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How Clients Make Therapy WorkReview - How Clients Make Therapy Work
The Process of Active Self-Healing
by Arthur C. Bohart, Karen Tallman
American Psychological Association, 1999
Review by Keith S. Harris, Ph.D.
Aug 31st 2000 (Volume 4, Issue 35)

The authors of How Clients Make Therapy Work are unrepentant optimists. Clients have within them, say Bohart and Tallman, the seeds of their own cures: "[T]he active efforts of clients are responsible for making psychotherapy work" (p. xi).

However, in another sense, these authors are also pessimists. The healing powers of the therapist are much more limited than professionals would like to believe, they claim. "It is the client's self-healing capacities and resources that are responsible for the resolution of problems and for change . . . in any form of psychotherapy" (p. xii).

In this view, the therapist's only role in achieving a successful outcome is to support and encourage the client in the self-healing process. The therapist is a "participant consultant" (p. 16), and all theoretical models and techniques can be equally effective in the psychotherapy endeavor (the "dodo bird" verdict), as long as this self-healing tenet isn't violated.

The so-called "medical model" of psychotherapy likens the client to a patient suffering from some externally caused disease or illness, which can be cured or eliminated by the intervention of the expert practitioner. Bohart and Tallman reject this understanding of therapy. They insist that clients' problems are not illnesses, but are rather the result of ineffective interactions with their environments. "Psychological problems arise when people's coping skills and abilities are unable to handle problems and obstacles that confront them in their life space" (p. 84). Throughout the book, the authors stress repeatedly that the therapist's job is to understand and support the client, not to direct treatment or "intervene". Success in psychotherapy is not a "cure" as in the control of symptoms or elimination of a pathogen. Therapy is seen to be more like the processes of education and exploration, in which the client's abilities and world-view are expanded.

The strengths of this book are several. The authors write clearly and illustrate their positions with case examples. Alternative positions are examined and discussed. Most chapters conclude with a concise recap of the major assumptions underlying the authors' view in that chapter, which helps the reader maintain focus. For the therapist, the book serves as a reminder that psychotherapy is by its nature more of a collaborative effort than most medical procedures. And it's good to recall the humanistic principle that people are, in general, problem-solving creatures who seek to actualize their potentials. But because psychotherapy clients vary in their abilities to understand themselves and in their motivation to achieve effective outcomes, the therapist must be adaptable in order to successfully achieve and maintain the role of coach and collaborator.

Some of the questions addressed near the end of the book deserve even further consideration. For example, can therapists effectively employ this approach when working with clients who suffer from biologically-based disorders, extreme personality styles, or secondary-gain issues? One illustration used by the authors is that of the court-ordered, involuntary client (p. 301). The authors suggest that if therapy is a medical-like procedure, such clients should successfully respond in spite of their resistance. However, the authors argue that therapy is not an external intervention, and that these clients can benefit only from a therapeutic relationship in which they feel supported and valued and in which they are active participants.

(It should be noted here that the use of medical terms by psychotherapists does not mean they define these terms in the same way physicians might. For example, although therapists have borrowed and make use of the term intervention, they would not see this as something done to the client, but rather as referring to the specific activities of the therapist in working with the client. In the same way, treatment in psychotherapy does not refer to an externally applied agent, but rather to the general process of therapy.)

Finally, in arguing for a humanistic approach to therapy, the authors of this book brings to the surface another significant issue, perhaps the most crucial issue facing psychotherapists in this era of managed care - - the lack of an operational definition of successful outcomes. That is, what exactly is psychotherapy supposed to accomplish? How do we know when it has been successful? Third-party payers and community mental health systems are increasingly reluctant to cover services that have ambiguous goals or that look too much like chitchat sessions. If, as suggested above, psychotherapy is more like an educational process than a medical procedure, how can we convince payers that it should be included in a medical-model treatment system? Quantitative and actuarial data are the best evidence for this sort of purpose, and such data is difficult to extract from qualitative research and clinical studies, especially when successful outcome is left loosely defined.

Keith Harris, PhD, is a clinical psychologist and supervisor of Victor Valley Behavioral Health Center in San Bernardino county, California. Hisinterests include clinical supervision, the empirical basis forpsychotherapy research (and its design), human decision-making processes,and the shaping of human nature by evolutionary forces.


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