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Beyond therapeutic models

section identifier imagethe front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers

Do therapists know what clients really want?

By Kate Kitchen

Autumn 2005, Vol 9 No 1


If it is true that “life is what happens to you while you’re busy making other plans,” as John Lennon said, then it might also be true that therapy is what happens while the therapist is busy following various therapeutic models.

According to Scott D. Miller and Barry Duncan’s web site, TalkingCure.com, four weighed factors account for change in psychotherapy: extra therapeutic factors – 40 per cent; collaborative relationship – 30 per cent; placebo, hope, expectancy – 15 per cent; and structure, model, technique – 15 per cent. Yet most psychotherapists focus on refining skills in their favourite therapeutic model of practice. Miller and Duncan report that since the mid-1960s, the number of therapy models has grown from 60 to more than 250. I have studied many of these models and teach a few.

Miller and Duncan are not trying to say that psychotherapy does not work – they can cite many studies saying that it does – but they do think we focus too much on particular differences among therapies. They suggest that various approaches work about equally well, and that it is the similarities, rather than the differences, that make therapy effective. Which takes us back to the four factors.

Miller and Duncan are also not saying that we should ignore models and techniques. But they do suggest that in discussion about what works in therapy, too much attention is paid to the elements that interest therapists, like models and techniques, and not enough to the other partner in the therapeutic process – the client. By focusing on what Miller and Duncan call the “client’s theory of change,” therapists can tap into those extra therapeutic factors that make up 40 per cent of change in therapy. In a section on client competence in their 2000 book The Heroic Client, Miller and Duncan encourage therapists to cast the client in the role of “primary agent of change." They suggest that therapy is most successful when clinicians pay more attention to the client’s ideas about what works best for them and then follow the client’s lead in, letting the choice of techniques be guided by the client’s wisdom.

Miller and Duncan are not suggesting that client-focused care is not already happening in various therapies; rather, they think the different therapies may be working more, not because the model or technique is particularly effective, but because the clinician matches the client’s idea of what is helpful. Miller and Duncan shift the focus from differences to similarities because they claim it is the similarities that account for effectiveness when models of change in therapy are researched.

Miller and Duncan also suggest shifting the view toward what works in therapy to the client’s point of view – the client’s theory of change should guide the therapist’s work, including decisions about which models and techniques might be helpful. Therapists have many well-developed theories about mental health and addiction and about how people change – biological, psychosocial, behavioural, psychodynamic models and so on; but Miller and Duncan suggest that therapy works best when the therapist focuses on the client’s theory of change. When therapists ask and listen for what their clients believe to be the cause of their problems and how they believe they will get better, the direction can tailor therapy to the individual client. Not only will the techniques be tailor-made, but the other factors affecting outcome will also be enhanced.

The therapeutic relationship (accounting for 30 per cent of the outcome) is enhanced when clients feel understood and respected. Miller and Duncan report that therapists can listen for those under-appreciated extra therapeutic factors – accounting for 40 per cent of change – as well. In fact, they suggest digging for more information. A therapist whose antenna is out for that unseen 40 per cent will be listening for references to people and places and situations that the client looks to for support, inspiration and learning. Regarding the client as the very heart of change gives psychotherapy the collaborative quality that can allow a client who is suffering to take steps toward healing and happiness. It can also give therapists the gift of being allowed to observe the courage of their clients in taking those steps.

John Lennon’s quote is a reminder that we get so caught up in our ideas of things and how they should be that we forget to actually notice how they are. This wisdom can also serve therapists. In The Heroic Client, Miller and Duncan state, “The different schools of therapy may be at their most helpful when they provide therapists with novel ways of looking at old situations, when they empower therapists to change rather than make up their minds about clients” (p. 58).


Kate Kitchen is an advanced practice clinician in the Mood and Anxiety Disorders Division at the Centre for Addiction and Mental Health in Toronto.

Too much attention is paid to the elements that interest therapists, like models and techniques, and not enough to the other partner in the therapeutic process – the client.