It’s comforting to think of ourselves as being responsive to our clients. But what does responsiveness actually look like and what’s the evidence it makes any difference to outcome?
Here we profile a paper that digs a little deeper into the subject.
The idea that I should restrict myself to one therapeutic approach has never made much sense to me, either intuitively or in practice. Perhaps that’s one of the reasons that I like to think of myself as being reasonably responsive to my client’s expressed preferences about how we might work together.
If the opposite of responsiveness is rigidity, I imagine most of us would want to see ourselves as being at the responsive end of the spectrum. How far, though, are we prepared to roll with the idea that the client really does know best?
“I didn’t want to hurt my therapist’s feelings, so I didn’t really say anything when things weren’t working. It was easier just to stop going.”
The quote above is from “John”, the client in a case study featured in a recent paper titled Therapist Responsivity to Patients’ Early Beliefs and Psychotherapy Process. The paper looks at two elements of therapist responsiveness through the lens of a single case study. It illustrates how the therapist sought to respond to the client’s beliefs about the efficacy of the proposed therapy (outcome expectation or OE for short), as well as his perception about treatment credibility. This is the extent to which the clients finds a given treatment ‘to be logical, suitable and efficacious’.
Responding to client preferences: What does the evidence tell us?
The nature of client preferences and their importance in the therapeutic process is highlighted in a chapter [i] in the excellent book edited by John Norcross: Psychotherapy Relationships that Work: Evidence-Based Responsiveness. In the chapter the authors outline the three main types of client preference from the literature: role preferences, therapist preferences and treatment type preferences.
These include the behaviours and activities that clients want themselves and their therapist to engage in e.g., whether client or therapist takes the more leading role, active advice-giving versus listening, preferences for tasks between sessions.
These may include therapist characteristics such as level of experience, ethnicity, age, sexual orientation and religion.
These include the client’s beliefs about the cause of the problem that has led them to seek help and the type or model of therapy they may prefer. In some cases, their preference for type or model of therapy will have been influenced by previous experience.
The meta-analyses of studies carried out by the chapter’s authors highlighted the importance of attending to client preferences: in terms of outcomes, the overall effect size in favour of clients who received their preferred therapy conditions was d = 0.31 (using Cohen’s d as the indicator of effect size.) This represents a small, but nonetheless significant effect on outcomes.
Responsiveness in practice
The paper mentioned earlier follows the therapist’s attempts to be mindful of and responsive to John’s outcome expectations (OE) and beliefs about the credibility of the proposed therapeutic direction. Below I’ve outlined three points in the process of therapy where these attempts and their outcomes are highlighted.
1. First session exploration of outcome expectation
The therapist explored John’s beliefs about therapy and identified his low expectation that it would be helpful in his case. His pessimism seemed to stem in part from his previous experiences of therapy. It also became apparent that in the past his doubts about the provider and the treatment approach had gone unexplored. When he had felt that the process wasn’t working, he simply stopped attending.
As a result of this discovery the therapist prepared John for the possibility of potential tensions in the alliance that might result and invited him to bring any concerns that he might be experiencing. She also noted John’s statement (see adjacent panel) about previous therapists being too “positive” and was careful not to outpace his own current level of hope by “promising more improvement that he was ready to accept.”
Actually, it feels better just to be able to tell you that I have some doubts about therapy and whether it’s going to actually help me feel better. I mean I’ve been this way for my whole life, you know? Before I sort of felt like they would just be so positive and tell me that I’m doing great, and that’s nice and all, but it made me feel like they didn’t really get it.
2. Cultivation of credibility perception and outcome expectation
In the initial session the therapist also explored John’s belief in the origins and maintenance of his anxiety. John’s reservations about the helpfulness of revisiting past early experiences were also explored. In the words of the therapist:
…..each person is an expert on themselves and every person is different. What might be helpful for one person, might not make sense at all for someone else…. I absolutely want to hear your beliefs about what might be helpful. There are many effective approaches to treatment. I think that together we can find the right one for you. It sounds like an approach that focuses on the here-and-now rather than your childhood makes sense. I think you also told me that you used to meditate, right? So, I was thinking that an approach that incorporates mindfulness might be a good fit for you.
As a result of these explorations the therapist proposed an approach based on the unified protocol (UP), an approach that combines elements such as mindfulness, cognitive therapy, and behavioural therapy. She also attempted to enhance John’s outcome expectation and views of the credibility of the approach by drawing on studies showing the effectiveness of the approach for people who complete therapy.
3. The client’s OE and treatment credibility beliefs decline
While John expressed initial enthusiasm for this different approach, he started to show signs of diminished hope and ambivalence about change. Specifically, he abandoned his diet in the belief that it would not work and expressed the fear that he might fall apart (as he had done before) if he tried to change. At an intellectual level, the suggested approach made sense to John. At an emotional level, however, the prospect of change also triggered a profound anxiety.
Instead of persisting with the UP, the therapist instead used motivational interviewing to work with John’s ambivalence, resistance and pessimism about the current approach. This led to John arguing for his own change and therapy taking a more generic CBT format that led to a clinically significant change after 12 sessions.
It could have been so very different……..
Had the therapist not been properly responsive to John’s limited expectations at the outset, and again later in the process, there is every likelihood that John would have had another premature ending. Not only that, he might well have continued to see himself as the problem.
Thankfully, the therapist was able to work in a way that was consistent with evidence showing that if we can work with client preferences, they are likely to have better outcomes.
So, just how flexible are you?
As I said at the start, the notion that I should restrict myself to one therapeutic approach has never made much sense to me. While I’ve always felt this intuitively, however, it is only more recently that I’ve discovered the evidence which supports this ‘felt sense’.
And how about you? Maybe the kind of responsiveness I’ve outlined here comes to you intuitively too. Or maybe not. Maybe the thought of stepping off your chosen path and, in the words of the authors ‘tailoring “on the fly”’, fills you with as much anxiety as the prospect of change did John.
Whichever it is, as ever, we’d love to hear your thoughts!
[i] J.K. Swift, J.L. Callahan & B.M. Vollmer. 2011. Preferences. In J.C. Norcross (Ed.), 2011, Psychotherapy Relationships That Work (2nd ed.). New York: Oxford University Press.
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