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 work with the first client. Perhaps in time you could come to understand and genuinely respect the way the second client is doing life. Let’s face it, though: if we base our assessment as therapists on first impressions and first sessions, we are likely to have concluded that the first client is a better “fit” for us than the second. But what factors went into this assessment? What factors — including aspects of the client, of ourselves, and of the situation — should we be taking into account when determining whether we should, or even can, work helpfully with someone? This article acknowledges the common understanding (backed up consistently by research) that a good therapeutic alliance is a prime predictor of success in therapy, and it also notes the converse: that not all therapists can work with all clients. It poses the question of which factors we should consider in making this assessment of therapist-client fit. We look at issues of personal fit, fit between methods/approaches and client preferences, issues of transference, and the “what else” that research has recently been turning up. We include a few tips for those who may discover they have a client they just “don’t like”.
Personal fit refers to the sense of whether you and your client like, respect, and get along with each other. Obviously, it is much easier 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 interpersonal relationships is something that, as therapists, we claim as our “stock in trade”, so we may be loath to admit that there is someone with whom we cannot build rapport. Yet despite even gargantuan efforts in some cases, there remain factors beyond the control of the therapist which impact on that indefinable factor of attraction — and through that, personal fit (Keelan, n.d.). We may, as in Scenario 2 above, merely have such a different lifestyle, outlook, and set of attitudes that we experience no commonality with the client. The client may have an attitude that we find we cannot work with: for example, attitudes of deeply held racial or other prejudice or a sense of entitlement. Or there may be no logical reason behind the antipathy, except that we remind the client of someone who treated them badly before (or the opposite: we have a reaction to the client based on our own past). We examine this question of transference separately in a moment, but for now, note a few quotes on the issue of personal fit.
Dr June Wolf, assistant clinical professor of psychology at Harvard Medical School: “You don’t have to like a person to do a good job as a therapist, but if you actively dislike somebody, 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: “Recent research has shown that the empathy required for therapeutic success is only possible when the therapist basically likes the client” (Baker, 2009).
And if the therapist really doesn’t click with the client? At the end of this article, we look at how you as therapist deal with that, but suffice it to say here that an active option must remain “gentle referral” of the disliked client to a colleague who will work better with the client than you will.
Fit between methods/approach and client preference/needs
If the notion that “therapeutic alliance is a prime factor in success” is the Number One understanding among those in helping professions, this is probably the second: there are myriad types of therapy; both clients and therapists differ in their preferences and their abilities to be engaged with a particular type. Let’s take the example of a therapist trained almost exclusively in psychodynamic methods. Let’s say that therapist receives into their rooms a client who basically had a pretty good upbringing, has a secure attachment to childhood caregivers, and just wants to upgrade his assertiveness skills in order to negotiate better work conditions with his boss. Maybe he needs to go back and look at early childhood issues — and maybe not — but if his 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 or solution-focused therapist.
The classical question
Psychological literature is rife with studies purporting to show 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 possible absence of a strong evidence base for a particular therapy, we suggest that the classical question posed by G.L. Paul to researchers is still the most pertinent:
“What therapy, by whom, is most effective for this individual with that specific problem and under which circumstances?” (Paul, 1967, p 111, italics in original)
In other words, more than a half-century later, we still need to seriously ask ourselves: is there a fit between method/approach (of which there are hugely more now than in 1967) and the particular client sitting in front of us?
Practices that help
One practice that can help — at least from the client’s perspective — is that of therapists giving, say, 30 minutes of free consultation when they first meet clients in order to afford them the opportunity to get a sense of the therapist, ask relevant questions, and generally assess whether they could fruitfully work with the person. Time is money, of course, and you may find that your practice would struggle to absorb that much free time given away. That is a fair enough concern, but the point must be made that as therapist you could end up losing more time, plus creating a toxic environment for your client, and even incurring reputational damage, if you were to carry on for numerous sessions only to find that your client’s preferred way of working and yours were incompatible. Thus, the free minutes at the beginning are valuable to you as well in order to assess fit.
Again, from the client’s perspective but with value for you is the practice employed by many therapists of putting onto their website the particular training and qualifications they hold, the methods or modalities that they use, and sometimes even a bit about themselves.
No fit? No fault
An important attitude, for both client and therapist to hold during any initial “meet and greet” session — or even after they have begun work together but will not continue — is that a lack of fit is no one’s fault. It is not a negative reflection on the client that you believe another therapist could serve them better; it is only you responding to signs and symptoms of poor fit in the highest ethical manner: by acknowledging you are not the one with whom this client will best heal. Likewise, it is no negative reflection on you if the client comes to that conclusion and bravely lets you know that your style isn’t what they need, or that they don’t feel totally comfortable with you. In this case, you may (if they agree) attempt to help them find a colleague or other therapist whom you sincerely believe might work out better for them (Keelan, n.d.). In some cases the lack of appropriateness has nothing to 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 a devastating, 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. Then in walked new client Annie, with whom Thomas readily connected and with whom she had numerous commonalities. Annie announced that she was there because of a painful breakup with her long-term partner which she “just didn’t see coming”. Thomas says she managed to get through the session without losing her composure (just!), but to her horror she broke down upon taking Annie to supervision. The supervisor was supportive but firm; she insisted that Thomas refer Annie onward, saying, “She is not the right client for you to see at this point”.
Thomas later reflected that, with her own life resonating so profoundly with the client’s, she could not be the “empty” or “blank” screen onto which the client could project feelings, unconscious messages, and relating patterns. She could not, when so over-identified with Annie’s experience, pick up on powerful feelings in the room and use them as clues about what Annie might be experiencing. Simply put, Thomas realised that she had “contaminated” the transference with her own highly similar experience, and she could not be emotionally available in a healing way. Which, she would later wonder, were Annie’s feelings? Which were hers? Whose strategies were the ones discussed for coping and healing? The transference and countertransference in this case were unable to be “mined” for the gold that they contained (Thomas, 2019).
Some therapists-in-training have commented that they seem to attract 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 already worked through her similar issue of a breakup.
The question of fit is broader, however, than merely attraction, preferences for working, or presence of transference.
What else? What the research is saying
Literature summarised in “Improving Cultural Competence”, a document produced by the U.S. Center for Substance Abuse Treatment and SAMHSA (Substance Abuse and Mental Health Services Administration, 2014) suggests that the overall results are inconclusive about the value of client-counsellor matching based on race, ethnicity, or culture. One study found that for people whose primary language was not English, counsellor-client matching for ethnicity and language predicted longer time in treatment and better outcomes for all ethnic groups studied: Asian-Americans, African Americans, Mexican Americans, and white Americans. For female clients, particularly (especially sexual abuse survivors), gender congruence was more important. Latinos responded well to ethnic matches, and racial and ethnic matching helped develop a working alliance between therapist and client in multicultural communities studied, with particular reference to Asian Americans and Pacific islanders. The document noted that other relevant variables in the research were age, marital status, training, and parental status (SAMSHA, 2014).
Intriguingly, a study using an assessment instrument entitled the “Structural Profile Inventory (SPI)”, which measures seven “independent yet interactive” variables, showed that client-therapist similarity on the SPI predicted a better psychotherapy outcome for the client, as measured by differences pre- and post-treatment on the BSI (Brief Symptom Inventory). That is, the more similar the therapist and client, the lower the degree of reported psychopathology at psychotherapy “outcome” (after 12 sessions). The seven SPI variables are: behaviours, affects, sensory imagery, cognitions, interpersonal, drugs/biological factors, or BASIC-ID (Herman, 1998). Clearly, this question of fit 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 a session or two with a new client and you realise that you are not only quite different from the client in ways significant to you both, but also, you seriously don’t “click” with the client. By way of summarising in unambiguous terms what we’ve been talking about, here are some ideas to help you decide whether 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 to accept — opportunity for growth as a clinician. You get to say, “I wasn’t the one to help that client; we were like chalk and cheese. But I helped him find a really compatible therapist, so he can make good progress now.” And then you get to go back to joyfully welcoming through the door all the ones where the fit is more like “hand-in-glove”: the ones who validate that you are, after all, an ok therapist.
- 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.