Where did the field go wrong by focusing on therapists' rather than clients' theories of change?
In forthcoming book, The Heart and Soul of Change, ISTC co-founders Hubble, Duncan, and Miller (1999) describe in detail the process of making client perceptions of problem formation and resolution the central organizing influence in therapy. They point out that the field in general and therapy in particular have been largely focused on therapist formulations. The result is a jumble of competing, complicated, and contradictory theories and practices that to outsiders can only seem like chaos!

The idea that clients' theories have important implications for outcome has a rich, but largely overlooked heritage in the therapy literature. For example, in 1955, Hooch proposed:

There are some patients who would like to submit to a psychotherapeutic procedure whose theoretical foundations are in agreement with their own ideas about psychic functioning. We feel that it would be fruitful to explain patient's own ideas about psychotherapy and what they expect from it (p. 322).

Later, Torrey (1972) asserted that sharing similar beliefs with clients about the causes and treatment of mental disorders is a prerequisite to successful psychotherapy. He suggested that when confronted with differences between themselves and their clients, therapists have a choice of adjusting their own beliefs or convincing clients that the therapist's point of view will lead to the desired therapeutic effect.

Wile (1977), too, believed that clients enter therapy with their own theories about their problems, how they developed, and how they are to be solved. "Many of the classic disputes which arise between clients and therapists can be attributed to differences in their theories of [etiology and] cure" (Wile, 1977, p. 437). Similarly, Brickman et al. (1982) hypothesized that many of the problems characterizing relationships between help givers and help recipients arise from the fact that the two parties are applying models that are out of phase with one another (p.375).

Brickman, P., Rabinowitz, V., Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982). Models of helping and coping. American Psychologist, 37, 368-384.

Hoch, P. (1955). Aims and limitations of psychotherapy. American Journal of Psychiatry, 112, 321-327.

Torrey, E. (1972). The mind game: Witchdoctors and psychiatrists. New York: Emerson Hall.

Wile, D. (1977). Ideological conflicts between clients and psychotherapists. American Journal of Psychotherapy, 37, 437-449.

Please click here to send an email to ISTC if you know of other references in the current or historical literature regarding the client's theory of change.

The Clinician's Illusion
Clinicians have historically believed two things: (1) long-term treatment is better than short-term; and (2) change in treatment is difficult and time consuming. In fact, in his massive review of the state of psychotherapy practice, Human Change Processes, Mahoney (1991) states that the latter belief is "one of the important points of convergence across contemporary schools of thought in psychotherapy" (p. 18). The question is, however, why would the schools agree on two ideas that are completely at odds with 40 years of research on change in therapy? The answer was partially hinted at in dramatic research by Cohen and Cohen (1984) on something they called the "clinician's illusion." In essence, these researchers showed that practicing clinicians tend to have expectations of treatment on the basis of their own clinical practices–practices which are wholly unrepresentative of the overall population of clients. Indeed, the practices of clinicians often contain a large number of clients who stay but are likely maintained rather than changed by the continued provision of treatment services. The result is a tendency to view client problems as more severe and enduring than they actually are and to expect lengthier periods of treatment than warranted. Worse yet, the clinician's illusion is passed from generation to generation because most supervision as well as most models of treatment are based on the same skewed population.

Cohen, P. and Cohen, J. (1984). The clinician's illusion. Archives of General Psychiatry, 41, 1178-1182.

The Dis-organized State of Therapy
During the 1950's and 60's, a series of intriguing experiments were conducted on the nature and effect of feedback on human activity. In one representative study, professor Alex Bavelas simultaneously exposed two participants to a series of pictures of either healthy or sick cells (Watzlawick, 1976). Neither person in the study could actually see the other while the experiment was being conducted and each was given the assignment to learn to distinguish between the two types of cells through a process of trial and error. Small lights marked "right" and "wrong" were the source of feedback each of the participants received about their respective choices.

There was just one "wrinkle" in the experiment of which both participants were unaware. Only one of them received accurate feedback about their guesses. When the light in this person’s cubicle indicated they had made the "right" choice, they had indeed guessed correctly. On the other hand, feedback for the second participant was not based on their own but rather on the guesses made by the first participant! Regardless of their choices, in other words, this person was told they were "right" if the other person had guessed correctly and "wrong" if the other had been incorrect. Data collected without their knowledge showed, at the conclusion of the experiment, that the first participant had learned to distinguish healthy from sick cells with an 80% rate of accuracy while the second continued to guess at no better than a chance rate.

These weren’t the only results, however. The two types of feedback also had a distinct and interesting impact on the theories each participant developed over the course of the study to differentiate between "healthy" and "sick" cells. The participant who received accurate–in other words, reliable–feedback ended the experiment with a very simple, concrete, and parsimonious explanation. The second participant, on the other hand, developed a complicated, subtle, and elaborate theory. This person, it must be recalled, had no way of knowing the feedback they received was not contingent on their own responses. Sometimes, as luck would have it, their responses happened to coincide with the correct answer. However, given the inconsistent–in other words, unreliable–feedback, this participant was prevented from learning anything about their own actions and choices.

Even these results may not seem all that surprising. Something more troubling occurred, however, when the two participants shared their respective theories with each other. In contrast to what one might hope and expect, the first participant was actually impressed with the complicated, mysterious and ultimately unreliable theoretical formulations of their co-participant. The second, on the other hand, dismissed the statistically accurate theory of the first as "naive and simplistic." In subsequent retests during which both participants received accurate feedback about their own guesses, the second continued to guess at little better than a chance rate. The performance of the first, however, who was now attempting to put some of the "brilliant" insights of their co-participant into practice, significantly worsened.

The parallels between the results of this study and the field of psychotherapy are striking. Historically divorced from systematic, reliable, and valid feedback about the outcome of most standard therapeutic practices, the field has become a jumble of competing, complicated, and oftentimes contradictory theories of treatment. Since the 1960's, for example, the number of available treatment approaches has increased a whopping 400% with no end in sight. Depending on the way models are counted some estimates are actually much higher (Garfield, 1982; Kazdin, 1986). In spite of this phenomenal growth, however, the actual overall effectiveness of psychological intervention has not improved in the least.

Garfield, S. (1994). Research on client variables in psychotherapy. In A. Bergin and S. Garfield (eds.). Handbook of Psychotherapy and Behavior Change (4th ed.). New York: Wiley, 190-228.

Kazdin, A.E. (1986). Comparative outcome studies of psychotherapy: Methodological issues and strategies. Journal of Consulting and Clinical Psychology, 54, 95-105.

Watzlawick, P. (1976). How Real is Real? Confusion, Disinformation, Communication. New York: Vintage.

One Session as Effective as Intensive Treatment for Alcohol Problems
In 1977, researchers Edwards, Orford, et al. stunned the alc oholism treatment industry when they published their study which found that a single session of advice with a family physician was as effective in treating people with alcohol problems as several months of intensive in and out-patient services. The study pointed to what many in the field already knew: there were major shortcomings in the treatment of this population. Chief among the limitations was the domination of the field by a single treatment ideology–that of Alcoholic's Anonymous. Some twenty years after the publication of this study, the number of treatment approaches and flexibility of treatment professionals has greatly increased. The result is that a greater, more diverse number of people are able to receive treatment earlier and more effectively than before.

Edwards et al. (1977). Alcoholism: A controlled trial of "treatment" and "advice." Journal of Studies on Alcohol, 38 (5), 1004-1031.