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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

Abstract I first briefly review the dodo bird verdict and suggest that we should be responding to it by looking for a new way to conceptualize how therapy works. Then I describe the dominant medical or treatment model of psychotherapy and how it puts the client in the position of a dependent variable who is operated on by supposedly potent therapeutic techniques. Next I argue that the data do not fit with this model. An alternative model is that the client is the most important common factor and that it is clients' self-healing capacities which make therapy work. I then argue that therapy has two phasesthe involvement phase and the learning phaseand that the involvement phase is the most important. I next review the five learning opportunities provided by therapy. Finally, I argue that a relational model of therapy focused on consultation, collaboration, and dialogue is better than a treatment model.

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: weak ego, etc.

patient is fixed by own choices.

treatment, applies to ----------> dysfunctional cognitions,--------> treatment. Now can make

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 on

therapist procedures, by investing ---------> life in them, thinking about the process, extracting meaning, creatively using procedures, ---------> to create change

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, cognitivebehavioral). 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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