Which client-related factors influence the therapeutic process? - Chapter 4

Research suggests that the client is primarily responsible for change during therapy. Several studies show the correlation between client factors and the results of the therapy. It is important to realize that correlation does not imply a causal relationship!

Client factors are identifiable beyond what takes place during therapy and are relatively stable and solid. This means that these factors are not just about the client's direct feelings towards the therapist. A good example of client factors are the personal characteristics of the client. A distinction can be made here between implicit and observable client factors.

What characteristics predict the outcome of therapy?

The level of active participation in the therapy is one of the best predictors of outcome. It is responsible for at least twenty percent of the improvement. Furthermore, clients who cooperate with the therapist do better during the therapy.

The level of resistance is a good predictor of unwanted results. Resistance refers to the behavior of the client that shows that there is a reluctance to participate in the tasks of the therapy.

Client openness to defensive behavior appears to be a good predictor of positive therapeutic outcomes. Furthermore, it has been found that intrinsic or autonomous motivation to participate in therapy is also a good predictor of this. This concerns the extent to which clients have voluntarily chosen to participate in therapy.

Fifteen percent of the variance of the therapeutic result can be explained by the client's belief in the effectiveness of the therapy ('self-fulfilling prophecy'). The client's expectations are related to the outcome of the therapy. However, there is a difference between certain client groups. For example, clients with substance abuse or anxiety problems may do better when they have high expectations, but this is not true for clients with depression.

Predilection refers to the client's belief about the origin of their stress and what will be helpful against this stress.

Clients with a higher level of manifested overt stress have better clinical outcomes. People with higher levels of psychosocial functioning seem to benefit the least from therapy.

Personality disorders are relatively long-lasting maladaptive (character) traits that can result in significant subjective stress and functional deterioration. Clients with psychological comorbidity (multiple mental disorders) appear to benefit less from therapy. It also appears that the more serious the personality disorder, the worse the therapeutic result. However, there appears to be a difference between various personality disorders. For example, clients with borderline or schizotypal personality disorder appear to have poorer therapeutic outcomes compared to clients with a dependent personality disorder.

The attachment style refers to an individual's pattern of behavior, thoughts, and feelings in close relationships. There are three types of attachment styles: safe, preoccupied/ambivalent and avoidant. Clients with a secure attachment style benefit more from therapy compared to clients with an unsafe attachment style. Furthermore, people with interpersonal difficulties (non-assertive, hostile, social avoidance) also benefit less from therapy.

Clients with a higher level of perfectionism show less improvement on a range of indicators compared to clients with a lower level of perfectionism.

Psychological mindedness is the ability to understand people and their problems in psychological terms.

What stages of change are there?

The basic assumption behind the 'Stages of Change' model of Prochaska and DiClemente is that behavioral changes are not immediate events, but processes that take time:

• Precontemplation: No motivation or intention to change in the next six months.

• Contemplation: Ambivalence, with an intention to change at some point in the future.

• Preparation: An intention to change in the next six months.

• Action: Open (overt) behavioral change.

• Maintenance: A focus on preventing relapse.

• Termination: No further temptation and a sense of total self-control.

What else does the outcome of the therapy depend on?

Therapeutic results are the same for both women and men. However, when significant differences are found, they are often in favor of women.

Research also shows that lesbian, gay and bisexual clients benefit as much from therapy as heterosexual clients. However, they do use psychotherapeutic services earlier and longer compared to heterosexual clients. 

Age is not related to therapeutic results, except for clients with depression. In clients with depression, it seems that younger clients respond better to therapy than older clients. 

Furthermore, some evidence has been found that clients of ethnic minorities or with a lower socioeconomic status are more likely to discontinue therapy and make less use of therapeutic services.

Chapter questions

1. Who is primarily responsible for change during therapy?

2. What is one of the best predictors of good results?

3. Which type of clients have better clinical results and which type benefits less from therapy?

4. Which mental disorders often have poor outcomes in therapy?

5. What processes do behavioral changes consist of?