NATURE OF SPECIFIC NATURE OF SPECIFIC THERAPUTIC VARIABLESTHERAPUTIC VARIABLES

Lecture 28Lecture 28

It would be pleasant if psychotherapy were a simple It 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, and conveys 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 time But it is often necessary to spend considerable time correcting patients' expectations that they will be given correcting patients' expectations that they will be given a simple psychological prescription. a simple psychological prescription.

Because psychotherapy is an active, dynamic Because psychotherapy is an active, dynamic process, passivity and lack of motivation can be process, 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 interaction the therapist, and the patient-therapist interaction affect the process of therapy in important affect the process of therapy in important ways.ways.

The outcomes of therapy are exceedinglyThe outcomes of therapy are exceedingly complex events that are not shaped by patient complex events that are not shaped by patient characteristics alone.characteristics alone.

They are also determined by therapist qualities They are also determined by therapist qualities and skills, the kinds of therapeutic procedures and skills, the kinds of therapeutic procedures employed, the circumstances and environment employed, the circumstances and environment of patients, and so on.of patients, and so on.

Now we will discuss some of the more Now we will discuss some of the more prominent prominent patient’s variablespatient’s variables that have that have been related to outcomes in traditional been related to outcomes in traditional therapies.therapies.

VARIABLES RELATING VARIABLES RELATING THE PATIENT OR THE THE PATIENT OR THE

CLIENTCLIENT

1. THE DEGREE OF PATIENT’S DISTRESS:1. THE DEGREE OF PATIENT’S DISTRESS:

A broad generalization often made by clinicians is that A broad generalization often made by clinicians is that the persons who need therapy the least are the the 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 is Good prognosis may be expected for a patient who is experiencing distress or anxiety but is functioning well experiencing distress or anxiety but is functioning well behaviorally.behaviorally.

At best, however, the research data are contradictory At best, however, the research data are contradictory and inconsistent.and inconsistent.

For example, one group of studies finds that greater For 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.

More recent studies seem to find with some More recent studies seem to find with some consistency that individuals who are more consistency that individuals who are more severely disturbed have poorer outcomes.severely disturbed have poorer outcomes.

In general, psychotherapy requires a In general, psychotherapy requires a reasonable level of intelligence; brighter reasonable level of intelligence; brighter individuals seem better able to handle the individuals 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. It First, psychotherapy is a verbal process. It requires patients to articulate their problems, to requires patients to articulate their problems, to frame them in words.frame them in words.

Second, psychotherapy requires patients to establish Second, psychotherapy requires patients to establish connections among events.connections among events.

Finally, to enable connections among events to be Finally, to enable connections among events to be made, psychotherapy requires a degree of made, psychotherapy requires a degree of introspection.introspection.

Behavioral forms of therapy have often been used with Behavioral forms of therapy have often been used with considerable success with individuals suffering from considerable success with individuals suffering from cognitive limitations.cognitive limitations.

A variety of behavior modification approaches are A variety of behavior modification approaches are quite feasible: as a generalization, when behavioral quite feasible: as a generalization, when behavioral deficits are the problem, behavioral techniques are deficits are the problem, behavioral techniques are frequently the preferred ones.frequently the preferred ones.

2. AGE:2. AGE: Younger patients are presumably more flexible or less Younger 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 the But 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 the It 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 of Research supports the efficacy of various forms of both cognitive-behavioral and psychodynamic both cognitive-behavioral and psychodynamic treatment with older adults.treatment with older adults.

3. MOTIVATION:3. MOTIVATION: Psychotherapy is sometimes a lengthy process and Psychotherapy 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 of It 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 new It may demand that the patient engage in new behaviors that will provoke anxiety.behaviors that will provoke anxiety.

Successful psychotherapy seems to require Successful psychotherapy seems to require motivation.motivation.

Psychotherapy is a voluntary process; one cannot be Psychotherapy is a voluntary process; one cannot be forced into it. When people are forced, either openly or forced into it. When people are forced, either openly or subtly, to become patients, they rarely profit from the subtly, to become patients, they rarely profit from the experience.experience.

Therapy is not likely to be of much benefit to the Therapy 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 marijuana to the college student who, following a marijuana charge, is given the option of reporting to a counseling charge, 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 an or to the person who undergoes therapy to protect an insurance claim. insurance claim.

Despite the conventional wisdom that cites client Despite the conventional wisdom that cites client motivation as a necessary condition for positive motivation as a necessary condition for positive change, research support is mixed.change, research support is mixed.

Yoken and Berman used client payment for services Yoken and Berman used client payment for services as an index of client motivation; they concluded that as an index of client motivation; they concluded that motivation appears to be unrelated to outcome.motivation appears to be unrelated to outcome.

4. OPENNESS:4. OPENNESS: Most therapists intuitively attach a better Most therapists intuitively attach a better

prognosis to patients who seem to show some prognosis to patients who seem to show some respect for and optimism about the utility of respect for and optimism about the utility of psychotherapy.psychotherapy.

Such persons can be more easily "taught to be Such persons can be more easily "taught to be good psychotherapy patients," in contrast to good psychotherapy patients," in contrast to patient patient who who view their difficulties as symptoms view their difficulties as symptoms that can be cured by an omniscient, authoritative that 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 therapeutic Thus, a kind of "openness" to the therapeutic process appears to make the patient a better bet process appears to make the patient a better bet for therapy.for therapy.

5. GENDER:5. GENDER: In the present climate, there are several prominent In the present climate, there are several prominent

issues related to gender.issues related to gender.

One is the relationship between the outcomes of One 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 sexism A 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 therapists Research into the question of whether therapists and counselors are guilty of gender bias and and counselors are guilty of gender bias and stereotyping is highly inconsistent.stereotyping is highly inconsistent.

Gender Aware TherapyGender Aware Therapy

Good, Gilbert, and Scher (1990) have even Good, Gilbert, and Scher (1990) have even recommended a brand of psychotherapy called recommended a brand of psychotherapy called Gender Aware Therapy (GAT).Gender Aware Therapy (GAT).

GAT integrates feminist psychotherapy and GAT integrates feminist psychotherapy and knowledge of gender into a treatment approach for knowledge of gender into a treatment approach for both women and men.both women and men.

Finally, although gender of the client has not been Finally, although gender of the client has not been reliably linked to outcome, it is probably true that reliably linked to outcome, it is probably true that gender of the therapist may be especially gender of the therapist may be especially important to consider in certain cases.important to consider in certain cases.

FEMINIST THERAPYFEMINIST THERAPY

For many years, therapy was a male-dominated For many years, therapy was a male-dominated enterprise.enterprise.

New treatment models were needed to deal with the New treatment models were needed to deal with the disorders prevalent among women.disorders prevalent among women.

Feminist therapy-a Feminist therapy-a therapy that would recognize the therapy that would recognize the manner in which women have been oppressed by manner in which women have been oppressed by society through the ages.society through the ages.

It acknowledges that many of the personal problems It acknowledges that many of the personal problems of women arise out of the social position women are of women arise out of the social position women are forced to adopt.forced to adopt.

The feminist approach views the relationship The feminist approach views the relationship between therapist and patient in terms of between therapist and patient in terms of equality rather than power versus equality rather than power versus subordination.subordination.

Feminists, in short, do not take kindly to the Feminists, in short, do not take kindly to the "power of expertise.“"power of expertise.“

Feminist therapists tend to be especially Feminist therapists tend to be especially attuned to specific emotional problems attuned to specific emotional problems experienced by women.experienced by women.

Also important are concrete issues such as Also important are concrete issues such as work, finances, and family choices.work, finances, and family choices.

6. RACE, ETHNICITY AND SOCIAL 6. RACE, ETHNICITY AND SOCIAL CLASSCLASS

It does appear that many therapeutic It does appear that many therapeutic techniques have been designed and developed techniques have been designed and developed for white, middle and upper-class patients.for white, middle and upper-class patients.

Banks (1972) has suggested that greater Banks (1972) has suggested that greater rapport and self-exploration may occur when rapport 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 failed Two decades of research have seemingly failed to show conclusively that ethnic minorities to show conclusively that ethnic minorities achieve differential treatment outcomes.achieve differential treatment outcomes.

It was Schofield (1964) who described the It was Schofield (1964) who described the psychotherapist's belief in the ideal patient as psychotherapist's belief in the ideal patient as the the YAVIS syndromeYAVIS syndrome (young, attractive, (young, attractive, verbal, intelligent, and successful).verbal, intelligent, and successful).

What has not been examined in great detail is What has not been examined in great detail is whether patients and therapists should be whether patients and therapists should be matched according to social class matched according to social class

or whether some forms of psychotherapy are or whether some forms of psychotherapy are more effective than others for patients from more effective than others for patients from lower socioeconomic levels.lower socioeconomic levels.

When there is a significant difference between the social When there is a significant difference between the social class or the values of the patient and those of the class or the values of the patient and those of the therapist, some researchers have found that the patient's therapist, 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 can Special efforts to build a therapeutic relationship can overcome the difficulties encountered when therapist and overcome 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 cultural Few would disagree; however, that cultural sensitivity sensitivity on on the part of the therapist is very important.the part of the therapist is very important.

It is imperative that clinical psychology develop culturally It is imperative that clinical psychology develop culturally sensitive therapists who can work effectively with sensitive therapists who can work effectively with culturally diverse populations.culturally diverse populations.

THERAPISTS’ REACTIONS TO PATIENTSTHERAPISTS’ REACTIONS TO PATIENTS

A therapist should be able to work with elegant A therapist should be able to work with elegant effectiveness regardless of her or his positive or effectiveness regardless of her or his positive or negative reactions to the patient.negative reactions to the patient.

Fortunately, the understanding and self-control of Fortunately, the understanding and self-control of therapists in their professional relations with therapists 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 and control of many lay persons in their social and interpersonal relationships.interpersonal relationships.

In at least one study, therapists were less inclined In at least one study, therapists were less inclined to treat hypothetical patients whom they did not to treat hypothetical patients whom they did not like as compared to those they liked.like as compared to those they liked.

Characteristics of the Characteristics of the TherapistTherapist

THE THERAPISTTHE THERAPIST It will hardly come as a shock to learn that certain It will hardly come as a shock to learn that certain

therapist characteristics may affect the process of therapist characteristics may affect the process of therapy.therapy.

Freud very early recognized the potential effects of the Freud very early recognized the potential effects of the psychoanalyst's personality on the process of psychoanalyst's personality on the process of psychoanalysis.psychoanalysis.

To "prevent" such personal factors from affecting the To "prevent" such personal factors from affecting the process, he recommended that analysts undergo process, he recommended that analysts undergo periodic analyses so that they could learn to periodic analyses so that they could learn to recognize and control them.recognize and control them.

Unfortunately, although nearly everyone agrees that Unfortunately, although nearly everyone agrees that therapist variables are important, there is much less therapist variables are important, there is much less agreement on specifics. How therapist characteristics agreement on specifics. How therapist characteristics contribute to therapy outcome has become an contribute to therapy outcome has become an important research area.important research area.

THERAPIST’sTHERAPIST’s SEX, AGE AND ETHNICITYSEX, AGE AND ETHNICITY

Beutler et al. report that the available research Beutler et al. report that the available research evidence suggests that therapist’s age is not evidence suggests that therapist’s age is not related to outcome, related to outcome,

that female versus male therapists do not appear that 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 to and that patient-therapist similarity with regard to ethnicity does not necessarily result in better ethnicity does not necessarily result in better outcome.outcome.

These therapist variables may interact with client These therapist variables may interact with client characteristics, setting for treatment, and modality characteristics, setting for treatment, and modality of treatment.of treatment.

THERAPIST’STHERAPIST’S PERSONALITYPERSONALITY In discussing therapist variables, Strupp and Bergin In 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 the First, even though the evidence shows that the therapist's personality is a potent force; other factors therapist's personality is a potent force; other factors in combination largely deter mine therapy outcomes.in combination largely deter mine therapy outcomes.

Second, research in this area has taken a back seat Second, 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 literature Krasner (1963), suggested that the research literature would depict the ideal therapist as: would depict the ideal therapist as:

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 of Respect 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, scientifically Intelligent, wise, curious, creative, artistic, scientifically oriented, competent, trustworthy, a model for the patient to oriented, 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.

Certainly no human being, let alone a therapist, could Certainly 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 very So the concept of the "ideal therapist" is not very useful.useful.

The influence of therapist personality traits on The influence of therapist personality traits on outcome has not received adequate research outcome has not received adequate research attention.attention.

The greatest amount of attention has been focused on The greatest amount of attention has been focused on dominance/dogmatism, locus of perceived control, and dominance/dogmatism, locus of perceived control, and cognitive processing style.cognitive processing style.

Each of these variables appears to affect outcome Each of these variables appears to affect outcome differentially depending on client traits and type of differentially depending on client traits and type of therapy (Beutler et al., 1994).therapy (Beutler et al., 1994).

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 unsuccessful that differentiates successful from unsuccessful therapists is their interest in people and their therapists is their interest in people and their commitment to the patient.commitment to the patient.

The attention to empathy, along with the related The attention to empathy, along with the related notions of warmth and genuineness, grew out of Carl notions 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 a Some research evidence has seemed to point to a relationship between these three qualities and relationship between these three qualities and successful out comes in therapy. successful out comes in therapy.

Researchers regard Researchers regard empathyempathy, , warmthwarmth, and , and genuinenessgenuineness as necessary but not sufficient as necessary but not sufficient conditions for good therapy outcomes.conditions for good therapy outcomes.

In more recent years, these three qualities have been In 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 features It has also been argued that these three features reflect not only qualities of the therapist but also reflect not only qualities of the therapist but also qualities of the therapeutic relationship.qualities of the therapeutic relationship.

Nature and strength of the working relationship Nature and strength of the working relationship between therapist and patient is a major contributor to between therapist and patient is a major contributor to positive outcome.positive outcome.

FREEDOM FROM PERSONAL PROBLEMSFREEDOM FROM PERSONAL PROBLEMS

Does personal therapy lead to greater Does personal therapy lead to greater effectiveness as a therapist?effectiveness as a therapist?

In a survey of 749 practicing therapists who In a survey of 749 practicing therapists who were APA members 45% responded regarding were 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 both more than a third reported high levels of both emotional exhaustion and depersonalization emotional exhaustion and depersonalization what is often called "burnout”.what is often called "burnout”.

Although therapists need not be paragons of Although therapists need not be paragons of adjustment, it is unlikely that a therapist beset with adjustment, it is unlikely that a therapist beset with emotional problems can be as effective as one would emotional problems can be as effective as one would like.like.

It is important that therapists recognize areas in their It 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 when The tendency to become angry or anxious when certain topics arise or the inability to handle a client's certain topics arise or the inability to handle a client's questions without becoming defensive is a signal that questions without becoming defensive is a signal that something is amiss. something is amiss.

Therapists must be able to look at their patients with Therapists must be able to look at their patients with objectivity and not become entangled in their personal objectivity and not become entangled in their personal dynamics.dynamics.

The therapy room is not a place for the gratification of The therapy room is not a place for the gratification of one's own emotional needs.one's own emotional needs.

SEXUAL EXPLOITATIONSEXUAL EXPLOITATION

Unfortunately, there are still too many examples Unfortunately, there are still too many examples of victimization of women by their male of victimization of women by their male therapists, and an increasing number of cases therapists, and an increasing number of cases of women being victimized by female therapists.of women being victimized by female therapists.

Many questions about this kind of unnatural Many questions about this kind of unnatural conduct arise such as: conduct arise such as:

what kinds of behaviors are appropriate on the what kinds of behaviors are appropriate on the part of the therapist, what patients should do in part of the therapist, what patients should do in response, and withresponse, and with whom they can lodge whom they can lodge complaints have been discussed in complaints have been discussed in Committee Committee on Women in Psychologyon Women in Psychology (1989). (1989).

EXPERIENCE AND PROFESSIONAL EXPERIENCE AND PROFESSIONAL IDENTIFICATIONIDENTIFICATION

Conventional wisdom suggests that the more Conventional wisdom suggests that the more experienced the psychotherapist, the more experienced 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 of Although this is intuitively appealing the bulk of research evidence has not supported this research evidence has not supported this position.position.

Paraprofessionals Paraprofessionals trained specifically to trained specifically to conduct psychotherapy produce outcomes conduct psychotherapy produce outcomes equivalent to, or even sometimes exceeding equivalent to, or even sometimes exceeding those produced by trained psychotherapists.those produced by trained psychotherapists.

Over the years, there have been many running feuds Over the years, there have been many running feuds over which profession is best over which profession is best equipped toequipped to carry out carry out proper therapy.proper therapy.

For a longtime, psychiatrists actively sought to prevent For a longtime, psychiatrists actively sought to prevent clinical psychologists from conducting therapy in the clinical psychologists from conducting therapy in the absence of psychiatric supervision.absence of psychiatric supervision.

In fact, no real evidence supports the argument that In fact, no real evidence supports the argument that one profession boasts superior therapists (be they one profession boasts superior therapists (be they clinical psychologists, psychiatric social workers, or clinical psychologists, psychiatric social workers, or psychiatrists.psychiatrists.

Thus, at this point in time, data do not seem to support Thus, at this point in time, data do not seem to support the superiority of one mental health profession over the superiority of one mental health profession over others in terms of effectiveness and client satisfaction.others in terms of effectiveness and client satisfaction.