How do therapists enhance family alliances? Sequential analyses of therapist-client behavior in two contrasting cases.

To identify alliance-related behavior patterns in more and less successful family therapy, the authors intensively analyzed two cases with highly discrepant outcomes. Both families were seen by the same experienced clinician. Results showed that participants' perceptions of the alliance, session impact, and improvement at three points in time were congruent with the families' differential outcomes and with observer-related alliance behavior using the System for Observing Family Therapy Alliances. In this measure, therapist behaviors contribute to the alliance and client behaviors reveal the strength of the alliance on four dimensions: Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family. In the poor outcome case, observer ratings and self-reported alliance scores revealed a persistently "split" alliance between family members; this family dropped out midtreatment. Only in the good outcome case did the clients follow the therapist's alliance-building interventions with positive alliance behaviors; sequential analyses showed that therapist contributions to Engagement significantly activated client Engagement behavior, and therapist Emotional Connection interventions significantly activated client Emotional Connection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist sexual orientation, gender, and counseling practices as they relate to ratings on helpfulness by gay and lesbian clients.

Three hundred ninety-two lesbian and gay volunteers described their experiences with 923 therapists, reporting therapist sexual orientation, therapist gender, and perceived helpfulness of the therapist in each case. Gay, lesbian, and bisexual therapists of both genders and heterosexual female therapists were all rated more helpful than heterosexual male therapists. Participants also reported whether each therapist exhibited 9 negative and 4 positive practices. Relative risk ratios indicated that 8 of the 9 negative therapist practices were significantly associated with (a) client designation of a therapist as unhelpful and (b) termination after 1 session. All 4 of the positive practices were inversely associated both with unhelpful ratings and with termination after 1 session. Therapist practices accounted for more of the variance in ratings of helpfulness than did therapist demographic characteristics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development of a system for categorizing client reactions to therapist interventions.

We developed a measure of client reactions to therapist interventions. The 21 categories of the measure were divided into 14 positive and 7 negative reactions, which differed significantly from each other on client helpfulness ratings. Preliminary validity data indicated that therapist intentions were related to client reactions more for successful cases than unsuccessful cases, pretreatment symptomatology was highly predictive of which reactions the clients reported, there were some predictable changes in reactions across time in treatment, and within-case correlations of reactions with client-rated session depth and smoothness indicated some similarities across cases. We discuss the case-specific nature of client reactions, methodological issues, and the need for greater therapist awareness of client reactions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship formation and relational control as correlates of psychotherapy quality and outcome.

This study examined the nature of therapist–client interactions within and across seven psychotherapy cases (a) to test whether therapeutic outcome is a function of a transition from relational incongruence to relational congruence (S. Strong, 1982), and (b) to investigate the relation of relational congruence and control to qualitative aspects of the therapy relationship and to therapy outcome. Measures of therapist and client response patterning served as indices of relational congruence and of relational control. Relationship quality was assessed in terms of therapist and client ratings of their working alliance and of therapy session depth and smoothness. Outcome was operationalized in terms of symptom reduction. Results showed limited support for a relationship between relational congruence and therapy outcome and suggested that relational control is not a significant factor in client or therapist evaluations of relationship quality or therapy outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of a client pretherapy orientation videotape.

Examined the effects of a videotaped psychotherapy orientation on clients' response to therapy, knowledge about therapy, utilization of services, and satisfaction with services and on therapist ratings of client attractiveness. 62 psychotherapy clients (mean age 29 yrs) at an urban community mental health center were randomly assigned to an oriented group, which viewed a pretherapy orientation videotape at admission, or to a control group. 14 therapists participated. The 11-min videotape described the relationship between client and therapist, encouraged clients to attend appointments, and stated that, although progress is rarely immediate, most clients find that therapy can lead to a reduction in anxiety and depression. Clients and therapists completed questionnaire and rating scales at intake and at 1-mo follow-up. It was found that oriented clients were able to understand and recall the information in the videotape, and the oriented group showed a greater decrease in self-reported symptoms than the control group after 1 mo. Client feedback regarding the videotape was favorable. In general, the 2 groups did not differ in their satisfaction with services, service utilization, or therapist ratings of client symptoms and functioning. (29 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of success in emotionally focused marital therapy

This study examined client variables expected to predict success in emotionally focused marital therapy (EFT), now the second most validated form of marital therapy after the behavioral approaches. The relationship of attachment quality, level of emotional self-disclosure, level of interpersonal trust, and traditionality to the therapy outcome variables, marital adjustment, intimacy, and therapist ratings of improvement, was examined. These variables were chosen for their relevance to the theory and practice of EFT and to intimate relationships in general. Overall, therapeutic alliance predicted successful outcome; the task dimension of the alliance in particular predicted couples' satisfaction. More specifically, one dimension of female partners' trust, their faith in their partner, predicted couples' satisfaction at follow-up. Females' faith also significantly predicted males' level of intimacy at follow-up. Males who were most likely to be nondistressed at termination indicated higher levels of proximity seeking on an attachment measure at intake, and older males and males whose partners had higher levels of faith in them were more likely to be nondistressed at follow-up. Traditionality was not found to be significantly related to outcome. Couples who made the most gains at follow-up also indicated lower initial marital satisfaction and included males who indicated lower levels of use of attachment figure on the attachment measure at intake. Males who made the largest gains at termination were older and were rated as less expressive by their partner on self-disclosure measures at intake. Age was the only variable significantly related to males' gains in satisfaction at follow-up. Implications for the practice of marital therapy and future research are delineated.     

Relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance.

The relationship of client satisfaction to outcome was investigated for adult outpatients (N? = ?152) from 3 urban community mental health centers. Clients completed a problem self-rating and the Brief Symptom Inventory (BSI) at intake, 10 weeks later, and 5 months later. Therapists' ratings of client adjustment were obtained at intake and termination. Clients' ratings of satisfaction with treatment were obtained at 10-week and 5-month follow-up. Correlations between satisfaction and client measures of outcome (client rating and BSI) based on pre-post changes, posttreatment adjustment, and Jacobson and Truax's (1991) method of measuring clinical significance were not significant. Correlations between satisfaction and therapist outcome ratings were significant but low for pre-post changes and clinical significance. The utility of client satisfaction as an outcome measure is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client attachment to therapist: Relations to transference and client recollections of parental caregiving.

This study examined the relations between client attachment to the therapist and therapist perceptions of transference, as well as between client attachment and recollections of parental caregiving. Participants were 51 client-therapist pairs in ongoing therapy. After a therapy session, clients completed a measure of their attachment to their therapists and a measure of their perceptions of parental caregiving during childhood. Therapists rated levels of positive and negative, and amount of, client transference. Both secure and preoccupied-merger attachment were positively related to both negative transference and amount of transference. Level of avoidant-fearful attachment was not correlated with any type of transference. Insecure attachment to the therapist was associated with more negative recollections of parental caregiving. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Myers-Briggs Type Indicator personality dimensions and perceptions of quality of therapy relationships.

Examined associations between perceived quality of therapy relationships and therapist and client scores on the Myers-Briggs Type Indicator (MBTI). 35 experienced therapists and 53 adult outpatients involved in long-term personal therapy completed the MBTI and measures of therapy relationship quality and pretherapy adjustment. More positive client ratings of the quality of the therapy relationship were associated with similarity of therapist and client in overall MBTI profiles and in the thinking–feeling and judging–perceiving dimensions of the MBTI. When therapists had higher extroversion and feeling scores, both therapists and clients rated the relationship more positively. The MBTI may be valuable in determining optimal therapist–client matches and in guiding therapists to better understand their impact on clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Formation of a therapeutic relationship: Experiences during the initial phase of psychotherapy as predictors of treatment duration and outcome.

Studied the formation of a psychotherapy relationship using self-reports of clients and therapists. Items designed as measures of a set of dimensions considered salient to the process of therapy were incorporated into client and therapist report forms. These were completed separately by clients and therapists immediately following each of the initial 10 sessions. It was hypothesized that report-form dimension scores early in treatment would predict persistence in treatment, duration of treatment, and retrospective evaluations of outcome. Subjects were 91 students (36 males, 55 females) attending a large urban unversity and 19 therapists (10 females, 9 males) on the staff of the university student counseling service. A number of client and therapist dimensions predicted persistence in treatment as early as the 3rd session. Dimension scores failed to predict duration of treatment for remainers, however. A greater number of dimension scores correlated with therapist outcome ratings than with client outcome ratings. (38 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment outcome and follow-up evaluation based on client case records in a mental health center.

Assessed the outcome of treatment of 121 mental health center clients (11–70 yrs of age), using therapist and independent global improvement ratings and independent ratings of notes in case records based on a client-specific goal-oriented outcome technique (Goal Attainment Scaling; GAS). Telephone follow-up of 50 clients provided a 2nd GAS assessment, client global improvement ratings, and 3 consumer satisfaction ratings. Findings indicate that (a) independently determined GAS scores and therapist and independent global ratings converged significantly, (b) the GAS procedure provided some increase in accuracy as well as an increase in specificity of outcome, and (c) client global ratings may reflect satisfaction with treatment rather than outcome. In view of the intercorrelations among measures and the relationship between GAS scores determined from case records and telephone interviews, case records may provide for accurate assessment of client problems and treatment success. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy outcome in a university-based psychology training clinic.

Evaluated the effectiveness of psychotherapy conducted by clinical psychology students in a university-based psychological training clinic. Factors contributing to positive outcomes were also explored. Based on both therapist (n?=?53) and client (n?=?59) perceptions of the overall helpfulness of therapy and on their ratings of perceived change in the specific problems treated, it is concluded that the student-conducted therapy was successful and provided a genuine service to the community. Therapies that terminated by mutual consent (vs termination by therapist or client alone) and those that were longer were more successful. The positive results are attributed to the careful supervision of each case, the enthusiasm of novice therapists, and the nature of the client sample. Implications for training and clinic policy are discussed. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A behavioral analysis of the determinants of marital satisfaction.

Tested hypotheses about the determinants of global ratings of marital satisfaction, the role of reciprocity in marital interaction, and the influence of external experiences on the marital relationship. 7 nondistressed married couples made daily observations of their spouse's pleasurable and displeasurable behavior for 14 consecutive days and daily ratings of the enjoyability of their outside experiences and of their satisfaction with the relationship. Multiple regression analysis, with satisfaction ratings as the criterion variable, showed that both types of displeasurable behavior contributed to rated satisfaction, accounting together for 65% of the explainable variance. For pleasurable behaviors, a sex difference was noted, with males emphasizing pleasurable instrumental behaviors from their spouses and females emphasizing pleasurable affectional behavior. The immediate tendency to reciprocate displeasurable behaviors was stronger than that for pleasurable behaviors. The influence of external experiences was negligible. (23 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist multicultural competency: A study of therapy dyads.

[Correction Notice: An erratum for this article was reported in Vol 44(1) of Psychotherapy: Theory, Research, Practice, Training (see record 2007-04278-014). The fifth author's name should be spelled as follows: Alexa Mislowack.] This study examined the role of therapist multicultural competence (TMC). Fifty-one therapy dyads completed measures of therapist multicultural competency, working alliance, and their satisfaction with therapy. Clients also completed measures of therapist attractiveness, expertness, trustworthiness, and empathy. Results showed strong associations between clients' ratings of TMC and ratings of the working alliance, therapist empathy, and satisfaction. Clients' combined rating of therapist expertness, attractiveness, and trustworthiness were not associated with their TMC ratings but were significantly associated with therapists' self-appraised TMC ratings. Therapists' ratings of their TMC were associated with their ratings of the working alliance and satisfaction with their work. Results are discussed in the context of the relevant literature, as are implications for training and research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of single therapists versus cotherapy teams in sex therapy.

Assigned 65 sexually dysfunctional couples to treatment by a single male therapist, a single female therapist, or a dual-sex cotherapy team. The male Ss in age ranged from 21 to 69 yrs; female Ss were aged 20 to 65 yrs. Mean duration of the Ss' relationships was 12.7 yrs. Treated dysfunctions included male erectile failure and premature ejaculation and female primary and secondary orgasmic dysfunction. Assessments of marital and sexual satisfaction and functioning were made at initial intake, at the start of therapy, immediately following therapy, and at a 3-mo follow-up. The assessment battery included the Sexual Interaction Inventory, a marriage inventory, patient global ratings, and measures of symptom remission. Repeated measures ANOVA and post hoc comparisons failed to reveal any differences in effectiveness of single therapists vs cotherapy teams. Furthermore, in cases treated by single therapists, a matching of sex of therapist with sex of the dysfunctional member of the couple did not lead to better outcome than for nonmatched cases. Overall, sex therapy was generally effective, although greater gains were shown in Ss' global ratings of satisfaction and in the psychometric measures of adjustment than in actual symptom remission. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist behavior as a determinant for client noncompliance: A paradox for the behavior modifier.

Examined the immediate impact of therapist behavior on client noncompliance in 2 studies involving 12 3.8–13.1 yr old socially aggressive children and their families. One family participated in both studies. Observation systems describing client and therapist behavior were used to code videotaped therapy sessions. In Study 1, the therapist behaviors teach and confront were associated with significant increases in the likelihood of client noncompliant reactions. Therapist behaviors facilitate and support were followed by reliable decreases in client noncompliance. In Study 2, the therapist behaviors teach and confront were manipulated in a series of single-S ABAB reversal designs. Results demonstrate that changes in therapist behaviors produced increases in client noncompliance. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The association between global and specific measures of the therapeutic relationship.

[Correction Notice: An erratum for this article was reported in Vol 31(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2009-17141-001). This article contained, as Figure 1, an SASB model. The authorship and copyrights for the model were not acknowledged. The following acknowledgement should have been included: "From Benjamin (1983), Intrex User's Manual. Intrex Interpersonal Institute, P.O. Box 581037, Salt Lake City, UT 84158. Reprinted by permission." An apology is offered to the author, Dr. Lorna Smith Benjamin. The particular version used in the article was developed in collaboration with Clinton W. McLemore.] Examined the association between global and specific measures of the therapeutic relationship in Sessions 3, 5, and 15 of 9 cases of time-limited psychodynamic psychotherapy. L. S. Benjamin's (see PA, Vol 53:2991; see also, 1984) structural analysis of social behavior (SASB) model provided the specific measure of relationship. There were more consistent associations between ratings of client contributions to the alliance and SASB ratings of client behaviors than there were for the same therapist variables. Additionally, analyses show that external (i.e., nonself) judgments of client and therapist contributions to the alliance, rather than therapist or client self-ratings of contributions to the alliance, were most frequently associated with the SASB behavior codes. Finally, different therapist and client behaviors seemed to be associated with quality of the therapeutic relationship at different points in the therapeutic process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist strategies for building involvement in cognitive–behavioral therapy for adolescent depression.

This study examined predictive relations between 9 therapist behaviors and client involvement in manual-guided, cognitive–behavioral therapy for adolescent depression. Analyses included 42 adolescents who met criteria for a depressive disorder (major depressive disorder, dysthymic disorder, or adjustment disorder with depressed mood) and who were treated in school-based clinics. Therapist behaviors hypothesized to promote client involvement were coded from Session 1 audiotapes; client involvement was coded from Session 2. Unlike prior research, the current study examined associations between behaviors and involvement while controlling for initial client resistance to isolate the therapist contribution to involvement. Results show that 3 therapist behaviors from Session 1 (attending to teen’s experience, exploring teen’s motivation, and less structure) predicted greater client involvement in Session 2, controlling for initial resistance. Only exploring motivation and less structure uniquely predicted Session 2 involvement when the 3 behaviors were examined simultaneously. Session 1 therapist behaviors predicted significant variance in involvement at Sessions 2, 4, and 8. Client initial presentation as resistant was associated with more exploring motivation and praising, but initial resistance did not explain associations between therapist behaviors and involvement. Implications for implementing evidence-based treatments are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relation of nonverbal behavior to client reactions.

Sixteen therapists each saw a volunteer client for a single counseling session. During a videotape review the clients recorded their reactions and the therapists recorded their perceptions of client reactions to each therapist intervention. Client nonverbal behaviors (speech hesitancies, vertical and horizontal head movements, arm movements, leg movements, postural shifts, adaptors, illustrators, and smiles) were examined to determine whether they were consistently associated with client reactions. The results indicated that horizontal head movements were associated with client reports of supported and therapeutic work reactions and were also associated with therapist perceptions of therapeutic work reactions; vertical head movements were associated with client reports of supported reactions; and speech hesitancies were associated with therapist perceptions of therapeutic work reactions. The results are discussed in terms of implications for practice and further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)