The document discusses the interplay between a therapist's personal characteristics and qualities (therapist variables) and a client's theory of change. It argues that the most effective therapy occurs when the therapist is aware of how their variables may influence the therapeutic alliance and adapts their approach to align with the client's theory of change. Case studies are presented to illustrate therapists monitoring client feedback to improve outcomes. Effective therapists recognize when their approach does not match a client's needs and make adjustments to better facilitate the client's process of change.

1. PEER REVIEWED
When therapist variables and the
client’s theory of change meet
BILL ROBINSON
Recent research confirms the importance of the client’s theory of change (CTC)—perceptions
and views the client has about the nature of the problem they bring to therapy and its possible
resolution. If the theory of the client is primary, what then does the therapist bring to the
encounter? BILL ROBINSON argues that the study of therapeutic effectiveness needs to focus
on the interplay between therapist variables (the person of the therapist) and the client’s theory
of change. When these two vital factors meet, something new is created. It is crucial that the
therapist becomes aware of, and manages, the effect of therapist variables on the alliance.
This can be monitored through eliciting client feedback on perceived progress and strength of
alliance. Case studies drawn from the author’s practice illustrate this process.
‘It is not death that a man should fear, but he should fear never beginning to live.’ Marcus Aurelius (2006).
T he term ‘the client’s theory of
change’ was first coined by
Duncan, Solovey and Rusk (1992).
therapeutic factors account for 40
per cent of outcome variance, while
the results of a later meta-analysis by
way to understand this is to reflect on
significant issues in our own lives. Did
we take time out to work through the
It was used to refer to the ‘informal’ Wampold (2001) put the figure at 87 issue on our own, or did we talk to a
theory of the client in contrast to the per cent. The concept of the client’s friend or a professional? If we talked
‘formal’ theories that can dominate theory of change does not imply that to another person, were we looking
professional discussions in counselling clients live with a clearly defined for empathy, advice or challenge?
and psychotherapy. This concept was theory of how change happens and When the change happened, did we
developed further in subsequent papers how problems can be overcome in their act impulsively or did we plan every
(Duncan & Moynihan, 1994; Duncan, lives. As Duncan and Sparks (2004) step carefully? If we connect with how
Hubble & Miller, 1997; Duncan & point out, ‘the client’s theory of change is the client experiences this process,
Miller, 2000; Duncan, Miller & not an anatomical structure in the client’s and adapt the therapeutic approach
Sparks, 2004). head to be discovered by your expert accordingly, we are more likely to be
The client’s theory of change (CTC) questioning. Rather, it is a plan that co- helpful than if we impose a therapist
refers to the perceptions and views evolves via the conversational unfolding constructed model of problem
the client has about the nature of the of the client’s experience, fuelled by your resolution.
problem they bring to therapy and caring curiosity’ (p.31). If the theory of the client is primary,
its possible resolution. Rather than When prompted to reflect on what what then does the therapist bring
the client having to accommodate has led to positive change in their to the encounter? In some instances,
the therapist’s theory of how change lives on previous occasions, or how all that may be needed is a non-
occurs, or risk being labelled resistant, difficult problems have been overcome, directive person-centred approach
the views of the client are central and clients will often recall internal and where the counsellor responds to the
therapy is tailored to their views about external resources they have used to client’s lead with empathy, respect
what is helpful or unhelpful. resolve problems in the past. In fact, and acceptance. For other clients,
In the light of recent research, a what may bring people to therapy is their theory of change may include a
change in emphasis from what the that they have forgotten or lost faith part for a counsellor who challenges,
counsellor perceives and does, to what in these abilities. The CTC refers to gives advice or designs strategies. As
the client perceives and does, makes the process by which clients experience Bachelor and Horvath (2000) point
good sense. According to Assay and change, and so encompasses more than out, ‘Effective responses are attitudes and
Lambert (1999), client and extra- just goals and expectations. A good interventions that are appropriate to the
60 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009

2. individual client. To develop an effective emphasise the importance of both with a focus on clients who I had
therapeutic relationship, sensitivity to therapist effects and the therapeutic not helped successfully. Was there a
client’s differential phenomenological relationship: ‘Despite the concerted particular presenting problem, age
worlds, as well as to relational needs and effort to control, reduce or eliminate group, gender, ethnic or socioeconomic
expectations, seems important’ (p.146). the effects of both therapist variability group, that I did not seem to help
Therapeutic models and techniques and extradiagnostic patient variables, because of variables associated with
may play their part as they give us research has not been able to escape the me as a therapist? This is a work still
different ways to consider the issue and need to recognize either the roles of the in progress that, to date, has yielded
suggest different responses. clinician or the reciprocal influence no clear answers. However, what has
been reinforced is the finding that
each therapeutic encounter is a one-off
The concept of the client’s theory of change encounter between a unique client with
their unique theory of change, and
does not imply that clients live with a clearly a unique therapist with their unique
response.
defined theory of how change happens and From their overview of research
into therapist variables Bergin and
how problems can be overcome in their lives. Garfield (2004) find little evidence
that the personal characteristics of the
therapist have any marked significance
Miller, Hubble and Duncan (2007) of patient and therapist qualities on in therapeutic outcomes. However,
suggest that ‘Who provides the treatment one another’ (p.227). Both therapist they emphasise that there is a lack
is a much more important determinant of factors and alliance factors are of of recent studies, and probably too
success than what treatment is provided’ major importance in client outcome few, to enable any clear conclusions
(p. 15). These therapist variables and there is significant overlap. In to be drawn. Since it has been shown
include observable traits such as the seeking to understand what makes repeatedly that the therapeutic model
therapist’s age, gender and race, and therapy successsful, a fruitful focus or technique used by the therapist is of
observable states such as professional could be to consider how therapist minor importance, what then are the
discipline, training and experience. effects meet the client’s theory of therapist variables that have the effect
They also include inferred traits such change, and build and maintain the on outcomes?
as personality and coping patterns, therapeutic alliance. Miller, Hubble and Duncan (2007)
level of emotional well-being, values Recently, having tracked my own address this question in their study of
and beliefs, and cultural attitudes clinical outcomes for the last seven ‘Supershrinks’. The term ‘supershrink’
(Bergin & Garfield, 2004). Despite years, I started to look at this data was first coined by D. F. Ricks in 1974
this, the focus of research in recent
years has moved from discrete therapist
characteristics to randomised clinical
trials that evaluate the type or model
of therapy offered (Bergin & Garfield,
2004).
Research further suggests the
most important aspect of therapy
that involves the therapist is the
therapeutic alliance. According
to Assay and Lambert (1999), the
therapeutic alliance accounts for 30
per cent of outcome variance. For
Wampold (2001), the alliance accounts
for more than half of the 13 per cent
attributed to therapeutic factors, rather
than client and extra-therapeutic
factors. Put another way, the alliance
accounts for seven times as much
outcome variation as the model or
technique being used by the therapist.
In a subsequent paper, Wampold and
Brown (2005) suggest that five per cent
of outcome variance can be attributed
to therapist effects. Beutler et al (2004),
in their study of therapist variables,
Illustration: © Paul Vismara, Stock Illustration, Getty Images.
PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009 61

3. and refers to the growing evidence that term ‘coniunctio’ in his exploration rate themselves in the areas of personal
there are wide differences between the of the process of psychotherapy. In well-being, close relationships, work
most effective and the most ineffective alchemy this refers to combining two and social activity. It is given at the
therapists in the field. Okiishi, chemicals to make a different third start of every session. The session by
Lambert, Nielson and Ogles (2003) chemical, but was used by Jung as a session results are tracked, and the
analysed data from fifty-six therapists symbol for intrapsychic processes and results are shared with the client and
in a university counselling setting and the encounter between therapist and used to inform the direction of future
showed that, ‘The therapists whose clients client. Using this metaphor, we can see work.
showed the fastest rate of improvement
had an average rate of change 10 times
greater than the mean for the sample. The …each therapeutic encounter is a one-off
therapists whose clients showed the slowest
rate of improvement actually showed an encounter between a unique client with
average increase in symptoms among their
clients’ (p.361). Wampold and Brown their unique theory of change, and a unique
(2005), in their study of therapists from
a managed care company, also report therapist with their unique response.
wide variation in outcomes achieved by
different therapists.
In an article that not only draws on the therapeutic encounter as a place The client’s experience of the
an analysis of therapeutic outcomes, where therapist variables (who we are therapeutic alliance is measured on the
but also on excellence in any field of and how we relate) and the client’s SRS developed by Duncan, Miller and
human endeavour, Miller, Hubble theory of change meet, and out of the Johnson (2002), validated by Duncan,
and Duncan (2007) conclude that resulting ‘coniunctio’ something new is Miller, Reynolds, Sparks, Claud,
the person who achieves superior created that is unique to that particular Brown and Johnson (2003) and is also
performance is the person who works pairing. available at www.talkingcure.com. This
hardest and in a directed and feedback- Growing evidence is emerging that is also a four item questionnaire that
informed way to improve performance the provision of ongoing feedback to asks the client to assess the alliance
of their task. The supershrinks in their the therapist can significantly improve according to: the degree to which they
study are hypervigilant to threats to the outcomes achieved by their clients feel understood and respected; how
the alliance with the client and check (Harmon, Hawkins, Lambert, Slade well their agenda is being followed;
out even minor concerns. They are & Whipple, 2005; Harmon, Lambert, how seriously their ideas for change
alert to anything that may sabotage the Smart, Hawkins, Nielson, Slade & are being considered; and whether
success of the joint endeavour with the Lutz, 2007; Anker, Duncan & Sparks, the relationship with the therapist is a
client. 2009). The last ten years have seen good fit. The SRS is given to the client
We may hypothesise from this that the development of user-friendly at the conclusion of every session. Any
what is crucial is how the therapist measures that enable us to monitor the ‘less-than-enthusiastic’ responses are
becomes aware of therapist variables client’s experience of improvement, or explored with the client with the aim
and manages their effect on the lack of it, and their experience of the of adjusting the direction of future
alliance. The most effective therapist therapeutic alliance. They can enable work so that the client can experience
will be the one who recognises us to monitor whether we are working it as more helpful.
problems in the alliance due to with the client’s theory of change or
The case of Jack
differences in background or outlook getting in the way of it. While the use
between therapist and client, or to of these measures may not turn every Jack is a retired man in his sixties.
the therapeutic approach used by the therapist into a supershrink, they can He suffered a brutal childhood and
therapist, or simply due to the therapist make a major contribution towards experienced further trauma as a
having a bad day. As a first priority, improving therapist performance. member of the armed forces. He also
the effective therapist will aim not to There are a number of reliable and suffers chronic pain from injuries
get in the way of the client’s theory of valid measures available. Two of the received in active service. Initially, he
change. They will ask ‘what part does most brief and user friendly are the came to therapy for help to deal with
my client’s theory expect me to play?’ They Outcome Rating Scale (ORS) and the his stress and outbursts of anger. His
will then ask ‘Is this a part I have the Session Rating Scale (SRS). anger was of particular concern. Given
skills to play and am capable of playing, The ORS was developed by Miller his military training, he knew that if
and is it a part that ethically I am willing and Duncan (2000), validated by he ‘totally lost it’ he had the ability to
to play?’ In examining the effectiveness Miller, Duncan, Brown, Sparks and do somebody serious harm.
or otherwise of counselling, a focus Claud (2003) and is available at www. In early sessions Jack talked a great
is needed on the interaction between talkingcure.com. The ORS monitors deal about his experience in his family
therapist variables and the client’s the client’s estimation of the level of origin and in the military. We
theory of change. of improvement. This is a four item explored how and why he had become
Carl Jung (1945) used the alchemical questionnaire that asks the client to the person he was, where his anger was
62 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009

4. coming from and what was likely to effective provided therapist factors did her own thoughts and feelings to
trigger it. This seemed to be going well not prevent them connecting with his decide on the appropriate course of
and Jack’s scores were moving slowly theory of change. action. This had not been a ‘therapeutic
upwards on the ORS when I noticed strategy’, but rather an expression of
The case of Jane
a slight dip in the SRS score. I took my assumptions that people had a right
this up with Jack who said that while Jane is a woman in her thirties. A to control the direction of their own
understanding himself and the triggers practicing Christian, she asked to see lives and, at the same time, to be safe
for his stress and anger was important, a counsellor who shared this faith. and secure. While we did not discuss
he felt it was now more urgent to be She had come to discuss some current her eventual action, our discussion had
able to manage his anger when it was issues in her life. However, between helped to empower her. At the same
triggered. I adjusted my approach the first two sessions Jane talked with time, my expressed concern that she
to our sessions in the light of this a friend who was dealing with the protect herself against further harm
feedback and subsequent scores on the effects of childhood sexual abuse. This led to her taking her husband with
ORS and SRS confirmed we were on conversation evoked memories of abuse her rather than acting alone. She may
the right track. Later, with strategies in that Jane herself had suffered years not have done this had we not had
place to manage the stress and anger, before. She felt these issues had never that discussion. It is possible also that
Jack initiated further discussion on been dealt with and were affecting her the faith that we share was a factor,
the origins of his anger and what it life still. She had considered making as she felt she was able to do what she
was that had led to his father being so a formal report and pursuing the legal did with the aid of a higher power.
brutal to him. He found this now to be route. I discussed with her the pros and She knew that her counsellor, while
helpful and healing, as was confirmed cons of taking this path. I pointed out being concerned for her safety, would
by his ORS and SRS scores. the challenges this would entail and understand and accept this and that
As it unfolded, Jack’s theory of stressed the need to ensure her own her action would not sabotage further
change was that he needed strategies physical and emotional safety. At the therapeutic work. Her ORS and SRS
to manage his emotions and a degree same time, I assured her that I would scores confirmed that her sense of
of understanding of himself and his support whatever decision she chose to personal well-being was improving
family. In the person of his therapist make. and that she was comfortable with the
he had someone who was willing and When Jane arrived for the next relationship with her counsellor.
able to work in a directive cognitive session she told me that she had traced For Jack, who had been a victim
way to address the former, and in a the perpetrator. She had knocked on of the abuse of power in his family
psychodynamic way to address the his door and, when he answered, told of origin and adult life, having his
latter. Nevertheless, the alliance him she had come to confront him experience validated and his ideas for
between us threatened to derail. Unlike with the past and to get an apology. change taken seriously, strengthened
a supershrink, I was unaware when After a tense conversation, she was the alliance between us. The initiation
my responses to him emphasised the able to elicit an apology. This action of formal feedback, and the message
wrong area. It was fortunate for us both resolved the issue for Jane.
that I made use of formal measurement
tools (ORS and SRS) to check that When the two vital factors of therapist
we were on track and alert me to the
danger. variables and the client’s theory of
As our work progressed, I became
aware that our beliefs and opinions change meet, real therapy begins…
on some political, social and religious
questions were quite different. This
did not hinder our ability to work Initially, as she recounted her story, I that this was listened to and acted
together because his theory of change was left speechless. It was not an action upon, assured him that, whether or
did not include winning the therapist that Jane had spoken of pursuing at not his therapist agreed with him,
and everyone else over to his way of our previous session. If she had, I was his ideas of what he needed at this
thinking. Another therapist factor aware that I would have urged her to particular time were given priority.
was that I had no difficulty relating reconsider, or at least have some idea of The experience of the therapeutic
to someone who held different views. the response she may get before taking relationship stood in sharp contrast
Whatever our differences, it was clear such bold action. While expressing to the invalidation and abuse he had
that we shared a primary concern for my admiration for her courage, I told experienced so often in his childhood
honesty and fairness, and a passionate her it was probable that this is how I and adult life. It demonstrated the type
belief in the right of children to safety, would have responded had she run it of relationship he was looking for with
acceptance and love. past me first. As we discussed this, other people in his life. Having his
If Jack had worked with another it emerged that our discussion in the views taken seriously and acted upon
therapist it is probable that the previous session had communicated a helped him to connect with his own
path trodden would have been very concern for her physical and emotional considerable strength of character. In
different, but could have been just as safety, while affirming her in following turn, this enabled him to manage his
PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 4 • AUGUST 2009 63

5. anger and stress levels, and improve the I did not have the skill and training, References
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D., Reynolds. L., Brown, J., & Johnson,
into play as I endeavour to meet the theory of change meet, real therapy
L. (2003). The session rating scale:
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To have said that I could not respond sometimes regardless of us, and Improving outcomes for poorly responding
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AUTHOR NOTES
(Rev. 2nd ed.). (Vol. 16, pp. 163–323).
Princeton, NJ: Princeton University Press. BILL ROBINSON is a counsellor with twenty five years
(Original work published 1946).
experience who has worked with individuals, couples and families
Lambert, M. J. (2004). Bergin and
Garfield’s Handbook of Psychotherapy
in a number of settings in Australia and the UK. He is now a
and Behaviour Change (5th Ed). New York: manager, counsellor and a senior supervisor with Relationships
John Wiley & Sons. Australia based in Mandurah, Western Australia. He is a certified
Miller, S. D., Duncan, B. L., Brown, J., CDOI (Client Directed Outcome Informed) trainer.
Sparks, J. A. & Claud, D. A. (2003). The
outcome rating scale: a preliminary study Comments: bill.robinson@wa.relationships.com.au
of the reliability, validity, and feasibility of
a brief visual analog measure. Journal of
Brief Therapy, 2(2), 91–100.
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