Assessing Therapist-client Fit
Please consider these two scenarios for a moment.
Scenario 1. The new client comes in and makes solid eye contact as she seats herself. You feel a surge of warmth toward her and are immediately interested. As the session progresses, you notice she is similar to you in certain unusual ways, and her passing remarks show her to have some of the same interests you do: like cave diving, researching ancestry, and travel shows. You just know this therapy is going to be successful.
Scenario 2. The new client takes the proffered chair and grunts at your wall hanging, making a disparaging remark about abstract art. His lifestyle seems completely alien to you, and as he talks, you get an increasingly strong reaction in your guts about some of his attitudes. Does he really believe it’s a workable way to do life, you wonder, if he thinks the world owes him a living?
Perhaps there would have been issues undermining your workwith the first client. Perhaps in time you could come to understand and genuinelyrespect the way the second client is doing life. Let’s face it, though: if webase our assessment as therapists on first impressions and first sessions, weare likely to have concluded that the first client is a better “fit” for usthan the second. But what factors went into this assessment? What factors —including aspects of the client, of ourselves, and of the situation — should webe taking into account when determining whether we should, or even can, workhelpfully with someone? This article acknowledges the common understanding(backed up consistently by research) that a good therapeutic alliance is aprime predictor of success in therapy, and it also notes the converse: that notall therapists can work with all clients. It poses the question of whichfactors we should consider in making this assessment of therapist-client fit. Welook at issues of personal fit, fit between methods/approaches and client preferences,issues of transference, and the “what else” that research has recently beenturning up. We include a few tips for those who may discover they have a clientthey just “don’t like”.
Personal fit
Personal fit refers to the sense of whether you and yourclient like, respect, and get along with each other. Obviously, it is mucheasier to work with a client toward their goal if mutual respect and liking are“in the room” between you. Just as obviously, the capacity to do interpersonalrelationships is something that, as therapists, we claim as our “stock intrade”, so we may be loath to admit that there is someone with whom we cannotbuild rapport. Yet despite even gargantuan efforts in some cases, there remainfactors beyond the control of the therapist which impact on that indefinablefactor of attraction — and through that, personal fit (Keelan, n.d.). We may,as in Scenario 2 above, merely have such a different lifestyle, outlook, andset of attitudes that we experience no commonality with the client. The clientmay have an attitude that we find we cannot work with: for example, attitudesof deeply held racial or other prejudice or a sense of entitlement. Or theremay be no logical reason behind the antipathy, except that we remind the clientof someone who treated them badly before (or the opposite: we have a reactionto the client based on our own past). We examine this question of transferenceseparately in a moment, but for now, note a few quotes on the issue of personalfit.
Dr June Wolf, assistant clinical professor of psychology atHarvard Medical School: “You don’t have to like a person to do a good job as atherapist, but if you actively dislikesomebody, it’s harder to do a good job” (Baker, 2009).
Dr Karen Maroda, a Milwaukee psychologist and author,commenting on therapist guilt about stopping work with someone: “Recentresearch has shown that the empathy required for therapeutic success is onlypossible when the therapist basically likes the client” (Baker, 2009).
And if the therapist really doesn’t click with the client? Atthe end of this article, we look at how you as therapist deal with that, butsuffice it to say here that an active option must remain “gentle referral” ofthe disliked client to a colleague who will work better with the client thanyou will.
Fit between methods/approach and client preference/needs
If the notion that “therapeutic alliance is a prime factorin success” is the Number One understanding among those in helping professions,this is probably the second: there are myriad types of therapy; both clientsand therapists differ in their preferences and their abilities to be engagedwith a particular type. Let’s take the example of a therapist trained almostexclusively in psychodynamic methods. Let’s say that therapist receives intotheir rooms a client who basically had a pretty good upbringing, has a secureattachment to childhood caregivers, and just wants to upgrade his assertivenessskills in order to negotiate better work conditions with his boss. Maybe heneeds to go back and look at early childhood issues — and maybe not — but ifhis strong preference is just to focus on the here-and-now, gain needed skills,and implement a solution, he might work better with a CBT-trained orsolution-focused therapist.
The classical question
Psychological literature is rife with studies purporting toshow that a given method or other is superior — and some modalities of therapy,such as CBT, are so heavily supported in research that they have been dubbed“the gold standard” (Leichsenring & Steinert, 2017). In the possibleabsence of a strong evidence base for a particular therapy, we suggest that theclassical question posed by G.L. Paul to researchers is still the mostpertinent:
“What therapy, by whom, is most effective for this individual with that specific problem and under which circumstances?” (Paul, 1967, p111, italics in original)
In other words, more than a half-century later, we stillneed to seriously ask ourselves: is there a fit between method/approach (ofwhich there are hugely more now than in 1967) and the particular client sittingin front of us?
Practices that help
One practice that can help — at least from the client’sperspective -- is that of therapists giving, say, 30 minutes of free consultationwhen they first meet clients in order to afford them the opportunity to get asense of the therapist, ask relevant questions, and generally assess whether theycould fruitfully work with the person. Time is money, of course, and you mayfind that your practice would struggle to absorb that much free time givenaway. That is a fair enough concern, but the point must be made that astherapist you could end up losing more time, plus creating a toxic environmentfor your client, and even incurring reputational damage, if you were to carryon for numerous sessions only to find that your client’s preferred way ofworking and yours were incompatible. Thus, the free minutes at the beginningare valuable to you as well in order to assess fit.
Again, from the client’s perspective but with value for youis the practice employed by many therapists of putting onto their website theparticular training and qualifications they hold, the methods or modalitiesthat they use, and sometimes even a bit about themselves.
No fit? No fault
An important attitude, for both client and therapist to holdduring any initial “meet and greet” session — or even after they have begunwork together but will not continue — is that a lack of fit is no one’s fault. Itis not a negative reflection on the client that you believe another therapistcould serve them better; it is only you responding to signs and symptoms ofpoor fit in the highest ethical manner: by acknowledging you are not the onewith whom this client will best heal. Likewise, it is no negative reflection onyou if the client comes to that conclusion and bravely lets you know that yourstyle isn’t what they need, or that they don’t feel totally comfortable withyou. In this case, you may (if they agree) attempt to help them find acolleague or other therapist whom you sincerely believe might work out betterfor them (Keelan, n.d.). In some cases the lack of appropriateness has nothingto do with personality, preferences, or even modalities used.
The role of history and transference
Bev Thomas, a psychologist and organisational consultant,recalls the time when, as a freshly qualified psychologist, she experienced adevastating, out-of-the-blue breakup with her boyfriend. Reeling and in pain,she nevertheless used her strong will to get out of bed and face her clients. Thenin walked new client Annie, with whom Thomas readily connected and with whomshe had numerous commonalities. Annie announced that she was there because of apainful breakup with her long-term partner which she “just didn’t see coming”. Thomassays she managed to get through the session without losing her composure(just!), but to her horror she broke down upon taking Annie to supervision. Thesupervisor was supportive but firm; she insisted that Thomas refer Annieonward, saying, “She is not the right client for you to see at this point”.
Thomas later reflected that, with her own life resonating soprofoundly with the client’s, she could not be the “empty” or “blank” screenonto which the client could project feelings, unconscious messages, andrelating patterns. She could not, when so over-identified with Annie’sexperience, pick up on powerful feelings in the room and use them as cluesabout what Annie might be experiencing. Simply put, Thomas realised that shehad “contaminated” the transference with her own highly similar experience, andshe could not be emotionally available in a healing way. Which, she would laterwonder, were Annie’s feelings? Which were hers? Whose strategies were the onesdiscussed for coping and healing? The transference and countertransference inthis case were unable to be “mined” for the gold that they contained (Thomas,2019).
Some therapists-in-training have commented that they seem toattract clients whose stories are very similar to issues they have faced, but overcome.The problem for therapist-client fit in the case of Thomas and client Annie —or any of us in an equivalent situation — comes because Thomas had not alreadyworked through her similar issue of a breakup.
The question of fit is broader, however, than merelyattraction, preferences for working, or presence of transference.
What else? What the research is saying
Literature summarised in “Improving Cultural Competence”, adocument produced by the U.S. Center for Substance Abuse Treatment and SAMHSA(Substance Abuse and Mental Health Services Administration, 2014) suggests thatthe overall results are inconclusive about the value of client-counsellormatching based on race, ethnicity, or culture. One study found that for peoplewhose primary language was not English, counsellor-client matching forethnicity and language predicted longer time in treatment and better outcomesfor all ethnic groups studied: Asian-Americans, African Americans, MexicanAmericans, and white Americans. For female clients, particularly (especiallysexual abuse survivors), gender congruence was more important. Latinosresponded well to ethnic matches, and racial and ethnic matching helped developa working alliance between therapist and client in multicultural communitiesstudied, with particular reference to Asian Americans and Pacific islanders. Thedocument noted that other relevant variables in the research were age, maritalstatus, training, and parental status (SAMSHA, 2014).
Intriguingly, a study using an assessment instrumententitled the “Structural Profile Inventory (SPI)”, which measures seven“independent yet interactive” variables, showed that client-therapistsimilarity on the SPI predicted a better psychotherapy outcome for the client,as measured by differences pre- and post-treatment on the BSI (Brief SymptomInventory). That is, the moresimilar the therapist and client, the lower the degree of reportedpsychopathology at psychotherapy “outcome” (after 12 sessions). The seven SPIvariables are: behaviours, affects, sensory imagery, cognitions, interpersonal,drugs/biological factors, or BASIC-ID (Herman, 1998). Clearly, this question offit is a big one!
Tips for when you just don’t like the client
So, let’s assume the worst case scenario: you’ve had asession or two with a new client and you realise that you are not only quitedifferent from the client in ways significant to you both, but also, youseriously don’t “click” with the client. By way of summarising in unambiguousterms what we’ve been talking about, here are some ideas to help you decidewhether you can capitalise on your negative feelings or it’s a referral job.
Reframe. The issue is not whether you like the person, but whether you can offer competent service. As noted above, it is more difficult when you have a strong (negative) reaction, so: can you get past the personal reactions which would affect the work?
Consider whether you can overcome the antipathy. If it’s just that the client has a disgusting habit (like picking their nose in session?), you may be able to disregard it, but if some of their standout values are irreconcilable with your own, it’s probably a no-go.
Use your feelings to move therapy forward. Use meta-communication: that is, communicate about the communication. You can frame it as the client’s experience: “you seem angry with me”. You can make it as an observation: “It seems we’re playing cat and mouse”. Or you can own the experience: “I feel like you’re taking shots at me”. It’s better to bring up these concerns as they happen.
Consult with colleagues/supervisor. Such discussions can centre on your question: “Is there a way I can use my personal feelings to more deeply understand the client’s challenge?”
Protect the integrity of your practice. We already mentioned potential reputational damage to therapists who insist on seeing a client where there is genuinely not a good fit. Beyond that, such clients are exhausting, and may deplete your energy for the rest of your clients. Reflect on whether you need to limit such cases.
Refer the client. And if all else fails, remember: there are some people we simply can’t help, or rather, we help them best by finding them a therapist who is suited to them. In this case, it’s about acknowledging that we can’t give them the therapy we think they need (Baker, 2009).
This last action, referral, brings you a unique — if hard toaccept — opportunity for growth as a clinician. You get to say, “I wasn’t theone to help that client; we were like chalk and cheese. But I helped him find areally compatible therapist, so he can make good progress now.” And then youget to go back to joyfully welcoming through the door all the ones where thefit is more like “hand-in-glove”: the ones who validate that you are, afterall, an ok therapist.
References
Baker, B. (2009). Deal with clients you don’t like. American Psychological Association, Vol 40(2). Retrieved on 24 November, 2019, from: Website.
Herman, S.M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. Journal of Psychotherapy Practice and Research, 1998 Winter; 7(1): 56-64.
Keelan, P. (n.d.). The importance of client-therapist fit in counselling. Drpatrickkeelan.com. Retrieved on 24 November, 2019, from: Website.
Leichsenring, F., & Steinert, C. (2017). Is cognitive behavioural therapy the gold standard for psychotherapy? The need for plurality in treatment and research. Journal of the American Medical Association. 2017; 318(14): 1323-1324. doi:10.1001/jama.2017.13737. Retrieved on 25 November, 2019, from: Website.
Paul, G.L. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology. 1967 Apr, 31(2): 109-118.
SAMHSA. (2014). Improving cultural competence, Treatment Improvement protocol (TIP) Series, No. 59. From: 3, Culturally responsive evaluation and treatment planning. Rockville, MD: SAMHSA and Center for Substance Abuse Treatment (US).
Thomas, B. (2019). The invisible line that divides a therapist and client. The Guardian. Retrieved on 25 November, 2019, from: Website.