Client Variables
Information comes from A) Previous Editions of
the Handbook, written by Sol Garfield, and the current edition (2004) written
by Clarkin & Levy ( in bold)
Selection-
Those who
seek treatment are more likely to feel helpless, be socially isolated, and have
low self-worth.
Higher SES:
more likely to be accepted for treatment; the more expert the staff, the more
stringent the selection criteria.
Mid & Upper class-outpatient
psychotherapy
Lower class- Inpatient & Rx
After being
accepted for therapy, 20-50% fail to come to first
session.
Women are more likely than men to
seek therapy and the elderly are more reluctant than the younger. According to
epidemiologic surveys, about 30% of adults will experience a diagnosable mental
condition in any given year and the majority of these individuals (56-60%) will
have more than one disorder. More than 70% of these folks receive no services
and only 13% obtained treatment from a mental health professional (p. 196).
Continuation-
10-15% of
patients will go to 20+ sessions.
Approximately
25% will drop out after the first session.
Premature
termination rates of 23-60% have been reported.
Predictors
of Continuation
SES
Education
Role
Induction Training
Completing
a test (ex. MMPI)
Household income
Negative attitudes toward treatment(-)
Incongruent treatment expectations(-)
Minorities generally underutilize
psychotherapy and drop out earlier.
Personality disorder diagnosis (-)
Not
Predictors
Gender,
Age, Diagnosis, Personality Measures
Outcome-
Predictors
Degree of
disturbance (-)
feeling
better by 3-4 sessions
patient
involvement in the therapeutic process.
Patient-Therapist
Marital Match
SES, in depression
Positive expectancy of outcome
Functional impairment; for example:
work, family (-)
Co-morbid Personality Disorder(-)
Quality of the therapeutic alliance
Not
Predictors
IQ, Age, Gender, Personality scales, race
Many years
ago Luborski made a statement that we know to be
accurate (other things being equal) about therapy,
“THOSE WHO
STAY IN TREATMENT IMPROVE, THOSE WHO IMPROVE ARE BETTER OFF TO BEGIN WITH THAN
THOSE WHO DO NOT IMPROVE, AND ONE CAN PREDICT RESPONSE TO TREATMENT BY HOW WELL
OFF THEY ARE TO BEGIN WITH”
Many have
speculated about ATI interactions where the Client variable is the Aptitude.
That is, some form of therapy (or therapist quality) may work better with some
types of clients. Examples of client
dimensions include: quality of object relations, attachment patterns, and client
reactance/resistance. “The finding of the ATI research to date has been
relatively disappointing, and Project Match is a prime example.” (Clarkin & Levy, 2004, p. 214).
Hare-Mustin ‘83
Most
theories of therapy are male ideas.
Women are the primary users of a mental health care system controlled by
men.
“Feminist
therapists emphasize that the therapist should be an agent of social change…
Increasing the woman’s awareness of sociopolitical pressures, supporting here
legitimate anger, including anger at the therapist... Encouraging
respect for herself and other women, helping her to recognize her choices and
change the context of her life.”
Guidelines
for therapy with women-
1. Therapy should be free of restrictions based
on gender defined roles.
2. Therapists should facilitate the examination
of the reality, variety & implications of sex-discriminatory practices.
3. Therapists should be knowledgeable about
research on sex roles and sexism.
4. Theoretical concepts employed should be free
of sex bias.
5. Psychologists should use non-sexist language
free of derogatory labels.
6. Psychologists should avoid establishing
source of problems within the client, when they are more properly attributable
to cultural factors.
7. Therapist and client should agree on terms of
therapy.
8. Privilege of communication rests with client.
9. If authoritarian processes are used as
techniques, therapy should not have the effect of maintaining the dependency of
women.
10. Client’s assertive behaviors should be
respected.
11. Psychologists whose clients have been
physically or sexually abused should acknowledge that the client is a crime
victim.
12. Therapist should recognize and encourage
exploration of a woman client’s sexuality, and should recognize her right to
define her own sexual preferences.
13. Psychologist should not have sexual
relationships with a client, or treat that client as a sex object.
Summary of findings from the process/outcome chapter of the Handbook. Summary of previous editions is
first, followed by the 2004 chapter (Orlinski, Ronnestad, & Willutzki).
Consistent
findings:
I. Therapeutic Contract
1. The details
of the therapeutic contract (Eg., payment vs. free, schedule, group vs. individual) don’t
matter
2. Implementation of the contract does.
Commonly
found implementation process-outcome correlates:
A. Goal consensus
B. Clarity of Expectations
C. Patient Role Preparation
D. Patient Verbal Activity
E. Patient Suitability
F.
Therapist Skill
II.
Therapeutic
Operations
Common
correlates:
A.
Focus on life problems and core personal relations.
B.
Experiential confrontation.
C.
Interpretation
From the patient’s And
rater’s perspective.
D.
Paradoxical Intention
E.
Patient cooperation, not resistance
F. Pos.
affective arousal
III.
Therapeutic
Bond **
(Esp.. From patient Perspect.)
A. Patient Openness
Not defensiveness
Most
robust process-Outcome relationships
P. Suitability, P. Openness, Global
Bond/Group Cohesion, P. Contribution to bond,
P.
Interactive collaboration, P. Expressiveness, P. Affirmation of T., Reciprocal
Affirmation, P. Cooperativeness, Therapeutic Realizations, and Treatment
Duration
The 2004 chapter acknowledges that
research from 1993-2001 generally replicates the above findings.
Some qualifications have emerged.
For examples, interpretations continue to be linked with positive outcomes but
have been found to predict negative outcomes when the interpretations focus on
transference issues in brief therapies. Homework compliance, as an example of
patient cooperation is also a predictor of outcome.
Focusing on patients’ resources has
also emerged as a positive predictor of outcome.