Influential Client Factors
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INFLUENTIAL CLIENT FACTORS: UNDERSTANDING AND ORGANIZING THERAPISTS’ PERCEPTIONS OF CLIENT FACTORS THAT INFLUENCE REPORTED OUTCOME OF THERAPY Susan N. Perkins Dissertation Submitted to the Faculty of the Virginia Polytechnic Institute and State University In partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY In Human Development Specialization in Marriage and Family Therapy Fred P. Piercy, Ph.D., Chair Megan L. Dolbin-MacNab, Ph.D. Adrian J. Blow, Ph.D. Peter E. Doolittle, Ph.D. April 29, 2010 Blacksburg, Virginia Key words: Client Factors, Common Factors, Therapy, Outcomes Copyright © 2010 by Susan N. Perkins. All Rights Reserved. Influential Client Factors: Understanding and Organizing Therapists’ Perceptions of Client Factors that Influence Reported Outcome of Therapy Susan N. Perkins ABSTRACT Researchers and clinicians report that they think the client is the most influential component in determining the outcome of therapy. Although a variety of studies have examined the impact of various client factors on the outcome of couple therapy, this research is not cohesive and produces inconsistent results. The purpose of this multi-method study is to present a sense of the range and depth of client factors that influence the outcome of couple therapy. The use of qualitative and quantitative methods allowed the data to build on existing research while expanding the range of client factors considered. Data were gathered using a dynamic, web-based survey which assigned participants to discuss a case of successful or unsuccessful couple therapy. Participants provided their own descriptions of influential client characteristics. Participants also rated how important they thought several literature-based client factors were. Quantitative data analysis utilized descriptive statistics, principal components analysis, and logistic regression. Qualitative data were analyzed in two stages, using content analysis. Results indicated that couples can be conceptualized by five arenas of couple focus; these arenas accurately predicted whether participants were discussing a successful or unsuccessful case of couple therapy 85.9% of the time. Regarding individual client characteristics, in general, clients whose couple therapy was successful tended to be open to each other and committed to the relationship and to therapy. Unsuccessful couple therapy tended to focus on a greater number of individual issues. Couple dynamics characteristics differed according to outcome groups; participants described four types of couple dynamics that influenced couple therapy to be unsuccessful. Data showed that many client factors influenced the outcome of couple therapy, and that uncommon client characteristics could be vital to the outcome of some cases. Participants described a client’s life events as impacting the outcome of couple therapy by increasing one person’s vulnerability to his or her partner. If the partner acted in a way that created a sense of connection or support, this contributed to successful couple therapy. The results are presented in connection to previous research, when possible. Finally, implications for theory, research, and clinical work with couples are discussed. DEDICATION to Esther Leianne whose big smile, big heart, and sparkling eyes bring joy to every day iii ACKNOWLEDGEMENTS There is something ironic about calling this an individual project; I could never have done it alone. First, my love for working with clients only makes sense to me if I think of it as God-given. Without the passion to help others and the ability to do the work of learning, I would not even have started on the journey that led me here. Many friends and family have supported me in this journey by making room in their lives for the overflow of mine. I am grateful, not only for the tasks they actually did, but also for the faith they had in me, and in this project, which motivated their sacrifices. Ross Perkins, Lil and David Tice, Hannah Cook, Lanette Smith, Robyn Nunley, Christine Bauer, Kat Hertlein, Kathy Surface, Jeremy Ball, Brenda Freeman, George Lyons—all provided vital support. Perhaps most notable has been Ross’ support. I consider myself extremely blessed to be married to a man who is more proud of my small successes than his own monumental accomplishments. In addition, Hannah’s unexpected perspective of seeing my discouragement with previous work as evidence of growth helped me accept and believe in myself. The PhinisheD group kept this independent project from being lonely. I also want to thank the participants of this study. The depth of information they provided amazed me. I estimated that the survey would take 15-20 minutes to complete. From reading the information they provided, it is obvious that most participants gave much more time. (One participant emailed, saying that she spent two hours taking the survey.) Based on a typical therapy rate of $100/50-min hr, estimating 20 minutes for completion, and multiplying by the 398 surveys used, participants provided, at minimum, $15,900 worth of their time. I am very grateful for this generous gift! iv Even with the best support in the world, and the richest data, I could not have maneuvered my way through this process without my committee. Adrian Blow and Megan Dolbin-MacNab invested their time in me and challenged me to improve the quality of my ideas and work. What you have taught me will undoubtedly improve my future work, also. Peter Doolittle took on the demanding task of turning my ideas into a dynamic survey. The excellence Peter put into the survey made this a much better project and challenged me to expand my thinking regarding what is important. Finally, it has been a tremendous honor to work with Fred Piercy, the chair of my committee. Fred has steadily guided, mentored, supported, and encouraged me throughout this process. Fred’s example of integrity, balance, scholarship, wisdom, maturity, respect, humility, and skill has continually challenged me to grow. I am a better scholar and person for having worked with Fred. v TABLE OF CONTENTS Chapter I: Introduction ................................................................................................................ 1 Is Couple Therapy Effective? ...................................................................................................... 1 The Client’s Role in the Outcome of Couple Therapy ................................................................ 3 Purpose of this Study ................................................................................................................... 8 Defining Key Terms .................................................................................................................... 8 Conclusion ................................................................................................................................. 10 Chapter II: Literature Review ................................................................................................... 12 A Brief History of Common Factors ......................................................................................... 12 The foundation of common factors. ....................................................................................... 12 Multiple concepts of common factors.................................................................................... 14 Common Factors Meets Marriage and Family Therapy ............................................................ 16 Highlighting the client factor component of the common factors. ........................................ 18 Considering the individual in couple therapy. ....................................................................... 22 Client factors interact with other aspects of treatment. .......................................................... 23 Calls for research of client factors in couple and family therapy .............................................. 25 Critiques of Common Factors.................................................................................................... 28 Critiques of common factors in marriage and family therapy. .............................................. 29 Client Factors in Couple Therapy: Selected Empirical Evidence ............................................. 31 Exploratory studies of client factors in couple therapy. ........................................................ 32 Using client factors to predict the outcome of couple therapy. ............................................. 35 Toward a Constellation of Client Factors .................................................................................. 38 Chapter III: Methods .................................................................................................................. 39 Research Questions ................................................................................................................... 39 Research Design Elements ........................................................................................................ 40 Multi-method research. .......................................................................................................... 40 Survey research. ..................................................................................................................... 42 Clinicians’ Views of Couple Therapy Outcome........................................................................ 44 Data Collection Process ............................................................................................................