Swift, J. K., Owen, J., & Miller, S. D. (2023). Client factors. In S. D. Miller, D. Chow, S. Malins, & M. A. Hubble (Eds.), The field guide to better results: Evidence-based exercises to improve therapeutic effectiveness (pp. 47–78). American Psychological Association. https://doi.org/10.1037/0000358-004
Research over 5 decades has demonstrated that client contributions explain the majority of the variance in psychotherapy outcome. That is, patient factors are much more predictive than the type of therapy offered. Effective therapists adjust their interactions and interpersonal stances to relevant patient characteristics. Most demographic variables are not related related to patient outcomes (age, gender, education level, socio-economic status). In this chapter, Swift and colleagues review the research on patient factors that are reliably associated with improvements in psychotherapy. Here I review of few of these factors. Role expectations and preferences refer to patients’ beliefs and preferences about what is likely to happen in therapy – that is, type of therapy, type of therapist, how active or passive the patient or therapist will be, and how long therapy might last. Research indicates that pre-therapy education and preparation results in improved client outcomes (d = .34). Patients’ motivation is also associated with more engagement and better results. Therapists who tailor interventions to patient motivation level result in better outcomes (d = .41). Client attachment style is also associated with patient outcomes such that those with more secure attachments tend to experience greater symptom relief (d = .35), and that reductions in insecure attachment is also related to better outcomes. Finally, reactance or resistance refers to the emotional reaction of patients when they feel stressed or threatened. This may result in rejecting an intervention or therapist. A recent meta-analysis found a large positive effect (d = .79) when therapists of highly resistant patients took a more passive stance and when therapists of less resistant patients took a more active stance in therapy.
Studies suggest how best to adapt interventions and therapist interpersonal stances for some patients based on their characteristics. Regarding expectations and preferences, therapists might spend time preparing their patients for what will happen in therapy and by collaboratively coming to an agreement on how therapy will proceed. Therapists should also tailor their interventions to the level of their patient’s motivation by focusing on supportive interventions when motivation is low (patients at the pre-contemplation stage of change), or helping the patient to set goals and make plans for changing behaviors when the level of motivation is moderate (patients at the preparation stage of change). For attachment insecurity, therapists who engage in interventions to help clients to experience more attachment security might see greater effects of therapy. These interventions might involve improving the patient’s quality of relationships, emotion regulation, and reflective capacities. The findings also suggest that therapists should be less directive with patients who have high levels of reactance or resistance but more directive for patients who have lower levels of reactance or resistance. These therapist interpersonal stances tailored to level of patient expectations, attachment style, motivation, and resistance have a better chance of engaging the client in therapy.