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).

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).

The development of a Brief Working Alliance Inventory for clients and therapists using multilevel factor analysis and item response theory in the United States and China.

This study aimed to investigate the multilevel factor structure of the therapist and client versions of the 12-item Working Alliance Inventory-Short Revised (WAI; Hatcher & Gillaspy, 2006) in the United States and China, and to create a three-item brief version (WAI-B3) using multilevel factor analysis (M-FA) and multilevel item response theory (M-IRT). We gathered eight data sets from two samples each in United States and China with a total of 21,623 sessions from 376 therapists and 2,455 clients. M-FA results with the first four data sets (two American and two Chinese) suggested that the 12-item WAI across therapist and client versions, and in both United States and China showed a dominant general WA factor with three specific subgroup factors corresponding to the Goal, Task, and Bond items. We then constructed a three-item WAI-B3 by selecting items 11, 10, and 9 through M-IRT, as the best representative of Goal, Task, and Bond subscales, respectively, for both the therapist and client versions in United States and China. With the other four data sets (two American, two Chinese) to test the WAI-B3, we found adequate multilevel reliability, structural validity, and convergent validity with the original 12-item WAI scores. Multilevel measurement invariance tests provided tentative and mixed support for the equivalence of WAI-B3 between the American and Chinese data sets and between therapist and client versions. We recommend that the WAI-B3 be used in routine clinical practice to track therapy process, and that the WAI-B3 be tested with other client and therapist populations and cultures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and validation of the Barriers to Using Immediacy Scale (BUIS).

Immediacy is a skill therapists use to process the therapeutic relationship in the here and now. Although immediacy has been shown to enhance the therapeutic process, therapists are often reluctant to use it (Hill et al., 2018). In three studies, we developed and tested a measure to assess reasons that therapists avoid using this skill: the Barriers to Using Immediacy Scale (BUIS). In Study 1, 185 North American therapist trainees completed the 45-item pilot measure. Exploratory factor analysis supported a four-factor structure (Concerns About Client Reactions, Concerns About Therapist Reactions, Negative Beliefs About Immediacy, Lack of Skills for Using Immediacy). In Study 2, with an international sample of 352 therapist trainees and professionals, confirmatory factor analyses supported the original four correlated factors model, as well as alternative models. In Study 3, 89 undergraduate students in a helping skills class completed the BUIS at three points during the semester. Students' total barriers and barriers due to a lack of skills decreased, but other perceived barriers did not decrease after training. Across all three studies, predicted correlations of BUIS scores were found with measures of self-efficacy for using immediacy, adherence to different theoretical orientations, communication style, and attachment style. Incremental validity was supported by the association of BUIS scores with measures of open communication and attachment style, after accounting for self-efficacy for immediacy. Limitations and future directions are discussed. (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).

Research evidence on psychotherapist skills and methods: Foreword and afterword.

This article serves as both the foreword and the afterword to the special section of Psychotherapy Research devoted to research reviews of psychotherapist skills and methods: it introduces the interorganizational Task Force that guided the reviews and then features its conclusions. We begin by operationally defining therapist skills and methods and then contrasting them with other components of psychotherapy. Next, we consider the typical assessment of skills and methods and how they are linked with outcomes (immediate in-session, intermediate, and distal) in the research literature. We summarize the strength of the research evidence on the skills and methods reviewed in the 8 articles in this special section and in the companion special issue in Psychotherapy. We end with diversity considerations, research limitations, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work.

Meaning in life measure: a five-Item short form and its measurement invariance across gender, age, and cultural contexts.

OBJECTIVE: The aims of this study were to develop a revised version of the Meaning In Life Measure (MILM; Hill et al., 2019) and investigate its multilevel measurement invariance at the between-person and within-person levels and multi-group measurement invariance across gender, age, and cultural groups. METHODS: We analyzed an international dataset including data from 1600 sessions with 384 clients in five continents (Africa, Asia, Europe, Latin America, and North America) using multilevel item response theory and multilevel factor analysis. RESULTS: We found that the revised 5-item MILM-5 had satisfactory reliability and structural validity with the overall sample. Further, it demonstrated measurement invariance across the between- and within-person levels, and also across gender and age groups. Across representative countries within continents, the MILM-5 had the same overall factor structure but all factor loadings and item intercepts significantly differed across cultural contexts. Implications are discussed regarding the assessment of meaning in life in international clinical settings.

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.

"Picking up the pieces": Patients' retrospective reflections of rupture resolution episodes during treatment.

Objective: Although theorists and researchers have stressed the importance of rupture resolution episodes for successful treatment process and outcome, little is known about patients' retrospective reflections about rupture resolution. Aim: The overarching goal of the present study was to use a mixed-method approach to examine patients' retrospective reflections on the frequency, types, and consequences of rupture resolution episodes and the association between rupture resolution episodes and patients' attachment orientation and treatment outcome. Method: Thirty-eight patients diagnosed with major depressive disorder (MDD) were interviewed, on average three years after termination, about their experiences of ruptures in short-term dynamic psychotherapy. Results: Thirty patients reported having experienced at least one rupture, with patients who showed less improvement in depressive symptoms more likely to report having had a rupture. Ruptures were judged as having been successfully resolved for 13 of these patients; suggesting that patients with a high level of attachment anxiety were less likely to be judged as having had a successful resolution. Patients whose ruptures were successfully resolved with the therapist's help reported better treatment process and outcome than patients whose ruptures were not successfully resolved. Conclusion: Results highlight the importance of hearing patients' perspectives on ruptures, rupture resolution, and treatment outcome.

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).

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).

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).

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).

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).

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).

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).

Who gets to talk: Interruptive behaviors in engager and non-engager intake sessions of psychodynamic psychotherapy.

Objectives: Many clients do not return after intake. We speculated that similarities between therapists and clients in terms of interruptive behaviors would predict whether clients returned after intake (engaged).Methods: Trained judges coded therapist and client interruptive behaviors (interruptions, overlaps of speech, and sentence completions) for one engager (client returned for at least 10 sessions) and one non-engager (client did not return after intake) adult clients for each of 25 doctoral student therapists in individual psychodynamic psychotherapy.Results: Although all interruptive behaviors were infrequent, clients were most likely to return after intake (engage) when they interrupted at about the same amount as their therapists, overlapped less than their therapists, and completed sentences more than their therapists.Conclusions: Interruptions, sentence completions, and overlaps of speech are types of interruptive behavior that appear to have different relational consequences.

"Where is the relationship" revisited: Using actor-partner interdependence modeling and common fate model in examining dyadic working alliance and session quality.

Building on previous studies (e.g., Kivlighan, 2007), we explored the application of actor-partner interdependence modeling (APIM) and the common fate model (CFM) in a multilevel framework to examine the dyadic multilevel associations between therapists' and clients' perceptions of working alliance and session quality. Forty-four therapists and their 284 adult community clients completed measures of working alliance and session quality after every session (a total of 8,188 sessions included in this study). We used APIM to unravel the mutual interdependence between therapist and client perceptions and used CFM to model both the shared and individual perceptions of the therapists and clients. APIM analyses showed that, at the between-session level, therapist and client perception of the session quality each was significantly predicted by the other's perception of the working alliance. At the between-client level, only therapist perception of the session quality was significantly predicted by the client's perception of the working alliance. There were no significant partner effects at the between-therapist level. CFM analyses showed that therapist-client shared perceptions of working alliance significantly predicted their shared perception of session quality at all three levels. In contrast, individual perceptions of working alliance correlated with individual perceptions of session quality for therapists only at the between-therapist and between-session levels, and for clients only at the between-client and between-session levels. Theoretical, methodological, and practical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).