Counseling Center and Therapist Effects on Changes in Suicidal Ideation among College Students Receiving Services on Campus: Comparisons across International Status, Race, Gender, and Sexual Orientation.

OBJECTIVE: Examine center- and therapist-level factors that may impact suicide ideation outcomes for college students with minoritized identities. METHOD: Data were drawn from a 2015-2017 data set collected from 136 university counseling centers that were part of the Center for Collegiate Mental Health. This study used a three-level model in hierarchical linear modeling with clients (Level 1; N = 122,212), clients nested in therapists (Level 2; N = 2,574), and therapists nested in counseling centers (Level 3; N = 120). RESULTS: Racially/ethnically minoritized students were 20%, LGBQ + students were 100% more likely, and women students were 20% less likely to have suicidal ideation at the first session, compared to White, male, heterosexual domestic students. LGBQ + students were 20%, and international students were 50% more likely to have suicidal ideation in the last session, compared to White, male, heterosexual domestic students. Cross-level interactions revealed that when therapists had a higher percentage of international students on their caseload, international students had decreased suicidal ideation. Similarly, when therapists had a higher percentage of male students on their caseload, their male students had decreased suicidal ideation. CONCLUSIONS: Findings from this study support the importance of experience and competence in working with minoritized students, as therapists who had more international and men students on their caseload fared better in decreasing the suicide ideation of respective students. This suggests that continued exposure to the unique challenges faced by particular minoritized groups of college students can enhance the quality of care delivered by therapists.

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).

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.

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).

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).

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).

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).

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.

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 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).

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).

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).

Illustrating systemic change in family therapy: How therapists' and clients' alliance perceptions codevelop over time.

Research showing that caregivers', adolescents' and therapists' perceptions of the therapeutic alliance become more similar over time has not examined conceptual models, like emotional contagion and interdependence, that are theorized to account for this convergence. Objective: We modeled codevelopment in systemic family therapy to examine mutual influence and shared environment processes among the alliance perceptions of youth, caregivers, and therapists. Method: The self-report version of the System for Observing Family Therapy Alliances (SOFTA-s) was administered after sessions 3, 6 and 9-156 Spanish maltreating families and 20 therapists. Results: Using a triadic version of the repeated measures actor-partner interdependence analysis, a random intercepts cross-lagged panel model, we found significant effects of the shared environment and mutual influence in caregivers' and therapists' alliance scores over time, reflecting emotional contagion. Additionally, (i) therapists' alliance scores at session 6 significantly predicted youth alliance scores at session 9, and (ii) therapist alliance at session 6 significantly mediated the relationship between caregiver alliance at session 3 and youth alliance at session 9, suggesting that therapists bridge the caregiver's and youth's perceptions of the alliance. In successful (compared to unsuccessful) cases, therapists' alliance perceptions at session 6 positively influenced caregivers' alliance perceptions at session 9. Conclusion: Therapist's perceptions of the alliance can bridge differences in alliance perceptions of caregivers and adolescents resulting in greater similarity in alliance perceptions over time.

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).

Therapist challenges and client responses in psychodynamic psychotherapy: An empirically supported case study.

In this case study of an adult female client working with a doctoral student female therapist in 85 sessions of individual psychodynamic psychotherapy, we analyzed the antecedents, challenges, and consequences for 53 challenges in the intake and first five sessions, the middle three sessions, and the final three sessions. Within the context of a strong therapeutic relationship and when the client was balanced in being defended as well as open/reflective, the therapist's challenges that were of high quality (deep, clear, empathic, and moderately forceful) were associated with the client becoming more open/reflective. In contrast, when the client was defended (but not open/reflective), the therapist's challenges were of lower quality and were associated with the client becoming more defended and closed off. Thus, both the antecedent client state and the quality of the therapist challenges were associated with the consequences of challenges in terms of the client's response. (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.

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).

Toward a broader understanding of split alliances in family therapy: Adding the therapist to the mix.

To broaden our understanding of a split alliance in family therapy, we investigated the frequencies and correlates of sessions in which therapists, youth, and caregivers reported markedly different perceptions of the alliance. The sample consisted of 156 Spanish families who received Alliance Empowerment Family Therapy (Escudero, Adolescentes y familias en conflicto, 2013) for child maltreatment. Family members and therapists rated the alliance on the SOFTA-s (Friedlander et al., Journal of Counseling Psychology, 2006, 53, 214) after sessions 3, 6, and 9; family members rated their perceptions of treatment progress before sessions 4, 7, and 10. A cluster analysis differentiated sessions with a split adult-youth alliance (27.7%) from a split family-therapist alliance (44.1%), and a balanced alliance (similar ratings across the three perspectives; 28.2%). Client-rated treatment progress was differentially associated with the type of alliance split and the average alliance rating, whereas better posttreatment outcomes (child functioning and family goal attainment) were associated with fewer sessions having either type of split alliance.

Con el fin de ampliar nuestros conocimientos de una alianza dividida en la terapia familiar, investigamos las frecuencias y las correlaciones de las sesiones en las cuales los terapeutas, los jóvenes y los cuidadores informaron percepciones marcadamente diferentes de la alianza. La muestra estuvo formada por 156 familias españolas que recibieron terapia familiar de empoderamiento y alianza (Escudero, 2013) para el maltrato infantil. Los miembros de la familia y los terapeutas calificaron la alianza en el SOATIF-s (Friedlander et al., 2006) después de las sesiones 3, 6 y 9; los familiares calificaron sus percepciones del avance del tratamiento antes de las sesiones 4, 7 y 10. Un análisis de agrupamiento diferenció las sesiones con una alianza dividida entre los adultos y los jóvenes (27.7 %) de una alianza dividida entre la familia y el terapeuta (44.1 %) y una alianza equilibrada (calificaciones similares entre las tres perspectivas; 28.2 %). El avance del tratamiento calificado por el paciente estuvo asociado diferencialmente con el tipo de alianza dividida y la calificación promedio de la alianza, mientras que los mejores resultados posteriores al tratamiento (el funcionamiento del niño y el logro de objetivos familiares) estuvieron asociados con menos sesiones que tenían cualquiera de los tipos de alianza dividida.

Disclosure and nondisclosure of physical health issues in psychodynamic psychotherapy.

In this exploratory study, 54 adult clients seen by 11 therapists in open-ended individual psychodynamic psychotherapy reported about disclosure and nondisclosure of physical health issues (PHI) within psychotherapy. Although clients reported at intake that they had moderately severe PHI, they discussed these issues in therapy only in 12% of sessions, and clients initiated the discussion about these issues nearly 75% of the time. The most frequently disclosed PHI were sleep, weight, illness, and pain. Clients were more likely to disclose if PHI were distressing, related to their mental health, relevant to the psychotherapy process, a priority, and if there was enough time in therapy for discussion. At the client level for disclosed PHI, depth of discussion was associated with client-rated alliance; clients who generally rated the alliance high were those who disclosed about the PHI, initiated the PHI discussion, and were not distressed by the PHI. At the session level, clients rated the alliance higher when they were distressed by the PHI but did not discuss it in depth. For nondisclosed PHI, clients reported a higher alliance if they generally and in particular sessions were not distressed about the PHI. (PsycInfo Database Record (c) 2022 APA, all rights reserved).