INTERVENTION: Subdomain 5: Therapist/Client Variables and Their Relation to Outcome Flashcards
What is the single most important factor contributing to therapy outcomes?
(Bohart & Wade, 2013)
- Clients make the single strongest contribution to outcome
——Clients are both IV and DV in therapy
What are the factors that impact therapy outcomes?
(Lambert, 1992)
Lambert’s Pie
1. Extratherapeutic factors: 40%
2. Therapeutic alliance/Common factors: 30%
3. Technique: 15%
4. Placebo: 15%
▪ Techniques are what we have a lot of control over
——* Focus on that
▪ Different therapists like different styles
▪ Therapist quality is what matters
What predicts poor attendance from clients?
(Bohart & Wade, 2013)
1. Lower SES
2. Ethnic minority status
3. Older age
4. Male
5. Fear of stigma
6. Ego-syntonic
What contributes to early termination?
(Bohart & Wade, 2013)
Early termination variables:
- Not associated with demographic variables
- Certain disorders
—▪ Personality disorders
—▪ Eating disorders,
—▪ Sex offenders,
—▪ Psychopathy - Certain personality traits
—▪ Resistance
—▪ Impulsivity
—▪ Hostility
—▪ Low motivation
Why might clients suddenly terminate?
(Bohart & Wade, 2013)
- Make early progress
—▪ Quit because they think they’re all good - Don’t make enough progress
—▪ Quit because they’re unhappy - Life circumstances (e.g., transportation, scheduling)
- Client not believing in treatment rationale
What can you do to prevent sudden termination?
(Bohart & Wade, 2013)
- Educating clients about course of therapy help decrease sudden termination
- Regular conversations about therapy expectations are recommended
What factors relate to good outcomes in therapy?
(Bohart & Wade, 2013)
- Client ratings of therapeutic alliance
—o More predictive than therapist ratings of alliance
—o Client’s love therapeutic presence: being in the moment with them - Internally motivated client
—o Readiness to change
—o Autonomy motivation
—o Therapy not activating their resistance - Acknowledging diversity differences
—o Ethnically diverse clients have better experiences when they perceive therapists as:
——o Open to the strengths in their culture
——o Recognizing the client’s unique position in their culture
——o Acting with awareness of the impact of client-therapist differences
——o Being open and nonjudgmental about religion
* Possible to improve even if beliefs about origin of the issue differ between client/therapist
What factors relate to bad outcomes?
(Bohart & Wade, 2013)
- Comorbid diagnoses
—o Personality disorder almost universally predicts - Confrontational therapists
—o Clients tend not to like it unless the client is being manipulative, then they do like it
What factors are either not related or show mixed results (for therapy outcomes)?
(Bohart & Wade, 2013)
- Little evidence about SES or ethnicity
- Social support
——Weak support for outcome (may be select cases)
What other client factors influence therapeutic outcomes? (1 of 2)
(Norcross & Wampold, 2011)
- Reactance:
—o How the client engages with interventions
——o High reactance = easily provoked/oppositional to direct demands (startled horse)
———Benefit from self-control methods and less structured treatment
——o Low reactance –> need more therapist directiveness and explicit guidance - Stage of change:
—a. Precontemplation –> minimize or deny problems –
——o Poor outcomes
—b. Contemplation –> acknowledge problems but not ready to change
—c. Action (most advanced) –> eager to begin working
——o Benefit from skills training and bx methods - Client Preferences
—o If a client gets their preference (therapy method, tx format, relationship style, therapist characteristic, tx length) – significantly better and less likely to dropout
—o Advantage of culturally adapted tx
What other client factors influence therapeutic outcomes? (2 of 2)
(Norcross & Wampold, 2011)
#4. Culturally-adaptive Interventions
—* May help
—* Difficult to interpret research though
—* One study showed support
—* Using client’s preferred language or matching clients/therapists on ethnicity/race
#5. Client coping style
—* Internalizers benefit from interpersonal or insight-oriented treatments
—* Externalizers benefit from symptom-focused and behavior-skills/skill-building treatments
#6. Religious
—* Incorporating their beliefs is equal or better than not incorporating (great, awesome, very informative Norcross)
—* Most important: open and nonjudgmental
#7. Hope
—* Client and therapist hope and optimism can help
#8. Secure attachment styles
—* Do better
What are the stages of change?
(Norcross et al. 2011)
- Precontemplation: no intention to change
—* Unaware or underaware of problems - Contemplation: Aware of problem and interested in change, but not committed to action
—* Struggle with what changing will mean giving up
—* The positive aspects of the behavior
—* The loss of money, time, energy to change - Preparation: Impending plan to change and small steps being taken
- Action: Person modifies behavior, experiences or environment to overcome problem
- Maintenance: Work to prevent relapse and consolidate gains
How does therapist effectiveness change the timeline of therapy?
(Okiishi et al., 2003)
Licensed psychologists have positive outcomes in fewer sessions
—o Most efficient therapist – 6-7 sessions to recover
—o Less efficient needed 94 sessions
What factors may make the difference in therapist effectiveness?
(Anderson et al., 2009)
- Facilitative Interpersonal Skills (FIS): therapist ability to respond to challenging therapy situations) highly related to outcomes
—▪ Way therapists react to challenges – may be difference in therapist effectiveness
(Laska et al., 2014) - Many therapist effect findings seem related to common factors
——Therapist’s explanation of treatment plan and how it fit
What are the state versus trait therapist factors?
(Cabral & Smith, 2011; Beutler et al., 2013)
- Two dimensions –> therapist traits and states and observable/inferred qualities
- Observable traits –> therapist demographics
—▪ Significant (small) favoring of female therapists – but generally no gender effect
—▪ Age – confounded with experience – weak relationship here
—▪ Ethnicity – no support for matching - Observable states –> professional discipline, experience, interpersonal psychotherapy style, adherence to treatment manuals, directiveness, and self-disclosure
—▪Psychotherapy specific training not related to success (confounded by training in program)
——▪More experience may or may not help outcomes (small effect sizes
Blatt et al., 1996)
———▪ Possible that client experience/time in therapy decreases their
anxiety about therapy - Friendly behaviors (with compatible dominance-submission styles) = better outcomes
- Adherence to manuals
—▪ Better outcomes BUT
—▪ Better therapists depart from manual to build therapeutic relationship
——▪ Client moderators whether they prefer directive therapy
——▪ Generally, directive ~ better
——▪ Therapist self-disclosure
———▪ Weak positive effect on outcome
———▪ Barret & Berman (2001) – associated with lowered distress
