299

B. L. Duncan & D. W. Moynihan tors. Placebo or expectancy effects include im- References provement that results from the client's knowl- ALEXANDER, L. B. & LUBORSKY, L. (1986). The Penn helping edge of being in treatment, and consists of alliance scales. In L. S. Greenberg and W. M. Pinsof variables such as therapist credibility and the use (Eds.), The psychotherapeutic process: A research hand- of encouragement, persuasion, and reassurance book (pp. 325-366). New York: Guilford. (Lambert, 1992). The selection of the content for ARKOWTTZ, H. (1992). A common factors therapy for depression. In J. C. Norcross and M. R. Goldfried (Eds.), Hand- conservation, as well as technique based upon the book of psychotherapy integration (pp. 402-432). New client's frame of reference, explicitly addresses York: Basic. and, therefore, enhances client expectancies re- BACHELOR, A. (1988). How clients perceive therapist empa- garding therapy. Meeting the client's expectations thy. 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