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Article 63

Exploring Client Satisfaction

From a Holistic Perspective

Ruth Chao, William E. Metcalfe, Wade Lueck, and Stephanie Petersen

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Clients’ satisfaction with their mental service is important for several reasons. First, client satisfaction is a good predictor of clients’ treatment outcome, premature termination, acceptability of new programs, and how effective counseling interventions are for clients’ specific problems. Second, client satisfaction data provide multiple-sided information to different professionals (e.g., counselors, administrators, coordinators, and receptionists), on clients’ degrees of acceptance of psychological interventions and administrative procedures. Client satisfaction data provide information for assessments of quality assurance in counseling centers.

Client satisfaction has gained the attention of both researchers and practitioners, with some scholars suggesting that it be included in the evaluations of clinical programs and practices (Heppner, Cooper, Mulholland, & Wei, 2001). However, clients begin to develop their impression while phoning for an appointment and at the moment they step into a counseling center, so clients’ satisfaction is broader than is covered by narrow outcome evaluations of counseling alone. Thus some researchers have encouraged adopting a broad definition of client satisfaction Pascoe (1983). Pascoe emphasized that it is important to know how “the receptor reacts to context, process, and result of his or her service experience” (p. 189). Context refers to the systemic or administrative aspects of counseling centers that are quite relevant to how clients receive therapy.

Counseling centers are made of two factors: counseling and system (i.e., how the centers organize their administration, how they deliver services). System means procedures and environment surrounding clients, including calling clients again, setting appointments, recording, setting up a specific number of sessions, notices of charge or no charge, waiting room setting, length of time awaiting counselors, and the overall atmosphere of the counseling center.

According to Gilmer and Deci (1977), organizational rules and systems have an impact upon people’s satisfaction. For example, receptionists often deal with upset, disturbed clients (Archer & Cooper, 1998). In view of the increased demands of consumer- oriented services, policies of standard service delivery request counselors to limit the first therapy appointment to just a certain number of days after initial intake interviews (Steenbarger & Smith, 1996). In addition, counseling centers involve organizational processes such as scheduling, referrals, and session limits for most clients besides offering counseling services. Clients also form impressions from intake forms and problem checklists that they are asked to complete. Eklund and Hansson (2001) found that the overall atmosphere of mental health settings, including order and organization, is significantly relevant to clients’ satisfaction and therapy.

Although session limits, referrals, making appointments, and other systemic aspects outside the therapy room are so widespread and quite relevant to therapy, a void exists in current literature on clients’ perceptions of such organizational operations. This is a serious lacuna in research on counseling centers.

Purposes and Research Hypotheses

Due to the need for a more comprehensive understanding of factors associated with clients’ satisfaction with counseling, we solicited clients’ reflection on their experiences in their own words. Additionally, we noted considerations with regard to the psychometric properties of currently available measures of client satisfaction (Steenbarger & Smith, 1996).

Thus, to study client satisfaction, we devised two open-ended questions to evoke clients’ self-generated responses that offer two advantages in this research. First, self-generated responses allow clients to describe their reactions in ways that truly represent their experiences and memories, instead of passive responses to predetermined categories provided by investigators. Second, clients’ self-generated responses to open-ended questions may capture all relevant aspects of clients’ experiences with counseling centers. In view of this situation, we proposed the following three general hypotheses. First, clients’ overall satisfaction significantly relates to their reactions to counselor interventions. Second, clients’ overall satisfaction significantly relates to their reactions to systemic aspects of counseling centers. Third, groups with different levels of satisfaction significantly differ on specific responses in counseling and in systemic aspects.

Method

Participants

Participants were 1,053 clients who obtained at least one session of personal counseling at a midwestern university counseling center. Participants consisted of 826 females and 227 males. Data indicated that undergraduate students were the largest proportion of clients. With regard to participants’ age, 80% of clients were under 25 years of age. Ethnic group representation was similar to the ethnic proportions on campus. Students of color represented 26% of the sample.

Measure and Procedure

The satisfaction survey consisted of (a) demographic questions (gender, age, year in academic status, race/ethnicity, sexual identity), (b) a rating of overall satisfaction (1 = dissatisfied; 2 = mixed; 3 = satisfied), and (c) two open-ended questions. These two questions were (1) “The things I liked best about my experiences with the Counseling Center were   ”, and (2) “The things I liked least about my experiences with the Counseling Center were   .” Participants’ responses were entered verbatim into the database. Each response was counted as mentioned or not mentioned (1= mentioned, 0 = not mentioned). Responses to “The things I liked best about my experiences with the Counseling Center were” were counted as positive responses. Responses to “The things I liked least about my experiences with the Counseling Center were” were counted as negative responses.

Four researchers independently sorted the 2,021 responses into the 22 groups. The groups of responses were then placed into three metacategories having to do with the counselor, system, or receptionist. The category of counselor includes responses about counseling and/or counselor. The category of system includes responses on appointments, waiting room, checklists, session limits, correspondence with counseling center, and other systemic aspects. The category of receptionist includes clients’ responses about receptionists (e.g., receptionists’ attitudes and efficiency). Among the 22 groups of interpretable responses, 10 were about counselors’ interventions with 6 positive responses and 4 negative; 10 were about systemic aspects with 6 positive and 4 negative; and 2 were about receptionist aspects with 1 positive and 1 negative. Kappa coefficients of .95 for the complete set of responses and .93 for the subset indicated excellent interrater agreement.

Data Synthesis and Statistical Analysis

Participants reported their overall levels of satisfaction—dissatisfied, mixed, and satisfied—on counseling services they received. The level of satisfaction was coded dichotomously (i.e., dissatisfied [1 = dissatisfied; 0 = no], mixed [1 = mixed; 0 = no], and satisfied [1 = satisfied; 0 = no]).

Seven hundred and fifty-three (753) participants who reported high levels of satisfaction with counseling services were grouped as satisfied, 155 participants who reported mixed overall satisfaction were grouped as mixed, and 145 participants who reported their overall dissatisfaction were grouped as dissatisfied.

Results

Preliminary Analysis

Before we conducted the primary analyses, we tested whether five variables (gender, age, year in school, race/ethnicity, and sexual identity) contributed to differences among the three groups of participants. An analysis of variance (ANOVA) indicated that male and female participants had no significant differences on overall satisfaction (F [2, 1051] = 2.05, p = .13). Nor did the participants from different ages have significant differences on overall satisfaction (F [32, 1021] = .97, p = .51). Nor did the participants with different years in school have significant differences on overall satisfaction (F [6, 1047] =1.98, p = .11). Nor did participants of different ethnicity have significant differences on overall satisfaction (F [15, 1038] = 1.03, p = .43). Nor did participants’ sexual identities have significant differences on overall satisfaction (F [3, 1050] = .64).

Primary Analysis

Clients were asked to rate their overall satisfaction with the counseling services they had received. Seventy- two percent (753) indicated that they were satisfied; 15% (155) reported feeling mixed; and 14% (145) acknowledged being dissatisfied with the counseling services they had received. A series of ANOVA on 22 responses revealed that the three groups (i.e., dissatisfied group, mixed group, and satisfied group) were significantly different on 12 responses and not significantly different on 7 responses (Table 1). On counselors’ work, the dissatisfied group was significantly lower than the satisfied group on all positive responses (i.e., “empathetic,” “knowing,” “gaining knowledge,” “symptom reduced,” “self- understanding,” “optimistic”). The dissatisfied group was significantly higher than the satisfied group on all negative responses of counselors’ work (i.e., “not helpful,” “confused,” “mistaken,” “no guidance/ advice”). The mixed group was also significantly higher than the satisfied group on all negative responses to counselors’ work. On the systemic aspects of mental service, the dissatisfied group was significantly lower than the satisfied group on the responses “useful,” “professional,” “available,” and “flexible.” The three groups had no significant differences on the responses, “free,” “confidential,” and “comfortable environment.” Among the negative responses on systemic aspects, the dissatisfied group was significantly higher on “appointment difficulties” than both the mixed and satisfied groups. The dissatisfied group was also higher on the response “session limit” than the mixed group. No significant differences among the three groups were found on responses, “other systemic aspects,” “friendly attitudes,” and “negative attitudes” of the receptionists.

Discussion

Our results suggested that our research supports our three hypotheses. In general, the survey results supported our hypothesis that clients’ overall satisfaction would significantly relate to their reactions to counselors’ interventions. Specifically, all three levels of overall satisfaction were significantly related to positive and negative reactions to counselors’ interventions. The three groups of clients significantly differed in 15 responses, 10 on counselors and 5 on systemic aspects (Table 1). The results partially supported our hypothesis that clients’ overall satisfaction would significantly relate to their reactions to systemic aspects of counseling centers. Clients who reported being dissatisfied and satisfied were significantly related to the positive and negative reactions to systemic aspects. Beyond psychological interventions, clients’ satisfaction was also related to their positive or negative perception of the entire systemic experience (e.g., perceiving the counseling center as a helpful and useful agency). Clients’ satisfaction arises from effective collaboration among all elements in the counseling center — the counselor and the system.

Future research on client satisfaction should assess clients’ perceptions of the entire functioning of the system. This study suggested that the clients developed their overall impression when they stepped into the counseling center, and their satisfaction was comprised of their impressions of more than counseling itself, and also their perception about the whole system they experienced. Therefore, a study across professional boundaries such as linking counseling with organizational psychology may be appropriate for advancing our understanding of counseling outcomes from clients’ perspectives.

In sum, the results had two implications. First, the whole counseling center system combines with counselors’ work to form clients’ satisfaction with their counseling experience. We learned from 1,053 clients’ statements that their satisfaction came from more quarters than just interactions with the therapists. Second, the whole system comprised 24% of positive responses and 47% of negative responses. This finding suggested that counseling centers need to pay an appropriate amount of attention to paraprofessional personnel and the whole system. Counselors alone are not responsible for clients’ satisfaction, for counseling is a shared cooperative operation with the entire system of the counseling center. Truly effective therapy requires a whole therapeutic environment, counselors, center milieu, center operations, and supportive staff, as the whole counseling center makes its holistic dynamic impact upon clients.

Table 1

Summary of Analysis of Variance on Client Responses

Note. Dis = Dissatisfied group; F=Satisfaction; Mixed = Mixed group; Sat = Satisfied group.

a Ever mentioned as a satisfying or dissatisfying reason from 1,053 participants.

b Significant differences come from posthoc tests on the three groups: dissatisfied, mixed, and satisfied.

c Positive Responses = Counselor Positive Subtotal + System Positive Subtotal + Receptionist Positive Subtotal

d Negative Responses = Counselor Negative Subtotal + System Negative Subtotal + Receptionist Negative Subtotal

e Total Response = Positive Responses + Negative Responses