The heroic client - Bohart
The Heroic Client: How Clients Make Therapy Work
Arthur C. Bohart
California State University Dominguez Hills and
Saybrook Graduate School and Research Center
abohart@csudh.edu
I. Virtually everyone says that it is clients who ultimately heal themselves in therapy. But do they really mean it? When you look at writing on how therapy works, it is from the therapist's side of the coin. Even in Carl Rogers' writings there is no description of the client's contribution to the therapy process. Rarely in writings do we encounter clients as active, planful, generative agents.
Instead, the standard view of therapy is patterned after the medical model. Client problems result from dysfunctions inside the client. Therapists use interventions to modify these dysfunctional structures and processes. This model can be diagrammed as follows:
Therapist chooses condition in patient: patient is fixed by
treatment, applies to ----------> dysfunctional cognitions,--------> treatment. Now can make
weak ego, etc. own choices.
The therapist is an expert who applies interventions. This places the emphasis on interventions. Even the relationship may be seen as an intervention.
II. But research findings generally do not support this model.
A. Dodo bird verdict that all bona fide approaches to therapy work approximately
the same for most problems.
B. Techniques and interventions account for comparatively little of the variance in
outcome (Lambert, 1992; Wampold, 2001). (Does not mean interventions
are useless).
C. Therapists matter much more than interventions (like teachers in school).
D. However, professional expertise, knowledge, and training has minimal effects. Paraprofessionals can be just as effective. Example: Bright, Baker, and Neimeyer (1999).
E. Self help procedures can work almost or just as well as professionally
provided therapy. Example: Jacobs et al. (2001), Norcross (2003), Pennebaker,
(1990).
F. Relationship variables matter more than interventions. Example: Norcross,
(2002).
III. Conclusion: therapy is a collaborative relationship between two intelligent agents. It is ultimately clients who take what therapists offer and make therapy work. Therapy can be seen as facilitating and/or freeing clients' intrinsic generative self-righting tendencies.
A. Example of how this explains above findings. Therapy can be modeled as following, in contrast to the "therapist-centric" model:
Clients operate therapist procedures, by investing
on ---------> life in them, thinking about the ---------> to create change
process, extracting meaning,
creatively using procedures,
translating therapy
experiences into everyday life
Clients can "make meaning" out of wildly different therapy approaches. However, clients often need support, a safe space, and some "workable structure" (which all bona fide therapies provide, as well as some self-help procedures), in order to mobilize their own capacities. Different clients may also take to different approaches (e.g., Beutler, 2001; Duncan & Miller, 2000).
B. Evidence: Client involvement is best predictor of outcome (Orlinsky, 2000).
C. Client perceptions of alliance, of empathy, and of other therapy characteristics
predict outcome either better than, or as well as, therapist ratings or ratings by
objective observers (Bohart et al., 2002; Busseri & Tyler, 2004; Orlinsky, Grawe,
& Parks, 1994).
D. Change happens before "operative" ingredients of therapy could take place
(Snyder et al., 1999). It can happen quickly (Miller, 2000).
E. Client views of what makes therapy work consistently emphasize relationship
variables such as being understood, accepted, and listened to; having a safe space
to explore in; support for dealing with current crises; support for trying out new
behaviors; and advice. What is not emphasized are techniques. Examples: Howe,
1993; Elliott & James, 1989; Levitt, 2004; Cullari, 2001; Phillips, 1984; Rodgers,
2003).
F. Clients' ratings of the collaborative nature of the therapy relationship are strong
correlates of outcome (Orlinsky et al., 1994).
IV. Considerable evidence supports the idea that humans have the potential for self-righting.
A. Resilience research. Vaillant (1998) , Norem (2001).
B. Longterm growth and change: Elder (1986), Vaillant (1998).
C. Post-traumatic growth (Tedeschi, Park, & Calhoun, (1998). Recent article
in American Psychologist.
D. Placebo effects.
E. Prochaska, Norcross, and Di Clemente (1994).
F. Pennebaker (1990).
G. Other research on importance of spirituality, etc.
G. But they often do not do it alone: social support.
V. How do clients make therapy work (with therapist assistance)?
A. Clients are active, planful agents. Rennie (2002), Levitt
and Rennie (2004).
B. Clients extract their own meanings from therapy. Elliott (1979), Elliott (1984),
Talmon (1990), Levitt and Rennie (2004), Levitt (2004), Bohart and Boyd (1997),
Bohart and Byock (2004), Bohart et al. (2004), Kuhnlein (1999)
C. Clients interpret and "construct" their own interventions from what they're
offered. Levitt and Rennie (2004), Levitt (2004), Bohart and Boyd (1997), Bohart
and Byock (2004), Talmon (1990).
D. Clients use the therapy environment as a "workspace" in which they can talk
out their problems and gain perspective. Phillips (1984), Rennie (2002).
E. Clients, as do all humans, have the potential for creativity and generativity. Cantor (2003), Staudinger & Baltes (1996), Duncan et al. (1997), Tallman et al.
(1994).
F. Underneath client defensiveness and/or hopelessness is the potential for
normal human motivation (Wile, 2002; Miller & Rollnick, 2002; Rogers, 1961). This may be tacit and implicit.
G. There is some "sense" in dysfunctional behavior (Linehan (1997): the nugget
of wisdom in the bucket of sand; Gendlin (1967); Duncan; Cantor, 2003).
H. Clients know more about their lives than we do. This may be tacit and
implicit. They may also have a sense of their strengths and weaknesses.
I. Clients have a potential capacity for rational thought (otherwise cognitive therapy wouldn't work).
J. Clients have a potential capacity for higher-order thinking (Pennebaker, 1989).
K. Clients use the same procedures for self-righting in everyday life as therapists use (Prochaska et al., 1994). Therapists use refined versions of these, drawing on implicit client potentials.
L. Clients "internalize" the therapist (Knox, 2003), which means they create
what they think the therapist would say and do in their heads. See Staudinger
and Baltes (1996). Suggests possible importance of client empathy.
M. Clients engage in between-session activities to facilitate change, including
expansion of use of outside resources (Cross et al., 1980).
N. Clients put insights into operation to produce change (Lieberman et al., 1973).
VI. Implications for Practice: Clients need to be involved.
A. The collaborative relationship is the most important thing because therapy
is two intelligent beings working together. Particularly important for reducing
defensiveness. Horse examples.
B. Client active involvement is crucial. Therapy interventions do not operate on
clients without clients' active participation in the process. Therapy is not surgery.
C. Two keys to client active involvement: helping them feel safe enough to be
involved, so they can find their own reasons for changing, and helping them feel
safe enough to be curious, risk-taking, and exploratory.
1. Helping clients move out of a resistant or defensive stance and access
their own intrinsic and identified (Sheldon and Elliot, 1999) motives for
change. Example: Motivational Interviewing (Miller and Rollnick, 2002).
2. Helping clients adopt a task focus (Bohart & Tallman, 1999; Tallman,
1996; Dweck, 1999). Also "frees up" proactive, generative intelligent
functioning.
D. Clients feel more involved when therapists take their ideas seriously (pay
attention to their theories of change (Duncan and Miller, 2000).
E. Clients who are involved are not merely complying. They are
participating by actively thinking, exploring, feeling, and creating.
VII. Implications for Practice: Clients can be creative problem solvers.
A. Analogy of therapy to learning situations. Five types of learning analogous
to different types of therapy. Clients, like students in school, can learn in
different ways. Different therapy approaches provide different types of
"learning opportunities" for clients.
1. empathic workspace/empathic witnessing (client-centered). Clients
have a chance to "hear themselves think and feel," to find their own
voices.
2. collaborative dialogue (psychoanalysis, narrative, cognitive). Clients
get a chance to "think along" with another person, get ideas and
perspectives from them.
3. interpersonal learning (psychodynamic, humanistic, cognitive-
behavioral). Clients get a chance to experience themselves being
effective, being in an interaction where they are prized.
4. structured exercises for creativity (solution-focused, gestalt,
experiential, EMDR). Clients get a chance to do things that stimulate
their creativity.
5. skills and habit learning (cognitive-behavioral). Clients get a chance
to try useful procedures that help them develop mastery of specific
problem situations.
B. Different clients may take to different approaches. May want different
approaches at different times (Gold, 1994). Matching of strategies by
personality (Beutler), possibly by learning style (Sternberg).
C. Therapeutic environment can reduce stress in order to promote clients'
higher levels of thinking (Pennebaker, 1989).
D. Promoting client creativity: providing moderate structure.
E. Helping clients gain distance and perspective. Acceptance (Linehan,
psychodynamic, experiential), Wile's "platform," Freud's "observing ego,"
mindfulness. The idea of "getting above" the problem as a solution, even
if the "problem" still exists. Similar to Bowen also, transcend anxiety.
F. Along with this support and promote clients' capacities for developing
self-efficacy (Bandura, 1997).
G. Therapists must be task focused: focus on failure as feedback, adopt a
learning orientation, and
H. Solve the moment (Wile, 2002), and focus on clients' zone of proximal
development (Vygotsky). Clients, as anyone, learn better when things go
one step at a time.
I. Promote a receptive, listening, open, exploratory mindset in contrast
to a defensive, overly deliberative, analytic, mindset.
VIII. Overall: Provide support, space, and structure. Work to reduce defensiveness, to promote an open, exploratory, task-focused mindset, and a learning orientation. Engage in collaborative dialogue. Listen to clients' ideas. Help them turn what they implicitly know into explicit knowledge. Can do with more directive approaches (cognitive-behavioral) or more exploratory approaches (psychodynamic, humanistic).
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