Multivariate study of the patient-therapist system: A replication and extension.

Replicates and extends the work of R. H. Moos and S. R. Clemes (see record 1967-07395-001) and F. van der Veen (see record 1965-08090-001). Each of 6 patients saw each of 4 therapists twice. The variables total activity, feeling words, action words, reinforcements each was scored separately for patient and therapist for each interview. Patient problem expression and therapist accurate empathy were rated for each interview. Consistent differences between patients accounted for substantially more variance than consistent differences between therapists on all variables. Patient * Therapist * Session interactions generally accounted for large proportions of the total variance. Results indicate that the therapist behaviors studied were not the result of a trait, of a given tendency to be empathic, or of a consistently applied therapeutic technique, but rather were very substantially situationally or patient determined. (23 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think.

Objective: To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance–outcome relationship. Method: We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used. Results: At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3–9 explained 14.7% of outcome variance. Conclusion: Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance–outcome relationship. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Relationship between patient-therapist compatibility and treatment effectiveness.

Studied patient attraction to therapist, therapist attraction to patient, and patient change as a function of interpersonally oriented therapist-patient compatibility. Fundamental Interpersonal Relations Orientation scale scores were used to assign a high- and a low-compatibility psychiatric patient to each of 24 therapists. High-compatibility matched patients were found to have a significantly more favorable view of their therapists after both 3 and 11 wk. of interaction. However, therapists did not prefer relating to their high-compatibility over their low-compatibility match patients. There was no difference in the amount of behavioral change found in the high-compatibility, low-compatibility, and untreated-control groups. It is concluded that by use of such matching procedures a higher level of interpersonal attraction can be promoted between patients and their therapists, but the significance of therapist-patient attraction for treatment effectiveness remains to be demonstrated. (39 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of therapist and patient mood on the therapeutic functioning of high- and low-facilitative therapists.

Determined the effects of presession moods of 12 therapists and their patients on level of therapist empathy, warmth, and genuineness. Results of an intensively designed study indicate that high- and low-facilitative therapists were differentially affected by therapist moods. High-facilitative therapists functioned more facilitatively under dysphoric moods than under positive, while the opposite was true of low-facilitative. There were no differences in tape-rated therapist facilitativeness under different patient moods for either group, yet patients of low-facilitative therapists did perceive such a difference. It is concluded that the therapist feelings preceding the facilitative therapy hour were not the same for high- and low-facilitative therapists. The use of the intensive design in psychotherapy process research is discussed. (44 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client and therapist variability in clients' perceptions of their therapists' multicultural competencies.

This study examined therapist differences in their clients' ratings of their therapists' multicultural competencies (MCCs) as well as tested whether therapists' who were rated as exhibiting more MCCs also had clients who had better therapy outcomes (N = 143 clients and 31 therapists). All clients completed at least 3 sessions. Results demonstrated that therapists accounted for less than 1% of the variance in their clients' Cross-Cultural Counseling Inventory–Revised (CCCI-R; T. D. LaFromboise, H. L. K. Coleman, & A. Hernandez, 1991) scores, suggesting that therapists did not differ in terms of how clients rated their MCCs. Therapists accounted for approximately 8.5% of the variance in therapy outcomes. For each therapist, their clients' CCCI-R scores were aggregated to provide an estimate of therapists' MCCs. Therapists' MCCs, based on aggregate CCCI-R scores, did not account for the variability in therapy outcomes that were attributed to them. Additionally, clients' race/ethnicity, therapists' race/ethnicity, or the interaction of clients'–therapists' race/ethnicity were not significantly associated with clients' perceptions of their therapists' MCCs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Some gender effects in a brief psychotherapy.

Two studies investigated the influence of therapist gender as well as patient age and pretreatment distress level on process and outcome in a brief 12-session psychodynamic psychotherapy. Pre- and posttherapy assessments disclosed that patients treated by female therapists experienced more symptomatic improvement and reported more satisfaction with treatment than those treated by male therapists. However, patient age accounted for twice, and patient pretreatment level of disturbance more than three times, the outcome variance contributed by gender. In Study 2 female therapists were judged to arouse less negative affect in women patients and to arouse fewer interpersonal difficulties. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Effects of Therapist and Patient Mood on the Therapeutic Functioning of High- and Low-Facilitative Therapists": Erratum.

Reports an error in the original article by Alan S. Gurman (Journal of Consulting and Clinical Psychology, 1973[Feb], 40[1], 48-58). On page 49, paragraph 2, line 8 should read "those preceded by negative therapist moods." (The following abstract of this article originally appeared in record 1973-21486-001.) Determined the effects of presession moods of 12 therapists and their patients on level of therapist empathy, warmth, and genuineness. Results of an intensively designed study indicate that high- and low-facilitative therapists were differentially affected by therapist moods. High-facilitative therapists functioned more facilitatively under dysphoric moods than under positive, while the opposite was true of low-facilitative. There were no differences in tape-rated therapist facilitativeness under different patient moods for either group, yet patients of low-facilitative therapists did perceive such a difference. It is concluded that the therapist feelings preceding the facilitative therapy hour were not the same for high- and low-facilitative therapists. The use of the intensive design in psychotherapy process research is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance.

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient-therapist interdependence: Cognitive and behavioral.

Each of 7 patients saw each of 4 therapists twice. After each session, therapists rated how they thought the patient and therapists should behave during psychotherapy. In addition, these patient and therapist behaviors were independently rated from tapes of the meetings. A balanced 4 * 7 design was utilized. Behavior rating data indicate that therapists are more influenced by patients than patients are by therapists. Comparisons of questionnaire and behavior rating data indicate that differences among therapists are more evident in how therapists think than in how they or patients behave. Implications for understanding the different roles of the psychotherapist are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care.

To estimate the variability in outcomes attributable to therapists in clinical practice, the authors analyzed the outcomes of 6,146 patients seen by approximately 581 therapists in the context of managed care. For this analysis, the authors used multilevel statistical procedures, in which therapists were treated as a random factor. When the initial level of severity was taken into account, about 5% of the variation in outcomes was due to therapists. Patient age, gender, and diagnosis as well as therapist age, gender, experience, and professional degree accounted for little of the variability in outcomes among therapists. Whether or not patients were receiving psychotropic medication concurrently with psychotherapy did affect therapist variability. However, the patients of the more effective therapists received more benefit from medication than did the patients of less effective therapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient-therapist matching for prediction of optimal and minimal therapeutic outcome

Exp I (a) established outcome criteria using evaluation ratings from 24 patient-therapist dyads; (b) produced 11 quantifiable personality predictors through factor analysis of 18 therapists' and 65 patients' scores on a test battery (including the MMPI and the Omnibus Personality Inventory); (c) identified 3 typological categories of both patients and therapists homogeneous with respect to these variables and 2 groups of therapists each homogeneous with respect to therapeutic approach; and (d) derived 5 regression equations predicting outcome for each patient and therapist group. Exp II, with 24 therapists and 56 patients who were university students or their spouses, utilized these findings to form 2 experimental dyad groups for which (a) optimal or (b) minimal therapist outcome ratings were predicted, and 2 control groups each for both optimal and deterioration matches that controlled for patient type and therapist type, respectively. Results indicate significant differences between mean outcome in the comparison of the deterioration-matched group both with its control and the optimally matched group. Findings demonstrate the usefulness of carefully planned matching techniques. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender and representation in psychotherapy.

Investigated the ways in which patient and therapist gender influence the nature of patients' internalized representations of their therapist and the therapeutic relationship. A sample of 66 patients (29 males) completed the Therapist Representation Inventory (J. D. Geller et al, 1982), a self-report instrument designed to assess discrete properties of evoked representations. Results indicated widespread similarities between male and female patients in terms of the forms with which representations are evoked and the themes embodied in these representations. The differences that emerged suggest that women are more likely to keep their therapists in mind (and for longer periods of time) when working on their problems outside of therapy and that women with male therapists are especially likely to daydream about therapy and acknowledge missing their therapist in between sessions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sexualization of therapeutic relationships: The dual vulnerability of patient and therapist.

Contends that consumerism (a humanistic-egalitarian therapeutic orientation) and feminism have heightened awareness of the problem of sexual intimacies between patients and therapists. Evidence suggests that sexual intimacy between patients and their therapists has become a more common mode of experience than previously thought. Sexual abuse occurs when the relationship between the patient and therapist is violated, and the patient is victimized by the therapist; erotic involvement between patient and therapist has been likened to incest. Data from the 1970's show that the overwhelming majority of sexually abusive therapists are male. Education during therapists' training period and alternatives for therapists at risk for sexually abusive behavior, including avoidance, referral, treatment programs, and punishment, are suggested as ways to deal openly with this small but severe problem. Public education, in a nonalarmist manner, is also recommended. (35 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Systematic effects of participant role on evaluation of the psychotherapy session.

This study identified systematic differences between therapists (n?=?114) and patients (n?=?119) in the process components that predict evaluation of psychotherapy sessions. The Comprehensive Scale of Psychotherapy Session Constructs was developed to measure 9 process variables and their relationships to session evaluation from the perspectives of therapist and patient. Regression equations predicting session evaluation from the process components for the 2 groups were significantly different. Therapist session evaluation was best predicted by therapist expertness, and patient session evaluation was best predicted by the therapist real relationship. The therapist real relationship negatively predicted therapist session evaluation when all process variables were considered simultaneously. Patient progress and patient involvement significantly and positively predicted both therapist and patient evaluation. (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)     

Attachment to the therapist.

This study examines the ways in which therapists function as attachment figures for patients. Patients in long-term psychoanalytic therapy answered questionnaires about their feelings about their therapists and their closest personal relationships. Components of attachment prominent in the therapeutic relationships were looking up to the therapist and feeling the therapist was responsive to emotional needs. Stronger attachment to therapists was associated with greater frequency and duration of therapy, a stronger working alliance, and greater security of the patients' attachment style, as well as with the gender of the patient and therapist. Using attachment theory to understand psychoanalytic relationships emphasizes the unique importance of a therapist to a patient and can offer new perspectives on both therapeutic and attachment processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client–therapist value similarity and psychotherapy outcome: A microscopic analysis.

Examined the association between patient–therapist pretreatment value similarity and subsequent improvement in 45 nonpsychotic psychiatric outpatients (aged 19–54 yrs) who were randomly assigned to 22 therapists. Pre-assignment assessment of similarity in 36 value dimensions on the Rokeach Value Survey was investigated to determine how the dimensions influenced symptomatic and global changes in the therapy process. Treatment outcome was assessed both by patient and therapist reports, and the SCL-90 was used to evaluate pre- to posttreatment symptom change on 9 symptom dimensions. In addition, therapists were asked to complete a subjective rating of improvement at the end of treatment. The results indicate that a complex pattern of similarity and differences in specific values promoted maximal improvement. Moreover, specific improvement measures were influenced differently by various patient–therapist value patterns. Generally, therapist ratings of outcome were enhanced by pretreatment dissimilarities in value placed on social ascendance and achievement and similar value emphasis being placed on humanistic and philosophical concerns. Patient ratings of outcome were also enhanced if patient and therapist shared philosophical and humanistic concerns, but were further facilitated if values relating to social attachment and independence were ranked differently for patient and therapist. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' and therapists' shared and unique views of the therapeutic alliance: An investigation using confirmatory factor analysis in a nested design.

Analyzed large general factor found in measures of the therapeutic alliance by use of confirmatory factor analysis (CFA) in a nested design. Ratings by 38 therapists and their 144 patients on the California Psychotherapy Alliance Scales (CALPAS), the Revised Penn Helping Alliance Questionnaire (HAQ-R), and the Working Alliance Inventory (WAI) were adjusted for therapist effects. A set of models for S and therapist ratings was tested with CFA, and a 3-factor model was confirmed, x–2(4)?=? 7.19, p> .13; GFI?=?.98; RMSR?=?.02; CFI?=?1.0. A shared-view factor (best represented by HAQ-R) accounted for 44% of patients' and 27% of therapists' variance. Unique factors accounted for 56% of therapists' and 43% of Ss' variance. S views split between HAQ and WAI factors; The WAI factor was most expressive of therapist views. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Process and outcome in psychotherapy and behavior therapy.

Three behavior therapists and 3 analytically oriented psychotherapists treated a total of 60 neurotic outpatients for 4 mo. Data were collected as part of a larger study by R. B. Sloane et al (1975). Measures of Rogers-Truax (C. B. Truax and K. M. Mitchell, 1971) factors, nonlexical speech characteristics, therapist informational specificity, and a content analysis of therapist activity were taken from recordings of the 5th interview. Therapists rated their feelings toward their patients, and patients completed the Relationship Questionnaire and rated therapists on an inventory by M. Lorr (see record 1965-10372-001). In psychotherapy, patients who were most liked by their therapists and those with greater total speech time showed greatest symptomatic improvement. Patients who used longer average speech durations improved most in both treatments. It is concluded that patient improvement was more a function of patient characteristics than of specific therapist interventions. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)