The document discusses several variables that can affect the outcomes of psychotherapy. It describes how psychotherapy requires motivation from patients and can be challenging, noting factors like a patient's level of distress, age, intelligence, and openness to the process. Gender is also mentioned as a variable, with questions around whether outcomes differ for male and female patients or if sexism influences therapy. The document aims to outline patient characteristics and variables in traditional therapies that can relate to treatment outcomes.

1. NATURE OF SPECIFICNATURE OF SPECIFIC
THERAPUTIC VARIABLESTHERAPUTIC VARIABLES
Lecture 28Lecture 28

2.  It would be pleasant if psychotherapy were a simpleIt would be pleasant if psychotherapy were a simple
routine in which the therapist makes a diagnosis,routine in which the therapist makes a diagnosis,
conveys it to the patient, gives a lecture or two, andconveys it to the patient, gives a lecture or two, and
presto, the patient is cured.presto, the patient is cured.
 But it is often necessary to spend considerable timeBut it is often necessary to spend considerable time
correcting patients' expectations that they will be givencorrecting patients' expectations that they will be given
a simple psychological prescription.a simple psychological prescription.
 Because psychotherapy is an active, dynamicBecause psychotherapy is an active, dynamic
process, passivity and lack of motivation can beprocess, passivity and lack of motivation can be
obstacles.obstacles.
 A number of factors involving the nature of the patient,A number of factors involving the nature of the patient,
the therapist, and the patient-therapist interactionthe therapist, and the patient-therapist interaction
affect the process of therapy in importantaffect the process of therapy in important ways.ways.

3. The outcomes of therapy are exceedinglyThe outcomes of therapy are exceedingly
complex events that are not shaped by patientcomplex events that are not shaped by patient
characteristics alone.characteristics alone.
 They are also determined by therapist qualitiesThey are also determined by therapist qualities
and skills, the kinds of therapeutic proceduresand skills, the kinds of therapeutic procedures
employed, the circumstances and environmentemployed, the circumstances and environment
of patients, and so on.of patients, and so on.
 Now we will discuss some of the moreNow we will discuss some of the more
prominentprominent patient’s variablespatient’s variables that havethat have
been related to outcomes in traditionalbeen related to outcomes in traditional
therapies.therapies.

4. VARIABLES RELATINGVARIABLES RELATING
THE PATIENT OR THETHE PATIENT OR THE
CLIENTCLIENT

5. 1. THE DEGREE OF PATIENT’S DISTRESS:1. THE DEGREE OF PATIENT’S DISTRESS:
 A broad generalization often made by clinicians is thatA broad generalization often made by clinicians is that
the persons who need therapy the least are thethe persons who need therapy the least are the
persons who will receive the greatest benefit from it.persons who will receive the greatest benefit from it.
 Good prognosis may be expected for a patient who isGood prognosis may be expected for a patient who is
experiencing distress or anxiety but is functioning wellexperiencing distress or anxiety but is functioning well
behaviorally.behaviorally.
 At best, however, the research data are contradictoryAt best, however, the research data are contradictory
and inconsistent.and inconsistent.
 For example, one group of studies finds that greaterFor example, one group of studies finds that greater
initial distress is associated with greater improvement.initial distress is associated with greater improvement.
Another group of studies finds exactly the reverse.Another group of studies finds exactly the reverse.

6.  More recent studies seem to find with someMore recent studies seem to find with some
consistency that individuals who are moreconsistency that individuals who are more
severely disturbed have poorer outcomes.severely disturbed have poorer outcomes.
 In general, psychotherapy requires aIn general, psychotherapy requires a
reasonable level of intelligence; brighterreasonable level of intelligence; brighter
individuals seem better able to handle theindividuals seem better able to handle the
demands of psychotherapy.demands of psychotherapy.
 This is so for several reasons:This is so for several reasons:
 First, psychotherapy is a verbal process. ItFirst, psychotherapy is a verbal process. It
requires patients to articulate their problems, torequires patients to articulate their problems, to
frame them in words.frame them in words.

7.  Second, psychotherapy requires patients to establishSecond, psychotherapy requires patients to establish
connections among events.connections among events.
 Finally, to enable connections among events to beFinally, to enable connections among events to be
made, psychotherapy requires a degree ofmade, psychotherapy requires a degree of
introspection.introspection.
 Behavioral forms of therapy have often been used withBehavioral forms of therapy have often been used with
considerable success with individuals suffering fromconsiderable success with individuals suffering from
cognitive limitations.cognitive limitations.
 A variety of behavior modification approaches areA variety of behavior modification approaches are
quite feasible: as a generalization, when behavioralquite feasible: as a generalization, when behavioral
deficits are the problem, behavioral techniques aredeficits are the problem, behavioral techniques are
frequently the preferred ones.frequently the preferred ones.

8. 2. AGE:2. AGE:
 Younger patients are presumably more flexible or lessYounger patients are presumably more flexible or less
"set in their ways“, so they do better in therapy."set in their ways“, so they do better in therapy.
 But there is no research evidence supporting theBut there is no research evidence supporting the
contention that older clients have a poorer prognosis.contention that older clients have a poorer prognosis.
 It is best to consider not age alone, but rather theIt is best to consider not age alone, but rather the
specific characteristics of the prospective patient.specific characteristics of the prospective patient.
Even a 55 years old but active patient can benefit.Even a 55 years old but active patient can benefit.
 Research supports the efficacy of various forms ofResearch supports the efficacy of various forms of
both cognitive-behavioral and psychodynamicboth cognitive-behavioral and psychodynamic
treatment with older adults.treatment with older adults.

9. 3. MOTIVATION:3. MOTIVATION:
 Psychotherapy is sometimes a lengthy process andPsychotherapy is sometimes a lengthy process and
demands much from a patient.demands much from a patient.
 It can be fraught with anxiety, setbacks, and periods ofIt can be fraught with anxiety, setbacks, and periods of
a seeming absence of progress.a seeming absence of progress.
 It may demand that the patient engage in newIt may demand that the patient engage in new
behaviors that will provoke anxiety.behaviors that will provoke anxiety.
 Successful psychotherapy seems to requireSuccessful psychotherapy seems to require
motivation.motivation.
 Psychotherapy is a voluntary process; one cannot bePsychotherapy is a voluntary process; one cannot be
forced into it. When people are forced, either openly orforced into it. When people are forced, either openly or
subtly, to become patients, they rarely profit from thesubtly, to become patients, they rarely profit from the
experience.experience.

10.  Therapy is not likely to be of much benefit to theTherapy is not likely to be of much benefit to the
prisoner who seeks therapy to impress a parole board;prisoner who seeks therapy to impress a parole board;
 to the college student who, following a marijuanato the college student who, following a marijuana
charge, is given the option of reporting to a counselingcharge, is given the option of reporting to a counseling
center or facing the prospect of jail;center or facing the prospect of jail;
 or to the person who undergoes therapy to protect anor to the person who undergoes therapy to protect an
insurance claim.insurance claim.
 Despite the conventional wisdom that cites clientDespite the conventional wisdom that cites client
motivation as a necessary condition for positivemotivation as a necessary condition for positive
change, research support is mixed.change, research support is mixed.
 Yoken and Berman used client payment for servicesYoken and Berman used client payment for services
as an index of client motivation; they concluded thatas an index of client motivation; they concluded that
motivation appears to be unrelated to outcome.motivation appears to be unrelated to outcome.

11. 4. OPENNESS:4. OPENNESS:
 Most therapists intuitively attach a betterMost therapists intuitively attach a better
prognosis to patients who seem to show someprognosis to patients who seem to show some
respect for and optimism about the utility ofrespect for and optimism about the utility of
psychotherapy.psychotherapy.
 Such persons can be more easily "taught to beSuch persons can be more easily "taught to be
good psychotherapy patients," in contrast togood psychotherapy patients," in contrast to
patientpatient whowho view their difficulties as symptomsview their difficulties as symptoms
that can be cured by an omniscient, authoritativethat can be cured by an omniscient, authoritative
therapist while they passively await the outcome.therapist while they passively await the outcome.
 Thus, a kind of "openness" to the therapeuticThus, a kind of "openness" to the therapeutic
process appears to make the patient a better betprocess appears to make the patient a better bet
for therapy.for therapy.

12. 5. GENDER:5. GENDER:
 In the present climate, there are several prominentIn the present climate, there are several prominent
issues related to gender.issues related to gender.
 One is the relationship between the outcomes ofOne is the relationship between the outcomes of
therapy and the gender of the patient.therapy and the gender of the patient.
 A second, more volatile issue is whether sexismA second, more volatile issue is whether sexism
operates in therapy and whether, for example,operates in therapy and whether, for example,
male therapists exploit female patients.male therapists exploit female patients.
 Research into the question of whether therapistsResearch into the question of whether therapists
and counselors are guilty of gender bias andand counselors are guilty of gender bias and
stereotyping is highly inconsistent.stereotyping is highly inconsistent.

13. Gender Aware TherapyGender Aware Therapy
 Good, Gilbert, and Scher (1990) have evenGood, Gilbert, and Scher (1990) have even
recommended a brand of psychotherapy calledrecommended a brand of psychotherapy called
Gender Aware Therapy (GAT).Gender Aware Therapy (GAT).
 GAT integrates feminist psychotherapy andGAT integrates feminist psychotherapy and
knowledge of gender into a treatment approach forknowledge of gender into a treatment approach for
both women and men.both women and men.
 Finally, although gender of the client has not beenFinally, although gender of the client has not been
reliably linked to outcome, it is probably true thatreliably linked to outcome, it is probably true that
gender of the therapist may be especiallygender of the therapist may be especially
important to consider in certain cases.important to consider in certain cases.

14. FEMINIST THERAPYFEMINIST THERAPY
 For many years, therapy was a male-dominatedFor many years, therapy was a male-dominated
enterprise.enterprise.
 New treatment models were needed to deal with theNew treatment models were needed to deal with the
disorders prevalent among women.disorders prevalent among women.
 Feminist therapy-aFeminist therapy-a therapy that would recognize thetherapy that would recognize the
manner in which women have been oppressed bymanner in which women have been oppressed by
society through the ages.society through the ages.
 It acknowledges that many of the personal problemsIt acknowledges that many of the personal problems
of women arise out of the social position women areof women arise out of the social position women are
forced to adopt.forced to adopt.

15.  The feminist approach views the relationshipThe feminist approach views the relationship
between therapist and patient in terms ofbetween therapist and patient in terms of
equality rather than power versusequality rather than power versus
subordination.subordination.
 Feminists, in short, do not take kindly to theFeminists, in short, do not take kindly to the
"power of expertise.“"power of expertise.“
 Feminist therapists tend to be especiallyFeminist therapists tend to be especially
attuned to specific emotional problemsattuned to specific emotional problems
experienced by women.experienced by women.
 Also important are concrete issues such asAlso important are concrete issues such as
work, finances, and family choices.work, finances, and family choices.

16. 6. RACE, ETHNICITY AND SOCIAL6. RACE, ETHNICITY AND SOCIAL
CLASSCLASS
 It does appear that many therapeuticIt does appear that many therapeutic
techniques have been designed and developedtechniques have been designed and developed
for white, middle -and upper-class patients.for white, middle -and upper-class patients.
 Banks (1972) has suggested that greaterBanks (1972) has suggested that greater
rapport and self-exploration may occur whenrapport and self-exploration may occur when
both therapist and patient are of the same race.both therapist and patient are of the same race.
 Two decades of research have seemingly failedTwo decades of research have seemingly failed
to show conclusively that ethnic minoritiesto show conclusively that ethnic minorities
achieve differential treatment outcomes.achieve differential treatment outcomes.

17.  It was Schofield (1964) who described theIt was Schofield (1964) who described the
psychotherapist's belief in the ideal patient aspsychotherapist's belief in the ideal patient as
thethe YAVIS syndromeYAVIS syndrome (young, attractive,(young, attractive,
verbal, intelligent, and successful).verbal, intelligent, and successful).
 What has not been examined in great detail isWhat has not been examined in great detail is
whether patients and therapists should bewhether patients and therapists should be
matched according to social classmatched according to social class
 or whether some forms of psychotherapy areor whether some forms of psychotherapy are
more effective than others for patients frommore effective than others for patients from
lower socioeconomic levels.lower socioeconomic levels.

18.  When there is a significant difference between the socialWhen there is a significant difference between the social
class or the values of the patient and those of theclass or the values of the patient and those of the
therapist, some researchers have found that the patient'stherapist, some researchers have found that the patient's
willingness to remain in therapy may suffer.willingness to remain in therapy may suffer.
 Special efforts to build a therapeutic relationship canSpecial efforts to build a therapeutic relationship can
overcome the difficulties encountered when therapist andovercome the difficulties encountered when therapist and
patient differ in background.patient differ in background.
 Goldstein has described a “psychotherapy for the poor”.Goldstein has described a “psychotherapy for the poor”.
 Few would disagree; however, that culturalFew would disagree; however, that cultural sensitivitysensitivity onon
the part of the therapist is very important.the part of the therapist is very important.
 It is imperative that clinical psychology develop culturallyIt is imperative that clinical psychology develop culturally
sensitive therapists who can work effectively withsensitive therapists who can work effectively with
culturally diverse populations.culturally diverse populations.

19. THERAPISTS’ REACTIONS TO PATIENTSTHERAPISTS’ REACTIONS TO PATIENTS
 A therapist should be able to work with elegantA therapist should be able to work with elegant
effectiveness regardless of her or his positive oreffectiveness regardless of her or his positive or
negative reactions to the patient.negative reactions to the patient.
 Fortunately, the understanding and self-control ofFortunately, the understanding and self-control of
therapists in their professional relations withtherapists in their professional relations with
patients exceed the understanding and self-patients exceed the understanding and self-
control of many lay-persons in their social andcontrol of many lay-persons in their social and
interpersonal relationships.interpersonal relationships.
 In at least one study, therapists were less inclinedIn at least one study, therapists were less inclined
to treat hypothetical patients whom they did notto treat hypothetical patients whom they did not
like as compared to those they liked.like as compared to those they liked.

20. Characteristics of theCharacteristics of the
TherapistTherapist

21. THE THERAPISTTHE THERAPIST
 It will hardly come as a shock to learn that certainIt will hardly come as a shock to learn that certain
therapist characteristics may affect the process oftherapist characteristics may affect the process of
therapy.therapy.
 Freud very early recognized the potential effects of theFreud very early recognized the potential effects of the
psychoanalyst's personality on the process ofpsychoanalyst's personality on the process of
psychoanalysis.psychoanalysis.
 To "prevent" such personal factors from affecting theTo "prevent" such personal factors from affecting the
process, he recommended that analysts undergoprocess, he recommended that analysts undergo
periodic analyses so that they could learn toperiodic analyses so that they could learn to
recognize and control them.recognize and control them.
 Unfortunately, although nearly everyone agrees thatUnfortunately, although nearly everyone agrees that
therapist variables are important, there is much lesstherapist variables are important, there is much less
agreement on specifics. How therapist characteristicsagreement on specifics. How therapist characteristics
contribute to therapy outcome has become ancontribute to therapy outcome has become an
important research area.important research area.

22. THERAPIST’sTHERAPIST’s SEX, AGE AND ETHNICITYSEX, AGE AND ETHNICITY
 Beutler et al. report that the available researchBeutler et al. report that the available research
evidence suggests that therapist’s age is notevidence suggests that therapist’s age is not
related to outcome,related to outcome,
 that female versus male therapists do not appearthat female versus male therapists do not appear
to produce significantly better therapeutic effects,to produce significantly better therapeutic effects,
 and that patient-therapist similarity with regard toand that patient-therapist similarity with regard to
ethnicity does not necessarily result in betterethnicity does not necessarily result in better
outcome.outcome.
 These therapist variables may interact with clientThese therapist variables may interact with client
characteristics, setting for treatment, and modalitycharacteristics, setting for treatment, and modality
of treatment.of treatment.

23. THERAPIST’STHERAPIST’S PERSONALITYPERSONALITY
 In discussing therapist variables, Strupp and BerginIn discussing therapist variables, Strupp and Bergin
(1969) made two points worth noting.(1969) made two points worth noting.
 First, even though the evidence shows that theFirst, even though the evidence shows that the
therapist's personality is a potent force; other factorstherapist's personality is a potent force; other factors
in combination largely deter­mine therapy outcomes.in combination largely deter­mine therapy outcomes.
 Second, research in this area has taken a back seatSecond, research in this area has taken a back seat
as behavioral therapies have gained in popularity.as behavioral therapies have gained in popularity.
 Krasner (1963), suggested that the research literatureKrasner (1963), suggested that the research literature
would depict the ideal therapist as:would depict the ideal therapist as:

24. Mature, well-adjusted, sympathetic, tolerant, patient,Mature, well-adjusted, sympathetic, tolerant, patient,
Kindly, tactful, nonjudgmental, accepting, permissive,Kindly, tactful, nonjudgmental, accepting, permissive,
Non-critical,Non-critical, warmwarm, likable, interested in human beings,, likable, interested in human beings,
Respect-ful, cherishing and working for a democratic kind ofRespect-ful, cherishing and working for a democratic kind of
interpersonal relationship with all people,interpersonal relationship with all people,
Free of prejudice, having a worthwhile goal in life, friendly,Free of prejudice, having a worthwhile goal in life, friendly,
encouraging, optimistic, strong,encouraging, optimistic, strong,
Intelligent, wise, curious, creative, artistic, scientificallyIntelligent, wise, curious, creative, artistic, scientifically
oriented, competent, trustworthy, a model for the patient tooriented, competent, trustworthy, a model for the patient to
follow, resourceful,follow, resourceful,
Emotionally sensitive, dependable, consistent, open, honest,Emotionally sensitive, dependable, consistent, open, honest,
frank, technically sophisticated, professionally dedicated,frank, technically sophisticated, professionally dedicated,
and so on.and so on.

25.  Certainly no human being, let alone a therapist, couldCertainly no human being, let alone a therapist, could
possibly possess all of these traits.possibly possess all of these traits.
 So the concept of the "ideal therapist" is not verySo the concept of the "ideal therapist" is not very
useful.useful.
 The influence of therapist personality traits onThe influence of therapist personality traits on
outcome has not received adequate researchoutcome has not received adequate research
attention.attention.
 The greatest amount of attention has been focused onThe greatest amount of attention has been focused on
dominance/dogmatism, locus of perceived control,dominance/dogmatism, locus of perceived control,
and cognitive processing style.and cognitive processing style.
 Each of these variables appears to affect outcomeEach of these variables appears to affect outcome
differentially depending on client traits and type ofdifferentially depending on client traits and type of
therapy (Beutler et al., 1994).therapy (Beutler et al., 1994).

26. EMPATHY, WARMTH AND GENUINNESSEMPATHY, WARMTH AND GENUINNESS
 SwensonSwenson (1971) has suggested that a major factor(1971) has suggested that a major factor
that differentiates successful from unsuccessfulthat differentiates successful from unsuccessful
therapists is their interest in people and theirtherapists is their interest in people and their
commitment to the patient.commitment to the patient.
 The attention to empathy, along with the relatedThe attention to empathy, along with the related
notions of warmth and genuineness, grew out of Carlnotions of warmth and genuineness, grew out of Carl
Rogers' (1951) system of client-centered therapy:Rogers' (1951) system of client-centered therapy:
 Some research evidence has seemed to point to aSome research evidence has seemed to point to a
relationship between these three qualities andrelationship between these three qualities and
successful out-comes in therapy.successful out-comes in therapy.

27.  Researchers regardResearchers regard empathyempathy,, warmthwarmth, and, and
genuinenessgenuineness as necessary but not sufficientas necessary but not sufficient
conditions for good therapy outcomes.conditions for good therapy outcomes.
 In more recent years, these three qualities have beenIn more recent years, these three qualities have been
regarded more as trainable and learnable skills.regarded more as trainable and learnable skills.
 It has also been argued that these three featuresIt has also been argued that these three features
reflect not only qualities of the therapist but alsoreflect not only qualities of the therapist but also
qualities of the therapeutic relationship.qualities of the therapeutic relationship.
 Nature and strength of the working relationshipNature and strength of the working relationship
between therapist and patient is a major contributor tobetween therapist and patient is a major contributor to
positive outcome.positive outcome.

28.  FREEDOM FROM PERSONAL PROBLEMSFREEDOM FROM PERSONAL PROBLEMS
 Does personal therapy lead to greaterDoes personal therapy lead to greater
effectiveness as a therapist?effectiveness as a therapist?
 In a survey of 749 practicing therapists whoIn a survey of 749 practicing therapists who
were APA members 45% responded regardingwere APA members 45% responded regarding
their own personal problems.their own personal problems.
 Further, out of 562 licensed psychologists,Further, out of 562 licensed psychologists,
more than a third reported high levels of bothmore than a third reported high levels of both
emotional exhaustion and depersonalizationemotional exhaustion and depersonalization
what is often called "burnout”.what is often called "burnout”.

29.  Although therapists need not be paragons ofAlthough therapists need not be paragons of
adjustment, it is unlikely that a therapist beset withadjustment, it is unlikely that a therapist beset with
emotional problems can be as effective as one wouldemotional problems can be as effective as one would
like.like.
 It is important that therapists recognize areas in theirIt is important that therapists recognize areas in their
own lives that are tender.own lives that are tender.
 The tendency to become angry or anxious whenThe tendency to become angry or anxious when
certain topics arise or the inability to handle a client'scertain topics arise or the inability to handle a client's
questions without becoming defensive is a signal thatquestions without becoming defensive is a signal that
something is amiss.something is amiss.
 Therapists must be able to look at their patients withTherapists must be able to look at their patients with
objectivity and not become entangled in their personalobjectivity and not become entangled in their personal
dynamics.dynamics.
 The therapy room is not a place for the gratification ofThe therapy room is not a place for the gratification of
one's own emotional needs.one's own emotional needs.

30. SEXUAL EXPLOITATIONSEXUAL EXPLOITATION
 Unfortunately, there are still too manyUnfortunately, there are still too many
examples of victimization of women by theirexamples of victimization of women by their
male therapists, and an increasing number ofmale therapists, and an increasing number of
cases of women being victimized by femalecases of women being victimized by female
therapists.therapists.
 Many questions about this kind of unnaturalMany questions about this kind of unnatural
conduct arise such as:conduct arise such as:
 what kinds of behaviors are appropriate on thewhat kinds of behaviors are appropriate on the
part of the therapist, what patients should do inpart of the therapist, what patients should do in
response, and withresponse, and with whom they can lodgewhom they can lodge
complaints have been discussed incomplaints have been discussed in CommitteeCommittee

31. EXPERIENCE AND PROFESSIONALEXPERIENCE AND PROFESSIONAL
IDENTIFICATIONIDENTIFICATION
 Conventional wisdom suggests that the moreConventional wisdom suggests that the more
experienced the psychotherapist, the moreexperienced the psychotherapist, the more
effective she or he will be with patients.effective she or he will be with patients.
 Although this is intuitively appealing the bulk ofAlthough this is intuitively appealing the bulk of
research evidence has not supported thisresearch evidence has not supported this
position.position.
 ParaprofessionalsParaprofessionals trained specifically totrained specifically to
conduct psychotherapy produce outcomesconduct psychotherapy produce outcomes
equivalent to, or even sometimes exceedingequivalent to, or even sometimes exceeding
those produced by trained psychotherapists.those produced by trained psychotherapists.

32.  Over the years, there have been many running feudsOver the years, there have been many running feuds
over which profession is bestover which profession is best equipped toequipped to carry outcarry out
proper therapy.proper therapy.
 For a longtime, psychiatrists actively sought to preventFor a longtime, psychiatrists actively sought to prevent
clinical psychologists from conducting therapy in theclinical psychologists from conducting therapy in the
absence of psychiatric supervision.absence of psychiatric supervision.
 In fact, no real evidence supports the argument thatIn fact, no real evidence supports the argument that
one profession boasts superior therapists (be theyone profession boasts superior therapists (be they
clinical psychologists, psychiatric social workers, orclinical psychologists, psychiatric social workers, or
psychiatrists.psychiatrists.
 Thus, at this point in time, data do not seem to supportThus, at this point in time, data do not seem to support
the superiority of one mental health profession overthe superiority of one mental health profession over
others in terms of effectiveness and client satisfaction.others in terms of effectiveness and client satisfaction.