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How People Change

06/11/11: Have you ever wondered what the stages are of making change in your life? Or do
you have someone in your life that is trying to make a change and you wish you could know
how to be more helpful? The following post will give a brief overview of the stages of
change, give some ideas on what you can do to make changes in your life, and help someone
else make change in theirs.

How Do People Change?


At the core, psychotherapy is about creating change, and there have been literally hundreds of
theories created over the years to explain how people change. Generally, these range from
altering thought patterns, processing emotions, making the unconscious conscious,
reinforcing behavior, connecting to our mortality (like having a major health problem),
developing new relationships, experiencing major consequences, providing incentives,
learning and having new experiences, or connecting to something greater than the self.
Unfortunately, during this time in world history, no one really knows for sure yet what the
best approach is, but there is evidence that all of these and many more actually work, which
is part of why counseling often uses them all.

Despite this range, one thing that we do know is the stages of change that we all move
through. With a few exceptions (like when there is an immediate and overwhelming reason to
change), this model holds true. This Transtheoretical Model of Change can be applied to
almost anything, and it has incredible research support as well. The stages are:

1. Precontemplation: the person is not planning to make a change and is likely unaware that
the behavior is problematic

2. Contemplation: the person recognizes that there is a problems and is considering making
a change sometime in the future

3. Preparation: the person is planning to make a change in the near future and is starting to
take small steps

4. Action: the person is implementing the change

5. Maintenance: the person has stabilized the change and is actively keeping it up

A classic example of this would be someone trying to quit smoking. In precontemplation, the
person smokes and is either unaware that this is a health risk or is uninterested in making
changes anyway. In contemplation, the person may know that smoking is a health risk and
has the idea of wanting to quit in the future, maybe within the next 6mo or a year. In
preparation, the person is researching how to quit, may set a quit date, and is ready to make
the change happen within the next month or so. In action, the person has begun the process of
cutting down or quitting; and in maintenance, the person has held to the change.

If you are looking to make a change in your life, it means you are already at least in
contemplation. If you are there, you may start to think about what the next steps are for
making the change, or what is preventing you from taking the next step right now. If you are
in preparation, maybe this article is giving you more information to do what you are trying to
do. A helpful thing in this stage can be setting a timeline for implementation, or accessing
more resources to make it happen, like going to counseling.

Can I Change Someone Else?


Questions about how to change someone else are some of the most common things I get
asked in therapy. Since relationships are so central to most of our lives, when someone is
doing something disruptive, we often wish the person would just change and make everything
better. Unfortunately, we are going to go with the bad news first: 90% or more of efforts to
change someone else are futile, especially if the person is in precontemplation. Conventional
wisdom says that we cannot change others, but we can change our reactions to them. Based
on that, I’d encourage you to read these three other articles first instead of this one if you are
someone who is often hoping for other people in your life to change: Acceptance Model of
Change; Over-functioning & Under-functioning; Therapeutic Lifestyle Changes.

So if you are still looking to change another person, it can be important to keep the
aforementioned stages in mind, and realize that this is a long term process, rather than
something that will instantly happen. Otherwise, there are three major approaches to take in
trying to change someone else: voicing a concern / making a request, motivational
interviewing, and long term conditioning. However, remember that much of this may not be
received well by the other person if they feel coerced or if their best interest in not stated
well.

1. Voicing Concern / Making a Request: It’s amazing how often we skip simply saying that
something is hurtful or that we are concerned about the person. If it is done, usually I hear
about it being said in frustration or in a heated argument, which is usually not effective.
Basically, doing this well can be tricky, so using the model of How to Say Hard Things can
be a potential guide for another approach.

2. Motivational Interviewing: The key with this is in helping people to move through the
stages of change by directing specific interventions toward them. For someone in
precontemplation that would mean providing some information to help the person recognize
that there is a problem and there is a need to change. In contemplation it would mean
identifying and removing specific barriers to change. In preparation it would mean assisting
the person in planning the actual change. In action it would mean supporting and validating
the progress. In maintenance it would mean reinforcing and support the change that was
made to help the person stay on track. All of these must come in a supportive and
compassionate environment to be effective.

3. Long Term Conditioning: The key here is setting up a consistent set of rewards and
punishments for certain behaviors that can result in change over longer periods of time. The
basics of this are implementing things that will make the target behavior unlikely to happen
again, which include positive punishment (adding something unpleasant) or negative
punishment (taking away something pleasant). Additionally, things that will make another
behavior more likely to happen again include positive reinforcement (adding something
pleasant) or negative reinforcement (removing something unpleasant). Over extensive periods
of time, if something like this was applied, it would be likely to produce at least some kind of
change in someone else, as long as it was consistently applied, the rewards and punishments
were sufficient, and tied to the behaviors directly.
Enemies of Change
The enemies of changing yourself or helping someone else change are criticism and
impatience. Being critical and judgmental often has the opposite of the hoped for outcome. A
lot of people come into my office and describe criticizing someone or voicing concern in a
judgmental tone, and they are “shocked” that the response wasn’t something like “wow you
know… I never saw it that way before. I will change that right away! Thank you for telling
me!” Instead they end up receiving defensiveness, a deeper entrenching of the problem, and a
more tense relationship. Impatience is equally damaging, since it can take a long time for
change to happen. Losing patience can stunt your progress, or that of the other person.

In conclusion, I often think it is more beneficial for people in close relationships or other
interpersonal situations to work on acceptance, tolerance, and personal change rather than
changing others, but there is occasionally a place for doing some of these things within a
supportive and loving relationship. Fortunately, counseling can help you move through these
processes or work on acceptance and making the best of what is possible without requiring a

Description
The dictionary describes counseling as provision of advice or guidance in decision-making,
in particularly in emotionally significant situations. Counselors help their clients by
counseling them. Counselors also help clients explore and understand their worlds and so
discover better ways of thinking and living.

Some definitions include:

...help clients understand and clarify their views of their lifespace, and to learn to reach their
self-determined goals through meaning ful, well-informed choices and through resolution or
problems of an emotional or interpersonal nature. (Burks and Steffire, 1979)

...work with individuals and with relationships which may be developmental, crisis support,
psychotherapeutic, guiding or problem-solving... (BAC 1984)

The task of counseling is to give the client an opportunity to explore, discover and clarify
ways of giving more satisfyingly and resourcefully. (BAC 1984)

A principled relationship characterized by the application of one or more psychological


theories and a recognized set of communication skills, modified by experience, intuition and
other interpersonal factors, to clients' intimate concerns, problems or aspirations. (Feltham
and Dryden, 1993)

A common factor in most counseling situations is that the client is demoralized, distressed or
otherwise in a negative state of mind about something.

Counseling can be for one person or a group (typically couples and families) and may be
delivered through a number of methods, from face-face dialogue, group work, telephone,
email and written materials.
Counseling is largely a voluntary activity whereby clients must wish to change and
collaborate willingly with the counselor. Early counseling activity in some cases involves
bringing referred clients to this point of readiness.

Results of counseling can include:

 Insight and understanding of oneself, with greater self-awareness.


 Changing of one's beliefs and mental models.
 Increased acceptance and appreciation of oneself.
 Increased emotional intelligence.
 Increased ability to control oneself and one's urges.
 Development of skills and abilities that require self-management.
 Improved motivation towards actions that are good for one's self.
 Understanding of others and why they act as they do.
 Increased appreciation and care for others.
 Improvement in relationships with others.
 Changing of relationship with family, friends and others.
 Making amends for past negative actions.

In summary, counseling typically leads to resolution of a living problem, learning of some


kind and/or improvements in social inclusion.

Counseling is also a profession, with national associations and control bodies, who, along
with academics, have explored its detail further.

Discussion
Contact between counselors and clients may be through a third party who refers the client.
The client may also seek out the counselor for help with their troubles.

Counselors often subscribe to particular schools of thought as to the most effective and useful
way of helping. A critical variable in this is the extent to which the solution to problems are
provided by the counselor or by the client. This leads to two very different roles for the
counselor: problem-solving or facilitator. A facilitative approach may also be used when a
more open exploration approach is used.

There are hence a number of theories in counseling, including those held by the client and
those held by the counselor. Theories provide simplified models for understanding and ways
of acting. They help the counselor how to percieve the client and decide what to do. They
may also provide the client ideas for what to think and do differently.

Counseling is particularly common at transition points in a person's life, where they are
moving from the familiar to the strange, going from child to adult, single to married and so
on. These changes can be difficult and the counselor can help their client successfully make
the change, both emotionally and cognitively.

There has been ongoing debate about the difference between counseling, coaching and
therapy and the boundaries are not at all clear. Therapy can be more clinical but counseling
still addresses serious issues, whilst 'coaching' can effectively be a euphemism for lighter
forms of counseling. Generally, counseling tends to have a more social focus, whilst therapy
and coaching are more individually focused.

Historically counseling in personal issues was done by close relatives, friends or the local
priest. Although counsel has always been given within families, parents and siblings are not
always the best people to do this when they are effectively a part of the problem. Likewise
with friends, the penetrating need of counseling means a fun-based friendship is not the best
place to go.

With the rise of the industrial revolution and the mobility of populations, this stable support
network was often lost. At this time caring professions started to develop and the asylum as a
place of entertainment faded as mental illness and simpler personal issues were taken more
seriously.

In the 20th century, counseling emerged as a profession, splitting from therapeutic


approaches and developing its own ways, although still retaining much in common with
therapy. There are still competing approaches within counseling that parallel therapeutic
though.

Religion has continued to be an influence in the development of counseling and several


counseling agencies grew out of religious organizations which sought to help people in need.
This has influence the general thinking withing counseling, which is suffused with Judeo-
Christian thought.

Counseling has also been influence by the arts and has had some focus here, for example in
using methods such as dance, painting and drama for therapeutic benefit in providing a
channel that enables people to express their emotions.

See also
A Brief History of Counseling and Therapy, Beliefs, Meaning, Learning Theory, Motivation

Burks, H.M. and Stefflre, B, (eds) (1979). Theories of Counseling, New York: McGraw-Hill

Dryden, W. and Feltham, C. (1993). Brief Counselling, A practical guide for beginning
practitioners, Milton Keynes: Open University Press

How to Achieve Success With Counseling


Dr. Cheryl A. MacDonald
To achieve success in counseling there has to be an agreed upon partnership. It takes time, energy and
effort by both the person receiving counseling and the therapist. It takes a collaborative effort by both
the counselor and the individual receiving the counseling.

Therapy is a commitment to make difficult adjustments in thinking patterns and behavior. Effective
counseling is a two way street. It takes a time, energy and financial commitment from the client to
make changes in behavior or thought patterns and then learn new ways of coping with thoughts,
feelings and behaviors. It is hard work! This article will be discussing, client characteristics, therapist
characteristics and treatment conditions that will help anyone achieve success with counseling.

The Therapy Relationship


The therapeutic alliance is a partnership where both therapist and patient agree on shared goals and
work together on tasks which conceivably will produce a positive result. This alliance is built on
acceptance, empathy and trust, with the perception that the relationship is a factor in successful
therapy. The connection or therapeutic alliance between therapist and client has been a focus and
examined many times throughout the historical development of psychotherapy. Copper & Lesser,
2011 explain the idea of the client being an active partner in the treatment process. Many therapists
agree with viewing the relationship that is established and collaboration between therapist and client
as one of the solutions if not the key, to the change process.

Past investigations have focused on client characteristics that have had an impact on the therapeutic
alliance, such as motivation level and the ability to form relationships have shown that these traits and
characteristics have an impact on both the relationship and the therapy outcome (Black et al.,
2005). The research further explains that the clients capacity to form a relationship provides
the foundation for the alliance, but it also appears that the
therapists capacity to form relationships is just as important. The literature does lead us to
believe that a good connection between therapist and client can happen quite
quickly, even within the first 10 minutes, but on average it takes 2-3 sessions (Littauer et al., 2005).

Empathy is an essential ingredient in the healing process. A therapist’s empathy toward their client
plays a role in developing the alliance, and its impact on the relationship is crucial. Moore (2006),
suggests empathy is not simply communicated orally, but also with an increase in eye contact, body
posture, tone of voice and listening skills. It is significant for therapists to think of not only the
therapeutic alliance, but also the ways in which they show empathy as an influence on treatment
results.
Why people go to counseling What is therapy?

By beyondboundaries on flickr
Creative Commons

There are numerous and varied reasons why people choose to go to counseling. Some people have
experienced traumatic events, which they would like to explore in a safe setting; bereavement,
separation, difficult life transitions, or distressful experiences from the childhood. Others seek help
with learning how to cope with specific psychological or behavioral traits which they would like to
change; depression, compulsive thoughts, difficulties with relationships or poor dietary habits. Many
people seek counseling to explore a general feeling that their lives are not quite right, or learn how to
cope with feelings of hopelessness associated with managing a chronic illness. However, it is not at all
necessary to have a serious problem to achieve success with counseling. People may turn to
counseling to develop a purpose, to find meaning in life, or attempt to stir up determination to achieve
a goal.

Some people do not want to be in counseling because they were coerced into treatment. “My husband
says I have a problem”. “My wife says I do not communicate”. “The judge says I have to do six
sessions”. “My doctor said it all in my head”. These are not ideal therapy conditions, and it will take
an experienced therapist to be able to help, and many do indeed benefit. Most people want to go to
counseling to improve some problem or find ways to cope with a distressful life event. Some people
experience feelings associated with anxiety mixed with the possibility of hope in removing or finding
new ways to cope with the problem. The anxiety is often about how they think they will be judged by
the therapist. The hope relates to having a positive attitude about their future ability to achieve success
with managing the problem.

Often patients come to therapy having distinct goals, the alleviation of symptoms of one sort or
another and then move onto contemplate other changes in the way they live. This is a laudable goal,
although, at this point, treatment no longer fits the medical model. Treatment is directed at the
difficulties everyone has in living and not just in ameliorating certain symptoms.

The Counselors Personality and Style

A therapist who is in the profession over a period of years may find that years later they are still
learning. This is because psychotherapy is not a manner of operational exactness, but a way of being
with a patient or a frame of mind. Like most things, therapy can be conducted poorly, less well or
very well and keep in mind that a therapist who is a good fit for one patient may not be with the
neighbor next door. A couple of studies have found a small correlation between therapist experience
and successful therapeutic outcomes, however, the bulk of the evidence supports the idea that a more
experienced therapist does not automatically produce more successful results (Hersoug, Hoglend,
Monsen, & Havik, 2001). That old saying “practice makes perfect” does not seem to apply in much of
the out-patient practice world.

One key element for solving problems and learning new ways to cope is the emotional attachment or
relationship people have with their therapist. Education is taught, learning occurs, feelings are
discussed, and thoughts are examined in relation to feelings. However, education, learning and
exploring of issues are not ideal conditions for receiving help with managing a problem. I cannot
stress how valuable it is for people to connect with the therapist and pay attention to the emotional
chemistry. The issue of achieving success in counseling depends on this relationship.

Another ideal condition for the counseling situation is that the therapist must perceive the client as a
whole person, not abnormal, difficult, or label someone with a psychiatric diagnosis. If therapists
show respect and kindness and if clients can accept these gifts, they will achieve success in managing
a problem. If genuine respect and understanding are not offered, and/or if the client cannot accept the
offer of assistance, achieving success in counseling is severely compromised. This means that
treatment may be a waste of time, energy and resources. However, I am often pleasantly surprised, as
sometimes the most resistant clients do indeed make a 180 degree turn and become most successful in
managing their life. Success in counseling does indeed relate to the relationship that people have with
their therapist.

There are many rules such as those related to privacy, respecting sexual boundaries, attentive
listening, and keeping the client as the focus of the discussion verses the therapist talking about their
own issues. However, these are basic expectations of all therapists. What people want to evaluate is
the therapists personality, their mannerisms and communication style. Some therapists, are more
talkative than others, some use specialized techniques, some use humor, others analyze, and some are
passive.The client needs to assess the therapists respect and evaluate how much the therapist seems to
care about what is being discussed and then evaluate if the therapist suits their needs. People deserve
the best match as this is their time and all clients deserve the professionalism it takes to help achieve
success. If the client and the therapist are a suitable personality match, the question remains as to what
are the client roles in achieving success in counseling.

Several themes emerge when clients are not successful in therapy. The main ones are intoxication or
abusing substances during appointments, clients that are off their medications or those that need
medications because they are psychotic, those that cannot make connections or lack insight, and those
whose personalities do not fit with the therapists. Counseling can be difficult for people with
significant character disturbances due to a lack of tolerance for emotional discomfort, as well as
having the incapacity to be consistent. People who do not have their basic needs met or those that are
extremely emotional also have a harder time in therapy. Resource barriers to success are lack of
transportation, finances, childcare and insurance.

One study indicates that counseling does help those that seek it out (Hoglend, 1999). Bachelor et al.
(2007) implies that a person with many clinical manifestations may have not as much skill to engage
and work productively with the therapist. Overall, it appears that collaboration, motivation,
personality characteristics, active engagement in the treatment tasks and the development of the
relationship all have a direct association with a successful outcome. However, all clients deserve the
therapist’s time, energy, caring and respect. Every client deserves to have these conditions even if the
client is carried into the office “kicking and screaming”. Clients should find a safe, private,
environment and a caring human being who will listen without judgment and without an air of
superiority. Find a counselor who strives to understand in a holistic fashion and from your point of
view.
By Shane Gorski on flickr
Creative Commons

The Four Client Qualities with Achieving Success in Counseling

Desire is the beginning of all achievements, not a dream, not a requirement, but a keen pulsating
desire which transcends everything. Some individuals will report that they want to make changes in
their life but lack the motivation or drive. They will begin by seeking therapy and indicate a desire for
change but will not or cannot make the effort necessary to carry out the process. The primary goal to
seek out therapy is that their life may have become so unmanageable that their life is in a state of
crisis. In addition, these clients may also be in emotional pain over such an extended time causing
their physical health to deteriorate.

A stressful situation may be upsetting, but it may also be beneficial. In various life situations, events
may have to get worse before they get better for the change process to develop. Therefore, a crisis can
be a life misfortune or calamity, but it can also be a way to make life better because it provides an
incentive for personal growth and development. Without a strong desire for change, improvements are
less likely to occur. When a person has both the desire to make changes and the motivation to do so,
this is half of what it takes to achieve success.

Belief is one of the most significant building bricks to achieving success in any venture. If someone
does not believe in themselves or in what they are attempting to accomplish then this makes the goal
almost impossible. The more people believe in something the more they raise their chances of being
successful. The concept of belief in oneself seems straightforward, but there are still those who fail
because they do not possess the belief that they can achieve their goals.

One reason people face serious and lasting emotional distress is that they do not think counseling or
psychotherapy can help. They have seen media programs or read books that disparage individuals
who seek counseling, or render counselors and psychotherapists in an unflattering manner. Some may
consider counseling as for the weak and cowardly. These people fail because they have little or no
confidence in the healing process of change. The successful person understands that it takes self-
esteem to achieve a goal. Successful people know that a certain amount of trust needs to be placed in
a health care provider. They may also examine any lack of confidence with the therapist in the
beginning stages of counseling. This lack of confidence in others may have arisen from early
childhood issues and be the primary source of a persons pain.
Many people have the hope that the first therapy meetings will fix everything negative going on in
their life and the first few sessions often do solve problems that people were already prepared to
resolve. However, the problems that remain after the first few meetings are the tough ones. What
people want to accomplish in counseling should be clearly defined during the beginning phases of the
therapy process. The next step would be to explore a reasonable time frame for reaching the goals and
decide on how progress will be measured.

Courage is not the absence of sorrow; it is, rather, the ability to push through life in spite of adversity.
Many who need counseling will not consider it, or they look for treatment and have trouble making
any adjustments in life. They want their world, circumstances or others to change, but they are not
willing to work on anything about themselves. It is surprising how much emotional pain a person can
suffer, just because they have difficulty embracing the idea of change. Many individuals have
difficulty with the process of change because it can cause much anxiety getting outside one’s comfort
zone. New habits, new methods of doing things, and changing thinking patterns or behaviors require
energy and time, as well as courage. The person with courage is not paralyzed by the fear; they are
empowered by it. Seeking help and making changes in lifestyle requires courage.

Patience and dedication unlocks the doors of imagination, allows vision, and gives us the right
ingredients to turn that dream into a reality. Those who believe “anything worth having is worth
waiting for”, will continue on in the quest for change, and are the ones who will triumph over
adversity. The counseling process requires such dedication and patience. The key to achieving success
in counseling is to support the course of treatment and recognize that some issues may take time to
resolve as these problems developed over many years. If people possess or develop these attributes in
the initial phase of counseling they will be on the path to success. Overcoming adversity and gaining
achievement is the culmination of all four attributes of Desire, Belief, Courage, and Patience. People
can have the real possibility of achieving success in counseling as well as achieving any realistic goals
set in life.

During the first few sessions, the client and the therapist are developing rapport and are preparing for
the work that it takes to make changes. In order to make a permanent change it involves a healthy
relationship with the therapist and this takes time. People who do not understand this will typically
leave quickly and say: “I went to therapy, and it didn’t work”. They were seeking and wanting advice,
not therapy and they misunderstand the concepts and principles of therapy. This explains why the
same problem may pop up throughout someone’s life. Therapy is about the relationship and working
through the core problem with a kind, caring, competent professional, in hopes that the same problem
will not re-surface at later date in time.

Therapy values the expression of emotion. What is also significant is whether the level of expressed
emotion teaches the therapist the relative importance of each issue (mild importance, moderate
importance and intensely important). Using anger as an example: One client may feel angry and
explode often, but each outburst displays the same level of emotional pain. This person gets a lot of
relief, but that is all, not to mention it confuses the therapist! Another client may occasionally get
angry, but they do mention anger whenever they feel it and they show whether the anger is high,
moderate or minor. This person gets more help at solving and coping with problems because the
feeling is clearly expressed and the therapist understands the issue. The next task is to explore and
assist with managing or coping with the discomfort. Having an understanding of feelings and how
people communicate that knowledge is critical in achieving success in therapy.
How to Evaluate Successful Counseling

People can determine whether their work with the counselor is successful if they begin to gain
insights about thoughts and behaviors. If clients feel they have been successful in making change,
learning new behaviors, learning something new about themselves, have an increase in coping skills,
and have fewer symptoms, then the goals have been accomplished. Reviewing the treatment plan is
helpful in maintaining and increasing success, thus, clients feel they have made progress.

At the end of successful therapy, clients will feel better equipped to tackle life’s changes and
challenges, by developing a slightly more flexible stance on how to handle life. People can decide
whether their work with the counselor is successful by assessing if they begin to gain insights about
thoughts and behaviors, which may have eluded them before they entered treatment. Over time,
people should be able to identify patterns in the way they behave, discover the sources and understand
stumbling blocks to happiness and then create different choices! The result is personal growth that
empowers change and assists people in becoming the person they would like to be in the world.
Therapy is about helping people achieve their goals. Over time, clients should be able to identify
patterns in the way they act, trace their sources and understand stumbling blocks to happiness. The
result is personal growth that empowers people to manage life and enjoy positive, life-affirming
relationships.

The benefits of achieving success with counseling are:


1. An immediate although perhaps modest relief of psychological pain and suffering.
2. There is a speeding up of the natural tendency to feel emotionally well and in certain chronic
states a slowing of the pathological process.
3. There is avoidance of certain social upheavals that acutely disturbed patients are
predisposed, such as the loss of a job, the dissolution of savings, the disturbance of family
life.
4. In certain cases, there is the improvement of a real growth of character. The individual thinks
better of themself and is better able to cope with stress that relates to the difficulties of
living.
5. People who have been in successful treatment have to a greater extent gained mastery in
themselves and their environment.
6. In such ways psychotherapy may have a significant impact in someone who is profoundly
emotionally upset, gradually, improving both mental state and performance.
In conclusion, people can achieve success in counseling to help overcome life’s challenges, regain a
sense of control (feel empowered), regain happiness in life, and experience a more flexible wider
range of emotional maturity. The practice of therapy is defined and achieving success is
accomplished by exploring behaviors, emotions, life’s problems and the therapy process then builds
on existing strengths. Health Psychology for Everyday Life, the book.

Live Well

video of Health Psychology and Therapy

Cheryl MacDonald, Psy’D.


Health Psychology of San Diego

To schedule an appointment or ask a question call 760 439-9331

References

Bachelor, A., Laverdiere, O., Gamache, D., & Bordeleau, V. (2007). Client’s collaboration in therapy:
Self-perceptions and relationships with client psychological functioning, interpersonal relations, and
motivation. Psychotherapy: Theory, Research, Practice, Training, 44(2), 175-192.

Black, S., Hardy, G., Turpin, G., & Parry, G. (2005). Self-reported attachment styles and therapeutic
orientation of therapists and their relationship with reported general alliance quality and problems in
therapy. Psychology & Psychotherapy: Theory, Research & Practice, 78, 363-377.

Cooper, M.G., & Leeser, J.G. (2011). Clinical social work practice an integrated approach (4th ed.).
Boston, MA: Allyn & Bacon.

Hersoug, A., Hogland, P., Monsen, J., & Havik, O. (2001). Quality of working alliance in
psychotherapy therapist variables and patient/therapist similarity as predictors. The Journal of
Psychotherapy Practice and Research, 10, 205-216.
Hoglend, P. (1999). Psychotherapy research new findings and implications for training and practice.
The Journal of Psychotherapy Practice and Research, 8, 257-263.

Littauer, H., Sexton, H., & Wynn, R. (2005). Qualities clients wish for in their therapists.
Scandinavian Journal of Caring Sciences, 19, 28-31.