Therapist and client perceptions of the working alliance: Codevelopment, linear growth, variability, and client functioning.

Using longitudinal client and therapist working alliance ratings, previous research examined how alliance: average value, linear growth, variability, stability (autocorrelation), and partner responsiveness were associated with client outcome. However, no research simultaneously examined all of these dimensions. Omitting important variables in analyses could lead to overestimation of related effects. Therefore, the purpose of this study was to examine these effects simultaneously. Therapists (N = 45) and clients (N = 236) rated alliance after every session (N = 10,720) and clients completed a measure of psychological distress after every eighth session. We used dynamic structure equation modeling to model longitudinal ratings using the longitudinal actor-partner interaction and location-scale models. Across sessions, there were significant linear growth and significant variability in client and therapist alliance ratings. The variability indicates multiple "V" patterns, which have been associated with alliance ruptures. Both actor effects were significant, showing session-to-session stability for client and therapist alliance. In addition, client-partner effect was significant, indicating higher-than-usual client alliance in a session predicting an increase in therapist alliance in the subsequent session. Growth in neither client-rated nor therapist-rated working alliances was significantly associated with client improvement. Lower variabilities (fewer fluctuations) in both client- and therapist-rated working alliances were associated with better outcomes. Higher therapist-actor and partner effects were associated with client improvement, but client-actor and partner effects were not associated with client improvement. Average working alliances were not associated with client improvement. Implications for practice and research were discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Group member attachment style interacts with actor and partner helping alliance to predict decreasing binge eating episodes.

OBJECTIVE: An individual's attachment style may impact how they interact with their therapy group. This study examined the moderating role of a group member's attachment on the dynamic relationships between that group member's (actor) and other group members' (partner) therapeutic alliances and symptom outcomes. Method: This is a secondary analysis of data from a trial testing the outcome of emotionally-focused group therapy for binge-eating disorder. The sample consisted of 2,360 sessions nested within 118 group members who attended a 20-session treatment. Patients recorded binge eating episodes (BEE), their body weight and an alliance measure session-by-session. RESULTS: Dynamic structural equation modelling showed decreases in BEE and weight over the therapy. When attachment style was not included in the model, higher-than-average partner's alliance scores in the previous session were related to decreases in BEE in the current session. Attachment style moderated these actor and partner effects. For patients with preoccupied attachments, higher-than-average actor alliance in the previous session was related to subsequent decreases in BEE. For patients with dismissing or disorganized attachments, higher partner alliance in the previous session was related to subsequent decreases in BEE. CONCLUSION: Group members' attachment characteristics can play a role in the development of alliance-outcome patterns in group therapy.

Working alliance after transferring from one therapist to another in a training clinic: Influence of therapist attachment style.

This study investigated how client working alliance changed after transferring from one therapist to another: (a) When pre- and post-transfer therapists' attachment anxiety/avoidance were congruently higher or lower and (b) when the pretransfer therapists' attachment anxiety/avoidance were more or less discrepant from the posttransfer therapists. A Tau-U analysis and a multilevel polynomial regression and response surface analysis were used to analyze longitudinal data about 23 transferred clients in open-ended psychodynamic psychotherapy with doctoral-level therapist trainees (n = 29). When first and second therapists' attachment anxiety/avoidance levels were congruent, the higher the two therapists' attachment anxiety and avoidance levels were, the greater was the decrement in clients' ratings of working alliance after transfers. When first and second therapists' attachment anxiety/avoidance levels were discrepant from each other, the more the first and second therapists' attachment were different from each other in terms of anxiety, the greater decrement in clients' ratings of working alliance there was after transfers. Meanwhile, the more the two therapists' attachment avoidance levels were different from each other, the less decrement in clients' ratings of working alliance there was after transfers. Therefore, the attachment orientations of the pre- and post-transfer therapists combined to influence client working alliance after transfers. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Family therapy for maltreated youth: Can a strengthening therapeutic alliance empower change?

We tested the process of change in Alliance Empowerment Family Therapy (AEFT; Escudero, 2013), a systemic, team-based approach for treating child welfare involved families. Since building and balancing strong personal and within-family therapeutic alliances are crucial for motivating and sustaining change in these multistressed, overburdened families, we assessed alliance perceptions over time in relation to two indices of therapy outcome, youth functioning, and family-specific goal attainment. Specifically, we administered the self-report version of the System for Observing Family Therapy Alliances (Friedlander et al., 2006) following Sessions 3, 6, and 9 to 156 Spanish families seen by 20 therapists in six agencies whose mission is to serve child welfare referred maltreated youth. Results showed that AEFT delivered in M = 11.04 sessions (SD = 3.29) was effective in attaining family-specific goals and improving child functioning, d = 1.16, as rated by the therapist team in coordination with the referring caseworker. A unique aspect of the study was the modeling, at each time point, of the shared therapeutic system alliance, a latent variable consisting of the therapist's rating of the alliance as well as the alliance ratings of the youth and primary caregiver. As we hypothesized, shared alliance perceptions strengthened with time and positively predicted posttreatment outcomes. Moreover, a comparison of linear growth models with and without the therapist's perspective showed that inclusion of the therapist ratings in the shared alliance variables improved the predictability of child and family outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Changes in group counseling engagement and conflict and growth in emotional cultivation for children and adolescents.

Group climate is an important factor in group counseling and psychotherapy process and outcome research. The current investigation examined group climate changes (from early to late sessions) at the within-group (i.e., group members) and between-group (i.e., group-as-a-whole) levels in predicting changes in group members' emotional cultivation in group counseling. A total of 236 Taiwanese children and adolescents across 41 groups participated in this study. Members' ratings of group climate (i.e., engagement and conflict) were partitioned into within-group and between-group components, and polynomial regression with response surface analysis was used to examine the association between changes in group engagement and conflict (at the member- and group-level) from early to late group sessions on changes in emotional cultivation. Results supported the theoretical hypothesis that when a group-as-a-whole reported increasing engagement from early to late group sessions, relative to other groups (i.e., between-group effect), members of that group experienced greater growth in emotional cultivation. Results also indicated that group members reported greater growth in emotional cultivation when there was consistent and high engagement or consistent and low conflict from early to late group sessions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Helping skills training: Outcomes and trainer effects.

We studied whether counseling self-efficacy increases after taking a helping skills course as well as whether trainer (instructor) effects are associated with postclass self-efficacy. We surveyed 551 undergraduate students and 27 trainers in helping skills courses across three semesters at one large mid-Atlantic U.S. public university. We found that students reported greater counseling self-efficacy after taking the course. In addition, trainers accounted for small but significant amount of the variance (7%) in changes in counseling self-efficacy. There was evidence that the instructors' authoritative teaching style but not their facilitative interpersonal skills were associated with increases in students' counseling self-efficacy. Implications for helping skills training are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Antecedents and consequences of open and closed questions in intake sessions of psychodynamic psychotherapy.

To investigate whether there are different antecedents and consequences of different types of therapist questions as this has implications for conducting psychotherapy and for training therapists.We examined the antecedents and consequences of questions for 88 clients working with 33 doctoral student therapists in psychodynamic psychotherapy. Questions were coded into open questions for thoughts (OQT), open questions for feelings (OQF), closed questions for facts (CQF), and closed questions other (CQO). The antecedents and consequences were assessed in terms of self-referring pronouns (SRP), self-referring emotion words (SRE), and number of words.In terms of antecedents, when clients were using a high number of SRP, therapists were more likely to ask OQT and CQO than CQF. When clients were using a high number of SRE, therapists were more likely to ask OQF than CQF. In terms of consequences, clients spoke less after CQF than the other three skills, used fewer SRP after CQF than after CQO, and used more SRE after OQF than CQF.CQO were more similar in terms of antecedents and consequences to OQT and OQF than to CQF.

A strong alliance is not enough: Item-level variation in an alliance measure moderates the alliance strength and client outcome relationship.

[Retraction notice: A retraction for this article was reported in Vol 70(4) of Journal of Counseling Psychology (see record 2023-89440-002). The following article (https://doi .org/10.1037/cou0000629) is being retracted. This retraction is at the request of coauthors Kivlighan and Hill after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. An was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article.] This study investigated within-client effects of session-to-session working alliance (WA) strength (mean of client's and therapists' ratings of Working Alliance Inventory [WAI] items for a session; WAI-M) and intra-individual variance of working alliance (WAI-IIV; variation in how the same individual responds to different items in the WAI for a session) of therapist and client on overall client functioning. Specifically, we explored how the strength and intra-individual variance for therapist and client working alliance at a previous session (Time t-1) would relate to overall client functioning at a current session (Time t). We also explored whether the effect of WA-M on overall client functioning would be different at different levels of WAI-IIV. The dynamic structural equation modeling (Asparouhov et al., 2018) was used to analyze longitudinal data from 4,489 sessions at a university clinic where 17 doctoral student therapists provided low-cost, open-ended, individual psychodynamic psychotherapy to 135 adult community clients. We found that client-rated WAI-M and WAI-IIV had positive within-client main effects on next-session client functioning when controlling for autoregressive effects. Findings on WAI-M by WAI-IIV interaction effects revealed that the relationship between WAI-M at a previous session and client functioning at a current session was significant only when WAI-IIV was low (i.e., high intra-individual consistency across WAI items). Therapists' WAI-M, WAI-IIV, and interaction of WAI-M and WAI-IIV did not predict the next session client functioning significantly. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Working alliance, therapist expressive skills, and client outcome in psychodynamic therapy.

Bordin's (1979) theory suggests that therapist techniques that call for client introspection and self-observation will be more effective when the working alliance (WA) is stronger. Psychodynamic therapists use expressive techniques to elicit this introspection and self-observation. We examined whether therapists' use of expressive skills (e.g., encouraging expression of thoughts and feelings; helping clients understand the reasons behind their thoughts, feelings, and behaviors) when the WA is high, versus low, was related to client outcome in open-ended, psychodynamic treatment. Ten therapists rated the WA with their 47 clients, who rated their perceptions of helping skills, after 2,284 counseling sessions. Clients also completed the Outcome Rating Scale (ORS) in reference to the week following each session. We examined time-ordered relationships by creating lagged variables for WA (T-2) and therapist expressive skills (TES; T-1) and used these scores to predict ORS ratings (T) in a three-level Hierarchical Linear Modeling (HLM) analysis (sessions nested within clients, nested within therapists). Lagged WA (T-2) and expressive skills (T-1) were decomposed into between-therapist, within-therapist, and within-clients components. We found a 3-way interaction for within-therapist working alliance, within-client WA at T-2, and expressive skills at T-1 predicting ORS at T. When clients who had a weaker WA with their therapist than the therapists' other clients, had a session with a stronger WA than the client's usual WA, then more expressive skills in the next session was related to better psychological well-being in the subsequent session. Implications and future directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cultural humility, working alliance, and Outcome Rating Scale in psychodynamic psychotherapy: Between-therapist, within-therapist, and within-client effects.

We examined how client working alliance (CWA) and therapist working alliance (TWA), and client-rated functioning (Outcome Rating Scale, ORS) related to client-perceived Cultural Humility (CH) of their therapist across the course of open-ended psychodynamic psychotherapy for 118 clients and 17 therapists. Clients and therapists completed measures of the WA after every session and clients completed the ORS prior to every session. Clients also judged their therapists' CH at Session 3, 8, and then every 8th session. CH data was partitioned into within-client, within-therapist, and between-therapists components and used to predict CWA, TWA, and ORS in a 4-level Hierarchical Linear Modeling (HLM) growth model. Between-therapist differences in CH were not related to next session CWA, TWA, or ORS, nor were these differences related to growth in CWA, TWA, and ORS. Within-therapist differences in CH were only related to the next session's CWA. At the within-client level, time-periods with higher CH, compared to clients' average CH, were associated with stronger next session (i.e., the immediate subsequent session) CWA and TWA, and time periods with lower CH, compared to clients' average CH, were associated with linear increase in CWA and TWA. Time-periods with high CH, compared to clients' average CH, were associated with significant increase in client functioning. Results suggest that lower CH weakens CWA and TWA in the next session but both CWA and TWA strengthen subsequently. By contrast, greater CH has no immediate effect on outcome but with greater CH psychological functioning increased over time. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mapping the progress of the process: Codevelopment of the therapeutic alliance with maltreated adolescents.

We used a longitudinal actor-partner interdependence model to examine the codeveloping alliance in alliance empowerment therapy (AET; Escudero, 2013), a manualized team-based approach developed in Spain specifically for child welfare-involved youth. In this first evaluation of AET, we sampled 102 adolescents, 83% of whom had been removed from their homes due to abuse or neglect, and 40% of whom were in crisis at the time of referral. Before each session, clients rated their improvement-so-far; after each session, both clients and therapists completed a brief alliance measure, an adaptation of the System for Observing Family Therapy Alliances (SOFTA-s; Friedlander et al., 2006) for individual therapy. In terms of outcome, clients' improvement ratings were significantly associated with posttreatment changes in overall functioning and personal goal attainment. With respect to the change process, growth was observed in both clients' and therapists' ratings of the alliance over 12 sessions, and an increased similarity in alliance ratings was due to more rapid growth in the therapists' ratings than the clients' ratings. Dynamic structural equation modeling indicated that at higher levels of adolescent goal attainment, a stronger association was observed between increased therapist-rated alliance and goal attainment. In other words, in the most effective cases, therapists were more responsive to how the adolescents seemed to have experienced the alliance in the previous session. The cocreated alliance perceptions were due to therapist (rather than client) responsiveness, as well as to unspecified aspects of sharing a therapy environment over time, such as familiarity with the process, regular meetings, and so on. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The within-client alliance-outcome relationship: A response surface analysis.

The authors examined how stability/change in working alliance predicted subsequent symptoms, and how stability/change in symptoms predicted subsequent alliance in a sample of 188 adult clients with 44 doctoral student therapists over the course of 893 eight-session time periods of individual psychodynamic psychotherapy. Clients completed the Working Alliance Inventory-Short Revised (WAI-SR; Hatcher & Gillaspy, 2006) after every session and the Outcome Questionnaire-45 (OQ; Lambert et al., 1996) before intake and every eighth session. The authors used multilevel polynomial regression and response surface analyses to examine within-client effects. The authors found that change in the alliance across an eight-session period did not have an immediate temporal effect on symptoms, but when alliance was stable and stronger compared to other periods, subsequent symptoms were lower. Similarly, change in symptoms across an eight-session period did not have an immediate temporal effect on alliance, but when symptoms were stable and lower compared to other periods, subsequent alliance was stronger. These results suggest that sustained improvements in the alliance contribute to subsequent symptom improvements, and vice versa. The authors conclude that it is important to work to improve and maintain improvements in the working alliance and symptoms. Limitations and future directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changes in meaning in life, working alliance, and outcome in psychodynamic psychotherapy: What leads to what?

We examined how meaning in life was associated with working alliance (WA) and outcomes, all from the client perspective. Random intercept lagged cross-panel analyses were used to analyze data from intake and after every eight sessions for the first 24 sessions of open-ended individual psychodynamic psychotherapy from 94 clients nested within 12 therapists. We found that, for all four time periods, working alliance in one 8-week time period predicted both Meaning in Life Measure-Experience (MILM-E) and Meaning in Life Measure-Reflectivity (MILM-R) in the subsequent time period, and MILM-R in one 8-week time period predicted client outcome in the subsequent time period. These findings suggest that having a strong working alliance is associated with clients developing more meaning in life, and reflectivity about meaning in life is associated with clients improving in psychotherapy. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Unpacking leader responsiveness effects of emotional cultivation groups: Using the variance partitioning method.

Theoretically, group leaders can play a significant role in contributing to the effectiveness of group counseling intervention. However, very few studies have examined the group leader's effects on the client-rated group counseling outcomes. We hypothesized that responsive group leaders who were caring, understanding, and respectful could serve as safe havens and secure bases to facilitate their group members' social and emotional cultivation. The current investigation examined the effects of leader responsiveness on group members' social-emotional cultivation (SEC). A total of 307 Taiwanese children and adolescent clients across 53 groups participated in an eight-session emotional cultivation group intervention. There were five time points of data collection (i.e., preintervention, third group session, sixth group session, postintervention, and a 4-week follow-up), and the variance partitioning method was used to partition longitudinal data into within-member, within-group, and between-group variance components. The results of hierarchical linear modeling revealed that the group leader's responsiveness significantly predicted group members' SEC at each of the three levels of analysis: Individual members had greater change in SEC when (a) they perceived higher leader responsiveness in a time period compared to the average rating of leader responsiveness across all time periods, (b) they perceived higher leader responsiveness compared to the average rating of leader responsiveness across all members in the same group, and (c) the group-as-a-whole perceived higher leader responsiveness than the average rating of leader responsiveness across all groups. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The triadic effect: Associations among the supervisory working alliance, therapeutic working alliance, and therapy session evaluation.

Several theorists (Bandura, 1969; Hackney & Goodyear, 1984; Searles, 1955) suggest parallels between the relationship in supervision and the relationship in therapy. We examined supervisor and therapist trainee ratings of supervisory working alliance (SWA) in 1 week predicting client-rated therapeutic working alliance (TWA) and client-rated therapy session evaluation (TSE) in the following week as well as TWA and TSE ratings in 1 week predicting SWA ratings in the following week. Our data included 663 weeks of therapy nested within 28 trainees nested within 15 supervisors, disaggregated into differences between supervisors, differences within supervisors, and differences within trainees. At the between-supervisor level, when supervisors' trainees rated the SWA higher on average compared with other supervisors' trainees' average SWA ratings, their clients' average TWA rating was higher. In contrast, when supervisors rated the SWA higher on average compared with other supervisors' average SWA ratings, their trainees' clients' average TSE rating was higher but the average TWA rating was lower. At the within-supervisor level, when trainees rated a higher SWA on average compared with other trainees' average SWA ratings with the same supervisor, their clients' average TSE rating was higher. The theoretical prediction of parallel relationships in supervision and therapy was supported, but only for between-supervisor and within-supervisor differences in SWA. We found no evidence that week-to-week changes in SWA or client-rated TWA or TSE reflected parallel relationships. We provide suggestions for further research, including exploring the mechanisms through which supervision relates to the therapy process and outcome. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Therapist initial attachment style, changes in attachment style during training, and client outcome in psychodynamic psychotherapy.

This study extended the cross-sectional therapist attachment literature by examining longitudinal changes of therapist attachment avoidance and anxiety in relation to client treatment outcome. Data consisted of 942 Outcome Questionnaire-45 assessments (Lambert et al., 1996, 2004) of 213 clients working with 30 therapists from a university clinic that provided psychodynamically/interpersonally oriented individual therapy, and yearly therapist self-report of attachment styles using the Experience in Close Relationships Scale (Brennan et al., 1998) over 2-4 years of training at a university clinic. Using multilevel growth modeling, we found that initial attachment anxiety or avoidance alone were not associated with treatment outcomes. Instead, therapists with small increases in attachment avoidance, from a low avoidance baseline, were more effective in helping clients reduce psychological distress than their peers. Findings suggest that small increases in attachment avoidance may be a beneficial development for trainees, as it may reflect a process of learning emotional boundary regulation (Skovholt & Rønnestad, 2003) and taking on the observer aspect of the participant-observer role (Sullivan, 1953). Current findings challenged the assumption that higher therapist attachment avoidance and anxiety is always associated with worse client outcome and suggested the importance of continuous self-reflection to understand how one's own attachment change impacts their clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changes in client attachment in relation to client distress: A response surface analysis.

Using multilevel polynomial regression and response surface analysis, we studied the association between Time 1 (T) and Time 2 (T + 1) attachment anxiety and attachment avoidance, and T + 1 psychological distress in 253 nine-session time periods for 65 adult community clients working with 13 doctoral student therapists in open-ended psychodynamic psychotherapy. Results indicated that when client attachment anxiety was consistent and higher from the beginning (T) to the end (T + 1) of a nine-session time period, clients tended to report higher distress at the end of the period; when attachment anxiety was consistent and lower across a time period, clients tended to report lower distress. When attachment anxiety decreased across a time period, clients reported lower distress at the end of the period; when attachment anxiety increased across a time period, clients reported higher distress. Neither within-client consistency nor change in attachment avoidance in a time period was significantly related to client distress at the end of the period. Limitations and implications of the present research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Helping skills courses: The effects of student diversity and numeric marginalization on counseling self-efficacy, counseling self-stigma, and mental health.

We examined the effects of racial/ethnic diversity and numeric marginalization on learning outcomes (changes in counseling self-efficacy, self-stigma for seeking counseling, and mental health) with 402 students in 30 sections of helping skills classes. Students self-identified as African American, Asian, Hispanic/Latinx, Other, or White. We operationalized class diversity with the diversity index developed by Chang (1999) and numeric marginalization as the percentage of students in the class that shared a target student's identity. Using two-level Hierarchical Linear Modeling (HLM; students nested within classes), we predicted counseling self-efficacy, counseling self-stigma, and mental health from student identity (Level 1), and the cross-level interaction between diversity and numeric marginalization (Level 2). Results suggested that classroom diversity had no effects on counseling self-efficacy but was associated with greater self-stigma. However, more classroom diversity was linked with better mental health for Latinx students. With African American students, numeric marginalization was associated with more counseling self-stigma. Surprisingly, for Asian students, numeric marginalization (i.e., a greater percentage of Asian students in a classroom) was linked with worse mental health. Finally, diversity had no effects on outcomes for White students. Findings demonstrate the importance of racial/ethnic composition in helping skills courses. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Facilitating exploration in psychodynamic psychotherapy: Therapist skills and client attachment style.

We examined how much 62 adult community clients working with 26 doctoral student therapists in the 10th session of individual, open-ended, psychodynamic psychotherapy engaged in affective and cognitive-behavioral exploration preceding and following four different therapist skills (restatement, reflection of feelings, open question for thoughts, open question for feelings). Overall, therapists used more skills focused on thoughts than feelings. At the between-therapists level, therapists tended to use more skills focused on affect when antecedent client affective exploration was high. An increase in affective exploration was associated with skills focused on feelings, however, clients low in attachment anxiety showed a decrease in affective exploration in response to paraphrases (i.e., restatements and reflections of feelings). Open questions for feelings were associated with an increase in cognitive-behavioral exploration, especially for clients low in attachment anxiety. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Therapist and counseling center effects on international students' counseling outcome: A mixed methods study.

We employed a convergent mixed methods design to examine therapist and counseling center effects on international student clients' (ISCs) counseling outcomes. Using the Center for Collegiate Mental Health (CCMH) data set (2015-2017), we conducted a three-level hierarchical linear model with clients (N = 85,110) nested in therapists (N = 1,267), and therapists nested in counseling centers (N = 111), with clients' international status predicting distress (DI) in their last sessions while controlling for initial DI. Compared to domestic students, the average last session DI was significantly higher among ISCs. Random effects were significant, suggesting that some therapists and centers were more effective in their work with ISCs than others. When the proportion of ISCs seen was accounted into the model, we found a cross-level interaction in which the last session DI differences between ISCs and domestic students were significant for centers seeing a small percentage of ISCs but not for centers with large percentages of ISCs in the caseload. Grounded theory analysis of qualitative data from 11 therapists with international backgrounds revealed therapist and center factors that converged with our quantitative findings. Participants reported adhering to general clinical frameworks when working with ISCs given the lack of training on international competence (which may help explain the effectiveness gap), but also noted nuanced culturally-informed components that likely contribute to more effectively working with ISCs. Findings around center effects were complemented by qualitative results emphasizing systemic representation and engagement with diversity, creative outreach efforts, and administrative/leadership support. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).