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Client's Theory Of Change

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The Client’s Theory of Change:

Consulting the Client in the Integrative Process


This article casts a critical eye upon the integration literature and asserts that, like psychotherapy in general, the client has been woefully left out of the therapeutic process. An alternative that privileges the client’s voice as the source of wisdom and solution is presented. It is proposed that conducting therapy within the context of the client’s own theory of change offers ways of integrating multiple therapy perspectives. An argument is made for not only recasting the client as the star of the drama of therapy, but also giving the heroic client directorial control of the action as it unfolds.



We feel that it would be fruitful to explain patient’s

own ideas about psychotherapy and what they expect from it.

Hoch (1955)

Many therapists have made the disappointing discovery that any given model that purports to ameliorate human suffering is limited. One size does not fit all. The field’s response has been rival schools, brand names, and high fashion in the therapy boutique of techniques. Thus, therapists have not suffered a dearth of models from which to choose; indeed, there are now more choices than Baskin and Robbins and Howard Johnson’s combined.

The up side, of course, is that under certain circumstances a given flavor may really hit the spot. The lure of increasing the efficiency of therapy through the selective application of disparate models has fueled interest in integrative strategies for practice. Eclectic theorists have sought to find relevant client characteristics beyond diagnosis to guide the selection process (e.g., the groundbreaking work of Beutler & Clarkin, 1990). Recent efforts have added an emphasis on matching relational methods (e.g., Blatt, 1992; Lazarus, 1993; Norcross & Beutler, 1997) looking for “relationships of choice” (Norcross & Beutler, 1997, p.44).

While the eclectic movement has not suffered from the “dogma eat dogma” (Saltzman & Norcross, 1990) mentality of warring factions of therapy, it is beginning to resemble the field as a whole with its immense heterogeneity. Norcross (1997) summarizes:

We have the prescriptive eclectics, pragmatically blending methods; we have the theoretical integrationists, actively smushing theories; we have the common factorists, relentlessly searching for underlying commonalities; and we have the system complementarists, astutely sequencing psychotherapy systems to maximize their domains of expertise… (p. 87).

Despite significant advances, Norcross (1997) suggests that the integration field invites confusion and irrelevancy unless the immense differences are defined, and the “me and not me” are established (p.87). In the spirit of addressing this concern, this article casts a critical eye upon the integration literature and asserts that, like psychotherapy in general, the client has been woefully left out of the therapeutic process. An alternative that privileges the client’s voice as the source of wisdom, solution, and model selection is presented.

A Tale of Two Dinosaurs

While the intellectual appeal of theoretical integration is compelling, the search for a unified metatheory is reminiscent of the rapid-fire development of models in search of the Holy Grail. The field has “been there, done that.” Given that model and technique only account for 15% of outcome variance (Assay & Lambert, 1999; Lambert, 1992; Miller, Duncan, & Hubble, 1997), theoretical integration efforts focus on the weakest link in the chain of factors accounting for change.

The love affair with models blinds therapists to the roles clients play in bringing about change (Duncan, Sparks, & Miller, 2000). As models proliferate, so do their specialized languages, systems of categories, and arsenal of techniques. All such articulations take place outside the awareness of those most affected. When models, whether integrative or not, crowd the thinking of therapists, there is little room left for clients’ modelsвЂ"their ideas about their predicaments and what it might take to fix themвЂ"to take shape. Client’s ideas, are, at best, patronized for the sake of friendliness or compliance; at worst, part and parcel of the problem, those very elements needing to be eradicated or transformed (Duncan, Miller, & Sparks, 2000).

A technical eclecticism based on empirically validated techniques (EVT) suffers the same problems that EVT’s bring to non-eclectic therapists. Efficacy over placebo or customary treatment is not differential efficacy over other approaches (Duncan & Miller, 2000). Where differences do occur over other models, they are often trivial and explainable by chance alone (Wampold, 1997). Further, efficacy speaks more to the approach’s privilege of being researched (Hubble, Duncan, & Miller, 1999) rather than how such research should be privileged. Finally, efficacy in randomized clinical trials does not equate to effectiveness in clinical settings; internal validity does not ensure external validity (Goldfried & Wolfe, 1998). More importantly, any technique, EVT or the plain variety of everyday practice, gains its power to change from its ability to enlist client’s resources, court the alliance, and fit the client’s view of what is helpful (Duncan, Hubble, & Miller, 1997).

The problem that plagues integrative efforts is the same problem that has all but reduced psychotherapy to medical diagnoses and the prescription of empirically validated treatmentsвЂ"the key figure, the client, has been left out of the loop. Most, if not all integrative efforts focus exclusively



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