Beneath the surface of long-term therapy: Therapist and client report of their own and each other's covert processes.

Therapists and clients reported on their own and their perceptions of each other's covert processes in long-term therapy. Therapists had a match rate of .45 for client reactions, with therapists rating match on therapeutic work reactions as helpful. Although 65% of clients left somethimg unsaid (primarily because of avoidance), only 27% of therapists were able to match what clients left unsaid. Of the clients, 46% had secrets (often sexual), primarily because of shame or insecurity. Clients had a match rate of .50 for therapist intentions, with therapists rating match on exploratory and restructuring intentions as helpful and both clients and therapists rating match on assessment intentions as not helpful. Thus, awareness of the other's covert processes had an effect on therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perceived sources of change in trainees’ self-efficacy beliefs.

Thought-listing procedures were used to examine the perceived incidence, size, direction, and bases of change in the session-level self-efficacy of therapists in training. Ninety-eight Master’s-level trainees completed a cognitive assessment task immediately after each session with a client in their first practicum. Participants typically reported modest-sized, positive changes in their therapeutic self-efficacy at each session. Seven perceived sources of change in self-efficacy were identified. Some of these sources (e.g., trainees’ performance evaluations, affective reactions) were consistent with general self-efficacy theory; others reflected the interpersonal performance context of therapy (e.g., perceptions of the therapeutic relationship and client behavior). Implications of the findings for training and future research on therapist development are considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Studying psychotherapy using the one-with-many design: The therapeutic alliance as an exemplar.

Most psychotherapy research uses a one-with-many design, in which each therapist (the one) treats multiple clients (the many), which raises the challenge of nonindependent data. We present a statistical model for analyzing data from studies that use a one-with-many design. This model addresses the problems associated with nonindependence and can address theoretically relevant questions. To illustrate this model, we analyzed data in which 65 therapists and their 227 clients rated their therapeutic alliance. The primary finding was that both therapist and client alliance ratings were largely relational (i.e., specific to the unique therapist–client combination). There was little consensus among clients treated by the same therapist about the quality of the therapeutic alliance, although some therapists reported forming stronger alliances than other therapists. There was substantial dyadic reciprocity, indicating that if a therapist reported an especially good alliance with a particular client (better than with his or her other clients), then that client was also likely to report an especially good alliance (better than those reported by the therapist’s other clients). (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)     

Interpersonal complementarity and the therapeutic alliance: A study of relationship in psychotherapy.

Examined the relationship between the therapeutic alliance and interpersonal complementarity during the early stage of psychotherapy. 36 pairs of patients (aged 18–57 yrs) and therapists from 14 outpatient settings recorded their perceptions of their therapeutic alliance, using a working alliance inventory, and rated each other's therapy behaviors on the Checklist of Interpersonal Transactions. There were positive associations between patient–therapist interpersonal complementarity and both patients' and therapists' perceptions of the alliance. The more extreme/abnormal the patient's interpersonal behavior, the more both patient and therapist perceived a less positive working alliance. (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)     

Comparing therapist and client perspectives on reasons for psychotherapy termination.

Examines the extent of agreement on the reasons for psychotherapy termination given by therapists and their clients. 194 client files in a psychology training clinic were reviewed to obtain reasons for termination cited by therapists in treatment termination reports. Telephone interviews were conducted with 87 of these former clients to determine their perspectives on reasons for termination. Consistent with previous research, there was little concordance among the reasons cited by therapists and by clients regarding clients' decisions to terminate therapy. Of the clients identified by therapists as terminating because of the successful attainment of therapeutic goals, three-quarters reported this reason as important in their termination decision; of those clients reporting termination because of attaining therapeutic goals, only half were identified by therapists as having achieved their goals. Dissatisfaction with therapy and/or the therapist were reported by many clients as important in their termination decisions; such factors were rarely cited by therapists as reasons for termination. Attention to discrepancies between client and therapist expectations of therapy and therapy termination is necessary to reduce the high rate of premature termination in psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-concept and self-esteem as moderators of client transference.

Operationalized transference as (a) the similarity of clients' perceptions of their therapist and their perceptions of their parents and (b) therapists' ratings on a transference scale, Therapy Session Check Sheet (TSCS; H. Graff and L. Luborsky, 1977), and examined the moderating role of self-esteem and ego development on client transference. Ss were 62 clients (aged 19–63 yrs) who were already involved in therapy, and 29 therapists (aged 25–61 yrs). The Barrett-Lennard Relationship Inventory (G. T. Barrett Lennard, 1962, 1973) measured the facilitative conditions (regard, empathy, and unconditionality) and therapist–parent similarity and the TSCS measured the therapists' perceptions of transference. Additional measures were the Ego Identity Scale (A. L. Tan, et al, 1977) and the Rosenberg Self-Esteem Scale (M. Rosenberg, 1979). Results support the idea that self-esteem and ego development impact a client's view of the therapist and parental figures and are associated with therapists' views of transference. Persons with low ego identity and low self-esteem tended to see their therapists and parental figures more dissimilarly; and the more transference that a therapist perceived, the greater the tendency for the client to have low ego identity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes.

Across several decades the effects of matching clients with therapists of the same race/ethnicity have been explored using a variety of approaches. We conducted a meta-analysis of 3 variables frequently used in research on racial/ethnic matching: individuals' preferences for a therapist of their own race/ethnicity, clients' perceptions of therapists across racial/ethnic match, and therapeutic outcomes across racial/ethnic match. Across 52 studies of preferences, the average effect size (Cohen's d) was 0.63, indicating a moderately strong preference for a therapist of one's own race/ethnicity. Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's own race/ethnicity somewhat more positively than other therapists. Across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists. These 3 averaged effect sizes were characterized by substantial heterogeneity: The effects of racial/ethnic matching are highly variable. Studies involving African American participants demonstrated the highest effect sizes across all 3 types of evaluations: preferences, perceptions, and outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The In-Session Self-Awareness of Therapist-Trainees: Hindering or Helpful?

Although therapist self-awareness has been hailed as a critical component of psychotherapy, recent evidence suggests that therapists' in-session self-awareness may hinder rather than help the therapeutic process. The authors examined the in-session self-awareness of therapists in training (trainees) in relation to their interpersonal involvement and the reactions of volunteer student clients (volunteer clients). Trainee in-session self-awareness variables predicted over 50% of the variance in their interpersonal involvement and the volunteer clients' perceptions of the therapeutic alliance. Contrary to previous research, trainees' level of in-session self-awareness was generally helpful rather than hindering from both the trainee and student-client perspectives. Potentially hindering aspects of in-session self-awareness did emerge, however, in that trainees' increasing efforts to manage their self-awareness were related to decreased trainee involvement and lower volunteer client ratings of the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

When hearing clients work with a deaf therapist.

Not being able to hear can present significant challenges for the therapist and for the deaf therapist/hearing client dyad. It can also create opportunities. Although the literature indicates that most culturally Deaf therapists work with Deaf clients due to their mutual use of American Sign Language, I describe (a) the background of an audiologically deaf therapist who relies on speech reading rather than sign language, and (b) this therapist's clinical work with hearing clients. Some of the relational dynamics of these treatments are identified, and I conclude by noting how attention to communication can benefit the work of all psychotherapists. (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)     

Processes involved in client-nominated relationship building incidents: Client attachment, attachment to therapist, and session impact.

Thirty volunteer clients of trainee therapists nominated an incident that was critical in the development of their therapeutic relationship. Clients completed the Client Attachment to Therapist Scale (CATS), the Experiences in Close Relationships Scale (ECRS), and the Session Impacts Scale (SIS). Clients reported an increase in attachment security with their therapists, along with perceptions of support and relief and increasing exploration following the relationship building incident. While clients' avoidant attachment was unrelated to attachment to the therapist prior to the incidents, in subsequent sessions avoidance was related to a change in secure attachment to therapist. Finally, client attachment to therapist but not general attachment was significantly related to in-session exploration. Findings are discussed in light of attachment theory and convergence with findings from the field of social psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist homophobia, client sexual orientation, and source of client HIV infection as predictors of therapist reactions to clients with HIV.

Four hundred twenty-five psychologists received vignettes depicting a male client who was either gay or heterosexual and whose source of HIV infection was sexual contact, a blood transfusion, intravenous drug use, or unspecified. Respondents' homophobia and reactions to the client in the vignette were measured. Canonical correlation analyses revealed that therapist attributions of client responsibility for problem cause were predicted by the source of HIV infection and therapist homophobia. In addition, therapists responded with less empathy, attributed less responsibility to the client for solving his problems, assessed the client's functioning to be worse, and were less willing to work with the client when the client's source of HIV infection was other than drugs, when the client was gay, and when therapists were more homophobic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The therapeutic alliance in adolescent substance abuse treatment: A one-with-many analysis.

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Concepts, processes and procedures: An introduction to the special issue on integration of concrete operating procedures.

Mahrer (1989b) described integration on the basis of concrete operating procedures as one of the more promising approaches to psychotherapy integration. In an attempt to examine this integrative approach, therapists from a variety of theoretical orientations were invited to share examples of how they had integrated into their preferred therapeutic approach interventions that were originally developed outside that framework. The articles in this special section provide illustrations of integration of specific procedures into four different theoretical frameworks. Although the articles discuss the incorporation of a wide variety of different types of interventions, as a group they suggest (a) that therapist operating procedures are understood more in terms of providing resources for an active collaborating client than as creating an impact upon the client, (b) that all therapist activities including procedures aimed at achieving problem resolution instantiate the therapeutic relationship, thus blurring the distinction between working on the relationship and working on client issues, and (c) that it is both possible and valuable for therapists to be flexible and creative in integrating new procedures into their therapeutic work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discriminating the "good" from the "bad" therapy hour: A study of dyadic interaction.

Investigated whether better interviews could be discriminated from worse interviews, using (1) relative client–therapist activity levels and (2) the degree of structure implicit in the therapist's messages. Eight 22–58 yr old clients and their therapists whose professional experience ranged from 1 to 4 yrs had congruent perceptions of 2 sessions, one good and one bad. Group and case-by-case comparisons were made of the natural language in these interviews. Results show metacomplementary patterns in both good and bad sessions, but client–therapist activity tended to be more asymmetrical in the worse interviews. In the bad sessions, these therapists either participated even more actively than their clients or were passive, while in their good sessions client–therapist participation levels were more balanced. In the good interviews, therapists consistently provided a moderate degree of structure (significantly more reassurance/encouragement, information, and interpretation), as opposed to lower structure (notably reflection/restatement) or higher structure (information seeking and guidance/advice) in their bad interviews. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Complementarity and symmetry in family therapy communication.

We examined relational control communication patterns in systemic family therapy sessions. Therapist interactions with each family member (N?=?29 families) were examined with the Family Relational Communication Control Coding System. Results showed significantly more complementarity, which reflects mutuality in the definition of a relationship, than symmetry, which characterizes relational control competition. Transitional probabilities showed that family members were likely to respond to therapists in a complementary manner (following therapist one-up, ↑, messages with one-down, ↓, messages and vice versa); therapists were likely to respond to client ↑ and ↓ messages in either a competitive symmetrical or complementary manner. Neither complementarity nor symmetry was predictive of family members' perceptions of the therapeutic alliance as measured by Couple and Family Therapy Alliance Scales (W. M. Pinsof and D. R. Catherall; see record 1987-23860-001). (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)