other than“it depends.”The reason is that the
outcomes of therapy are exceedingly complex
events that are not shaped by patient characteristics
alone. They are also determined by therapist quali-
ties and skills, the kinds of therapeutic procedures
employed, the circumstances and environment of
patients, and so on. Eventually, the field will have
to identify specifically which kinds of patients ben-
efit from which procedures, under which circum-
stances, and by which therapists (Kiesler, 1966;
Paul, 1967).
With the foregoing caveat firmly in mind, we
can discuss some of the more prominent patient
variables that have been related to outcomes in tra-
ditional therapies.
The Degree of the Patient’s Distress. Abroad
generalization often made by clinicians is that indi-
viduals who need therapy the least are the people
who will receive the greatest benefit from it. A
more sophisticated version of this relationship is
reflected in Truax and Carkhuff’s (1967) distinction
between patients’feelings of disturbance and their
overt behavioral disturbance. This distinction implies
to many clinicians that a good prognosis may be
expected for a patient who is experiencing distress
or anxiety but is functioning well behaviorally.
Early research data on this issue were contradic-
tory and inconsistent (which, again, probably reflects
the impossibility of coming to a simple conclusion
without considering many other factors). For exam-
ple, one group of studies finds that greater initial
distress is associated with greater improvement (e.g.,
Stone, Frank, Nash, & Imber, 1961). Another group
of studies (e.g., Barron, 1953) finds exactly the reverse.
To complicate matters further, Miller and Gross
(1973) contend that the relationship between im-
provement and the initial disturbance is curvilinear;
that is, patients with little disturbance or extreme dis-
turbance show poorer outcomes than do moderately
disturbed patients. This question remains an important
issue for further exploration, even today.
Intelligence. Some therapeutic approaches require
a great deal of talking, articulation of past experi-
ences, insights, and introspection. These therapeutic
approaches may rely on metaphors and complex
thematic associations between one’s experiences.
These types of therapies require a reasonable level
of intelligence (Garfield, 1994).
However, behavioral forms of therapy have
often been used with considerable success with
individuals across a great range of intellectual abil-
ity. A variety of behavior modification approaches
are quite feasible, especially when goals involve spe-
cific behavioral changes rather than insight. Perhaps
for this reason, behavioral approaches are very com-
monly used when working with young children
and adolescents or when working on issues that
involve a desire for behavioral change.Age. Other things being equal, young adults have
long been considered the best bets for therapy, as
compared to older adults. In contrast, there does not
seem to be a clear trend between age and psychother-
apy success among youth. As compared to older
adults, younger adults are presumably more flexible
or less“set in their ways.”Perhaps younger patients
are better able to make the appropriate connections
because they are closer to their childhood years, or
perhaps they have been reinforced for negative beha-
viors less often than their older counterparts. In any
event, the notion that younger persons do better in
therapy is quite prevalent among clinicians. Research
evidence supporting the contention that older clients
have a poorer prognosis, however, is weak at best
(Clarkin & Levy, 2004; Garfield, 1994; M. L. Smith
et al., 1980).
It is best to consider not age alone, but rather
the specific characteristics of the prospective
patient. It often happens that a 55-year-old will
be an active, open, introspective person who can
really benefit from therapy. In short, denial of
therapy to an elderly person can be construed as
a form of ageism in some instances! Fortunately,
research supports the efficacy of a variety of
cognitive-behavioral, behavioral, and brief psy-
chodynamic treatments with older adults suffering
from anxiety and depressive disorders, two com-
mon forms of psychological problems in this age
group (Ayers, Sorrell, Thorp, & Wetherell, 2007;
Fiske, Wetherell, & Gatz, 2009).322 CHAPTER 11