Development and validation of an 8-item version of the Real Relationship Inventory-Client form.

OBJECTIVE: To develop and validate a very brief version of the 24-item Real Relationship Inventory-Client (RRI-C) form. METHOD: Two independent samples of individual psychotherapy patients (Nsample1 = 700, Nsample2 = 434) completed the RRI-C along with other measures. Psychometric scale shortening involved exploratory factor analysis, item response theory analysis, confirmatory factor analysis (CFA), and multigroup CFA. Reliability and convergent and discriminant validity of the scale and subscales were also assessed. RESULTS: The 8-item RRI-C (RRI-C-SF) preserves the two-factor structure: Genuineness (k = 4, α = .86) and Realism (k = 4, α = .87), which were correlated at r = .74. CFA provided the following fit indices for the bifactor model: X2/df = 2.16, CFI = .99, TLI = .96, RMSEA = .07, and SRMR = .03. Multigroup CFA showed that the RRI-C-SF was invariant across in-person and remote session formats. The RRI-C-SF demonstrated high reliability (α = .91); high correlation with the full-length scale (r = .96); and excellent convergent and discriminant validity with measures of other elements of the therapeutic relationship, personality characteristics, current mental health state, and demographic-clinical variables. Clinical change benchmarks were calculated to serve as valuable tools for both research and clinical practice. CONCLUSION: The RRI-C-SF is a reliable measure that can be used for both research and clinical purposes. It enables a nuanced assessment of the genuineness and the realism dimensions of the real relationship.

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).

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).

Some directions for research and theory on countertransference.

The topic of countertransference (CT) has been a controversial one over the decades, and its various, often conflicting, definitions have made it difficult to gather clear and consistent empirical evidence about the phenomenon. The growing awareness that CT occurs across theoretical orientations has fueled the need for research on CT, its effects, how it emerges in treatment, and how it can be used to enhance psychotherapy. In this paper, we reflect on three studies published in the special section on CT that we believe advance the field of CT research. We also provide future directions for CT theory and research, including attending to CT definitions and their rationale in empirical studies, striving for methodological diversity, differentiating acute and chronic CT, and continuing to investigate CT management.

Do therapists improve in their ability to assess clients' satisfaction? A truth and bias model.

We used the truth and bias model to examine changes in tracking accuracy and under/overestimation (directional bias) on therapists' judgments about clients' satisfaction. We examined 3 factors of clinical experience that could moderate accuracy: (a) overall level of acquaintanceship with a client, operationalized as treatment length (i.e., less or more time seeing a client), (b) time point in therapy with a specific client, operationalized as session number (i.e., earlier or later in treatment with a client), and (c) order (1st client seen, 2nd client seen . . . last client seen across two years of training in a psychology clinic) in which clients were seen. We conducted a three-level hierarchical linear modeling using data on 6054 sessions, nested in 284 adult clients, nested in 41 doctoral student therapists providing open-ended psychodynamic individual psychotherapy. We found that therapists were able to accurately track client-rated session evaluations with less underestimation (i.e., lower tendency to estimate that clients were less satisfied than they actually were) as they gained experience (both treatment length and client order). Furthermore, therapists exhibited greater tracking accuracy gains over the span of shorter treatments and when working with clients earlier in their clinical training. In longer treatments and with clients seen later in training, tracking accuracy was stable and consistent. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Therapist-client agreement about their working alliance: Associations with attachment styles.

Recent research on attachment in therapy indicates that therapist attachment style is related to therapists' agreement with their clients on the quality of their working alliance (WA; Kivlighan & Marmarosh, 2016). This study builds on these findings by examining how both the therapist's and the client's attachment style may be related to their agreement on the WA. The authors expected that less anxious and less avoidant clients working with less anxious and less avoidant therapists would have higher WA agreement. Using hierarchical linear modeling, they analyzed archival session data from 158 clients and 27 therapists at a community clinic. In terms of overall level agreement (averaged across sessions), therapists and clients significantly disagreed on their WA ratings, with therapists rating the WA lower than did their clients; but there was more therapist-client level-agreement when therapists had relatively less attachment avoidance. In terms of (linear) WA agreement from session to session, the authors found no main effects for either therapist or client attachment style alone, but several significant interactions between therapist and client attachment styles. Session-to-session agreement on the WA was higher when clients and therapist had "matching" (both higher or both lower in attachment anxiety or attachment avoidance) or "complementary" (one higher in attachment avoidance, the other lower in attachment anxiety, or one higher in attachment anxiety, the other lower in attachment avoidance) attachment styles than when styles were noncomplementary. The authors discuss these findings in terms of the attachment-related communication, signaling, and behavior that may be occurring in therapy dyads. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Congruence and discrepancy between working alliance and real relationship: Variance decomposition and response surface analyses.

We examined how congruence and discrepancy in clients' and therapists' ratings of the working alliance (WA) and real relationship (RR) were related to client-rated session quality (SES; Session Evaluation Scale). Ratings for 2517 sessions of 144 clients and 23 therapists were partitioned into therapist-level, client-level, and session-level components and then analyzed using multilevel, polynomial regression and response surface analysis. For both clients and therapists, at all levels of analysis (except the therapist level for therapist ratings), SES was highest when combined WA and RR ratings were high, and lowest when combined ratings were low. For client ratings, discrepancy between WA and RR, at the client and session levels, was associated with greater session quality. Some clients perceived greater session quality when, across all sessions, WA was stronger than RR and other clients perceived greater session quality when RR was stronger than WA. Within clients, session quality was highest when some sessions had a stronger WA than RR whereas other sessions had a stronger RR than WA. These findings are compatible with a responsiveness framework, therapists varied the balance of WA and RR to suit situational demands or needs of different clients. When therapists rated WA and RR the opposite pattern of results emerged; clients perceived greater session quality when therapists' WA and RR ratings, for a session were high and consistent (i.e., no discrepancy between WA and RR). In addition, across all sessions, clients perceived greater session quality when WA and RR ratings were high and consistent. (PsycINFO Database Record

Therapist immediacy: The association with working alliance, real relationship, session quality, and time in psychotherapy.

OBJECTIVE: This longitudinal analysis examined the relationship between amount of therapist immediacy in sessions and client post-session ratings of working alliance (WAI), real relationship (RRI), and session quality (SES). METHOD: Using hierarchal linear modeling (HLM), we disaggregated the variables into within-client (differences between sessions in immediacy) and between-clients (differences between clients in immediacy) components, in order to test associations over time in treatment. Three hundred and sixty four sessions were nested within 16 clients and 9 therapists. RESULTS: When therapists used more immediacy in a session, clients gave higher SES ratings for that session, compared to their sessions with less immediacy (within-client effect). For WAI, it appeared to matter when immediacy was used in treatment. The interaction effect between time in treatment and within-client immediacy revealed that early in treatment, more immediacy in a session was related to lower WAI for that session, whereas later in treatment, more immediacy in a session was related to higher WAI for that session. Another interaction effect was found between time in treatment and between-clients immediacy. Clients with less immediacy in treatment, gave higher SES scores for early sessions, than clients with more immediacy in treatment. CONCLUSIONS: Immediacy has an overall positive effect on session quality, but the time in which it is used in treatment and client characteristics should be taken into account both in practice and research.

Working alliance, real relationship, session quality, and client improvement in psychodynamic psychotherapy: A longitudinal actor partner interdependence model.

We used the Actor Partner Interdependence Model (APIM; Kashy & Kenny, 2000) to examine the dyadic associations of 74 clients and 23 therapists in their evaluations of working alliance, real relationship, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy. There were significant actor effects for both therapists and clients, with the participant's own ratings of working alliance and real relationship independently predicting their own evaluations of session quality. There were significant client partner effects, with clients' working alliance and real relationship independently predicting their therapists' evaluations of session quality. The client partner real relationship effect was stronger in later sessions than in earlier sessions. Therapists' real relationship ratings (partner effect) were a stronger predictor of clients' session quality ratings in later sessions than in earlier sessions. Therapists' working alliance ratings (partner effect) were a stronger predictor of clients' session quality ratings when clients made greater improvement than when clients made lesser improvement. For clients' session outcome ratings, there were complex three-way interactions, such that both Client real relationship and working alliance interacted with client improvement and time in treatment to predict clients' session quality. These findings strongly suggest both individual and partner effects when clients and therapists evaluate psychotherapy process and outcome. Implications for research and practice are discussed.

The therapist, the client, and the real relationship: an actor-partner interdependence analysis of treatment outcome.

The relationship between treatment progress (as rated by both clients and therapists) and real relationship (also rated by both clients and therapists) was decomposed into between-therapist and within-therapist (between-client) effects and analyzed using the actor-partner interdependence model. We reanalyzed a subset of the data, 12 therapists and 32 clients, from Gelso et al.'s (2012) study of brief, theoretically diverse outpatient treatment. Consistent with and extending previous research, clients whose therapists provided higher average levels of client-perceived real relationship across the clients treated by a given therapist had better progress ratings from both themselves and their therapists. Within each therapist's caseload, differences between clients in client- or therapist-rated real relationship were unrelated to either client- or therapist-rated outcome. Clients whose therapists provided higher average levels of therapist-perceived real relationship, across the clients treated by the therapist, had worse progress ratings from the therapists. The results provide additional evidence for the importance of between-therapist differences in therapeutic relationship qualities, both client and therapist rated.

Is training effective? A study of counseling psychology doctoral trainees in a psychodynamic/interpersonal training clinic.

We investigated changes over 12 to 42 months in 23 predoctoral trainees during their externship training in a psychodynamic/interpersonal psychotherapy clinic. Over time, trainees increased in client-rated working alliance and real relationship, therapist-rated working alliance, client-rated interpersonal functioning, ability to use helping skills (e.g., challenges, immediacy), higher-order functioning (e.g., conceptualization ability, countertransference management), feelings about themselves as therapists (e.g., more authentic, more self-aware), and understanding about being a therapist (e.g., theoretical orientation, curiosity about client dynamics). In contrast, trainees did not change in engaging clients (return after intake or for at least 8 sessions), judge-rated psychodynamic techniques in third and ninth sessions across clients (although trainees used more cognitive-behavioral techniques over time in third but not ninth sessions), or changes in client-rated symptomatology. Trainees primarily attributed changes to graduate training, individual and group supervision, research participation, and working with clients. Implications for training and research are discussed.

Love and sexuality in the therapeutic relationship.

We examine sexual and loving feelings, on the part of both the therapist and patient, as they relate to their real relationship, patient transference, and therapist countertransference. Loving feelings (agape) often are part of a strong real relationship and they tend to have a positive effect. Sexual feelings, too, may be part of the real relationship, but they are also often more conflict-based, residing in the transference and countertransference experience. It is deeply important for the therapist to seek understanding of his or her own and the patient's loving and sexual feelings, and to tease apart, as much as possible, the extent to which they are real relationship versus transference-countertransference-based. The patient's loving and sexual feelings toward the therapist need to be explored and understood just as other feelings. Although it is crucial that the therapist seek understanding of his or her own loving and sexual feelings toward the patient, we express serious reservations about the therapeutic value of sharing these with the patient.

To be or not to be immediate with clients: the use and perceived effects of immediacy in psychodynamic/interpersonal psychotherapy.

The purpose of this study was to investigate the use and perceived effects of immediacy in 16 cases of open-ended psychodynamic psychotherapy. Of 234 immediacy events, most were initiated by therapists and involved exploration of unexpressed or covert feelings. Immediacy occurred during approximately 5% of time in therapy. Clients indicated in post-therapy interviews that they remembered and profited from immediacy, with the most typical observed consequences being clients expressing feelings about the therapist/therapy and opening up/gaining insight. Amount of immediacy was associated with therapists' but not clients' ratings of session process and outcome. Therapists focused more on feelings and less on ruptures, and initiated immediacy more often with fearfully than with securely attached clients. Implications for practice, training, and research are offered.

A tripartite model of the psychotherapy relationship: Interrelations among its components and their unfolding across sessions.

The tripartite model of the therapy relationship, which includes the working alliance, real relationship, and transference-countertransference configuration, has been a useful way to conceptualize the complexity of the connection between a therapist and a client. However, little research has focused on the interrelationships between these three components over time. This study sought to replicate the findings of Bhatia and Gelso (2018) by examining the between-person relationships among each of the three elements averaged across all sessions. Additionally, we extended earlier work by examining the within-person relationship between the working alliance, the real relationship, and transference-countertransference with themselves as well as with each of the other elements across sessions. Using 5,931 sessions across 142 clients and 36 therapists, we examined time-ordered associations among the cocreated working alliance, cocreated real relationship, and the therapist-rated transference-countertransference configuration using latent variable dynamic structural equation modeling. Results replicated the findings of Bhatia and Gelso (2018), demonstrating that in one session, the working alliance and the real relationship were positively related, and both the working alliance and the real relationship were negatively related to the transference-countertransference configuration. Regarding the interrelations over time, the findings revealed that the working alliance in the previous session had a significant and positive relationship with real relationship in the current session, and the real relationship in the previous session was related to reduced transference-countertransference in the current session. These findings provide support for complex interrelations among the components over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Attachment theory as a guide to understanding and working with transference and the real relationship in psychotherapy.

Recent decades have witnessed an extraordinary amount of conceptual and empirical work on attachment theory in psychology and psychotherapy. Attachment theory is discussed in the present article as a way of understanding and fostering therapeutic work with 2 other key relationship constructs that have been theorized to be elements of all psychotherapies: client transference and the real relationship existing between the therapist and patient. Fundamental features of attachment, transference, and the real relationship are summarized. Particular emphasis is given to the role of the therapist as a secure base and a safe haven within the real relationship, and to the patient's internal working model as it relates to transference. A case of long-term psychodynamic psychotherapy conducted by the first author is presented to illuminate the 3 main constructs. The case demonstrates both the usefulness of attachment theory and the fact that any single theory cannot explain all of the complex features of a given treatment.

Transference and client attachment to therapist in psychodynamic psychotherapy.

Although there are theorized connections between client transference and their attachment to their therapists (Bowlby, 1969/1982), limited empirical research exists examining their association over the course of psychotherapy. We thus examined the association between positive and negative transference and client attachment to therapist across the course of open-ended psychodynamic psychotherapy for 49 cases with doctoral student therapists and adult community clients who had at least 32 sessions. Using a Bayesian multilevel structural equation model framework, results indicated that client secure attachment increased and avoidant-fearful attachment decreased across the course of psychotherapy. For clients with higher preoccupied-merger attachment at the beginning of therapy, therapists perceived more fluctuation in negative transference over time than for clients with other attachment styles. Implications for research, practice, and therapist training are offered. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The unfolding of the real relationship and the outcome of brief psychotherapy.

This study sought to assess the association of client- and therapist-rated real relationship with each other and with the outcome of brief psychotherapy. It also aimed to determine whether changes over time in perceptions of the real relationship and increasing convergence between clients' and therapists' ratings of the real relationship were associated with outcome. Forty-two clients and their therapists (n = 19) at 2 university counseling centers completed measures assessing the strength of their real relationship after every session of brief psychotherapy. They also completed an outcome measure at the end of treatment. Clients' ratings of the real relationship after the first session, first quarter of treatment, and after all sessions combined related to outcomes. Therapists' ratings of the real relationship at these time points did not relate to outcome. However, increases over time in therapists' ratings of real relationship strength, as well as increasing convergence with clients' ratings of the real relationship, did relate to outcome. Implications for future research and practice are discussed.

The real relationship in a postmodern world: theoretical and empirical explorations.

A theory of the real relationship, including its place in the overall therapeutic relationship, is amplified. The real relationship is seen as a key component of all psychotherapy relationships. It exists from the first moment of contact between therapist and patient, and it deepens as the work progresses. Recently, reliable measures of the real relationship from the therapist's and client's perspectives have been developed, and these measures have demonstrated sound beginning validity. Studies have explored the variables with which the real relationship correlates and have demonstrated significant relationships to treatment progress and outcome. The real relationship appears to be a promising variable for future study, and potentially fruitful directions for such study are noted.

The sister concepts of the working alliance and the real relationship: on their development, rupture, and repair.

Jeremy Safran has presented seminal and widely applicable clinical theory and research around the therapeutic alliance and ruptures in the alliance. We explore areas of agreement with and departure from some of Safran's key conceptualizations on these topics, focusing on overlap and distinctions between two constructs theorized to be fundamentally significant elements of all therapeutic relationships: the working alliance and the real relationship. We share Safran's view that the alliance centrally implicates an emotional bond between patient and therapist, as well as an agreement about the goals of treatment and the tasks needed to attain those goals. We depart from Safran, however, in his belief that the real relationship should be seen as part of the emotional bond of the working alliance. Instead, we argue that the real relationship and the working alliance (including the bond aspect of the alliance) are best viewed as highly interrelated but distinct aspects of the therapeutic relationship. In addition, a distinction is made between the working bond (part of the working alliance) and the personal bond (part of the real relationship). Hence, we examine the concept of rupture in the working alliance, and in the real relationship as well. The nature of ruptures is discussed, as well as what therapists can do to repair them. A more limited definition of ruptures than the broader conception that has evolved in recent years is proposed. It is suggested that, whereas ruptures in the working alliance generally can be repaired to the benefit of the work, ruptures in the real relationship are likely to be more damaging to the treatment.

Editorial introduction.

This editorial discusses the Special Section on New Psychotherapy Treatments. The articles in this section each present individual studies of new psychotherapeutic treatments or literature reviews of research on such treatments. These studies do not meet what currently is viewed as the methodological gold standard for treatment outcome studies in our field. Instead, they generally represent beginning efforts at studying new treatments. They reflect the kinds of studies and reviews that have great heuristic potential, and they also ought to be of value to the psychotherapy practitioner. (PsycINFO Database Record (c) 2010 APA, all rights reserved).