Client Contributions
Clients are what make services work and are the single most important contributors to change and outcome. Estimates are that client factors provide between one-third and one-half of the overall variance in outcome. Effective approaches identify, highlight, and encourage client contributions to change. Client factors comprise internal strengths and external resources including support systems. Internal strengths include optimism, persistence, resilience, protective factors, coping skills, and abilities utilized in vocational, educational, and social settings. External resources refer to relationships, social networks, and systems that provide support and opportunities. Examples are family, friends, employment, and educational, community, and religious supports. External resources also include affiliation or membership in groups or associations that provide connection and stability. Client support systems are central in maintaining long-term change.

The Relationship and Alliance
Client ratings of the therapeutic relationship and alliance are significantly related to therapeutic outcome and are possibly the best and most consistent predictors of improvement. Those who are engaged and connected with practitioners are likely to benefit most from services. Practitioners who are attuned to the importance of clients' relational needs and monitor relationships are better able to ensure that clients feel heard, understood, and connected. Effective practitioners monitor their relationships with clients and remain responsive to changes throughout the course of services. The term alliance highlights the collaborative partnership between clients and practitioners. In addition to the strength of the client-practitioner bond, the degree to which clients collaborated with practitioners regarding processes (e.g., how to meet, when to meet), service directions, and goal establishment as well as methods to achieve those goals is paramount. The quality of the client's participation in services is a crucial determinant of outcome. Negative outcome is often traced to clients being excluded from decisions regarding services.

Cultural Competence
Culture specifically refers to a system of shared beliefs, values, customs, behaviors, and artifacts among various groups within a community, institution, organization, or nation. From generation to generation, members of society use their cultural references to cope with their world and with one another. Culture is reflected though diversity which refers to other characteristics by which persons may prefer to self-define. This includes, but is not limited to an individual's age, developmental and acquired disability, gender/sex, sexual orientation, religious/spiritual identification, indigenous heritage, national origin, social and economic class background and residential location (i.e., urban suburban, rural), other social locations as vocational and recreational choices, partnership status, parenthood (or not), attractiveness, body size and shape, and state of physical health. Culture is a powerful filter through which behavior can be understood; however, no one aspect provides a comprehensive explanation of it. Multiple factors vary in their degree of influence. Cultural competence is a cornerstone of a strengths-based philosophy. It translates to having the capacity to function effectively in other cultural contexts. It is reflected through awareness and practices that involve learning new patterns of behavior and effectively applying them in the appropriate settings. This requires valuing diversity, which means accepting and respecting differences. People come from different backgrounds, and their customs, thoughts, ways of communicating, values, traditions, and institutions vary accordingly. Practitioners continue to expand knowledge of different cultural backgrounds through education and experiential activities. In addition, culturally competent practitioners:

     are actively in the process of becoming aware of their own assumptions about human 
behavior, values, biases, preconceived notions, personal limitations, and so forth

     actively attempt to understand the worldviews of their culturally different clients without negative judgment

     are in the process of actively developing and practicing appropriate, relevant, and sensitive intervention strategies and skills in working with their culturally different clients

Change as a Process
Three points characterize the principle of change as a process. First, emphasis is on enhancing change as opposed to searching for explanations about the nature of problems. Time is spent more productively when the practitioner and client focus on and enhance the factors responsible for change-in-general rather than on identifying and then changing the factors a theory suggests are responsible or causing problems-in-particular. An emphasis on practitioner-derived explanations is indicated only when clients communicate that they prefer such a focus or agree with practitioners as to the possible benefits of the focus. Second, change is constant; people, situations, and problems are not static. Problems fluctuate in frequency, intensity, and duration. Recognizing this variability, practitioners engage clients in conversations to learn more about times when problems are more or less manageable or absent altogether. This includes finding out about the influence that clients have over problems and factors that can increase this influence. Explorations of differences and influences help practitioners understand how change occurs in clients' lives and how they are able to mobilize their resources in problematic situations. Third, change is predictable. All large-scale meta-analytic studies of client change indicate that the most frequent improvement occurs early in services. The duration of services depends primarily on factors such as the severity of clients' symptoms and personality characteristics as well as the strength of their social systems. Therefore, some clients may respond and make appreciable gains more slowly than others. Research suggests that as services progress, a reliable course of diminishing returns occurs with more and more effort required to obtain barely noticeable differences in client improvement. Even though the amount of change decreases over time, as long as progress is being made, services can remain beneficial. It is not the length of service that is most important but practitioners' collaboration with clients to determine what clients want to have change, when things are better, and when needs, goals, and outcomes have been achieved. Practitioners should consider that clients will vary in their use of therapeutic services; some will move in and out very quickly. Others will attend services over extended periods of time or in rounds (i.e., intermittently, a few sessions at a time). Thus, flexibility in terms of allowing for clients' entry, termination, and reentry is needed.

Expectancy and Hope
Expectancy and hope factors refer to the portion of improvement derived from clients' expectations for treatment, their development of hope, and the credibility they place on the rationale for the specific techniques used in services. Effective practitioners not only maintain an awareness of expectancy and hope but also focus on ways to increase the two in all aspects of services. Clients' and practitioners' expectations about services are crucial, especially at the beginning. The expectation that services can lead to positive change is one that counteracts demoralization and increases hope. Practitioners' attitudes can promote or dampen hope. Expectancy is multifaceted. First, both the client and practitioner must believe in the procedures and restorative power of services. Clients' expectations can help serve as a placebo and can counteract demoralization, activate hope, and advance improvement. In most cases, what accounts for a significant part of a specific change is the client's belief in the technique or method being used and in the practitioner (the feeling of being in good hands) rather than the specific technique or method used. Important aspects in bringing about change include (1) the processes and practices practitioners use that contribute to the expectancy for change and increase in hope, (2) clients' and practitioners' belief in the treatments and the rationales behind them, and (3) the fit between methods and clients' perspectives about their problems and possibilities for solution. Expectancy and hope offer a remedy to impossibility. When things are going poorly, most people would like their lives, at some level, to improve, at least minimally. Hope for this improvement is not about people looking at the world through rose-colored glasses but recognizing that if people have choices, most prefer things to be better. An underlying pessimism or negativity-unless to emphasize with the client-can dampen hope and represent the difference between clients having a positive experience and continuing services.