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
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 collabo-
ration 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-
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
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
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.
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 infor-
mal 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 effective-
ness, 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-
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-
B. L. Duncan & D. W. Moynihan
tors. Placebo or expectancy effects include im- References
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