Why should it be a surprise that the very factors that were operating in a client's life before counseling also have a crucial effect on therapy? Clients who are, for example, persistent, open and optimistic, who, for that matter, have a supportive grandmother or are members of a religious community are more likely to make gains in therapy.
What else is important to therapeutic success? Researchers Alexandra Batchelor and Adam Horvath argue in their comprehensive 1999 review article that the client's perception of the therapeutic connection is the second most important ingredient of successful therapy, accounting for 30 percent of the outcome. In other words, therapy is much less about method than about the quality of the bond established between therapist and client. To many clinicians, this may seem obvious, but partisans of models and manuals too easily ignore this basic truth: The nature of a client's relationship with a therapist is more important than our cherished theoretical schools, our favorite techniques or our most worshiped gurus.
As we approach a far-reaching transformation in the way mental health services are delivered, it is more important than ever that we recognize that the very foundation of our work is the tailoring of our approaches to the unique needs and circumstances of each client. When you try to do therapy by a book, research tells us that things may not go according plan. For example, researcher Hans Strupp's classic studies, collectively known as the Vanderbilt II Psychotherapy Training Project, conducted in the early 1990s, demonstrated the dangers of overprogramming therapy. Strupp compared the work of therapists before and after they were trained with a manual on psychodynamic therapy. The results: Those who followed the manual were less approving and supportive of their clients, less optimistic and more authoritarian and defensive. Before health care systems organize themselves according to the recommendations of the APAs about what constitutes effective treatment, we need to heed such findings, as well as the previously mentioned study by Castonguay and Goldfried--practitioners of standardized therapy are in danger of developing better relationships with their treatment manuals than with their clients.
Nevertheless, within the medical world, the concept of empirically supported standardized treatments has tremendous appeal. Today, we may stand on the brink of a misguided system of "integrated care" in which manualized therapy will reduce clinicians to mere technicians. And, to make matters worse, integrated data bases will make it easier than ever for managed care organizations to keep track of whether our clients are adhering to the standardized regimens prescribed for them. Lists of approved treatments will give health care bureaucrats a potent weapon to use against those of us who don't order off the menu. This could even leave us in the ethically dubious position of enforcing compliance with treatments we don't endorse, and reporting our clients' lapses to the HMOs.