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  1. 1. PEER REVIEWED When therapist variables and the client’s theory of change meet BILL ROBINSON Recent research confirms the importance of the client’s theory of change (CTC)—perceptions and views the client has about the nature of the problem they bring to therapy and its possible resolution. If the theory of the client is primary, what then does the therapist bring to the encounter? BILL ROBINSON argues that the study of therapeutic effectiveness needs to focus on the interplay between therapist variables (the person of the therapist) and the client’s theory of change. When these two vital factors meet, something new is created. It is crucial that the therapist becomes aware of, and manages, the effect of therapist variables on the alliance. This can be monitored through eliciting client feedback on perceived progress and strength of alliance. Case studies drawn from the author’s practice illustrate this process. ‘It is not death that a man should fear, but he should fear never beginning to live.’ Marcus Aurelius (2006). T he term ‘the client’s theory of change’ was first coined by Duncan, Solovey and Rusk (1992). therapeutic factors account for 40 per cent of outcome variance, while the results of a later meta-analysis by way to understand this is to reflect on significant issues in our own lives. Did we take time out to work through the It was used to refer to the ‘informal’ Wampold (2001) put the figure at 87 issue on our own, or did we talk to a theory of the client in contrast to the per cent. The concept of the client’s friend or a professional? If we talked ‘formal’ theories that can dominate theory of change does not imply that to another person, were we looking professional discussions in counselling clients live with a clearly defined for empathy, advice or challenge? and psychotherapy. This concept was theory of how change happens and When the change happened, did we developed further in subsequent papers how problems can be overcome in their act impulsively or did we plan every (Duncan & Moynihan, 1994; Duncan, lives. As Duncan and Sparks (2004) step carefully? If we connect with how Hubble & Miller, 1997; Duncan & point out, ‘the client’s theory of change is the client experiences this process, Miller, 2000; Duncan, Miller & not an anatomical structure in the client’s and adapt the therapeutic approach Sparks, 2004). head to be discovered by your expert accordingly, we are more likely to be The client’s theory of change (CTC) questioning. Rather, it is a plan that co- helpful than if we impose a therapist refers to the perceptions and views evolves via the conversational unfolding constructed model of problem the client has about the nature of the of the client’s experience, fuelled by your resolution. problem they bring to therapy and caring curiosity’ (p.31). If the theory of the client is primary, its possible resolution. Rather than When prompted to reflect on what what then does the therapist bring the client having to accommodate has led to positive change in their to the encounter? In some instances, the therapist’s theory of how change lives on previous occasions, or how all that may be needed is a non- occurs, or risk being labelled resistant, difficult problems have been overcome, directive person-centred approach the views of the client are central and clients will often recall internal and where the counsellor responds to the therapy is tailored to their views about external resources they have used to client’s lead with empathy, respect what is helpful or unhelpful. resolve problems in the past. In fact, and acceptance. For other clients, In the light of recent research, a what may bring people to therapy is their theory of change may include a change in emphasis from what the that they have forgotten or lost faith part for a counsellor who challenges, counsellor perceives and does, to what in these abilities. The CTC refers to gives advice or designs strategies. As the client perceives and does, makes the process by which clients experience Bachelor and Horvath (2000) point good sense. According to Assay and change, and so encompasses more than out, ‘Effective responses are attitudes and Lambert (1999), client and extra- just goals and expectations. A good interventions that are appropriate to the 60 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009
  2. 2. individual client. To develop an effective emphasise the importance of both with a focus on clients who I had therapeutic relationship, sensitivity to therapist effects and the therapeutic not helped successfully. Was there a client’s differential phenomenological relationship: ‘Despite the concerted particular presenting problem, age worlds, as well as to relational needs and effort to control, reduce or eliminate group, gender, ethnic or socioeconomic expectations, seems important’ (p.146). the effects of both therapist variability group, that I did not seem to help Therapeutic models and techniques and extradiagnostic patient variables, because of variables associated with may play their part as they give us research has not been able to escape the me as a therapist? This is a work still different ways to consider the issue and need to recognize either the roles of the in progress that, to date, has yielded suggest different responses. clinician or the reciprocal influence no clear answers. However, what has been reinforced is the finding that each therapeutic encounter is a one-off The concept of the client’s theory of change encounter between a unique client with their unique theory of change, and does not imply that clients live with a clearly a unique therapist with their unique response. defined theory of how change happens and From their overview of research into therapist variables Bergin and how problems can be overcome in their lives. Garfield (2004) find little evidence that the personal characteristics of the therapist have any marked significance Miller, Hubble and Duncan (2007) of patient and therapist qualities on in therapeutic outcomes. However, suggest that ‘Who provides the treatment one another’ (p.227). Both therapist they emphasise that there is a lack is a much more important determinant of factors and alliance factors are of of recent studies, and probably too success than what treatment is provided’ major importance in client outcome few, to enable any clear conclusions (p. 15). These therapist variables and there is significant overlap. In to be drawn. Since it has been shown include observable traits such as the seeking to understand what makes repeatedly that the therapeutic model therapist’s age, gender and race, and therapy successsful, a fruitful focus or technique used by the therapist is of observable states such as professional could be to consider how therapist minor importance, what then are the discipline, training and experience. effects meet the client’s theory of therapist variables that have the effect They also include inferred traits such change, and build and maintain the on outcomes? as personality and coping patterns, therapeutic alliance. Miller, Hubble and Duncan (2007) level of emotional well-being, values Recently, having tracked my own address this question in their study of and beliefs, and cultural attitudes clinical outcomes for the last seven ‘Supershrinks’. The term ‘supershrink’ (Bergin & Garfield, 2004). Despite years, I started to look at this data was first coined by D. F. Ricks in 1974 this, the focus of research in recent years has moved from discrete therapist characteristics to randomised clinical trials that evaluate the type or model of therapy offered (Bergin & Garfield, 2004). Research further suggests the most important aspect of therapy that involves the therapist is the therapeutic alliance. According to Assay and Lambert (1999), the therapeutic alliance accounts for 30 per cent of outcome variance. For Wampold (2001), the alliance accounts for more than half of the 13 per cent attributed to therapeutic factors, rather than client and extra-therapeutic factors. Put another way, the alliance accounts for seven times as much outcome variation as the model or technique being used by the therapist. In a subsequent paper, Wampold and Brown (2005) suggest that five per cent of outcome variance can be attributed to therapist effects. Beutler et al (2004), in their study of therapist variables, Illustration: © Paul Vismara, Stock Illustration, Getty Images. PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009 61
  3. 3. and refers to the growing evidence that term ‘coniunctio’ in his exploration rate themselves in the areas of personal there are wide differences between the of the process of psychotherapy. In well-being, close relationships, work most effective and the most ineffective alchemy this refers to combining two and social activity. It is given at the therapists in the field. Okiishi, chemicals to make a different third start of every session. The session by Lambert, Nielson and Ogles (2003) chemical, but was used by Jung as a session results are tracked, and the analysed data from fifty-six therapists symbol for intrapsychic processes and results are shared with the client and in a university counselling setting and the encounter between therapist and used to inform the direction of future showed that, ‘The therapists whose clients client. Using this metaphor, we can see work. showed the fastest rate of improvement had an average rate of change 10 times greater than the mean for the sample. The …each therapeutic encounter is a one-off therapists whose clients showed the slowest rate of improvement actually showed an encounter between a unique client with average increase in symptoms among their clients’ (p.361). Wampold and Brown their unique theory of change, and a unique (2005), in their study of therapists from a managed care company, also report therapist with their unique response. wide variation in outcomes achieved by different therapists. In an article that not only draws on the therapeutic encounter as a place The client’s experience of the an analysis of therapeutic outcomes, where therapist variables (who we are therapeutic alliance is measured on the but also on excellence in any field of and how we relate) and the client’s SRS developed by Duncan, Miller and human endeavour, Miller, Hubble theory of change meet, and out of the Johnson (2002), validated by Duncan, and Duncan (2007) conclude that resulting ‘coniunctio’ something new is Miller, Reynolds, Sparks, Claud, the person who achieves superior created that is unique to that particular Brown and Johnson (2003) and is also performance is the person who works pairing. available at This hardest and in a directed and feedback- Growing evidence is emerging that is also a four item questionnaire that informed way to improve performance the provision of ongoing feedback to asks the client to assess the alliance of their task. The supershrinks in their the therapist can significantly improve according to: the degree to which they study are hypervigilant to threats to the outcomes achieved by their clients feel understood and respected; how the alliance with the client and check (Harmon, Hawkins, Lambert, Slade well their agenda is being followed; out even minor concerns. They are & Whipple, 2005; Harmon, Lambert, how seriously their ideas for change alert to anything that may sabotage the Smart, Hawkins, Nielson, Slade & are being considered; and whether success of the joint endeavour with the Lutz, 2007; Anker, Duncan & Sparks, the relationship with the therapist is a client. 2009). The last ten years have seen good fit. The SRS is given to the client We may hypothesise from this that the development of user-friendly at the conclusion of every session. Any what is crucial is how the therapist measures that enable us to monitor the ‘less-than-enthusiastic’ responses are becomes aware of therapist variables client’s experience of improvement, or explored with the client with the aim and manages their effect on the lack of it, and their experience of the of adjusting the direction of future alliance. The most effective therapist therapeutic alliance. They can enable work so that the client can experience will be the one who recognises us to monitor whether we are working it as more helpful. problems in the alliance due to with the client’s theory of change or The case of Jack differences in background or outlook getting in the way of it. While the use between therapist and client, or to of these measures may not turn every Jack is a retired man in his sixties. the therapeutic approach used by the therapist into a supershrink, they can He suffered a brutal childhood and therapist, or simply due to the therapist make a major contribution towards experienced further trauma as a having a bad day. As a first priority, improving therapist performance. member of the armed forces. He also the effective therapist will aim not to There are a number of reliable and suffers chronic pain from injuries get in the way of the client’s theory of valid measures available. Two of the received in active service. Initially, he change. They will ask ‘what part does most brief and user friendly are the came to therapy for help to deal with my client’s theory expect me to play?’ They Outcome Rating Scale (ORS) and the his stress and outbursts of anger. His will then ask ‘Is this a part I have the Session Rating Scale (SRS). anger was of particular concern. Given skills to play and am capable of playing, The ORS was developed by Miller his military training, he knew that if and is it a part that ethically I am willing and Duncan (2000), validated by he ‘totally lost it’ he had the ability to to play?’ In examining the effectiveness Miller, Duncan, Brown, Sparks and do somebody serious harm. or otherwise of counselling, a focus Claud (2003) and is available at www. In early sessions Jack talked a great is needed on the interaction between The ORS monitors deal about his experience in his family therapist variables and the client’s the client’s estimation of the level of origin and in the military. We theory of change. of improvement. This is a four item explored how and why he had become Carl Jung (1945) used the alchemical questionnaire that asks the client to the person he was, where his anger was 62 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009
  4. 4. coming from and what was likely to effective provided therapist factors did her own thoughts and feelings to trigger it. This seemed to be going well not prevent them connecting with his decide on the appropriate course of and Jack’s scores were moving slowly theory of change. action. This had not been a ‘therapeutic upwards on the ORS when I noticed strategy’, but rather an expression of The case of Jane a slight dip in the SRS score. I took my assumptions that people had a right this up with Jack who said that while Jane is a woman in her thirties. A to control the direction of their own understanding himself and the triggers practicing Christian, she asked to see lives and, at the same time, to be safe for his stress and anger was important, a counsellor who shared this faith. and secure. While we did not discuss he felt it was now more urgent to be She had come to discuss some current her eventual action, our discussion had able to manage his anger when it was issues in her life. However, between helped to empower her. At the same triggered. I adjusted my approach the first two sessions Jane talked with time, my expressed concern that she to our sessions in the light of this a friend who was dealing with the protect herself against further harm feedback and subsequent scores on the effects of childhood sexual abuse. This led to her taking her husband with ORS and SRS confirmed we were on conversation evoked memories of abuse her rather than acting alone. She may the right track. Later, with strategies in that Jane herself had suffered years not have done this had we not had place to manage the stress and anger, before. She felt these issues had never that discussion. It is possible also that Jack initiated further discussion on been dealt with and were affecting her the faith that we share was a factor, the origins of his anger and what it life still. She had considered making as she felt she was able to do what she was that had led to his father being so a formal report and pursuing the legal did with the aid of a higher power. brutal to him. He found this now to be route. I discussed with her the pros and She knew that her counsellor, while helpful and healing, as was confirmed cons of taking this path. I pointed out being concerned for her safety, would by his ORS and SRS scores. the challenges this would entail and understand and accept this and that As it unfolded, Jack’s theory of stressed the need to ensure her own her action would not sabotage further change was that he needed strategies physical and emotional safety. At the therapeutic work. Her ORS and SRS to manage his emotions and a degree same time, I assured her that I would scores confirmed that her sense of of understanding of himself and his support whatever decision she chose to personal well-being was improving family. In the person of his therapist make. and that she was comfortable with the he had someone who was willing and When Jane arrived for the next relationship with her counsellor. able to work in a directive cognitive session she told me that she had traced For Jack, who had been a victim way to address the former, and in a the perpetrator. She had knocked on of the abuse of power in his family psychodynamic way to address the his door and, when he answered, told of origin and adult life, having his latter. Nevertheless, the alliance him she had come to confront him experience validated and his ideas for between us threatened to derail. Unlike with the past and to get an apology. change taken seriously, strengthened a supershrink, I was unaware when After a tense conversation, she was the alliance between us. The initiation my responses to him emphasised the able to elicit an apology. This action of formal feedback, and the message wrong area. It was fortunate for us both resolved the issue for Jane. that I made use of formal measurement tools (ORS and SRS) to check that When the two vital factors of therapist we were on track and alert me to the danger. variables and the client’s theory of As our work progressed, I became aware that our beliefs and opinions change meet, real therapy begins… on some political, social and religious questions were quite different. This did not hinder our ability to work Initially, as she recounted her story, I that this was listened to and acted together because his theory of change was left speechless. It was not an action upon, assured him that, whether or did not include winning the therapist that Jane had spoken of pursuing at not his therapist agreed with him, and everyone else over to his way of our previous session. If she had, I was his ideas of what he needed at this thinking. Another therapist factor aware that I would have urged her to particular time were given priority. was that I had no difficulty relating reconsider, or at least have some idea of The experience of the therapeutic to someone who held different views. the response she may get before taking relationship stood in sharp contrast Whatever our differences, it was clear such bold action. While expressing to the invalidation and abuse he had that we shared a primary concern for my admiration for her courage, I told experienced so often in his childhood honesty and fairness, and a passionate her it was probable that this is how I and adult life. It demonstrated the type belief in the right of children to safety, would have responded had she run it of relationship he was looking for with acceptance and love. past me first. As we discussed this, other people in his life. Having his If Jack had worked with another it emerged that our discussion in the views taken seriously and acted upon therapist it is probable that the previous session had communicated a helped him to connect with his own path trodden would have been very concern for her physical and emotional considerable strength of character. In different, but could have been just as safety, while affirming her in following turn, this enabled him to manage his PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009 63
  5. 5. anger and stress levels, and improve the I did not have the skill and training, References quality of his life and his relationships or because my model of therapy Anker, M. G., Duncan, B. L. & Sparks, J. A. with others. The fact that in Jack’s case did not include giving strategies or (2009). Using client feedback to improve we did not share the same beliefs, but understanding, would have obstructed couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal could accept and respect each other’s the working out of his theory of of Consulting and Clinical Psychology, views, turned what could have been a change. Ethically, all I could have done 77(4), 693-704. negative into a positive. would have been to get out of the way Assay, T. P., & Lambert, M. J. (1999). The For Jane, the experience of someone and refer him to a colleague who was empirical case for the common factors who questioned and challenged, but able and willing to help him do both in therapy: Quantitative findings. In M. A. affirmed her right to trust her own of those things. Jane needed someone Hubble, B. L. Duncan, & S. D. Miller (Eds.), judgment enabled her to take the who would collaborate with her and The heart and soul of change: What works action she did. The message that her respect her judgement, rather than in therapy (pp. 33-56). Washington, DC: American Psychological Association. therapist trusted her to back her own someone who would direct her. This judgement, even though at the time is not to say that direction cannot ever Bachelor, A., & Horvath, A. (1999). The he might have had doubts about the be the right way to go, but in this case, therapeutic relationship. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The course of action she had chosen, helped at this time, it would not have been heart and soul of change: What works her to trust herself and to trust the helpful. A therapist variable here was in therapy (pp. 113-178). Washington, therapeutic process to address other that it did not bother me that a client DC: American Psychological Association problems in her life. had used her own judgement to decide Press. The use of the formal feedback tools on a major course of action without Beutler, L., Malik, M. L., Alimohamed, is constantly surprising and humbling running it past me first. As Miller and S., Harwood, T. M., Talebi, H., Noble, S. on various dimensions; how much I Duncan (2000) state, ‘Accommodating & Wong, E. (2004). Therapist variables, can learn from my clients, how wrong the client’s theory, therefore builds a strong In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and I can be in my initial estimates of their alliance. The therapist attends to what the Behaviour Change (5th Ed, pp. 227–306). capability, and how wrong I can be in client considers important, addresses what New York: John Wiley & Sons. my opinion about what is helpful to the client indicates is relevant, and tailors Duncan, B. L., Hubble, M. A., & Miller, S. them. This is not to say that I avoid both in and out of session intervention D. (1997). Psychotherapy with ‘impossible’ initiating ideas and possible solutions. to accomplish goals specified by the client. cases: The efficient treatment of therapy However, I do not pursue them if the The therapist and client work to construct veterans. New York: Norton. message from the client is that they interventions that fit with the client’s Duncan, B., Miller, S. & Sparks, J. A. are not helpful. The therapy room experience and interpretation of the (2000). The heroic client: A revolutionary is not a place where people come to problem’ (p.17). way to improve effectiveness through be given a diagnostic label and the To return to the alchemical client-directed, outcome-informed therapy. San Francisco: Jossey-Bass. manualised treatment that is supposed metaphor, who I am and who Jack and to go with it. As a therapist, it is a place Jane are met in a particular time and Duncan, B. L. & Moynihan, D. W. (1994). where I come with my personality, place, and were able to interact with, Applying outcome research: Intentional utilization of the client’s frame of reference. beliefs, cultural background, theories, affect and change each other. This Psychotherapy, 31, 294–301. techniques and everything else created something that neither on their that makes me a unique person and own, or with anyone else, could have Duncan, B. L., Solovey, A. D. & Rusk, G. S. (1992). Changing the rules: A client- unique counsellor. As Duncan and created. It produced an outcome that directed approach to therapy. New York: Sparks (2004) point out, ‘You are was unique to that particular pairing. Guilford. multidimensional—you are already many This is not to say that either could not Duncan, B. L. & Sparks, J. A. (2004). things to many people (friend, partner, have achieved a successful resolution Heroic clients, heroic agencies: Partners parent, sibling). Use your complexity to fit of their problems with anyone else, but for change - a manual for client-directed clients’ (p.22). the path to achieving this would not outcome-informed therapy and effective, The client comes to therapy with have been the same. Every therapeutic accountable, and just services. E-Book: their presenting problem(s), their encounter, like every other human ISTC Press. solutions, their internal and external relationship, results in a particular Duncan, B. L. & Miller, S. D. (2000). Clients resources and, arising out of all of this, ‘coniunctio’ that could not be produced theory of change: consulting the client their own unique theory of change. by any other combination. in the integrative process. Journal of Psychotherapy Integration, 10(2), 169-187. The many variables that contribute When the two vital factors of to ‘me’ as a therapist then come therapist variables and the client’s Duncan, B., Miller, S., Sparks, J, Claud, D., Reynolds. L., Brown, J., & Johnson, into play as I endeavour to meet the theory of change meet, real therapy L. (2003). The session rating scale: challenge to connect with this person begins as we connect with who the preliminary psychometric properties of and their theory. Jack needed both client is and allow clients to connect a ‘working’ alliance measure. Journal of understanding of how he had become with who we are. It is then we can Brief Therapy, 3, 3–12. the person he was and strategies to deal recognise their strength and true Harmon, C., Hawkins, E. J., Lambert, with potential dangers this gave rise to. heroism. Sometimes because of us, M. J., Slade, K., & Whipple, J. S. (2005). To have said that I could not respond sometimes regardless of us, and Improving outcomes for poorly responding to either one of these needs because sometimes in spite of us, they just do it. clients: the use of clinical support tools 64 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009
  6. 6. and feedback to clients. In Session: A Miller, S. D., Hubble, M. & Duncan, B. Wampold, B. E. (2001). The great Journal of Clinical Psychology, 61(2),175– (2008). Supershrinks: What is the secret of psychotherapy debate: Models, methods 185. their success? Psychotherapy in Australia, and findings. Hillsdale, NJ:Erlbaum. 14(4), 14–22. Harmon, S. C., Lambert, M. J., Smart, D. Wampold, B., & Brown, J. (2006). M., Hawkins, E., Nielsen, S. L., Slade, K., Okiishi J., Lambert M. J., Nielsen S. Estimating variability in outcomes & Lutz, W. (2007). Enhancing outcome for L. & Ogles. B. M. (2003). Waiting for attributable to therapists: A naturalistic potential treatment failures: Therapist- supershrink: an empirical analysis of study of outcomes in managed care. client feedback and clinical support tools. therapist effects. Clinical Psychology & Journal of Consulting and Clinical Psychotherapy Research, 17(4), 379–392. Psychotherapy, 10(6), 361–73. Psychology, 73(5), 914–923. Jung, C. G. (1966). The psychology of the transference. In H. Read, M. Fordham, G. Adler, & W. McGuire (Eds.) (R. F. C. Hull, Trans.), The collected works of C. G. Jung AUTHOR NOTES (Rev. 2nd ed.). (Vol. 16, pp. 163–323). Princeton, NJ: Princeton University Press. BILL ROBINSON is a counsellor with twenty five years (Original work published 1946). experience who has worked with individuals, couples and families Lambert, M. J. (2004). Bergin and Garfield’s Handbook of Psychotherapy in a number of settings in Australia and the UK. He is now a and Behaviour Change (5th Ed). New York: manager, counsellor and a senior supervisor with Relationships John Wiley & Sons. Australia based in Mandurah, Western Australia. He is a certified Miller, S. D., Duncan, B. L., Brown, J., CDOI (Client Directed Outcome Informed) trainer. Sparks, J. A. & Claud, D. A. (2003). The outcome rating scale: a preliminary study Comments: of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91–100. Make a difference in the lives of people who need people. There are unique callings that attract unique people. Those who want to inspire others and help them learn. Those who want to offer spiritual help and counsel, who’ll empower, support and encourage. People who care about social justice, equity and inclusion as they relate to individuals, families, communities and regions. People who choose to develop leadership skills based on emotional, social and ethical intelligence. Check our unique courses for unique people in: Community Education, Community Counselling, Community Health & Development, Professional Supervision and Human Resource Management at /health FoR MoRE inFoRMaTion: associate Professor Barbara Pamphilon Postgraduate and non-school leavers apply T (02) 6201 2323 on Line at: F (02) 6201 2263 E UC434 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009 65