what therapists bring to therapy: an examination of
TRANSCRIPT
i
WHAT THERAPISTS BRING TO THERAPY: AN EXAMINATION OF
THERAPIST EFFECTS ON THE ALLIANCE AND THE CHARACTERISTICS
WHICH BUILD THE THERAPIST-CLIENT ALLIANCE
Katie Wyman, BA (Hons) Psych
A thesis submitted in partial fulfilment of the requirements for the award of the
Professional Doctorate of Psychology (Counselling) by Swinburne University of
Technology
February 2011
ii
ABSTRACT
The therapeutic alliance is well established as an important common factor of
therapies. This thesis focused on the therapists’ contribution to the therapeutic alliance.
Although there has been substantial research into therapists’ factors which relate to
therapy outcome, and the research pertaining to therapist effects on outcome is
developing, there is little research which has focused on the impact of the therapist on
the alliance. Given the association between alliance and therapy outcome it is important
to know what contributes to the development of strong alliances.
This thesis aimed to examine therapist effects on the early client-rated alliance,
as well as on the rate of growth in alliance, as perceived by clients, over the course of
therapy. Thereafter it sought to identify therapist characteristics which explained
difference between therapists with relatively strong or weak early alliances and growth
in these alliances. It was hypothesised that early alliance and growth in alliance would
be associated with therapists’ early maladaptive schemas, attachment style, degree of
mindfulness, experiential avoidance, theoretical orientation, and the amount of
supervision and personal therapy they had received. Furthermore it was hypothesised
that therapists’ and clients’ attachment style would interact such that the early alliance,
and the rate of alliance growth, would be higher when the therapist and client
attachment style was different (i.e. avoidant and anxious), compared to when their
attachment style was similar (e.g. both avoidant). Similarly it was hypothesised that
therapists’ experience and client attachment would interact, such that when clients have
greater attachment insecurity more experienced therapists will have a stronger early
alliance, and rate of growth in alliance, than less experienced therapists.
These hypotheses were examined in a sample of 53 therapists who together
counselled 222 clients attending a university psychology clinic. Analysis was
conducted using multilevel modelling and demonstrated that 15% of the variation on
early alliance scores, and 85% of the variation in linear growth in alliance, was
attributable to differences between therapists. The differences between therapists on
early alliance were not significant and hence an analysis of the impact of therapists’
characteristics on this variable was not undertaken. Several therapist characteristics
explained the significant differences between therapists on alliance growth. The amount
of supervision therapists had received in their career to date was negatively associated
with alliance growth, whereas psychological flexibility and the schema approval-
iii
seeking were positively associated with alliance growth. Therapists’ anxious
attachment, when paired with clients’ anxious attachment, had a deleterious effect on
alliance growth.
This thesis highlights that specific therapist characteristics do influence their
capacity to develop alliances with their clients. Therapists’ experiential avoidance is a
psychological process that is amenable to change and, given its association with
alliance, therapists’ training may be improved by some focus on this. The results
suggest that therapists’ schema and attachment anxiety, which are generally considered
maladaptive, can have a positive effect on alliance. The therapeutic contexts which
allow these vulnerabilities to operate as strengths are discussed. The counterintuitive
result for supervision is concerning given psychologists’ investment in this type of
professional development. Hence there is a pressing need for further examination of the
impact of therapists’ supervision on the alliance. Overall, this research points to the
importance of considering how therapists, alongside clients and therapies, contribute to
the alliance and by association, good therapy outcomes.
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ACKNOWLEDGEMENTS
I am grateful to live at a place and time where questions can be freely pursued and
opportunities for study given. Practically, I’m indebted to the Swinburne University
Tuition Fee Scholarship for financial assistance. Much thanks to my supervisors
Dr. Roger Cook, Dr. Benedict Williams, and Dr. Naomi Crafti who have given me a
space in which I can learn, and helped me navigate unknown territories. The kind and
thoughtful assistance of Denny Meyer is much appreciated.
More personally, I have many people to thank: Mum for believing in me, always. To
Chris, Wendy, James, Harry, Luke, Christine, Kate, Jessica, Julia, Geoff, Felicity and
Mia, for keeping me grounded in the important stuff of life. My friends, for their
ongoing interest and encouragement; for sharing the preciousness, ordinariness,
messiness and richness of our lives. Nicole and Kirsty, for your generous feedback.
Greg, my partner in learning and love. I thank my dad, who left with me a love of
questions and knowledge, and because I know he would be so proud.
Over the past six years I’ve been fortunate to meet my mentors, Ivan, George and
Claire, who shared with me the interiors of the therapeutic relationship. I also want to
thank my colleagues, for thinking, questioning and being in the work with me. And for
their care and humanity in bringing theory to life.
This thesis could not exist without the community of researchers and therapists who
together create a web of ideas that I’m pleased to be a part of. Equally I’m indebted to
the kindness of the clients and therapists who participated in this research.
I hope I may contribute in turn.
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DECLARATION
I declare that this thesis does not incorporate without acknowledgement any material
previously submitted for a degree at any university or education institution or for
publication without due acknowledgement. I further declare that the ethical principles
of the Australian Psychological Society in relation to research have been observed and
all requirements pertaining to the ethics clearance by Swinburne Human Research
Ethics Committee were properly met.
Katie Wyman
October 2010
vi
TABLE OF CONTENTS
ABSTRACT…………………………………..…………………………………… ii
ACKNOWLEDGEMENTS…...…………………………………………………. iv
DECLARATION…………………………………………………………………..v
LIST OF TABLES…………………………………………………………………xii
LIST OF FIGURES………………………………………………………………. xiii
CHAPTER 1: THE THERAPEUTIC ALLIANCE AND THERAPIST
EFFECTS: AN INTRODUCTION TO THE STUDY….. 1
1.1 The Therapeutic Alliance………………………………………………….1
1.2 Therapist Effects………………………………………………………….. 4
CHAPTER 2: THE ASSOCIATION BETWEEN THERAPISTS’
PERSONAL OR PROFESSIONAL CHARACTERISTICS
AND THE ALLIANCE: A REVIEW OF THE RELEVANT
LITERATURE………………………………………….… 9
2.1 Therapists’ Professional Characteristics………………………………... 9
2.1.1 Experience and training………………………………………….. 9
2.1.2 Personal therapy and supervision……………………………….. 13
2.1.3 Adherence and competence………………………………………. 21
2.1.4 Theoretical orientation…………………………………………… 22
2.1.5 In-session behaviour and technique……………………………... 24
2.1.6 Summary: therapists’ professional characteristics……………...26
2.2 Therapists’ Personal Characteristics…………………………….……… 27
2.2.1 Therapists attachment, past and current familial relations and
interpersonal style………………………………………………… 28
2.2.1.1 Interpersonal theory and attachment theory…………… 28
2.2.1.2 Therapists’ attachment style…………………………….. 31
2.2.1.3 Therapists past and current relational experiences…….. 38
2.2.1.4 Therapists’ interpersonal style…………………………... 42
2.2.1.5 Therapists’ Early Maladaptive Schema…………..……...45
2.2.2 Therapists’ personality…………………………………………… 47
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2.2.3 Therapists’ self-awareness……………………………………….. 50
2.2.3.1 Mindfulness……………………………………………….. 51
2.2.3.2 Psychological flexibility…………………………………... 58
2.3 Summary…………………………………………………………………... 59
2.4 The Current Study: Therapist Effects, Therapist Characteristics
and the Therapeutic Alliance……………………………………………. 60
2.4.1 Research aims……………………………………………………... 61
2.4.2 Hypotheses………………………………………………………… 62
CHAPTER 3: METHOD…………………………………………………. 63
3.1 Overview of the Design…………………………………………………… 63
3.2 Sample……………………………………………………………………... 63
3.2.1 Client sample……………………………………………………… 64
3.2.2 Therapist sample………………………………………………….. 66
3.3 Measures…………………………………………………………………... 67
3.3.1 Client measures…………………………………………………… 67
3.3.1.1 Personal demographics…………………………………… 68
3.3.1.2 Working Alliance Inventory - Short Form Revised……..68
3.3.1.3 Attachment Style Questionnaire…………………………. 69
3.3.1.4 Schwartz Outcome Scale…………………………………. 71
3.3.1.5 Depression Anxiety and Stress Scales…………………… 72
3.3.1.6 Inventory of Interpersonal Problems – 32………………. 73
3.3.1.7 World Health Organisation Quality of Life Scale-Brief.. 74
3.3.2 Therapist measures……………………………………………….. 76
3.3.2.1 Personal demographics…………………………………… 76
3.3.2.2 Professional demographics……………………………….. 76
3.3.2.3 Cognitive and Affective Mindfulness Scales – Revised.... 76
3.3.2.4 NEO - Five Factor Inventory…………………………….. 77
3.3.2.5 Acceptance and Action Questionnaire – II……………… 79
3.3.2.6 Counsellor Theoretical Orientation Scale………………. 80
3.3.2.7 Young Schema Questionnaire - Short Form 3………..… 80
3.3.2.8 Attachment Style Questionnaire…………………………. 82
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3.4 Procedure………………………………………………………………….. 83
3.4.1 Client sample……………………………………………………… 84
3.4.1.1 Initial Questionnaire……………………………………… 84
3.4.1.2 Progress Questionnaire…………………………………... 84
3.4.1.3 Final Questionnaire…………………………………….… 85
3.4.2 Therapist sample………………………………………………….. 86
CHAPTER 4: ANALYTIC METHOD…………………………………... 87
4.1 Preliminary Analysis……………………………………………………... 87
4.1.1 Difference between clients with and without therapist data…… 87
4.1.2 Symptomatic improvement over the course of therapy………... 87
4.2 Main Analysis……………………………………………………………... 89
4.2.1 Conceptual considerations……………………………………….. 89
4.2.1.1 Growth model versus last-point carried forward………. 90
4.2.1.2 Anchoring the intercept…………………………………... 91
4.2.1.3 Outliers……………………………………………………..91
4.2.1.4 Sample size………………………………………………… 92
4.2.2 Two-level fully unconditional model…………………………….. 93
4.2.3 Three-level growth models……………………………………….. 93
4.2.3.1 Unconditional model……………………………………… 94
4.2.3.2 Conditional models……………………………………….. 94
4.2.3.3 Three-level conditional growth models with cross-level
interaction terms………………………………………….. 95
CHAPTER 5: RESULTS………………………………………………… 97
5.1 Descriptive Statistics……………………………………………………… 97
5.1.1 Client descriptive statistics for baseline measures and early
WAI scores………………………………………………………… 97
5.1.2 Descriptive statistics for therapist measures……………………. 100
5.2 Data Preparation………………………………………………………….. 106
5.3 Selection of Young Schema Questionnaire-S3 Subscales………………. 106
5.4 Preliminary Analysis……………………………………………………... 107
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5.4.1 Differences between clients with and without corresponding
therapist data……………………………………………………… 107
5.4.2 Symptomatic improvement over the course of therapy………... 109
5.5 Main Analysis……………………………………………………………... 111
5.5.1 Two-level fully unconditional model…………………………..….111
5.5.2 Three-level growth models……………………………………….. 113
5.5.2.1 Unconditional model……………………………………… 113
5.5.2.2 Conditional model………………………………………… 116
5.5.2.3 Three-level conditional growth models with cross-level
interaction terms………………………………………….. 122
5.5.3 Post-hoc analysis………………………………………………….. 126
CHAPTER 6: DISCUSSION……………………………………... 128
6.1 Overview of the Chapter…………………………………………………. 128
6.2 Brief Summary of the Results……………………………………………. 128
6.3 Therapist Effects on the Alliance…………………………………………131
6.3.1 The significance of therapists effects on the alliance…………… 134
6.4 The Impact of Therapists Early Maladaptive Schemas, Psychological
Flexibility, and Supervision on Alliance Development………………..... 135
6.4.1 Therapists’ Early Maladaptive Schemas………………………... 136
6.4.1.1 Description of approval-seeking, unrelenting standards
and self-sacrifice Early Maladaptive Schemas………….. 136
6.4.1.2 The relevance of therapists’ Early Maladaptive
Schemas…………………………………………………… 137
6.4.1.3 Explaining the positive relation between therapists’
Early Maladaptive Schemas and alliance development... 140
6.4.1.3.1 Approval-seeking…………………………………. 140
6.4.1.3.2 Self-sacrifice and unrelenting standards………... 142
6.4.1.4 Summary: therapists’ Early Maladaptive Schemas
and alliance development ………………………………... 145
6.4.2 Psychological Flexibility………………………………………..… 146
6.4.2.1 Psychological flexibility and therapists’ performance..... 148
6.4.2.2 The relevance of therapists’ psychological flexibility to
the alliance………………………………………………… 149
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6.4.3 Supervision………………………………………………………... 151
6.4.3.1 Explanations for the negative association between
supervision and alliance development…..……………….. 152
6.5 Therapists’ Attachment and Alliance Development……………………. 156
6.5.1 The impact of therapists’ attachment, considered in isolation,
on alliance development………………………………………….. 156
6.5.2 The impact of therapists’ attachment, considered with
clients’ attachment, on alliance development…………………… 158
6.5.3 Interpreting these results in light of the published research…... 160
6.5.4 Why might client and therapist attachment interact in their
association with alliance………………………………………….. 162
6.5.4.1 Interpersonal theory……………………………………… 162
6.5.4.2 The alliance as an attachment relationship……………... 165
6.5.4.2.1 The provision of a secure base…………………… 165
6.5.4.2.2 Mentalization……………………………………… 166
6.5.5 Summary: therapists and client attachment and the
alliance…………………………………………………….. 169
6.6 Therapists’ characteristics not associated with alliance development
in the current study……………………………………………………….. 170
6.6.1 Personal therapy………………………………………………….. 171
6.6.2 Experience………………………………………………………… 172
6.6.3 Theoretical orientation…………………………………………… 174
6.6.4 Personality………………………………………………………… 175
6.6.5 Mindful self-awareness…………………………………………… 176
CHAPTER 7: CONCLUSION…………………………………………….178
7.1 Overview of Significant Findings……………………………………...….178
7.2 Overall Implications and Limitations of the Current Study…………... 179
7.3 Final Comments…………………………………………………………... 185
REFERENCES……………………………………………………………………. 186
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APPENDICES
A QUALITATIVE DETAILS OF THERAPISTS’
EXPERIENCE…………………………………………………… 208
B STUDY PROCEDURES……………………………………….… 209
C ETHICS APPROVAL……………………………………………. 230
D CLIENT MATERIALS………………………………………….. 232
E THERAPIST MATERIALS……………………………………... 261
F SCHEMA DESCRIPTIVES……………………………………... 286
G DIFFERENCES ON CLIENT BASELINE MEASURES FOR
CLIENTS WITH OR WITHOUT THERAPIST DATA:
MLM RESULTS………………………………………………….. 287
H SCREENING OF THERAPISTS VARIABLES IN
THREE-LEVEL MODEL: RESULTS………………………….. 293
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LIST OF TABLES
3.1 Organisation of subscales on the YSQ-S3…………………………………. 83
3.2 Client questionnaires………………………………………………………. 85
5.1 Descriptive statistics for client baseline measures………………….……… 99
5.2 Pearson correlations between ASQ subscales for client sample………….... 100
5.3 Descriptive statistics for early WAI-SR ratings………………………….… 100
5.4 Descriptive statistics for therapist measures…………………………….…. 102
5.5 Pearson correlation between ASQ subscales for therapist sample………… 103
5.6 Professional demographic variables for therapist sample………………..… 104
5.7 Correlations between variables measuring therapists characteristics……… 105
5.8 Descriptive statistics for selected YQS-S3 subscales completed by
Therapists……………………………………………………………….….. 107
5.9 Fixed and random effects for two-level MLMs with baseline ASQ
confidence, WHO social, and WAI-SR total as the dependent variable
and DATA entered as a level two independent variables……………..…… 108
5.10 Fixed effects (top) and variance component (bottom) for two-level MLMs
of change in SOS, DASS total and WHOQOL-BREF subscales…….…… 110
5.11 Fixed effects (top) and variance component (bottom) for two-level
MLMs of change in IIP-32 subscales……………………………….…….. 111
5.12 Fixed and random effects for a two-level unconditional model of early
WAI-SR ratings………………………………………………………….… 112
5.13 Three-level unconditional growth model of WAI-SR ratings…….….……. 114
5.14 Three-level conditional growth models for WAI-SR ratings: significant
level three (therapists) independent variables…………………..….…….… 116
5.15 Conditional growth models for WAI-SR ratings with backwards deletion
of therapist contextual variables………………………………….…..……. 120
5.16 Percent increment in modelled variance in the conditional model with
therapist contextual variables………………………………………….…… 122
5.17 Final three-level growth model of WAI-SR ratings with therapist
attachment × client attachment interactions…………………………..….… 124
5.18 Percent increment in modelled variance in the conditional model with
therapist Attachment × Client Attachment Interactions…………………… 125
5.19 Three-level growth model of WAI-SR with therapist experience × client
attachment interactions……………………………………………..……… 126
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LIST OF FIGURES
Figure 3.1 Participant flow chart indicating response rates and excluded
Data………………………………………………………………… 64
Figure 3.2 Categories of employment in the client sample………….………… 65
Figure 3.3 Types of illnesses reported by clients……………………………… 66
Figure 4.1 Two-level multilevel model……………………………….……..… 88
Figure 4.2 Three-level multilevel model…………………………….………… 88
Figure 6.1a Alliance development trajectories of therapists on the 25th, 50th,
and 75th percentile of approval-seeking ……….………………….. 129
Figure 6.1b Alliance development trajectories of therapists on the 25th, 50th,
and 75th percentile of supervision………………………………... 130
Figure 6.1c Alliance development trajectories of therapists on the 25th, 50th,
and 75th percentile of experiential avoidance…. ….………….….. 130
Figure 6.2 Significant correlations between self-sacrifice, approval-seeking,
unrelenting standards and other therapists characteristics
Measured…………………………………………………………… 143
Figure 6.3 Interaction between therapists’ and clients’ anxious attachment on
alliance development………………………………………………. 158
Figure 6.4 Interaction between therapists’ anxious attachment and clients’
avoidant attachment on alliance development……………………... 159
1
CHAPTER 1
THE THERAPEUTIC ALLIANCE AND THERAPIST EFFECTS: AN
INTRODUCTION TO THE STUDY
1.1 The Therapeutic Alliance
What makes therapy therapeutic? This is an important and enduring question. A
seminal study by Luborsky, Singer, and Luborsky (1975) reviewed comparative
treatment research to find no differences in outcomes between the psychoanalytic,
humanistic and behavioural therapies of the time. This supported and reignited interest
in Rosenzweig’s (1936) argument for therapeutic equivalence which he had dubbed
“The Dodo Bird Verdict: everybody has won and all must have prizes” (Hunsley &
Di Giulio, 2002). Rosenzweig argued that psychotherapies are equivalent because
‘common factors’ present in the process and structure of most treatments are responsible
for their effectiveness. While support for the Dodo Bird Verdict is not universal
(Cautilli, 2006; Hunsley & Di Giulio, 2002) many common factors have been proposed.
The alliance between therapists and their clients is considered one of the most
promising common factors (Ackerman et al., 2001; Martin, Garske, & Davis, 2000).
The concept of the alliance can be traced back to Freud, who noted the
importance of the ‘patient’ attaching himself [sic] to the analyst (Horvath, 2005).
Analytic theorists have grappled with the concept henceforth (Hartley & Strupp, 1983;
Horvath, 2006). The term the ‘working alliance’ originated with Greenson (1965), an
analyst who distinguished the working alliance from the ‘real relationship’ and
described it as the patient’s reality-based (i.e. rational, non-neurotic) contact with the
analyst and cognitive capacity to perform the analytic work. It was considered different
from, but equivalent in status, to transference dynamics (Hartley & Strupp, 1983).
Interest in the alliance waned with the introduction of behavioural treatment, then
returned in the 1950’s with Carl Rogers’, and other humanistic and experiential
therapists’ interest in the therapy relationship (Horvath, 2006).
Despite its long history in psychotherapy theory and research there is no agreed
on definition of the alliance (Baldwin, Wampold, & Imel, 2007) and many terms are
used interchangeably including therapeutic alliance, working alliance, therapeutic bond
and helping alliance (Horvath & Bedi, 2002; Martin et al., 2000).
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Like Martin et al. (2000), the term ‘alliance’ is adopted throughout this review to
represent the general construct.
Amongst the various conceptualisations of the alliance, Bordin’s (1979) “the
working alliance,” is the most widely held and used (Baldwin et al., 2007; Crits-
Christoph, Gibbons, & Hearon, 2006; Obegi, 2008) and unlike Greenson’s (1965)
earlier definition, his is considered to be pan-theoretical (Bordin, 1979; Horvath & Bedi,
2002). Bordin’s theory of the working alliance is essentially “the degree to which the
therapy dyad is engaged in collaborative, purposeful work” (Hatcher & Barends,
2006, p. 293). This definition highlights that the working alliance is about the work of
therapy and is interpersonal in nature (Hatcher & Barends, 2006). Bordin outlines three
aspects of the working alliance (1) agreement on the goals of therapy, (2) agreement on
the tasks to be undertaken to achieve those goals, and (3) and a level of trust and
attachment in the relationship appropriate to the work of therapy.
The measurement of the alliance began in 1976 with the development of The
Penn Alliance Scales which were based on a psychodynamic conceptualisation of the
alliance (Elvins & Green, 2008). Since then at least six scales have been developed,
largely based on the conceptualisations provided by Greenson (1965) and Bordin
(1979). Consequently, these alliance scales are highly correlated (Martin et al., 2000).
In psychotherapy research the most extensively utilized scale is the Working Alliance
Inventory (WAI; Martin et al., 2000). Based on Bordin’s conceptualisation, this scale
was developed by Horvath and Greenberg (1989) to provide a pantheoretical measure of
working alliance. Accordingly, it consists of three subscales; goal, task and bond,
designed to measure the three aspects of the working alliance as defined by Bordin.
The operationalisation and measurement of various alliance concepts may
present the alliance in a misleadingly simple manner. Whilst it is beyond the scope of
this thesis, it is important to note that there are many complex and long-held questions
about the alliance which remain topics of theoretical debate (Safran & Muran, 2006).
These include questions about how the alliance develops (Obegi, 2008); whether the
alliance is interpersonal or intrapersonal; how it relates to other relationship processes;
whether it is conscious or unconscious; whether it is rational or transference based; and
whether the alliance is facilitative or an active ingredient of therapy (Horvath, 2006).
Despite this lack of conceptual clarity, empirical research into the alliance has
been extensive and sustained, perhaps because of its positive association with therapy
outcome. Studies consistently demonstrate that stronger alliances are associated with
3
treatment success (Beutler et al., 2004); usually defined as the amelioration of the
clients’ symptoms. Two meta-analyses of those studies correlating alliance and outcome
have found effect sizes of 0.26 (Horvath & Symonds, 1991) and 0.22 (Martin et al.,
2000). Although these effect sizes are considered small to medium they are similar to
the effect sizes of other therapy processes, and this relation between alliance and
outcome has been consistent (Martin et al., 2000). Alliance research has also
established that client ratings are more predictive of outcome than therapist ratings, and
ratings made early in therapy, are more predictive of outcome than later alliance ratings
(Castonguay, Constantino, & Holtforth, 2006; Horvath, 2001; Horvath, 2005).
Recently, alliance research has focused on the pattern of alliance development
(client-rated) revealing stable and linear growth patterns are most typical. Stable, linear
growth (deRoten et al 2004; Kivlinghan & Shaughnessy, 2000) and U-shaped patterns
(Kivlinghan & Shaughnessy, 2000) have been found in very brief (4 session) treatment.
Stable patterns (i.e. beginning and remaining high) and linear growth patterns were
found to account for most client patterns in eight and sixteen-session therapy, however,
rapid improvement and deteriorating curves were also found (Stiles et al. 2004).
Stable and linear growth also accounted for most of the client alliance patterns in
therapies lasting up to 40 sessions, and there was some tentative evidence of a U-shaped
pattern (Kramer, de Roten, Beretta, Michel, & Despland, 2009). In Dinger and
Schauenburg’s (2008) study most inpatient therapy alliance patterns depicted an early
improvement curve, but stable, U-shaped and late improvement patterns were also
evident.
Client-rated alliance patterns have been associated with outcome in all but two
studies (Stiles et al., 2004; Kramer, de Roten, Beretta, Michel, & Despland, 2008).
However the particular pattern which predicts outcome differs between studies. Linear
growth, stable (de Roten et al., 2004) and U-shape (Kivlighan & Shaughnessy, 2000)
patterns have been more predictive of outcome than other alliance patterns in very brief
treatment. Brief V-shaped deflections (also known as sequences of rupture and repair)
related to good outcome in psychodynamic and cognitive behavioural treatments
(Stiles et al., 2004); and, initial improvement or late improvement related to the best
outcome in inpatient treatment (Dinger & Schauenburg 2008). In one of the more
comprehensive studies of alliance patterns and outcomes, linear alliance growth related
to outcome whereas the initial level of alliance, mean alliance, or quadratic growth
(U-shape) in alliance were not (Kramer et al., 2009).
4
The correlational nature of alliance research prevents one from drawing the
conclusion that strong alliances cause good therapy outcome. Other explanations for
this correlation have not been ruled out. For example, symptom improvement could
cause better alliances, or a third variable could be acting on both alliance and outcome
creating a misleading association between alliance and outcome (Crits-Christoph et al.,
2006). These possibilities, while important to note, have been taken up by other
researchers (e.g. Baldwin et al., 2007; Barber, Connolly, Crits-Christoph, Gladis &
Siqueland, 2000; Klein et al., 2003; Puschner, Wolf & Kraft, 2008) and will not be
addressed here. Regardless of why the alliance–outcome association occurs, the
evidence strongly suggests that where therapists and clients share a strong alliance,
therapy outcome is likely to be good. Thus, research examining what contributes to
strong alliances may lead to a better understanding of how to enhance this important
process in therapy. How therapist-related variables may contribute to the alliance is the
particular focus on this review. The importance of considering the therapist as a variable
in therapy process and outcome is underlined by the ‘therapist effects’ research.
1.2 Therapist Effects
As distinct from the common factors research is the “therapist effects” research
which examines the differences between therapists. This is in contrast to treatment
outcome studies which focus on the differences between treatments, i.e. “treatment
effects”. As is delineated below, this research has shown large differences between
individual therapists in terms of client outcomes and ratings of therapy processes.
Ricks (1974) published one of the earliest studies pointing to variability between
therapists’ performance. He compared two therapists treating adolescent boys and
found that the outcomes for one therapist (dubbed “supershrink”) were far superior to
the other therapist (dubbed “pseudo-shrink”). Several subsequent studies have
advanced this finding. For instance, Luborsky and colleagues (1986) re-analysed data
from four treatment outcome studies and found, in each study, statistically significant
therapist effects on clients’ symptom change pre- to post-therapy. Similarly, in a highly
controlled study where therapist effects were minimised through use of a treatment
manual, one therapist achieved significantly better results than others with respect to
client symptom change (Shapiro, Firth-Cosens, & Stiles, 1989). In another sample of
therapists treating clients with substance use disorders or depression some therapists’
5
clients achieved consistently better symptom improvement. As therapists had
equivalent case loads in terms of client symptom severity at baseline, the differences in
outcome can be attributed to differences between therapists (Luborsky, McLellan,
Diguer, Woody, & Seiligman, 1997).
Using much larger samples of therapists and clients than the previous studies,
more recent efforts to estimate therapist effects have used hierachical linear modelling
(HLM). Such a method allows for the analysis of nested data, can tolerate missing data,
and unlike single level regression methods does not require independent observations
(Baldwin et al., 2007). Using this method to analyse data from a sample of highly
trained therapists treating Panic Disorder, Huppert et al. (2001) found 0-18%
(depending on outcome measured) of variance in outcome was due to therapists. More
recently data from the National Institute of Mental Health Treatment of Depression
Collaborative Research Program produced two very different results. Specifically, the
analysis published by Kim, Wampold and Bolt (2006) found 8% of variance in outcome
was attributable to therapists and none of the variance in outcome was attributable to the
type of treatment. In contrast the analysis published by Elkin, Falconnier, Martinovich
and Mahoney (2006a) found none of the variability in outcome was attributable to
therapists. While both papers employed HLM, several commentaries on the papers
suggest differences in the application of HLM may explain the divergent results (Crits-
Christoph & Gallop, 2006; Soldz, 2006). When other like studies are taken into
account, therapist effects on outcome are considered to be small to medium (Crits-
Christoph & Gallop, 2006).
The aforementioned studies of therapist effects utilised data from treatment
outcome studies. It has been widely noted that outcome studies employ methods such as
therapist training, use of manuals, as well as adherence and competency ratings to
reduce the variability between therapists (Beutler et al., 2004; Wampold, 2001).
Naturalistic samples on the other hand contain fewer controls and are likely to contain
greater therapist variability (Crits-Christoph et al., 1991; Wampold & Brown, 2005).
Wampold and Brown (2005) conducted a HLM analysis on a naturalistic sample
of 6156 adults who had received at least six months of psychotherapy from 581
therapists. Therapy was funded by a managed care company who collected outcome
data for all funded clients. Outcome data consisted of the Life Status Questionnaire, a
version of the Outcome Questionnaire-45 (OQ-45; Lambert et al., 2004). Findings
6
suggested that, when clients’ initial symptom severity was taken into account, 5% of the
variance in client outcome could be attributed to the therapist.
Okiishi, Lambert, Eggett, Nielsen and Dayton (2006) collected outcome data
from 71 therapists who had seen at least 30 clients each at a university counselling
clinic. The total number of clients in the sample was 6499 and outcome was measured
using the OQ-45. At baseline therapists’ caseloads were equivalent in terms of initial
client symptom severity. Therapists were ranked according to the degree and speed of
client change. HLM was used to compare the top 10% to the bottom 10% of therapists.
Results showed significant differences between these groups of therapists; top therapists
had significantly more clients recovered or improved and significantly less clients who
had deteriorated compared to their bottom ranked peers. Overall, 4.1% of outcome
variability was due to therapists (Crits-Christoph & Gallop, 2006).
Lutz, Leon, Martinovich, Lyons and Stiles (2007) also used HLM to analyse
naturalistic data from a managed care company. The sample comprised 1,198
psychotherapy outpatients treated by 60 therapists. A number of different outcome
measurements were used and repeated on average six times, providing more reliable
outcome measurement than previous studies (Okiishi et al., 2006; Wampold & Brown,
2005). They found that therapists were responsible for 8% of the variance in client
symptom change across sessions, and 17% of the variance in the rate of client
improvement. It is possible in these naturalistic samples (where clients were not
randomised to therapists), that unaccounted for variables are responsible for the results.
However, results of these naturalistic samples are comparable to those reported in
treatment outcome samples, suggesting that therapist effects on symptom change are in
the order of 4 – 8% and may be larger when the rate of client improvement is
considered.
Therapist effects are best understood in the context of treatment effects, which
are estimated at 1% (Wampold, 2001). Taking this into account, even the conservative
estimate of 4% for therapist effects is substantial and supports Wampold’s (2001)
assertion that the therapist is more significant to treatment outcome than the type of
treatment.
Although there are few studies in this area, there is also evidence that therapists
significantly differ on the strength of the alliance they establish with clients (Dinger,
Strack, Leichsenring, Wilmers, & Schauenburg, 2008). The available evidence,
7
articulated below, suggests therapist effects on alliance are greater than therapist effects
on outcome.
Hatcher, Barends, Hansell, and Gutfreund (1995) found the magnitude of
therapist effects on the alliance depended on who rated the alliance. When the therapist
rated the alliance, variance due to therapists ranged from 20-29% (depending on the
alliance scale used), whereas when the client-rated the alliance, variance due to
therapists was 0% - 6% (again depending on the alliance scale used).
Results also suggest that the magnitude of therapist effects on alliance is related
to who rates the alliance (Hersoug, Hoglend, Havik, Lippe & Monsen, 2009).
Hersoug et al. (2009) measured the alliance over the course of long term psychotherapy
lasting up to 120 sessions. When the therapist rated the alliance there was a significant
difference between therapist perception of the initial alliance but not the rate of growth
in alliance over sessions. When the client-rated the alliance neither the initial alliance
score nor the rate of alliance growth over the course of therapy was significantly
different between therapists. Even though the results for client-rated alliance were not
statistically significant there may have been substantial variation between therapists on
this variable as indicated by calculation of the intraclass correlation coefficient.
Unfortunately they did not report the required parameters for calculation of this statistic.
In their study of trainee therapist–client dyads, Patton and Kivlinghan (1997)
reported variance in alliance ratings between therapist–client dyads was 65%, whereas
variance on alliance between sessions was 26%. Despite randomisation of clients to
trainees, trainees only saw one client each. Thus variability on alliance scores will also
be due to client differences.
The most substantial study of therapist effects on alliance to date has been
undertaken by Dinger, Strack, Leichsenring, Wilmers, and Schauenburg (2008) who
examined therapist effects on alliance and pre- post symptom change. A sample of
2554 clients received individual therapy from 50 therapists during inpatient
psychodynamically-oriented therapy. Patients’ alliance ratings were based on their
relationship with their individual therapist only and ratings were made at the end of
therapy. Therapist effects on patient outcomes varied from 3 –16% depending on the
outcome measured. Therapist effects on patient-rated alliance was a much higher 33%.
Further, the relationship between alliance and outcome also differed between therapists;
in some therapists a strong alliance was associated with positive outcome, for other
therapists the association between alliance and outcome was smaller “or even
8
nonexistent” (Dinger et al., 2008, p. 351). Thus, “even if a positive therapeutic alliance
is generally helpful, exactly how helpful it will turn out to be depends on the therapist”
(Dinger et al., 2008, p. 352). In a later study, also conducted in an inpatient setting,
variance on alliance due to therapist was 6.6% and variance due to clients was 56.3%.
The remaining variance was taken by temporal variation (Dinger, Strack, Sachsse, &
Schauenburg, 2009). These figures are lower than Dinger et al.’s (2008) study as they
are based on a three-level model which included repeated alliance measures.
Caution is warranted when interpreting these studies as clients were not
randomised to therapists. Thus, it is possible that these results are due to differences in
client symptom severity or other influential differences across therapist caseloads.
Recent research has also examined the relative contributions of both the
therapist and client to variability in the alliance–outcome relation. Baldwin, et al.(2007)
analysed data from a sample of 331 clients seen by 80 therapists from 45 university
counselling centres. Outcome was determined by pre-post changes on the OQ-45 and
alliance was measured using the WAI (Horvath & Greenberg, 1989). Using HLM they
found that therapist variability, but not client variability, predicted the alliance-outcome
correlation. Therapists with average stronger alliances had statistically significant better
outcomes than therapists with weaker average alliances.
In conclusion, the therapist effects research suggests that differences between
therapists account for a substantial amount of variance in alliance ratings, therapy
outcome, and the strength of the alliance–outcome association. The importance of the
alliance is underlined by the common factors research which suggests the alliance is
consistently associated with outcome regardless of the type of therapy being delivered.
Given the implications of the alliance and evidence of therapists’ variability in
establishing alliances with their clients, an important research question emerges: if
therapists differ in their capacity to form alliances, what are the characteristics of
therapists who are more effective in this regard? This question is the subject of the
literature reviewed in the next chapter.
9
CHAPTER 2
THE ASSOCIATION BETWEEN THERAPISTS’ PERSONAL OR
PROFESSIONAL CHARACTERISTICS AND THE ALLIANCE: A REVIEW
OF THE RELEVANT LITERATURE
The research regarding the impact of therapist characteristics on the strength of
alliance is now reviewed. Both therapists’ professional characteristics and personal
characteristics are considered. Many authors have noted that while much research has
examined the impact of various therapist characteristics on outcome, comparatively
little has focused on the impact of various therapist characteristics and alliance1
(Ackerman & Hilsenroth, 2003; Bernier & Dozier, 2002; Black, Hardy, Turpin, &
Parry, 2005; Hersoug, Hoglend, Monsen, & Havik, 2001; Horvath & Bedi, 2002;
Ligiero & Gelso, 2002). For this reason, for those therapist characteristics where there
is minimal literature pertaining to alliance, the available literature about therapists’
contribution to outcome is also reviewed. Given the association between alliance and
outcome it is relevant to consider therapists’ contribution to both. The review will focus
on therapists treating adult client populations.
2.1 Therapists’ Professional Characteristics
In the current study, therapists’ “professional characteristics” refer to those
qualities of therapists that are developed in relation to their therapy role or profession.
Specifically, these are therapist experience and training, participation in personal
therapy and supervision, adherence and competence, therapy orientation as well as in-
session behaviour and technique.
2.1.1 Experience and training
Intuitively, one might assume that more experienced therapists, compared to
their less experienced counterparts, would obtain better therapy outcomes and develop
stronger alliances with their clients. Yet, research has called this assumption into
1 Although the contribution of therapist characteristics to the alliance is considered here in isolation the author acknowledges that therapist and client characteristics are “continuously interacting aspects of an immensely complex interpersonal reality” (p. 11; Hick, 2008).
10
question. A number of early meta-analyses have found no association between
therapists’ years of practice and therapy outcomes (Crits-Christoph et al., 1991; Shapiro
& Shapiro, 1982) and that professional and para-professional counsellors obtain similar
client outcomes (Burman & Norton, 1985). Two more recently published meta-
analyses found contrary results. Lyons and Woods (1991) found therapist experience
was significantly correlated with the treatment effects of Rational-Emotive Therapy.
Stein and Lambert’s (1995) meta-analysis showed modest effect sizes for therapist
training level and experience on client improvement. However, the most recent meta-
analysis suggests that neither experience nor training in psychotherapy is related to
therapeutic success (Beutler et al., 2004). Similarly, in recent large studies of therapist
effects, neither therapists’ professional degree or experience has been found to account
for variance in treatment outcomes (Anderson, Ogles, Patterson, Lambert &
Vermeersch, 2009; Okiishi et al., 2006; Okiishi, Lambert, Nielsen, & Ogles, 2003;
Wampold & Brown, 2005).
One study found that the experience – outcome association was moderated by
length of treatment such that more experienced therapists were more effective over a
shorter duration (Burman & Norton, 1985) than less experienced therapists. There is
also limited evidence that therapist experience or training is associated with certain
skills such as greater accuracy in rating the quality of client’s emotional experience
(Machado, Beutler, & Greenberg, 1999) and greater use of interpretation in
psychodynamic therapy (Hersoug, Bogwald, & Hoglend, 2003). Interestingly,
compared to less experienced therapists, those with more experience (defined as number
of clients seen) were less likely to project their response to others onto the client, but
more likely to project their wishes onto clients (Hamilton and Kivlinghan, 2009).
A small number of studies have examined the impact of therapist experience on
the alliance (Dunkle & Friedlander, 1996; Hersoug et al., 2009; Hersoug et al., 2001;
Kivlinghan, Patton & Foote, 1998; Mallinckrodt & Nelson, 1991; Meier, Donmall,
Barrowclough, McElduff & Heller, 2005). Mallinckrodt and Nelson (1991) examined
50 therapist – client dyads from university counselling or training clinics. Clients
completed measures of psychological symptoms prior to therapy, and both clients and
therapists completed the WAI after the third session. WAI scores were compared across
three groups of therapists: novice therapists (graduate students in their first practicum);
advanced trainees (graduate students ranging from their second practicum to internship);
and experienced therapists (full time post-doctoral therapists). Findings showed that,
11
compared to their less experienced peers, more experienced therapists formed greater
client-rated alliances on the goal and task subscales of the WAI. Thus, from the clients’
perspective, experienced therapists become better at collaborating with clients about
their therapy goals and the tasks that are required to achieve them. However, therapists’
experience was unrelated to their capacity to form a bond with their clients. One
explanation for these results is that therapists’ ability to form bonds with their clients is
a capacity they have developed (or not) before entering the profession. On the other
hand, how to collaborate on goals and tasks of therapy is acquired through their
training.
When therapists rated the alliance, a non-linear relationship between bond and
experience was evident. Specifically, advanced trainees rated themselves lower on the
bond and task scales than both less experienced and more experienced therapists.
Perhaps after basic skills are mastered and the therapist graduates from a novice to
advanced trainee level of experience they become more sensitised to weaknesses in the
bond component of alliance. This sensitivity may then resolve with further experience
as therapists become more skilled in forming connections with clients, and responding
to ruptures in the connection. Conclusions are necessarily limited as the range of
experience in this sample was restricted; average experience for the most experienced
therapists was 3.17 years postgraduate.
Meier, et al. (2005) also found the experience–alliance relationship differed
depending on who rated the alliance. Meier and her colleagues examined 24 therapists
treating 187 clients beginning residential drug rehabilitation. Client-rated alliance was
higher when therapists had formal qualifications and when therapists were ex-addicts.
Therapist-rated alliance was higher when therapists had less experience in their current
role. Again, therapists with more experience perceived their alliances as weaker
compared to their less experienced counterparts.
The importance of rater-perspective (i.e. who is rating the alliance), is also
highlighted in Hersoug et al.’s (2001) study. In univariate analysis client-rated alliance
was lower when therapists were more experienced and had more training. However,
such associations disappeared when these variables were entered with therapist personal
variables in a multiple regression, suggesting they did not explain any additional
variance once therapist personal variables were considered. On the other hand therapist
training and therapist skill (as perceived by the therapist), were positively related to
therapist-rated WAI. Experience showed the opposite pattern of associations with
12
therapist-rated alliance compared with client-rated alliance; therapist experience was not
associated with alliance in univariate analysis but became significant when considered
with the other therapist variables in multivariate analysis, suggesting the possibility of
suppressor effects. Not only do these studies suggest that the alliance rater perspective
is important, they also suggest complex relationships between therapists’ experience
and training variables and therapists’ personal characteristics.
In a study of long term therapy (i.e. from 20 to more than 120 sessions)
Hersoug et al. (2009) found that more training resulted in weaker client-rated alliance
level at session 20, 60 and 120 but was unrelated to growth in alliance, whereas
therapist experience was unrelated to client-rated alliance. On the other hand, training
was unrelated to therapist-rated alliance level or growth in alliance, however there
experience had a trend level association with weaker therapist-rated alliance at sessions
20, 60 and 120.
As part of a larger study Dunkle and Friedlander (1996) sampled client-
therapist dyads from university counselling clinics and university training clinics.
Therapists were coded 1 – 6 depending on years of formal training, one point was added
for every year of post doctoral experience. Therapists recruited participants by asking
the next client who reached the 3rd, 4th or 5th session to complete the Working
Alliance Inventory Short form (WAI-S; Tracey & Kokotovic, 1989). In univariate
analysis therapist experience did not significantly correlate with any aspect of the WAI.
Kivlinghan et al. (1998) replicated the Dunkle and Friedlander (1996) study in a
sample of 40 therapist – client dyads from university counselling centres. They
operationalized and measured experience on a continuous scale in the same manner as
Dunkle and Friedlander. Prior to therapy clients completed a measure of attachment
(i.e. Adult Attachment Scale; Collins & Read, 1990) and after their third session they
completed the WAI. Like the original study (Dunkle & Friedlander, 1996) there was no
significant relationship between therapist experience and total WAI scores. However,
in this study clients’ attachment was also considered. Clients with secure attachment
had higher alliance scores compared to those with insecure attachment. Notably, there
was an interaction between client attachment and therapist experience such that when
clients had greater discomfort with intimacy, they formed stronger alliances with more
experienced therapists when compared with less experienced therapists. Thus, it
appears therapist experience has more bearing on the alliance when clients have greater
attachment difficulties.
13
In summary, a great deal of research suggests that therapist experience is
unlikely to be related to therapy outcomes, although a limited amount of research
highlights interactions between therapist experience and variables such as client age and
length of treatment. Overall, the results of the six studies investigating the alliance –
therapist experience association are equivocal with some studies showing a direct
relation between these variables (Mallinckrodt & Nelson, 1991; Meier et al., 2005) and
others not (Dunkle & Friedlander, 1996; Hersoug et al., 2001; Hersoug et al., 2009;
Kivlighan et al., 1998). These studies highlight the divergence in results depending on
rater perspective (client or therapist) and the influence of client attachment as a
moderating variable on the alliance–experience association.
2.1.2 Personal therapy and supervision
Approximately three-quarters of mental health professionals have received
personal therapy (Norcross & Guy 2005) which is considerably higher than the
prevalence of personal therapy in the general population (Norcross, 2005).
Furthermore, studies have shown 59% (Orlinksy & Ronnestad, 2005) and 68%
(Norcross, Geller & Kurzawa, 2000) of therapists engage in multiple episodes of
therapy.
Qualitative studies of therapists’ personal therapists show therapists value their
personal therapy as an aspect of their training as psychotherapists (Grimmer & Tribe,
2001; Macran, Stiles & Smith, 1999; Wiseman & Shefler, 2001). Specifically,
therapists who participate in personal therapy report benefits such as: learning self care;
receiving support during times of difficulty (Grimmer & Tribe, 2001; Macran et al.,
1999) self-development (Macran et al., 1999; Wiseman & Shefler, 2001); developing
the ability to separate their feelings from their clients’ feelings (Grimmer & Tribe, 2001;
Macran et al., 1999) learning about the client role and developing trust and respect for
clients (Macran et al., 1999); learning about the therapist role and therapy process
(Grimmer & Tribe, 2001; Macran et al., 1999; Wiseman & Shefler, 2001) validating
therapy as an effective psychological intervention (Grimmer & Tribe, 2001) and,
deepening their capacity for authenticity and relatedness in their alliance with clients
(Wiseman & Shefler 2001).
It is difficult to generalise these results as therapists who think highly of
personal therapy may be more likely to participate in qualitative research. However,
14
supporting these qualitative results are therapist surveys. A recent review of eight
therapist surveys suggested that 88- 90% of therapists receiving personal therapy find it
helpful and 1%-7% of therapists report negative outcomes (Norcross, 2005). Those
therapists who found therapy helpful reported improvements in “self-esteem, work
functioning, social life, emotional expression, characterological conflicts and symptom
severity” (Norcross, 2005, p. 843). Therapists also highly regard personal therapy as a
training experience and rank it among the top three contributors to professional
development along with client contact and supervision. Professional development that
occurs as a consequence of personal therapy occurs in areas pertinent to the alliance.
For instance results from therapist surveys found that all of the therapists “lasting
lessons” from their personal therapy were about the interpersonal aspects of
psychotherapy, such as:
the centrality of warmth, empathy, and the personal relationship; knowing
what it feels like to be a patient; the importance of transference and
countertransference; the need for personal treatment among therapists; the
inevitable “human-ness” of the therapists; and the need for more patience
and tolerance in psychotherapy. (Norcross, 2005, p. 843)
Quantitative studies have sought to examine whether there is a discernible
benefit of therapists’ personal therapy on client outcomes. Although quantitative
investigation of the effect of personal therapy on client outcomes began over 50 years
ago (e.g. Strupp, 1955), the question has not been satisfactorily answered. The most
recent review concluded that, to date, there is little evidence in the studies to show
personal therapy has a measurable effect on outcome (Macran & Shapiro, 1998).
Nevertheless, quantitative studies indicate that therapists who have received more
personal therapy are less likely to project their wishes onto clients (Hamilton &
Kivlinghan, 2009), have less countertransference (Dube & Normandin, 1999), and
appear warmer, more empathic and genuine (Macran & Shapiro, 1998.)
Studies in this area are few in number (Macran & Shapiro, 1998); many are poor
in quality and none are randomised or controlled (Macran & Shapiro 1998; Norcross,
2005). Orlinsky et al. (2005) suggest that, due to the nature of the variable under
consideration, studies are unlikely to detect an effect of personal therapy on outcome
and it is likely that therapists’ personal therapy has an indirect impact on outcome
through its influence on other interpersonal therapy processes. Similarily, Macran and
15
Shipiro (1998) suggest that future research in this area focus on therapy processes.
Along these lines two published studies have investigated the impact of therapists’
personal therapy on alliance (Gold & Hilsenroth, 2009).
Wheeler (1991) surveyed members of the British Association of student
counsellors treating clients with eating disorders. Therapists were asked to choose a
client to complete the CALPAS, a measure of the alliance. Therapists were also asked
to complete the CALPAS according to how they thought their clients would rate it and
to also complete questionnaires which indicated the degree of therapy, supervision and
training they had received. Bivariate correlations showed personal therapy was
negatively associated with therapist (-.609) and client (-.321) alliance ratings.
Similarly, supervision was negatively associated with therapist (-.215) and client (-.166)
ratings of alliance. In both cases the association was stronger when the therapist, rather
than the client, rated the alliance. This study has several limitations which undermine
its generalizability and utility. First, these results cannot be generalised to clients with
disorders other than eating disorders; second, significance tests were not reported thus
it is not known whether the reported correlations were due to chance; third, given the
therapist response rate was very small (14% agreed to participate, half of whom
returned questionnaires), and no data was available on non-responders, the
characteristics of this sample may differ from therapists more generally; and fourth,
therapists chose the clients to participate which may have led to the selection of
particular types of clients such as those with an strong existing alliance with their
therapist.
Recently Gold and Hilsenroth (2009) reported a quasi-experimental study of the
impact of therapist personal therapy on the alliance formed during a structured three-
session assessment process known as “the therapeutic model of assessment”.
Outpatient clients at a university based community clinic were allocated to two groups
of therapists; those who had not had personal therapy and those who had received
personal therapy. Thirty clients were in each group. The clients in the “no-therapy”
group were selected from a larger pool of clients to match to the 30 clients in the
“therapy group” on age, gender, marital status, primary diagnosis and psychiatric
severity. Therapists were advanced doctoral students trained in short-term dynamic
therapy and were conducting insight-oriented exploratory therapy with clients in the
study. Therapists treated between one and seven clients each. Clients were asked to
complete the Combined Alliance Short Form – patient version (CASF-P) which is based
16
on the WAI, the Penn Helping Alliance Questionnaire and the CALPAS. The CASF-P
produces four subscales: confident collaboration; goals and tasks; bond; and, idealised
relationship. Similarly, therapists completed the therapist version of this scale
(CASF-T), which is scored to create three subscales: shared goals; bond, goal and task
disagreement; and, therapist confidence in treatment. Alliance ratings were made after
the third session in which clients had received feedback from the assessment.
Results showed no significant differences in client-rated alliance between the
therapy and no-therapy groups. However, therapists-rated alliance was higher in the
therapy group. Subscale scores suggested that therapists in the therapy group were
significantly more confident in their ability to help their clients and reported more
agreement on the goals and tasks of therapy than the no-therapy therapists. Such results
are commensurate with qualitative reports. While there were no differences in client
ratings between groups the authors noted that clients in the therapy group had therapies
twice as long as clients in the no therapy group indicating that therapist personal therapy
may be related to client dropout. They also suggested that when clients question the
goals and tasks of therapy or issues of termination arise, therapists who had personal
therapy were more confident and thus better able to address these issues. The authors
suggest that the therapeutic model of assessment may have moderated the differences
between therapist who had or had not had personal therapy. The sample was
homogenous in other ways; all clients rated the alliance highly, clients had only a mild
to moderate degree of distress, and therapists were all advanced doctoral students at a
similar stage of training. Thus, these results cannot be generalised to other early
assessment or therapy processes, more experienced therapists or more distressed clients.
Taken together these studies challenge the assumption that personal therapy is
necessarily beneficial to the alliance. Obviously, with only two studies, further research
is required before conclusions can be drawn.
Over the last twenty-five years there has been an increasing focus on supervision
as an avenue of therapists training (McLeod, 2003; Sterner, 2009). Moreover,
supervision is required for registration in Australian professional bodies for
psychologists, psychiatrists and counsellors. However, like therapy, the research into its
influence on improving client outcomes has produced equivocal findings (Bambling,
2000; Freitas, 2002). While there are well over 30 reviews of supervision (Bambling,
King, Raue, Schweitzer & Lambert, 2006; Ellis, Ladany, Krengel & Schult, 1996), only
a few studies have investigated the impact of supervision on outcome (Bambling, 2000;
17
Holloway & Neufeldt, 1995), and overall they lack methodological rigour (Bambling,
2000; Ellis et al., 1996; Freitas, 2002) to the extent that “the majority of the
investigations of supervision were simultaneously unlikely to detect true effects and
very likely to find spurious significant results” (Ellis et al. 1996, p. 43). Nevertheless,
supervision has been found to positively impact on therapist development in ways that
may lead to improved client outcomes (Bambling et al., 2006). For instance a positive
supervisory relationship increases supervisees’ tendency to adopt observed supervisors’
skills, supervision contributes to basic counselling skill development, increases
supervisees’ confidence and decreases role ambiguity and anxiety (Bambling, 2000;
Bambling et al., 2006). Supervision has been associated with the trainees’ in session
behaviour, interpersonal skills, attitude towards the client, and an ability to implement a
specific treatment and show empathy (Callahan, Almstrom, Swift, Borja, Heath, 2009).
However, negative effects of supervision have also been noted. Henry, Strupp,
Butler, Schacht and Binder (1993) investigated therapist behaviours following one year
of training in a manual-guided form of time-limited dynamic psychotherapy. Training
consisted of small group (four in each group) seminar and supervision. Sixteen
therapists in the study were recommended by senior colleagues. They treated 84
outpatients and had equivalent caseloads in terms of clients’ assessed capacity for
dynamic therapy. Therapy sessions were recorded and sessions three and sixteen were
rated on the Vanderbilt Therapeutic Strategies Scale and Structural Analysis of Social
Behaviour (SASB; Benjamin, 1982).
The SASB is a commonly used yet complex instrument, hence is briefly detailed
here. An assumption underlying the measure is that social behaviour has a basic
structure with certain behaviours associated with each other (Benjamin, 1974). The
measure consists of three surfaces: what is going to be done to or for the other person
(“Other”), what is going to be done to or for the self (“Self”), and intra-personal
behaviour directed towards self (“Introjects”). On each of these surfaces the horizontal
axis represents affiliation (the poles of this dimension are love and hate) and the vertical
axes of represents interdependence (for the Other surface the poles represent dominate
and emancipate; for the Self surface the poles represent submit and to be emancipated).
Each surface consists of 36 behaviours which appear in a diamond shape around the
axis, the behaviours are represented on this two dimensional space according to how
they relate to the two axis, affiliation and interdependence. The Other and Self surfaces
map onto each other such that the behaviour appearing in the same topological location
18
on each surface are thought to be complementary, such that one behaviour invites the
other, e.g. dominate - submit. The introject surface maps onto the Other surface in that
it represents what would happen if the behaviour represented on the Other was directed
towards oneself, e.g. criticise (Other) relates to self-criticise (Introject). The introject is
a psychoanalytic concept which suggests that an individuals’ attitudes towards
themselves is an internalisation (or introjection) of the way they were treated by
significant others (Benjamin 1975). The modern version of this instrument has multiple
forms which are used to measure these surfaces.
Returning to the Strupp et al. (1993) study, SASB and other ratings were
compared for therapists’ sessions prior to and post training. A statistically significant
deterioration in interpersonal and interactional aspects of therapy was also observed.
Specifically, after training, therapists showed an increase in complex communication,
which usually contains embedded criticism. They were also less optimistic, less
supportive of clients’ confidence, spent less time evaluating clients’ feelings, and were
more authoritarian in their behaviour. These results cannot be generalised to
supervision practices more broadly as the supervision provided was part of training in a
specific treatment, however, it does suggest that a simple positive association between
supervision and improvements to therapists’ interpersonal functioning cannot be
assumed.
Further analysis of this data revealed some other effects of supervision.
Therapists who had received supervision from the supervisors who used a more
structured approach (i.e. specific learning tasks and precise feedback) utilised more
time-limited dynamic psychotherapy techniques in their therapies (Henry, Schacht,
Strupp, Butler & Binder, 1993). After training all therapists increased their degree of
adherence to the therapy protocol, however this was more pronounced for therapists
who had less prior supervision than their peers in the study (Henry et al., 1993).
Perhaps therapists become closed to new treatment approaches with supervision. This
study shows the presence and absence of supervision and the type of supervision has
clearly impacted therapists’ professional approach.
There are only a few studies which have investigated the relation between
therapists’ supervision and the alliance. Hilsenroth, Ackerman, Clemence, Strassle and
Handler (2002) compared the alliance ratings of two groups of clients; those treated by
therapists who received four hours (1.5 individual and 2.5 group) of structured clinical
supervision in a therapeutic model of assessment, and therapists receiving four hours
19
(1 individual and 3 group) non-structured supervision in psycho-dynamic eclectic
treatment. Alliance was rated using the CASF-P on the third or fourth session. Results
showed that total alliance score as well as rating of the task and goal subscale was
higher in the group who had received the structured supervision. However results are
confounded as therapists in each supervision group were receiving training in different
models of assessment, thus it is unclear whether the results are due to the differences
between supervision or assessment method.
Bambling et al. (2006) also compared therapists’ performance under different
supervision conditions: skill-focus supervision, process-focus supervision, and no
supervision. They used a sample of volunteer therapists and supervisors who, in
exchange for their participation, were trained in skills or process focused supervision or
the eight-session problem-solving therapy that was used with all clients. Clients with a
primary diagnosis of major depression were recruited through advertising and mental
health networks and were provided therapy free of charge. Therapists were randomly
assigned to clients. The samples of supervisors who provided the skill-focused or
process-focused supervision were matched. Clients rated the alliance (on WAI) and
completed symptom measures at sessions one, three and eight. Results showed that
clients whose therapists were supervised rated the alliance higher, had a greater
reduction in symptoms, rated their therapy more highly, and were more likely to
complete therapy than clients of therapists without supervision. Furthermore, the
positive association between alliance and improvement in symptoms of depression was
stronger in the supervised group. While there were significant differences on client
measures between therapists who were supervised or not supervised there were no
significant differences on variables measured between the skills-focused or process-
focused supervision groups.
The quality of the supervisor-supervisee alliance may also be associated with the
supervisee-client alliance. This was shown in a study of inexperienced trainee
therapists providing four sessions of counselling to volunteer undergraduate clients and
supervised by doctoral students in counselling psychology. Supervisors watched
counselling sessions through a one-way mirror and provided 50 minutes of supervision
after each session. Alliance was also rated after each session, with client-supervisee
alliance rated by clients, and supervisee-supervisor alliance rated by supervisees.
Results showed a linear increase in client alliance scores over time and that the rate of
20
client alliance growth was associated with the rate of supervisee alliance growth (Patton
& Kivlinghan, 1997).
In summary, qualitative and survey research suggests that therapists find
personal therapy useful in enhancing their relationship with their clients. Additionally,
personal therapy has been associated with therapist and therapy processes that are also
likely to have a positive impact on alliance. Two studies have directly investigated this
association. The Wheeler (1991) study showed a negative impact of personal therapy
on the alliance and the Gold and Hilsenroth (2009) study found no difference in client-
rated alliance between clients randomly assigned to therapist with or without personal
therapy. Interpretation of these results is limited. The Wheeler study had several
methodological flaws including a lack of significance testing and a very low response
rate. The Gold and Hilsenroth study was methodologically sophisticated and highly
controlled with all therapists trained in and providing the same therapy. While this
increases the internal validity of the findings, its ecological validity is limited and
cannot be generalised to the effect of personal therapy on client-rated alliance more
broadly.
The status of the research on the relation between alliance and therapists’
supervision is similar to that of alliance and personal therapy. Only three, quite
different, studies exist on the supervision – alliance relation. One shows supervision in
a structured assessment is better than “supervision as usual” in a standard information
gathering assessment approach (Hilsenroth et al., 2002). Another shows supervision is
superior to no-supervision in the problem-solving treatment for depression (Bambling et
al., 2006), and the third shows client-therapist alliance growth is associated with
supervisee-supervisor alliance growth (Patton & Kivlighan, 1997). Taken together they
indicate supervision may positively relate to alliance, however before these results can
be generalised, they would need to be replicated and extended to different treatment
settings as well as different client and therapists populations. Furthermore, these studies
all focus on how current supervision effects current client alliances. However, over the
course of their career, therapists usually participate in many episodes of supervision
with different supervisors and possibly in different therapeutic approaches. The
question of the cumulative effects of past supervision on current client alliances remains
unanswered.
21
2.1.3 Adherence and competence
Adherence and competence are closely related concepts (Barber, Sharpless,
Klostermann, & McCarthy, 2007; Roth & Fonargy, 2005). Adherence is defined as the
degree to which therapists implement treatment according to a treatment manual.
Competence is about how well or skilfully the therapist implements the treatment (Roth
& Fonargy, 2005). A therapist must have adherence to a specified treatment in order to
have competence for that treatment (Barber et al., 2007). Results from research in this
area are equivocal. The results of two research reviews suggest there is evidence of a
relationship between therapist competence and client symptom improvement albeit a
smaller one than might be expected (Barber et al., 2007; Roth & Fonargy, 2005).
However, a recent meta-analysis found no association between adherence and outcome
or competence and outcome (Webb, DeRubeis & Barber, 2010).
Two studies suggest that alliance may have a moderating impact on the
relationships between adherence and outcome, and competence and outcome. In Webb
et al.’s (2010) meta-analysis, studies which controlled for alliance when examining the
competence - outcome relation had statistically smaller effect sizes. Similarly, Barber
et al. (2006) reported, the relationship between adherence and outcome was moderated
by client alliance ratings. When therapists had high alliance scores, their adherence had
little impact on outcome, whereas when therapists had low alliance scores a moderate
level of adherence was associated with better outcomes.
Few studies have focused on the relationship between adherence, competence
and alliance. Therapists’ adherence to CBT or Interpersonal Therapy for the treatment
of bulimia nervosa has been associated with better alliance (Loeb et al., 2005).
Conversely, therapist technical competence in “short-term anxiety-provoking therapy”
was unrelated to alliance (Swartberg & Stiles, 1994) although both alliance and
technical competence were positively related to treatment outcome. Therapist
competence has been found to relate to observer rated therapist warmth and friendliness
(O'Malley et al., 1988), characteristics which are associated with the alliance. Until
further research is conducted the association between alliance and therapist competence
and adherence remains unclear.
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2.1.4 Theoretical orientation
Therapies and the therapists who deliver them, differ on the emphasis they place
on the alliance. In some therapies, such as traditional and contemporary psychoanalysis
(Safran & Reading, 2008; Stolorow, Brandchaft & Atwood, 1995) and gestalt therapy
(Hycner & Jacobs, 1995), the alliance is the cornerstone of treatment. In other therapies
the role of the alliance is to enable the delivery of non-alliance related techniques,
which are considered the active ingredient in the therapy (e.g. CBT). Given this, one
would expect the strength of the alliance may differ between therapists of different
orientations. Furthermore, for therapies where the alliance is the central active
ingredient, one would expect that a weaker alliance would have a greater negative
impact on outcome than for therapies where the alliance is secondary to non-alliance
related techniques.
In both controlled and naturalistic studies of therapist effects, therapists’ self-
ascribed orientation has not accounted for the differences between therapists on therapy
outcome (Anderson et al, 2009; Huppert et al., 2001; Lambert, 2009; Okiishi et al.,
2006; Okiishi et al., 2003; Wampold & Brown, 2005). These studies, however were
not explicitly designed to examine this relationship and did not examine the alliance.
Only one published study to date has shown that therapists of different
orientations differ in the strength of therapist-rated alliance (Black et al., 2005).
Psychodynamic / psychoanalytic therapists rated alliances weaker than humanistic
therapists, cognitive behavioural therapists and cognitive-analytic / integrative
therapists. Psychodynamic therapists, compared to therapists of the other orientations,
also reported more therapist-perceived problems in therapy (Black et al., 2005).
Obviously, little can be concluded on the basis of one study. Furthermore, as discussed
earlier, therapist-rated and client-rated alliances do not tend to have a strong correlation.
Thus, this study is limited in that it only examined therapist-rated alliances. It is
possible that psychodynamic therapists, due to their focus on transference and
countertransference issues may be sensitised to strains or nuances in the relationship
that ultimately results in a weaker perception of the alliance, hence leading to a lower
rating of the alliance than therapists without this focus.
Rather than studying self-ascribed orientation, two studies have considered the
relationship between therapist attitudes about psychotherapy and therapy outcome.
Specific therapist attitudes about the treatment of depression have been found to
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discriminate more effective therapists from less effective therapists (in terms of
symptom reduction). Specifically, more effective therapists had a psychological rather
than a biological orientation, placed less emphasis on medication and expected
treatment to require more sessions before symptoms improved (Blatt, Sanislow, Zuroff,
& Pilkonis, 1996). The Therapists Attitudes Scale (Sandell et al., 2004; Sandell et al.,
2007) was used to measure therapist attitudes. Specifically, they measured what
therapists believe are the curative factors of therapy (i.e. adjustment, insight, kindness),
therapists’ perception of their therapeutic style (i.e. neutrality, supportiveness, self-
doubt) and therapists’ basic assumptions about human nature and therapy (i.e.
irrationality, artistry, pessimism). The sample consisted of 237 clients and 142
therapists. In multivariate analysis, therapists’ attitudes were not associated with
symptomatic improvement during long-term psychotherapy. However, client
improvement at one-year follow-up showed moderate association with therapists’
attitudes. Clients’ improvement was greater when therapists believed kindness to be a
curative factor, assumed therapy is akin to artistry, and perceived themselves as having
a neutral style. The effect of these therapist attitudes on client improvement seem to be
delayed. Studying therapeutic attitudes rather than orientation may enable a finer-
grained understanding of the relationship between therapists’ orientation and the
therapeutic process or outcomes.
Therapists’ orientation is also related to therapists’ personal characteristics.
Psychoanalytic therapists and cognitive behavioural therapists have been found to
significantly differ in terms of their motivational aims, cognitive styles, epistemological
beliefs, interpersonal behaviours and commitment to their chosen orientation (Arthur,
1999). Therapists’ orientation may influence how they emotionally respond to clients’
expressed emotion (Viney, 1994) and has been associated with their personality traits
(Topolinski & Hertel, 2007). Specifically, therapists’ insight (verses behavioural)
orientation is positively associated with the personality trait intuition. Similarly,
therapist “psychoanalytic attitude” is positively associated with the personality
dimensions “openness to experience”, “intuition” and “need for cognition”. The
association between therapist orientation and personality is stronger in therapists further
progressed in their career (Topolinski & Hertel, 2007) suggesting that as therapists
develop their character has greater influence on the orientation they ascribe to.
In summary, there is some early evidence to suggest that (1) therapeutic attitudes
may be associated with client outcomes (2) therapists’ theoretical orientation may relate
24
to the strength of alliance formed, (3) there are meaningful differences between the
personal characteristics of therapists of different theoretical orientations.
2.1.5 In-session behaviour and technique
In-session behaviour and technique refers to how therapists actually behave with
their clients. Such behaviour can be observed and measured from several perspectives
including therapist, client or observers.
Several therapist in-session behaviours are associated with pre-post therapy
symptom change. Analysis of observer-rated data suggests that therapists who relate in
a belittling, blaming, ignoring or neglecting manner, and who also engage in complex
communication (i.e. mixed messages) with their clients, have poorer outcomes than
therapists who refrain from such behaviour (Henry, Schacht, & Strupp, 1990).
Likewise, friendly behaviours have consistently been associated with positive client
outcomes (Beutler et al., 2004).
Similarly, from a client’s perspective, therapists who demonstrate less empathy
are less effective (Lafferty, Beutler, & Crago, 1989). An unexpected finding was that
therapists who perceive themselves as behaving in a supportive manner or see their
clients as involved in therapy were less effective than their peers (Lafferty et al., 1989).
This is converse to the observer-rated data that generally suggests supportive behaviour
improves alliance. Perhaps this reflects a discrepancy between therapists self-
perception of their supportiveness and how others perceive them.
Therapists’ in-session behaviour has also been associated with several
therapeutic processes. For instance, client involvement in motivational interviewing is
associated with observer ratings of therapists’ acceptance, egalitarianism, empathy and
warmth (Moyers, Miller, & Hendrickson, 2005). Interestingly, in the same study, client
involvement was also associated with therapists who were observed to confront, warn
and direct clients. However, this was only the case for therapists who were also
considered interpersonally skilful (Moyers et al., 2005). As one might expect, therapists
who are observed to be rigid in planning treatment, disregarding of the clients aims and
needs, using the client to gratify their own needs, and critical of clients are more likely
to have clients who are observed to be less involved in treatment and show greater
hostile resistance (Marmar, Weiss, & Gaston, 1989). Similarly there is a negative
25
association between clients’ perception of therapists as distracted, tired and bored, and
clients rating of session quality (Saunders, 1999).
Clients’ perception of therapist interpersonal style and its relation to client-rated
alliance has also been studied (De Weert-Van Oene & de Jong, 2006). Clients currently
in substance use treatment (N=83) rated themselves and their therapists on the
Interpersonal Check List – Revised (La Forge & Suczek, 1955). They also completed a
measure of the HAQ (Luborsky et al., 1996), a measure of alliance consisting of two
scales; cooperation and helpfulness. Several elements of clients’ interpersonal style
were related to both aspects of the alliance. However, after the contribution of client
interpersonal style was partialled out, therapist interpersonal style accounted for 26% of
the variance in cooperation and 22% of variance in helpfulness. Client perception of
their therapist as dominant was negatively associated with client ratings of the
cooperation and helpfulness aspects of alliance.
Premised on a review of 24 studies published between 1983 and 2001,
Ackerman and Hilsenroth (2003) concluded that stronger alliances are associated with
therapists who are perceived as behaving in a manner that is “flexible, experienced,
honest, respectful, trustworthy, confident, interested, alert, friendly, warm and open” (p.
28) Therapist techniques associated with a positive therapeutic alliance are exploration,
support, reflection, noting past therapy success, accurate interpretation, facilitating
expression of affect, attending to client experience, affirmation and communicating
understanding (Ackerman & Hilsenroth, 2003). A similar set of therapists’ attributes
and techniques have also been associated with the development of a strong alliance
during assessment interviews and the first session of therapy (Hilsenroth & Cromer,
2007).
Based on a review of six studies Ackerman and Hilsenroth (2001) found that
specific therapist in-session behaviours that harm the alliance were “over structuring the
therapy, failure to structure the therapy, inappropriate self-disclosure, managing,
unyielding transference interpretation, belittling [and] superficial interventions”
(p .182). Therapists who are perceived as “rigid, uncertain, exploitative, critical,
distant, tense, aloof [and] distracted” (p. 182) are also likely to have weaker alliances
with their clients (Ackerman & Hilsenroth, 2001).
With respect to therapist technical activity and alliance, most research has
focused on therapist in-session behaviour and there are consistent findings that certain
in-session behaviours are associated with the strength of alliance. While this research
26
suggests how a therapist behaves with their client is important to alliance, it is limited to
subjective accounts of behaviour and does not shed light on the intra-psychic, personal
characteristics of therapists that impact on the alliance.
2.1.6 Summary: therapists’ professional characteristics
The following conclusions can be drawn from the literature examining regarding
therapist professional characteristics and outcome. One, therapist experience or
theoretical orientation does not seem to be related to client outcomes. Two, therapist
competence and adherence have a small relation to outcome. Three, personal therapy
and supervision have not been demonstrated to influence outcome. Four, the impact of
competence and adherence on outcome may be moderated by the alliance. Five, certain
therapist in-session behaviours, as perceived by therapists, clients or therapy observers,
are associated with outcome.
In contrast, despite limited research examining the relation between therapist
professional characteristics on alliance, significant associations have been found.
Specifically, alliance has been found to be higher in structured supervision compared to
unstructured supervision (Hilsenroth et al., 2002), in clients of supervised therapists
compared to clients of non-supervised therapists (Bambling et al., 2006), and in cases
where the therapist - supervisee alliance was high (Patton & Kivlinghan, 1997). Only
one study (Black et al., 2005) has examined theoretical orientation and found
psychodynamic therapists rated the alliance lower than other therapists. One study
found personal therapy was negatively associated with alliance (Wheeler 1991),
whereas another found no association (Gold & Hilsenroth, 2009). Similarly conflicting
results were found in the two studies of therapist adherence and competence (Loeb et
al., 2005; Swartberg & Stiles, 1994). Alliance has been associated with therapists’
experience in two of the six studies reviewed (Mallinckrodt & Nelson, 1991; Meier et
al., 2005). Obviously it is premature to draw conclusions, as not only is the research in
it’s infancy, but many of the studies are not directly comparable. Replication studies
and studies which extend this inquiry are both warranted. Given the paucity of research
in this area it is interesting that it has illuminated some relationships between these
variables and alliance, albeit in conflicting directions. It is possible that these variables
have a greater impact on therapist processes such as the alliance than therapy outcomes,
and should not be ruled out of future therapy process research.
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2.2 Therapists’ Personal Characteristics
The therapist’s personal characteristics refer to those aspects of the therapist that
are about their personhood, rather than their professional training, role or behaviour.
They are the characteristics that the therapist brings to, rather than receives from, his or
her professional training and work. Since the 1970’s considerable research has
investigated what characteristics of the therapist may impact on outcome (Lambert,
1989, 2009) and a number of therapist personal characteristics have been studied
including, personality, personal adjustment, attitudes, intellectual values, sexual values,
religious commitment and dress (Lambert, 1989). Over the last two decades, however
there has been a reduction in the amount of research and research funding in this area
(Beutler et al., 2004).
A number of large studies, reviews and meta-analysis have been conducted and
concluded that an array of therapist factors are not related to treatment outcome. These
include therapist age, sex (Beutler et al., 2004; Blatt et al., 1996; Dinger et al., 2008;
Huppert et al., 2001; Lambert, 1989, 2009; Okiishi et al., 2006; Wampold & Brown,
2005), race, religion, socio-economic status or marital status (Beutler et al., 2004; Blatt
et al., 1996; Lambert, 1989). Research examining the role of therapist values on
treatment outcome is sparse and inconsistent and there is no consistent or robust finding
about therapists’ personality and therapy outcome (Beutler et al., 2004). The research
indicates that therapists’ level of adjustment, cultural attitudes, as well as dogmatic and
controlling introjects are related to client outcomes in expected directions (Beutler et al.,
2004).
On the basis of these findings Lambert (2009) has recently proposed that it may
be more fruitful to focus research in this area on therapy processes rather than therapy
outcome:
“many attempts to identify client and therapist variables that distinguish
effective from ineffective therapist… have been undertaken and have
produced mixed results. Certainly the ‘empirically unsettled problem’ of
finding viable typing variables for therapist and patient does not exist for
lack of trying… given the mixed results, it must be said that there is little
reason to believe we can succeed at such a task, although it is probably
clear that variables that come directly from the process of therapy… will
provide better answers than those further away from the process…” (p. 83)
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The next section is a review of research investigating the relationship between
therapist personal characteristics and therapy process, specifically the alliance.
Research literature in this area has focused on five types of therapist personal
characteristics: attachment style, quality of current and past familial relationships,
interpersonal style, personality and degree of self-awareness.
2.2.1 Therapist attachment, past and current familial relations and
interpersonal style
Empirical research examining the therapist personal contribution to the alliance
has been largely guided by Attachment theory and Interpersonal theory. These two
theories are recognised as pointing to the centrality of therapist and client interpersonal
style in understanding the therapeutic relationship (Bernier & Dozier, 2002). Before the
results of the empirical literature is presented a brief review of each of these theories,
their therapeutic application and theoretical relevance to therapist personal
characteristics is provided.
2.2.1.1 Interpersonal theory and attachment theory
The basic premise of interpersonal theory is that “personality is developed,
maintained, and best understood within the context of interpersonal transactions”
(Bernier & Dozier, 2002, p. 34). The founder of interpersonal theory, Harry Stack
Sullivan, suggested that interpersonal anxiety, and attempts to minimise it, are an
individual’s basic motivating force (Teyber, 2000). Anxiety is experienced when an
individual is disapproved of or rejected by others. Thus, to minimise anxiety children
learn which of their behaviours elicit or reduce disapproval and rejection, and hence
anxiety (Bernier & Dozier, 2002). This early interpersonal learning develops into stable
self-other relational patterns (Teyber, 2000) which are self-perpetuating as they elicit
confirmatory reactions and responses from others (Bernier & Dozier, 2002).
Interpersonal theory refers to the instances where interpersonal behaviour elicits its
most likely reaction as ‘complementarity’ (Bernier & Dozier, 2002). Complementary
reactions, although not necessarily healthy or adaptive, reduce interpersonal anxiety and
29
can occur through reciprocity (e.g. dominance elicits submission) or correspondence
(e.g. friendliness elicits friendliness; Bernier & Dozier, 2002).
A central aim of interpersonal therapy is the provision of a ‘corrective emotional
experience’ whereby the therapist “disengage[s] from the complementary responses so
as to interact with the client differently than do other significant individuals in the
client’s life” (Bernier & Dozier, 2002, p. 35). Through this process the client develops
more flexible and diverse interpersonal behaviours (Bernier & Dozier, 2002).
Such a theory highlights the potential ways that therapists’ personal
characteristics may affect the alliance. First, therapist-client dyads with dissimilar
interpersonal styles are likely to be more able to engage in non-complementary
responses (Bernier & Dozier, 2002). Second, therapists who are flexible and open in
their adoption of interpersonal styles may be more able to adopt the appropriate style for
each of their clients (Bernier & Dozier, 2002). Third, therapists’ interpersonal style,
influenced by their developmental experiences, may influence the pattern of
interpersonal interaction that they instigate with clients.
“Attachment theory is a theory of the lifespan development of close
relationships” (Daniel, 2005, p. 969). Bowlby (1958, 1959, 1960) and Ainsworth
(1967) developed attachment theory positing that infants develop an attachment
relationship with their caregivers and that attachment relationships involve an
affectional bond to another individual. Such relationships “are characterised by a need
to maintain proximity, distress upon separation, joy upon reunion, and grief at loss”
(Daniel, 2005, p. 969). Attachment figures function as a secure base from which an
individual can venture from to explore the world around them, and return to in times of
distress (Daniel, 2005). The quality of the attachment relationship is formed through
the infant’s experiences with his or her caregivers. Through these experiences the infant
or child develops internal working models (i.e. mental representations) of oneself and
others in attachment related interactions which shape their expectations, perceptions,
feelings and behaviours in ensuing relationships (Bernier & Dozier, 2002; Daniel, 2005;
Main, Kaplan & Cassidy, 1985).
In analysing data from the Strange Situation paradigm in the late 1970’s,
Ainsworth articulated three attachment styles: secure, anxious / ambivalent and avoidant
(Ainsworth, Blahar, Waters, & Wall, 1978; Karen, 1994). Since then, multiple
categorical or dimensional taxonomies of attachment styles have been developed
(i.e. Bartholomew & Horowitz, 1991; Collins & Read, 1990; Hazan & Shaver, 1987).
30
Most recently it has been proposed that two dimensions of attachment underlie existing
self-report measures of attachment and are consistent with dominant taxonomies
(Brennan, Clarke, & Shaver, 1998). These dimensions are attachment anxiety and
attachment avoidance. Attachment anxiety is characterised by an unceasing
doubtfulness about the responsiveness of attachment figures and a strong tendency to
pursue closeness and reassurance. Attachment avoidance is characterised by a
discomfort with intimacy and defensive self-reliance. Both these types of attachment
are called insecure. Secure attachment on the other hand is characterised by individuals
who have positive expectations that others will be available and responsive, and are able
to balance closeness and autonomy (Obegi, 2008). Attachment styles have been found
to be relatively stable (Daniel, 2005) and influence interpersonal behaviour throughout
childhood, adolescence and adulthood (Bernier & Dozier, 2002). Attachment styles are
thought to be self-perpetuating, influencing the individual to interact with others in a
manner which confirms their thoughts, feelings and expectations about close
relationships (Daniel, 2005).
Attachment theory is central to the theoretical frameworks of a number of
discrete therapies (e.g., psychodynamic therapies, mentalization based therapy), and has
influenced thinking about psychotherapy more generally (Wallin, 2007). Regardless of
the type of therapy, a clients’ attachment style will influence how they engage in
therapy (Daniel, 2005) and a client’s attachment style will elicit or “pull for” behaviours
from the therapist which confirm their internal working models (Daniel, 2005).
Therapists informed by attachment theory aim to respond to the client in a manner
which will disconfirm the client’s unhelpful internal working models of relationships
and thus interrupt the model’s continuity (Pistole & Watkins, 1995). Furthermore, as
Bowlby (1988) stated “the therapist’s role is analogous to that of mother who provides
her child with a secure base from which to explore the world” (p. 40). Empirical
research has demonstrated “mothers” capacity to provide a secure base is associated
with their attachment styles (Dozier, Cue, & Barnett, 1994). In light of this, Daniel
(2005) argues that:
...just as the attachment patterns of parents predict their ability to function as a
secure base for their children, the attachment patterns of the therapist would be
expected to predict their ability to establish a secure working relationship with
clients. (p. 976)
31
In summary, according to both Interpersonal Theory and Attachment Theory,
the interpersonal context of therapy is an important component of therapy. By
definition the interpersonal context, of which the alliance is part, is created by both
client and therapist (i.e., co-created). Thus, both the clients’ and therapists’
interpersonal functioning and attachment style may impact upon the alliance. Attention
is now turned to examining the empirical findings about therapists’ contribution.
2.2.1.2 Therapists’ attachment style
In comparison to studies of client attachment and alliance, there are fewer
studies on therapist attachment and alliance (Daniel, 2005) and they have produced
mixed results. Dunkle and Friedlander (1996) published one of the first studies of
therapist attachment and the alliance. As noted earlier, their sample comprised client-
therapist dyads from university counselling clinics and university training clinics.
Therapists were mostly (78%) psychodynamic or eclectic in orientation. Therapists
completed various self-report scales to measure an introject called ‘self-directed
hostility’ (SASB / INTREX), social support (Social Provisions Scale; Cutrona &
Russell, 1987) and attachment (Adult Attachment Scale; Collins & Read, 1990). The
AAS has three scales, “Close” and “Depend” are related to secure attachment and
“anxiety” is related to anxious attachment. Therapists recruited participants by asking
the next client who reached the third, fourth or fifth session to complete the WAI-S.
The analysis showed higher bond scores were associated with less self-directed
hostility, more social support and higher scores on the Close subscale of the AAS.
Thus, the emotional connection between therapist and client improves as therapists are
more comfortable with closeness and intimacy, have a supportive social network and
have less introjected hostility. Although therapists’ social network, introjects and
attachment were related, and they all showed unique association with the bond aspect of
alliance.
Unfortunately, multivariate analysis of the Task and Goal WAI-S subscales was
not reported. However, univariate analysis showed the Close and Depend subscales of
the AAS had moderate positive associations with both Goal and Task subscales. Thus
therapists’ capacity for intimacy and the degree to which they are comfortable
depending on others seems to benefit all aspects of alliance. Also in a univariate
analysis, therapist social support had a moderate positive association with the Goal
32
subscale. Thus, social support seems to have a positive impact on both the bond and
goal aspect of alliance. Whilst the Close and Depend subscales of the AAS were
associated with all WAI subscales, the anxiety subscale on the AAS was not
significantly correlated with any aspect of the WAI in either univariate or multivariate
analysis. This suggests therapists’ anxiety and fears of abandonment in relationships
did not impact on the client-rated alliance.
As stated earlier, introject theory posits that people learn to treat themselves like
important others have treated them (Henry et al., 1990). Thus, a person who has been
treated in a hostile fashion may come to treat himself or herself in the same manner.
Henry et al.’s (1990) study offers an explanation of how the therapists’ introject “self-
directed hostility”, may impact on the alliance. They observed recorded therapy
sessions and found that therapists who had greater self-directed hostility were more
likely to treat their clients in a disaffiliative manner; e.g., belittling, blaming, ignoring
and neglecting. As previously discussed such behaviour is likely to inhibit or impair the
alliance.
In another study therapists’ attachment and personality were both considered in
relation to alliance. Black et al. (2005) sampled 491 therapists from various
professional backgrounds and theoretical orientations, over half of which had more than
10 years post-qualification experience. Therapists completed a battery of tests to
measure attachment (Attachment Style Questionnaire; Feeney, Noller, & Hanrahan,
1994), neuroticism and extroversion (Brief Eysenck Personality Questionnaire) and
alliance (Agnew Relationship Measure – therapist form; Agnew-Davies, Stiles, Hardy,
Barkham, & Shapiro, 1998). The alliance measure was modified for therapists to
provide an average rating of the alliance across their client caseload rather than the
alliance for a specific client as is usually the case. In univariate analysis, extroversion,
neuroticism and all five of the attachment subscales on the ASQ were associated with
alliance. However, when both personality and attachment scales were examined
together only two attachment scales were uniquely associated with the alliance. Secure
attachment was positively related with alliance. Correspondingly, alliance was
negatively associated with preoccupation with relationships; a type of insecure
attachment. Such individuals desire closeness to the point of merger and worry about
being without relationships, being abandoned and others not valuing them. Both the
preoccupied and secure attachment styles were associated with alliance even after the
impact of therapist extroversion and neuroticism where partialled out.
33
This study has several limitations. First, therapists provided an average rating of
alliance, across their caseloads, using an amended scale. Average ratings are likely to
be less precise than ratings of a specific client and while the amended scale showed
good reliability (Cronbach’s alpha = .84) no data is available to evaluate the validity of
this scale. Second, correlations may be inflated by common method variance whereby
the rater of both the alliance and attachment is the same. While the problem of common
method variance is a widespread issue in research (Podsakoff, MacKenzie, Podsakoff,
& Lee, 2003) it seems particularly pertinent here. Theoretically, therapist attachment
style, which could be considered the filter through which they perceive and experience
relationships, is likely to affect the way therapists perceive and thus rate their
relationships with clients. More preoccupied therapists, by definition, are likely to
focus on, or be sensitive to inevitable ruptures and problems in the alliance which may
explain why they rated the alliance as poorer than less preoccupied therapists. Third,
there was a low response rate (36%) coupled with an absence of data about the type of
non-responders. Together these limitations restrict the generalisability of this study.
The results of Fuertes et al.’s (2007) study are contradictory to Black et al.
(2005). In their sample of 59 client-therapist dyads in various outpatient settings,
clients and therapists rated the alliance on the WAI-S. Clients had at least five sessions
prior to completing the WAI-S and the median number of sessions in the sample was
30. Therapists completed the Experiences in Close Relationships Scale (Brennan et al.,
1998), a dimensional measure of anxious and avoidant attachment in romantic
relationships. Results showed a negative correlation between therapist avoidant
attachment and therapist ratings of alliance. Client-rated alliance was not associated
with therapist attachment, however client-rated therapy progress was negatively
associated with therapist’s avoidant attachment and anxious attachment. Therapists’
attachment was unrelated to their ratings of therapy progress. Thus, the importance of
therapist attachment depended on which perspective of the alliance was considered.
A serious limitation of Fuertes et al.’s (2007) study is that therapists chose
which clients to recruit. Several factors may have biased recruitment: therapists may
have been reticent to recruit clients likely to rate the alliance poorly as it might reflect
badly on them; therapists may not have approached clients who they considered fragile
for concern about negative impact of study demands; or therapists may not have
approached clients with weak alliances for fear that this would result in an alliance
34
rupture or therapy termination. Such systematic bias in client selection and the low
response rate (28%) limits the generalisability of the results.
Ligiero and Gelso (2002) found therapist and observer rated alliance was not
associated with therapist attachment. Data was collected from 50 trainee therapists and
their 46 supervisors. Therapists completed a range of measures including a measure of
attachment (Relationship Questionnaire; Hazan & Shaver, 1987). Therapists and their
supervisors completed the WAI-S for one of the therapist’s clients. Therapists’ alliance
ratings were based on their last three sessions with a client who had completed between
three and nine sessions. Supervisors alliance ratings were based on a review of their
supervisees’ audiotaped therapy sessions and supervision. However, it was not
specified that supervisors had to listen to entire tapes. The averaging of alliance over
sessions and potentially incomplete viewing of therapy tapes by supervisors may have
weakened the accuracy of alliance ratings and may explain the lack of association
between alliance and therapist attachment. However, in another study, therapist
attachment has also been associated with observer rated alliance.
Berry et al. (2008) reported the results of a study of 20 mental health clinicians
treating clients with schizophrenia, schizotypal disorder and delusional disorder.
Therapists completed an unpublished attachment scale (based on existing measures of
attachment). Alliance ratings were made by an observer and were based on a five-
minute recorded interview where therapists talked about their thoughts and feelings
about the client. Results suggested that therapists with lower attachment anxiety have a
more positive relationship with their clients, whereas therapists with lower attachment
avoidance were more accurate judges of their client’s interpersonal problems (on the
inventory of interpersonal problems). Berry et al., noted that the specific alliance rating
method utilised could easily be influenced by social desirability demands.
Interpretation is further limited by the use of an unpublished attachment scale. These
methodological limitations restrict what conclusions can be drawn, however, they are
consistent with the finding Black et al., (2005), and thus lend support to the hypothesis
that therapists’ anxious attachment influences the strength of alliance.
Like others Tyrrell, Dozier, Teague and Fallot (1999) also found mental health
case managers’ attachment to relate to client-rated alliance. Additionally they
considered the interaction between case manager and client attachment. They collected
data from a sample of 21 mental health case managers and 54 of their clients who they
had worked with for at least six months. Clients had a range of serious mental illnesses
35
such as psychosis, mood disorders and comorbid substance abuse. Clients rated the
alliance on the WAI. Both case managers and their clients completed a range of therapy
outcome measures. They also completed the Adult Attachment Interview, which was
scored to provide an index of de-activating or hyper-activating attachment styles.
Individuals with deactivating attachment tend to minimise the importance of early
attachment relationships and maintain interpersonal distance (i.e. avoidant attachment),
whereas individuals with hyperactivating attachment tend to be preoccupied with
attachment relationships (i.e. anxious attachment). Results suggest that client and case
manager attachment interact to affect both alliance and outcome. Specifically, less
deactivating case managers had stronger alliances with clients who were more
deactivating. The reverse was also the case; more deactivating case managers had
stronger alliance with clients who were less deactivating. The same combination of
therapist and client attachment style also related to greater improvements in clients’
quality of life. Thus, better alliances and outcomes occurred when client and therapists
had different attachment styles. However, a study by Romano, Fitzpatrick and Jensen
(2008) found interactions between therapist and client attachment and the alliance
produced different results.
They studied client-therapist dyads with volunteer clients and masters students
completing their first practicum. Both clients and therapists completed the Experience
in Close Relationships Scale. Clients also completed the WAI and a range of outcome
measures each session. The effects of therapists’ and clients’ attachment avoidance and
attachment anxiety on mid therapy (session 5-9) client-rated alliance was analysed with
hierarchical linear regressions. Neither therapist attachment anxiety or attachment
avoidance was associated with alliance ratings. Furthermore, the interaction between
client and therapist attachment anxiety and avoidance was not significantly associated
with the alliance. The different results produced by Tyrell et al. (1999) and Romano et
al. (2008) may be a result of either different samples (case managers versus students) or
different scales (interview versus self-report).
Sauer, Lopez and Gormley (2003) simultaneously examined client and therapist
attachment and growth in alliance over sessions. They collected data from 13 therapists
seeing 17 clients at university or community counselling centres. Therapists were
currently completing their training; 76% had less than five years experience. Therapists
who agreed to participate in the study were asked to recruit one or more of their new
clients whom they expected to see for more than seven sessions. Therapist and clients
36
completed a measure of attachment (Adult Attachment Inventory; Simpson, 1990) and
alliance (WAI) after session one, alliance ratings were also obtained after sessions four
and seven. Contrary to previous studies, therapist anxious attachment showed a
significant positive association with client-rated alliance after the first and fourth
sessions (but not seventh). Furthermore, therapists’ attachment anxiety explained a
substantial amount of the variation between alliance ratings. When the change in
alliance over time was considered, therapist attachment anxiety was associated with a
greater decline in alliance scores from the first to seventh session. Client attachment
was not associated with alliance scores in any analysis. In their explanation of these
unexpected findings, Sauer et al., (2003) suggest: “anxious therapists are better at
perceiving variation in others and responding differently depending on the needs of the
other person because they are highly invested in establishing connections” (p. 379). It
appears, however, that the initial benefit of such as style on establishing an alliance may
wear off, or become a negative influence over time.
There are several limitations noted by the authors including a small sample size
and the absence of data about the characteristics of the client sample. Generalisability
is also limited as the therapists chose which clients to invite at intake. Potentially,
therapists may have systematically screened out particular clients (e.g. those judged
from intake information as difficult, fragile, or unlikely to participate).
Recently, Dinger et al. (2009) also examined the impact of therapist attachment
on alliance growth. Similar to Sauer et al. (2003) a naturalistic design was employed
and attachment was measured using the Adult Attachment Interview. Two dimensions
of therapists’ attachment were examined: secure-insecure and dismissive-preoccupied.
Alliance was rated by the client on the HAQ after every session. Dinger el al. also
collected data on clients’ interpersonal style using the Inventory of Interpersonal
Problems (IIP). The mid-treatment alliance level, linear alliance development and
quadratic (U-shaped) alliance development was examined using HLM.
Results showed clients, on average, had a significant linear alliance
development. The mid-treatment level of alliance and rate of growth in alliance
significantly differed between clients and between therapists. Client interpersonal
problems were associated with the mid-treatment alliance and curvilinear growth at a
trend level of significance (i.e. p <.10). Most therapists in the sample had a secure
attachment style. Nevertheless, therapists’ attachment was significantly associated with
alliance such that less preoccupied (i.e. more dismissive) therapists had a higher mid-
37
treatment level of alliance and inverted U-shape alliance development, however this
latter finding was only at trend level of significance. When clients’ interpersonal
problems and therapists’ attachment were considered together they were found to
interact. With clients who had a greater level of interpersonal problems, more
preoccupied therapists had an inverted U-shaped alliance. Thus, the effect of therapist
preoccupation differed depending on the level of clients’ interpersonal problem to the
degree that it changed from a U-shape to an inverted U-shape with clients who had a
low or high degree of interpersonal problems respectively. Therapists’ attachment
security was not related to alliance scores.
A number of criticisms of this study have been made including the few
statistically significant findings given the number of analysis conducted, that those
findings that were significant were generally weak (Silberschatz, 2009), and the poor
generalizability of findings to other treatment settings given the highly resourced and
intensive treatment program where the study was conducted (Holmes, 2009).
To summarise, of the studies reviewed above, five have found associations
between therapist attachment and client-rated alliance (Dinger et al. 2009; Dunkle &
Friedlander, 1996; Sauer et al., 2003), observer-rated alliance (Berry et al., 2008) or
therapist – rated alliance (Black et al., 2005; Fuertes et al., 2007). Yet three found no
association between therapists’ attachment and observer- or therapist-rated alliance
(Ligiero & Gelso, 2002) or client-rated alliance (Fuertes et al., 2007; Romano et al.,
2008). Four studies have examined the interaction of clients’ and therapists’ attachment.
One showed an interaction between therapists’ attachment and client attachment (Tyrell
et al., 1999), another found and interaction between therapists’ attachment and client
interpersonal problems (Dinger et al., 2009), however two failed to find any such
interactions (Romano et al., 2008; Sauer et al., 2003). It is difficult to integrate these
results. While alliance has been rated variously from client, therapist and observer
perspectives, differences in alliance perspective do not explain the contradictory results.
Another layer of complexity is that these nine studies have used seven different
interview or self-report measures of attachment. Whereas the AAI is an indirect
measure of unconscious attachment representations, self-report scales measure the
conscious attitudinal and behavioural aspects of attachment. Furthermore, within the
array of self-report measures available, some measure overall relationship quality
whereas others focus on a specific relationship. Some emphasise past relationships
38
whereas others are focused on current, adult relationships (Stein, Jacobs, Ferguson,
Allen & Fonagy, 1998).
Considering the studies that found a positive association between therapist
attachment and alliance, the particular type of therapist attachment found to associate
with alliance differs between studies. One study found attachment security is positively
associated with the alliance (on AAS) whereas anxious attachment is not significantly
related (Dunkle & Friedlander, 1996). Another also showed a positive association for
secure attachment (on AAI) and negative association for anxious attachment (Black et
al., 2005). For the two remaining, one uncovered a significant negative association with
attachment anxiety (on an unpublished scale), but not attachment avoidance (Berry et
al., 2008), whereas another showed a negative relationship with attachment avoidance
(on ECR) but not anxiety (Fuertes et al., 2007) for therapist but not client ratings.
Conversely, Sauer et al. (2003) uncovered a positive association between attachment
anxiety (on AAI) and initial alliance ratings, but a negative relationship between anxiety
and growth in alliance.
Various methodological problems of these studies have been noted and include
small sample sizes, low response rates, non-random selection of participants, poor
definition of sample characteristics, and measurement problems such as common
method variance, use of scales with inadequate testing of psychometric properties, and
averaging of alliance ratings across therapist caseload. While therapist attachment has
been found to relate to the alliance in some studies, further, more methodologically
sound research is required before conclusions on this matter can be made.
2.2.1.3 Therapists’ past and current relational experiences
As detailed in the previous section, therapist introjects have been associated with
client-rated alliance (Dunkle & Friedlander, 1996). Both introjects and attachment
styles are formed in early relationships with caregivers (Ainsworth et al., 1978;
Henry et al., 1990). Potentially, a therapist’s history of relational experiences, through
association with attachment and introjects or otherwise, may impact on the alliance. A
number of studies have investigated this possibility.
Hilliard, Henry and Strupp (2000) analysed data from the Vanderbilt II study, a
large trial of the effects of time limited dynamic psychotherapy in an outpatient sample.
Clients received 25 weekly sessions of psychotherapy and completed a range of
39
symptoms measures and three sections of the SASB/INTREX questionnaire which
provided a measure of: introjects; early parental relations (relationship with each parent
between the ages of 5 and 10); and interpersonal process (an alliance measure).
Therapists also completed the early parental relations and interpersonal process sections
of this questionnaire. A recording of the third therapy session was also rated for
interpersonal process by an observer using the SASB.
Based on interpersonal theory, Hilliard et al. (2000) hypothesised that clients’
early parental relations will impact on the alliance and the alliance will relate to
outcome. It was also hypothesised that clients’ early parental relations will have a
direct association with treatment outcome such that clients with poorer early relational
experiences will have poorer outcomes regardless of the alliance. Therapists’ early
parental relations were also expected to be associated with alliance if therapists had not
adequately dealt with their personal problems during their psychotherapy training.
Therapists’ early parental relations however, were not expected to directly impact on
therapy outcome. It should be noted here that interpersonal theory draws from
psychodynamic traditions, and in such traditions personal therapy is integral to
therapists’ training.
The results of the study supported Hilliard et al.’s (2000) hypothesis. Client and
therapist-rated alliance was associated with outcome after the effects of client’s early
parental relations were partialled out. Outcome was also associated with client early
parental relations, but not therapist early parental relations, after alliance was controlled.
Clients’ early parental relations were significantly correlated with client-rated
(but not therapist or observer-rated) alliance. The converse was also found; therapist
early parental relations were significantly correlated with therapist-rated (but not client
or observer-rated) alliance. In both cases, disaffiliative early parental relations were
associated with poorer alliance ratings.
Hilliard et al. (2000) suggest that, despite the extensive training that therapists
involved in this study had received, it was not enough “in correcting the impact of their
own interpersonal histories on their psychotherapeutic work” (p. 130). It should be
noted that therapists’ interpersonal histories were only associated with their therapist
rated alliance. As articulated earlier, the common rater perspective may account for the
relation between these variables. A third variable, common to the therapist, may be
responsible for both therapists’ recall of their interpersonal histories and therapist
perception of the alliance.
40
While Hilliard et al. (2000) intended their study to be a test of interpersonal
theory, the results can also be looked at through the lens of attachment theory. For
instance, therapists with poorer early parental relations are likely to have had insecure
attachment which, if continued into adulthood, may negatively impact on alliance
formation and maintenance.
The results of two further studies suggest that therapist current parental relations
may also impact the alliance. Lawson and Brossart (2003) examined a sample of 20
therapist- client dyads. Therapists were completing their advanced practicum for a
Doctoral degree in counselling psychology. Clients were selected on the basis of being
the next client assigned to the therapist. Clients completed the WAI at sessions three,
seven and termination in addition to several outcome measures. Therapist completed
the Personal Authority in Family Systems Scale (PAFS; Bray, Williamson, & Malone,
1984) which provides a measure of current intergenerational fusion/individuation,
intergenerational triangulation and personal authority. Intergenerational fusion refers to
the degree to which an individual is undifferentiated from their family.
Intergenerational triangulation refers to the engagement of a third party to reduce the
tension between two people. Personal authority involves capacity for independent
thinking and behaviour, self-responsibility, capacity for intimacy and, ability to
establish clear boundaries (Bray et al., 1984; Nichols, 2006). The achievement of
personal authority in the family system is conceptualised as a developmental task which
occurs between ages 35 and 45 years (Bray et al., 1984).
In standard multiple regression analysis personal authority accounted for 38%
and 27% of variance in WAI scores in the third and seventh session respectively.
Fusion accounted for 18% of variance of WAI in the third session. Triangulation
accounted for 38% of variance in WAI at the seventh session and at termination. Thus,
there was a significant association between several aspects of therapist current family
relations and the clients’ perception of the alliance. Interestingly, both unhealthy
parental relations (fusion and triangulation) and healthy parental relations (personal
authority) were positively associated with alliance. This is similar to results from van
Walsum, Lawson and Bramson (2004) who found student physicians’ current family
triangulation (measured on PAFS) was positively related to alliance formed during a
mock client interview. However, consistent with Hilliard et al. (2000), Lawson and
Brossart (2003) did not find an association between therapist-parent relations and client
treatment outcome.
41
Unlike Hilliard et al. (2000) who reported that problematic early parental
relations had a deleterious effect on the alliance, the findings of both (Lawson &
Brossart, 2003; van Walsum et al., 2004) suggest that problematic current therapist
parental relations may have a positive effect on alliance. Several other studies have
produced similar counterintuitive findings. Trainee therapists rated by their supervisors
as effective perceived their early interactions in their family environment less positively
(on the perceived early childhood family influence scale) than trainees rated as less
effective (Watts, Trusty, Canada, & Harvill, 1995). Similarly, lower perceived
healthiness in current family of origin (on family of origin scale) of novice therapists
was related to higher pre-training skills in interpersonal facilitation (Wilcoxon, Walker,
& Hovestadt, 1989).
Interpreting their results, Lawson and Brossart (2003) suggest “the combination
of therapists’ over-connectedness and autonomy with parents creates a substrate that
influences therapists’ interaction with others” (p. 391). Their analysis, however, did not
test whether there was an interaction between personal authority and fusion or
triangulation, thus at this point their explanation remains speculative. Limitations in
their study include a small sample and potential problems with the validity of the PAFS
scales (Lawson & Brossart, 2003; van Walsum et al., 2004). It is also possible that
there is a non-linear relationship between current therapist-parental relations and
alliance. For instance, therapists with a moderate degree of current or historical
dysfunction in their relationship with their parents might create a stronger alliance than
those with high or low dysfunction in their current or historical parental relations.
Compared to therapists with little or no dysfunction in their parental relations, therapists
with moderate dysfunction, may be more sensitised to, or experientially knowledgeable
about, the types of interpersonal problems that their clients might face. Yet the
dysfunction is not so high as for it to overwhelm the therapist or be difficult to contain
in their professional role. The means for the PAFS are not reported in the
aforementioned studies thus the levels of therapist- parental dysfunction in these
samples are not known. Such speculations may account for the results of Lawson and
Brossart, and van Walsum et al. (2004) however they do not explain why early
therapist-parent relations have a deleterious effect on alliance, in contrast to current
therapist-parent relations having a beneficial impact on the alliance. This may be due to
methodological and sample differences in these studies.
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Both attachment theory and interpersonal theory propose that one’s attachment
style or introjects will influence their interpersonal style (Bernier & Dozier, 2002).
Indeed, Haggerty, Hilseroth and Vala-Stewart (2008) demonstrated that a secure
attachment style has significant negative correlations with seven of the eight
interpersonal problems measured on the Inventory of Interpersonal Problems. Both
anxious and avoidant attachment styles had large positive associations with the
interpersonal problems: vindictiveness, coldness and social inhibition. Avoidant
attachment was also negatively associated with dominance. Like therapists’ current
and early relational experiences and attachment style, it is possible that therapist
interpersonal style is also associated with alliance. A limited amount of research has
examined this and will now be addressed.
2.2.1.4 Therapists’ interpersonal style
Two studies in the Norwegian Multisite Study of Process and Outcome in
Psychotherapy research examined the association between therapists’ interpersonal
problems and alliance. Interpersonal problems were measured using the IIP, a widely
used scale that yields two dimensional scores: control (dominance - submission); and,
affiliation (cold - friendly). In the first study Hersoug et al., (2001) examined the
association between IIP scores and alliance ratings made in the third and twelfth
sessions and also took into account therapists’ experience, early bonding with parents,
introjects and therapist-client values similarity. In the second study Hersoug et al.
(2009) examined the association between therapists’ interpersonal style and alliance in
the 20th, 60th and 120th session as well as growth in alliance in long term therapy.
Therapists’ early bonding with mothers and training experiences were also considered.
Clients enrolled in the study were engaged in mostly open-ended psychodynamic
therapy. In both studies therapists’ scores on IIP – cold were negatively associated with
client-rated alliance in the 12th (Hersoug et al., 2001), 20th, 60th and 120th sessions
(Hersoug et al., 2009). However, therapists’ scores on the IIP-cold scale were not
associated with client-rated alliance on the third session in the 2001 study.
When therapists rated the alliance IIP-cold this was negatively associated with
12th session alliance in a univariate analysis. However, unlike its association with
client-rated alliance, it was not significantly associated with the alliance once therapists’
experience was controlled in a multiple regression. IIP-cold was not associated with
43
third session therapist-rated alliance. The results for the 2009 study showed IIP-Cold
was related to a lower level of therapist-rated alliance in the 20th, 60th and 120th
sessions and was associated with a negative alliance development at a trend level. This
suggests that not only does therapists’ interpersonal coldness relate to a lower level of
alliance at particular time-point, but it is also associated with an overall decline in
therapist-rated alliance. Perhaps therapist alliance ratings are not affected by IIP –cold
until well into therapy (i.e. session 20 onwards but not session 3 or 12).
The variable “early bonding with parents” (mother and father) also showed
different associations between early and later alliance ratings and differed depending on
who rated the alliance. In univariate analysis early bonding with mother and father
showed a positive association with client-rated alliance at session 12. However, it
explained no additional variance on WAI score when therapists’ experience,
interpersonal style and introjects were controlled. Interestingly, warm parental bonding
with mother remained significantly associated with therapist-rated session three alliance
after these other therapist characteristics were controlled. In the 2009 study early
bonding with mother (not father) was measured and this showed a positive association
with client-rated alliance in the 20th, 60th and 120th session, but no significant
association with therapist-rated alliance. Thus, it seems maternal bonding is associated
with client-rated alliance in later sessions and with therapist-rated alliance in earlier
sessions.
Hersoug et al.’s (2009) study also examined therapist age and revealed that older
therapists rated the alliance more highly at sessions 20, 60 and 120, but age was not
related to client alliance ratings. In the earlier study (Hersoug et al., 2001), therapist
introjects and other IIP dimensions were also examined. Self-attack introject was
positively associated with therapist-rated session three alliance suggesting that
therapists higher on self-attack initially see the alliance more positively than therapists
lower on this introject. Later in therapy (session 12), therapists high on avoidant and
exploitative interpersonal style rated the alliance lower. However, these variables did
not remain significant when they were considered with other therapist variables in
multiple regressions, indicating that they did not remain uniquely predictive of alliance
once other therapists’ characteristics were accounted for. Like most of the variables
studied by Hersoug et al. (2001) the association between client-therapist value similarity
and alliance was related to rater-perspective with this being relevant for client-rated, but
not therapist-rated alliances.
44
Like Hersoug et al. (2001), Dinger, Strack, Leichsenring and Schauenburg
(2007) also used the IIP to measure therapist interpersonal style and examine its
relationship to alliance, however, their sample was substantially different having fewer
therapists (n= 31) and more clients (n=1513). Therapists, mainly physicians, were
psychodynamically orientated. Their clients had affective, anxiety, adjustment or
personality disorders and individual therapy was provided while clients were receiving
inpatient treatment. On admission clients completed a symptom measure (SCL-90-R;
Derogatis, 1983) and the IIP. On discharge clients repeated the SCL-90-R and
completed a measure of the alliance (i.e. HaQ) retrospectively rating the alliance with
their individual therapists.
Data was analysed using multilevel regression and showed alliance was related
to outcome, however, neither client or therapist interpersonal style was associated with
the alliance. Therapists’ interpersonal style was not associated with client outcome, yet
clients’ interpersonal style was. Specifically, clients who were less submissive had
better outcomes.
There was no interaction effect between therapist and client interpersonal style
on outcome. Neither similarity on the affiliation dimension, or complementarity on the
control dimension was related to better client outcomes. Interestingly, therapists’
interpersonal style interacted with alliance on outcome. Specifically, compared to their
more affiliative counterparts, therapists who were less affiliative (i.e. more cold than
friendly) had a stronger relation between alliance and outcome. Hence, “good
therapeutic alliance was related to good outcome, but the relation between alliance and
outcome differed between the participating therapists. Good alliances were especially
helpful when the therapist described him or herself as too cold” (Dinger et al., 2007,
p. 154).
It is possible that the lack of association between alliance and therapist
interpersonal style alone or through interaction with client interpersonal style, was due
to the nature of the sample. Clients’ contact with other treating staff in the inpatient unit
may have diluted the impact of the individual therapist on the client (Dinger et al.,
2007). Nevertheless, the results of this study highlight that the alliance-outcome
relation may be moderated by therapists’ interpersonal style.
With only three published studies in this area, the question of whether therapist
interpersonal style is related to alliance or outcome remains largely unanswered.
Hersoug et al’s (2001, 2009) studies highlight these variables having different impacts
45
on alliance at difference stages of the therapy and depending on who rated the alliance.
Therapists’ cold interpersonal style has been significant in all three studies in this area
and is associated with alliance and the alliance-outcome relation. Hersoug and
colleagues’ findings about the positive impact of therapists’ warm parental bonds early
in therapy support the findings of Hilliard et al. (2000) that therapists’ early parental
relations are related to alliance as rated by the therapist. Unlike Hilliard et al. who
found no relation between therapists’ early parental relations and client- rated alliance,
Hersoug et al.’s results suggest that the effect of therapists’ early parental relations are
related to client-rated alliance later in therapy. These findings justify further research in
this area.
2.2.1.5 Therapists’ Early Maladaptive Schema
A concept both relevant to Attachment Theory and Interpersonal Theory is Early
Maladaptive Schemas (EMS). Unlike attachment style or introjects, the concept of
EMS arose from the Cognitive Behavioural tradition, and is the central focus of Schema
Therapy, a type of Cognitive Behavioural Therapy. Despite arising from a different
theoretical and therapeutic tradition EMS are conceptually related to attachment styles
and introjects.
Like attachment styles and introjects, EMS are posited to develop through early
developmental experiences. Young (1990) and Young, Klosko and Weishaar (2003)
have identified five schema domains: disconnection and rejection; impaired autonomy
and performance; impaired limits; other-directedness; and, overvigilance and inhibition.
Young and his colleagues have identified the particular types of developmental
experiences which contribute to the development of EMS in each domain. For instance,
they assert that for individuals with EMS in the domain of other-directedness: “as
children, they were not free to follow their natural inclination…. The typical family of
origin is based on conditional acceptance: Children must restrain important aspects of
themselves in order to obtain love or approval” (Young et al. 2003, p.19). Thus,
children learn from and adapt to their early environment and in doing so develop EMS,
which are defined as:
broad, pervasive themes or patterns, comprised of memories, emotions,
cognitions, and bodily sensations, regarding oneself and one’s
relationship with others, developed during childhood or adolescence,
46
elaborated through one’s lifetime and dysfunctional to a significant
degree. (Young et al., 2003. p. 7)
Young et al. (2003) have pointed out that the concept of internal working
models, central to attachment theory, overlaps with the concept of EMS. EMS can be
thought of as “dysfunctional internal working models”, which “direct attention and
information processing” (Young et al., 2003, p. 55). Young et al. propose that
individuals develop maladaptive coping styles which help them adapt to the EMS and
avoid the overwhelming affects that the EMS provoke. Typically, individuals are
unaware of their coping styles, which although functional in some respects, often serve
to perpetuate the EMS. Young identified three maladaptive coping styles: surrender,
avoidance, and overcompensation.
Surrender behaviours involve acting in ways consistent with the EMS. For
example a person with an approval-seeking EMS may try to impress others and gain
their acceptance. An individual who has a self-sacrifice EMS may give to others
without asking for anything in return, whereas a person with unrelenting standards may
use excessive time and energy trying to be perfect (Young et al., 2003).
Avoidance behaviours involve behaving in ways that avoid the EMS being
activated. For those with approval-seeking, they may avoid contact with people whom
they want approval from. An individual with self-sacrifice might avoid situations that
require giving or taking, and those with unrelenting standards might procrastinate or
avoid circumstances in which their performance will be evaluated (Young et al., 2003).
Overcompensation behaviour, is essentially fighting the EMS “by thinking,
feeling, behaving and relating as though the opposite of the schema were true” (p. 35).
An individual with an approval-seeking EMS may overcompensate by provoking others
disapproval, or alternatively, staying in the background (Young et al., 2003). For those
with a self-sacrifice EMS, overcompensation could involve giving very little to others,
and for those with unrelenting standards it might mean disregarding standards and being
careless (Young et al., 2003). Overcompensation may appear healthy, and can be if the
behaviour is proportionate and skilful, typically however overcompensation behaviour
is “excessive, insensitive or unproductive” (p. 35).
While there is empirical support for the 18 EMS identified by Young (1990),
there is little research to date on therapists EMS’ and the impact that they might have on
the outcome or process of therapy. Young et al. (2003) assume that therapists will have
47
EMS to some degree and, in concordance with the concept of complementary responses,
that therapist and client EMS can trigger and self perpetuate each other. Therapists’
EMS may also interfere with their capacity to respond to the clients’ unique needs, or, if
therapists’ clients have the same schema, the therapists may over-identify and hence
collude with the client (Young et al., 2003). The results of a study by Spinhoven,
Giesen-Bloo, Van Dyck, Kooiman and Arntz (2007) provide some support for these
ideas. In a sample of clients with borderline personality disorder being treated with
either Schema Therapy or Transference Focussed Therapy, they found that clients’
alliance ratings improved from early to mid treatment when they and their therapists had
dissimilar EMS. However, improvement in mid to late client-rated alliance scores was
not associated with therapists-client schema dissimilarity. In this study schema
dissimilarity between client and therapist was calculated for the 16 EMS and summed to
derive a total dissimilarity score, thus the impact of particular EMS was not reported.
While schema dissimilarity was related to the development of early to mid alliance it
was not associated with outcome, or with therapists rated alliance.
Given the emerging evidence suggesting that therapists’ attachment and
interpersonal style impact on the alliance, and that client-therapists’ schema
dissimilarity is related to alliance development, it is possible that therapists’ EMS,
considered in isolation, will also relate to the alliance. Of particular interest is the
schema “punitiveness” as it is conceptually similar to the introjects “self-directed
hostility” and “self-attack”, that previous research has indicated may be important
therapist qualities in relation to the alliance (Dunkle and Friedlander 1996; Hersoug et
al., 2001). The advantage of examining the impact of EMS on the alliance is that the
eighteen EMS identified by Young et al. (2003) offer a precise of taxonomy which have
significant empirical support. Furthermore, EMS are open to change and the
technology to do this is established. Thus if EMS are negatively related to alliance, it is
possible to intervene to ameliorate there impact.
2.2.2 Therapists’ personality
Personality is “a complex pattern of deeply embedded psychological
characteristics that are expressed automatically in almost every area of psychological
functioning” (Millon & Davis 1996, p. 2). Personality incorporates, although is not
48
limited to, interpersonal style (Millon & Davis 1996) and shows small to moderate
associations with attachment (Picardi, Caroppo, Toni, Bitetti, & DiMaria, 2005).
Surprisingly, only two papers to date have examined the impact of therapist personality
on the alliance. Nelson and Stake (1994) found therapists who were more extroverted
(versus introverted) and feeling (versus thinking) (rated on the Myers-Briggs Type
Indicator) obtained higher client- and therapist-rated alliance measured on the Patient
Questionnaire and Therapist Questionnaire (Strupp, Fox, & Lessler, 1969).
Chapman (2009) conducted a more comprehensive study collecting data from 34
trainees enrolled in various counselling courses and treating clients attending mental
health training clinics. Therapists completed the NEO-FFI which provides measures of
the “Big Five” personality traits, and were asked to invite as many of their clients as
possible to complete the WAI-short form between sessions three and seven. Therapists
also completed the WAI. Sixty-two clients participated in the study with 38% of
therapists treating more than one client. Data was analysed using Generalised
Estimating Equations which takes into account the nested nature of the data. Three of
the Big Five personality traits were associated with alliance however the nature of the
association depended on who rated the alliance. Client-rated alliance was related to
two therapists’ traits; openness and neuroticism. Therapists’ openness was negatively
associated with alliance, and therapists’ neuroticism (specifically the negative effect
component) was positively associated with alliance.
The positive finding for low therapist openness is counter-intuitive. The authors
note therapists, on average, were high on openness so ‘low’ openness in this sample
equated to an average level of openness in the community. Hence, a more accurate
interpretation is that alliance was higher where therapists had an average degree of
openness than where therapists had a very-high degree of openness. Nevertheless, the
results of other research suggests high openness, rather than an average level of
openness, may have a beneficial impact on alliance. For instance, therapists who are
high on openness to aesthetics, a facet of openness to experience, are more likely to
accept and be aware of individuals’ similarities and differences (Thompson, Brossart,
Carlozzi, & Miville, 2002), which assumedly, would positively influence the alliance.
Furthermore, openness to experience is particularly evident in a group of peer-
nominated “passionately committed therapists” who were in the 99th percentile on this
trait (Dlugos & Friedlander, 2001).
49
The positive association with neuroticism is also unexpected given individuals
high in neuroticism have a tendency to experience negative affects and are at higher
risk of psychiatric problems and psychological distress (Costa & McCrae, 1992).
Again the authors note the average score on neuroticism was 44 (low) and that “high”
neuroticism in this sample were only slightly above average when compared with
community norms. Perhaps it is more accurate to interpret this finding in the reverse,
i.e. alliance is low when therapists are low in neuroticism. According to Costa and
McCrae (1992) individuals low in neuroticism “are usually calm, even-tempered, and
relaxed, and they are able to face stressful situations without becoming upset or rattled”
(p. 15). Perhaps a degree of anxiety and emotional reactivity in therapists
communicates to clients that they are affected by, and responsive to them. Thus clients
may perceive therapists who are very relaxed as unaffected by their psychological
concerns. Obviously this interpretation of the result for neuroticism remains conjecture
until further research is undertaken.
In contrast to clients, therapists rated the alliance high when they were lower in
neuroticism, specifically in the self-reproach component of this trait. It follows that
therapists lower in self-reproach would view the alliance more positively than therapists
high in this trait. Interestingly, therapists high in agreeableness, specifically the
component “non-antagonistic orientation”, rated the alliance lower than therapists low
in agreeableness. This result is difficult to explain as intuitively one would expect
individuals who are altruistic and eager to help others (i.e. agreeable) would rate the
alliance higher than therapists who are competitive, egocentric and sceptical of others
(i.e. disagreeable). Whilst this dimension of personality affected therapist ratings it
was not related to client-rated alliance.
These results suggest that therapist personality relates to alliance in novice
therapists, however not in the directions that one may intuitively expect. These results
cannot be generalised to more experienced therapists who may be more likely to draw
on their learned and practised therapeutic skills rather than their innate way of relating
as driven by their personality. Furthermore, more experienced therapists may have
developed greater self-awareness and are more able to identify how their personality
and other personal qualities impact on the alliance and are thus more able to avoid or
moderate any negative impact they might have. The role of such self-awareness on the
alliance is reviewed next.
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2.2.3 Therapists’ self-awareness
Many traditions of psychotherapy emphasise the importance of therapists’ self-
awareness (Williams, 2008). Self-awareness is seen as a necessary in order for
therapists to be able to distinguish whether their reactions and feelings towards a client
is related to their own or their clients’ psychological material, to be able to use their
own feelings and responses to the client as sources of clinical information, and to
respond choicefully rather than reflexively to clients (Grepmair, Mitterlehner, Leow,
Bachler et al., 2007; Teyber, 2000; Winnicott, 1947; Young, Klosko, & Weishaar,
2003). Bowlby (1988) highlights the importance of therapists’ awareness in moderating
the effects of their own relationship histories on the therapeutic relationship:
…a patient’s way of construing his relationship with his therapist is not
determined solely by the patient’s history: it is determined no less by the way
the therapist treats him. Thus the therapist must strive always to be aware of the
nature of his own contribution to the relationship which, among other influences,
is likely to reflect in one way or another what he experienced himself during his
own childhood. (p. 141)
Although the term self-awareness has long been used in psychological and
psychotherapy literature it is ill-defined. Recently, Williams (2008) has defined
different types of self-awareness. She uses the term “self-awareness” to refer to self-
insight; “self-consciousness” refers to the trait of being continuously attuned to internal
states both positive and negative; and “self-focused attention” to refer to momentary
shifts toward being aware of oneself in the moment.
Empirical findings about the impact of these various types of therapist
awareness on the process and outcome of therapy are mixed. Therapist self-focused
attention to their feelings (such as anxiety and confusion), critical self-talk and non-
verbal behaviours during sessions appears to have negative impacts in several domains.
It is associated with therapists’ negative perception of themselves, their clients and the
therapy process and is positively associated with therapist anxiety (Williams, 2008).
Such self-focus has been both negatively (Williams, 2008) and positively (Fauth &
Williams, 2005) associated with client-ratings of therapist helpfulness. There are
various ways that novice therapists manage distracting self-focussed attention, however
these management strategies have been shown to negatively impact on their
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interpersonal involvement in session and client-ratings of session impact (Fauth &
Williams, 2005).
Therapists’ emotional awareness, assessed through their written responses to
scenarios, has been positively associated with accurate identification of emotional
quality but was unrelated to accurate identification of emotional intensity (Machado et
al., 1999). Finally, therapists coached to self-monitor certain processes during therapy
sessions did not receive significantly better outcomes than therapists who did not
receive this coaching (Kaufman, 2000).
The aforementioned studies have drawn on different measurement methods and
conceptualisations of self-awareness so it is not possible to make direct comparisons.
Given the emphasis on therapist self-awareness in the therapy training (Corey, 2005;
Egan, 2007) and the theoretical literature, and therapists’ qualitative accounts of the
importance of using personal therapy in order to increase their self-awareness (Jennings
& Skovholt, 1999; Wiseman & Shefler, 2001), it is surprising that there is not more
research on the impact of therapists’ self-awareness on therapy process and outcome.
Recently mindfulness, a particular type of awareness has become a focus for research
attention and a rich empirical literature about this topic is developing. While research
about therapist mindfulness and therapy processes is nascent, mindfulness is emerging
as an important therapist characteristic. An overview of mindfulness and how it relates
to therapists and therapy alliance and outcome is reviewed below.
2.2.3.1 Mindfulness
Mindfulness is commonly understood as “the awareness that emerges through
paying attention on purpose, in the present moment, and non-judgementally to the
unfolding of experience moment by moment” (Kabat-Zinn, 2003, p. 145). Recently
mindfulness researchers have further operationalized mindfulness articulating two
components:
The first component involves the self-regulation of attention so that it is
maintained on immediate experience, thereby allowing for increased
recognition of mental events in the present moment. The second component
involves adopting a particular orientation toward one’s experiences in the
present moment, an orientation that is characterised by curiosity, openness and
acceptance. (Bishop et al., 2004, p. 232)
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The bulk of research attention relating to mindfulness has been focused on its
therapeutic effects. Mindfulness based therapies are associated with significant
improvements in symptoms in a number of psychological and medical conditions
including chronic pain, anxiety disorders, binge eating disorder, fibromyalgia, psoriasis,
and prevention of relapse in depression (Baer, 2003). In non-clinical populations
mindfulness has been associated with reductions in stress-levels, medical and
psychological symptoms (Anderson, Lau, Segal, & Bishop, 2007; Baer, 2003;
Carmody, Reed, Kristeller, & Merriam, 2008) and improved emotional wellbeing
(Anderson et al., 2007). Conservative estimations of average effect sizes of
mindfulness-based interventions at both post-treatment and follow-up are in the order of
0.59 (a medium effect; Baer, 2003).
Importantly, mindfulness can be trained; mindfulness based interventions
increase participants’ mindfulness as measured by various self report scales (Anderson
et al., 2007; Carmody & Baer, 2008; Carmody et al., 2008; Shapiro, Oman, Thoresen,
Plante, & Flinders, 2008). Further, increases in mindfulness have been found to
mediate the relationship between mindfulness training and reductions in perceived
stress and rumination (Oman, Hedberg, & Thoresen, 2006; Shapiro et al., 2008) and
improvements in psychological functioning (Carmody & Baer, 2008). Mindfulness
seems to have a positive impact on interpersonal functioning with more mindful
individuals being more expressive in social situations and less likely to be negatively
impacted by other peoples’ distress (Dekeyser, Raes, Leijssen, Laysen, & Dewulf,
2008).
In relation to therapists’ mindfulness, most interest has been directed at the
benefits that mindfulness might offer in reducing therapists’ stress and burnout. Several
randomised control studies have demonstrated that 8-week mindfulness interventions
for health practitioners (i.e. Mindfulness Based Stress Reduction and Eight Point
Program) cause significant improvements in medical students anxiety, psychological
distress and empathy (Shapiro, Schwartz, & Bonner, 1998), and improvements in health
professionals self-compassion (Shapiro, Astin, Bishop, & Cordova, 2005), perceived
stress (Oman et al., 2006; Shapiro et al., 2005) life satisfaction (Oman et al., 2006),
burnout (Galantino, Baime, Maguire, Szapart, & Farrar, 2005; Oman et al., 2006), and
mood (Galantino et al., 2005). Similarly, May and Donovan (2007) found, in a sample
of 55 practising psychologists, counsellors and social workers, levels of mindfulness
53
had positive univariate associations with satisfaction with life, positive affect and job
satisfaction, and a negative association with negative affect and burnout.
A number of qualitative studies have found that therapists perceive their
meditation practice (the traditional way of developing mindfulness) to benefit their
work. Such therapists report improvements in their capacity to relate to their clients in a
manner which is positive, open (Rothaupt & Morgan, 2007), accepting and empathic
(Nanda, 2005). They find that they are more present and aware of what is emerging for
clients, better able to listen, less reactive and more able to connect and feel compassion
for their clients (Nanda, 2005). Intuitively, one would expect such therapist attitudes
and behaviours of the like would enhance therapeutic processes and outcomes.
Three studies to date have examined the impact of therapist meditation practice
or mindfulness on therapy outcomes. In lieu of any research on the relationship between
mindfulness and alliance, these are reviewed. Two highly controlled studies by
Grepmair et al, (2007) and Grepmair, Mitterlehner, Leow and Nickel (2007) were both
conducted in an inpatient psychotherapy hospital. All patients had a DSM-IV disorder,
primarily adjustment, mood, personality, anxiety, somatoform and substance use
disorders. Psychologists were completing a three-year psychotherapy internship.
Inpatient therapy was from four to six weeks duration and consisted of two individual
psychotherapy sessions, five group therapy sessions, two gestalt therapy group sessions,
five psychoanalytically-informed body psychotherapy group sessions, two sessions of
progressive muscle relaxation and eight hours of sports and gymnastics groups per
week. Patients provide socio-demographic data and completed the Structured Clinical
Interviews (SCID) and SCL-90-R pre and post therapy. At the completion of therapy
patients completed the Questionnaire of Changes in Experience and Behaviour (VEV),
an assessment of patient perceived personal changes over the course of therapy. After
each session patients also rated session quality on the session questionnaire for general
and differential individual psychotherapy (STEP). This measure yields three subscales:
clarification perspective, problem solving perspective, and relationship perspective.
The first study comprised 58 therapists treating 113 patients (Grepmair,
Mitterlehner, Leow, & Nickel, 2007). In the first phase treatment remained unchanged.
In the second phase therapists participated in meditation practice with a Japanese Zen
master for one hour each workday. Patients receiving treatment during phase one were
compared with patients receiving treatment during phase two. There was no significant
difference between groups on any variable measured at baseline. At discharge patients
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of the meditating therapists made significantly more positive ratings of therapy sessions
and their improvement over the course of treatment. Compared to the patients in the
first phase, clients of meditating therapists had significantly lower scores on eight of the
SCL-90 subscales: specifically the global severity index, somatisation, obsessiveness,
anxiety, hostility, phobic anxiety and psychoticism.
In the second study these results were replicated and extended (Grepmair,
Mitterlehner, Leow, Bachler et al., 2007). This study utilised a double blind
randomised controlled design. Patients (n=124) were randomly assigned to therapists
(n = 18) who in turn were randomly assigned to a Zen meditation group or control
group. The meditating therapists participated in meditation as part of their ongoing
training. Control group therapists participated in the Zen meditation at a later point.
Neither therapists nor patients were aware of their involvement in this particular study.
Treatment, research measures, and the Zen meditation were identical to the Grepmair,
Mitterlehner, Leow and Nickel (2007) study, however, the duration of treatment was
nine weeks. Therapists in each group were equivalent with respect to years of training,
academic qualification and gender. No therapists were meditating prior to participating
in the study. Remarkably, neither of these studies had patient or therapist attrition.
Compared to the patients of the control group therapists, patients of the
meditating therapists had better results on almost all research scales. After their
sessions they subjectively experienced more progress in terms of understanding their
own psychodynamics, the nature of their difficulties, and the how their development
may proceed. Overall, they rated more progress in therapy. They had significantly
higher pre – post treatment changes on most of the SCL-R-90 scales; somatisation,
obsessiveness, insecurity in social contact, degree of depression, anxiety, hostility,
phobic anxiety, psychotisim and global severity index. All but one of these changes
was significant at the <0.001 level.
Whilst these two studies suggest that therapists’ meditation practice may
improve client outcome, a study by Stanley and colleagues (2006) produced
contradictory results. They sampled 145 adult clients at a university based outpatient
community mental health centre who were treated by 23 trainee psychologists
completing their first placement. Most clients (87%) had at least one DSM-IV disorder,
predominately mood, anxiety or personality disorders. Clients were treated with various
forms of manual based therapy including interpersonal therapy, motivational
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interviewing, cognitive processing therapy, exposure and response prevention,
dialectical behavioural therapy and relaxation training.
In order to examine the impact of therapists’ mindfulness, therapists completed
the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) which
measures one component of mindfulness; moment-to-moment attentional awareness. At
intake therapists rated their clients’ symptom severity on the Clinical Global
Impressions scale (CGI). At termination therapists and clients rated symptom
amelioration using the CGI. Higher scores on the CGI indicate worse symptoms or less
improvement. Therapists also rated their clients overall functioning on the Global
Assessment of Functioning (GAF) at intake and termination.
Data was analysed using a series of multiple regressions. Results suggested that
therapists’ mindfulness had a significant, negative correlation with client functioning at
termination (GAF scores) after initial client functioning was controlled. There was no
significant relation between mindfulness and client symptom severity when initial
symptom severity was controlled. Thus, clients of more mindful therapists had worse
therapist-rated functioning at termination, however, were not significantly different in
terms of their symptom change, compared to clients of less mindful therapists.
Further, therapist’s mindfulness had a significant positive correlation with
therapist-rated symptom improvement. Yet there was no significant relation with client
–rated symptom improvement. Thus, clients of more mindful therapists were perceived
by their therapists (but not by themselves), as less improved than clients of less mindful
therapists.
The authors conclude that “the level of improvement, or degree of positive
treatment outcome, was not as great for the client of the more mindful therapist”
(p.332) and suggest this might be because mindfulness taxes therapists’ attentional
capacity,
…the very mindful therapist may be more easily derailed from
manual-based treatment at various points in the session due to the
limitations of working memory to deal with both attention to the delivery
of manual-based therapy and attention to the moment-to-moment statements
and behaviours of the client and to moment-to-moment internal experiences.
(Stanley et al., 2006, p. 333)
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There are several limitations to this study, which undermine this conclusion. First, there
was a significant negative association between therapist mindfulness and therapist-rated
GAF at intake. Thus, mindful therapists either had poorer functioning clients at intake
or they perceived their clients as poorer functioning at intake. Either scenario limits the
validity of the study. Second, after intake GAF or CGI was controlled in the two
significant multiple regressions. The addition of therapist mindfulness into the equation
seemed to account for only a small change in variance; change in R-Squared was from
0.62 to 0.63 in the prediction of termination GAF, and from 0.00 to 0.09 in the
prediction of therapist-rated improvement. Unfortunately, interpretation is limited as
R-Square adjusted and R-Square change statistics were not reported, however it appears
that therapist mindfulness did not substantially improve the explained variance. Third,
there was significant missing data from their sample, whilst GAF measures were
obtained pre- and post-therapy for all clients (n=145), only 53 clients completed CGI
ratings of symptoms at termination and 101 had therapist-rated CGI at intake and
termination. It is not known whether the missing data was random or systematic. Thus,
the generalisability and interpretation of these results is limited.
Whilst the Stanley et al. (2006) findings clearly need replication before they can
be taken seriously, the results are not necessarily conflictual with previous studies,
(i.e. Grepmair, Mitterlehner, Leow, Bachler et al., 2007; Grepmair, Mitterlehner, Leow,
& Nickel, 2007) as the independent variables were different (meditation practice versus
level of mindfulness). Whilst several studies have found a link between levels of
mindfulness measured by self report and mindfulness training (Anderson et al., 2007;
Carmody & Baer, 2008; Carmody et al., 2008; Shapiro et al., 2008), or mindfulness
practice conducted outside of training (Carmody & Baer, 2008) others have not. For
example, May and Donovan (2007) found therapists’ mindfulness practice
(e.g. meditation) is not associated with self-report measures of mindfulness. To clarify
the associations between therapist meditation practice, degree of mindfulness and client
outcomes both therapists’ mindfulness practice and level of mindfulness require more
extensive examination.
There is little research on how therapist mindfulness impacts the therapeutic
relationship (Hick, 2008). In an unpublished study of 19 therapist-client dyads,
therapist mindfulness (measured using the MAAS) was positively associated with both
client and therapist perceptions of the alliance measures on the WAI (Wang, 2006, cited
in Hick, 2008).
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Whilst empirical evidence about the association between the alliance and
mindfulness is lacking, the importance of the mindfulness to therapy processes such as
the alliance has been articulated from a number of theoretical perspectives. Bien (2008)
describes mindfulness as a “quality of non-judgemental, open, accepting awareness”
(p. 40) and notes that these qualities are similar to therapist qualities emphasised in a
number of traditions. For instance, in psychoanalysis there is an emphasis on listening
to clients’ disclosures with uncritical, non-judgemental and benign curiosity; self-
psychology emphasises ‘experience near’ understanding of clients; and, humanistic
psychology and systems psychology privilege understanding over change (Bien, 2008).
From the perspective of contemporary behavioural therapies it is suggested that
therapists who are themselves mindful will be more sensitive to subtle changes in
clients’ in-session behaviour and can be more present in their personhood rather than
relating to clients from an assumed role. Furthermore, mindful therapists can model the
mindful behaviour and attitudes that they may want to elicit in the client (Wilson &
Sandoz, 2008).
From a relational psychoanalytic perspective therapist mindfulness may help the
therapist to become ‘disembedded’ from an enactment with their client (Safran &
Reading, 2008). Safran and Reading (2008) argue that mindful awareness allows the
therapist to acknowledge their current feelings towards the client, create an ‘internal
space’ where they can decrease their attachment to any particular feeling and refine
their attention and awareness of their own contributions to enactments in the therapy
relationship. Similarly, Martin (2002) notes that the qualities of mindfulness enable an
attentional freedom in the therapist where “attitudes as being right, controlling the
situation, or maintaining therapist self-esteem give way to a quiet, more limber,
nonbiased, and non-reactive response” (p. 299).
Considering therapists’ information-processing and affect-regulation capacities,
Grepmair, Mitterlehner, Leow, Bachler et al. (2007) highlight:
the task of a psychotherapist is highly complex, involving simultaneous
perception of the patient’s verbal and nonverbal expressions, self-regulation of
one’s perceptions and management of countertransference reactions. Thus, all
psychotherapists must direct their attention to the best possible advantage
during therapy. (p. 332)
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Given that mindfulness is, in part, “self-regulation of attention” (Bishop et al., 2004) it
may potentially assist therapists to meet the information-processing and affect-
regulation demands of their therapy work.
In summary, the empirical literature suggests mindfulness has significant
therapeutic effects as a clinical intervention and in non-clinical applications. It appears
to have several benefits for health practitioners and may lead to improved outcomes for
clients of meditating therapists. Theoretically, there are several persuasive arguments as
to the benefits of mindful therapists. Research on the relation between therapists’
mindfulness and the alliance is likely to provide a useful contribution to this field.
2.2.3.2 Psychological flexibility
A concept closely related to mindfulness is psychological flexibility. This is the
capacity to contact the present moment fully and consciously, “and based on what the
situation affords, to persist or change behaviour in the service of chosen values”
(Pierson & Hayes, 2007, p. 9). Mindfulness is a component of psychological flexibility,
however psychological flexibility also consists of several commitment and behaviour
change capacities. Thus, psychological flexibility can be considered a related, albeit,
broader concept than mindfulness.
Pierson and Hayes (2007) articulate several reasons that therapists’
psychological flexibility may have a powerful influence on the therapy relationship as
well as other therapeutic processes and outcomes. They argue that therapists without
this characteristic (i.e. those who are psychologically inflexible) will tend to avoid their
own internal experiences (i.e. thoughts, memories, feelings, action urges, sensations)
and this avoidance may lead to them failing to explore client topics if they touch on
personally difficult material. Therapists who are unaware of their internal experiences
(because they avoid it) may also fail to use these experiences as a source of clinical
information about events occurring in the session. Pierson and Hayes argue that
therapists who avoid their own experience cannot be genuine as the methods they use to
avoid their own experiences involve “self-fakery” and “self-manipulation”. For
example, hiding feelings of uncertainty though bravado and certainty. Not only will
such avoidance be at the cost of genuineness, it is also likely to tax therapists’
attentional capacity as they expend attentional resources tracking their own
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psychological processes, and interrupting their ability to focus on the client (Pierson &
Hayes, 2007). Psychologically inflexibility also involves a ‘fusion’ with thoughts such
that thoughts are seen as literal truths rather than an ongoing process of mental
experiences (Luoma & Hayes, 2003). Thus, therapists who are psychologically
inflexible are vulnerable to becoming “fused” with either their own or their clients
thoughts (e.g. client is “treatment resistant”, “a damaged person”, “therapy is stuck”)
which narrows the behavioural options or alternative perspectives available to the
therapist (Pierson & Hayes, 2007).
A considerable amount of research has shown that psychological flexibility is
negatively associated with psychopathology (Gratz, Tull and Gunderson, 2008;
Kashdan, Barrios, Forsyth, Steger, 2006; Kelly & Forsyth, 2009; Plumb, Orsillo,
Luterek, 2004; Tull and Gratz 2008) and mediates outcomes in Acceptance and
Commitment Therapy treatment for a range of disorders (Ruiz, 2010). Reductions in
therapists’ preoccupation with negative thoughts about difficult clients, after an brief
ACT intervention for stigma, was related to a reduction in burnout (Hayes et al., 2004).
The therapist behaviours that Pierson and Hayes (2007) associate with therapist
psychological inflexibility, that is avoiding particular topics, failing to adequately attend
and focus on the client, behaving in a phony manner, and fusing with thoughts about the
client or therapy, may well undermine the therapeutic relationship. This question is yet
to be addressed empirically.
2.3 Summary
The person of the therapist and how his or her qualities relate to the outcome of
their therapeutic work has long been considered theoretically and empirically. More
recently, research has also focused on the alliance and other therapy processes. The
therapist effects research has demonstrated that the person of the therapist matters and
in some quarters it is argued that the person of the therapist matters as much as or more
than the type of treatment they are delivering (Wampold, 2001). While it is clear that
therapists differ in terms of the outcomes they achieve, even after a considerable degree
of research only equivocal findings have been made with respect to determining the
types of qualities which characterise successful therapists. Noting this, Lambert (2009),
a pioneer in the field, has suggested that examination of therapists’ impacts on therapy
60
processes might be more successful. The alliance is an important therapy process,
common to all therapies, which is consistently linked to therapy outcomes.
Research to date has found associations between the alliance and a several
therapist professional characteristics: therapist experience, theoretical orientation,
personal therapy and supervision, adherence, and competence and in-session behaviour.
This research has been exclusively correlational, thus causation is not established.
Furthermore, in most of these areas only a small number of studies have been conducted
and these suffer from the numerous methodological problems which have been noted.
The published research papers on therapist personal characteristics are also few in
number, but like therapists’ professional characteristics, several variables have been
associated with alliance. Specifically, therapist attachment, current and past
relationships, interpersonal style, personality, and mindful self-awareness have been
associated with alliance. However, in the cases where there are multiple studies the
results are often conflicting. While the state of the research does not invite confident
conclusions, these professional and personal characteristics show promise as variables
that distinguish therapists who are more or less effective in establishing and developing
an alliance with their clients.
2.4 The Current Study: Therapist Effects, Therapist Characteristics and the
Therapeutic Alliance
The focus of the current study is two fold. First, to identify the degree of
therapist effects on the alliance. Second, to identify therapist characteristics, both
professional and personal, that may account for therapist effects on the alliance. Based
on empirical and theoretical literature reviewed in this chapter, the following
professional and personal characteristics were selected: experience; amount of personal
therapy; amount of supervision received; theoretical orientation; attachment,
personality; mindfulness; experiential avoidance; and, early maladaptive schema.
Represented in this list are personal characteristics that have already shown some
promise as variables that may distinguish therapists who are more or less capable of
forming a strong alliance, as well as therapist characteristics which have yet to be
explored in alliance research to date.
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2.4.1 Research aims
The broad aims of this study are to advance the field of enquiry in alliance
research in the following ways. First, as has been noted, much of the literature is mired
by methodological problems such as failing to address common rater bias, and failing to
use statistical procedures appropriate for nested samples (i.e. clients within therapists)
where observations are not independent. In the current study, methodologically sound
instruments are selected and statistical analysis suitable for nested data is utilised. The
alliance is rated from the client perspective as it is more predictive of outcome, and
importantly, to avoid common-rater bias that is present in much of the research to date.
Second, this study is designed to consider both therapists’ effects, and the contribution
of therapists’ characteristics, on both early alliance and the development of the alliance
over the course of therapy. This is considered important given some therapists’
characteristics have been found to have different associations with alliance depending
on when in the therapy alliance is measured, and there is emerging evidence that the
pattern of alliance development, as well as the strength of early alliance, is related to
therapy outcomes. To date, there is minimal research which has examined the impact of
therapist characteristics on both of these alliance parameters.
Third, the current study is expected to extend the literature on the association
between alliance and therapists’ supervision, personal therapy, and personality. This
will be achieved by examining these variables in a sample of therapists with a range of
experience, treating clients with a variety of clinical and non-clinical presentations, and
utilising a range of therapeutic modalities. Previously these therapists’ characteristics
have only been studied in comparatively homogenous samples of therapists and clients
which, while increasing internal validity, decreases ecological validity. The literature
pertaining to therapists’ orientation will be extended by classifying orientation
dimensionally rather than categorically.
The current study will replicate the existing research on therapist experience by
examining its interaction with client attachment. Similarly, it will replicate research on
attachment by examining therapists’ attachment as both a main effect, and its interaction
with client attachment. Finally, this study will begin empirical analysis of therapists’
mindfulness, psychological flexibility and EMS, which although theoretically
associated with alliance, have not appeared in the published empirical research on
therapist characteristics and the alliance.
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2.4.2 Hypotheses
The present study tests the following hypotheses:
(1) there will be significant difference between therapists on the early client-rated
alliance;
(2) there will be a significant difference between therapists on the rate of growth in
alliance over sessions;
(3) therapists’ EMS, personality, attachment, mindfulness, experiential avoidance,
amount of supervision, amount of therapy and theoretical orientation will be
associated with their early alliance scores;
(4) therapists’ EMS, personality, attachment, mindfulness, experiential avoidance,
amount of supervision, amount of therapy and theoretical orientation will be
associated with the rate of growth in alliance over sessions;
(5) therapist and client attachment will interact in their association with the early
alliance. Specifically, early alliance would be higher when the therapist and client
had different attachment styles (i.e. anxious attachment and avoidant attachment);
(6) therapist and client attachment will interact on their association with the rate of
growth in alliance over sessions. Specifically, alliance growth will be higher when
the therapist and client had different attachment styles;
(7) Therapists’ level of experience and client attachment will interact in their association
on alliance, whereby when clients have greater attachment insecurity more
experienced therapists will have higher early alliance than less experienced
therapists;
(8) Therapists’ level of experience and client attachment will interact in their association
on alliance, whereby when clients have greater attachment insecurity more
experienced therapists will have stronger rate of growth in alliance than less
experienced therapists.
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CHAPTER 3
METHOD
3.1 Overview of the Design
In order to test the stated hypotheses a naturalistic study of client-therapist dyads
was utilised. All variables were measured using self-report scales. Data was collected
from both clients and therapists. The therapists in the sample each had a number of
clients, making the design nested. In the case of clients, data was collected prior to
their beginning counselling; selected measures were repeated during the course of their
counselling; and data was collected at the termination of therapy. As such this was a
repeated measures design.
3.2 Sample
The sample consisted of client-therapist dyads from an Australian university
psychology clinic. The training clinic is staffed by post-graduate psychology students
who provide low-cost counselling for the general public.
The study consisted of 267 clients who completed a total of 539 questionnaires.
This represented a response rate of almost 70%. Similarly the therapist response rate
was 79%. Data analysis required completed questionnaires from client-therapist dyads,
therefore clients or therapists without data from their corresponding partner in the dyad
were excluded, as shown in Figure 3.1. Clients returned two questionnaires on average,
however the number of questionnaires returned by clients ranged from one to ten. As
indicated in Figure 3.1, the majority of clients completed the baseline questionnaire
about half of those also did at least one progress questionnaire. A much smaller number
completed only progress questionnaires. Completion of final questionnaires was
generally poor with only 57 final questionnaires returned for the entire sample.
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Clients: Therapists:
Figure 3.1. Participant flow chart indicating response rates and excluded data.
3.2.1 Client sample
The client sample comprised adults aged between 18 and 79, with a mean age of
32 years. Sixty-three percent were women. Fifty-three percent were in paid
employment. As displayed in Figure 3.2 most of those who were employed were in
professional roles, however a range of employment categories were represented. Five
percent of clients in the sample (hereafter referred to as clients) were unemployed.
Twenty-two percent of clients specified their occupation as a student, 3% were retired,
0.4% were engaged in volunteer work, and 2% were occupied with home duties and/or
parenting. Employment data were missing for 15% of the sample.
Eligible clients (n = 385)
Clients enrolled in study (n = 267)
Total therapists treating clients at the clinic (n = 67)
Therapists enrolled in the study (n = 53)
Baseline (n = 93)
≥ 1 progress (n = 36)
Baseline and ≥ 1 progress (n = 93)
Therapists with no clients in the study (n = 3)
Declined or were not approached to participate (n = 115)
Declined participation (n = 14)
Therapists with clients in the study (n = 50)
Tt
Dp(
Tes
Dw
Clients with corresponding therapist data (n = 222)
Final (n = 29)
65
Figure 3.2. Categories of employment in the client sample.
Most clients were born in Australia (66%), United Kingdom (6%), New
Zealand (3%), or India (2%). However, in total, 32 countries of birth were represented
amongst clients. Six percent of data for this variable was missing.
A quarter of the clients had never had counselling; 28% had previously had eight
or fewer sessions; 15% had between 9 and 20 sessions; and, 22% had previously
received over 20 sessions of counselling. Ten percent of the data was missing for this
variable.
Twenty six percent of clients reported having an illness and 63% reported no
illness (11% of responses were missing). Amongst clients reporting an illness most
identified one illness (64.8%); however some participants had two (19.7%), three
(8.5%), four (4.2%) and five (1.4%) illnesses. One client reported having thirteen
illnesses. As demonstrated in figure 3.3, the types of illnesses reported included both
physical and psychiatric illnesses, most commonly reported were anxiety and mood
disorders.
%
5%
10%
15%
20%
25%
pro
fess
iona
l
cler
ical
/ad
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istra
tion
com
mun
ity /
pers
onal
ser
vice
sale
s
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an /
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s
man
ager
s
labo
urer
s
mac
hina
ryop
erat
or /
driv
er
% in
cat
egor
y
Employment categories
66
Figure 3.3. Types of illnesses reported by clients.
Compared with the percentage of the sample having an illness somewhat more
participants reported taking medication (33.5%). Missing data for this variable was
10.8%. Only 32.7% provided data on the types of medication taken. From the data
provided, 59.1% reported taking one medication, 28.4% reported taking two
medications and 12.5% took between 3 and 6 medications.
3.2.2 Therapist sample
The 53 therapists were completing their first placement in a Masters or Doctoral
Degree in Counselling or Clinical Psychology. All therapists had completed
prerequisite subjects in psychological assessment and basic counselling skills. Eighty-
three percent of therapists were female. Ages varied from 23 to 59 years old (mean 36.4
years). Most therapists identified themselves as Australian (76%). Also represented
were therapists identifying themselves as European (6%), American, German, Greek,
0
5
10
15
20
25
30
35
card
iova
scul
ar
derm
atol
ogic
al
ear n
ose
& th
roat
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inal
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met
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us
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Num
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f clie
nts
Illness category
67
Indian, Asian and Multi-ethnic (each 2%). Eight percent of data was missing for this
item.
The sample consisted of therapists with a wide range of educational attainment
and professional experience. All therapists had completed a bachelor degree with
honours, or a Graduate Diploma in Psychology; however, 36% had also completed one
or more graduate diplomas, bachelor degrees or masters degrees in areas other than
psychology. Therapists were either provisionally or fully registered psychologists with
up to 24 years experience in counselling or related fields (see Appendix A for details of
experience).
Most therapists identified themselves as eclectic in orientation (48%). To a
lesser extent therapists identified having specific orientations: cognitive-behavioural
(25%), humanistic (21%), psychodynamic (4%), and transpersonal (2%).
3.3 Measures
Self-report data was collected from clients and therapists. Measures for both
samples were selected on the basis of effective measurement of the construct of interest,
being psychometrically sound and where possible brief.
3.3.1 Client measures
In order to test the stated hypotheses client measures were selected to quantify
the strength of alliance and clients attachment style. In order to complete preliminary
analyses (which is explained in Chapter 4) client measures were also selected to
examine the degree of client psychological or emotional disturbance at baseline and
clients’ symptomatic improvement and changes to quality of life over the course of
therapy. As clients were attending a generalist counselling clinic, symptom measures
were selected on the basis of them being applicable in this setting. Measures were
selected to examine overall well-being, stress, interpersonal problems, quality of life
and, given their high prevalence (Andrews, Henderson & Hall, 2001), anxiety and
depression.
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3.3.1.1 Personal demographics
Participants were asked to provide their date of birth, sex, occupation, country of
origin, extent of previous counselling and current illnesses and medications.
3.3.1.2 Working Alliance Inventory – Short Form – Revised (WAI-SR)
The WAI-SR (Hatcher & Gillaspy, 2006) is a 12 item self-report scale
developed to measure the working alliance between therapist and client from the client’s
perspective. The WAI-SR has been derived from the longer 36-item WAI which was
developed to measure Bordin’s (1979) conceptualisation of the working alliance.
The WAI and its short-form (Tracey & Kokotovic, 1989) have been used
extensively in therapy process research and have good reliability and validity (Elvins
& Green, 2008). Likewise the WAI-SR has demonstrated good validity and reliability.
Cronbach alpha co-efficients for the WAI-SR range from .85 – .90 for the subscale
scores, and .91 – .92 for the total score (Hatcher & Gillaspy, 2006). Hatcher and
Gillaspy (2006) found the WAI-SR to have good convergent validity; correlating .74
and .80 respectively with The Penn Helping Alliance Questionnaire (Alexander &
Luborsky, 1986) and The California Psychotherapy Alliance Scales (Gaston, 1991).
The three subscales of the WAI-SR are Bond, Task, and Goal. Each scale
contains four statements that clients rate on a 5-point Likert scale, with anchor points
ranging from 1 (seldom) to 5 (always). The Bond subscale refers to the strength of the
bond between the client and therapist and includes items such as, “I believe _____ likes
me”. Respondents are asked to mentally insert the name of their therapist on the line.
The Task subscale refers to client and therapist agreement about the tasks of therapy and
how these tasks will lead to achieving the client’s goals. Items include statements such
as, “As a result of these sessions I am clearer as to how I might be able to change”. The
Goal subscale measures the degree to which the client and therapist agree on the goals
of therapy and includes items such as “We have established a good understanding of
the kind of changes that would be good for me”. Subscale scores and the total score
range from 1-5. Higher scores indicate a stronger working alliance. Confirmatory
factor analysis in two different samples has demonstrated that the WAI-SR has a three-
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factor solution consistent with the three subscales (Hatcher & Gillaspy, 2006), an
improvement from its earlier versions; the WAI and WAI - short form.
3.3.1.3 Attachment Style Questionnaire
The Attachment Style Questionnaire (ASQ; Feeney, Noller & Hanrahan, 1994)
was designed to provide a broad-based measure of adult attachment dimensions. A self-
report measure was chosen over using an interview measure of attachment as the
available resources would not enable the use of time-intensive attachment interviews.
The ASQ was chosen for the current study over other well-known self-report attachment
measures because it does not assume experience in romantic relationships. This is
important because it is likely that some participants in the client or counsellor samples
will not have had romantic relationship. The scale consists of 40 items rated on a
6-point Likert scale from one (totally disagree) to six (totally agree). The ASQ derives
five scale scores which measure different aspects of attachment.
The “Confidence (in self and others)” scale represents secure attachment.
People who are high on this scale are comfortable in relationships, they neither worry
about depending on others or others depending on them. They are able to be
emotionally close to others but are not worried about being alone, being accepted or
being abandoned. The scale consists of items such as; “I find it relatively easy to get
close to other people”, “I feel confident about relating to others”, and “If something is
bothering me, others are generally aware and concerned”. The remaining four scales
represent aspects of insecure attachment.
The scale “Discomfort with Closeness” represents a type of avoidant attachment.
People high on this dimension are uncomfortable with emotional closeness. They find
it difficult to trust and depend on others. The scale contains items such as “I prefer to
depend on myself rather than other people”, “Other people have their own problems, so
I don’t bother them with mine”, and “I worry about other people getting too close”.
“Relationships as Secondary (to achievement)” relates to a dismissive style of
attachment. People high on this dimension are comfortable without close relationships
and prioritise achievement over relationships with others. They prefer to feel
independent and self-sufficient, not depending on others or having others depend on
them. Items on this scale include “Peoples’ worth should be judged by what they
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achieve”, “To ask for help is to admit you are a failure”, and “I am too busy with other
activities to put much time into relationships”.
“Need for Approval” reflects a need for others’ approval and confirmation.
People high on this dimension are worried about whether others value them. Although
they want close relationships they remain anxious about others’ disapproval. Items in
this scale include “I wonder why other people would want to be involved with me”,
“When I talk over my problems with others, I generally feel ashamed or foolish”, and
“It’s important that others like me”.
Like the Need for Approval scale, the “Preoccupation with Relationships” scale
reflects anxiousness in relationships. Specifically, people scoring high on this scale
want to be close to, or merge with, others. They find others are reluctant to get as close
as they would like and this desire for closeness may in fact scare others off. They worry
about being without relationships, being abandoned and others not valuing them. Items
include “I find that others are reluctant to get as close as I would like”, “I worry a lot
about my relationships”, and “I often feel left out or alone”.
Psychometric testing suggests that the ASQ is a reliable and valid measure of
attachment. Based on an Australian sample the scales have adequate reliability with
Cronbach alphas of .80 for Confidence, .84 for Discomfort with Closeness. .79 for Need
for Approval, .76 for Preoccupation with Relationships and .76 for Relationships as
Secondary (Feeney et al., 1994). Internal consistency tended to be lower in an Italian
clinical sample (Cronbach alpha ranging from .67 – .74) and non-clinical sample
(Cronbach alpha ranging from .64 – .73; Fossati et al., 2003). Test-retest reliability over
10 weeks on a sample of university students ranged between .67 (Relationships as
Secondary) and .78 (Need for Approval; Feeney et al., 1994).
ASQ scales have strong correlations in the expected directions with Hazan and
Shaver’s (1987) forced choice attachment scale, supporting ASQ’s construct validity.
Adequate concurrent validity is also evident in the patterns of correlations with the
theoretically related concepts of family functioning, extraversion and neuroticism.
When subject to cluster analysis, scores on the ASQ were able to identify distinct
attachment groups (Feeney et al., 1994). Within a clinical sample, scale scores have
been found to distinguish people with and without personality disorders (Fossati et al.,
2003).
The ASQ scores seem to be affected by gender and culture. Males scored
significantly higher than females on the Relationships as Secondary Scale in an
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Australian and Italian sample (Feeney et al., 1994; Fossati et al., 2003) and significantly
lower on the Need for Approval and Preoccupation with Relationships scales in an
Italian sample (Fossati et al., 2003). The results of one study suggest the scale does not
have adequate validity for Malaysians (Ng & Trusty, 2005), thus further examination of
the ASQ’s psychometric properties in culturally diverse samples is required.
Results of principal components analysis in a non-clinical Australian sample
(Feeney et al., 1994) and a multiple-group components analysis in clinical and non-
clinical Italian samples (Fossati et al., 2003) demonstrate a 5-factor solution consistent
with the 5 scales described above.
Results of several studies suggest the presence of two higher factors – anxiety
and avoidance (Brennan, Clarke & Shaver, 1998; Fossati et al., 2003; Fraley, Waller, &
Brennan, 2000). Studies by Brennan et al. (1998) and Fossati et al. (2003) support the
convergent and discriminant validity of these higher-order factors. The five ASQ scales
can be used to indicate these two higher-order factors with ‘anxiety’ made up of Need
for Approval and Preoccupation with Relationships, and ‘avoidance’ consisting of
Discomfort with Relationships, Relationships as Secondary, and Confidence (reverse
scored; Trusty, Ng, & Watts, 2005). These two higher order factors were used in the
analysis as they are considered to underly all self-report attachment measures (Brennan
et al., 1998), and would better enable the results of the current study to be compared to
existing research.
3.3.1.4 Schwartz Outcome Scale (SOS)
The SOS (Blais et al., 1999) is a brief outcome measure developed for use
across a number of different treatment modalities and theoretical approaches. The SOS
is not specific to any one type of psychological problem; rather it measures a broad
dimension of psychological health encompassing life satisfaction, interpersonal
effectiveness, positive self-appraisal, optimism and the absence of psychiatric
symptoms (Blais & Baity, 2005; Blais et al., 1999).
The SOS consists of 10 items rated on a 7-point Likert scale from 0 (never) to 6
(all or nearly all the time). Sample items are: “I am able to handle conflicts with
others” and, “I feel hopeful about my future.” Scores range between 0 and 60 with
higher scores representing greater psychological wellbeing. A score of 43 is considered
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the cut-off between clinical and non-clinical levels of psychological distress. Scores
from 44-59 indicate minimal distress; from 36-43 indicate mild distress; from 25-35
indicate moderate distress; and from 1-24 indicate severe distress (Blais & Baity, 2005;
Blais et al., 1999).
The SOS has been validated in clinical and non-clinical populations. It is
unifactorial and has acceptable reliability and construct validity. Over a range of
samples internal consistency was high with a Cronbach alpha coefficient between .90
and .96 (Blais & Baity, 2005; Blais et al., 1999; Young, Waehler, Laux, McDaniel,
& Hilsenroth, 2003), and one week test-retest reliability between .86 and .88 (Blais
& Baity, 2005; Blais et al., 1999; Young et al., 2003). The SOS shows positive
correlations with other self-report, projective or observer measures of well-being,
positive affect, desire to live, satisfaction with life and self-esteem. Additionally, the
scale negatively correlates with measures of psychiatric symptoms, hopelessness,
fatigue and negative affect (Blais & Baity, 2005).
3.3.1.5 Depression Anxiety and Stress Scales
The DASS was “designed to measure the negative emotional states of
depression, anxiety and stress” (p. 1) and to be able to discriminate between these states
(Lovibond & Lovibond, 1995). The 21-item version of this scale, the DASS-21, is used
in this research. Items are rated on a 4-point Likert scale from 0 (did not apply to me at
all) to 3 (applied to me very much, or most of the time). Respondents are asked to
consider how they have been over the past week. A total score, ranging from 0-126,
and three subscale scores, ranging from 0-42, can be derived. Higher scores reflect
more severe emotional states. Each subscale consists of seven items; the Depression
subscale consists of items to measure symptoms associated with dysphoric mood; the
Anxiety subscale consists of items that measure symptoms of physical arousal, panic
attacks and anxious affect; and, the Stress subscale items measure symptoms such as
tension, becoming easily upset or agitated, irritability and a tendency to overreact to
stressful events (Martin, Bieling, Cox, Enns, & Swinson, 1998). The three subscales of
the DASS also index a common factor, thus the total score can be considered an
indicator of general psychological distress (Gloster et al., 2008; Henry & Crawford,
2005; Martin et al., 1998).
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Psychometric testing of the DASS-21 shows that the scale has good reliability
and validity. The scale has been found to discriminate between depression, anxiety and
stress, and between clinical and non-clinical samples. It correlates in the expected
directions with conceptually similar and dissimilar scales (Gloster et al., 2008; Henry &
Crawford, 2005; Martin et al., 1998).
Overall, the scale has demonstrated good internal consistency, with Cronbach
alpha ranging from .87 - .94 (Depression), .82 - .87 (Anxiety), .89 - .91 (Stress), and
.93 – .94 (full scale score; Gloster et al., 2008; Henry & Crawford, 2005; Martin et al.,
1998).
A factor structure consistent with the three DASS subscales has been
demonstrated through exploratory (Martin et al., 1998) and confirmatory (Gloster et al.,
2008; Henry & Crawford, 2005) factor analysis of the DASS-21 in clinical and non-
clinical samples. Norms for the DASS were developed based on a large clinical and
non-clinical sample (Henry & Crawford, 2005).
3.3.1.6 Inventory of Interpersonal Problems – 32 (IIP-32)
The IIP-32 (Barkham, Hardy, & Startup, 1994) was developed as a short form from the
Inventory of Interpersonal Problems (Horowitz, Bear, Ureno, & Villasenor, 1988).
The IIP-32 is a measure of interpersonal problems. It has eight subscales: Hard
to be Assertive, Hard to be Sociable, Hard to be Supportive, Hard to be Involved, Too
Aggressive, Too Open, Too Caring, and Too Dependent. The 32 items that comprise
the scale are phrased in terms of what the individual finds hard and what the individual
does too much. For example, “I put other people’s needs before my own too much”, “It
is hard for me to disagree with other people”. Each item is rated on a 5-point Likert
scale from 0 (not at all) to 4 (extremely). The total score is an overall indicator of
interpersonal problems.
The short form was developed after examining the factor structure of the IIP
which was found to have eight interpretable factors (Barkham et al., 1994). The IIP-32
uses the highest loading items on these factors to create the eight subscales described
above. The eight subscales of the IIP-32 have been replicated in a confirmatory factor
analysis (Barkham, Hardy, & Startup, 1996).
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Psychometric testing of the IIP-32 suggests that it has good internal consistency,
has convergent and discriminative validity, is stable (Huber, Henrich, & Klug, 2007;
Woodward, Murrell, & Bettler, 2005), and is sensitive to change (Horowitz et al., 1988;
Huber et al., 2007).
Like the original scale, the IIP-32 has acceptable reliability and validity.
Cronbach alpha ranges from .70 to .89 for the subscales and .86 – .90 for the total score
across a range of samples (Barkham et al., 1996). Two month test-retest reliability for
most subscales fall between .70 – .81. However, subscales Hard to be Assertive, Hard
to be Sociable, and Hard to be Supportive are lower: .56, .66 and .66 respectively. The
scale appears sensitive in detecting change in people who have completed
psychotherapy; it also differentiates a general population sample from a clinical
outpatient sample with the latter obtaining significantly higher scores on all subscales
except Too Open (Barkham et al., 1996).
3.3.1.7 World Health Organisation Quality of Life Scale – Brief
(WHOQoL-BREF)
The WHOQoL-BREF is a self-report scale measuring subjective quality of life
(QOL) which the World Health Organization defines as “an individuals perception of
their position in life in the context of the culture and value systems in which they live,
and in relation to their goals, expectations, standards and concerns” (p. 299; Skevington,
Lofty, & O'Connell, 2004). The WHOQoL-BREF captures “health-driven” QOL such
that it is assumed that full-health relates to maximum QOL (Hagerty et al., 2001).
The WHOQoL-BREF consists of 26-items rated on a 5-point Likert scale.
Twenty-four items are summed and transformed linearly to a 0-100 scale to create four
domain scores; Physical, Psychological, Social Relationships and Environmental. The
two remaining items provide single-item measures of overall QOL and general health.
Higher scores indicate higher QOL.
The domain of Physical Health consists of items enquiring about pain and
discomfort, dependence on medical treatment, energy and fatigue, mobility, sleep and
rest, activities in daily living, and work capacity. The Psychological Health domain
consists of items about positive and negative affect, spirituality, cognitive functioning,
body image and self-esteem. The Social Relationships domain includes three items
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focused on personal relationships, sexual activity and social support. The Environment
domain contains items about physical safety, quality of physical environment, financial
resources, opportunity for acquiring knowledge and skills, recreation opportunities and
participation, and access to quality health care and transportation.
Several studies have demonstrated the WHOQoL-BREF has sound
psychometric properties. Internal consistency has been examined across a range of
samples, including healthy individuals and those with psychiatric or physical illnesses,
and is acceptable for all domains other than the Social Relationships domain. This
domain achieves a marginal internal consistency, with Cronbach alpha between .66 and
.74 (Skevington, Sartorius, Amir, & The WHOQOL Group, 2004), which may be
because it only consists of three items (The WHOQOL Group, 1998). For the
remaining domains, Cronbach alphas range from .82 - .87 (Physical), .75 - .83
(Psychological) and .73 - .81 (Environment; Skevington, Lotfy et al., 2004; Skevington,
Sartorius et al., 2004; The WHOQOL Group, 1998). Test-retest reliability was
examined in a number of well and unwell samples over a two to eight week period.
Pearson correlations were between .66 and .87 for the four domains (The WHOQOL
Group, 1998).
Skevington, Lotfy et al.’s (2004) exploratory and confirmatory factor analysis of
the WHOQoL-BREF demonstrated a four factor solution consistent with the four
domains. However, other studies of the WHOQoL-BREF’s factor structure are
inconsistent (Hagerty et al., 2001).
The Physical, Psychological and Social Relationships domains are sensitive
enough to detect change in a sample of people treated for depression (The WHOQOL
Group, 1998), and domain scores adequately discriminate between people with and
without medical or psychiatric illness (Skevington, Lotfy et al., 2004; The WHOQOL
Group, 1998). Correlations between the WHOQoL-BREF domain scores and other
QOL scales are in the expected direction and demonstrate sufficient construct validity
(The WHOQOL Group, 1998).
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3.3.2 Therapist measures
3.3.2.1 Personal demographics
Therapists were asked to provide their date of birth, sex, and country of origin.
Given that therapists’ mindfulness was a characteristic of interest, and mindfulness is
traditionally fostered through meditation practice, therapists were asked whether they
meditated, and, if so, the type of meditation, frequency of meditation and how long they
had been practising meditation.
3.3.2.2 Professional demographics
Therapists were asked to nominate their main theoretical orientation. They were
also asked to provide the following details about their education and experience:
completed university degrees, amount and duration of completed non-university
counselling/psychology related courses, hours of supervision received to date
(excluding current placement supervision), amount of personal therapy received, and
the amount and duration of counselling-related experience (both paid and unpaid).
3.3.2.3 Cognitive and Affective Mindfulness Scales – Revised (CAMS-R)
The CAMS-R (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007) is a 12-
item self-report measure of mindfulness. The CAMS-R conceptualises mindfulness as
multifaceted; consisting of attention, present-focus, awareness and acceptance. Such a
conceptualisation is consistent with the definitions of Bishop et al. (2004) and Kabat-
Zinn (2003). The CAMS-R assumes mindfulness to be “a response tendency that tends
to be stable across situations, yet is modifiable by life experience including mindfulness
training” (p. 188, Feldman et al., 2007).
The scale consists of 12 items such as “I try to notice my thoughts without
judging them” (Awareness), “I am able to pay close attention to one thing for a long
period of time” (Attention), “I am able to focus on the present moment” (Present-
focus), and “I am able to accept the thoughts and feelings I have” (Acceptance). Each
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item is rated on a 4-point Likert scale from 1 (rarely/not at all) to 4 (almost always).
The total score ranges from 12 - 48 with higher scores indicating a greater degree of
mindfulness.
The scale shows significant associations with other self-report measures of
mindfulness: it correlates .55 with Mindful Attention Awareness Scale (Brown and
Ryan, 2003), .66 with the Freiburg Mindfulness Inventory (Buchheld, Grossman &
Walach, 2002; Feldman et al., 2007) and .67 with the Kentucky Inventory of
Mindfulness Skills (Baer, Smith & Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, &
Toney, 2006). Discriminant and convergent validity has also been established with the
CAMS-R, with the questionnaire correlating in a theoretically consistent manner with
several emotion regulation styles. Specifically, the CAMS-R obtained moderate
correlations with scales measuring wellbeing and adaptive emotion regulation, and
moderate negative correlations with scales measuring psychological distress, worry,
rumination, experiential avoidance, and thought suppression (Feldman et al., 2007).
Confirmatory factor analysis shows that the CAMS-R consists of one second-
order latent factor (mindfulness) and four first order latent factors: attention, present-
focus, awareness, and acceptance (Feldman et al., 2007). The overall scale has been
found to have an acceptable level of internal consistency (Cronbach alpha .74 – .81)
across a range of samples (Baer et al., 2006; Feldman et al., 2007). The first-order
latent factors have low internal consistency and medium to large first-order covariances,
suggesting that there is considerable interrelationship between them. Thus use of these
factors to derive subscale scores is discouraged (Feldman et al., 2007).
3.3.2.4 NEO – Five Factor Inventory (NEO-FFI)
The NEO-FFI (Costa & McCrae, 1985) consists of five scales (labelled N, E, O,
A, C) widely used to measure the “Big Five” personality dimensions: neuroticism,
extraversion, openness to experience, agreeableness and conscientiousness. These
dimensions, as defined by Costa and McCrae (1985) are articulated below.
Neuroticism reflects maladjustment and a susceptibility to experience emotional
distress and negative affect. Those high in neuroticism have a tendency towards
irrational ideas, impulsivity, and a diminished ability to cope with stress. In contrast,
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those low in neuroticism are emotionally stable, calm and even-tempered, and more able
to cope with stressful situations.
Extraversion is the tendency towards sociability. Extraverts prefer large groups,
are talkative, active and assertive. They have an upbeat, optimistic, energetic
disposition. Introverts on the other hand are reserved, have a preference to be alone,
have even-paced energy and are independent.
People high in openness to experience are curious about themselves and the
world around them. They have an active imagination and are independent, such that
they are prepared to think about unconventional ideas and values. They tend to have
experientially rich lives, experiencing emotions more intensely than those low on this
trait. Those low on this dimension may be described as closed. This trait is not
considered to be a psychological defence, rather people low on this dimension are
conservative, prefer familiarity and have more muted emotional responses and a
narrower range of interest than those high on this personality dimension.
Agreeableness reflects a person’s interpersonal style. People who are agreeable
can be considered altruistic, sympathetic to others, wanting to help others and trusting
that others will help them. Those who are disagreeable will tend to be egocentric,
competitive and sceptical of others. Although agreeable people tend to be more
popular, they are not necessarily more psychologically healthy than disagreeable people.
Conscientiousness relates to a person’s self-control and abilities in planning and
completing tasks. People who are conscientious are determined, purposeful and
achievement oriented. Those high in conscientiousness are reliable and meticulous,
they are likely to achieve occupationally and academically, and have a tendency for
fastidiousness and workaholism. Those low on conscientiousness will be more casual
in working towards their goals.
The NEO-FFI is a 60-item scale derived from the longer, 240-item NEO-PI-R.
Items are rated on a 5-point Likert scale from 0 (strongly disagree) to 4 (strongly
agree), or from 4 - 0 in the case of reverse scored items. Raw scores are converted to
gender-specific standardised scores (T-scores), which have a mean of 50. The majority
of scores are between 20 and 80. Although each scale measures a personality dimension
rather than categories, scores can be summarised as very low (T≤34), low (T= 35-44),
average (T= 45-55), high (T= 56 – 65) and very high (T≥66).
The factor structure of the NEO-FFI has been shown to be consistent with its
subscales (Murray, Rawlings, Allen, & Trinder, 2003) and adequate for the
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measurement of the Big Five personality factors (Tokar, Fischer, Snell, & Harik-
Williams, 1999). Test-retest reliability is adequate over 3 months (.79, .79, .80, .75, .83;
Costa & McCrae, 1992) and 30 months (.75, .83, .86, .73, .80); for N, E, O, A, and C
scales respectively (Murray et al., 2003). Cronbach alpha coefficients for the five
subscales are between .73 to .87 (Holden & Fekkan, 1994; Murray et al 2003)
suggesting that, overall, it has adequate internal consistency.
3.3.2.5 Acceptance and Action Questionnaire – II (AAQ-II)
The AAQ-II (Bond et al., 2009) is a measure of experiential avoidance.
Experiential avoidance “occurs when a person is unwilling to remain in contact with
particular private experiences (e.g. bodily sensations, emotions, thoughts, memories,
images, behavioural predispositions) and takes steps to alter the form or frequency of
these experiences or the contexts that occasion them, even when these forms of
avoidance cause behavioural harm” (Hayes et al., 2004, p. 554). The scale consists of
10 items, which are rated on a 7-point Likert scale from 1 (never true) to 7 (always
true). Scores range between 7 and 70; low scores indicate experiential avoidance and
high scores indicate experiential acceptance (also called psychological flexibility).
Preliminary research suggests that scores below a cut off between 45 and 48 indicate
psychological distress (Bond et al., 2009).
To determine the psychometric properties of the scale, data from 3280
participants across seven diverse samples were analysed (Bond et al., 2009). The mean
Cronbach alpha was .83 with a range from .76 – .87. Test-retest reliability was .80 at 3
months, and .78 at 12 months. Exploratory and confirmatory factor analysis conducted
on a range of diverse samples suggests that the scale is unifactorial (Bond et al., 2009).
The AAQ-II appears to have good convergent and discriminant validity,
correlating with theoretically similar or dissimilar scales in the expected directions
(Bond et al., 2009) and correlating with response delay (an indicator of avoidance) in an
experimental study (Cochran, Barnes-Holmes, Barnes-Holmes, Stewart & Luciano,
2007). The AAQ-II has good predictive validity, predicting scores on a self-report
measure of psychological distress after 12 months as well as various objective measures
of workplace performance (Bond et al., 2009).
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3.3.2.6 Counsellor Theoretical Orientation Scale (CTOS)
The CTOS (Poznanski & McLennan, 1999) is designed to measure therapists’ beliefs
about the practice of counselling. The scale consists of two subscales, each measuring
a dimension of therapists’ preferred way of knowing. The Rational-Intuitive subscale
measures therapists’ preference for logical and analytic reasoning or intuitive knowing.
This subscale includes items such as “the concept of unconscious processes is of limited
therapeutic value”. The Objective-Subjective subscale measures therapists’ views of
reality in terms of rationalism and empiricism, or subjective experience. It includes
items such as “valid information comes only from empirical research”.
Each subscale consists of 20 statements which respondents rate on a 7-point
Likert scale from one (completely disagree) to seven (completely agree). Scores on
each subscale range from 20-140. Higher scores on each subscale indicate preferences
for rational (versus intuitive) knowing and objective (versus subjective) knowing.
Factor analysis indicates a two-factor solution that is consistent with the
theoretically derived subscales. Internal consistency is adequate, with Cronbach alpha
of .87 for the Objective-Subjective, and .81 for the Rational-Intuitive subscales
(Poznanski & McLennan, 1999). Concurrent validity has been demonstrated by
comparing therapists’ CTOS scores with their self-ascribed theoretical frameworks.
Consistent with the theoretical literature, compared to therapists of other frameworks
cognitive behavioural therapists showed highest preference for rationality and
objectivity, psychodynamic therapists showed highest preference for intuition,
experiential/phenomenological therapists showed highest preference for subjectivity and
family/systemic therapists had intermediate scores on both subscales (Poznanski &
McLennan, 1999).
3.3.2.7 Young Schema Questionnaire – Short Form 3
The YSQ-S3 (Young, 2005) is a 90-item self-report scale that is an extension of
the 75-item Young Schema Questionnaire – short form 2 (YSQ-S2; Young & Brown,
2003). The YSQ-S2, inturn, was derived from the full, 205-item, version of the scale
(YSQ; Young & Brown, 1990). Items with the highest factor loadings on the full scale
were selected for the YSQ-S2. The YSQ-S3 is essentially the same as its earlier
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version, with the addition of 15 items that measure a further three EMS: Approval-
Seeking/Recognition-Seeking; Negativity/Pessimism; and Punitiveness. The eighteen
EM S are arranged under five schema domains as displayed in Table 3.1.
The “schema domains”, “schema subscales” and items that make up the YSQ-S3
were theoretically derived. Results of factor analytic studies of the YSQ-S2 support the
theoretical structure of the scale. Welburn, Coristine, Dagg, Pontefract and Jordan
(2002), using a clinical population, found the YSQ-S2 had 15 factors, with 70 of the 75
items loading on factors consistent with the scale’s theoretical structure. Only one item
did not have a significant loading on any factor, and four items cross-loaded on two
factors. The EMS Dependency/Incompetence had three of the four cross loading items,
suggesting that there is some overlap between this EMS and the EMS Insufficient Self-
Control/Self Discipline, Subjugation, and Vulnerability to Harm or Illness. Subsequent
exploratory and confirmatory factor analysis in samples of South Korean and Australian
students suggest a 13-factor solution, with the Dependence/Incompetence and
Enmeshment/Undeveloped Self EMS not being supported in these analyses (Oei &
Baranoff, 2007).
The YSQ-S2 schema subscales appear to have good reliability, with most
studies reporting alpha coefficents between .71 and .93 (Glaser, Campbell, Calhoun,
Bates, Petrocelli, 2002; Waller, 2001; Welburn et al., 2002), however in Stopa’s study
the Vulnerability to Harm or Illness, and Dependence/Incompetence EMS had
reliability coefficients below .7. The construct validity of the YSQ-S2 has been
supported in several studies where the schema subscales were associated, in
theoretically coherent ways, with symptoms of anxiety, depression (Glaser et al., 2002;
Welburn et al., 2002), paranoia (Welburn et al., 2002), and general psychological
distress (Glaser et al., 2002). There is also evidence of the scale’s discriminative
validity. Waller, Meyer and Ohanian (2001) found women with bulimia nervosa scored
higher than women without this disorder on 14 of the 15 YSQ-S2 EMS. Furthermore,
the Defectiveness/Shame and Insufficient Self-Control/Self-Discipline EMS
discriminated women with and without bulimia.
There is some evidence that females and males score differently on the YSQ-S2.
Welburn et al. (2002) found that females scored higher than males on five EMS: Self-
Sacrifice, Enmeshment/Undeveloped Self, Failure, Abandonment/Instability and
Defectiveness/Shame, and Stopa, Thorne, Waters and Preston (2001) found males
scored higher than females on the Entitlement/Grandiosity EMS. In one study,
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respondents’ mood state had a small yet statistically significant impact on their scores
on the Emotional Deprivation, Defectiveness/Shame, and Entitlement/Grandiosity EMS
(Stopa et al., 2005).
Unlike the YSQ-S2 the YSQ-S3 does not have any published studies of its
psychometric properties. Given that 75 items and 15 EMS are the same on both
versions, the psychometric properties of the earlier version can be assumed to apply to
the 15 schema subscales that are in the later version. However, for the three additional
schema subscales on the latest version (i.e. Approval-Seeking/Recognition-Seeking,
Negativity/Pessimism, and Punitiveness), the psychometric properties are not
established at this point.
3.3.2.8 Attachment Style Questionnaire
A description of this scale was provided earlier (see section 3.3.1.3).
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Table 3.1 Organisation of Subscales on the YSQ-S3 Schema Domain and Schema subscales Disconnection and rejection Defectiveness / Shame Abandonment / Instability Emotional Deprivation Mistrust / Abuse Social Isolation / Alienation Impaired autonomy and performance Failure Vulnerability to Harm or Illness Enmeshment / Undeveloped Self Dependence / Incompetence Impaired limits Insufficient Self-Control / Self-Discipline Entitlement / Grandiosity Other-directedness Subjugation Self-Sacrifice Approval-Seeking / Recognition-Seeking Overvigilance and inhibition Punitiveness Emotional Inhibition Negativity / Pessimism Unrelenting Standards / Hypercriticalness
3.4 Procedure
Client and therapist data were collected between September 2006 and December
2008. Clients were allocated to therapists through the clinic’s triage procedure, which
involved the Clinic Director assigning each client to a therapist. This assignment was
based on (a) the availability of the client and therapist; (b) the client’s requests for
therapists with certain attributes (e.g. gender, age); (c) perceived difficulty and content
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of the client’s presenting problem; (d) the therapist’s interests (e.g. to work with adults /
children, certain types of problems); and (e) the therapist’s level of skill and experience.
Prior to commencement of this study an audit of previous data collection in this clinic
was undertaken and used to inform extensive data collection procedures (see Appendix
B). Ethics approval was granted by Swinburne University Human Research Ethics
Committee (see Appendix C).
3.4.1 Client sample
Clients of the clinic were invited to complete three types of questionnaires, an
Initial Questionnaire, Progress Questionnaires, and a Final Questionnaire. The scales
comprising each of these questionnaires are detailed in Table 3.2 and the complete
questionnaires are provided in Appendix D.
3.4.1.1 Initial Questionnaire
The Initial Questionnaire was distributed to all new clients at the clinic on the
occasion of their first visit. Following its completion clients began their therapy.
3.4.1.2 Progress Questionnaire
Progress Questionnaires were given to clients at the end of every fourth session
by their therapists. Clients were invited to complete the Progress Questionnaire
regardless of whether they had completed the Initial Questionnaire. Clients new to the
study were given written information and asked for written consent to participate at this
point. Progress Questionnaires were completed at the end of the session or taken home,
completed and returned at the next session.
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3.4.1.3 Final Questionnaire
Final Questionnaires were given to participating clients who either unilaterally
or bilaterally terminated counselling. These questionnaires were given to clients by
their therapists in the final session or posted to them by the researcher with instructions
to return the questionnaire within the reply paid envelope provided. In cases where the
questionnaire was not returned within one month a reminder was posted. Given the
delay in confirming that the client had terminated, often final questionnaires were
returned several months after the final session. Only questionnaires completed within
six weeks of termination were included in the data analysis.
Table 3.2 Client Questionnaires Scales Construct Initial Progress Final
Questions about personal demographics
Personal demographics
X
Schwartz Outcome Scale Wellbeing X X X
World Health Organisation Quality of Life
Quality of life X X
Depression Anxiety and Stress Scale
Psycho-pathology X X X
Attachment style questionnaire Adult Attachment X
Inventory of interpersonal problems -32
Interpersonal functioning
X X
Working alliance inventory – short form revised
Therapeutic relationship
X X
In order to increase therapist compliance to the research protocol, the researcher
scored the questionnaires and provided a copy of each client’s scored questionnaires to
their therapists. This was the case for all questionnaires other than the WHOQoL-
BREF and WAI-SR. The psychometric properties of the WHOQoL-BREF make it
inappropriate for individual assessment (TheWHOQoLGroup, 1998). The WAI-SR
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results were not distributed to therapists as, given that the scale asks clients to rate their
relationship with their therapist, doing so may have influenced clients’ responses. In
order to increase client compliance, they were informed that the WAI-SR would not be
seen by their therapists. In order to maintain client confidentiality, clients handed their
questionnaires, in a sealed envelope, to the receptionist.
3.4.2 Therapist sample
Therapists who were currently working, or began work, at the clinic during the
data collection period were given written information about the project and asked to
complete the ‘Therapist Questionnaire’. Participation was voluntary and completed
questionnaires remained confidential. Questionnaires were coded to ensure the
researcher remained blind as to which therapists completed each questionnaire.
Information about the blinding procedures was given to therapists to reassure them of
their confidentiality and to enhance the likelihood of accurate responding. Therapists
were sent up to four written reminders about returning the questionnaires. A complete
copy of therapists questionnaire is provided in Appendix E.
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CHAPTER 4
ANALYTIC METHOD
4.1 Preliminary Analysis
Preliminary analysis was undertaken to establish whether the sample of clients
with therapists’ data available was equivalent to the sample of clients without
therapists’ data available on baseline measures and on early alliance scores. No data on
non-participating clients of non-participating therapists were available
Preliminary analysis was also undertaken to examine whether the clients in the
sample benefited from counselling. This would help establish whether this client group
behaves in a similar fashion to other client groups in that they experience a decrease in
symptoms. Given that the clients were being counselled by student therapists this was
important to establish empirically.
4.1.1 Differences between clients with and without therapist data
A series of two-level Multilevel Models (MLM; see Figure 4.1) were specified
to determine whether therapists who had or had not provided data had equivalent client
caseloads with respect to client symptoms at baseline, and early WAI-SR ratings (i.e.
the first measurement of alliance which occurred at session 2, 3, 4, 5 or 6). At level one
(client level) each client baseline symptom measure or the early WAI-SR rating was
entered as the dependent variable in separate analysis. At level two (therapist level) a
binary variable specifying whether therapists had provided data (“DATA”) was entered
as an independent variable. The intercept was specified as random in order to test
whether therapists differed on the intercept, and, if so, whether it was explained by the
variable DATA.
4.1.2 Symptomatic improvement over the course of therapy
A series of three-level MLMs (see Figure 4.2) was constructed to examine client
symptom change over the course of therapy. Level one consisted of clients’ scores on
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each symptom measure completed pre- and post-therapy in the case of WHOQoL-
BREF and IIP-32; or repeatedly administered over the course of therapy in the case of
DASS and SOS. Level two consisted of clients nested within therapists, and level three
consisted of therapists. Only clients who would be included in the main analysis, that
is those with accompanying therapists’ data, were included in this analysis.
A growth curve MLM was chosen as it was able to deal with both missing data,
and the nested design. Further discussion of the suitability of MLM for this type of
data is given in section 4.2. Following the example of Lutz et al. (2007), and Elkin et al.
(2006a) curvilinear growth on symptom measures was modelled by using log
transformation of session number. This assumes that the most rapid response occurs
early in therapy and change slows down as therapy progresses (Baldwin, Berkeljon,
Atkins, Olsen, & Nielsen, 2009). The slope was allowed to vary at random between
therapists and between clients. The intercept was fixed at the client and therapist level.
Anchoring the slope in this way reduces the intercept source of random variation and
increases the reliability of the slope estimate, improving statistical power (Elkin et al.,
2006b).
Figure 4.1. Two-level multilevel model.
Figure 4.2. Three-level multilevel model.
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4.2 Main Analysis
The main analysis examined the following hypothesis:
(1) there would be significant difference between therapists on the early client-rated
alliance;
(2) there would be a significant difference between therapists on the rate of growth in
alliance over sessions;
(3) therapists’ EMS, personality, attachment, mindfulness, experiential avoidance,
amount of supervision, amount of therapy and theoretical orientation would be
associated with their early alliance scores;
(4) therapists’ EMS, personality, attachment, mindfulness, experiential avoidance,
amount of supervision, amount of therapy and theoretical orientation would be
associated with the rate of growth in alliance over sessions;
(5) therapist and client attachment would interact in their association with the early
alliance. Specifically, early alliance would be higher when the therapist and client
had different attachment styles (i.e. anxious attachment and avoidant attachment);
(6) therapist and client attachment would interact on their association with the rate of
growth in alliance over sessions. Specifically, alliance growth would be higher
when the therapist and client had different attachment styles;
(7) Therapists’ level of experience and client attachment will interact in their association
on alliance, whereby when clients have greater attachment insecurity more
experienced therapists will have higher early alliance than less experienced
therapists;
(8) Therapists’ level of experience and client attachment will interact in their association
on alliance, whereby when clients have greater attachment insecurity more
experienced therapists will have stronger rate of growth in alliance than less
experienced therapists.
4.2.1 Conceptual considerations
As previously stated, the nature of the data was nested, with each therapist
having several clients, and each client having several repeated measures. Whilst the
study protocol specified that the progress questionnaire (which included the WAI-SR)
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was to be completed every four sessions, starting at session four, in actuality this is not
what transpired. Few clients completed a progress questionnaire every four sessions.
Given the hypothesis and nature of the data MLM was considered to be the
most suitable analytic method. This method enables the use of all data without
requiring cases with missing time points to be deleted and can handle unequal sample
sizes within therapists (Baldwin et al., 2007). It is also possible to analyse nested data
without violating the assumption of independent observations (Baldwin et al., 2007) and
the assumption of homogeneity of regression (Taska, Illing, Joyce, Ogrodniczuk, 2009)
that is required for traditional multiple regression. In fact, rather than nested data being
a source of methodological problems, in multilevel approaches the amount of variance
at each level of the analysis can be explained (Baldwin et al., 2007).
There is considerable argument as to the most appropriate specification of
multilevel models for the examination of therapist effects (Soldz, 2006; Elkin et al.,
2006b; Wampold & Bolt, 2006; Serline, Wampold & Levin, 2003; Crits-Christoph, Tu
& Gallop, 2003). The relevant arguments will be considered in turn to determine the
most appropriate specification for the requirements of the current analysis.
4.2.1.1 Growth model versus last-point carried forward
Growth models that include data observed during treatment provide a better
account of how clients change over time and increase the reliability of change rates, and
thus increase the statistical power of the model (Elkin et al., 2006b). However, in these
models client variability is increased compared to models using only pre- and post-data
(Wampold & Bolt, 2006). The increase in client variability reduces therapist variability
and thus decreases therapist effects (Wampold & Bolt, 2006). An alternative to growth
models is to use only two data points utilising the last data point carried forward
approach to deal with missing data. However, such analyses assume no change after the
last available data point (Elkin et al, 2006b) and treat endpoint data as if it were
collected at the same time-point. This may violate the assumption that data is missing
completely at random (Crits-Christoph, Tu & Gallop, 2003).
Given the naturalistic nature of the current research, clients varied in the number
of sessions that they completed. Thus there is not a discrete endpoint for the sample as
a whole. Further, there are too few completed final questionnaires (n = 29) to complete
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the analysis with this data alone. For these reasons, it was considered preferable to use
a growth curve model rather than the last-point carried forward method. Furthermore,
given the size of the sample, increasing the power of the model through using a growth
curve approach remained desirable despite the consequent inflation of client variance.
4.2.1.2 Anchoring the intercept
Whether or not the intercept is anchored requires specification in a growth curve
model. Wampold and Bolt (2006) have argued client variance is (spuriously) increased
in models where the intercept is anchored, as this assumes that the baseline measure has
no measurement error, thus variance in the initial scores becomes variability in client
slopes. This, in turn, can reduce estimates of therapist effects as demonstrated by
Wampold and Bolt (2007) in a simulation study. As well as reducing therapist effect
sizes, anchoring the first observation violates the assumption that all repeated
measurements contain equal amounts of error (Wampold & Bolt, 2007). In contrast
Elkin et al. (2006b) suggest client intercepts should be anchored in therapist effects
research, as doing so allows clients’ trajectories to be summarised by the rate of change.
They also suggest that anchoring in this way reduces the intercept source of random
variation and increases the reliability of the slope estimate, improving statistical power.
Anchoring was not appropriate in the current study, as accurate estimation of therapist
and client variance was considered more important than estimating the rate of change in
alliance. Further, anchoring the intercept would mitigate against examining differences
between therapists on the alliance at intercept.
4.2.1.3 Outliers
Another consideration is how outliers should be treated. Wampold and Bolt
(2006) argue that classifying very competent or incompetent therapists as outliers and
eliminating them from an analysis is nonsensical, suggesting that it would be analogous
to eliminating clients with very poor or good outcomes from a treatment study,
something clearly unacceptable in research trials of therapies. Deleting high-
performing or low-performing therapists has the effect of reducing therapist variability
and thus reducing therapist effects (Wampold & Bold, 2006). In the Elkin et al.
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(2006a) study of therapist effects on outcome, therapist effects were mainly attributable
to one therapist, representing 1.85% of the sample (Lutz et al., 2007). Lutz et al. (2007)
argue “the importance of therapist effects is more limited if they are attributed to a very
small number of extremely good or poor therapists” (p. 33), thus, in their study of
therapist effects they reanalysed the data with extremely high and low performing
therapists removed. This approach, however lacks ecological validity. In “real-world”
practice low- and high-performing therapists are unlikely to be detected, let alone
stopped from practising. Wampold and Bolt (2006) convincingly argue that the
removal of therapist outliers in therapist effects research is not acceptable, regardless of
whether there is only two percent or more therapists who outperform (or under perform)
other therapists. The objective of therapist effects research is to examine the degree to
which therapists differ in their performance, thus deleting the extremes of the
distribution would result in an analysis that only examines differences between
therapists vetted as average. This is not the question at hand. Given these
considerations therapist outliers of this nature are retained in the analysis. As
recommended by Stoltz (2006) therapist outliers are reported.
4.2.1.4 Sample size
Kreft and de Leeuw (1998) suggest for a two-level MLM a minimum of 30
groups with 30 observations per group. The current sample is somewhat smaller than
this, however the use of MLM with samples smaller than Kreft and de Leeuw’s (1998)
recommendation is an acceptable practice as evidenced by publication in peer reviewed
journals (e.g. Sauer et al., 2003; Dinger et al., 2009; Elkin et al. , 2006a; Kim et al.,
2006; Hersoug et al., 2009; Zuroff, Kelly, Leybman, Blatt & Wampold, 2010). An
alternative to MLM would be to use multiple regression models with higher-order
variables disaggregated to the individual level, or individual level data aggregated to
higher levels. However, this would result in a violation of the assumption of
independent observations, thereby increasing chances of Type I errors (Tasca et al.,
2009). Given these considerations MLM remained an appropriate choice for the current
study. The small sample limits the robustness of the analysis and is taken into
consideration in the interpretation of the results.
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In sum, given the above considerations and hypotheses to be examined, two
types of MLM were used: a two-level fully unconditional model and three-level growth
curve models.
4.2.2 Two-level fully unconditional model
A two level growth model was used to test hypothesis one: that there would be
significant difference between therapists on the early alliance. The two levels consisted
of clients within therapists (level one), and therapists (level two). At level one early
WAI-SR ratings were entered as the outcome variable. This was a fully unconditional
model (no predictor variables were entered at level one or two). This model produces
three parameters: the fixed and random effects for the intercept, and estimate of error
variance.
Prior to conducting the analysis it was planned to use two level growth models
to test the hypothesis regarding the association between therapists’ professional and
personal characteristics on early alliance (hypotheses three) and the interaction between
therapist attachment or experience and client attachment on early alliance (hypotheses
five and seven). Given the non-significant result of the unconditional model (see
section 5.5.1) these hypotheses did not need to be tested.
4.2.3 Three-level growth models
The second set of unconditional and conditional models included three levels:
repeated measures within clients (level one), clients within therapists (level two), and
therapists (level three). At level one the outcome variable was the clients’ WAI-SR
rating (log transformed). This was modelled as a linear function of session number.
Although it would be informative to examine curvilinear growth there was not enough
power in the model and data set to include both linear and curvilinear session slopes.
Furthermore, in order to model curvilinear growth, three data points are required, and
since not all clients had three data points, this requirement would have substantially
reduced the sample size. Linear-growth alliance patterns seem to be the most common
(de Roten et al 2004, Kivlingham & Shaughnessy, 2000; Stiles et al., 2004; Kramer et
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al., 2009) and are related to treatment outcome (Kramer et al., 2009). Given these
considerations only linear growth was modelled.
Two parameters were estimated at each level in this model: the intercept, which
was the client’s initial alliance score; and the slope, which was the change in alliance
score each session. It was expected that the initial WAI-SR score (i.e. intercept) and
change in WAI-SR scores over time (i.e. slope) would differ between clients, thus the
intercept and slope were specified as random at level two. Similarly, at level three
(therapists) the intercept and slope were specified as random in order to enable an
analysis of difference between therapists.
4.2.3.1 Unconditional model
An unconditional model was specified in order to test hypothesis two: that there
would be a significant difference between therapists on the rate of growth in alliance
over sessions. In this model no independent variables were entered at level two or
three.
4.2.3.2 Conditional models
A set of conditional models was specified to test hypothesis four, that therapists’
EMS, personality, attachment, mindfulness, experiential avoidance, amount of
supervision, amount of therapy and theoretical orientation would be associated with the
rate of growth in alliance over sessions. An approach of exploratory model building
was undertaken in order to identify which therapist characteristics best explained the
WAI-SR intercept and slope. The therapist characteristics in question were those
measured by ASQ - higher order factors Anxiety and Avoidance; NEO-FFI scales;
CAMS-R; AAQ-II; CTOS scales; selected YSQ-S3 scales; amount of personal therapy;
and, amount of supervision. Given the early stage of development of this body of
research, and that entering all variables simultaneously was not possible with the given
sample size, an exploratory approach was considered appropriate and consistent with
the approach taken in the published literature (e.g. Sauer et al., 2003; Dinger et al.,
2009).
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Following the example set by Dinger et al., (2009), as a first step, therapist
variables were entered separately at level three. This screening method, while enabling
an orderly selection of variables for the final model, increases the chances of Type I
error. Given this, unlike Dinger and colleagues who used a significance level at p <.10,
a more stringent significance level of p <.05 was chosen for inclusion in the final model.
As a second step, therapist variables that were found to be significant in the screening
were entered simultaneously in a three-level growth model.
4.2.3.3 Three level conditional growth models with cross-level interaction terms
Hypothesis six was that therapist and client attachment would interact on their
association with the growth in alliance. Specifically, alliances would be higher when
the therapist and client had different attachment styles (e.g. anxious attachment and
avoidant attachment). In order to examine this hypothesis, clients’ Anxiety and
Avoidance scores (on the ASQ) were entered at level two, and therapist Anxiety and
Avoidance scores were entered at level three. This created the interaction terms for
both the intercept and the slope: client Avoidance × therapist Avoidance; client
Avoidance × therapist Anxiety; client Anxiety × therapist Avoidance; and, client
Anxiety × therapist Anxiety.
The client attachment variables entered at level two were group mean centred in
order to adjust for any therapist differences in regards to client attachment. Group mean
centring is considered preferable to grand mean centring in naturalistic research designs
in order to adjust for any differences between therapists which may arise from non-
random assignment of clients to therapists (Gallop & Tasca, 2009). Error terms were
not included for the interactions as there were too few degrees of freedom to run a
model with this many parameters.
Finally, a model was developed in order to examine hypothesis eight: that
therapists’ level of experience and client attachment will interact in their association on
alliance, whereby when clients have greater attachment insecurity more experienced
therapists will have stronger growth in alliance than less experienced therapists. In this
model clients’ Anxiety and Avoidance scores were entered at level two (group mean
centred) and therapist Experience was entered at level three. Again error terms were not
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included for the interactions as there were too few degrees of freedom to run a model
with this many parameters.
All multilevel data analyses were conducted with HLM 6 software
(Raudenbush, Bryk, Congdon, 2000). All other analyses were conducted with PASW
Statistics - Version 18 (2009).
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CHAPTER 5
RESULTS
5.1 Descriptive Statistics
5.1.1 Client descriptive statistics for baseline measures and early WAI scores
Descriptive statistics for client baseline measures (i.e. from the Initial
Questionnaire) are reported in Table 5.1. Scores on the SOS and DASS indicate clients
ranged from minimally to severely distressed. SOS mean scores indicate moderate
distress commensurate with clinical population norms (Blais & Baity, 2005) and more
severe (i.e. 5 points lower) than a comparable US outpatient sample (Blais & Baity,
2005). Similarly, scores on the DASS indicate clients, on average, were experiencing
moderate levels of depression, anxiety and stress. Compared to Australian outpatient
norms (Lovibond & Lovibond, 1995) the client sample was, on average, slightly less
anxious and depressed (both 4 points lower), and had similar levels of stress.
Scores on the Psychological and Social subscales of the WHOQoL-BREF were
20 points lower than Australian inpatient and outpatient norms, indicating the sample
had substantially lower QOL on these domains than the comparison sample. On the
remaining WHOQoL-BREF domains the sample had similar average scores to the
Australian outpatient norms.
The IIP-32 and ASQ give an indication of client interpersonal functioning.
Scores on the IIP-32 and ASQ covered the full range of possible scores, suggesting
clients varied substantially in interpersonal functioning and covered the full spectrum of
attachment security and insecurity.
Means and standard deviations on the IIP-32 were similar to US norms from a
university outpatient clinic (Barkham et al., 1996) and indicated, on average, that clients
experienced a moderate degree of interpersonal problems. Comparison sample means
are only available for the five ASQ subscales, not the two higher-order factors. The
mean scores for the five subscales in the client sample were similar to those obtained in
samples of people who were categorised as being insecurely attached (Ng & Trusty,
2005; Feeney et al, 1994).
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Pearson correlations between ASQ subscales are displayed in Table 5.2. The
pattern of correlations between subscales is consistent with the two higher-order factors
Anxiety and Avoidance. As has been found elsewhere, scales representing Avoidance
were moderately correlated with scores representing Anxiety (Ng & Trusty, 2005)
suggesting that these dimensions of attachment are not mutually exclusive. It is notable
that most of the correlations were larger than those found in comparable samples
(Fossati et al., 2003; Feeney et al., 1994; Ng & Trusty, 2005), indicating a greater
degree of overlap between attachment dimensions in this sample.
The internal consistency for most of the client baseline measures were above
acceptable cutoffs with Cronbach alpha .7 or above (Pallant, 2007). The internal
consistency for IIP Too Dependent, WHOQoL Social, WHOQoL Environmental were
below this cut off. Low reliability of WHOQoL Social subscale has been reported
elsewhere and is attributed to its small number of items (The WHOQOL Group, 1998).
Given that these scales had good psychometric properties generally (Barkham et al,
1996; The WHOQOL Group, 1998; Skevington, Sartorius et al., 2004) and were not
involved in the primary analysis no further action was required.
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Table 5.1 Descriptive Statistics for Client Baseline Measures
Sample with therapist data
Sample without therapist
data Whole sample
Variable n M SD Range n M SD Range Cronbach alpha
DASS Total 161 51.48 26.38 2-120 39 54.31 28.79 0-110 .94 Anxiety 172 12.38 9.66 0-38 42 14.21 10.89 0-38 .84 Depression 177 17.86 10.92 0-42 42 18.5 10.69 0-42 .90 Stress 174 21.13 9.54 0-42 39 22.77 10.79 0-42 .87 SOS 180 31.66 11.50 0-59 41 30.27 11.00 6-56 .92 IIP-32 Total 160 1.49 0.64 0-3.6 38 1.47 0.65 0.2-3.4 .87 Hard to be assertive 176 1.89 1.07 0-4 39 1.71 1.08 0-3.5 .87 Hard to be sociable 178 1.54 1.09 0-4 40 1.78 1.18 0-4 .89 Hard to be supportive 180 1.05 0.99 0-4 40 .9 0.89 0-3.3 .84 Hard to be involved 175 1.37 1.06 0-4 40 1.34 1.08 0-3.8 .80
Too open 178 1.66 0.94 0-4 39 1.69 0.93 0-3.3 .70 Too caring 173 1.69 0.92 0-4 40 1.69 0.99 0-3.8 .76 Too dependent 178 1.65 0.88 0-4 40 1.61 0.92 0-4 .68 Too aggressive 179 1.37 1.06 0-4 40 1.31 0.89 0-4 .87
WHO QoL Psychological 172 45.13 17.06 0-96 39 43.06 16.61 15-88 .80 Physical 171 62.97 17.70 0-96 40 65 15.87 14-96 .80 Social 174 45.11 22.42 0-100 41 48.58 23.19 0-92 .69 Environmental 173 61.01 15.05 12-97 39 62.34 17.52 25-94 .57
ASQ Avoidance 168 3.30 0.69 1.6-5.1 37 3.35 0.82 1.6-4.8 .91 Anxiety 167 3.88 0.77 2.0-5.5 38 3.79 0.78 1.7-5.0 .85 Confidence 174 3.63 0.89 1.1-6.0 39 3.48 0.99 1.0-5.4 .85 Secondary 171 2.52 0.77 1.0-4.6 39 2.32 0.82 1.0-4.3 .73 Preoccupation 171 3.93 0.78 2.0-5.9 40 3.87 0.86 2.0-5.6 .75 Discomfort 174 3.79 0.84 1.8-5.8 39 3.98 1.01 2.0-5.7 .86 Approval 172 3.83 0.95 1.4-6.0 38 3.71 0.98 1.3-5.9 .81 Note. Confidence = Confidence (in Self and Others); Secondary = Relationships as Secondary; Preoccupation = Preoccupation with Relationships; Discomfort = Discomfort with Closeness; Approval = Need for Approval.
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Table 5.2 Pearson Correlations Between ASQ Subscales for Client Sample Subscale 1 2 3 4 1. Confidence - 2. Discomfort -.65** - 3. Approval -.59** .54** - 4. Preoccupation -.46** .35** .58** - 5. Secondary -.37** .48** .38** .26** Note. *p < .05; **p < .01.
Descriptive statistics for early WAI-SR scores are reported in Table 5.3. For
both the subsamples with and without therapists’ data, scores on the Bond subscale
were highest, followed by Goal and Task subscales. The internal consistency for WAI-
SR total and subscales were all above .8 suggesting the scale had very good internal
consistency in this sample (Pallant, 2007).
Table 5.3 Descriptive Statistics for Early WAI-SR Ratings Sample with therapist data Sample without therapist data Whole sample
WAI-SR subscale n M SD Range n M SD Range Cronbach alpha
Total 75 3.83 0.59 2.17-4.83 14 3.89 0.67 2.25-4.83 .88
Task 79 3.62 0.70 2.0-4.75 14 3.42 0.90 1.25-4.5 .82
Goal 76 3.82 0.76 1.5-5.0 14 3.97 0.92 2.25-5.0 .85
Bond 79 4.04 0.78 1.0-5.0 15 4.27 0.76 2.5-5.0 .83
5.1.2 Descriptive statistics for therapist measures
Descriptive statistics for therapist measures are reported in Table 5.4.
Therapists’ CAMS-R scores were restricted in range with no scores below 29,
indicating the sample did not contain therapists with low levels of mindfulness. The
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mean score on the CAMS-R (M = 38.49) was almost identical to the mean found in a
sample of 58 Australian Psychotherapists (M = 38.20; May & Donovan, 2007) and
somewhat higher than the means found in student and psychiatric samples (M = 31.4
and M = 29.1 respectively; Feldman et al, 2005). The mean therapists’ score on the
AAQ-II (M = 55) was higher than that of community norms (M = 50; Bond et al., 2009)
and well above the cutoff (45-48) for psychological distress. However, 11.3% of
therapists scored below 48, indicating that a minority of therapists in the sample were
experiencing a level of experiential avoidance indicative of psychological distress.
Meditation was practised by 42% of the sample. Of the therapists who
meditated, some did so daily (5%), most did so weekly (71%), and others less than
weekly (24%). On average the meditating therapists had been practising meditation for
four years, however meditation practice ranged from one month to sixteen years.
Mean scores on the NEO-FFI, indicate therapists had “average” scores on N and
C, and “high” scores on E, O and A. Scores ranged from “very low” to “very high”
categories on all scales except O, which had no scores in the “very low” category, and
C, which did not have scores in the “very high” category.
Therapists’ scores on CTPS were restricted in range and indicated a tendency to
value rational over intuitive knowing, and objective over subjective knowing. There are
no norms for this scale, however the therapists’ scores can be compared to scores from a
study of Australian Registered Psychologists from cognitive, psychodynamic, systemic
and experiential therapeutic frameworks (Poznanski & McLennan, 1998). Among the
Registered Psychologists, cognitive therapists scored higher than the other
psychologists on both CTPS scales. Mean scores from the therapist sample were higher
than the cognitive therapists on both CTPS scales. It is notable that the lowest-scoring
therapists on the Rational-Intuitive scale in the current study were still higher than all
therapists, from all theoretical frameworks, in the sample of Registered Psychologists.
Similarly on the Objective-Subjective scale the lowest scoring therapists in the current
study privileged objective ways of knowing more than the experiential and systemic
therapists. Thus, in comparison to the sample of Registered Psychologists, the sample
of therapists in the current study is relatively homogenous and subscribe to therapeutic
frameworks that are strongly objective and rational.
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Table 5.4 Descriptive Statistics for Therapists Measures
Variable n M SD Possible range
Actual Range Cronbach alpha
AAQ-II 53 54.79 6.42 7-70 28-65 .81 CAMS-R 53 38.49 4.44 12-48 29-46 .78
NEO-FFI
Neuroticism 53 46.60 8.41 20-100 31-66 .80 Extroversion 53 55.98 9.90 20-100 34-75 .81 Openness 53 62.96 8.37 20-100 43-75 .71 Agreeableness 53 57.60 10.41 20-100 30-75 .79 Conscientiousness 53 49.57 9.54 20-100 29-64 .82 ASQ Avoidance 53 2.49 0.45 1-6 1.6-3.6 .88 Anxiety 53 3.03 0.48 1-6 1.9-4.1 .74 Confidence 53 4.62 0.45 1-6 3.4-5.4 .73 Discomfort 53 2.91 0.61 1-6 1.6-4.7 .83 Approval 53 2.90 0.57 1-6 1.3-4.0 .65 Preoccupation 53 3.15 0.56 1-6 1.8-4.9 .65 Secondary 53 2.05 0.48 1-6 1.0-3.1 .62 CTPS Rational-Intuitive 53 60.63 9.18 20-140 43-79 .72 Objective-Subjective 53 74.97 13.15 20-140 46-107 .85
Therapists’ average scores on the ASQ were similar to those obtained in
samples of individuals categorised as having a secure attachment style (Ng & Trusty,
2005; Feeney et al., 1994). Therapists were more securely attached than clients.
Pearson correlations between ASQ subscales were consistent with the two
higher-order factors. In fact, scales making up the higher-order factor Avoidance
(Confidence, Secondary, Discomfort) were more highly correlated than in other
published studies (Fossati et al., 2003; Feeney et al., 1994; Ng & Trusty, 2005; see
Table 5.5). Conversely, scales contributing to the higher-order factor Anxiety were less
highly correlated than has been reported in other samples, albeit still significant at the
p <.01 level. Like the client sample, subscales representing the higher-order factor
Avoidance were correlated with subscales representing the Anxiety factor. Not
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surprisingly the two higher-order factors Anxiety and Avoidance showed a moderate
correlation (r = .45, p <.01).
Cronbach alpha was acceptable for most of the counsellor scales and subscales.
The alpha for ASQ subscales Approval, Secondary and Preoccupation were below the
acceptable cutoff of .7. However, the higher order factors on the ASQ (Anxiety and
Avoidance), which were used in the main analysis, had acceptable internal consistency.
Table 5.5 Pearson Correlations between ASQ Subscales for Therapist Sample Subscale 1 2 3 4 1. Confidence - 2. Discomfort -.67** - 3. Approval -.37** .27 * - 4. Preoccupation -.29* .53 ** .43** - 5. Secondary -.56** .52 ** .29* .14 Note. *p < .05; **p < .01.
The large standard deviations and ranges for the variables Supervision, Course,
Experience, and Therapy indicated therapists varied widely in these areas. Therapists
were students in a postgraduate course which explicitly recruits students with prior
experience in the counselling field, thus the large amount of professional development
activity engaged in by some therapists was expected. The distribution of scores on each
item was negatively skewed and contained some outliers, thus percentiles are reported
in Table 5.6 to provide a more accurate representation of the sample’s professional
activities. For the 33 therapists who had participated in supervision (prior to beginning
their placement at the clinic), they had, on average, 85 sessions of supervision with an
average of two supervisors (range 1-4). Details of therapists’ responses to schema
scales are reported in the Data Preparation section.
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Table 5.6 Professional Demographic Variables for Therapist Sample percentiles Professional demographics n M SD Range 25% 50% 75% Supervision (hours) 50 56.34 93.80 0-400 0 10 96.25 Courses (weeks) 53 29.13 39.86 0-208 4 12 42.5 Experience (months) 50 67.15 72.93 0-288 12 42.5 98.63 Therapy (sessions) 53 33.79 64.71 0-330 2 12 34.42
Pearson correlations between therapist measures are displayed in Table 5.7.
Correlations were generally low to medium in magnitude. All significant correlations
were in the expected directions, with the sole exception of a negative correlation
between AAQ-II and therapy. Intuitively one may expect that therapists engaging in a
greater amount of personal therapy would show lower levels of experiential avoidance
rather than more as is the case in this sample.
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Table 5.7
Correlations Between Variables Measuring Therapists Characteristics
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 Age - 2 CAMS .03 - 3 CTPS-rational -.32* -.24 - 4 CTPS- objective -.23 -.07 .21 - 5 NEO- N -.09 -.57** -.12 .05 - 6 NEO- E -.25 .27 .24 .09 -.28* - 7 NEO- O -.01 .05 -.004 -.28* -.03 .23 - 8 NEO- A .11 .28* -.02 -.30* -.12 .23 .16 - 9 NEO- C -.22 .42** .17 .02 -.17 .36** -.09 .17 - 10 SS -.32* -.01 .09 .05 .28* .06 -.004 .28* .42** - 11 US -.11 -.02 .04 .12 .14 .15 .23 -.01 .29* .24 - 12 En -.15 .08 .15 .11 -.1 .1 .28* -.27* .15 -.03 .37** - 13 AS -.33 -.08 .23 .16 .04 .19 .16 -.25 .29* .29* .49** .50** - 14 P .06 -.14 -.12 .26 .11 -.25 -.08 .01 .11 .34* .35* .21 .26 - 15 AVO .15 -.44** -.250 .12 .39** -.54** -.16 -.44**-.37** .01 .07 -.02 -.03 .04 - 16 ANX -.11 -.46** -.2 .07 .75** -.2 -.03 -.11 -.11 .39** .16 .07 .13 .25 .45** - 17 Cour .29* .01 -.15 -.81 .11 -.07 -.13 .2 .05 -.02 -.01 -.26 -.24 -.05 .09 .05 - 18 Super .18 -.24 -.18 -.02 .19 -.26 -.15 .03 -.09 -.04 -.08 -.12 -.08 .15 .19 .19 .48** - 19 Ther .16 -.05 -.15 -.2 .16 .11 .39** .12 -.13 -.13 -.18 .12 -.05 -.26 .03 .30* .18 -.07 - 20 Exp .24 -.38** .05 -.01 .02 -.18 -.04 -.07 -.16 -.04 -.23 -.06 .04 -.04 .33* .16 .39** .53** .14 -
21 AAQ -.07 .54** .23 -.23 -.63** .26 .02 -.02 .22 -.18 -.07 .05 .03 -.40** -.30* -.61** -.13 -.33* -.29* -21
Note. CAMS = CAMS-R; NEO = NEO-FFI; SS= self sacrifice; US = unrelenting standards; En - Entitlement; AS = Approval seeing; P= punitiveness; AVO= ASQ Avoidance; ANX = ASQ Anxiety; Cour = Course; Super = supervision, Ther = Therapy; Exp = Experience; AAQ = AAQ-II. *p < .05; **p < .01.
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5.2 Data preparation
The distributions of client and therapist data were examined and measures
displaying significant skew were transformed, which simultaneously removed outliers.
Therapist data had 14 cases (33%) with missing data. The modal number of missing
items per case was one (M = 1.64). Client baseline data had 74 cases (33%) with
missing data. The modal number of missing items per case was one (M = 3.25). In
both groups instances data was missing completely at random and thus the missing data
would not bias the analysis. Imputation was considered preferable to deleting missing
cases for the Therapist Questionnaire and client Initial Questionnaire. Data from these
questionnaires was to be entered in levels two and three of MLM analysis. As MLM
does not permit missing data at levels two or three, listwise deletion of client baseline
(level 2) or therapist (level 3) data would have resulted in the loss of a substantial
number of therapist-client dyads and hindered further analysis. Missing therapist and
client baseline data was imputed using SPSS 17 EM estimation routine. Missing data
from client progress questionnaires and final questionnaires were deleted casewise
during analysis if the required number of data points for that case was not met.
In all MLM analysis ordinary least-squares estimates of fixed effects were not
substantially different from least-squares estimates with robust standard errors. This
indicates there was no reason to suspect violation of assumptions, and that there were no
large misspecifications in the model (Raudenbush & Bryk, 2002). Line graphs of WAI-
SR scores over sessions were examined for outliers, in terms of client WAI-SR score
trajectories within each therapist. No outliers were evident.
5.3 Selection of YSQ Subscales
Five of the eighteen YSQ-S3 subscales were selected for inclusion as
independent variables in the main analysis. An a priori decision had been made to
include the Punitiveness subscale from the YSQ-S3. Additional YSQ-S3 subscales
were included on the basis of their being relatively prominent in the therapist sample.
Most of the subscales had a mean below two, and a standard deviation below 0.65,
suggesting therapists generally had low scores for most subscales and there was little
variation in scores across the sample. Subscales with a mean of two or more and a
107
range of three or more were selected for inclusion. This cutoff was chosen as scores
above two on the YSQ-S3 are considered “meaningful” (Schema Therapy Institute,
2010); although there are no norms available to examine this assertion. A range of three
or more was chosen in order to focus on EMS on which therapists showed
heterogeneity. The subscales which met these criteria were: Self-Sacrifice, Unrelenting
Standards/Hypercriticalness, Entitlement/Grandiosity, Approval-Seeking/
Recognition-Seeking, and Punitiveness. Descriptive statistics for these scales are
reported in Table 5.8, descriptive statistics for the remaining schema scales reported in
Appendix F. Herein EMS will be referred to by their short names: Unrelenting
Standards (i.e. Unrelenting Standards / Hypercriticalness), Entitlement (i.e. Entitlement
/ Grandiosity), and Approval-Seeking (i.e. Approval-Seeking / Recognition-Seeking)
respectively.
Internal consistency for unrelenting standards and approval-seeking were below
acceptable levels. This may, in part, be due to these items consisting of only five items
each (Pallant, 2007), in this case the mean inter-item correlation can give a better
indication of internal consistency, which was within the acceptable range (.2 - .4;
Pallant, 2007) for these EMS.
Table 5.8 Descriptive Statistics for Selected YSQ-S3 Subscales Completed by Therapists
Subscale M SD Min – Max (range)
Cronbach alpha
Mean Inter-Item Correlation
Self-Sacrifice 3.21 0.80 2-6 (4) .72 .35 Unrelenting Standards 3.34 0.76 1.6-5.2 (3.6) .60 .23 Entitlement 2.39 0.76 1-5 (4) .72 .35 Approval-Seeking 2.57 0.63 1-5 (4) .67 .29 Punitiveness 1.99 0.67 1-4 (3) .75 .38 5.4 Preliminary Analysis
5.4.1 Differences between clients with and without corresponding therapist data
Examination of random effects indicated none of the baseline measures differed
significantly between therapists at the p < .05 level. As displayed in Table 5.9 random
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effects for two symptom measures, WHO Social and ASQ Confidence, and the initial
WAI-SR ratings were significant at a trend level (p < .10). Fixed effects for the binary
variable DATA were not significantly different for these or any other symptom
measure, indicating that there were no significant differences in baseline measures, or
initial WAI scores, between clients with or without corresponding therapist data. In
these, and all following analysis, robust standard errors are reported as the number of
highest-level units (in this case therapists) is large (Raudenbush & Bryk, 2002).
Parameters for all analyses are presented in Appendix G.
Table 5.9 Fixed and Random Effects for Two-Level MLMs with Baseline ASQ Confidence, WHO Social, and WAI-SR Total as the Dependent Variable and DATA Entered as a Level Two Independent Variables Parameter ASQ - CONFIDENCE
Fixed effect Coefficient SE t-ratio df p value Intercept 3.748 0.197 19.032 60 <.001
DATA -0.126 0.152 -0.828 60 .411 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.803 0.896 Level 2 Intercept 0.022 0.022 76.638 60 .072
WHO - SOCIAL
Fixed effect Coefficient SE t-ratio df p value Intercept 40.715 5.484 7.424 61 <.001
DATA 4.247 4.437 0.957 61 .343 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 473.251 21.754 Level 2 Intercept 37.982 6.163 79.236 61 .058
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EARLY WAI-SR – TOTAL
Fixed effect Coefficient SE t-ratio df p value Intercept 1.633 0.045 36.552 46 <.001 DATA 0.035 0.037 0.951 46 .347 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.014 0.118 Level 2 Intercept 0.002 0.041 59.376 46 .089 Note. Number of therapists / clients for each analysis was as follows: ASQ Confidence n = 62 /n = 213; WHO Social n = 63 / n = 215; WAI-SR Total n = 48 / n = 102. 5.4.2 Symptomatic improvement over the course of therapy
Tables 5.10 and 5.11 detail parameters of log change over session on the DASS,
SOS, WHOQoL-BREF (Table 5.10) and IIP-32 (Table 5.11). The fixed effects for log
session slope provide a measure of average client growth on these outcome measures.
Significant variance components were obtained on the slope for DASS and Schwartz
models, indicating that, overall, clients experienced a decrease in symptoms of
depression, anxiety and stress, and increased overall wellbeing.
The WHOQoL-BREF and IIP-32 were only measured at baseline and
termination. Only a small subset of clients completed both of these questionnaires. The
fixed effects slopes were statistically significant for all four WHOQoL-BREF domains,
suggesting clients’ quality of life improved over the course of counselling. The only
statistically significant slope on the IIP-32 was the subscale Too Aggressive (p <.001).
The slope for the IIP-32 subscale Too Dependent showed a trend level improvement
(p = .052). With a sample this size it is likely that the chance of a Type II error is
inflated. Furthermore, as only 10% of clients completed pre- and post- IIP-32 and
WHOQoL-BREF measures, the results for these scales cannot be generalised to the
entire sample.
Taken together, these results indicate that the client sample experienced a
reduction in symptoms and improvement in their wellbeing from session to session. For
the subset of clients completing baseline and final questionnaires their quality of life
110
and tendency to be too aggressive and too dependent had improved by the termination
of counselling.
Table 5.10
Fixed Effects (top) and Variance Component (bottom) for Two-Level MLMs of change in SOS, DASS Total and WHOQOL-BREF Subscales Parameter SOS# DASS# Social Environment# Physical# Psychological Fixed effects
Intercept. 4.63*** (0.07)
6.96*** (0.15)
45.13*** (1.81)
5.79*** (0.09)
6.02*** (0.12)
45.14*** (1.07)
Log session slope
0.55*** (.09)
-.97*** (0.17)
14.01*** (3.64)
1.16*** (0.24)
0.77* (0.28)
10.79* (3.24)
Random effects Level 1
Error 1.03 [1.02]
2.85 [1.69]
500.43 [22.37]
1.48 [1.22]
2.14 [1.46]
289.85 [17.03]
Level 2 Log session slope
0.30*** [0.55]
0.88*** [0.94]
48.49 [6.96]
0.0007 [0.03]
0.29 [0.54]
7.40 [2.72]
Level 3 Log session slope
0.09 [0.29]
0.24 [0.49]
0.78 [0.88]
0.19 [0.43]
0.004 [0.066]
36.22 [6.02]
Deviance 1376.49 1708.03 1777.75 636.86 699.01 1646.66 Note. Fixed effects error in parentheses. Random effects standard deviations in brackets. # Denotes variables square-root transformed. Number of therapists and clients for each analysis was as follows: SOS, n = 46 / n = 128; DASS, n = 45 / n = 121; Social, n = 16 / n = 22; Environment n = 17 / n = 23; Physical and Psychological n = 17 / n = 22. Number of estimated parameters = 5 *p < .05; **p < .01; *** p<.001
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Table 5.11 Fixed Effects (top) and Variance Component (bottom) for Two-Level MLMs of Change in IIP-32 Subscales Parameter Assert Open Caring Dependent Involved# Social# Supportive# Aggressive#
Fixed effects
Intercept 1.88*** (0.07)
1.67*** (0.06)
1.68*** (0.06)
1.64*** (0.07)
1.02*** (0.05)
1.12*** (0.04)
.85*** (0.03)
1.05*** (0.04)
Log Session slope
-.16 (0.19)
-.12 (0.15)
-.22 (0.16)
-.29 (0.14)
.006 (0.09)
-.04 (0.09)
-.07 (0.09)
-.024*** (0.06)
Random effects Level 1
error 1.11 [1.05]
0.88 [0.94]
0.83 [0.91]
0.75 [0.87]
0.32 [0.57]
0.27 [0.52]
0.29 [0.54]
0.25 [0.49]
Level 2 Slope
0.007 [0.09]
0.06* [0.25]
0.005 [0.067]
0.003 [0.05]
0.0007 [0.0265]
0.0002 [0.0155]
0.0001 [0.0109]
0.0003 [0.0178]
Level 3 Slope
0.14 [0.37]
0.002 [0.045]
0.12 [0.34]
0.04 [0.19]
0.004 [0.061]
0.03 [0.16]
0.02 [0.13]
0.00009 [0.0096]
Deviance 589.91 548.34 525.25 514.15 338.21 308.62 327.14 290.99 Note. Fixed effects error in parentheses. Random effects standard deviations in brackets. # denotes variables square-root transformed. Number of therapists (n = 17) and clients (n = 23) for each analysis. Number of estimated parameters =5. *p < .05; **p < .01; *** p<.001 5.5 Main analysis
5.5.1 Two-level fully unconditional model
Data from 87 clients and 41 therapists were entered in this two-level model.
Table 5.12 shows the fixed and random effects for this model. The level one fixed
effect for the intercept was statistically significant, indicating clients (within therapists)
differed on their early WAI-SR rating. The level two random effect for the intercept
was non-significant at the .05 level, indicating the early WAI-SR ratings did not
significantly differ between therapists.
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Table 5.12 Fixed and Random effects for Two-Level Unconditional Model of Early WAI-SR Ratings Fixed Effect Parameter Coefficient SE t-ratio df p value Intercept
1.669 0.015 115.444 40 < .001
Random Effect Variance
component SD χ2 df p value
Level 1 Error variance 0.013 0.113 Level 2 Intercept 0.002 0.047 55.209 40 .055 Despite the nonsignificant result at level two, the percent of variance on the
WAI-SR attributable to therapists can be determined by calculation of the intraclass
correlation coefficient (ρI). This is calculated as the ratio of variance attributable to
therapists, to the total variance (Wampold & Serlin, 2000) as shown in Equation 1.
ρI = therapist variance / (therapist variance + error variance) (1)
ρI = .00222 / (.00222 + .01267)
ρI = .1490
The proportion of variance on the early WAI-SR ratings due to therapists was 14.90%.
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5.5.2 Three-level Growth Models
5.5.2.1 Unconditional model
Two-hundred and two WAI-SR ratings from 65 clients within 39 therapists were
entered into the initial unconditional growth model, which modelled the effect of
session number on WAI-SR ratings. Results are displayed in Table 5.13. Level one
fixed effects indicate, on average, the initial alliance score was 1.66, and increased an
average of .0057 units per session. This alliance growth was statistically significant
across all clients and therapists.
Random effects at level two were statistically significant for the intercept and
slope with p values < .001 and < .05 respectively. This indicates significant variation
among clients (within therapists) on both the initial status of their alliance and increase
in alliance over sessions.
Random effects at level three were not significant for the intercept, indicating
that therapists did not significantly differ on initial alliance ratings. This is consistent
with the results from the two level unconditional model. The level three slope was
statistically significant at the .05 level, indicating therapists did differ on the rate of
growth on clients’ WAI-SR ratings.
The level two variance component was zero at five decimal places (given in
HLM 6 output). In order to calculate the variance component beyond five decimal
places the standard deviation was squared. This yielded a level two variance component
of 0.00000408 and a level three variance component of 0.0000244. These random
effects variance components are very small, due, in part, to the log transformed WAI-
SR scale having a maximum score of 2 and a range of 0.58.
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Table 5.13 Three-Level Unconditional Growth Model of WAI-SR Ratings Parameter Fixed effect Coefficient SE t-ratio df p value Intercept 1.656 0.016 102.161 49 < .001 Slope 0.006 0.001 3.981 < .001 Random effect Variance
component SD χ2 df p value
Level 1 Error variance .00679 .08239 Level 2 Intercept .00748 .08647 57.206 26 .001 Slope 0.00000408 .00202 46.765 26 .008 Level 3 Intercept .00253 .05026 50.880 38 .079 Slope 0.0000244 .00494 65.765 38 .004 Statistics for the current covariance components model: Deviance = –370.68. Number of parameters estimated = 9
To understand the degree that therapists differed on the intercept and slope, the
ratio of differences was calculated. There are two methods for calculating such a ratio:
(a) comparing therapist variance to overall variance (sessions within clients, clients
within therapists, therapist mean slope or intercept); and (b) comparing therapist
variance to client variance, but removing the variance due to session to session
variability (i.e. sessions within clients). Following the example set by Lutz et al.
(2007) the second alternative was chosen as most appropriate as it represents the
“conceptual meaning of therapist effects” (p. 34). Calculation of the intercept and slope
is shown in Equation 2 and 3 respectively.
115
Percent variance between therapists on intercept = level 3 intercept variance
component / (level 2 intercept variance component + level 3 intercept variance
component) (2)
= .00253 / (.00747 + .00253)
= .253
= 25.3%
Percent variance between therapists on slope = level 3 slope variance component /
(level 2 slope variance component + level 3 slope variance component) (3)
= .0000244 / (.00000408 + .0000244)
= .857
= 85.7%
Thus, 25.3% of the variance on initial WAI-SR ratings, and 85.7% of the variance on
the rate of session-to-session growth in WAI-SR ratings, is due to therapists.
When the model equations were plotted on a line graph they showed most
therapists had positive growth in WAI-SR over sessions. However one therapist had
negative growth over sessions. While this therapist was an outlier in the equations
produced by the three level unconditional growth model, he was not an outlier on when
WAI-SR raw scores were inspected. Furthermore there was nothing on the therapist
baseline measures that distinguished this therapist, thus he did not seem to be an
anomaly in the therapist sample.
The three level unconditional growth model was re-run with this therapists’
scores deleted and the percentage of variance between therapists on the slope was
reduced to 38%. This is a substantial reduction in variance, however, as previously
stated, the deletion of outliers is not considered appropriate, and, as such the therapist’s
data was retained in the analysis.
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5.5.2.2 Conditional model
In order to explain the statistically significant difference between therapists on
the rate of change in WAI-SR ratings over sessions, a conditional model was specified.
Therapists’ characteristics were entered at level three as predictors of the slope. No
predictors were entered for the intercept, as the previous unconditional model (see
section 5.5.2.1) suggests therapists did not differ on this parameter. As stated in the
analytic approach as a first step potential therapist variables were screened
consecutively. From these models six variables were significant at the .05 level: YSQ-
S3 - Unrelenting Standards, YSQ-S3 - Approval-Seeking, YSQ-S3 - Self-Sacrifice,
Supervision, Therapy and AAQ-II. All parameters for these analyses are presented in
Table 5.14. Parameters for variables which did not reach significance at the p < .05
level are detailed in Appendix H.
Table 5.14 Three level Conditional Growth Models for WAI-SR Ratings: Significant Level Three (Therapists) Independent Variables
AAQ-II (square root transformed) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6538 0.0162 102.008 49 < .001 Slope 0.0055 0.0014 4.091 48 < .001 AAQ-II 0.0017 0.0007 2.457 48 .018 Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00681 0.08252 Level 2 Intercept 0.00855 0.09245 57.524 24 < .001 Slope 0.00001 0.00319 47.467 24 .003 Level 3 Intercept 0.00212 0.04603 49.075 40 .154 Slope 0.00001 0.00384 53.894 39 .057
117
Self-sacrifice (log transformed) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6580 0.0162 102.350 49 < .001 Slope 0.0055 0.0015 3.692 48 .001 Self-sacrifice 0.0170 0.0071 2.411 48 .020 Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00695 0.08338 Level 2 Intercept 0.00685 0.08275 56.159 25 .001 Slope 0.00000 0.00174 46.035 25 .007 Level 3 Intercept 0.00258 0.05076 51.918 39 .081 Slope 0.00002 0.00491 69.624 38 .002
Approval-Seeking (square root transformed) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6518 0.0152 108.655 49 < .001 Slope 0.0061 0.0013 4.857 48 < .001 Approval-Seeking 0.0078 0.0025 3.054 48 .004 Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00659 0.08120 Level 2 Intercept 0.00972 0.09860 58.557 22 < .001 Slope 0.00002 0.00476 49.923 22 .001 Level 3 Intercept 0.00054 0.02328 47.889 42 .246 Slope 0.00000 0.00186 46.521 41 .255
118
Unrelenting standards Fixed effect Coefficient SE t-ratio df p value Intercept 1.6562 0.0162 102.073 49 < .001 Slope 0.0056 0.0015 3.797 48 < .001 Unrelenting standards
0.0016 0.0006 2.606 48 .013
Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00675 0.08218 Level 2 Intercept 0.00750 0.08662 57.419 25 < .001 Slope 0.00001 0.00249 47.233 25 .005 Level 3 Intercept 0.00250 0.04998 51.157 39 .092 Slope 0.00002 0.00479 62.388 38 .008
Supervision (log transformed) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6555 0.0159 104.076 49 < .001 Slope 0.0014 0.0057 3.952 48 < .001 Supervision -0.0024 0.0010 -2.424 48 .019 Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00692 0.08318 Level 2 Intercept 0.00751 0.08668 57.258 25 < .001 Slope 0.00000 0.00104 46.369 25 .006 Level 3 Intercept 0.00265 0.05148 50.604 39 .101 Slope 0.00003 0.00526 76.909 38 < .001
119
Therapy Fixed effect Coefficient SE t-ratio df p value Intercept 1.6517 0.0162 101.708 49 < .001 Slope 0.0062 0.0013 4.663 48 < .001 Therapy -0.0017 0.0008 -2.072 48 .043 Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00667 0.08167 Level 2 Intercept 0.00878 0.09371 57.990 24 < .001 Slope 0.00002 0.00408 48.809 24 .002 Level 3 Intercept 0.00186 0.04318 49.183 40 .151 Slope 0.00001 0.00338 51.212 39 .091 Note. Number of therapists / clients for each analysis was as follows: Supervision 39 / 65; AAQ-II and Therapy 41/65; Self-Sacrifice and Unrelenting Standards 50 / 65; Approval-Seeking 43 / 65. In the second step the six significant therapist characteristics were entered
simultaneously in the three level growth model. Again they were only entered as
predictors of the slope. Random slopes and intercepts were permitted at level two and
level three. Although the intercept at the therapist level was non-significant in an
unconditional model, it did not mean that there was no variation at that level, in fact
partitioning of variation in Equation Two showed 25.3% variance at this level. Thus,
allowing the intercept to vary at level three was considered to more accurately reflect
the data than a fixed slope.
With six variables entered into this model (Model 1) Approval-Seeking was the
only one to emerge as significant at the .05 level. A backwards deletion method was
employed to select the final model. Variables with the highest p-value, and in most
cases smallest variance component, were deleted in consecutive models. Three
variables were deleted: Therapy (Model 2), then Unrelenting Standards (Model 3), then
Self-Sacrifice (Model 4). Parameters for these models are shown in Table 5.15.
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Table 5.15 Conditional Growth Models for WAI-SR ratings with Backwards Deletion of Therapist Contextual Variables Model 1 Model 2 Model 3 Model 4
Parameter Coefficient p-value Coefficient p-
value Coefficient p-value Coefficient p-
value Fixed effects
Intercept 1.6550 (0.0160) < .001 1.6551
(0.0158) < .001 1.6552 (0.0158) < .001 1.6541
(0.0155) < .001
Session slope
0.0053 (0.0013) .001 0.0053
(0.0013) < .001 0.0053 (0.0013) < .001 0.0055
(0.0012) < .001
Unrelenting standards
0.0001 (0.0010) .870 0.0001
(0.0010) .868 - - - -
Self-sacrifice
0.0054 (0.0071) .453 0.0055
(0.0069) .430 0.0058 (0.0061) .341 - -
Approval-Seeking
0.0066 (0.0031) .037 0.0067
(0.0029) .026 0.0069 (0.0024) .008 0.0075
(0.0024) .003
Supervision -0.0016 (0.0009) .094 -0.0016
(0.0010) .109 -0.0017 (0.0009) .075 -0.0020
(0.0009) .030
Therapy -0.00004 (0.0009) .967 - - - - - -
AAQ-II 0.0013 (0.0014) .109 0.0014
(0.0069) .047 0.0014 (0.0006) .035 0.0014
(0.0006) .036
Random effects
Level 1
error 0.00706 [0.08405] 0.00706
[0.08405] 0.00708 [0.08414] 0.00704
[0.08389]
Level 2
Intercept 0.00834 [0.09132] < .001 0.00833
[0.09129] < .001 0.00823 [0.09069] .001 0.00849
[0.09208] < .001
Slope 0.00001 [0.00271] .002 0.00001
[0.00270] .001 0.00001 [0.00255] .009 0.00001
[0.00265] .004
Level 3
Intercept 0.00158 [0.03970] .213 0.00158
[0.03970] .279 0.00163 [0.04038] .107 0.00164
[0.04052] .162
Slope 0.00001 [0.00326] .024 0.00001
[0.00326] .049 0.00001 [0.00334] .012 0.00001
[0.00329] .035
Deviance {number of estimated parameters}
-379.862 {15} -379.861
{14} -379.849 {13} -379.484
{12}
Note. Fixed effects error in parentheses. Random effects standard deviations in brackets.Number of therapists / clients for each analysis was as follows: 43/65 (model 1); 45/65 (model 2); 39/65 (model 3); 41/65 (model 4). Number of measures entered at level 3 = 252.
121
The final model (i.e. Model 4) included three predictor variables: Approval-
Seeking, Supervision, and AAQ-II. Approval-Seeking was a significant predictor in
Model 1 (with 6 predictors) and all subsequent reduced models. AAQ-II reached
significance once Therapy (Model 2) was deleted, and Supervision reached significance
once Therapy, Unrelenting Standards and Self-Sacrifice were deleted (Model 4). Thus,
there appears to be overlapping variance between AAQ-II and Therapy, and between
Supervision, Therapy, Unrelenting Standards and Self-Sacrifice.
The final model suggests the variable Supervision was associated with a decline
in WAI-SR ratings and Approval-Seeking and AAQ-II were associated with growth in
WAI-SR ratings. Specifically, a one unit increase in total supervision sessions resulted
in a .002 unit decrease in WAI-SR scores per session; a one unit increase in Approval-
Seeking scores resulted in a .008 unit increase in WAI-SR scores per session; and a one
unit increase in AAQ-II scores resulted in a .0014 unit increase in WAI-SR scores per
session. The final conditional model was significantly different (χ2 =8.79, df 3,
p = .031) from the three-level unconditional growth model.
In the conditional model the percentage of variance on the slope due to
therapists was re-calculated (using equation 4; see below). Variance components were
calculated to seven decimal points to improve accuracy of calculations. The addition of
therapist predictors reduced the percentage of variance due to therapists on the slope
from 86% to 60%.
Percentage of slope variance due to therapist
= .0000107 / (.0000070 + .0000107)
= .0000107 / .0000177 = .6045 = 60.45%
122
The proportion of variance explained in the conditional model was determined
by calculating pseudo R2 equation (Raudenbush & Bryk, 2002 ; Tasca et al., 2009):
pseudo R2 = (Unconditional coefficient - Conditional coefficient) (4)
/ Unconditional coefficient
As shown in Table 5.16 this yields increase of 35% and 56% in explained variance
(pseudo-R2) in the conditional model for the intercept and slope respectively and a 3%
reduction in error.
Table 5.16 Percent Increment in Modelled Variance in the Conditional Model with Therapist Contextual Variables Model Error Therapist intercept Therapist slope Unconditional .00679 .00253 .0000244 Conditional .00704 .00164 .0000107 pseudo-R2 -3.38% 35.18% 56.14%
5.5.2.3 Three level conditional growth models with cross-level interaction terms Due to missing client baseline data, the data set available to examine therapist
and client interactions had fewer data points available than the previous three-level
unconditional growth model, which did not use client baseline data. Prior to examining
interactions, the three-level unconditional growth model was repeated with this reduced
data set, utilising 199 level one data points, 51 clients and 36 therapists. Results were
consistent with the previous unconditional model. At level two the intercept
(coefficient .00567, χ2 = 41.29, df(15), SD = .07531, p < .0005) and slope (coefficient
<.00001, χ2 = 33.25, df(15), SD = .00209, p = .005) significantly varied between clients
(within therapists). At level three the intercept did not show significant variation
between therapists (coefficient .00370, χ2 = 42.82, df(35), SD = .06086, p = .171).
However therapists did significantly differ on the rate of change in alliance over time
(slope .00003, χ2 = 55.82 df(35), SD = .00506, p = .014). The deviance statistic for this
model was –303.31, with nine estimated parameters.
123
As outlined in section 4.2.2.3 interaction terms were entered for client Anxiety
and Avoidance and therapist Anxiety and Avoidance for the intercept and slope.
Although therapists did not show significant differences on the intercept in the
unconditional growth model, clients showed significant differences at level two for the
intercept and slope. Therefore the intercept was also modelled. In this model three
interaction terms were significant at the p <.05 level. For the intercept, client
Avoidance interacted with therapist Anxiety (coefficient -.208951, t(181)=2.223,
p =.027). For the slope client Avoidance interacted with therapist Anxiety
(coefficient .025324, t(181) = 2.647, p = .009) and client Anxiety interacted with
therapist Anxiety (coefficient -.016088, t(181) = 2.007, p = .046). These significant
interaction terms were entered into a second model. Results for this model are
displayed in Table 5.17. In this model the client Anxiety × therapist Anxiety interaction
remained significant, but the client Avoidance × therapist Anxiety interaction was
reduced to a trend level of significance. The client Avoidance × therapist Anxiety
interaction on the intercept was no longer significant.
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Table 5.17 Final Three Level Growth Model of WAI-SR with Therapist Attachment × Client Attachment Interactions Parameter Fixed effect Coefficient SE t-ratio df p value
Intercept Intercept 1.6566 0.0210 78.775 48 < .001Intercept (client) × Avoidance (therapist) -0.0249 0.0283 -.929 182 .354
Avoidance (client) × Anxiety (therapist) -0.0716 0.0573 -1.248 182 .214
Session slope
Intercept (client) × intercept (therapist) 0.00646 0.00199 3.247 48 .003
Intercept (therapist) × Avoidance (client) -0.00367 0.00279 -1.317 181 .190
Avoidance (client) × Anxiety (therapist) 0.01131 0.00586 1.929 181 .055
Intercept (therapist) × Anxiety (client) 0.00193 0.00226 0.853 181 .395
Anxiety (client) × Anxiety (therapist) -0.00908 0.00411 -2.058 181 .041
Random effect Variance
component SD χ2 df p value
Level 1 Error variance 0.00648 0.08049 Level 2 Intercept 0.00554 0.07441 40.758 11 < .001 Slope 0.00000 0.00172 31.860 10 .001Level 3 Intercept 0.00378 0.06152 44.200 38 .226 Slope 0.00003 0.00521 59.378 38 .015 Deviance 310.41 Number of estimated parameters 15
125
Client Anxiety alone was not significantly related to the growth in the WAI-SR
ratings. However, increases in client Anxiety accompanied by increases in therapist
Anxiety resulted in a decrease in WAI-SR ratings over sessions. Similarly, client
Avoidance alone was not significantly associated with WAI-SR ratings. However
increases in client Avoidance accompanied by increases in therapist Anxiety were
associated with growth in WAI-SR ratings over sessions. This interaction was
significant at a trend level.
This model was tested against the previous unconditional model for this data set.
The chi-square statistic is nonsignificant (χ2 = 7.09, df (6), p = .31) suggesting that the
addition of these interaction terms did not improve the variance explained by the model.
Changes in explained variance (pseudo-R2) from the addition of interaction
terms in the conditional model are displayed in Table 5.18. The conditional model
resulted in a substantial increase in explained variance for the client slope and small
increase for the client intercept; however the amount of explained variance for the
therapist intercept and slope was slightly reduced and the level one error slightly
increased.
Table 5.18 Percent Increment in Modelled Variance in the Conditional Model with Therapist Attachment × Client Attachment Interactions
Model Error Client intercept Client slope Therapist
intercept Therapist
slope Unconditional .00667 .00567 .000006 .00370 .0000256 Conditional .00648 .00554 .0000029 .00378 .0000271 pseudo-R2 2.85% 2.29% 51.66% -2.16% -5.86%
Table 5.19 displays the results from a three-level growth model with client
Avoidance and Attachment entered as an independent variables at level two, and
therapist Experience entered as an independent variable at level three for the intercept
and slope. Consistent with the previous model, there were no main effects for client
Avoidance or Anxiety. Furthermore, there were no interaction effects for client Anxiety
or Avoidance and therapist Experience for the intercept or slope.
126
Table 5.19
Three Level Growth Model of WAI-SR with Therapist Experience × Client Attachment Interactions Parameter Fixed effect Coefficient SE t-ratio df p valueIntercept Intercept 1.6510 0.0199 83.050 48 < .001 Intercept × Avoidance -0.0500 0.0283 -1.769 181 .078 Avoidance × Experience 0.0049 0.0066 0.738 181 .462 Intercept × Anxiety 0.0191 0.0297 0.643 181 .521 Anxiety × Experience 0.0034 0.0047 0.712 181 .477Slope Slope × Intercept 0.0070 0.0018 3.884 48 >.001 Avoidance × Intercept 0.0003 0.0031 0.091 181 .928 Avoidance × Experience -0.0004 0.0008 -0.489 181 .625 Anxiety × Intercept -0.0020 0.0029 -0.590 181 .556 Anxiety × Experience -0.0003 0.0006 -0.560 181 .576 Random effect Variance component SD χ2 df p valueLevel 1 Error variance 0.00658 0.08109 Level 2 Intercept 0.00552 0.07431 40.585 12 < .001 Slope 0.00000 0.00161 31.127 12 .002Level 3 Intercept 0.00402 0.06339 46.509 36 .113 Slope 0.00003 0.005333 61.877 36 .005Deviance –309.56 Number of estimated parameters 17
5.5.2.4 Post-hoc Analysis
The negative association between Supervision and WAI-SR is unexpected. It
was noted that the Supervision variable (untransformed) had an large skew, with three
therapists outliers who had 250, 390 and 400 hours of supervision. Once transformed,
these were no longer outliers. Nevertheless, given the counterintuitive results for the
Supervision - WAI-SR association, the final conditional model (Model 4) was rerun
with these three values deleted. The results were essentially the same with the
127
Supervision variable having a slightly larger variance component (coefficient -.002047,
t(42) = 2.246, p=.030) and the same p-value.
In total there were seventeen therapists who had not had any supervision prior to
their current placement. To further understand the association between supervision and
alliance the final model was rerun with the Supervision variable transformed into a
categorical variable: No Supervision (0) / Supervision (1). The results for the
Approval-Seeking and AAQ-II variables were essentially the same. The categorical
Supervision variable was non-significant (coefficient -.002905, t(42) =1.676, p=.101),
but was trending towards Supervision having lower WAI-SR scores than No
Supervision, which is consistent with the results of the continuous Supervision variable.
The amount of supervision showed significant, positive correlations with the
number of courses undertaken (.482) and experience (.525). It is possible that these
variables confound the supervision - alliance growth association. In order to rule this
out, the variables “experience” and “course” were screened in the three level conditional
growth model with the same parameters as the initial variable screening procedure.
Alliance growth was not significantly related to course (coefficient -.000130, t (48)
=0.098, p=.923), but was associated with experience (coefficient -.000262, t(48)
=1.917, p=.061) at a trend level. Note that the experience variable was square root
transformed and the course variable was logarithm transformed.
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CHAPTER 6
DISCUSSION
6.1 Overview of the Chapter
The aim of this study was to determine whether therapists differed in their
capacity to establish and develop alliances with their clients and, if so, to identify
characteristics of therapists who were more effective in this regard. In this chapter a
brief summary of the significant results is given followed by detailed description and
analysis of the findings. Theory relevant to the interpretation of these results is detailed.
Incorporated into this analysis is a comparison of the current findings with the existing
research and consideration of the limitations of the study. The practical applications of
these findings along with the future research directions are also discussed in this
chapter.
6.2 Brief Summary of the Results
Two aspects of the client-rated alliance served as dependent variables in this
study, one, the early alliance, defined as a measurement of the alliance taken between
sessions two and six, and, two, the linear growth of alliance over time, which will also
be termed “alliance development”. The results suggest there is a significant variation
between therapists on the rate of alliance development; some therapists are better at
developing the alliance with their clients than others. Further, there are several
therapist characteristics that are associated with alliance development. The amount of
supervision therapists have received in their career to date (prior to beginning their
placement at the university psychology clinic) was negatively associated with alliance
development, whereas experiential acceptance, and the EMS approval-seeking were
positively associated with alliance development. The different alliance development
trajectories for therapists at the 25th, 50th and 75th percentile on each of these
characteristics are shown in Figure 6.1. While therapists’ attachment alone was not
related to alliance development, it interacted with clients’ attachment in its association
129
with alliance development. Therapist anxious attachment, when paired with clients’
anxious attachment, had a deleterious effect on alliance development.
1.66
1.72
1.79
1.85
1.91
RLR
EW
TOT
2.00 12.00 22.00 32.00 42.00
SESSION4
SQ_ADMIR = -0.108SQ_ADMIR = 0.021SQ_ADMIR = 0.082
Figure 6.1a. Alliance development trajectories of therapists on the 25th, 50th and 75th
percentile of approval-seeking.
Approval seeking 25th percentile 50th percentile 75th percentile
Alli
ance
Session number
130
1.66
1.74
1.81
1.89
1.97R
LRE
WTO
T
2.00 12.00 22.00 32.00 42.00
SESSION4
LG_SUPER = -1.003LG_SUPER = -0.087LG_SUPER = 0.979
Figure 6.1b. Alliance development trajectories of therapists on the 25th, 50th and 75th
percentile of supervision.
1.66
1.72
1.79
1.85
1.91
RLR
EW
TOT
2.00 12.00 22.00 32.00 42.00
SESSION4
RSQREAAQ = -0.642RSQREAAQ = 0.069
RSQREAAQ = 0.402
Figure 6.1c. Alliance development trajectories of therapists on the 25th, 50th and 75th
percentile of experiential avoidance.
Session number
Alli
ance
Supervision 25th percentile 50th percentile 75th percentile
AAQ-II 25th percentile 50th percentile 75th percentile
Session number
Alli
ance
131
6.3 Therapist Effects on the Alliance
Two hypotheses in this study concerned therapist effects: first, there would be a
significant difference between therapists on the early client-rated alliance (hypothesis
one); and second, that there would be a significant difference between therapists on the
rate of growth in alliance over sessions (hypothesis two).
Hypothesis one was examined in a two-level unconditional MLM with clients
nested within therapists. The intraclass correlation coefficient provides a ratio of
variance attributable to therapists, to the total variance. It suggests that 15% of variance
of the early alliance was due to therapists. However, the differences between therapists
on the early alliance were not statistically significant.
The three-level unconditional growth MLM, while not used to test this hypothesis,
is consistent with these results. While 25% of variance on the intercept was due to
therapists, the differences between therapists on the intercept were not statistically
significant.
The early alliance and the intercept on the three-level growth MLM, although
related, were calculated differently. The intercept is the value of the alliance when all x
values, in this case session number, equal zero. It does not make conceptual sense to
think of the intercept score as the alliance at the pre-therapy timepoint (i.e., session
zero). The alliance, being a relationship between the client and therapist, cannot actually
exist prior to the client and therapist meeting. It makes better conceptual sense to refer
to the intercept as measuring the initial level of alliance. Unlike the early alliance,
which consists of actual measurements taken between sessions two and six, the initial
alliance is calculated on the basis of the regression equations for all clients in the
analysis, regardless of whether they had early alliance data. Despite these differences
between the early alliance and the initial alliance, calculation of therapists’ effects on
these parameters were consistent – both showing non-significant differences between
therapists.
Taken together, these analyses suggest that therapists do not differ on the strength of
the early alliance they establish with their clients. Thus, hypothesis one is not
supported. It is notable, however, that the amount of variance due to therapists was
15% on the early alliance, and 25% on the initial alliance, and the random effects were
significant at a trend level (p=.055 and .079 respectively). It is possible that, given
more power in the model, these random effects would become significant and thus a
132
type II error has been made. Despite these trend-level significance levels, analyses of
the relationships between therapist characteristics and the early or initial alliance were
not undertaken as it did not make conceptual sense to be entering predictors for non-
significant differences. As a result hypotheses three, five and seven, which pertained to
the association between therapist charactereistics and the early alliance, were not
examined.
Hypothesis two stated that there would be a significant difference between therapists
in the rate of linear growth in alliance over sessions, i.e. alliance development. This
hypothesis was supported by the results. Calculation of the intraclass correlation
coefficient suggested 86% of variance on the alliance slope was due to therapists.
While significant therapists’ effects were not apparent in the early alliance or initial
alliance, they emerged when alliance development was considered. Furthermore, the
alpha level (p <.004) approached what is typically considered highly significant.
Overall, compared to existing literature, the current study reveals large
estimations of therapists’ effects on the early alliance and alliance development. The
early alliance finding can be compared to other studies which also examined alliance
measured at a single time point in therapy. For example, Hatcher et al. (1995) found
therapist differences accounted for only 6% of the variance on client-rated alliance
scores. The current study found double that amount of variance on the early alliance
which, like Hatcher et al. was calculated on the basis of a single alliance rating.
However, these studies used different analytic methods (HLM versus Confirmatory
Factor Analysis), had different samples (eclectic treatment versus long term
psychodynamic psychotherapy), and measured the alliance at a different point in
therapy. Any of these differences could account for the discrepant findings. Dinger et
al. (2008) measured client-rated alliance at the termination of inpatient therapy, which
on average lasted for 12 weeks. Although the alliance was collected at a single time
point, it is not comparable to the ‘early alliance’ time-point used here. Dinger and her
colleagues reported over 33% of variance on alliance (HAQ) at termination was due to
therapists. It is notable that this figure is larger than what was found in the current
study and also Hatcher et al.’s study. It is possible that the variability between
therapists becomes greater as therapy progresses and this is why Dinger et al.
discovered greater variance than the current study. The interpretation is open to
conjecture at this point, especially given that Dinger et al.’s sample of therapists and
clients are not really comparable to those used in the current study.
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Therapist effects on alliance development have been published in one study.
Dinger et al. (2009) examined both linear and quadratic alliance growth in an inpatient
sample who received an average of 12 weeks of individual psychotherapy provided
once or twice a week. The therapists’ effects for the slope and curve parameters, whilst
not reported, can be calculated from the parameters provided and are of the order of
13.9% for the intercept, 20% for the linear slope, and 4.8% for the quadratic curve. In
contrast to the work Dinger et al., the 86% of variance in alliance development due to
therapists in the current study is very large.
Several factors may have contributed to the larger therapist variance in alliance
in the current study. The current study included therapies up to 42 sessions long and
occurred on an outpatient basis, while the clients in Dinger et al.’s (2009) study had a
maximum of 24 sessions over 12 weeks and treatment was provided as part of a
structured inpatient treatment program. The therapists in the current study had a range
of experience and allegiances to different schools of therapy. In such a heterogeneous
sample differences between therapists style might be more evident. Another key
difference between the current study and Dinger et al.’s study was that clients in Dinger
et al.’s study came into contact with multiple therapists per week, which may result in
either their alliance to one therapist being diluted, or their ratings of this alliance being
impacted on by their overall experience of treatment resulting in a less precise
measurement of alliance with their individual psychotherapist.
It is also the case that therapist variance on the slope reduced to 38% when one
therapist, who showed a substantial decline in alliance growth (in model equations), was
deleted from the analysis. While the deletion of cases from the therapist sample is, as
argued earlier, inappropriate in therapist effects research, this finding does suggest that a
substantial amount of variance can be attributed to one therapist. Nevertheless, the 38%
of variance on the alliance in this alternative model still remains very large.
The current study, taken together with the published literature, suggests that
there are noteworthy therapist effects on the development of the alliance. Compared to
the therapist effects on outcome, which range from 0-18% (Crits-Cristoph & Gallop,
2006; Elkin et al., 2006a; Huppert et al., 2001; Kim et al., 2006; Lutz et al., 2007;
Wampold & Brown, 2005) depending on the outcome measure used, method of
analysis, and the study design (i.e. controlled or naturalistic), this study found large
therapists’ effects in early alliance, inital alliance and alliance development (15%, 25%
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and 86% respectively). The impact of factors such of length of treatment and the
homogeneity of the sample on therapists effects are yet to be untangled.
6.3.1 The significance of therapist effects on the alliance
Does it matter that therapists differ in the degree of alliance they establish early
on in therapy and develop over the course of therapy? It is well established that the
strength of early alliance is related to outcome regardless of the type of therapy
(Horvath & Symonds, 1991; Martin et al., 2000). It has recently been demonstrated that
therapists’ variability in early client-rated alliance predicts outcome, whereas the client
variability in early client-rated alliance does not (Baldwin, Wampold & Imel, 2007).
This means that therapists who generally have higher alliances with their clients have
significantly better client outcomes than therapists who generally have lower alliances
with their clients (Baldwin et al., 2007). Thus, not only is the early alliance associated
with outcome, but it is the therapists’ contribution to the alliance that is especially
important in this association.
The alliance pattern has also been shown to relate to the effectiveness of therapy
in terms of outcome. While the most effective pattern of alliance growth (i.e., linear,
stable, quadratic) has not been established, two studies have found an association
between linear growth in alliance and better client outcomes in very brief treatment (de
Roten et al., 2004), and longer term therapy (i.e., 40 sessions; Kramer et al., 2009).
The findings from the current study may inform future training applications. For
instance, the finding that a large amount of variation in alliance development was due to
therapists would suggest a need to train therapists to monitor and develop alliance over
time as an effective intervention to improve alliance formation and development.
Alternatively, if the variance in linear alliance growth was due to other factors, such as
what the client contributes, there would be less potential for intervention other than
through addressing the alliance-relevant client factors in the therapy itself. Of course,
more robust findings concerning the alliance pattern-outcome association are required
before such an intervention is justifiable.
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6.4 The Impact of Therapists’ Early Maladaptive Schemas, Psychological
Flexibility and Supervision on Alliance Development
Three therapist variables emerged as being significantly associated with alliance
development: experiential avoidance, amount of supervision to date, and the EMS
approval-seeking. The model which included these therapist variables as independent
variables (i.e., a conditional model) was significantly better than a model that did not
contain any independent variables (i.e., an unconditional model). This indicates that the
addition of therapists’ predictors added to the explanation of alliance growth. Together
these variables accounted for a 56% increase in explained variance on the therapist
slope. This means that the model successfully explained a large amount of the variance
in alliance development between therapists. These findings provide partial support for
hypothesis four: that therapists’ EMS, personality, attachment, mindfulness, experiential
avoidance, amount of supervision, amount of therapy and theoretical orientation would
be associated with the rate of growth in alliance over sessions. The support is partial in
that, while approval-seeking, experiential avoidance and supervision were associated
with alliance development, several other of the therapists’ characteristics identified in
this hypothesis were not.
These results are the product of correlational analysis, thus causation or
directionality cannot be inferred. While, on the basis of such analysis, it cannot be
stated that certain therapist variables cause faster or slower alliance development, such
an interpretation seems most plausable. It does not make sense to conclude that the rate
of alliance development caused certain therapist characteristics such as the amount of
supervision they had received, their experiential avoidance or approval-seeking. While
it is most plausable to consider the therapists’ characteristics as influencing alliance
development and not the other way around, it is nevertheless possible that the observed
relation is spurious in that a third variable may be responsible for the finding. An
examination of this possibility and an interpretation of why these particular therapist
variables were significant will be discussed in the following section. The variables that
initially emerged as having significant association with alliance development, but were
displaced by other variables, and the variables that showed no association with alliance
development are also of interest and will be considered.
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6.4.1 Therapists’ Early Maladaptive Schemas
In total, five therapist EMS were included in the analysis: self-sacrifice,
unrelenting standards, approval-seeking, entitlement, and punitiveness. Although there
were eighteen EMS measured, these five EMS were most prominant in this sample of
therapists. In univariate analyses therapists’ level of self-sacrifice, unrelenting
standards and approval-seeking were related to alliance developement. When these
EMS were examined simultaneously only approval-seeking remained significant. After
a detailed description of these EMS, a discussion of these results is undertaken.
6.4.1.1. Description of approval-seeking, unrelenting standards and self-sacrifice
Early Maladaptive Schemas
Young et al. (2003) suggest people with approval-seeking EMS:
value gaining approval or recognition from other people over developing a
secure and genuine sense of self. Their self-esteem is dependent on the reactions
of others rather than on their own reaction. The EMS often includes an
excessive preoccupation with social status, appearance, money or success as a
means of gaining approval or recognition. It frequently results in major life
decisions that are inauthentic and unsatisfying. (p. 20)
The focus of individuals with the self-sacrifice EMS is on the needs of others.
Patients with the self-sacrifice EMS voluntarily meet the needs of others at the
expense of their own gratification. They do this in order to spare others pain,
avoid guilt, gain self-esteem, or maintain an emotional connection with someone
they see as needy. The EMS often results from an acute sensitivity to the
suffering of others. It involves the sense that one’s own needs are not being
adequately met and may lead to feelings of resentment. (Young et al., p. 20)
Both the approval-seeking and self-sacrifice EMS, belong to the schema domain
Other Directedness. As this name suggests, individuals with EMS in this domain place
excessive emphasis on the responses of others. This occurs at the expense of their own
needs and awareness of their own preferences. Individuals with an unrelenting
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standards EMS do not share this excessive focus on others but rather tend to suppress
their spontaneous feelings and impulses, a characteristic of EMS in the over-vigilance
and inhibition domain. Specficially those with the unrelenting standards EMS:
strive to meet very high internalised standards, usually in order to avoid
disapproval or shame. The schema typically results in feelings of constant
pressure and hyper-criticalness towards oneself and others… The schema
usually presents as: (1) perfectionism (e.g. the need to do things “right”,
inordinate attention to detail, or underestimating one’s level of performance);
(2) rigid rules and ‘shoulds’ in many area of life, including unrealistically high
moral, cultural, or religious standards; or (3) preoccupation with time and
efficiency. (Young et al., 2003, p. 21)
6.4.1.2 The relevance of therapists’ Early Maladaptive Schemas
There is little written about therapists’ EMS. Spinhoven et al (2007) found that
dissimilarity between clients and therapists on EMS was related to improvement in
client-rated alliance from early to mid therapy. However, the impact of therapists’ EMS
on the alliance was not examined, so these results are not directly comparable to the
current study. Leahy (2001) theorised that therapists’ EMS will impact on the types of
countertransference they experience and developed the Therapist Schema Questionnaire
which corresponds to the Young Schema Questionnaire. Unfortunately there are no
published psychometric properties for the Therapist Schema Questionnaire and it is not
known how it correlates with the suite of Young Schema Questionnaires.
Leahy (2001) suggested that the most common therapist EMS were “demanding
standards” (i.e. unrelenting standards / hypercriticalness), “abandonment” (i.e.
abandonment / instability), “special superior person” (i.e. entitlement / grandiosity),
“need for approval” (i.e. approval-seeking / recognition-seeking), “excessive self-
sacrifice” (i.e. self-sacrifice) and “autonomy” (i.e. enmeshment / undeveloped self).
One published study has used the Therapist Schema Questionnaire to investigate
the prevalence of EMS in 64 post-graduate trainee CBT therapists at different stages in
their training (Haarhoff, 2006). If therapists responded 5 (somewhat true) or 6 (very
true) to any item for a EMS, the EMS was rated as present. The four most prevalent
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EMS in the sample were: demanding standards (75-87%); special superior person (62-
87%); excessive self-sacrifice (57-62%); and, need for approval (31–50%).
In the current study the EMS with the highest mean (and thus highest level of
intensity) was unrelenting standards, followed by self-sacrifice, approval-seeking,
entitlement, insufficient self-control and punitiveness. This is highly consistent with the
Haarhoff (2006) study, despite the differences in the scales used and scoring procedure
(presence of EMS versus level of EMS). The results of the current study and Haarhoff
(2006) study are also consistent with Leahy’s (2001) observation about common
therapist EMS. Neither Haarhoff or Leahy mention insufficient self-control and
punitiveness, probably because these EMS are not included on the Therapist’s Schema
Questionnaire.
While little empirical data exists to elucidate the therapeutic consequences of
therapists’ EMS, Leahy (2001) has suggested several ways in which these EMS might
manifest in therapists’ behaviour. Leahy suggests that therapists with a Need for
Approval EMS will endorse statements such as “I want to be liked by the patient. If the
patient isn’t happy with me, then it means I’m doing something wrong” (p. 257). He
writes “these ‘pleasing’ therapists may be highly skilled in showing empathy for the
patient and, by virtue of this empathy, certainly help the patient to feel valued and
understood” (p. 252). However, he notes that these same therapists will have limited
capacity to challenge the patient, set limits and boundaries, and tolerate the patient’s
anger. They may be reluctant to diagnose patients for fear of alienating them, and avoid
actions which may lead to patients being angry with them. These are all surrender and
avoidance behaviours. He predicts “the therapist and patient may continue in a
“chumship” that goes unchallenged by either party until the patient eventually
recognises that he or she is getting nowhere and leaves treatment” (p. 253).
Overcompensation behaviour for therapists with this and other EMSs were not
elucidated by Leahy. Possibilities include therapists disregarding the clients’ views of
them, or if the client expresses disapproval, to blame the client for this.
Like those with approval-seeking EMS, therapists with excessive self-sacrifice
are also likely to be anxiously aware of their relationship with clients. These therapists
may “overemphasise the importance of their relationships with patients” (Haarhoff,
2006, p. 129). The connection with the client is likely to serve their own needs for
connection such that they fear the client will abandon them. They may also experience
guilt if they perceive themselves as better off compared to their clients (Haarhoff,
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2006). Such experience may lead to surrender and avoidance behaviours such as “going
‘overboard’ to meet the needs of the patient” (Haarhoff, 2006, p. 129) or avoiding
upsetting the patient. These therapists may transgress boundaries by doing things such
as extending the therapy session, and “tolerating missed appointments” (Haarhoff, 2006,
p. 130). Overcompensation, might involve therapists holding boundaries too firmly and
becoming annoyed, rejecting or dismissive of clients whom they perceive as needy.
Therapists with unrelenting standards are less likely than those with self-
sacrifice and approval-seeking to look to their clients to fulfil their needs for emotional
connection and approval. However, they may set perfectionistic standards for both
themselves and their clients. The therapist, believing there is a correct way for therapy
to proceed, may become frustrated or insecure when the unexpected happens (Leahy,
2001). Schema avoidance and surrender behaviours may involve the therapists making
excessive demands of the client, being technique driven, overemphasising structure,
becoming controlling and intolerant, or refusing clients who they perceived as too
difficult” (Leahy, 2001). If therapists with this EMS overcompensate they may under-
prepare for session, be late or cancel sessions, or not show due diligence to note taking
and other administrative tasks.
Up to this point the surrender coping behaviours of therapists with approval-
seeking (e.g., seeking to impress) have been emphasised. It is difficult to see how
overcompensation behaviour for approval-seeking, unrelenting standards and self-
sacrifice would facilitate alliance growth. Such behaviour may involve provoking
disapproval or staying in the background (for approval-seeking), adopting sloppy
standards (for unrelenting standards) or giving very little (for self-sacrifice). Likewise,
it is difficult to imagine that self-sacrificing therapists would take up a therapist role if
they had to rely on avoidance behaviours such as avoiding situations which require
giving and taking. It is possible however, that such an avoidance behaviour might not
be enacted with a particular client but in therapists’ work overall. For instance, having
periods of sick-leave or retreating from client work for periods of time, or refusing to
take particular types of clients. Indeed, the finding that in a sample of health
professionals, self-sacrifice and unrelenting standards are associated with the emotional
exhaustion component of burnout (Bamber & McMahon, 2008), and self-sacrifice was
significantly correlated with work absences due to sickness (Bamber & McMahon,
2008) goes someway to support this conjecture. However, to delineate these
possibilities, a more fine grained analysis is required.
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It is not difficult to imagine how many of the possible EMS driven therapist
behaviours described above may have a deleterious effect on the alliance. However, in
the current study these EMS had a positive effect on alliance development. A closer
examination of this result is now undertaken.
6.4.1.3 Explaining the positive relation between therapists’ Early Maladaptive
Schemas and alliance development
6.4.1.3.1 Approval-seeking
Young’s (1990) formulation is of Early Maladaptive Schemas. Accordingly the
presence of EMS in non-clinical populations has been associated with emotional
instability, low levels of agreeableness (Sava, 2009); psychological distress (Cecero,
Beitel & Prout, 2008; Schmidt, Joiner, Young & Telch, 1995); and axis I and II
symptomotology (Harris & Curtin, 2002; Pinto-Gouveia et al. 2006; Price, 2007;
Schmidt et al., 1995). In light of this, and the possible consequences of therapists’ EMS
described above, the finding that three therapist EMS show positive associations with
alliance development is, at first glance, counterintuitive.
The positive association between EMS and alliance development may, in part,
be explained by the mild intensity of the EMS in the sample. For instance, the mean for
approval-seeking in the sample was 2.6 and the standard deviation was .63. Therefore,
most of the therapists in the sample were in the range of 1.97 (mostly untrue of me) to
3.26 (slightly more true than untrue). The highest score was 5 (mostly true of me).
Thus, it is more accurate to suggest that therapists with a moderate amount of approval-
seeking were more effective in developing the alliance than therapists low on this
schema.
Compared to those with severe EMS, for individuals whose schema is moderate
in intensity, the schema will be less pervasive; it will be triggered less often and they
will not experience negative affect as intensely or for as long (Young et al., 2003).
Given this, individuals with only moderate levels of a schema may be more able to
experience and contain their schema related affects and thus less likely to engage in
maladaptive coping behaviour.
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While the moderate intensity of approval-seeking in this sample may explain
why it was not negatively associated with alliance development, it does not explain how
this schema was in fact positively associated with alliance development. One
possibility is, due to the schema, therapists with an approval-seeking schema have
acquired skills useful for alliance building. Individuals who are approval-seeking, as
elucidated earlier, are highly focused on the other. Despite their motivation being
anxiety driven, therapists with this schema are likely to be practised at attending and
attuning to the other, skills that have been extensively written about as central to the
process of counselling generally (Egan, 2007), and specific psychotherapies such as
humanistic, experiential (Bohart, Elliott, Greenberg & Watson, 2002; Elliott, Watson,
Goldman, Greenberg, 2004) and relational (Erskine, Moursund & Trautmann, 1999;
Wallin, 2007) psychotherapies, as well as some psychoanalytic psychotherapies (Kohut,
1982; Stolorow, Brandchaft & Atwood, 1995).
Close attention to the other is also referred to as communicative attunement,
which is defined as an “active, ongoing effort to stay attuned on a moment-to-moment
basis with the client’s communications and unfolding process” (Bohart et al., 2002, p.
90). Such attunement is considered to contribute to clients feeling understood,
respected and safe (Bohart et al., 2002; Erskine et al., 1999). Clients’ experiences of
being attended to and respected by their therapist have been positively associated with
alliance (Ackerman & Hillenroth, 2003).
In summary, therapists with a moderate degree of approval-seeking are likely to
be practised and skilled at attending and attuning to the others. Such therapists’ skills
are an important therapy process and are related to the types of therapist behaviours
associated with strong alliances. Thus, one interpretation of the current results is that it
is the development of these skills in the approval-seeking therapists that explains the
positive association between approval-seeking and alliance development. Given that
therapists only had a moderate degree of this schema, they may have been able to
develop useful skills but have not become governed by the schema to the extent that
they cannot pursue other important tasks of therapy (such as challenging clients,
maintaining boundaries, tolerating clients’ anger). It might be the case that this schema
has an inverted U-shape association with alliance development, with only moderate
levels having a beneficial effect. One limitation of this study is that only linear alliance
development was examined, ruling out the examination of this possibility.
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6.4.1.3.2 Self-sacrifice and unrelenting standards
Self-sacrifice is a schema also indicative of a tendency to focus on the other and
was related to alliance development in the univariate analysis. Unrelenting standards
was likewise related to alliance development in univariate analysis. Neither of these
EMS, however, were related to alliance development in multivariate analysis.
Therapists who are self-sacrificing, like those who are approval-seeking, may
achieve better growth in alliance due to their capacity to attend and attune to their
clients. However, self-sacrifice was no longer significant when it was considered in the
MLM alongside approval-seeking, amount of supervision and experiential avoidance.
Of these variables self-sacrifice was only significantly associated with approval-
seeking, hence, it is likely that it is its shared variance with approval-seeking that led to
it being dislodged from the final model.
Whilst approval-seeking and self-sacrifice share a focus on the other, they
clearly have unique components. What differentiates these EMS conceptually is the
motivation for the other-directedness; while those with need for approval require
approval, those with self-sacrifice want to help people who they see as needy and may
act in an self-sacrificing way so as not to hurt the other. When using a schema
surrender coping style, those with approval-seeking will try to impress whereas those
with self-sacrifice will give to others.
Self-sacrifice was significantly, and positively, associated with age,
agreeableness, conscientiousness, attachment anxiety, punitiveness, and neuroticism.
Conscientiousness was the only variable that both self-sacrifice and approval-seeking
were associated with. In fact all three EMS are related to conscientious, however,
conscientious alone was not associated with alliance growth. For clarity, a diagram of
the associations between self-sacrifice, approval-seeking and unrelenting standards and
the other therapists’ characteristics measured in the current study is provided in
Figure 6.2.
As indicated through its association with neuroticism, attachment anxiety and
punitiveness, therapists who were higher on self-sacrifice were more distressed than
therapists higher on approval-seeking. Approval-seeking, on the other hand, was
associated with unrelenting standards and entitlement. Entitlement is “the assumption
that one is superior to other people, and therefore entitled to special rights and
privileges” (p. 19). In this sample the average level of entitlement on the YSQ-S3 was
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2.4 and most counsellors were in a range of 1.6 to 3.2. Thus, entitlement was generally
mild. In a milder form, entitlement, as a facet of narcissism, can be loosely
conceptualised as self-esteem (Millon & Davis, 2000). Thus-far, while the approval-
seeking and self-sacrifice EMS both indicate other-directedness, therapists with
approval-seeking seem to be less distressed and may have more self-esteem than those
with self-sacrifice.
Figure 6.2. Significant correlations between self-sacrifice, approval-seeking,
unrelenting standards and other therapist characteristics.
Unrelenting standards, like approval-seeking, was related to entitlement.
Conceptually, therapists with unrelenting standards and approval-seeking will both be
driven to perform, albeit for different reasons; to meet high internal expectations, or to
garner the approval of the other, respectively. Although it is conjecture at this point,
perhaps therapists’ attempts to impress clients or achieve their own high standards,
results in them displaying their knowledge and skills and being more active in the
therapy. Clients might in turn have more confidence that the therapists know what they
are doing, especially in respect to the task and goals of therapy, and this may explain
their higher alliance ratings. In fact, appearing confident and experienced to their
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clients, and noting past therapy successes, are therapists’ behaviours that have been
shown to be related to stronger alliances (Ackerman & Hillensroth, 2003).
The combination of the therapists’ absence of distress, raised self-esteem, and a
strong drive to perform, may be particularly important in alliance development.
Considered together, these qualities may reflect the therapist’s capacity to maintain
good self-other boundaries, that is, to maintain a differentiated sense of self in the face
of another’s distress and demands. This is different from diffuse boundaries where
there is a tendency to merge with the other, losing touch with ones affects, thoughts and
desires, and becoming absorbed in the mental states of others (Johnson, 1994; Yontef,
1993). If therapists cannot maintain differentiation, then they will not be in a position
to direct the therapy or provide emotional-containment (Gabbard & Wilkinson, 1994;
Hycner & Jacobs, 1995; Rothschild, 2006; Wallin, 2007; Yontef, 1993).
The pattern of associations between the therapists’ variables measured in this
sample indicate that therapists with approval-seeking schema may have both a tendency
for other-directness as well as have good self-other boundaries. Whereas therapists with
self-sacrifice and unrelenting standards schema, seem to have only one of these
elements. Perhaps the therapists’ qualities important to alliance development are the
combination of both other-directness and robust self-other boundaries. While this
interpretation of the results is just that – an interpretation, drawing on the attachment
research, there is some support for these ideas. The alliance has been likened to an
attachment relationship (Obegi, 2008; Parish & Eagle; 2003; Pistole, 1999). Given
this, what is important in the development of a secure attachment relationship, may also
be important to the development of a strong alliance relationship. Wallin (2007), like
others, links the role of the therapist to that of parents. He identified the importance of
attunement to the development of attachment “to the extent that the parent can attune to
the child’s emotional signals, there is the potential to respond effectively to the child’s
emotional needs…. In doing so, the parent strengthens the attachment bond” (p. 104).
Wallin (2007) goes on to elucidate that as well as being attuned, parents also
need to convey a sense of “coping and stability”; a sense that they are able to deal with
the child’s distress. Extending this to therapists suggests that it is also important for
therapists to be both attuned to the client and able to convey to clients that they have the
capacity to respond, which requires them to have maintained an adequate level of
differentiation. Therapists with a leaning towards approval-seeking, it is argued, may
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be competent in both of these matters and, as such, showed stronger alliance
development in this study.
6.4.1.4 Summary: Therapists’ Early Maladaptive Schemas and alliance
development
The examination of therapists’ EMS in the current study suggests that they may
be an important therapist characteristic to consider further. In order to determine what,
if anything, should be done about the impact of therapists’ schema on alliance
development, it is important to identify whether or not there is an inverted U-shaped
relationship between therapist schema and alliance development. That is, whether
moderate levels of certain schema are related to better alliance development than either
low levels or high levels of the schema.
It has been proposed here that therapists’ psychological make-up, in terms of
their EMS, relates to the interpersonal skills they have developed, specifically skill in
attuning to others. Alongside of this, it has been suggested that the approval-seeking
schema might also reflect the therapists’ capacity to maintain good self-other
boundaries. In essence, a mediation model is proposed; that therapists with approval-
seeking EMS have developed skills in attunement and have good self-other boundaries
which, in-turn, positively affect alliance development. This hypothesis, grown out of
the current research, is yet to be tested. Both replication and elaboration of the current
results is required with future research.
It is noted that the EMS entitlement and punitiveness were not found to relate to
alliance development. There is little comparative literature on therapist entitlement,
however, the research on therapists’ self-attack or self-directed hostility is relevant.
Dunkle and Friedlander (1996) found therapists with less self-directed hostility had high
client ratings on the bond aspect of the early alliance. Hersoug et al. (2001) found
therapists’ self-attack hostility was related to higher therapist- and client-rated alliance
at session three and twelve respectively. As the results for the current study concern
alliance development, they are not conflicting with the aforementioned findings. It may
be the case that therapists’ punitiveness schema relates to early alliance but not alliance
development.
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6.4.2 Psychological flexibility
In the final model, therapists with greater psychological flexibility had stronger
alliance development than their peers with less psychological flexibility. Psychological
flexibility exists on a continuum with experiential avoidance, with experiential
avoidance representing those low on psychological flexibility. To date, there are no
published studies examining the association between the alliance and therapists’
psychological flexbility. However, there is a wealth of empirical research about the
contruct of psychological flexibility itself. Aspects of this research that may illuminate
the relation between therapists’ psychological flexbility and alliance development are
now discussed.
Having psychological flexibility allows people to free up their attentional
resources from trying to manage their internal experience, so they can focus on what is
occurring in their immediate environment, and depending on their given goal, decide on
a course of action (Bond & Bunce, 2003). In contrast, experiential avoidance is a
process where, having negatively evaluated ones private thoughts, feelings, and
sensations, deliberate efforts are made to control or escape from them (Hayes, Strosahl
& Wilson, 1999). In essence, individuals who are experientially avoidant, avoid their
internal experiences even when this avoidance comes at the cost of not pursuing valued
activities and awareness of their environment. In the process of therapy, therapists can
have their own difficult internal material triggered. When this happens to a highly
experientially avoidant therapist, they may base their next response to the client on their
need to control or get rid of a particular private experience2, rather than on what would
best serve the client’s therapy in that moment. It this scenario clients may sense that
therapists are not adequately focused on them and what they are trying to achieve in
therapy and rate the alliance accordingly.
There are a multitude of ways that therapists might be experientially avoidant;
common examples are thought suppression, dissociation or numbing, distraction,
changing or deflecting a topic of conversation, denial and minimisation, keeping busy,
rumination and worry. Even therapy interventions can be called on for the purposes of
experiential avoidance. For example, therapists might passively listen when it might be
2 Private experience is a technical term used to refer to an individual’s experiences that are not directly observable to others. This includes thoughts, feelings, memories, physical sensations and action urges.
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better to interrupt, because they are avoiding the feelings and thoughts that arise when
they interrupt. The same might occur for directing (when its better to follow),
introducing topics (rather than stay silent) and problem solving (rather than exploring
feelings). The list is long and goes from the obvious to the subtle. It is vital to make
the distinction that it is not the form of behaviour which determines whether experiential
avoidance is present but rather its function. Furthermore, experiential avoidance is not
bad per se, experiential avoidance may be useful in some circumstances depending on
one’s goals. However, the current research suggests that therapists who show a general
tendency for experiential avoidance, will develop weaker alliances overtime, than
therapists who are less avoidant.
Beyond therapy processes there is a large and growing body of research that
suggests the tendency towards high levels of experiential avoidance, as measured on the
AAQ-II, is associated with psychological distress and dysfunction. Given that
experiential avoidance in non-clinical population is most relevant to a therapist
population, a brief review of relevant findings from a non-clinical population are
provided here.
Experiential avoidance is strongly related to measures of general
psychopathology (Hayes et al., 2004) and is predictive of emotional distress following
stressful evens (Plum, Orsillo & Luterek, 2004). In health professionals, experiential
avoidance has been associated with more stress and emotional problems, worse general
health, vitality, social and emotional functioning among rehabilitation workers
(McCracken & Yang, 2008), and is negatively correlated with wellbeing in ambulance
workers (Mitmansgruber, Beck & Schubler, 2008). It is also counterproductive as an
emotion regulation strategy as it tends to lead to increased frequency of the responses
that it is attempting to inhibit (Gross, 1998a, 2002; Wegner, 1994). Moreover, it
interferes with the experience of pleasure that comes from being immersed in activity,
and reduces the frequency and intensity of positive emotions (Gross & John 2003;
Kashdan, Barrios, Forsyth & Steger, 2006).
Experiential avoidance has been found to mediate a wide range of psychological
processes (Kashdan & Breen 2007; Ruiz, 2010; Tull & Gratz, 2008) indicating that
experiential avoidance may be central to many psychological processes. In
experimental studies, experiential avoidance has been shown to be related to greater
severity of panic symptoms and fear in an observational fear challenge (Kelly &
Forsyth, 2009), and more anxiety and emotional discomfort in CO2 inhalation and
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hyperventilation challenges (Felnder, Zvolensky, Eifert & Spira, 2003). Experimental
studies also support the contention that individuals with less experiential avoidance are
more able to notice and effectively respond to subtle changes in their immediate
environment (Bond, Flaxman & Bunce, 2008). Not all these variables are relevant to
the alliance, however, what these studies do indicate is that therapists who are
experientially avoidant are more likely to have lower levels of psychological wellbeing,
and be more vulnerable to psychological distress, and less able to effectively respond to
changes in their environment.
6.4.2.1 Psychological flexibility and therapists’ performance
Some findings that are particularly relevant to therapists’ interpersonal
performance relate to the impact that emotional suppression, a type of experiential
avoidance. Individuals who suppress emotions are aware they are being inauthentic and
deceiving others about their true thoughts and feelings (John & Gross, 2004).
Emotional suppression is also related to attachment avoidance, less social closeness and
support (John & Gross 2004).
In an experimental study emotional suppression, compared to cognitive
reappraisal, caused memory impairments for social information presented during the
period the individual was suppressing emotions. Further, John and Gross (2004) report
that individuals interacting with people who used emotional suppression experienced
more stress than people who were interacting with individuals using cognitive
reappraisal. While cognitive reappraisal can in fact be used as a method of experiential
avoidance, it seems that emotional suppression is a particularly problematic technique
for experiential avoidance in terms of its impact on interpersonal interactions. These
findings indicate that therapists using emotional suppression may come across as
inauthentic to their clients and be more stressful to interact with.
Psychological flexibility has also been related to work performance. Bond and
Bunce (2003) found that higher levels of psychological flexibility predicted, one year
later, employees who had better mental health and performed better on an objective
measure of workplace performance. Furthermore, the direction of association was
unidirectional and independent of negative affectivity and locus of control, which were
controlled in the analysis. While these studies were not examining therapist
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performance, it does highlight the predictive impact of experiential avoidance. Perhaps
incorporating the development of psychological flexibility into therapist training might
have an impact on subsequent performance and wellbeing.
Psychological flexibility also seems to impact how individuals respond to
psychological and educational interventions. Bond et al. (2008) found that employees
higher in psychological flexibility derived greater benefit, in terms of mental health and
work absence rates, from a workplace intervention. They conclude that “people with
higher levels of psychological flexibility have greater capacity to notice and respond
more effectively to goal-related opportunities at work” (p. 652). Similarly, high levels
of psychological flexibility have been associated with reduced levels of stigma towards
people with psychological disorders following a short educational workshop (Masuda et
al., 2007). Perhaps the therapists in the current study who were more psychologically
flexible were more able to learn from their coursework and clients. For instance,
perhaps they were better able to notice their mistakes, or the impact of their
interventions on the alliance, and being open to influence, were able to adjust their
therapeutic interventions according to what they learned.
6.4.2.2 The relevance of therapists’ psychological flexibility to the alliance
Psychological flexibility was associated with alliance growth in the hypothesised
direction in this study. That is, therapists with greater psychological flexibility have
greater growth in alliance over time. While it is clear from the aforementioned studies
that psychological flexibility is related to psychological wellbeing and adaptive
functioning, this does not entirely explain its association with alliance development. In
the current study psychological flexibility was, as expected, negatively associated with
variables indicative of psychological distress; specifically neuroticism (-.63),
punitiveness (-.40), attachment avoidance (-.30) and attachment anxiety (-.61).
However, these variables were not in themselves associated with alliance development,
indicating the association between psychological flexbility and alliance development
were not based on its association with psychological wellbeing. Further studies
controlling for these variables are required to confirm this.
It is also interesting to note that, although psychological flexibility and
mindfulness are related concepts and, in the current study, were significantly correlated
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(.54), only psychological flexibility was associated with alliance development. This
indicates that the impact of psychological flexibility on alliance development was not
only due to the mindfulness dimension of the concept.
So, what are the unique aspects of experiential avoidance or psychological
flexbility that explain its relation to alliance development? The measure of this concept
is called the Acceptance and Action Questionnaire (AAQ-II). Its name implies it is
specifically focused on the impact of thoughts, feelings and other private experiences on
action. Some items which highlight this are “My thoughts and feeling do not get in the
way of how I want to live my life”, “My painful memories prevent me from having a
fulfilling life”, “Emotions cause problems in my life.” Thus it is not the presence of
difficult private experiences which matter, but rather how they impact on behaviour.
For therapists, Pierson and Hayes (2007) suggest experiential avoidance has several
consequences for their behaviour: they may restrict the topics they will engage in with
client, fail to use internal experiences as a source of clinical information, act
inauthentically, and overall have a narrowed repertoire of behaviours available to them
at any given moment.
In sum, psychologically flexible therapists are likely to be able to maintain their
focus on the task and goals of therapy as they do not get diverted by their own private
experiences and attempts to control or avoid it. Therapists might appear to clients to be
more steadfast in their focus on the therapy process and this may translate to clients
perceiving a strengthening of alliance over time as it relates to agreement on tasks and
goals. Furthermore, as stated earlier, the psychologically flexible therapists may be
more capable of learning from their experiences with clients, that is, they may be more
responsive. This in turn may lead to the client feeling understood and attended to.
Psychologically flexible therapists are also more likely to seem authentic and be less
stressful to interact with than their experientially avoidant peers. These qualities may
result in clients perceiving a stronger bond with their therapists.
Again, it is interesting to consider the list of therapists’ behaviours which
Ackerman and Hilsenroth (2003) identified as being related to the alliance. Among
other things these included flexibility, openness, and attentiveness to client experience.
As stated above, it seems that therapists who are psychologically flexible would have
more capacity in all of these areas, which in turn accounts for the stronger alliance
development.
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6.4.3 Supervision
Therapists in this sample who had received more supervision had a slower rate
of alliance development than did therapists who had received less supervision. Only
supervision hours from the therapists’ supervision history, prior to their placement at the
university clinic, were included. Therapists were asked to also nominate how many
supervisors they had, first, to prompt them to remember all the supervision they had,
and second, to provide an indication of the breadth of supervision.
As indicated in Chapter Five (section 5.1.2), there was a large negative skew in
the sample for this variable; 50% of therapists had 10 or less hours of supervision,
however 25% of the sample had over 96 hours of supervision and three therapists had
over 200 hours of supervision. The maximum amount of supervision in the sample was
400 hours. When only the therapists who had some supervision were considered, the
average amount of supervision was 85 hours with, on average, two supervisors.
Considering that for registration as a psychologist (in Victoria, Australia) between 80
and 96 hours of supervision are required, 400 hours is clearly a great deal of
supervision. Although transformation of the variable corrected this skew, it was
possible that the supervision-alliance growth association was influenced by the
therapists with very large amounts of supervision. To investigate this posibility the
analysis was repeated with three outliers (therapists with 250, 390 and 400 hours of
superivsion) removed. The same result was obtained; more supervision was associated
with a slower alliance development.
As there were 17 therapists who had not received any prior supervision, the
analysis was repeated with supervision specified as a categorical variable; “supervision
or no supervision”. While this analysis did not reach statistical significance, the
direction of results were consistent with previous analysis with therapists with no
supervision trending towards higher alliance growth than therapists with supervision.
The negative relation between superivsion and alliance development is
counterintuitive and goes against practice wisdom where supervision is considered an
important part of therapists training (Callahan, Almstrom, Swift, Borja & Heath, 2009).
In fact, in Victoria Australia, where this research was conducted, psychologists must
participate in supervision to become a registered psychologist and to become a member
of specialist colleges. Registered psychologist-supervisors must in turn receive their
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own supervision to maintain their supervisor accreditation. Thus, participation in
supervision is embedded in the training and acreditation systems for psychologists.
It is tempting to explain this counterintuitive result by appealing to other
variables which may explain the supervision-alliance growth association. In any
correlational research there is always the possibility that an association between two
variables is spurious in that it is actually created by a third variable. While this remains
a possibility for the case in hand, the examination of a wide range of therapist variables
in the current research enables a number of potential “third” variables to be ruled out.
This result cannot be explained by the association of supervision and alliance
development with the following variables: the Big Five personality variables; anxious or
avoidant attachment style; degree of mindfulness; five EMS, personal therapy or
theoretical orientation (in terms of the rational-intuitive, and objective-subjective
dimensions). These were all examined separately and were not significantly associated
with alliance growth, nor were they significantly correlated with supervision.
Additionally supervision was not correlated with age, so it is unlikely that age
confounds the results.
Supervision was significantly associated with three other therapists’ variables
indicating therapists with more supervision were also more likely to have more work
experience, more training, and be more experientially avoidant than their less
supervised peers. However, it was not its connection to experience and training alone
which explained its association with alliance development, as post hoc analysis showed
these variables were not associated with alliance development. Despite supervision
being related to experiential avoidance, it remained in the final model with experiential
avoidance, indicating supervision contributed unique variance to the modelling of
alliance development.
6.4.3.1 Explanations for the negative association between supervision and alliance
development
There is very little research on therapists’ supervision and the alliance with
which to compare this finding. The research which has been conducted to date has
found client alliance ratings differ under different supervision conditions (Hilsenroth et
al, 2002), and that therapists receiving supervision have superior client-alliance ratings
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to therapists who do not receive supervision (Bambling et al., 2006). While these
studies suggest that supervision has a postitive impact on alliance, neither of them
considered the supervision “dose” in terms of the amount of supervision over a
therapists’ career. Hersoug et al. (2009) examined professional training over the
course of therapists’ career, which included supervision, formal post-graduate training
and personal therapy. They found that therapists’ professional training was negatively
associated with the level of client-rated alliance at sessions 20, 60 and 120 of therapy,
however, it was not related to alliance development. While Hersoug et al. confounded
supervision with other aspects of training, their results are consistent with the current
findings in that training appeared to have a negative impact on client-rated alliance.
Some support and explanation for the findings of the current study can also be
found in Henry et al.’s (1990) study and follow-up analysis (Henry et al., 1993). They
found that experienced therapists, after receiving one year of supervision in time-limited
dynamic psychotherapy, showed a deterioration in interpersonal and interactional
aspects of their behaviour with clients. Therapists increased their complex
communication, were less optimistic, less supportive of patients’ confidence, spent less
time evaluating clients’ feelings and were more authoritarian in their behaviour.
Therapists who had more supervision prior to participating in the study showed less
adherence to the therapy protocol than their less supervised peers. As supervision
participation increased, therapists seemed to become less open to changing their
practice. Potentially, like Henry et al’s (1993) therapists, the therapists in the current
study with more supervision may have been less open to learning, and displayed more
complex communication with clients, negatively impacting alliance development.
A limitation of this study is that the simple measurement of supervision in this
study (i.e. amount of hours to date), is a blunt and single-item measure that may lack
psychometric reliability and validity. For instance therapists may have inaccurately
reported the amount of supervision or included professional activities that are not
supervision. No definition of supervision was given on the questionnaire as it was
assumed that therapists would know what does and does not constitute supervision,
however that might not be the case. Studying supervision in this way also leaves many
uncontrolled and unaccounted for variables. Most markedly, it does not account for the
type or quality of supervision.
Supervision cannot be talked about as a homogenous concept. A brief database
search of titles (with the terms “supervision” and “therapist” entered as subjects),
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revealed multiple types of supervision models: live; outcome-oriented; group reflective;
relational; process; working alliance model; feminist, and so on. This list is far from
comprehensive but shows the diversity in approaches to supervision. The therapists in
this study may have participated in any one or more of these types of supervision. Most
of the therapists in the sample were not registered psychologists, so the supervision
received was not necessarily provided by more senior psychologists for the purposes of
psychology registration. It is also not known how the therapists in the study accessed
supervision, or importantly, whether the superivision they had received was
independent of their employer. The independence of the supervisor from the employer
has been found to be significant to the supervisees’ degree of trust (Webb & Wheeler,
1998), which, one may assume, could effect the strength of the supevisee-supervisor
alliance.
In addition to there being no information about the type of supervision, the
quality of supervision is also unaccounted for. Qualitative studies have highlighted that
superivision is not always productive. Supervisees, have reported negative experiences
in supervision (Gray, Ladany, Ancis & Walker, 2001) which can lead to supervisees
being “deeply hurt and confused by their experiences in supervision”, experiencing
ongoing self-doubt, leaving the profession altogether (Nelson & Friedlander, 2001) and
having a negative effect on their work with clients (Gray et al., 2001).
Until recently, there has been a lack of attention to the training of supervisors
(Holloway & Neufeldt, 1995; Sundin, Ogren & Boethius, 2008; Milne, 2009). For
example, the Psychologists Registration Board of Victoria only introduced specific
registration for supervisors in 2005. Thus, the quality and training of supervisors and
supervision has only recently received systematic attention.
Despite these potential problems with the measurement of supervision in this
study, ecologically there is a benefit to measuring supervision as a simple “dose” over
the course of a career. Therapists are likely to have a number of supervisors over their
career and access them in many different ways, e.g. privately, through line supervision,
and through appointed placement supervisor. Further, registration bodies, while
specifying the amount of supervision psychologists are required to participate in, do not
specify the method of supervision to be undertaken. It is the quantity of supervision
that is focused on.
Beyond the type and quality of supervision there remain other unaccounted for
variables that may explain the negative association between supervision and alliance
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development. For instance, therapists with large amounts of supervision who elect to
pursue a Masters or Doctoral degree in psychology may differ in important ways from
their less experienced student-peers. For instance, even after substantial amounts of
supervision, they may lack confidence in their ability and seek further study to redress
this. Possibly, therapists with this degree of prior training would approach further study
differently. For example, they may be motivated to study for the qualification, or “piece
of paper” so to speak, and hence approach their placement work differently, perhaps
with a sense of resentment as they have to go back to basics, or work for no charge.
Having prior supervision, they might be less inclined to stretch themselves beyond their
established practises, or having practised a certain way, defensively hold onto their
approaches to justify their practice to date. Alternatively, the placement demands may
be developmentally inappropriate for them. All these propositions remain speculative at
this point. However, there is clearly a number of possibilities to explore which may
account for the counterintitive association between supervision and alliance growth in
the current study.
Given the lack of specificity in this measure of supervision, and the limitations
of correlational research, results need to be interpreted with caution. Equally, the results
should not be explained away because they are inconvenient. The results suggest that
the differences between therapists on alliance development are associated with the
amount of supervision the therapist has received to date. Therapists with more
supervision had a slower alliance development. As previously mentioned, the
consequences of linear alliance development to client outcome is yet to be robustly
established in the literature. Until it is, the importance of this finding remains uncertain.
However, these results do call into question the functioning of supervision in two clear
ways: one, that it leads to increases in therapists capacity to facilitate therapy processes;
and two, more is better. It suggests that there is more to be understood about the impact
of supervision on the alliance and perhaps other therapy processes, especially
considering that it is a core aspect of professional training and practice. In a climate of
evidence based treatment, it seems behoven on the field to aspire to evidence based
training. The lack of quality research on therapists’ supervision noted by a number of
authors (Bambling, 2000; Ellis et al., 1996; Freitas, 2002) obviously needs addressing.
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6.5 Therapists’ Attachment and Alliance Development
Most of the published research focusing on therapists’ personal characteristics
and the alliance has focused on therapists’ attachment style. In the current study the
association between therapists’ attachment and alliance development was studied both
as a main effect along with numerous other therapist characteristics, and in interaction
with client attachment. With regard to the interaction it was hypothesised that therapist
and client attachment will interact with their association with alliance development
(hypothesis 6). The results of the current study support this hypothesis and are
analysed in detail below. A number of theoretical arguments are put forward which
might explain the proposed relation between therapist attachment and alliance in this
and other studies.
6.5.1 The impact of therapists’ attachment, considered in isolation, on alliance
development
The results of the current study suggests that therapists’ attachment, on its own,
was not related to alliance growth. This is consistent with other studies that have found
no association between client-rated alliance and therapists’ attachment (Fuertes et al.,
2007; Romano et al., 2008), and is inconsistent with studies that have found an
association between client-rated alliance and therapist attachment (Dunkle &
Friedlander, 1996). However, these studies are not directly comparable to the current
study because they have examined alliance at a single time point rather than alliance
development as is the case here.
Two studies have found associations between therapists’ attachment and client-
rated alliance development (Dinger et al., 2009; Sauer et al., 2003). Dinger et al.
(2009), collected HAQ alliance ratings after every session of individual inpatient
psychotherapy, which, on average, was 12 weeks long. Therapists’ attachment was
significantly associated with alliance development such that less preoccupied (i.e. more
dismissive) therapists had an inverted U-shape alliance development. However, this
latter finding was only at trend level of significance. Again, this study is not directly
comparable with the current study. Most markedly, Dinger et al. only examined the
relationship between therapist attachment and a U-shaped alliance trajectory, rather than
linear development as is the case in the current study. Furthermore, they measured
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attachment using the Adult Attachment Interview (AAI) in an inpatient sample.
Nevertheless, these results do support the contention that the impact of therapists’
attachment on alliance may depend on the stage of therapy.
Sauer et al. (2003) examined a small sample of 13 therapists treating 17 clients.
They used the Adult Attachment Inventory to measure attachment and the WAI to
measure alliance at sessions one, four and seven. Therapists’ attachment anxiety was
positively associated with single alliance ratings at sessions one and four. However,
when they examined alliance development they found therapists’ attachment anxiety
was associated with a decline in alliance growth.
Whilst Sauers et al.’s (2003) study seems underpowered, this does not explain
the discrepancy between their findings and the finding of the current study, as
underpowered analyses are actually less likely to obtain significant findings. Whilst the
analysis undertaken in the current study may also suffer from a lack of power, it had
sufficient power to find other significant associations, so this does not fully explain the
lack of a main effect for therapist attachment.
One major difference between the current study and that of Sauer et al. (2003) is
the time frame over which alliance was measured. In the Sauer et al. study alliance was
measured at defined points up until session seven, whereas in the current study the
alliance was measured at variable time points up until session 42. Both the Dinger et al.
(2009) and Sauer et al. results suggest that therapists’ attachment may impact on the
alliance differently at different stages of therapy. The non-significant results for
therapists’ attachment in this study may be explained by the fact that linear alliance,
examined over a longer course of therapy, was insensitive to the association between
therapists’ attachment in early alliance development (i.e. linear growth in the first seven
sessions of therapy) as well as being insensitive to detecting curvilinear alliance
development.
A number of studies of therapist attachment and alliance have not offered a
precise timeframe of alliance measurement (e.g. Berry et al., 2008; Black et al., 2005;
Furtes et al., 2007; Tyrell et al., 1999), and most have not considered alliance
development. Given that the impact of therapists’ characteristics may depend on the
timing of alliance measurement within the course of therapy, studies would be improved
by precisely defining the time of alliance measurement and examining the impact of
therapists’ attachment at different points in therapy (i.e. early alliance; early alliance
development; and linear and curvilinear development over the course of therapy).
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6.5.2 The impact of therapists’ attachment, considered with clients’ attachment,
on alliance development
Whilst, in isolation, therapist attachment style was not associated with alliance
development, a significant interaction emerged when client attachment style was also
considered. Specficially, therapists’ attachment anxiety interacted with client
attachment anxiety. This interaction is depicted in Figure 6.3. When clients and
therapists both had high attachment anxiety, or when they both had low attachment
anxiety, the alliance development was slower than when clients and therapists had
different degrees of attachment anxiety. In other words high anxious therapist with low
anxious clients, or high anxious clients with low anxious therapists.
1.66
1.79
1.91
2.04
2.16
RLR
EW
TOT
2.00 12.00 22.00 32.00 42.00
SESSION4
ASQANX1 = -0.448,ATT_ANX = -0.675ASQANX1 = -0.448,ATT_ANX = 0.557ASQANX1 = 0.794,ATT_ANX = -0.675ASQANX1 = 0.794,ATT_ANX = 0.557
Figure 6.3. Interaction between therapists’ and clients’ anxious attachment on alliance
development.
Note. Low and high anxiety is calculated as an average of the bottom 25% and top 25%
scores on attachment anxiety.
There was also a trend level (p = .055) interaction for client avoidant attachment
and therapist anxious attachment. This association was significant in the initial model
_____ Client anxiety = -0.448 (low) Therapist anxiety -.0675 (low) --------- Client anxiety = -0.448 (low) Therapist anxiety 0.557 (high) _____ Client anxiety = 0.794 (high) Therapist anxiety -0.675 (low) -------- Client anxiety = 0.794 (high) Therapist anxiety 0.557 (high)
Session number
Alli
ance
159
with all interaction terms entered, however, was reduced to a trend level association
when only significant interaction terms were entered for the final model. As depicted in
Figure 6.4, this interaction indicates that when clients are high in avoidance they have
faster alliance development with therapists who are high in anxiety compared to
therapists low in anxiety. However, when clients are low in avoidance they have faster
alliance development with therapists low in anxiety compared to therapists high in
anxiety.
Therapists’ avoidant attachment style did not show any significant interaction
with client attachment styles.
1.63
1.75
1.88
2.00
2.12
RLR
EW
TOT
2.00 12.00 22.00 32.00 42.00
SESSION4
ASQAVO1 = -0.370,ATT_ANX = -0.675ASQAVO1 = -0.370,ATT_ANX = 0.557ASQAVO1 = 0.699,ATT_ANX = -0.675ASQAVO1 = 0.699,ATT_ANX = 0.557
Figure 6.4. Interaction between therapists’ anxious attachment and clients’ avoidant
attachment on alliance development.
Note. Low and high anxiety and avoidance score is calculated as an average of the
bottom 25% and top 25% scores on the attachment scale.
Inspection of the direction of the interactions seems to indicate that along the
anxious dimension of attachment, alliance development is faster if the therapist and
client differ in the intensity of anxiety. However, when comparing different types of
_____ Client avoidance = -0.37 (low) Therapist anxiety -.068 (low) ------- Client avoidance = -0.37 (low) Therapist anxiety 0.56 (high) _____ Client avoidance = 0.69 (high) Therapist anxiety -0.68 (low) --------- Client avoidance = 0.69 (high) Therapist anxiety 0.56 (high)
Session number
Alli
ance
160
attachment style (i.e. anxious and avoidant) it seems that the alliance development is
faster when the client and therapists are similar on the intensity of their (different)
attachment styles.
Whilst there was a statistically significant interaction between client and
therapist attachment style on alliance development, when the conditional MLM (with
significant interaction terms) was compared to the unconditional model (with no
interaction terms entered), the model did not emerge as being significantly different.
Thus, the inclusion of interaction terms did not result in a model that explained more
overall variance. This result may be due to a lack of power in this model and data set
given that the sample size was small and the model was complex.
The conditional model resulted in over 50% increase in explained variance of
the client slope, however a decrease of 5.9% explained variance of the therapist slope.
As such the model was much better at explaining differences on alliance development
between clients than it was any difference between therapists. Given that variance was
explained at the client rather than the therapist level, it is plausible to suggest that the
interaction between clients’ and therapists’ anxious attachment explains differences
between clients, rather than between therapists, on alliance development.
6.5.3 Interpreting these results in light of the published research
Four published papers have examined the interaction of client and therapist
attachment on the alliance. Tyrell et al. (1999) examined the attachment styles, using
the AAI, of therapists (who in this research were clinical case managers) and their
clients with mental illness. Attachment was measured on one bipolar dimension from
hyperactivating (anxious attachment) to deactivating (avoidant attachment). They found
less deactivating (i.e. more hyperactivating) therapists had stronger alliances with
clients who were more deactivating than clients who were less deactivating (i.e. more
hyperactivating). A trend level finding emerged for more deactivating therapists to
form stronger alliances with less deactivating (i.e. more hyperactivating) clients than
with more deactivating clients. Put more simply, anxious therapists formed better
alliances with avoidant clients, and avoidant therapists formed stronger alliances with
anxious clients.
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Despite using a different method of measuring the alliance (interview versus
self-report), in the current study, therapists and clients attachment interacted with
alliance. Given that Tyrell et al. (1999) used one bipolar scale of attachment whereas
the current study used two separate scales to measure the two dimensions of attachment
it is not possible to directly compare the interactions. However, both studies suggest
that alliance is stronger where the attachment style of the therapist and client is
different. Furthermore Tyrell et al. examined alliance at one, undefined, time point
rather than alliance development over time as was done in the current study.
The only published paper on therapists’ attachment and alliance development is
by Sauer et al. (2003). As discussed earlier they found only a main effect for therapists’
attachment. They also examined the interaction between therapists’ and clients’
attachment for which there were no significant findings. The discrepancy between these
results and those of the current study are not easily explained. Both studies used a self-
report measure of attachment, both involved a naturalistic sample of clients attending
community or university counselling clinics. The counsellors in both studies were
similar, although the Sauer et al. sample had more psychodynamic therapists and
systemic therapists, and the current study had more eclectic therapists. As noted
previously, the major difference was in the time that the alliance was measured with
Sauer et al. only measuring alliance up to session seven. The lack of support in Sauer et
al’s study may also be due to a lack of power in their analysis; although this did not
negate them finding a main effect for therapist attachment.
Nevertheless, Sauer et al.’s (2003) results are similar to those obtained by
Romano et al. (2008) who did not find a significant interaction between therapist and
client attachment and the alliance. Romano et al.’s design differed from the current
study as they examined alliance at a single point in time (between sessions 5 and 9) and
sampled a group of students who volunteered to be clients. Using volunteer clients
lacks some ecological validity as these clients, as a group, are likely to have different
qualities, than individuals who seek out counselling as did the clients in the current
study. Romano et al. also used a different method of analysis (hierarchical linear
regressions) to sample client-therapist dyads, rather than using a nested model. They
note the possibility of Type II errors in their paper due to a small sample or
homogenous client and therapist samples.
Consequently, the current study supports the results of Tyrell et al. (1999) but
not those of Romano et al. (2008) and Sauer et al. (2003). However, due to differences
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in study design the reasons for these discrepancies cannot be easily resolved. The
design of future research may benefit from further clarification and consideration of the
theoretical reasons for an attachment-alliance association. Some of these theoretical
considerations are elucidated below.
6.5.4 Why might client and therapist attachment interact in their association with
alliance
In addition to the current study, there are two studies which suggest that client
and therapist attachment interact in their association with alliance. A number of
explanations about why this might be the case have been provided. These suggestions
are reviewed and extended here.
6.5.4.1 Interpersonal theory
In the Tyrell et al. (1999) study client outcome as well as alliance was examined.
The same pattern of client and therapists’ attachment that pertained to better alliance
was also associated with better outcomes. Tyrell et al. suggested that the combination
of more deactivating clients with less deactivating therapists related to better client
outcomes, because when therapists had a different attachment style to their clients, they
modelled for their client a different way of coping. This in turn was thought to
challenge the clients’ characteristic coping style and offer an alternative method of
emotional regulation and being in relationships. In therapeutic terms, it provided a
corrective emotional experience. For instance, Tyrell et al. suggest that hyperactivating
therapists were likely to maintain interpersonal closeness and focus on emotional
distress which challenged the style of deactivating clients who were likely to minimise
distress and maintain interpersonal distance (Tyrell et al., 1999). However, when it
comes to the alliance, Tyrell et al. expected that this would lead to lower client-rated
alliance due to the fact that clients may be threatened by therapists who, because of their
dissimilar attachment style, would related differently. Therefore, to explain their
unexpected results, they suggest that clients and therapist, having worked together for at
least seven months, had established a secure attachment from within which the clients
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could tolerate the therapists’ different way of managing distress and being in
relationships. While therapists in the sample varied on the hyperactivating versus
deactivating dimension of attachment, most therapists were secure when it came to the
autonomy versus nonautonomy dimension. Perhaps therapists’ security on this
dimension enabled the development of a secure attachment as Tyrell et al. suggest.
Mohr et al. (2005) found that therapists’ negative countertransference
behaviours were more likely to occur when the therapist and client had a dissimilar
attachment style, for instance avoidant counsellors with preoccupied clients. Like
Tyrell et al. (1999) they suggested that when therapists are paired with dissimilar clients
(in terms of attachment), rather than therapists being able to provide a corrective
emotional experience, their style of emotion regulation is challenged, and negative
countertransference ensues.
Unlike Tyrell et al. (1999), the current study, measured alliance from early in the
therapy process, thus it is unlikely that therapists had established a secure base prior to
the first alliance ratings. It could be the case that clients who have therapists’ with
dissimilar attachment styles initially rate the alliance lower, due to them finding the
therapists’ interpersonal style threatening or confusing. Moreover, in starting from this
low base, there is more room for the alliance to improve as they become familiar and
less threatened by the therapist. However, there was not a significant difference
between therapists on the initial or early alliance, and examination of Figure 6.4
indicates the slopes that grew more rapidly had a higher intercept compared to the
slower growing slopes. Thus the “starting from low base” explanation does not seem
valid.
Tyrell et al.’s (1999) explanation is based on how people with different
attachment styles cope interpersonally, and what impact such styles might have within
the client-therapist dyad. Bernier and Dozier (2002) suggest, when therapists and
clients are similar the therapists may be more likely to engage in complementary
behaviours. In contrast, when therapists are dissimilar from their clients they are more
likely to provide non-complementary responses which are thought to lead to corrective
emotional experiences. How such responses might manifest in the pattern of
interactions observed in the current study are offered below.
One way to examine the interaction between client and therapist anxious
attachment on alliance development is to consider why clients who are high in anxiety
would perceive a stronger alliance development with therapists who are low in anxiety
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rather than therapists who are high in anxiety. A client who is anxious in their
attachment style is preoccupied with relationships and has a strong need for approval.
Therapists who are anxious are likely to show the same concerns. Wallin (2007)
suggests anxious therapists may be more likely to empathise with anxious clients and
this may go someway to reassure clients, temporarily alleviating their attachment
preoccupations and need for approval. However, anxious therapists are also at risk of
merging or over-identifying with such clients, and like their anxious clients, they are
likely to underplay their own strengths (Wallin, 2007). Clients may perceive the
anxious therapists as not strong enough to be able to help them or contain their anxieties
and as a result perceive a weaker alliance than if they were with less anxious therapists.
In this case anxious therapists may be less able to provide non-complementary
responses as, due to their own anxiety, they may have lost the psychological space or
therapeutic space required to do so.
Clients with high attachment avoidance rated the alliance higher when their
therapists were relatively high in attachment anxiety than when therapists were
relatively low in attachment anxiety. In this instance, the therapist’s anxiety, rather than
threatening the client (as Tyrell et al. suggested), may have assisted them to reach out to
avoidant clients who tend to maintain interpersonal distance. Such interpersonal contact
may provide a corrective experience if clients usually experience others as disengaging
with them when they withdraw. Such contact may also assist the development of the
alliance.
However, when clients are low on avoidance (either because they are secure or
because they are anxious), the therapists’ anxiety no longer seems to facilitate client-
rated alliance development. Here the preference is for therapists low on anxiety.
Perhaps with clients with a good capacity to reach to the other (either because they are
secure, or because they are anxious), the therapists’ anxiety is not required; the client
can make interpersonal contact themselves. Potentially therapists who are anxious are
less capable of adapting their usual strategy and may instigate interpersonal contact
when it is not required. This then becomes a misattunement to the clients’ needs which
may interfere with alliance development.
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6.5.4.2 The alliance as an attachment relationship
It has been argued that the concept of the alliance and attachment overlap
(Obegi, 2008; Parish et al., 2003; Pistol, 1999; Tyrell et al. 1999). Obegi (2008)
proposes that the bond aspect of the alliance is an “in-progress attachment to therapists”
(p. 431). Similarly Pistole (1999) states “the conditions for establishing an attachment-
caregiving bond are implicit in most counselling situations” (p. 439). Pistole suggests
clients begin counselling in a state of distress and vulnerability and that the anxiety
involved in entering therapy activates the attachment system which leads the client to
seek “proximity to and care from someone stronger and wiser…” (p. 439). When the
counsellor responds to these signals, secure attachment develops (Pistole, 1999).
Parish et al. (2003) provide some empirical support for these observations. They
identified nine elements of attachment relationships that were conceptually related to
client-therapist alliances and found a measure of these attachment elements to be
correlated with a measure of alliance. Among the attachment elements, those regarding
the therapist providing a secure base and being available and responsive explained the
most variance in alliance scores.
Given the association between attachment and alliance, it is appropriate to
consider therapists’ capacity to establish attachment relationships with their clients,
what their own attachment histories bring to bear on this capacity, and how this might
inform an interpretation of the current findings and research about therapists’
attachment and the alliance more generally.
6.5.4.2.1 The provision of a secure base
An attachment figure, such as a therapist, may provide a secure base for the
other, in this case the client. Dozier et al. (1994) and Wallin (2007) suggest that it is
therapists’ secure attachment status, rather than different or complementary attachment
status, that gives them the capacity to form a secure base with their clients. Some
research evidence supports the idea that therapists’ insecure attachment may interact
with clients’ attachment style in problematic ways. For instance therapists’ insecure
attachment has been related to negative transference behaviour (Ligero & Gelso, 2002).
Similarly, Dozier et al. (1994) found that secure therapists compared to their insecure
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peers were able to respond to the underlying dependency needs of both preoccupied and
dismissing clients. However, those therapists who were insecure only responded to the
obvious needs of clients. They suggest “clinicians who are insecure appear to feel the
pull of the clients attachment strategies and act accordingly” (p. 798).
Given the emphasis on the security of therapists’ attachment for the provision of
a secure base, it is important to consider the severity of attachment anxiety and
attachment avoidance in this sample of therapists. The maximum score on the ASQ was
six. The mean level of attachment anxiety in the therapist sample was 3 (slightly
disagree) with a range of 2 to 4. The mean attachment avoidance was 2.5 (between
strongly disagree and slightly disagree) with a range from 1.6 to 3.6. Norms are not
available for this scale. However, some indication of the severity can be understood by
considering the scale anchors, which indicate that, the most highly anxious counsellor
endorsed statements assessing attachment anxiety at a “slightly agree” level.
Inspection of the five subscales which comprise the two higher order factors suggest
that the counsellor sample had similar scores to other samples deemed secure (Feeney et
al., 1994; Ng & Trusty, 2005), whereas the client sample scores were closest to samples
deemed insecure (Feeney et al., 1994; Ng & Trusty, 2005).
Perhaps the therapists in this sample were “secure enough” in their attachment
style to provide a secure base for their clients and, as long as a secure base is
established, the therapists’ difference from the clients in terms of attachment style
actually benefits the development of the alliance as the current results suggest. The
concept of mentalization, a recent advance of attachment theory, might go some way to
explain how this difference in attachment style or intensity might help establish the
therapist-client attachment, and by association, alliance.
What follows is a discussion of mentalization theory and how this might relate
to the current research findings. While, these interpretations are speculative at this
point, they may inform the future direction of this kind of research.
6.5.4.2.2 Mentalization
The concepts of mentalization and specifically “contingent” and “marked’
mirroring may offer some insight as to why therapists who had different attachment
from the client (either type or intensity - but not both), had a stronger development of
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alliance over time. A brief introduction to mentalization is provided below to embed
these terms in their proper context.
Mentalisation, also referred to as reflective function, is “the process by which
we realize that having a mind mediates our experience of the world” (Fonargy,
Gergeley, Jurist, & Target, 2002, p. 3), or more simply put, it is the “capacity to
envision and think about mental states, in oneself and in others, in the service of
building realistic models of why they behave, think, and feel as they do” (Bouchard, et
al., 2008, p. 48).
Mentalization and attachment are related but not equivalent systems (Diamond
et al. 2003), they are “loosely coupled” (Fonargy & Bateman, 2008). For instance
securely attached children have been found to be more advanced in the development of
mentalization (Fonargy & Bateman, 2008); measures of mentalization negatively
correlate with measures of attachment security (Bouchard et al, 2008); like insecure
attachment, poor mentalizing ability is associated with psychiatric symptomatology
(Fonagy et al., 1996); and, maternal mentalization fosters the child’s secure attachment
(Fonargy & Bateman, 2008). This last point is particularly important as it shows how
attachment styles are transmitted intergenerationally. Fonargy reported that when
mothers can mentalize, despite their own problematic attachment histories, they are
more likely to have secure children compared to mothers with similarly problematic
attachment histories who cannot mentalize (Fonargy, Steele & Steele, 1991).
Mentalizing is not learned in isolation, but rather one learns to mentalize through
interacting with a mentalizing other (Sharp & Fonargy, 2008).
It is suggested that the therapists’ capacity to mentalize, in order to facilitate
client mentalization, is the “critical facet of the therapeutic relationship and the essence
of the mechanism of change” (Fonargy & Bateman, 2008, p. 415). Wallin (2007) also
argues that therapists’ capacity to mentalize allows them to “reach, resonate with, and
respond in an attuned fashion to, [clients] experience...” (p. 134) and in doing so,
develop an alliance. While the development of clients capacity to mentalize is the
explicit target of mentalization based therapy, it is thought to be an important, but
perhaps implicit, process in psychotherapy more generally (Fonargy et al., 2002;
Holmes, 2001). One of the ways that a mentalization based therapist will teach the
client to mentalize is through the provision of marked and contingent mirroring,
processes that occur naturally between a mentalizing caregiver and child (Fonagy,
Gergely & Target, 2007).
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There are two aspects of therapists’ mirroring of client internal experience that
are thought to be required: contingent and marked. Contingent mirroring is accurate,
i.e. the therapist reflects back through their words and non-verbal expressions an
accurate mirror of the client’s internal experience. Reflections are ‘marked’ when they
are offered in a way that it it made clear that it is a reflection of the client’s internal
experience, rather than the therapist’s, and in turn allows the client to develop
awareness of his or her own mind (Wallin, 2007).
Mirroring or reflecting back a client’s experience is a basic counselling
microskill (Egan, 2010; Hill, Stahl & Roffman, 2007; Ivey, Ivey & Zalaquett, 2010;
Kuntze, van der Molen & Born, 2009). Therapists providing mentalization based
therapy consciously respond to their clients with marked and contingent mirroring.
Therapists informed by other frameworks, like those in the current sample, are less
likely to purposefully provide marked and contingent mirroring but, nevertheless, may
intuitively do so. One explanation for the interaction between client and therapist
attachment on the alliance development found in the current study and by Tyrell et al.
(1999) is that therapists are better able to provide marked and contingent mirroring
when their attachment style is different from that of the client, yet secure enough to
establish a secure base. If therapists have insecure attachment styles it is probable, that
like insecure parents, they will be less able to mentalize generally, and to respond to
clients with marked and contingent mirroring specifically (Wallin, 2007). In this
scenario, by virtue of their difference from clients, therapists provide marked mirroring.
That is, because they are different in attachment style or intensity, they mirror in such a
way that clients can recognise that therapists are mirroring back his or her affect, rather
than the therapists reflecting back the therapists affect. However, if therapists are too
different, for instance they have a different attachment style and intensity of attachment
security, they may not mirror accurately, that is provide contingent mirroring.
Some support for this idea is provided by Diamond et al. (2003). On the basis of
four case studies they concluded that “in order for the patient to use the therapeutic
relationship as a scaffold from which to develop the capacity to understand self and
other in terms of mental states, patient’s and therapist’s reflective functioning [i.e.
mentalization] must be complementary, neither to distant nor too parallel” (p. 253).
Given the importance of mentalizing and the provision of marked and contingent
mirroring to the development of secure attachment relationships (Fonargy & Bateman,
2008; Fonagy, Gergely & Target, 2007; Wallin, 2007), it is likely that these qualities are
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also important to the alliance. When clients feel contained and understood through
marked and contingent mirroring, and do not feel either overwhelmed by the therapists’
affect or internally empty as a result of unmarked or non-contingent mirroring, it is
likely that they will rate the alliance as stronger, and that these experiences will enable
the alliance to develop over time. Importantly, in this study, the concepts of marked
and contingent mirroring may explain why therapists with a different attachment style
to their clients (either different intensity, or different style) showed a stronger alliance
development.
6.5.5 Summary: therapist and client attachment and the alliance
The current study reveals an interaction between therapist attachment and client
attachment on alliance development. Yet, therapist attachment alone was not related to
alliance development. These results have been compared to the existing research, which
overall are equivocal. Although the attachment interactions in the current study were
significant, they did not explain more variance on alliance development than an
unconditional model. Hence, while these results are clincally interesting and
theoretically relevant, more research is required to clarify their influence on the alliance.
Given that therapists’ attachment has been significantly associated with alliance in a
number of studies, an investment in large well designed studies with adequate power
and controls is justified.
The analysis and interpretation of the current findings identify questions for
future research. For example, whether the association between alliance and therapists’
attachment alone, or in interaction with client attachment, is influenced by (1) the time
alliance is measured, (2) whether alliance is conceptualised as the level at a single point
in time or an alliance pattern, (3) the particular pattern of alliance development, and
(4) the duration of therapy.
Future research might also pay more attention to the overall security of
therapists’ attachment. For instance, is the relationship between therapists’ attachment
and alliance different when therapists are in a “mild” range of attachment insecurity
(i.e. slightly anxious or slightly avoidant), compared to therapists who are very insecure
in their attachment (i.e. very anxious, very avoidant, or disorganised).
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Interpersonal theories and attachment theories have been used to explain why
therapist and client attachment interacted on alliance development. Taking an
interpersonal approach it has been argued that difference in the degree of therapists’ and
clients’ anxious attachment, or attachment styles, better equips therapists to provide
non-complementary responses, and responses which will enable interpersonal contact.
Such responding is a pre-requisite of alliance development.
From the perspective of attachment theory it has been argued that, as long as
therapist attachment remains within a normal range, the differences between the
therapist and client on attachment intensity or style is actually functional as it enables
the therapist to provide marked and contingent mirroring. However, this hypothesis is
yet to be tested empirically and might be the topic of future research enquiry. It has
been proposed here that attachment and alliance are overlapping concepts. While there
are theoretical arguments to support this, very little empirical evidence exists and this
might also be a topic of future research.
6.6 Therapists’ Characteristics Not Associated with Alliance Development in the
Current Study
Given that there is little research on therapist characteristics and the alliance, an
exploratory approach was undertaken in the current research. In addition to the
variables discussed above (schema, psychological flexibility, supervision and
attachment), there were five other therapists’ personal or professional variables
screened to test whether they were associated with alliance development: mindfulness,
theoretical orientation, “Big Five” personality factors, personal therapy and experience.
While personal therapy was associated with alliance growth univariately, this did not
remain the case in multivariate analysis. The other variables examined were not
associated with alliance growth in any of the analysis. It is interesting to note that two
of the three therapists’ predictors (EMS and psychological flexibility) that turned out to
be significantly related to alliance growth have not been examined in the published
alliance research to date. Whereas, variables that have been related to alliance in
previous research such as experience, orientation and personality, did not turn out to be
significant in this research. These nonsignificant findings will now be discussed.
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6.6.1 Personal therapy
The degree to which therapists had participated in their own therapy was
negatively associated with alliance development in univariate analysis. This indicates
that therapists who had received more personal therapy to date had slower alliance
development with their clients, than therapists who had received less personal therapy.
The direction of this association is consistent with the finding of Wheeler (1991) who
found a small, yet significant negative correlation between personal therapy and client-
rated alliance. The association between personal therapy and alliance growth did not
remain significant when considered alongside the other therapist predictors, suggesting
it no longer contributed unique variance to the model.
The only other therapist variables that personal therapy was associated with
were openness (.39), attachment anxiety (.30) and experiential avoidance (-.29). It is
likely that its shared variance with psychological flexibility was responsible for its
statistical insignificance in the multivariate model. It is possible that individuals who
are experientially avoidant to seek or continue in therapy as another method of
experiential avoidance, in essence hoping that through therapy they find a way to
alleviate their disturbing private experiences. Furthermore, given their experiential
avoidance they might require more therapy session to engage in the therapy tasks which
require them to contact and process painful private experiences. Those therapists who
had engaged in more personal therapy had higher attachment anxiety which may also
explain why they seek out or remain in therapy. Otherwise, on the variables measured
in this study, they were not any more distressed than other therapists: they did not have
higher levels of neuroticism, attachment avoidance or punitiveness schema. Thus, the
association between personal therapy and distress is unlikely to be the reason for its
univariate association with alliance development.
The current research is an advance on the previous work of Wheeler (1991) and
Gold and Hillsenroth (2009) as clients with a range of distress and disability, and
therapists with a range of experiences and theoretical orientations, were sampled.
Furthermore, although it suffers from the inherent limitations of a naturalistic design
(i.e. lack of internal controls) measuring personal therapy as a “dose” has ecological
validity and is pragmatic. An alternative would be to compare therapists currently in
therapy versus those not currently in therapy (the approach taken by Gold, 2009).
However, the applicability of findings would be limited; it is not realistic to expect that,
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should current therapy be beneficial to the alliance, that therapists stay in therapy ad
infinitum.
Orlinsky et al. (2005) propose that personal therapy is unlikely to have
discernible impact on outcome and, indeed, research to date is consistent with this view
(Macran & Shapiro, 1998). Orlinsky et al. suggested that personal therapy is more
likely to have an association with therapy processes, such as the alliance. The current
results suggest that, although personal therapy was observed to have a deleterious effect
on alliance development in univariate analysis, this association was better accounted for
by other variables. This suggests the association between personal therapy and alliance
development is complex. Future research ought to interpret simple correlations between
therapists’ personal therapy and therapy process with caution and, where possible
investigate other variables which may better account for associations found. Given the
emphasis on personal therapy in some therapists’ training, the impact of personal
therapy on alliance and other therapy processes remains worthy of further investigation.
6.6.2. Experience
It has been argued that therapist experience is more likely to matter with
complex clients (Kivlinghan et al., 1998). This idea was examined in the current study
though examining the interaction between therapist experience and client attachment on
alliance growth. It was hypothesised that therapists’ level of experience and client
attachment will interact in their association on alliance development, whereby when
clients have greater attachment insecurity more experienced therapists will have
stronger rate of growth in alliance than less experienced therapists (hypothesis 8).
Findings indicate therapists’ experience did not interact with client attachment on
alliance development. Therefore this hypothesis was not supported.
This result is in contrast to Kivlinghan et al. (1998) who, in a similar sample,
found an interaction between client attachment and therapists’ experience on the client-
rated early alliance. Specifically, clients with greater discomfort with intimacy, a type
of avoidant attachment, rated the alliance higher when they had therapists with more
experience compared to therapists with less experience. In the Kivlinghan et al. study,
therapists’ experience was operationalised on a scale from one to six. Therapists were
assigned one point for each year of formal training and one point for every year of post
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doctoral experience. Such an operationalisation was not appropriate for the current
sample, in the Australian context. Furthermore, Kivlingham et al.’s operationalisation
of experience might be better considered as experience and training. The
operationalisation of experience (see Appendix E) in the current study did not include
training.
The operationalisation of experience in the current study did not take into
account the amount of client contact, and it privileged time in the role over the amount
of hours per week. For instance, a therapist who had worked 20 hours a week for two
years and a therapist working 40 hours per week for two years would receive the same
rating. Furthermore, like the supervision variable, quality was not accounted for in this
operationalisation of experience even though therapists had a wide array of experience
(as detailed in Appendix A). Therapists with 12 months experience offering telephone
counselling, 12 months experience as a therapist or 12 months experience as an
individual or group psychotherapist would all be rated the same on this item, even
though the depths of counselling and degree of counselling experience in the roles are
obviously different.
The nonsignificant findings regarding therapist experience may be accounted for
by the bluntness of this single item measure of experience. That said the measures of
experience used by Hersoug et al. (2001) and Meier et al. (2005), who used years of
post-graduate experience, and months working with drug users or in current role
(respectively), also suffer a lack of specificity but nevertheless were significantly
associated with experience.
The reason that clients’ attachment security is of interest in terms of therapist
experience is that clients with more insecure attachment encounter difficulty in
relationships, including the alliance with their therapist (Daniel, 2005; Horvath & Bedi,
2002). Relationships are particularly difficult for individuals who, having both avoidant
and anxious attachment styles, are disorganised in their attachment (or unresolved
depending on the attachment taxonomy). Such individuals have difficulty establishing
an optimal interpersonal distance; their avoidant style will lead them to seek distance
from others, whereas their anxious style will lead them to seek proximity (Johnson,
1994; Karen, 1994; Wallin, 2007). Unfortunately because the avoidant and anxious
attachment dimensions were considered separately in this study, clients who were
disorganised were not identified. It might be the case that therapists’ experience is
pertinent when working with clients who are disorganised, rather than insecure on only
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one of the attachment dimensions. Future research may take this attachment dimension
into account when examining the client attachment and therapist experience interaction.
Post-hoc analysis found neither experience nor the number of therapy-related
courses the therapists had undertaken were related to alliance development as a main
effect. This is consistent with Hersoug et al. (2009), who also reported no association
between experience and alliance development, or level of alliance at the 20, 60 and
120th sessions of psychotherapy. Dunkle & Friedlander (1996) found no association
between therapists’ experience and early client-rated alliance. However, a number of
other studies have reported positive associations between therapists’ experience and
client-rated alliance (Mallinckrodt & Nelson, 1991; Meier et al., 2005). These studies
are not directly comparable to the current study as they have examined early alliance
and used a different operationalisation of experience.
Although the current research suffers the aforementioned limitations, the
results are consistent with the large body of literature on therapists’ experience and
client outcome, which suggests there is not a robust association between these variables.
Taken together these lines of research question the assumption that more experienced
therapists develop better alliances and achieve better client outcomes than their less
experienced peers.
6.6.3 Theoretical orientation
Therapists’ theoretical orientation, measured on the dimensions rational-intuitive
and objective-subjective, was not related to alliance development. There are no other
published studies that have examined how a dimensional conceptualisation of
theoretical orientation relates to alliance. The only study that examined theoretical
orientation and alliance conceptualised theoretical framework categorically and
measured the therapist-rated alliance (Black et al., 2005). They found psychodynamic
therapists rated the alliance lower.
It is notable that when the scores on the CTPS were examined in isolation they
did not seem restricted in range. However, when compared to other samples of
therapists the sample of therapists in the current study seems quite homogenous. They
demonstrated a strong tendency towards objective and rational ways of knowing, which
is associated with cognitive-behavioural orientations. This is despite the fact that
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therapists’ self-ascribed orientation included eclectic, cognitive-behavioural,
humanistic, psychodynamic, and transpersonal frameworks.
Perhaps the relative homogeneity of the therapists’ orientation contributed to the
nonsignificant finding and a larger range of theoretical orientations are required before
an association with alliance becomes apparent. Alternatively, orientation may have no
bearing on alliance. Further research will be required to address either of these
possibilities.
Therapists ascribe to theoretical orientations, which form a major part of their
identity as therapists, both how they identify themselves and how others identify them.
However, to date, research does not support the hypothesis that orientation is related to
client outcome. The results of this study also suggest that theoretical orientation is not
associated with client-rated alliance development. Whilst there are limitations in this
body of research, the results so far indicate that the relevance of theoretical orientation
to alliance and client outcome is inconclusive. The emphasis given to theoretical
orientation might be best moderated by the empirical data.
6.6.4 Personality
The “Big Five” personality variables measured by the NEO-FFI were not
associated with alliance development in this study. There is only one other published
study of therapists’ personality and alliance (Chapman et al., 2009). Chapman found
that early alliance (rated between sessions three and seven) was related to two
therapists’ personality traits; openness and neuroticism. Therapists’ openness was
negatively associated with alliance, and therapists’ neuroticism (specifically the
negative effect component) was positively associated with alliance. The current
findings do not contradict these findings as it is possible that therapists’ personality did
relate to the early level of alliance, however, exerted no influence over how the alliance
developed from that point. Furthermore, in the current study therapists openness did
show a trend level (p=.075) negative association with alliance development, yet this was
not included in further analysis as it did not meet the more stringent cut-off for the
screening procedure. The impact of therapist personality on the alliance certainly
remains an important construct for further analysis.
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6.6.5 Mindful self-awareness
Therapists’ level of mindfulness, as rated on the CAMS-R, was not associated
with alliance development. One of the reasons for the lack of association between
mindfulness and alliance development may have been the restriction in range on the
CAMS-R. Therapists’ scores were in the top 50% of possible scores and the mean was
well above means found in student and psychiatric populations. Even the lowest
scoring therapists on this scale seemed to have a moderate degree of mindfulness, thus
perhaps there is no discernible difference between moderately mindful and very mindful
therapists, whereas there might be difference on alliance development between
therapists with low levels of mindfulness and therapists with a high degree of
mindfulness.
There is a dearth of published quantitative studies examining how therapists’
degree of mindfulness, or even mindfulness practice, impacts on the alliance. One
unpublished report (Wang, 2006, cited in Hick, 2008) suggests that therapists’
mindfulness, as measured on the Mindful Attention Awareness Scale, was related to
therapist- and client-rated alliance. The alliance was rated on the WAI, however it is
unknown at what point in therapy this occurred. Due to the study’s unavailability, a
critical examination cannot be undertaken. The current findings are not necessarily
contradictory as the dependent variables in these studies were different (single
measurement of alliance, versus growth in alliance).
Earlier it was suggested that therapist capacity to attune to their clients was
likely to positively impact the development of alliance. One may expect that
attunement and mindfulness are related capacities. Indeed, this has been suggested by a
number of psychotherapy and mindfulness experts (Hick, 2008; Siegel, 2007; Wallin,
2007). Psychological flexibility is also a concept closely related to mindfulness and, in
the therapists sample, they showed a significant, moderate correlation. Given the
conceptual overlap between mindfulness and both attunement and psychological
flexibility, concepts which both seem related to alliance development, it is surprising
that mindfulness was not also associated with alliance development.
These results are also surprising considering that, perhaps more so than the other
variables examined here, mindfulness has been widely discussed as a beneficial
characteristic of therapists (Hick, 2008; Siegel, 2010; Segal, Williams & Teasdale,
2002; Wallin, 2007; Wilson, 2008) elucidated by the recent books on the subject -
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“Mindfulness and the Therapeutic Relationship” (Hick & Bien, 2008) and “The Mindful
Therapist” (Siegel, 2010). There is also a strong emphasis on therapists’ self-
awareness in training (Egan, 2007; Corey, 2005; Yalom, 2001), and the empirical
findings which suggest various health, psychological and interpersonal benefits of
mindfulness (Anderson et al., 2007; Bear, 2003; Carmody & Baer, 2008; Dekeyser et
al., 2008).
While there is some research showing therapist meditation is related to better
client outcomes (Grepmair et al, 2007; Grepmair, Mitterlehner, et al. 2007), the research
is not consistent (Stanley et al., 2006) and, as discussed here, the research on
mindfulness and alliance is minimal. At this point it appears as though the
psychotherapy narrative is ahead of the data. As such, further research on therapists’
mindfulness and how it influences therapy processes and outcomes is required.
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CHAPTER 7
CONCLUSION 7.1 Overview of Significant Findings
The question of what makes therapy work is longstanding. One important
ingredient is the alliance between client and therapist. Strong alliances have been
consistently related to positive therapy outcomes making it important therefore to
consider what contributes to the formation of a strong alliance. Being a relationship, the
alliance is co-created by both the client and the therapist. To date, much of the research
has focused on client characteristics that are associated with strong alliance and
empirical analysis of therapists’ contributions has largely been left out. The current
research sought to address this imbalance.
There are two lines of research that were undertaken. First an examination of
therapist effects on the alliance. That is, whether there were significant differences
between therapists on the strength of alliance they develop with their clients. Two
different aspects of the alliance were examined; the early alliance, and alliance
development over the course of therapy. Second, the study undertook to examine what
types of professional and personal characteristics of the therapist might explain the
differences between therapists on alliance development.
The use of multilevel modeling allowed the clients and therapists’ contribution
to the early alliance and alliance development to be partialed out. Results showed that
15% of the differences in early alliance scores, and 86% of the differences on the rate of
alliance development, could be attributed to therapists. Therapists seem to have a
greater impact on how quickly the alliance grows or develops over time than they do on
the early level of alliance. The therapist effects found in the current study are substantial
when compared to therapists’ effects on outcome which are in the order of 6-9%
(Wampold, 2001) and treatment effects which have been calculated at 0-1% (Wampold,
2001).
These results lend themselves to the next research question, which was: what
characteristics of the therapist explain these differences? This analysis was only
undertaken for alliance development, as the analysis of therapists’ effects showed it was
only this parameter for which the differences between therapists were significant.
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Four therapists’ characteristics were found to be associated with the alliance
development: supervision, experiential avoidance, approval-seeking and, when clients’
attachment is taken into account, the therapists’ attachment. Two of these, approval-
seeking and experiential avoidance, have not been examined in published research of
this kind. Taken together, these findings suggest that the personal and professional
characteristics of the therapists do matter in the degree to which they are able to develop
alliances with their clients.
7.2 Overall Implications and Limitations of the Current Study
The implications these findings have for research is straight forward: research
ought to continue examination of therapists’ personal and professional characteristics
and continue to illuminate what therapists contribute to the alliance and other therapy
processes. Lambert (2009) commented that the search for the therapists’ characteristics
related to good client outcomes was pointless, and that examining therapy process may
be more fruitful, a stance that the current study supports.
The implications that these findings have for training and practice are more
complicated. There is certainly no evidence on which to base selection criteria for
applicants to therapy training. However, it might be beneficial for training programs to
consider the interface between the therapist and their skill development. Approval-
seeking therapists may have a greater capacity for intuitive attending and attuning to the
other and require a different type of tuition than trainees who are less approval seeking.
Perhaps, where trainees have characteristics (such as an approval-seeking schema) that
give them an intuitive feel for certain skills, training can assist them apply these skills
judiciously, as well as monitor the potential problems that may arise from these same
qualities. Of course the link between certain schema and therapists’ capacity to attune
to clients is only theoretical at this point in time and is an area for further exploration.
The observation that some early maladaptive schemas are beneficial is
interesting given that personal therapy is often recommended for therapists to address
their own psychological vulnerabilities. This finding calls into question the requirement
for therapists to resolve their own problematic EMS for the benefit of their performance
as therapists. The therapist in the currently study had, on average a mild-to-moderate
level of EMS and the sample had very few therapists with very high levels of EMS.
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The benefits of therapists’ approval-seeking schema on alliance development may
disappear if therapists with more severe levels of these EMS were sampled. Future
research might consider the shape of the association of EMS with the alliance. It has
been noted that psychometric properties of the third iteration of the Young Schema
Questionnaire used in the current study have not been published. Therefore, the
publication of the relevant psychometric properties will aid the future interpretation of
these findings.
There were a minority of therapists in the sample whose level of experiential
avoidance was suggestive of psychological distress. Experiential avoidance relates to
how one responds to internal experiences, rather than the occurrence of the experience.
Therapists in this sample who tend to avoid or control their private experiences had
slower alliance development. A number of observations about how this might happen
have been discussed and this result is consistent with the broader literature which
highlights the negative impact of experiential avoidance in interpersonal functioning
and psychological wellbeing more generally.
Considering the results for therapists’ schema and experiential avoidance
together, one may consider how they could interact. For instance, therapists high on
approval-seeking but low on experiential avoidance might have better alliances than
therapists high on approval-seeking and high on experiential avoidance. In the former
therapists may have experiences which arise from their approval seeking (i.e. worry
about whether their client likes them, anxiety about their performance) but not get
entangled in trying to make these experiences any different from what they are.
Whereas therapists with the latter combination might have the same schema related
experiences which they try and avoid or control, draining their attentional resources.
This hypothesis was not able to be examined but would be an enlightening development
in future studies.
Experiential avoidance is something that one can change. Research on
Acceptance and Commitment Therapy shows that this therapy effects reductions in
experiential avoidance (Ruiz, 2010), however, other types of interventions may also be
able to do this (Berking, Neacsiu, Comtols & Linehan, 2009). Given this, the practice
implications are relatively straightforward. Therapists in training or fully qualified
therapists could assess their level of experiential avoidance in general, as well as
identify what aversive private experiences are elicited in their work with clients. They
may then consider developing their capacity to accept these experiences.
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Supervision and personal therapy provide a place in which therapists are
encouraged to become aware of the interaction between themselves and their work.
Indeed, the comments above that suggest therapists reflect on how their own EMS and
experiential avoidance impact on their work are topics which may be worked on in both
supervision and therapy. However, the current findings do not show a benefit of
personal therapy or supervision on alliance development, rather they show it is
detrimental.
The detrimental effect of personal therapy on alliance development seems better
accounted for by its association with experiential avoidance. However, the relationship
between supervision and alliance development in this sample seems robust.
Supervision remained significant in the final model, even when potential outliers were
deleted. Furthermore, several alternative explanations for the association (i.e. therapists
with large amounts of supervision have certain qualities which confound the result)
were ruled out. While there were limitations to the measurement of supervision and the
analysis more generally, the result is consistent with the results of Hersoug et al. (2009)
and Henry et al. (1990), which also call the benefits of supervision into question.
Supervision is a highly valued professional activity woven into the training and
development of therapists. Given this, it is a matter of some urgency to undertake a
closer examination of the impact of supervision on therapists’ performance.
The current study is consistent with the small amount of published literature
showing that therapist and client attachment style interact on alliance. Both
interpersonal theory and attachment theory can be used to explain such an interaction.
Specifically, it has been argued that where clients and therapists are different on either
attachment style (e.g. high avoidance and high anxiety) or attachment intensity (e.g. low
anxious and high anxious), but not both (e.g. high anxiety and low avoidance), this
difference facilitates the provision of non-complementary responses enabling greater
interpersonal contact. This difference may also facilitate the provision of contingent
and marked mirroring, which assists in developing an attachment relationship such as
the alliance.
Practically, therapists might consider both their own attachment style and the
attachment style of their clients. Should they be similar therapists may need to be
particularly vigilant on monitoring how they respond to their client and how this
similarity may impact on their capacity to hold the therapeutic space.
182
While the consideration of attachment is usually the forte of psychodynamic
therapists, these dynamics were operating in a heterogeneous sample of therapists with
different theoretical orientations. Thus, it might be the case that therapists generally
need to pay some attention to attachment even if it is not the focus of their intervention.
Such considerations can be couched in the common language of engagement.
Therapists may consider how themselves and their clients are likely to engage given
their respective attachment styles, and then consider how they might adjust their usual
manner of engagement to work with each particular dynamic.
One of the limitations of the attachment findings was the lack of norms on the
ASQ upon which to compare the therapist sample. While their scores were similar to
other secure samples, this is not a precise indicator of security. Interpretation would
have been aided if the relative normality of therapists’ attachment was known because,
given the types of problems that insecurely attached individuals encounter, in samples
of therapists’ whose attachment is clearly insecure, it is unlikely that the same linear
association with alliance would be found. Once again this is a matter for future research
to address.
One way to improve client outcomes is to increase therapists’ capacity to
develop the alliance. Given that therapists differ a lot in this capacity, there is much
room for improvement. Training clinics could routinely monitor client-rated alliance.
This is an appealing option as it is easier to gather measures of client-rated alliance, than
it is to assess outcome. On the basis of these ratings, more and less effective therapists
can be identified, as has been demonstrated in the work of Duncan and Miller (2008).
Once identified, therapists’ effectiveness may be addressed through training in relevant
skills as well as considering the impact of their personal characteristics such as their
level of experiential avoidance. This provides an opportunity to intervene to improve
the alliance before the termination of therapy.
Given the lack of research on therapist characteristics and the alliance, an
exploratory approach to address the research aims was undertaken. This allowed for the
examination of a number of therapists’ characteristics which either theoretically or
empirically had some link to alliance. This exploratory approach was both a strength
and weakness of the study. It was a strength because it allowed a number of therapists’
characteristics to be explored simultaneously. This enabled the variables which
explained the most variance on alliance development to be identified. Further, it
enabled a rich interpretation of the results as a number of possible confounding
183
variables could be ruled out. Nevertheless, an exploratory approach introduces the
problem of type I errors; the screening of a large number of therapists’ variables,
relative to the sample size, meant that the chances of finding significant variables were
increased. Thus, the requirement for replication of this research cannot be understated.
Also, a feature of the analysis was that backwards deletion of the therapist
characteristics was used to determine the final three-level conditional growth model.
Such an approach can lead to over-fitting of the model to this particular sample and thus
limit it’s generalisability. Given this possibility, it is important that future research
continue to consider all of the variables which were found to be associated with alliance
including those which did not make the final model: unrelenting standards, self-
sacrifice, and personal therapy. Considering also that the analysis may have been
underpowered it cannot be concluded that the non-significant variables are not
associated with alliance development. This is especially the case for the therapist
personality trait openness as this was found to have a trend level negative association
with alliance development.
The current study was undertaken in a university psychology clinic providing
psychological therapies to the general public. Being a naturalistic study, therapist
effects were able to be examined in a “treatment as usual” setting. Indeed scores on
clients’ baseline measures showed that this sample was comparable to other outpatient
samples, and preliminary analysis showed, as one would expect, that clients
experienced increased wellbeing and a decrease in symptoms over the course of
therapy.
The naturalistic setting of the research is a strength in terms of ecological
validity, especially given the impressive response rate (i.e. 70% for clients and 79% for
therapists). However, many uncontrolled variables remain. While therapists did not
choose who was invited to participate in the study, they were able to influence which
clients continued in the study as it was the therapist who gave the clients the progress
questionnaires. It was observed that some therapists did this more than others. It is
unknown whether this involved a systematic exclusion of clients from the study or
whether it might have been related to other factors such as therapists’ diligence. There
were also clients who unilaterally terminated treatment and did not complete a final
questionnaire. It has been observed that weakened alliances are related to unilateral
termination (Samstag et al., 1998), thus the absence of data from these clients may have
184
resulted in an underestimation of therapist effects as clients with low alliance scores did
not provide data.
More broadly, there is debate about the statistical generalisability of the results
of MLM analysis (Siemer & Joormann, 2003; Serline, Wampold & Levin, 2003; Crits-
Christoph, Tu & Gallop, 2003). Examination of this debate is beyond the scope of this
thesis, however it serves as a reminder of the limits of this quantitative methods.
Additionally, the application of this type of analysis to clinical psychological research is
relatively new (Tasca et al, 2009) and debate continues with respect to the most
appropriate specifications of MLM models.
Given the limited sample size and number of clients within therapists, it was not
possible to test both linear and curvilinear models of alliance development. Should
there have been more power in the model a significant finding for therapists’ effects on
early alliance may have emerged and allowed the hypothesis pertaining to therapists’
characteristics on this aspect of the alliance to be tested. It was unfortunate that these
hypotheses could not be tested as the different findings of various researchers in this
area may partly be explained by therapist characteristics having different impacts
depending on which aspect of the alliance is examined.
The parameters of this research meant that the therapist has been focused on in a
somewhat artificially isolated manner. The alliance is co-created, meaning that
contributions are made by both clients and therapists. While the interaction between
therapist and client attachment was included in this study, many more interactions are
possible. Nevertheless, this research suggests that there are qualities that therapists
“bring to the therapy” that influence the therapy process. As stated earlier, most of the
literature examining contributions to the alliance has been focused on the client. Such
research remains justifiable, as even though the current study focused on the significant
difference between therapists on the intercept and slope, significant differences between
clients on the intercept and slope were observed. Whilst knowing the types of clients
who find it harder to develop an alliance can sensitize therapists to possible problems in
alliance development, beyond the therapy itself, it is difficult to influence client factors.
On the other hand, much can be done to influence therapists and reduce the variance
that they show on alliance development. Thus, research into the therapist contribution
is likely to have the greatest practical applications.
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7.3 Final Comments
How much does the personhood of the therapist matter? This is a vexed
question. On one side of the dialectic, it is argued that therapists and the relationships
they form with their clients is the therapy; on the other side of the dialectic, therapists
are seen as technicians whose role is to deliver the technology. The overwhelming
focus of research and training on treatments, rather than therapists, implies that it is the
treatment that matters for the healing of the client. The therapist effects research has
begun to call this assumption into question, showing that differences between therapists
may be larger than differences between treatments. Put more simply, the therapist
matters.
This current research furthers the therapist effects literature showing that
therapists vary widely in the degree to which they can develop the alliance with their
clients. Further, the current study has uncovered a number of therapist characteristics
which relate to a stronger capacity to build alliances. However, it must be remembered
that the therapists in this study were not being examined in isolation of the treatments
they were delivering. Treatments remain relevant. It might be an unnecessary dialectic,
between therapist and therapy that has emerged in the psychotherapy narrative, and in
fact, in research and in practice, both must remain in play.
186
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Appendix A
Qualitative details of therapists’ experience
Areas of practice The counsellors in this study recorded the following areas of practice and specific populations that they had gained experience: alcohol and other drugs; gambling; student populations; couples; posttraumatic stress disorder; sexual health; and, homeless youth. The roles and job titles that they reported are contained in Table A1. Table A1
Role Job title
Case work / support work Student welfare officer Family support worker Child protection worker Disability support worker Psychiatric disability support worker Domestic Violence worker Youth worker Crisis support worker Job search skills trainer Early intervention Mental illness information and referral advisor
Psychologist Educational Private Practice Organisational
Group support
Telephone counselling
Group Support
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Appendix B
Study Procedures
Audit of 2004/2005 Psychology Clinic data collection for previous studies
Clinicians’ guide
Reception procedures
Questionnaire feedback (to counsellor) pro-forma
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AUDIT OF 2004/2005 PSYCHOLOGY CLINIC OUTCOME STUDY Purpose Prior to 2006 the Psychology Clinic had been collecting data for an outcomes study. This outcomes study has suffered missing data. This audit was made in preparation for the implementation of a new study of therapeutic alliance. On the basis of these result new proceedures for data collection would be created. There are two primary questions about the pre-2006 data collection.:
o How well is the current data collection occurring? o What are the barriers to accurate and timely data collection?
Method
o Interviews were conducted with clinic administration staff and five current student counsellors working at the clinic
o Every 15th current client file was reviewed to assess whether the questionnaires had been administered and completed
o The last 10 closed files were reviewed to assess whether the questionnaires had been administered and completed
o Where paper record indicated questionnaires were completed this was compared against the excel spreadsheets of entered data
o 2004/2005 client questionnaires were reviewed to see the proportion of pre-questionnaire, 4-session, and post-questionnaires that had been completed in the past
Findings Interviews In brief the current procedure is (1) reception staff give client a pre-questionnaire prior to their first session and this is returned to the counsellor, (2) counsellors give clients the 4-session questionnaire, (3) counsellors enter the questionnaire on an excel spreadsheet and email the results to Pip, (4) Pip puts it onto the main database, (4) paper questionnaires go into a box in the reception office which is cleared by reception staff. Most people seemed to have a basic understanding of what they needed to do with the questionnaires, at least the first three steps. However, there was a lot of confusion about other aspects of the outcome study. Counsellors advised that they did not know in enough detail the overall purpose of study, how the information was getting used and what the scales were measuring. Thus, it did not hold much meaning or significance for them and was difficult to prioritise, communicate the study to the client and make relevant for their counselling with the client. Furthermore, when counsellors tried to seek information about the outcome study there did not seem to be anyone who was able to help them and the study seemed disorganised. There did not seem to be a culture of administering the questionnaires nor a network of knowledge about the study amongst peers. This seems to have lead to frustration and a giving-up on the outcome study. The study stopping and starting again seemed to compound this confusion.
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Other points of confusion about peoples roles was evident; people were not sure who was meant to inform the counsellors about the study, who was meant to check compliance, and who should give out the post-questionnaire and survey. Getting the questionnaires completed was also another major concern. There seemed to be general agreement that the procedure whereby reception staff hand out the pre-questionnaire to clients was working. However, in cases where clients were obviously anxious on the phone or on the initial appointment the pre-questionnaire might not be mentioned or given out. The questionnaire may also not be given out prior to the first appointment as the client attends late. Thus, data may not be collected from this set of clients who may be more distressed or disorganised. Once the questionnaire was given to the client there were several problems in it being completed. First, the pre-questionnaire has been given to clients after the first session, thus it can no longer be a baseline measure. Second, often when pre-questionnaires and 4-session questionnaire were given to the clients to take home they were not returned, as both the clients and counsellors forgot. It is also unclear to counsellors what they should have done in this case, e.g. should they persist with getting the client to complete the pre-questionnaire after the first session? And, if the pre-questionnaire is not completed, is there any point doing the 4-session one? Post-questionnaires seem to be rarely given out and completed and counsellors are not sure how to administer this in cases where the client stopped attending without a planned termination period. After-hours appointments also presented some difficulty as the usual reception staff were not available to administer the questionnaire and if a client’s appointment was in the last appointment time there was no time afterwards for them to complete the questionnaire as the clinic was shutting. There was some concern about the frequency of the 4-session questionnaire, it seemed too much to ask of the clients, possibly interfering with the therapeutic rapport. Also as the counselling process is only beginning in the first four sessions it was considered premature and unproductive to be focusing on outcomes and progress. Data entry presented several problems for counsellors: the instructions in general were not clear and difficult to clarify with others; the instructions were different on different computers; how items were to be coded was also unclear (e.g. which items are reversed and what is the direction of the scales - is strongly disagree scored with a 1 or 5?); and the spreadsheet had mistakes in it. Given that these problems existed, and counsellors were entering data for a project that they felt disconnected from, data entry seems to be a time consuming, frustrating and annoying task that many people seem to avoid. Suggestions for improvement The following ideas were generated during the interviews:
1. It was often suggested that counsellors need to be better informed about the outcome study including the details about the actual questionnaires and the data collection process. This could be done through an orientation to the study, perhaps given by their supervisor on their first supervision session. An information sheet was also suggested.
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2. Several suggestions focused on improving data entry by: not having to reverse score; opportunities for counsellors to practice data entry; and a better formatted spreadsheet by using colours and boarders to better distinguish questionnaires and limits on the spreadsheet cells as so the wrong numbers cannot be entered. Employing a research assistant to complete the data entry was also suggested.
3. It was thought that the questionnaire needed to be able to be better incorporated into the counselling process.
4. More structured procedures. 5. Provision of feedback to the counsellors about the research results.
File reviews Excel 20 preliminary and 3 four weekly questionnaires have been emailed to Pip between September 2005 and May 2006. No final questionnaires on excel. Seven students have sent this data to administration. Current client records Fifteen cases were reviewed. In all but one case the file cover sheet was completed, however mostly this just included the dates of the appointments. When the cover sheet did indicate the status of the questionnaires three times it indicated the pre-questionnaire was completed, once it indicated the pre-questionnaire was not completed and once it indicated that the pre-questionnaire and 4-session questionnaire was completed. In nine of the fifteen cases there was no evidence that questionnaires had been completed. Contained in the files were five pre-questionnaires, one 4-session questionnaire and one 6-session questionnaire. In one file the cover sheet indicated that the pre-questionnaire had been completed however it was not in the file or on the excel spreadsheet. In one of these fifteen cases the pre and 4 weekly questionnaire was on excel. Discharged clients records Ten files were reviewed. In all cases the front sheet was completed with appointment dates however only once did this sheet indicate the status of the questionnaire completion. None of theses cases had questionnaires entered on excel, in most cases (8) there was no evidence that the questionnaires had been completed. Two of the files contained pre-questionnaires. 2004/2005 data Pre-questionnaires: 134 6 weekly questionnaires: 48 Post questionnaires: 4 Conclusions How well is the data-collection occurring?
o The counsellors own report, file reviews and the excel spreadsheet provide a consistent picture that data-collection for the outcome project is lacking. Of the
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25 files reviewed, in only 8 cases was there evidence of a questionnaire being completed.
o Pre-questionnaires were most frequently completed in the 2004/2005 data. o 4-session questionnaires seem to be rarely completed in the recent cases,
however it seems notable that there were far more of the 4-session questionnaires completed in 2004/2005 than in previous years. It is possible that the procedures and presence of a student using the data in this period improved data collection.
o Post-questionnaire data has not been successfully collected in the past or at present. There was no evidence of any post-questionnaire being completed in the 25 files reviewed or in the excel spreadsheets.
What are the barriers to accurate and timely data collection?
o Failure to communicate the purpose of the project to the counsellors o The outcome study does not seem to be adequately integrated with counselling
practice. o There does not seem to be an adequate research milieu at the clinic to support
counsellors in assisting with the data collection. o Lack of clarity on the data collection procedures. o Lack of clarity on the data entry procedures. o Often, questionnaires, especially 4-session and post-questionnaires are not being
given to the clients and when they are clients are not bringing them back and counsellors are generally not following this up. This does not seem due to a lack of support for the notion of an outcome study, but rather seems to flow from problems with clear procedures and communication of the project.
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CLINICIANS’ GUIDE
Swinburne Psychology Clinic Research Project:
Counselling process and therapeutic change for clients attending the Swinburne Psychology Clinic
COUNSELLORS GUIDE
Purpose of the project The purpose of this study is two-fold. One, to understand how counselling effects client’s psychological well-being; and two, to understand how the personal psychological qualities of counsellors are related to the process of counselling and therapeutic change. This is an important area to pursue, as the results should inform the counselling profession about how counselling practice may be improved. This project involves collecting data from counsellors and clients at the clinic. This document pertains to the collection of client data only. Specifically outlined are the steps that counsellors are required to take, as part of their placement, in collecting client data. There are three different questionnaires that clients complete:
o Pre-questionnaire, completed prior to the first appointment o Progress-questionnaire, completed every 4 sessions o Final-questionnaire, completed at the termination of counselling
Questionnaire details The names of the measures used to make up each of the questionnaires are provided in the following table. Details about each of these scales are included on page 5 of this document. Measure Construct Pre-
questionnaire Progress- questionnaire
Final- questionnaire
Questions about date of birth,sex, occupation, country oforigin, experience of previouscounselling and current illnessesand medications
Personal demographics
X
Schwartz Outcome Scale Psychologicalwellbeing
X X X
World Health OrganisationQuality of Life – AustralianVersion
Quality of life X X
Depression Anxiety and StressScale
Depression, anxiety & stress
X X X
Attachment style questionnaire Adult Attachment
X
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Inventory of interpersonalproblems -32
Interpersonal functioning
X X
Working alliance inventory –short form revised
Therapeutic relationship
X X
Data collection - procedures Collection of questionnaire data is part of the routine practice at the clinic. As well as providing information for research it can also inform client assessment and treatment planning. Counsellors are responsible for ensuring the required questionnaires are completed at each of the three time-points. The procedures for doing so are outlined below. Pre-questionnaire
o At the time of arranging clients first appointment, the administration staff (Barb and Pip) ask clients to come in 20 minutes early to complete paperwork.
o When clients arrive, the reception staff give clients the pre-questionnaire to complete in the waiting room before their appointment begins.
o Counsellors collect the questionnaire at the start of the first session. If it seems suitable, the counsellor can offer the clients feedback from the completed questionnaires in the next session.
o If the client does not attend early and has not completed the questionnaire prior to the appointment time the counsellor asks the client to complete the questionnaire at the start of the session. Thus, the counsellor sits with the client in the interview room while the client completes the questionnaire. The counsellor can explain to the client that the questionnaire, as well as being for research purposes, is used to provide the counsellor with information to aid their assessment of client’s psychological functioning. After the client has completed the questionnaire, the counsellor proceeds with the initial appointment.
Progress-questionnaire
o Counsellors are to give the client the progress-questionnaire 10 minutes prior to the end of the 4th session for the client to complete in the interview room. Thus, counsellors will need to advise the client at the outset of the 4th session that the last 10 minutes will be spent on this activity and allow sufficient time for it. Counsellors can leave the clients to complete the questionnaire and meet them in the reception area where they pay for their session and make a next appointment. Alternatively, counsellors can stay in the room while the client completes the questionnaire. In this case counsellors need to be mindful of maintaining a non-intrusive presence as one of the questionnaires that the clients are completing is about the working alliance. At the end of the questionnaire clients are advised to seal the completed questionnaire in an envelope and hand it to the reception staff.
o If the questionnaire cannot be completed at this time (e.g. as the client is particularly distressed or it is otherwise deemed counter-therapeutic) then the client can be asked to complete the questionnaire at the end of the fifth session of counselling using the same procedure as outlined above.
o If they do not complete it after the 4th or 5th session they can take it home to complete and give it to reception or their counsellor prior to the 6th session. This is only to be done in exceptional circumstances.
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Note: Progress-questionnaires can be completed regardless of whether pre-questionnaires have been completed. However, if the pre-questionnaire has not been completed then the client will need to sign the consent form. These consent forms are available in the student room. Final-questionnaires Client termination of counselling may occur unilaterally (the client stops coming of his or her own accord, usually without planning this with the counsellor) or bilaterally (the counsellor and client agree to terminate, usually a number of sessions prior to the final session). Procedures for data collection differ depending on the type of termination. Client unilateral termination
o When it is established that a client is not returning to the clinic a letter is usually sent to them (ideally, this should be within 1 month of their last missed appointment). Enclosed with this letter, the counsellor can send a final-questionnaire with a reply-paid envelope addressed to the clinic. This questionnaire is sent in cases where:
- the client has consented to participate in the project - the client has attended at least 3 sessions
There is a covering note to accompany this questionnaire it can be found in the student room. After the client has been sent the questionnaire the counsellor is to inform Katie Wyman of this by leaving a message for her in the research communications book at reception.
Bilateral termination o When client’s termination of counselling is planned, prior to the last
appointment the counsellor can give the client the final-questionnaire that can be returned prior to the last appointment.
o If the client does not return the questionnaire prior to this appointment, the counsellor should request that they complete it in the waiting room before their last appointment.
o If the client cannot complete it before leaving the clinic after their last appointment, then they can take it home with a reply-paid envelop. In this case then the client’s name needs to be given to Katie so she can follow-up its completion. A message for Katie can be left in the research communications book at reception.
Processing of the questionnaires Questionnaires are to be given to the reception staff. The reception staff give the questionnaire to Katie to process. Katie will then score the questionnaires and place a copy of the questionnaires and a summary sheet of questionnaire scores in the client’s file. Katie will endeavour to do this within one week of receiving the questionnaire so the counsellor can use this information. As part of the questionnaire clients complete the Working Alliance Inventory. This inventory measures how the client views the relationship with their counsellor. In order for the client to be able to honestly complete this questionnaire, it is necessary that this information not be shared with the counsellor. In the event that the client hands the
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progress-questionnaire or final-questionnaire to the counsellor rather than the receptionist, the counsellor is to put the questionnaire into an envelope and hand it to reception. All information, other than the Working Alliance Inventory, will be provided to counsellors after Katie has processed the questionnaires. Data collection - frequently asked questions What do I do if the client does not fill in questionnaire prior to beginning the first appointment? Once you introduce yourself to the client, you might outline the tasks of the first session, which includes the completion of the questionnaire. Explain to clients that the information that they provide on the questionnaire will inform you about some of the things that they are experiencing, can be helpful to tailor counselling to their needs, and can be used to evaluate how counselling is progressing. Ask clients to complete the questionnaire prior to beginning the other tasks of the first appointment. This said, completion of the questionnaire is voluntary and thus, clients are free to decide not to complete the questionnaires. However, they must be given the opportunity to participate. What do I do if clients have not done a pre-questionnaire and they are up to their 4th session? Clients can participate in the project even if they have not completed the pre-questionnaire. If this is the case, clients must be given the client information and consent form to read and sign prior to filling out the progress-questionnaire. What do I do if the client is distressed at time of questionnaire completion? If a client arrives at an appointment distressed or in crisis, it may be counter- therapeutic to ask them to complete the questionnaires. In this case, ask the clients to complete the questionnaire as soon you judge them able to safely do so. Please note in the research communication book if completion of the questionnaire deviates from the procedures in this or other ways. What do I do if the client wishes to withdraw from the study? There are several reasons why clients may be reluctant to participate:
(1) Clients may not want to do a particular questionnaire, however they may be willing to do other questionnaires at a later time-point. For example, they may have completed the pre-questionnaire and the first progress-questionnaire, however after the 8th session they may not want to complete the next progress-questionnaire, but be willing to complete the questionnaire after the 12th session. In this case the client has not withdrawn from the study, rather they have skipped a questionnaire.
(2) Alternatively, a client may not want to complete a questionnaire and not want to be approached about the study or fill out questionnaires in the future. In this case the client has withdrawn from the study.
In both of these circumstances counsellors can let Katie know what has occurred by leaving a message in the research communications book at reception.
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What do I do if the client has been at the clinic for prior episodes of counselling? If the client has been to the clinic before, regardless of whether they have participated in the research project in the past, they are to be invited to participate in the study at the initiation of this latest episode of counselling. If the client has completed questionnaires in the past, the counsellor may want to explain that we are collecting different information now and that questionnaire completed in the past may not give the counsellor an accurate understanding of their current concerns. What do I do if the client is handed over from another counsellor? If the client has not participate in the project with the former counsellor they should be invited to participate in the project, completing the pre-questionnaire prior to their first appointment with the new counsellor. If the client is currently enrolled in the project the new counsellor can continue administering these questionnaires. If you are not sure whether the client has participated in the project, please leave a message for Katie in the research communications book and she let you know where the client is up to with the research. When is the next questionnaire due if the client has completed a progress- questionnaire in the 5th or 6th session. The progress-questionnaire is to be completed four sessions after the completion of the earlier questionnaire. For example, if the client has completed the pre-questionnaire in the 1st session, the progress-questionnaire in the 4th session and then the next progress-questionnaire in the 9th session. Then the next progress-questionnaire is due in the 13th session. Information about the measures which make up the client questionnaires Schwartz outcome scale (references: Blais et al. (1999). Development and initial validation of a brief mental health outcome measure. Journal of Personality Assessment, 73 (3), 359-383. Blais, M. A. and Baity, M. R. (2005) Administration and scoring for the Schwartz Outcome Scale-10. Department of Psychiatry Massachusetts General Hospital, Harvard Medical School) The Schwartz outcome scale is a brief outcome measure developed for use across a number of different treatment modalities and theoretical approaches. The outcome measure is not specific to any one type of psychological problem; rather it measures a broad dimension of psychological health encompassing life satisfaction, interpersonal effectiveness, positive self-appraisal, optimism and the absence of psychiatric symptoms. The scale has been validated in clinical and non-clinical populations. It is made up of a single factor and has acceptable psychometric properties. This scale correlates with other measures of well-being, positive affect, desire to live, satisfaction with life and
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self-esteem. Additionally, the scale negatively correlates with measures of psychiatric symptoms, hopelessness, fatigue and negative affect. The scale is scored by summing each item. Scores range between 0 and 60 with higher scores representing greater psychological wellbeing. A score of 43 is considered the cut-off between patient and non-patient distributions. If a client begins counselling with a score below 43 and finishes counselling with a score above 43 this can indicate meaningful clinical improvement. Furthermore, a change in 8 or more is thought to indicate real change and is not likely to be due to chance. Cut-off scores to classify different levels of distress are indicated in the table below. Total score Distress level 44-59 Minimal 36-43 Mild 25-35 Moderate 24-1 Severe Table taken from Blais and Baity (2005) p 9. Norms are available for this scale and are based on a sample of non-patients, outpatients and inpatients, 62% of the sample is female. Non-patients are predominantly Caucasians, from community and college samples in the United States of America. The norms are provided in the table below. Group N Mean SD Effect Size (d) relative to
the non-patient group Non-patients 757 49.0 6.9 Outpatients 804 36.6 11.6 1.33 Inpatients 1471 28.0 14.2 1.78 All patients 2275 31.1 13.9 1.47 Table taken from Blais and Baity (2005) p 6. World Health Organisation Quality of Life – Australian Version (reference: The World Health Organisation Quality of Life (WHOQOL) Study, Australian WHOQOL-100, WHOQOL-BREF, and CA_WHOQOL Instruments, Users Manual and Interpretation Guide, April 2000, Melbourne WHOQOL Field Study Centre University of Melbourne Department of Psychiatry, St Vincent’s Mental Health Service, Melbourne Australian.) The WHOQoL-BREF is a 26 item self-report scale. All items are rated on a 5 point likert scale. There are four domains in the WHOQoL-BREF – physical, psychological, social relationships and environmental, plus two individual questions assessing overall QoL and general health. Items that make up these scales are detailed in the table below.
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Scale Items Overall quality of life 1 Satisfaction with health 2 Physical health 3 (R= reverse), 4 (R), 10, 15, 16, 17, 18 Psychological health 5, 6, 7, 11, 19, 26 (R) Social relationships 20, 21, 22 Environment 8, 9, 12, 13, 14, 23, 24, 25 The domains have a score range of 0-100. The two individually scored items (Q1 and Q2) have a score range of 1-5. Higher scores indicate higher QoL. Unfortunately, the test-retest reliability of the WHOQoL-BREF is not high enough for the scale to be used at the individual level, rather is designed and appropriate for use at the population level. Thus, clinical utility of the scale is limited. Nevertheless, items can be scrutinised on an individual level, noting low scoring items that may highlight issues to be followed up on during counselling. Depression Anxiety Stress Scales (DASS) (reference: Lovibond, S H and Lovibond, P F (1995). Manual for the Depression Anxiety Stress Scales (2nd Ed.) Psychology Foundation Monograph, Sydney.) The DASS is an instrument developed in Australia by Lovibond and Lovibond. There are number of versions of the scale, the 21-item version is used in this research. The DASS was “designed to measure the negative emotional states of depression, anxiety and stress” and to be able to discriminate between these three states. There are three 7-item subscales that measure each of these emotional states. The depression subscale consists of items to measure dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or over-involvement, anhedonia and inertia. The anxiety subscale consists of items that measure autonomic arousal, skeletal musculature effects (e.g. trembling), situational anxiety and subjective experience of anxious affect. The stress subscale measures difficulty in relaxing, nervous arousal, easily upset/ agitated, irritable/over-reactive and impatient. The DASS measures the core symptoms of these three syndromes however additional symptoms (e.g. sleep, appetite disturbance) may also be present and may need to be assessed using additional scales or during an interview. The DASS is based on a dimensional rather than a categorical model of classification. Thus, the difference between clinical and non-clinical populations is a matter of degree. People cannot be assigned a diagnostic category solely on the basis of DASS scores. Items measuring each of these constructs are rated in a 4-point likert scale according to how they have been in the past week. DASS subscale scores range from 0 – 42, with lower scores reflecting less severe emotional states. These scales can be interpreted using the ranges in table below. These are based on norms from a sample of 2914 people aged 17 - 69 years old from clinical and non-clinical populations.
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Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely severe 28+ 20+ 34+ Attachment style questionnaire (reference: Feeney, J. A., Noller, P. and Hanrahan, M. (1994) Assessing Adult Attachment. In Attachment in Adults: Clinical and developmental perspectives. Ed. M. B. Sperling and W.H. Berman. The Guilford Press; New York.) The Attachment Style Questionnaire was designed to provide a broad-based measure of dimensions of adult attachment. It was also created to be applicable to adolescents and people without experience of romantic relationships. The scale consists of 40 items which participants rate on a 6-point likert scale from totally disagree to totally agree. The scale contains five scales that have been derived from factor analysis. The confidence subscale represents secure attachment and relates to a persons confidence in themself and others. (Items: 1, 2, 3, 19, 31, 33 reverse, 37, 38) The remaining subscales express different elements of insecure attachment. The discomfort with closeness subscale is representative of avoidant attachment. (Items: 4, 5, 16, 17, 20 reverse, 21 reverse, 23, 25, 26, 34) Need for approval relates to both people with fearful or preoccupied attachment reflecting “individuals’ need for others’ acceptance and confirmation. (Items: 11, 12, 13, 15, 24, 27, 35) The Preoccupation with relationships subscale relates to a “preoccupation with relationships, which involves an anxious reaching out to others in order to fulfil dependency needs. It relates to the concepts of anxious/ambivalent attachment (Using Hazan & Shavers, 1987 conceptualisation) or preoccupied attachment (Using Bartholomew’s conceptualisation). (Items: 18, 22, 28, 29, 30, 32, 39, 40) Relationships as secondary relates to a dismissing style of attachment (as characterised by Bartholomew) whereby individuals place an emphasis on achievement and independence in order to defend against vulnerability or being hurt. (Items: 6, 7, 8, 9, 10, 14, 36)
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Inventory of Interpersonal Problems – 32 (reference: Barkham, M., Hardy, G. H. and Startup, M. (1996). The IIP-32: A short version of the Inventory of Interpersonal Problems. British Journal of Clinical Psychology, 35, 21-35.) The IIP-32 was developed to measure interpersonal problems in terms of what a person finds hard and what they do too much in the interpersonal domain. The scale consists of 32 items that can be broken down into 8 scales, each made up of 4 items. These 8 scales can be combined to create 4 bipolar scales representing problems in 4 domains. This is illustrated below.
• Problems relating to competition: Hard to be assertive --- vs --- Too aggressive
• Problems relating to socializing: Hard to be sociable --- vs --- Too open
• Problems relating to nurturance: Hard to be supportive --- vs --- Too caring
• Problems relating to independence: Hard to be involved --- vs --- Too dependent The individual items that make up these scales are as follows Hard to be assertive: 2, 11, 6, 4 Too aggressive: 28, 30, 20, 21 Hard to be sociable: 7, 3, 1, 9 Too open:10 (reverse), 24, 29, 17 (reverse) Hard to be supportive: 16, 14, 15, 13 Too caring: 25, 18, 26, 32 Hard to be involved: 5, 19, 12, 8 Too dependent: 31, 27, 22, 23 Norms have been developed for the IIP-32, however the samples used to create these norms are limited and are not broadly representative of the general population or outpatients, thus they need to be used with caution. General population norms are based on 82 volunteer participants from university psychology clinics and outpatient norms are based on 120 clients referred to treatment at a university clinical psychology department. These norms (and standard deviations) are reproduced in the table below.
Male Female Scale General Population
Outpatient Population
General Population
Outpatient Population
H. assertive 1 (0.82) 1.95 (1.21) 1.23 (0.95) 1.82 (1.17) H. sociable 1.18 (0.88) 1.68 (1.31) 0.87 (0.75) 1.64 (1.28) H. supportive 0.90 (0.71) 1.11 (0.85) 0.42 (0.35) 0.89 (0.99) T. caring 1 (0.80) 1.52 (0.97) 1.47 (0.94) 1.83 (1.07) T. dependent 0.98 (0.73) 1.68 (0.93) 1.01 (0.86) 1.56 (1.01) T. aggressive 0.92 (0.82) 1.63 (1.06) 0.76 (0.68) 1.42 (1.09) H. involved 1.09 (0.89) 1.64 (1.15) 0.74 (0.87) 1.24 (1.11) T. open 1.60 (0.82) 1.39 (1.07) 1.86 (0.83) 1.52 (1.06) Total 1.02 (0.54) 1.59 (0.74) 0.95 (0.52) 1.47 (0.65)
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Working Alliance Inventory – Short form revised The working alliance inventory is a 12 item self report-scale designed to measure the alliance between themselves and their counsellor. There are three subscales that measure the client’s perspective on the tasks and goals of therapy and the bond between themselves and their counsellor. Details on scoring this instrument are not provided here as client scores on this scale will not be provided to counsellors. Suggestions of how to integrate with counselling practice Each of these scales may be a useful aid to your counselling work. The information contained in these scales may be used to (1) measure client progress and outcomes and (2) provide information that may assist you plan counselling interventions. The scales that will be particularly useful will depend on the clients presenting problem. For instance, if a client is seeking assistance for depression, anxiety or stress the DASS scale may assist you to assess particular symptoms and the degree to which these are present and change over time. If a client is presenting with relationship problems information from both the IIP-32 and attachment style questionnaire may help you develop an understanding of various factors which may be contributing to the clients problems. The overview of each of the measures provided on the previous pages should assist you in understanding the possible applications of these measures. It is also suggested that you discuss client’s responses to these scales in supervision. Where to go with questions Should you have questions about this research project there are number of people that you can ask for assistance. This includes:
o the clinic director, Roger Cook who is one of the investigators on this project ([email protected]; phone number provided)
o Naomi Crafti, who is an investigator on this project and supervises Katie Wyman ([email protected]; phone number provided)
o Katie Wyman, who coordinates the implementation of this project (phone number provided, email [email protected])
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RECEPTION PROCEDURES
Psychology Clinic Research Project:
Reception procedures
Clients
1. When the first appointment is made clients are asked to attend the session 20 minutes early in order to complete the necessary paper work.
2. Katie takes the name of each new client from the appointment book.
3. When clients arrive they are given the pre-questionnaire to complete prior to
their appointment time. If the client arrives on time or late the questionnaire is to be given to the counsellor to take into the appointment with them.
4. After clients complete their questionnaire (pre, 4-weekly or post) they are given
to reception who put them in a box for Katie to collect.
Katie will:
(a) Collect the questionnaires, score them and place feedback in the clients file (b) Monitor when questionnaires are due by noting clients attendance
from the appointment book (c) Place reminders and necessary paperwork in clients file when 4-
session questionnaires are due (d) Follow-up post-questionnaires which are sent to clients by their
counsellors
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QUESTIONNAIRE FEEDBACK (TO COUNSELLOR) PRO-FORMA
Pre-questionnaire Scores
Client name:__________________________Date (questionnaire scored):_______ This document provides the raw scores and basic interpretative information (where available) for the measures used on the client pre-questionnaire. For further information about these scales please see the document titled “Research Project – Clinicians Guide” Schwartz Outcome Scale Score interpretation Total score:___________ DASS Subscales: Depression-___________Anxiety-___________Stress-____________ Total score:______ World Health Organisation - Quality of Life Scale Unfortunately, the test-retest reliability of this scale is not high enough for the scale to be used at the individual level, rather is designed and appropriate for use at the population level. Thus, clinical utility of the scale is limited. Nevertheless, items can be scrutinised on an individual level, noting low scoring items that may highlight issues to be followed up on during counselling. Attachment style questionnaire Subscale scores range from 1-6 where 1= totally disagree, 2=strongly disagree, 3=slightly disagree, 4=slightly agree, 5=strongly agree, 6=totally agree. The scores below are the average of all items on that subscale. Higher scores reflect higher endorsement of each construct. For example, higher scores refect more confidence; more discomfort with closeness; more need for approval; more preoccupation with relationships and greater endorsement of relationships as secondary. The subscale confidence represents secure attachment; the remaining scales are all types of insecure attachment. Cut-off scores are not available to aid the interpretation of these scores. However, one may note on which scales this client scores highest and lowest. For further definition of these subscales refer to the Research Project - Clinicians Guide. Confidence:________ Discomfort with closeness:________ Need for approval:________ Preoccupation with relationships:________ Relationships as secondary:________
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Inventory of Interpersonal Problems Scores range from 0 – 4. The scores below are an average across items scores for the subscale. Higher scores reflect more difficulty on that domain. Subscale scores: Problems relating to competition:
Hard to be assertive________ Too aggressive________
Problems relating to socializing: Hard to be sociable________ Too open________
Problems relating to nurturance:
Hard to be supportive________ Too caring________
Problems relating to independence: Hard to be involved________ Too dependent ________
Norms:
Male Female Scale General Population
Outpatient Population
General Population
Outpatient Population
H. assertive 1 (0.82) 1.95 (1.21) 1.23 (0.95) 1.82 (1.17) H. sociable 1.18 (0.88) 1.68 (1.31) 0.87 (0.75) 1.64 (1.28) H. supportive 0.90 (0.71) 1.11 (0.85) 0.42 (0.35) 0.89 (0.99) T. caring 1 (0.80) 1.52 (0.97) 1.47 (0.94) 1.83 (1.07) T. dependent 0.98 (0.73) 1.68 (0.93) 1.01 (0.86) 1.56 (1.01) T. aggressive 0.92 (0.82) 1.63 (1.06) 0.76 (0.68) 1.42 (1.09) H. involved 1.09 (0.89) 1.64 (1.15) 0.74 (0.87) 1.24 (1.11) T. open 1.60 (0.82) 1.39 (1.07) 1.86 (0.83) 1.52 (1.06) Total 1.02 (0.54) 1.59 (0.74) 0.95 (0.52) 1.47 (0.65)
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Progress-questionnaire Scores Client name:__________________________Date (questionnaire scored):_______ This document provides the raw scores and basic interpretative information (where available) for the measures used on the client progress-questionnaire. For further information about these scales please see the document titled “Research Project – Clinicians Guide” Schwartz Outcome Scale Score interpretation Total score:___________ DASS Subscales: Depression-___________Anxiety-___________Stress-____________ Total score:______
228
Final-questionnaire Scores Client name:__________________________Date (questionnaire scored):_______ This document provides the raw scores and basic interpretative information (where available) for the measures used on the client pre-questionnaire. For further information about these scales please see the document titled “Research Project – Clinicians Guide” Schwartz Outcome Scale Score interpretation Total score:___________ DASS Subscales: Depression-___________Anxiety-___________Stress-____________ Total score:______ World Health Organisation - Quality of Life Scale Unfortunately, the test-retest reliability of this scale is not high enough for the scale to be used at the individual level, rather is designed and appropriate for use at the population level. Thus, clinical utility of the scale is limited. Nevertheless, items can be scrutinised on an individual level, noting low scoring items that may highlight issues to be followed up on during counselling. Inventory of Interpersonal Problems Scores range from 0 – 4. The scores below are an average across items scores for the subscale. Higher scores reflect more difficulty on that domain. Subscale scores: Problems relating to competition:
Hard to be assertive________ Too aggressive________
Problems relating to socializing: Hard to be sociable________ Too open________
Problems relating to nurturance:
Hard to be supportive________ Too caring________
Problems relating to independence: Hard to be involved________ Too dependent ________
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Norms:
Male Female Scale General Population
Outpatient Population
General Population
Outpatient Population
H. assertive 1 (0.82) 1.95 (1.21) 1.23 (0.95) 1.82 (1.17) H. sociable 1.18 (0.88) 1.68 (1.31) 0.87 (0.75) 1.64 (1.28) H. supportive 0.90 (0.71) 1.11 (0.85) 0.42 (0.35) 0.89 (0.99) T. caring 1 (0.80) 1.52 (0.97) 1.47 (0.94) 1.83 (1.07) T. dependent 0.98 (0.73) 1.68 (0.93) 1.01 (0.86) 1.56 (1.01) T. aggressive 0.92 (0.82) 1.63 (1.06) 0.76 (0.68) 1.42 (1.09) H. involved 1.09 (0.89) 1.64 (1.15) 0.74 (0.87) 1.24 (1.11) T. open 1.60 (0.82) 1.39 (1.07) 1.86 (0.83) 1.52 (1.06) Total 1.02 (0.54) 1.59 (0.74) 0.95 (0.52) 1.47 (0.65)
230
Appendix C
Ethics Approval
231
Sent: Tuesday, August 29, 2006 11:36 AM Subject: SUHREC Project 0607/020 Ethics Clearance To: Dr Naomi Crafti/Ms Katie Wyman, Faculty of Life and Social Sciences Dear Naomi and Katie SUHREC Proj 0607/020- Counselling process and therapeutic change for clients attending the Swinburne Psychology Clinic Researchers: Dr Naomi Crafti, Ms Katie Wyman Approved Duration: 29 August 2006 - 31 December 2008 I am pleased to advise that Chair of SHESC2 (H&B-B) or delegated member has approved the revisions and clarification as emailed/submitted by you today in response to previous communication (SHESC2 emails of 15 and 24 August 2006). Unless otherwise notified, human research activity in the project may commence in line with standard or any special conditions for on-going ethics clearance. The standard conditions for ethics clearance include the following: - Researchers are required to immediately report anything which might warrant review of ethical approval of the protocol, including: (a) serious or unexpected adverse effects on participants; (b) proposed changes in the protocol; and (c) unforseen events that might affect continued ethical acceptability of the project. If the research project is discontinued before the expected date of completion researchers must inform the HREC immediately. - An annual progress report is due and a final report on the completion (or cessation) of the project. Please let me or Leah Cattanach (ext 4361) know if you require an ethics clearance certificate and if you have any concerns or queries about on-going ethics clearance. The SUHREC project number should be cited in any communication. Best wishes for the project. Yours sincerely Keith Wilkins for Leah Cattanach Secretary, SHESC2 ******************************************* Keith Wilkins Research Ethics Officer Office of Research and Graduate Studies (Mail H68) Swinburne University of Technology P O Box 218 HAWTHORN VIC 3122 Tel: 9214 5218
232
Appendix D
Client Materials
Client information and consent form
Pre-questionnaire
Progress questionnaire
Final questionnaire
233
Client information sheet for project titled
“Counselling process and therapeutic change for clients attending the Swinburne Psychology Clinic”.
What the study is about. The Psychology Clinic is a teaching and educational facility operated by Swinburne University of Technology for the combined benefits of students and the wider community. The counselling students who provide the services of the Psychology Clinic aim to provide clients with high quality counselling at low cost. As part of an educational institution, the Psychology Clinic is committed to continually assessing and improving the services provided. Because of this philosophy, we at the Psychology Clinic, are asking you to assist us with our quest for quality counselling. The purpose of this study is two fold. First, to understand the effectiveness of counselling in bringing about beneficial change to our client’s psychological well-being. Second, to understand how the personal psychological qualities of counsellors are related to both the quality of the professional relationship that they form with their clients, and the degree of therapeutic change that their clients experience. This is an important area to pursue, as the results should inform counsellors about how they can improve their counselling practice. Who can participate? We are inviting people to participate in this study if they are at least 18 years old and attend to Swinburne Psychology Clinic for individual counselling. What participation involves. Participation in this study involves signing an informed consent form and completing three slightly different questionnaires: one before beginning counselling, one after finishing counselling and the other at regular intervals over the course of your counselling at the Psychology Clinic. The first and last questionnaires take about 30 minutes; the questionnaire completed at regular intervals takes less than 5 minutes. After completing the questionnaires we would like you to seal your questionnaire in an envelope and give it to the reception staff at the Psychology Clinic. Your participation in this study is completely voluntary, your decision to participate or not participate in this study, does not have any impact on the counselling service provided at the Psychology Clinic. You are free to withdraw from the study at any time.
234
How your information is used. In the event that we find the results of this project to be of interest to the wider psychological community, we may decide to publish the results in an academic journal. Should this occur, no identifiable information would be included in any way, and your anonymity will be protected. Your counsellor will also be given the results from most of the surveys that you complete. They will use this information to further understand the problems that you are experience and to tailor counselling to your needs. Who is conducting this study? Katie Wyman is a student at Swinburne University. She is undertaking this research as part of a Doctorate in Counselling Psychology. Two psychologists from Swinburne University’s Faculty of Life and Social Science supervise Katie: Dr. Naomi Crafti and Dr. Roger Cook. Who to contact if you have questions or concerns. Any questions or concerns regarding the project entitled “counselling process and outcomes for clients at the Swinburne Psychology Clinic” can be directed to the Senior Investigator, Naomi Crafti, of the School of Psychology, on telephone number 92145355. If this questionnaire raises any personal issues for you while you are not at the Psychology Clinic, please contact the Psychology Clinic on (03) 9214 8653 or contact a crisis line, such as Lifeline on 131 114. We understand that this may be a difficult time for you, and appreciate your gift of time in participating in this project. Thank-you, Roger Cook Director: Swinburne Counselling Clinic This research conforms with the principles set out in the Statement on Research Ethics endorsed by the Faculty of Life and Social Sciences, and has been approved by the Research Ethics Committee, Swinburne University of Technology. If you have any complaints about the conduct of this research project, you can contact Research Ethics Officer, Office of Research and Graduate Studies (H68), Swinburne University of Technology, P O Box 218, HAWTHORN VIC 3122. Telephone: (03) 9214 5218
235
Informed consent form for project titled “Counselling process and therapeutic change for clients attending the Swinburne Psychology
Clinic”.
I, (name) __________________________________________________________, have read and understood the information on the Client Information Sheet.
I agree to participate in this activity, realising that I may withdraw at any time.
I agree that research data collected for the study may be published or provided to other researchers on the condition that anonymity is preserved and that I cannot be identified.
SIGNITURE:________________________________________
DATE:_______________________
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Preliminary questionnaire for project entitled: “Counselling process and therapeutic change for clients attending the
Swinburne Psychology Clinic”. Thankyou for agreeing to participate in this study and welcome to the Psychology Clinic at Swinburne University of Technology. In order for us to know more about the clients who come to the Psychology Clinic, please provide the following information: Name:________________________________________________________ Today’s date: ____/____/____ (dd/mm/yy) Date of birth: ____/____/____ (dd/mm/yy) Sex (circle): Male / Female Occupation: ____________________________________________________ Country of origin: ________________________________________________ Previous counselling (please tick): I have never had counselling before I have had 1 – 8 sessions of counselling before I have had 9 - 20 sessions of counselling before I have had more than 20 sessions of counselling before
If you have had more than 20 sessions of counselling, please estimate how many:
_____sessions or _______months and _______ years. Do you currently suffer from any illness? (circle): Yes / No
If you answered “yes”, please list below any current illnesses: ________________________________________________________ ________________________________________________________
Are you currently taking any medications? (circle): Yes / No If you answered “yes”, please list the medications that you take:
________________________________________________________ ________________________________________________________
237
QUESTIONNAIRE ONE Below are 10 statements about you and your life that help us see how you feel you are doing. Please respond to each statement by circling the response number that best fits how you have generally been over the last seven days (1 week). There are no right or wrong responses and it is important that your responses reflect how you feel you are doing. Please be sure to respond to each statement. All or
Never nearly all of the time
1. Given my current physical condition, I am satisfied with what I can do. 0 1 2 3 4 5 6
2. I have confidence in my ability to sustain important relationships. 0 1 2 3 4 5 6
3. I feel hopeful about my future.
0 1 2 3 4 5 6
4. I am often interested and excited about things in my life. 0 1 2 3 4 5 6
5. I am able to have fun.
0 1 2 3 4 5 6
6. I am generally satisfied with my psychological health. 0 1 2 3 4 5 6
7. I am able to forgive myself for my failures. 0 1 2 3 4 5 6
8. My life is progressing according to my expectations. 0 1 2 3 4 5 6
9. I am able to handle conflicts with others. 0 1 2 3 4 5 6
10. I have peace of mind.
0 1 2 3 4 5 6
238
QUESTIONNAIRE TWO Please read each statement and circle number 0,1,2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows:
0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
1. I found it hard to wind down. 0 1 2 3
2. I was aware of dryness of my mouth. 0 1 2 3
3. I couldn’t seem to experience any positive feeling at all. 0 1 2 3
4. I experienced breathing difficulties (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion).
0 1 2 3
5. I found it difficult to work up the initiative to do things. 0 1 2 3
6. I tended to over-react to situations. 0 1 2 3
7. I experienced trembling (e.g. in the hands). 0 1 2 3
8. I felt that I was using a lot of nervous energy. 0 1 2 3
9. I was worried about situations in which I might panic and make a fool of myself.
0 1 2 3
10. I felt that I had nothing to look forward to. 0 1 2 3
11. I found myself getting agitated. 0 1 2 3
12. I found it difficult to relax. 0 1 2 3
239
0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
13. I felt down-hearted and blue. 0 1 2 3
14. I was intolerant of anything that kept me from getting on with what I was doing.
0 1 2 3
15. I felt I was close to panic. 0 1 2 3
16. I was unable to become enthusiastic about anything. 0 1 2 3
17. I felt I wasn’t worth much as a person. 0 1 2 3
18. I felt that I was rather touchy. 0 1 2 3
19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat).
0 1 2 3
20. I felt scared without any good reason. 0 1 2 3
21. I felt that life was meaningless. 0 1 2 3
240
QUESTIONNAIRE THREE This assessment asks how you feel about your quality of life, health, and other areas of your life. Please answer all the questions. If you are unsure about which response to give a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the past week. Please read each question and assess your feelings, for the past week, and circle the number on the scale for each question that gives the best answer for you.
Very Poor Poor Neither Poor nor
Good Good Very Good
1. How would you rate your quality of life? 1 2 3 4 5
Very Dissatisfied
Fairly Dissatisfied
Neither Satisfied nor Dissatisfied Satisfied Very
Satisfied 2. How satisfied are you with your health?
1 2 3 4 5
The following questions ask about how much you have experienced certain things in the past week.
Not at All
Slightly
Somewhat
To A Great Extent
Completely
10. Do you have enough energy for everyday life? 1 2 3 4 5
11. Are you able to accept your bodily appearance? 1 2 3 4 5
12. Have you enough money to meet your needs? 1 2 3 4 5
13. How available to you is the information you need in your daily life?
1 2 3 4 5
14. To what extent do you have the opportunity for leisure activities? 1 2 3 4 5
Not at All
Slightly
Moderately
Very
Extremely 15. How well are you able to get around physically? 1 2 3 4 5
241
The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the past week.
Very Dissatisfied
Fairly Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied Very Satisfied
16. How satisfied are you with your sleep? 1 2 3 4 5
17. How satisfied are you with your ability to perform your daily living activities?
1 2 3 4 5
18. How satisfied are you with your capacity for work? 1 2 3 4 5
19. How satisfied are you with yourself? 1 2 3 4 5
20. How satisfied are you with your personal relationships? 1 2 3 4 5
21. How satisfied are you with your sex life? 1 2 3 4 5
22. How satisfied are you with the support you get from your friends? 1 2 3 4 5
23. How satisfied are you with the conditions of your living place? 1 2 3 4 5
24. How satisfied are you with your access to health services? 1 2 3 4 5
25. How satisfied are you with your transport? 1 2 3 4 5
Never
Infrequently
Sometimes
Frequently
Always
26. How often do you have negative feelings such as blue mood, despair, anxiety and depression?
1 2 3 4 5
242
QUESTIONNAIRE FOUR Here is a list of problems that people report in relating to other people. Please read the list below, and for each item, select the number that describes how distressing that problem has been for you. Then circle that number according to the following scale.
not at all a little bit moderately quite a bit extremely 0 1 2 3 4
For example How much have you been distressed by this problem? It is hard for me to: get along with my relatives 0 1 2 3 4
Part I The following are things you find hard to do with other people.
It is hard for me to:
1. join in on groups 0 1 2 3 4
2. be assertive with another person 0 1 2 3 4
3. make friends 0 1 2 3 4
4. disagree with other people 0 1 2 3 4
5. make a long-term commitment to another person 0 1 2 3 4
6. be aggressive toward other people when the situation calls for it
0 1 2 3 4
7. socialise with other people 0 1 2 3 4
8. show affection to people 0 1 2 3 4
9. feel comfortable around other people 0 1 2 3 4
10. tell personal things to other people 0 1 2 3 4
11. be firm when I need to be 0 1 2 3 4
12. experience a feeling of love for another person 0 1 2 3 4
13. be supportive of another person’s goals in life 0 1 2 3 4
14. really care about other people’s problems 0 1 2 3 4
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Part II. The following are things that you do too much.
20. I fight with other people too much 0 1 2 3 4
21. I get irritated or annoyed too easily 0 1 2 3 4
22. I want people to admire me too much 0 1 2 3 4
23. I am too dependent on other people 0 1 2 3 4
24. I open up to people too much 0 1 2 3 4
25. I put other people’s needs before my own too much 0 1 2 3 4
26. I am overly generous to other people 0 1 2 3 4
27. I worry too much about other people’s reactions to me 0 1 2 3 4
28. I lose my temper too easily 0 1 2 3 4
29. I tell personal things to other people too much 0 1 2 3 4
30. I argue with other people too much 0 1 2 3 4
31. I am too envious and jealous of other people 0 1 2 3 4
32. I am affected by another person’s misery too much 0 1 2 3 4
15. put somebody else’s needs before my own 0 1 2 3 4
16. take instructions from people who have authority over me
0 1 2 3 4
17. open up and tell my feelings to another person 0 1 2 3 4
18. attend to my own welfare when somebody else is needy
0 1 2 3 4
19. be involved with another person without feeling trapped
0 1 2 3 4
244
QUESTIONNAIRE FIVE Show how much you agree with each of the following items by rating them on this scale:
1 2 3 4 5 6 totally
disagree strongly disagree
slightly disagree
slightly agree strongly agree totally agree
1. Overall, I am a worthwhile person. 1 2 3 4 5 6
2. I am easier to get to know than most people.
1 2 3 4 5 6
3. I feel confident that other people will be there for me when I need them.
1 2 3 4 5 6
4. I prefer to depend on myself rather than other people.
1 2 3 4 5 6
5. I prefer to keep to myself. 1 2 3 4 5 6
6. To ask for help is to admit that you’re a failure.
1 2 3 4 5 6
7. People’s worth should be judged by what they achieve.
1 2 3 4 5 6
8. Achieving things is more important than building relationships.
1 2 3 4 5 6
9. Doing your best is more important than getting on with others.
1 2 3 4 5 6
10. If you’ve got a job to do, you should do it no matter who gets hurt.
1 2 3 4 5 6
11. It’s important to me that others like me. 1 2 3 4 5 6
12. It’s important to me to avoid doing things that others won’t like.
1 2 3 4 5 6
13. I find it hard to make a decision unless I know what other people think.
1 2 3 4 5 6
14. My relationships with others are generally superficial.
1 2 3 4 5 6
15. Sometimes I think I am no good at all. 1 2 3 4 5 6
245
1 2 3 4 5 6 totally
disagree strongly disagree
slightly disagree
slightly agree strongly agree totally agree
16. I find it hard to trust other people. 1 2 3 4 5 6
17. I find it difficult to depend on others. 1 2 3 4 5 6
18. I find that others are reluctant to get as close as I would like.
1 2 3 4 5 6
19. I find it relatively easy to get close to other people.
1 2 3 4 5 6
20. I find it easy to trust others. 1 2 3 4 5 6
21. I feel comfortable depending on other people.
1 2 3 4 5 6
22. I worry that others won’t care about me as much as I care about them.
1 2 3 4 5 6
23. I worry about people getting too close.
1 2 3 4 5 6
24. I worry that I won’t measure up to other people.
1 2 3 4 5 6
25. I have mixed feelings about being close to others.
1 2 3 4 5 6
26. While I want to get close to others, I feel uneasy about it.
1 2 3 4 5 6
27. I wonder why people would want to be involved with me.
1 2 3 4 5 6
28. It’s very important to me to have a close relationship.
1 2 3 4 5 6
29. I worry a lot about my relationships. 1 2 3 4 5 6
30. I wonder how I would cope without someone to love me.
1 2 3 4 5 6
31. I feel confident about relating to others.
1 2 3 4 5 6
32. I often feel left out or alone. 1 2 3 4 5 6
246
1 2 3 4 5 6
totally disagree
strongly disagree
slightly disagree
slightly agree strongly agree totally agree
33. I often worry that I do not really fit in with other people.
1 2 3 4 5 6
34. Other people have their own problems, so I don’t bother them with mine.
1 2 3 4 5 6
35. When I talk over my problems with others, I generally feel ashamed or foolish.
1 2 3 4 5 6
36. I am too busy with other activities to put much time into relationships.
1 2 3 4 5 6
37. If something is bothering me, others are generally aware and concerned.
1 2 3 4 5 6
38. I am confident that other people will like and respect me.
1 2 3 4 5 6
39. I get frustrated when others are not available when I need them.
1 2 3 4 5 6
40. Other people often disappoint me. 1 2 3 4 5 6
PLEASE PLACE THIS QUESTIONNAIRE IN THE ENVELOPE (ATTACHED)
AND HAND IT INTO THE PSYCHOLOGY CLINIC RECEPTION
THANKYOU
247
Progress questionnaire for project entitled: “Counselling process and therapeutic change for clients attending the
Swinburne Psychology Clinic”. This questionnaire is one in a series of questionnaires that the Psychology Clinic is using in order to better understand how counselling affects your wellbeing and about the process of counselling. We are grateful for you continued participation in the project and thank-you for taking the time to complete this questionnaire. If you have any questions about this project please contact the clinic director Dr Roger Cook on 9214 8653. Name:________________________________________________________ Today’s date: ____/____/____ (dd/mm/yy) Your counsellors name:___________________________________________
248
QUESTIONNAIRE ONE Below are 10 statements about you and your life that help us see how you feel you are doing. Please respond to each statement by circling the response number that best fits how you have generally been over the last seven days (1 week). There are no right or wrong responses and it is important that your responses reflect how you feel you are doing. Often the first answer that comes to mind is your best. Please be sure to respond to each statement. All or
Never nearly all of the time
1. Given my current physical condition, I am satisfied with what I can do. 0 1 2 3 4 5 6
2. I have confidence in my ability to sustain important relationships. 0 1 2 3 4 5 6
3. I feel hopeful about my future.
0 1 2 3 4 5 6
4. I am often interested and excited about things in my life. 0 1 2 3 4 5 6
5. I am able to have fun.
0 1 2 3 4 5 6
6. I am generally satisfied with my psychological health. 0 1 2 3 4 5 6
7. I am able to forgive myself for my failures. 0 1 2 3 4 5 6
8. My life is progressing according to my expectations. 0 1 2 3 4 5 6
9. I am able to handle conflicts with others. 0 1 2 3 4 5 6
10. I have peace of mind.
0 1 2 3 4 5 6
249
QUESTIONNAIRE TWO Please read each statement and circle number 0,1,2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows:
0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
1. I found it hard to wind down. 0 1 2 3
2. I was aware of dryness of my mouth. 0 1 2 3
3. I couldn’t seem to experience any positive feeling at all. 0 1 2 3
4. I experienced breathing difficulties (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion).
0 1 2 3
5. I found it difficult to work up the initiative to do things. 0 1 2 3
6. I tended to over-react to situations. 0 1 2 3
7. I experienced trembling (e.g. in the hands). 0 1 2 3
8. I felt that I was using a lot of nervous energy. 0 1 2 3
9. I was worried about situations in which I might panic and make a fool of myself.
0 1 2 3
10. I felt that I had nothing to look forward to. 0 1 2 3
11. I found myself getting agitated. 0 1 2 3
12. I found it difficult to relax. 0 1 2 3
250
0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
13. I felt down-hearted and blue. 0 1 2 3
14. I was intolerant of anything that kept me from getting on with what I was doing.
0 1 2 3
15. I felt I was close to panic. 0 1 2 3
16. I was unable to become enthusiastic about anything. 0 1 2 3
17. I felt I wasn’t worth much as a person. 0 1 2 3
18. I felt that I was rather touchy. 0 1 2 3
19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat).
0 1 2 3
20. I felt scared without any good reason. 0 1 2 3
21. I felt that life was meaningless. 0 1 2 3
251
QUESTIONNAIRE THREE Instructions: Below is a series of statements about experiences people may have with their counselling or counsellor. Some items refer directly to your counsellor with an underlined space – as you read the sentences, mentally insert the name of your counsellor in place of the _______ in the text. For each statement, please take your time to consider your own experience and the fill in the appropriate bubble. Important: The rating scale is not the same for all the statements. PLEASE READ CAREFULLY! *** This questionnaire is CONFIDENTIAL – you counsellor will not see your answers ***
PLEASE PLACE THIS QUESTIONNAIRE IN THE ENVELOPE (ATTACHED)
AND HAND IT INTO THE PSYCHOLOGY CLINIC RECEPTION - THANKYOU
252
Final questionnaire for project entitled: “Counselling process and therapeutic change for clients attending the
Swinburne Psychology Clinic”. This is the final questionnaire in a series of questionnaires that the Psychology Clinic is using in order to better understand how counselling affects your wellbeing and about the process of counselling. We are grateful for you continued participation in the project and thank-you for taking the time to complete this and the previous questionnaires. If you have any questions about this project please contact the clinic director Dr Roger Cook on 9214 8653. Name:________________________________________________________ Today’s date: ____/____/____ (dd/mm/yy) Your counsellors name:___________________________________________
253
QUESTIONNAIRE ONE Below are 10 statements about you and your life that help us see how you feel you are doing. Please respond to each statement by circling the response number that best fits how you have generally been over the last seven days (1 week). There are no right or wrong responses and it is important that your responses reflect how you feel you are doing. Please be sure to respond to each statement. All or
Never nearly all of the time
1. Given my current physical condition, I am satisfied with what I can do. 0 1 2 3 4 5 6
2. I have confidence in my ability to sustain important relationships. 0 1 2 3 4 5 6
3. I feel hopeful about my future.
0 1 2 3 4 5 6
4. I am often interested and excited about things in my life. 0 1 2 3 4 5 6
5. I am able to have fun.
0 1 2 3 4 5 6
6. I am generally satisfied with my psychological health. 0 1 2 3 4 5 6
7. I am able to forgive myself for my failures. 0 1 2 3 4 5 6
8. My life is progressing according to my expectations. 0 1 2 3 4 5 6
9. I am able to handle conflicts with others. 0 1 2 3 4 5 6
10. I have peace of mind.
0 1 2 3 4 5 6
254
QUESTIONNAIRE TWO Please read each statement and circle number 0,1,2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows:
0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
1. I found it hard to wind down. 0 1 2 3
2. I was aware of dryness of my mouth. 0 1 2 3
3. I couldn’t seem to experience any positive feeling at all. 0 1 2 3
4. I experienced breathing difficulties (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion).
0 1 2 3
5. I found it difficult to work up the initiative to do things. 0 1 2 3
6. I tended to over-react to situations. 0 1 2 3
7. I experienced trembling (e.g. in the hands). 0 1 2 3
8. I felt that I was using a lot of nervous energy. 0 1 2 3
9. I was worried about situations in which I might panic and make a fool of myself.
0 1 2 3
10. I felt that I had nothing to look forward to. 0 1 2 3
11. I found myself getting agitated. 0 1 2 3
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0 1 2 3 did not apply to me
at all applied to me in
some degree, some of the time
applied to me to a considerable degree,
a good part of the time
applied to me very much, or most of the
time
12. I found it difficult to relax. 0 1 2 3
13. I felt down-hearted and blue. 0 1 2 3
14. I was intolerant of anything that kept me from getting on with what I was doing.
0 1 2 3
15. I felt I was close to panic. 0 1 2 3
16. I was unable to become enthusiastic about anything. 0 1 2 3
17. I felt I wasn’t worth much as a person. 0 1 2 3
18. I felt that I was rather touchy. 0 1 2 3
19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat).
0 1 2 3
20. I felt scared without any good reason. 0 1 2 3
21. I felt that life was meaningless. 0 1 2 3
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QUESTIONNAIRE THREE This assessment asks how you feel about your quality of life, health, and other areas of your life. Please answer all the questions. If you are unsure about which response to give a question, please choose the one that appears most appropriate. This can often be your first response. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the past week. Please read each question and assess your feelings, for the past week, and circle the number on the scale for each question that gives the best answer for you.
Very Poor Poor Neither Poor nor
Good Good Very Good
1. How would you rate your quality of life? 1 2 3 4 5
Very Dissatisfied
Fairly Dissatisfied
Neither Satisfied nor Dissatisfied Satisfied Very
Satisfied 2. How satisfied are you with your health?
1 2 3 4 5
The following questions ask about how much you have experienced certain things in the past week.
Not at All
Slightly
Somewhat
To A Great Extent
Completely
10. Do you have enough energy for everyday life? 1 2 3 4 5
11. Are you able to accept your bodily appearance? 1 2 3 4 5
12. Have you enough money to meet your needs? 1 2 3 4 5
13. How available to you is the information you need in your daily life?
1 2 3 4 5
14. To what extent do you have the opportunity for leisure activities? 1 2 3 4 5
Not at All
Slightly
Moderately
Very
Extremely 15. How well are you able to get around physically? 1 2 3 4 5
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The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the past week.
Very Dissatisfied
Fairly Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied Very Satisfied
16. How satisfied are you with your sleep? 1 2 3 4 5
17. How satisfied are you with your ability to perform your daily living activities?
1 2 3 4 5
18. How satisfied are you with your capacity for work? 1 2 3 4 5
19. How satisfied are you with yourself? 1 2 3 4 5
20. How satisfied are you with your personal relationships? 1 2 3 4 5
21. How satisfied are you with your sex life? 1 2 3 4 5
22. How satisfied are you with the support you get from your friends? 1 2 3 4 5
23. How satisfied are you with the conditions of your living place? 1 2 3 4 5
24. How satisfied are you with your access to health services? 1 2 3 4 5
25. How satisfied are you with your transport? 1 2 3 4 5
Never
Infrequently
Sometimes
Frequently
Always
26. How often do you have negative feelings such as blue mood, despair, anxiety and depression?
1 2 3 4 5
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QUESTIONNAIRE FOUR Here is a list of problems that people report in relating to other people. Please read the list below, and for each item, select the number that describes how distressing that problem has been for you. Then circle that number according to the following scale.
not at all a little bit moderately quite a bit extremely 0 1 2 3 4
For example How much have you been distressed by this problem? It is hard for me to: get along with my relatives 0 1 2 3 4
Part I The following are things you find hard to do with other people.
It is hard for me to:
1. join in on groups 0 1 2 3 4
2. be assertive with another person 0 1 2 3 4
3. make friends 0 1 2 3 4
4. disagree with other people 0 1 2 3 4
5. make a long-term commitment to another person 0 1 2 3 4
6. be aggressive toward other people when the situation calls for it
0 1 2 3 4
7. socialise with other people 0 1 2 3 4
8. show affection to people 0 1 2 3 4
9. feel comfortable around other people 0 1 2 3 4
10. tell personal things to other people 0 1 2 3 4
11. be firm when I need to be 0 1 2 3 4
12. experience a feeling of love for another person 0 1 2 3 4
13. be supportive of another person’s goals in life 0 1 2 3 4
14. really care about other people’s problems 0 1 2 3 4
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Part II. The following are things that you do too much.
20. I fight with other people too much 0 1 2 3 4
21. I get irritated or annoyed too easily 0 1 2 3 4
22. I want people to admire me too much 0 1 2 3 4
23. I am too dependent on other people 0 1 2 3 4
24. I open up to people too much 0 1 2 3 4
25. I put other people’s needs before my own too much 0 1 2 3 4
26. I am overly generous to other people 0 1 2 3 4
27. I worry too much about other people’s reactions to me 0 1 2 3 4
28. I lose my temper too easily 0 1 2 3 4
29. I tell personal things to other people too much 0 1 2 3 4
30. I argue with other people too much 0 1 2 3 4
31. I am too envious and jealous of other people 0 1 2 3 4
32. I am affected by another person’s misery too much 0 1 2 3 4
15. put somebody else’s needs before my own 0 1 2 3 4
16. take instructions from people who have authority over me
0 1 2 3 4
17. open up and tell my feelings to another person 0 1 2 3 4
18. attend to my own welfare when somebody else is needy
0 1 2 3 4
19. be involved with another person without feeling trapped
0 1 2 3 4
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QUESTIONNAIRE FIVE Instructions: Below is a series of statements about experiences people may have with their counselling or counsellor. Some items refer directly to your counsellor with an underlined space – as you read the sentences, mentally insert the name of your counsellor in place of the _______ in the text. For each statement, please take your time to consider your own experience and the fill in the appropriate bubble. Important: The rating scale is not the same for all the statements. PLEASE READ CAREFULLY! *** This questionnaire is CONFIDENTIAL – you counsellor will not see your answers ***
PLEASE PLACE THIS QUESTIONNAIRE IN THE ENVELOPE (ATTACHED)
AND HAND IT INTO THE PSYCHOLOGY CLINIC RECEPTION
THANKYOU
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Appendix E
Therapist materials
Counsellor information and consent form
Counsellor questionnaire
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Counsellors information sheet for project titled: “Counselling process and therapeutic change for clients attending the
Swinburne Psychology Clinic”. What the study is about. The purpose of this study is two fold. First, to understand the effectiveness of counselling in bringing about beneficial change to client’s psychological well-being. Second, to understand how the personal psychological qualities of counsellors are related to both the quality of the professional relationship that they form with their clients, and the degree of therapeutic change that their clients experience. This is an important area to pursue, as the results should inform the counselling profession about how counselling practice may be improved. Who is conducting this study? Katie Wyman is a student at Swinburne University. She is undertaking this study as part of a Doctorate in Counselling Psychology. Two psychologists from Swinburne University’s Faculty of Life and Social Sciences supervise Katie: Dr. Naomi Crafti and Dr. Roger Cook. Who can participate? Students will be invited to participate in the study if they began their placement at the Swinburne Psychology Clinic from July 2006 and/or have clients enrolled in the study. The study involves the collection of information from both counsellor and clients at the clinic. The data collected from clients includes information about their comfort in relationships, views about the therapeutic relationship, interpersonal problems, quality of life and psychopathology. This information form relates only to the aspect of the study involving the participation of counsellors. What participation involves. Participation in this study involves signing an informed consent form and completing a questionnaire that takes about 40 minutes. As well as collecting information on your personal and professional demographics, this questionnaire is designed to measure your: response to emotions, thoughts, memories and bodily sensations; personality; comfort in relationships; and, core beliefs. Your participation in this study is completely voluntary, your decision to participate, or not participate, does not have any consequences for your placement at the Psychology Clinic. You are free to withdraw from the study at any time. The time taken to complete this questionnaire can be recorded as placement hours at the Psychology Clinic. How your information is used. The information contained in these questionnaires is confidential it is not shared with your supervisor, clinic staff or anybody else. Given that
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counsellors undertaking their placement at the Psychology Clinic may have relationships with the study investigators it is essential that counsellor information remains confidential. In order to achieve this a number of procedures have been put in place, namely: - Your information will be returned in sealed envelopes, your name will
not be recorded on the questionnaires rather each questionnaire will have a code number which is assigned prior to the questionnaire being sent to you. The codes will be assigned by Naomi Crafti who will retain the key to these codes.
- Throughout the study your information will be stored in locked filing cabinets away from the Psychology Clinic. Your demographic details, professional details and the remaining scales will be stored separately from each other.
- Katie Wyman will handle the data in such a way she remains unaware of which counsellor has completed each questionnaire.
Your anonymity is of up-most importance to the researchers and we hope that you will contact us if you have any hesitation about the way in which your information will be handled. In the event that we find the results of this project to be of interest to the wider psychological community, we may decide to publish the results in an academic journal. Should this occur, no identifiable information would be included in any way, and your anonymity will be protected. Who to contact if you have questions or concerns. Any questions or concerns regarding the project entitled “counselling process and outcomes for clients at the Swinburne Psychology Clinic” can be directed to the Senior Investigator, Naomi Crafti, of the School of Psychology, on telephone number 92145355. If this questionnaire raises any personal issues for you, you may wish to seek assistance from Student Services or a private counsellor. If suitable you may also seek assistance from your placement supervisor or the clinic director. We would like to thank-you for taking the time to consider and perhaps complete this study. Your contribution is sincerely appreciated. Thank-you, Roger Cook. (Director: Swinburne Counselling Clinic) This research conforms with the principles set out in the Statement on Research Ethics endorsed by the Faculty of Life and Social Sciences, and has been approved by the Research Ethics Committee, Swinburne University of Technology. If you have any concerns about the conduct of this research project, you can contact Research Ethics Officer, Office of Research and Graduate Studies (H68), Swinburne University of Technology, P O Box 218, HAWTHORN VIC 3122. Telephone: (03) 9214 5218
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Informed consent form for project titled:
“Counselling process and therapeutic change for clients attending the Swinburne Psychology Clinic”.
I, (name) _________________________________________________________, have read and understood the information on the Counsellor Information Sheet.
I agree to participate in this activity, realising that I may withdraw at any time.
I agree that research data collected for the study may be published or provided to other researchers on the condition that anonymity is preserved and that I cannot be identified.
SIGNATURE:________________________________________
DATE:_______________________
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Counsellors questionnaire for project titled: “Counselling process and therapeutic change for clients attending the
Swinburne Psychology Clinic”. Instructions: This package contains three sections (a) questions about your personal demographics (b) questions about your professional demographics and (c) a range of psychological measures. Please note that when you return these questionnaires, these sections will be stored separately. This is to ensure the anonymity of your responses to the psychological measures. The researchers are committed to your information remaining confidential, hence a number of procedures have been put in place to ensure this occurs. Should you have any questions about this please feel free to contact the investigators listed on the information sheet. (Part A) Demographic and professional details 1. What is your age (years)?_______________ 2. What is your gender?______________ 3. To what ethnic group do you belong or identify yourself with? __________ TODAYS DATE: ____/____/____ (dd/mm/yy)
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(Part B) Professional demographics 3. Please list all university obtained degrees: _________________________ ______________________________________________________________ ______________________________________________________________ 4. Please list the counselling/psychology related courses (non-university) that you can recall participating in. Please list all courses and workshops even if you are not sure if they qualify. If you run out of room please use the back of this page. 5. Excluding placements and academic supervision, please indicate in the table below how much supervision in counselling/psychology you have received? (if you have had multiple supervisors please list them all separately) Supervisor: Approximately how many 1hr sessions: Supervisor 1 Supervisor 2 Supervisor 3 Supervisor 4 Supervisor 5 (please use back of page is more room is required) 6. Excluding any university placements how much experience have you had working as a counsellor or in a similar role? Role: Duration (years and months): e.g. telephone counsellor 2 years 6 months e.g. aged care case manager 9 months e.g. disability support worker 3 years
(please use back of page is more room is required)
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7. Currently, how would you describe your main theoretical orientation? (please circle one)
Behavioural
Cognitive – behavioural
Eclectic
Feminist
Humanistic (gestalt / existential / client-centred / process-experiential)
Psychoanalytic Psychodynamic
Other – please describe___________________
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(Part C) QUESTIONNAIRE ONE The following statements represent a range of theoretical and procedural views expressed by counsellors and therapists. Please indicate the extent of your agreement or disagreement with each statement, by using the scale below.
1 2 3 4 5 6 7 completely
disagree moderately
disagree somewhat disagree
equally agree and disagree
somewhat agree
moderately agree
completely agree
1. Unconscious motives and intuitive processes should be considered as essential aspects of psychological theory.
1 2 3 4 5 6 7
2. Unconscious motivation is a very important aspect of human behaviour.
1 2 3 4 5 6 7
3. The emotional process in counselling or psychotherapy is a vital agent of change.
1 2 3 4 5 6 7
4. Interpretation of symbolic meaning enables illumination of the depth of human experience.
1 2 3 4 5 6 7
5. The concept of unconscious processes is of limited therapeutic value.
1 2 3 4 5 6 7
6. I generally prefer to practice a goal- directed approach to counselling or psychotherapy.
1 2 3 4 5 6 7
7. Understanding of a client’s childhood is crucial to therapeutic change.
1 2 3 4 5 6 7
8. Counselling or psychotherapy should focus on ‘hear-and-now’ experiences: There is no need to focus on the client’s past.
1 2 3 4 5 6 7
9. Human beings need to know meanings rather than simply factual information.
1 2 3 4 5 6 7
10. It is essential to focus on feeling and meaning as communicated by a client.
1 2 3 4 5 6 7
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QUESTIONNAIRE TWO Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice. 1 2 3 4 5 6 7 never true very
seldom true seldom true sometimes
true frequently
true almost
always true always true
1. Its OK if I remember something unpleasant.
1 2 3 4 5 6 7
2. My painful experiences and memories make it difficult for me to live a life that I would value.
1 2 3 4 5 6 7
3. I’m afraid of my feeling. 1 2 3 4 5 6 7
4. I worry about not being able to control my worries and feelings.
1 2 3 4 5 6 7
5. My painful memories prevent me from having a fulfilling life.
1 2 3 4 5 6 7
6. I am in control of my life. 1 2 3 4 5 6 7
7. Emotions cause problems in my life. 1 2 3 4 5 6 7
8. It seems like most people are handling their lives better than I am.
1 2 3 4 5 6 7
9. Worries get in the way of my success. 1 2 3 4 5 6 7
10. My thoughts and feeling do not get in the way of how I want to live my life.
1 2 3 4 5 6 7
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QUESTIONNAIRE THREE People have a variety of ways of relating to their thoughts and feelings. For each of the items below, rate how much each of these ways applies to you.
1 2 3 4 rarely / not at all sometimes often almost always
1. It is easy for me to concentrate on what I am doing. 1 2 3 4
2. I am preoccupied by the future. 1 2 3 4
3. I can tolerate emotional pain. 1 2 3 4
4. I can accept things I cannot change. 1 2 3 4
5. I can usually describe how I feel at the moment in considerable detail.
1 2 3 4
6. I am easily distracted. 1 2 3 4
7. I am preoccupied by the past. 1 2 3 4
8. It’s easy for me to keep track of my thoughts and feelings. 1 2 3 4
9. I try to notice my thoughts without judging them. 1 2 3 4
10. I am able to accept the thoughts and feelings I have. 1 2 3 4
11. I am able to focus on the present moment. 1 2 3 4
12. I am able to pay close attention to one thing for a long period of time.
1 2 3 4
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QUESTIONNAIRE FOUR Carefully read all of the instructions before beginning. This questionnaire contains 60 statements. Read each statement carefully. For each statement circle the response that best represents your opinion. Circle SD if you strongly disagree or the statement is definitely false.
Circle D if you disagree or the statement is mostly false.
Circle N if you are neutral on the statement, if you cannot decide, or if the
statement is about equally true and false.
Circle A if you agree or the statement is mostly true.
Circle SD if you strongly agree or the statement is definitely true.
For example, if you strongly disagree or believe that a statement is definitely false, you would circle SD for that statement.
Example
SD D N A SA Fill in only one response for each statement. Respond to all of the statements, making sure that you fill in the correct response.
1. I am not a worrier. SD D N A SA
2. I like to have a lot of people around me. SD D N A SA
3. I don’t like to waste my time daydreaming.
SD D N A SA
4. I try to be courteous to everyone I meet. SD D N A SA
5. I keep my belongings neat and clean. SD D N A SA
6. I often feel inferior to others. SD D N A SA
7. I laugh easily. SD D N A SA
8. Once I find the right way to do something, I stick to it.
SD D N A SA
9. I often get into arguments with my family and co-workers.
SD D N A SA
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10. I’m pretty good about pacing myself so as to get things done on time.
SD D N A SA
11. When I’m under a great deal of stress, sometimes I feel like I’m going to pieces.
SD D N A SA
12. I don’t consider myself especially “light-hearted”.
SD D N A SA
13. I am intrigued by the patterns I find in art and nature.
SD D N A SA
14. Some people think I’m selfish and egotistical.
SD D N A SA
15. I am not a very methodical person. SD D N A SA
16. I rarely feel lonely or blue. SD D N A SA
17. I really enjoy talking to people. SD D N A SA
18. I believe letting students hear controversial speakers can only confuse and mislead them.
SD D N A SA
19. I would rather cooperate with others than compete with them.
SD D N A SA
20. I try to perform all the tasks assigned to me conscientiously.
SD D N A SA
21. I often feel tense and jittery. SD D N A SA
22. I like to be where the action is. SD D N A SA
23. Poetry has little or no effect on me. SD D N A SA
24. I tend to be cynical and sceptical of others’ intentions.
SD D N A SA
25. I have a clear set of goals and work toward them in an orderly fashion.
SD D N A SA
26. Sometimes I feel completely worthless. SD D N A SA
27. I usually prefer to do things alone. SD D N A SA
28. I often try new and foreign foods. SD D N A SA
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29. I believe that most people will take advantage of you if you let them.
SD D N A SA
30. I waste a lot of time before settling down to work.
SD D N A SA
31. I rarely feel fearful or anxious. SD D N A SA
32. I often feel as if I’m bursting with energy. SD D N A SA
33. I seldom notice the moods or feelings that different environments produce.
SD D N A SA
34. Most people I know like me. SD D N A SA
35. I work hard to accomplish my goals. SD D N A SA
36. I often get angry at the way people treat me. SD D N A SA
37. I am a cheerful, high-spirited person. SD D N A SA
38. I believe we should look to our religious authorities for decisions on moral issues.
SD D N A SA
39. Some people think of me as cold and calculating.
SD D N A SA
40. When I make a commitment, I can always be counted on to follow through.
SD D N A SA
41. Too often, when things go wrong, I get discouraged and feel like giving up.
SD D N A SA
42. I am not a cheerful optimist. SD D N A SA
43. Sometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement.
SD D N A SA
44. I’m hard-headed and tough-minded in my attitudes.
SD D N A SA
45. Sometimes I’m not as dependable or reliable as I should be.
SD D N A SA
46. I am seldom sad or depressed. SD D N A SA
47. My life is fast-paced. SD D N A SA
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48. I have little interest in speculating on the nature of the universe or the human condition.
SD D N A SA
49. I generally try to be thoughtful and considerate.
SD D N A SA
50. I am a productive person who always gets the job done.
SD D N A SA
51. I often feel helpless and want someone else to solve my problems.
SD D N A SA
52. I am a very active person. SD D N A SA
53. I have a lot of intellectual curiosity. SD D N A SA
54. If I don’t like people, I let them know it. SD D N A SA
55. I never seem to be able to get organised. SD D N A SA
56. At times I have been so ashamed I just wanted to hide.
SD D N A SA
57. I would rather go my own way than be a leader of others.
SD D N A SA
58. I often enjoy playing with theories or abstract ideas.
SD D N A SA
59. If necessary, I am willing to manipulate people to get what I want.
SD D N A SA
60. I strive for excellence in everything I do. SD D N A SA
Have you responded to all of the statements? ______ Yes ______ No Have you responded accurately and honestly? ______ Yes ______ No
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QUESTIONNAIRE FIVE Show how much you agree with each of the following items by rating them on this scale:
1 2 3 4 5 6 totally
disagree strongly disagree
slightly disagree
slightly agree strongly agree totally agree
1. Overall, I am a worthwhile person. 1 2 3 4 5 6
2. I am easier to get to know than most people.
1 2 3 4 5 6
3. I feel confident that other people will be there for me when I need them.
1 2 3 4 5 6
4. I prefer to depend on myself rather than other people.
1 2 3 4 5 6
5. I prefer to keep to myself. 1 2 3 4 5 6
6. To ask for help is to admit that you’re a failure.
1 2 3 4 5 6
7. People’s worth should be judged by what they achieve.
1 2 3 4 5 6
8. Achieving things is more important than building relationships.
1 2 3 4 5 6
9. Doing your best is more important than getting on with others.
1 2 3 4 5 6
10. If you’ve got a job to do, you should do it no matter who gets hurt.
1 2 3 4 5 6
11. It’s important to me that others like me. 1 2 3 4 5 6
12. It’s important to me to avoid doing things that others won’t like.
1 2 3 4 5 6
13. I find it hard to make a decision unless I know what other people think.
1 2 3 4 5 6
14. My relationships with others are generally superficial.
1 2 3 4 5 6
15. Sometimes I think I am no good at all. 1 2 3 4 5 6
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1 2 3 4 5 6 totally
disagree strongly disagree
slightly disagree
slightly agree strongly agree totally agree
16. I find it hard to trust other people. 1 2 3 4 5 6
17. I find it difficult to depend on others. 1 2 3 4 5 6
18. I find that others are reluctant to get as close as I would like.
1 2 3 4 5 6
19. I find it relatively easy to get close to other people.
1 2 3 4 5 6
20. I find it easy to trust others. 1 2 3 4 5 6
21. I feel comfortable depending on other people.
1 2 3 4 5 6
22. I worry that others won’t care about me as much as I care about them.
1 2 3 4 5 6
23. I worry about people getting too close.
1 2 3 4 5 6
24. I worry that I won’t measure up to other people.
1 2 3 4 5 6
25. I have mixed feelings about being close to others.
1 2 3 4 5 6
26. While I want to get close to others, I feel uneasy about it.
1 2 3 4 5 6
27. I wonder why people would want to be involved with me.
1 2 3 4 5 6
28. It’s very important to me to have a close relationship.
1 2 3 4 5 6
29. I worry a lot about my relationships. 1 2 3 4 5 6
30. I wonder how I would cope without someone to love me.
1 2 3 4 5 6
31. I feel confident about relating to others.
1 2 3 4 5 6
32. I often feel left out or alone. 1 2 3 4 5 6
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1 2 3 4 5 6
totally disagree
strongly disagree
slightly disagree
slightly agree strongly agree totally agree
33. I often worry that I do not really fit in with other people.
1 2 3 4 5 6
34. Other people have their own problems, so I don’t bother them with mine.
1 2 3 4 5 6
35. When I talk over my problems with others, I generally feel ashamed or foolish.
1 2 3 4 5 6
36. I am too busy with other activities to put much time into relationships.
1 2 3 4 5 6
37. If something is bothering me, others are generally aware and concerned.
1 2 3 4 5 6
38. I am confident that other people will like and respect me.
1 2 3 4 5 6
39. I get frustrated when others are not available when I need them.
1 2 3 4 5 6
40. Other people often disappoint me. 1 2 3 4 5 6
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QUESTIONNAIRE SIX Listed below are statements that people might use to describe themselves. Please read each statement, then rate it based on how accurately it fits you over the past year. When you are not sure, base your answer on what you emotionally feel, not on what you think to be true. A few of the items ask about your relationships with your parents or romantic partners. If any of these people have died, please answer these items based on you relationships when they were alive. If you do not currently have a partner but have had partners in the past, please answer the item based on your most recent significant romantic partner. Choose the highest score from 1 to 6 on the rating scale below that best describes you, then write your answer on the line before each statement.
1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
1. I haven’t had someone to nurture me, share him/herself with me, or care deeply about everything that happens to me.
1 2 3 4 5 6
2. I find myself clinging to people I’m close to because I’m afraid they’ll leave me.
1 2 3 4 5 6
3. I feel that people will take advantage of me. 1 2 3 4 5 6
4. I don’t fit in. 1 2 3 4 5 6
5. No man / woman I desire could love me once he or she saw my defects or flaws.
1 2 3 4 5 6
6. Almost nothing I do at work (or school) is as good as other people can do.
1 2 3 4 5 6
7. I do not feel capable of getting by on my own in everyday life.
1 2 3 4 5 6
8. I can’t seem to escape the feeling that something bad is about to happen.
1 2 3 4 5 6
9. I have not been able to separate myself from my parent(s) the way other people my age seem to.
1 2 3 4 5 6
10. I think that if I do what I want, I’m only asking for trouble.
1 2 3 4 5 6
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1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
11. I’m the one who usually ends up taking care of the people I’m close to.
1 2 3 4 5 6
12. I am too self-conscious to show positive feelings to others (e.g. affection, showing I care).
1 2 3 4 5 6
13. I must be the best at most of what I do; I can’t accept second best.
1 2 3 4 5 6
14. I have a lot of trouble accepting “no” for an answer when I want something from other people.
1 2 3 4 5 6
15. I can’t seem to discipline myself to complete most routine or boring tasks.
1 2 3 4 5 6
16. Having money and knowing important people make me feel worthwhile.
1 2 3 4 5 6
17. Even when things seem to be going well, I feel that it is only temporary.
1 2 3 4 5 6
18. If I make a mistake, I deserve to be punished.
1 2 3 4 5 6
19. I don’t have people to give me warmth, holding, and affection.
1 2 3 4 5 6
20. I need other people so much that I worry about losing them.
1 2 3 4 5 6
21. I feel that I cannot let my guard down in the presence of other people, or else they will intentionally hurt me.
1 2 3 4 5 6
22. I’m fundamentally different from other people.
1 2 3 4 5 6
23. No one I desire would want to stay close to me if he or she knew the real me.
1 2 3 4 5 6
24. I’m incompetent when it comes to achievement.
1 2 3 4 5 6
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1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
25. I think of myself as a dependent person when it comes to everyday functioning.
1 2 3 4 5 6
26. I feel that a disaster (natural, criminal, financial, or medical) could strike at any moment.
1 2 3 4 5 6
27. My parent(s) and I tend to be over- involved in each other’s lives and problems.
1 2 3 4 5 6
28. I feel as if I have no choice but to give in to other people’s wishes, or else they will retaliate, get angry, or reject me in some way.
1 2 3 4 5 6
29. I am a good person because I think of others more than myself.
1 2 3 4 5 6
30. I find it embarrassing to express my feelings to others.
1 2 3 4 5 6
31. I try to do my best; I can’t settle for “good enough”.
1 2 3 4 5 6
32. I’m special and shouldn’t have to accept many of the restrictions or limitations placed on other people.
1 2 3 4 5 6
33. If I can’t reach a goal, I become easily frustrated and give up.
1 2 3 4 5 6
34. Accomplishments are most valuable to me if other people notice them.
1 2 3 4 5 6
35. If something good happens, I worry that something bad is likely to follow.
1 2 3 4 5 6
36. If I don’t try my hardest, I should expect to lose out.
1 2 3 4 5 6
37. I haven’t felt that I am special to someone. 1 2 3 4 5 6
38. I worry that people I feel close to will leave me or abandon me.
1 2 3 4 5 6
281
1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
39. It is only a matter of time before someone betrays me.
1 2 3 4 5 6
40. I don’t belong; I’m a loner. 1 2 3 4 5 6
41. I’m unworthy of the love, attention, and respect of others.
1 2 3 4 5 6
42. Most other people are more capable than I am in areas of work and achievement.
1 2 3 4 5 6
43. I lack common sense. 1 2 3 4 5 6
44. I worry about being physically attacked by people.
1 2 3 4 5 6
45. It is very difficult for my parent(s) and me to keep intimate details from each other without feeling betrayed or guilty.
1 2 3 4 5 6
46. In relationships, I usually let the other person have the upper hand.
1 2 3 4 5 6
47. I’m so busy doing things for the people that I care about that I have little time for myself.
1 2 3 4 5 6
48. I find it hard to be free-spirited and spontaneous around other people.
1 2 3 4 5 6
49. I must meet all my responsibilities. 1 2 3 4 5 6
50. I hate to be constrained or kept from doing what I want.
1 2 3 4 5 6
51. I have a very difficult time sacrificing immediate gratification or pleasure to achieve a long-range goal.
1 2 3 4 5 6
52. Unless I get a lot of attention from others, I feel less important.
1 2 3 4 5 6
282
53. You can’t be too careful; something will almost always go wrong.
1 2 3 4 5 6
54. If I don’t do the job right, I should suffer the consequences.
1 2 3 4 5 6
55. I have not had someone who really listens to me, understands me, or is tuned into my true needs and feelings.
1 2 3 4 5 6
56. When someone I care for seems to be pulling away or withdrawing from me, I feel desperate.
1 2 3 4 5 6
57. I am quite suspicious of other people’s motives.
1 2 3 4 5 6
58. I feel alienated or cut off from other people. 1 2 3 4 5 6
59. I feel that I’m not lovable. 1 2 3 4 5 6
60. I’m not as talented as most people are at their work.
1 2 3 4 5 6
61. My judgement cannot be counted on in everyday situations.
1 2 3 4 5 6
62. I worry that I’ll lose all my money and become destitute or very poor.
1 2 3 4 5 6
63. I often feel as if my parent(s) are living through me – that I don’t have a life of my own.
1 2 3 4 5 6
64. I’ve always let others make choices for me, so I really don’t know what I want for myself.
1 2 3 4 5 6
65. I’ve always been the one who listens to everyone else’s problems.
1 2 3 4 5 6
66. I control myself so much that many people think I am unemotional or unfeeling.
1 2 3 4 5 6
1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
283
67. I feel that there is constant pressure for me to achieve and get things done.
1 2 3 4 5 6
68. I feel that I shouldn’t have to follow the normal rules or conventions that other people do.
1 2 3 4 5 6
69. I can’t force myself to do things I don’t enjoy, even when I know it’s for my own good.
1 2 3 4 5 6
70. If I make remarks at a meeting, or am introduced in a social situation, it’s important for me to get recognition and admiration.
1 2 3 4 5 6
71. No matter how hard I work, I worry that I could be wiped out financially and lose almost everything.
1 2 3 4 5 6
72. It doesn’t matter why I make a mistake. When I do something wrong, I should pay the consequences.
1 2 3 4 5 6
73. I haven’t had a strong or wise person to give me sound advice or direction when I’m not sure what to do.
1 2 3 4 5 6
74. Sometimes I am so worried about people leaving me that I drive them away.
1 2 3 4 5 6
75. I’m usually on the lookout for people’s ulterior or hidden motives.
1 2 3 4 5 6
76. I always feel on the outside of groups. 1 2 3 4 5 6
77. I am too unacceptable in very basic ways to reveal myself to other people or to let them get to know me well.
1 2 3 4 5 6
78. I’m not as intelligent as most people when it comes to work (or school).
1 2 3 4 5 6
1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
284
79. I don’t feel confident about my ability to solve everyday problems that come up.
1 2 3 4 5 6
80. I worry that I’m developing a serious illness, even though nothing serious has been diagnosed by a doctor.
1 2 3 4 5 6
81. I often feel I do not have a separate identify from my parent(s) or partner.
1 2 3 4 5 6
82. I have a lot of trouble demanding that my rights be respected and that my feelings be taken into account.
1 2 3 4 5 6
83. Other people see me as doing too much for others and not enough for myself.
1 2 3 4 5 6
84. People see me as uptight emotionally. 1 2 3 4 5 6
85. I can’t let myself off the hook easily or make excuses for my mistakes.
1 2 3 4 5 6
86. I feel that what I have to offer is of greater value than the contributions of others.
1 2 3 4 5 6
87. I have rarely been able to stick to my resolutions.
1 2 3 4 5 6
88. Lots of praise and compliments make me feel like a worthwhile person.
1 2 3 4 5 6
89. I worry that a wrong decision could lead to disaster.
1 2 3 4 5 6
90. I’m a bad person who deserves to be punished.
1 2 3 4 5 6
1 2 3 4 5 6 completely untrue of
me
mostly untrue of
me
slightly more true
than untrue
moderately true of me
mostly true of me
describes me
perfectly
285
EXPERIENCE WITH THERAPY AND MEDITATION 1. Have you received individual or group personal therapy? YES / NO
(circle) If yes, approximately how many sessions have you had?
__________ Individual __________ Group
2. Do you practice regular meditation? YES / NO (circle)
If yes, what is the main type of meditation that you practice? (please circle one)
Shamatha / calm abiding / tranquillity Insight / vipashyana Mindfulness Visualisation
Yoga (please describe) ________________________________
Relaxation (please describe) ____________________________
Other (please describe) ________________________________
If yes, how often do you meditate? (please circle one)
Daily 2-3 times per week 4-5 times per week 6-7 times per week
Other (please describe) ________________________________
If yes, approximately how long have you been practicing meditation?
_______________ months _______________ years
286
Appendix F
Schema descriptives
Table F1 Descriptive statistics for therapists’ scores on YSQ-S3 subscales not included in the
analysis
Schema scale n M SD Min – Max (range)Insufficient self-control 51 2.1059 .76644 1-3.4 (2.4) Pessimism – worry 52 1.8231 .58162 1-3.4 (2.4) Practical incompetence / dependence 53 1.5435 .42495 1-2.6 (2.6) Vulnerability to harm / illness 53 1.5811 .48874 1-2.8 (2.8) Enmeshment 53 1.5170 .50602 1 – 3.2 (2.2) Subjugation 53 1.8226 .48304 1 – 3.0 (2) Emotional inhibition 53 1.9642 .47031 1 – 3.1 (2.1) Social Isolation 52 1.8192 .63772 1 – 4.6 (3.6) Defectiveness/ unlovability 52 1.3885 .43820 1 – 2.6 (1.6) Failure to achieve 52 1.6385 .55170 1 – 3.4 (2.4) Mistrust 51 1.8314 .64544 1 – 3.8 (2.8) Emotional deprivation 52 1.5077 .60645 1 – 3.4 (2.4) Abandonment 52 1.8538 .62386 1 – 3.6 (2.6)
287
Appendix G
Difference on client baseline measures for clients with or without therapist data: MLM results
Table G1 Fixed and Random Effects for Two-Level MLMs with Baseline ASQ, WHOQOL-BREF, DASS, SOS, IIP-32 subscales, and age. Parameter ASQ – DISCOMFORT
Fixed effect Coefficient SE t-ratio df p value
Intercept 3.614 0.183 19.79 60 <.001 DATA 0.185 0.141 1.29 60 .201 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.761 0.872 Level 2 Intercept 0.003 0.053 66.66 60 .258 ASQ - APPROVAL Fixed effect
Coefficient SE t-ratio df p value
Intercept 3.952839 0.172 0.17 22.938 <.001 DATA -0.119 0.133 -0.90 60 .374 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.913 0.955 Level 2 Intercept 0.0003 0.0185 51.30 60 >.500 ASQ - PREOCCUPATION Fixed effect
Coefficient SE t-ratio df p value
Intercept 3.982 0.146 60 <.001 DATA -0.056 0.121 -0.47 60 .642 Random effect
Variance component SD χ2 df p value
Level 1Error variance 0.639 0.800 Level 2 Intercept 0.0002 0.0129 52.41 60 >.500
288
ASQ - SECONDARY Fixed effect
Coefficient SE t-ratio df p value
Intercept 2.719 0.170 15.92 60 <.001 DATA -0.202 0.134 -1.50 60 .138 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.594 0.770 Level 2 Intercept 0.011 0.104 65.50 60 .292 AGE Fixed effect
Coefficient SE t-ratio df p value
Intercept 34.553 3.005 11.50 63 <.001 DATA -2.241 2.436 -0.92 63 .361
Random effect
Variance component SD χ2 df p value
Level 1 Error variance 92.851 9.636 Level 2 Intercept 31.029 5.570 145.92 63 <.001 WHOQoL-BREF PSYCHOLOGICAL Fixed effect
Coefficient SE t-ratio df p value
Intercept 47.199 2.916 16.19 61 <.001 DATA -2.071 2.284 -0.91 61 .368 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 288.140 16.975 Level 2 Intercept 0.141 0.375 48.47 61 >.500
WHOQoL-BREF PHYSICAL (transformed) Fixed effect
Coefficient SE t-ratio df p value
Intercept 5.810 0.344 16.90 61 <.001 DATA 0.189 0.281 0.67 61 .503 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 2.004 1.416 Level 2 Intercept 0.091 0.302 67.64 61 .261
289
WHOQoL-BREF ENVIRONMENTAL (transformed) Fixed effect
Coefficient SE t-ratio df p value
Intercept 5.616 0.274 20.53 61 <.001 DATA 0.178 0.221 0.81 61 .423
Random effect
Variance component SD χ2 df p value
Level 1 Error variance 1.648 1.284 Level 2 Intercept 0.004 0.060 59.41 61 >.500 DASS - ANXIETY Fixed effect
Coefficient SE t-ratio df p value
Intercept 2.953 0.301 9.81 60 <.001 DATA 0.232 0.214 0.919 60 .362 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 2.459 1.568 Level 2 Intercept 0.002 0.043 52.79 60 >.500
DASS - STRESS Fixed effect
Coefficient SE t-ratio df p value
Intercept 19.500 1.940 10.05 60 <.001 DATA 1.633 1.610 1.01 60 .315 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 95.477 9.771 Level 2 Intercept 0.064 0.254 51.78 60 >.500 DASS - DEPRESSION Fixed effect
Coefficient SE t-ratio df p value
Intercept 3.827 0.231 16.57 61 <.001 DATA 0.120 0.153 0.78 61 .436
Random effect
Variance component SD χ2 df p value
Level 1 Error variance 2.242 1.498 Level 2 Intercept 0.0008 0.0288 45.38 61 >.500
290
SOS (SQUARE ROOT TRANSFORMED) Fixed effect
Coefficient SE t-ratio df p value
Intercept 4.861 0.170 28.60 61 <.001 DATA -0.154 0.125 -1.24 61 .221 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 1.283 1.133 Level 2 Intercept 0.0003 0.0176 42.60 61 >.500 IIP-32 Hard to be supportive Fixed effect
Coefficient SE t-ratio df p value
Intercept 0.948 0.090 10.50 60 <.001 DATA -0.082 0.069 -1.20 60 .236 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.299 0.547 Level 2 Intercept 0.00007 0.00816 47.69 60 >.500
IIP-32 Hard to be involved (square root transformed) Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.048 0.121 8.68 59 <.001 DATA -0.027 0.092 -0.29 59 .774 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.329 0.573 Level 2 Intercept 0.005 0.070 60.39 59 .425 IIP-32 Too aggressive (square root transformed) Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.043 0.099 10.58 60 <.001 DATA 0.010 0.072 0.14 60 .886 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.244 0.494 Level 2 Intercept 0.004 0.060 64.32 60 .327
291
IIP-32 Hard to be assertive Fixed effect
Coefficient SE t-ratio df p value
Intercept 2.068 0.236 8.76 60 <.001 DATA -0.178 0.197 -0.90 60 .371
Random effect
Variance component SD χ2 df p value
Level 1 Error variance 1.145 1.070 Level 2 Intercept 0.002 0.043 64.36 60 .326 IIP-32 Too open Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.630 0.200 8.61 60 <.001 DATA 0.031 0.164 0.19 60 .849 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.880 0.938 Level 2 Intercept 0.001 0.033 57.28 60 >.500
IIP-32 Too caring Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.689 0.213 7.94 60 <.001 DATA -0.0006 0.1835 -0.003 60 .998 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.880 0.938 Level 2 Intercept 0.0008 0.0289 61.62 60 .418
IIP -32 Too dependent Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.690 0.181 9.33 60 <.001 DATA -0.042 0.138 -0.305 60 0.761 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.783 0.885 Level 2 Intercept 0.006 0.078 63.49 60 .354
292
IIP-32 Hard to be sociable (square root transformed) Fixed effect
Coefficient SE t-ratio df p value
Intercept 1.040 0.110 9.42 60 <.001 DATA 0.088 0.088 1.00 60 .321 Random effect
Variance component SD χ2 df p value
Level 1 Error variance 0.001 0.030 65.64 60 .288 Level 2 Intercept 0.275 0.524 Note. Number of client and therapist for each analysis was as follows: ASQ-Discomfort 213/62; ASQ-Approval 210/62; ASQ-Preoccupation 211/62; ASQ-Secondary 210/62; Age 269/65; WHOQoL-BREF Psychological 211/63; WHOQoL-BREF Physical 211/63; WHOQoL-BREF Environmental 212/63; DASS-Anxiety 214/62; DASS-Stress 213/62; DASS-Depression 219/63; SOS 221/63; IIP-32 Hard to be supportive 220/62; IIP-32 Hard to be involved 215/62; IIP-32 Too aggressive 219/62; IIP-32 Hard to be assertive 216/62; IIP-32 Too Open 217/62; IIP-32 Too caring 213/62; IIP-32 Too dependent & IIP-32 Hard to be sociable 218/62.
293
Appendix H
Therapists variables screened out of further analysis Table H1 Three-level Conditional Growth Models for WAI-SR Ratings: Non-Significant Level Three (Therapists) Independent Variables.
NEO-FFI - Neuroticism Fixed effect Coefficient SE t-ratio df p value Intercept 1.6561 0.0163 101.42 49 < .001 Slope 0.0057 0.0014 3.97 48 < .001 Neuroticism -0.000006 0.000104 -0.05 48 0.958 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0823 0.0068 Level 2 Intercept 0.0866 0.0075 57.22 26 0.001 Slope 0.0021 0.0000 46.80 26 0.008 Level 3 Intercept 0.05014 0.00251 50.84 38 0.079 Slope 0.00492 0.00002 50.62 37 0.003
NEO-FFI - Extroversion Fixed effect Coefficient SE t-ratio df p value Intercept 1.6566 0.0164 101.22 49 < .001 Slope 0.0056 0.0014 3.87 48 < .001 Extroversion 0.00008 0.00007 1.07 48 0.289 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0824 0.0068 Level 2 Intercept 0.0861 0.0074 57.17 23 0.001 Slope 0.00227 0.00001 46.92 23 0.003 Level 3 Intercept 0.05187 0.00269 51.17 41 0.133 Slope 0.00489 0.00002 65.28 40 0.007
294
NEO-FFI - Openness Fixed effect Coefficient SE t-ratio df p value Intercept 1.6522 0.0170 97.03 49 < .0005 Slope 0.0061 0.0013 4.55 48 < .0005 Openness -0.00015 0.00008 -1.82 48 .075 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0066 0.0810 Level 2 Intercept 0.0083 0.0911 58.51 26 < .0005 Slope 0.00002 0.00399 49.38 26 .004 Level 3 Intercept 0.00252 0.05021 50.47 38 .085 Slope 0.00001 0.00363 50.62 37 .067
NEO-FFI: Agreeableness Fixed effect Coefficient SE t-ratio df p value Intercept 1.6562 0.0162 102.53 49 < .001 Slope 0.0057 0.0014 3.96 48 < .001 Agreeableness 0.00003 0.00008 0.39 48 0.695 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0824 0.0068 Level 2 Intercept 0.0863 0.0075 57.20 25 < .001 Slope 0.0020 0.0000 46.71 25 0.006 Level 3 Intercept 0.04991 0.00249 50.90 39 0.096 Slope 0.00499 0.00002 66.98 38 0.003
295
NEO-FFI: Conscientiousness Fixed effect Coefficient SE t-ratio df p value Intercept 1.6557 0.0159 104.07 49 < .001 Slope 0.0056 0.0015 3.82 48 0.001 Conscientiousness 0.00011 0.00009 1.21 48 0.234 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0829 0.0069 Level 2 Intercept 0.0857 0.0074 56.67 22 < .001 Slope 0.0022 0.0000 46.48 22 0.002 Level 3 Intercept 0.0494 0.0024 50.96 42 0.162 Slope 0.00471 0.00002 63.61 41 0.013
CAMS-R Fixed effect Coefficient SE t-ratio df p value Intercept 1.6560 0.0162 102.03 49 < .001 Slope 0.0057 0.0014 4.02 48 < .001 CAMS-R 0.0001 0.0002 0.46 48 0.648 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0824 0.0068 Level 2 Intercept 0.0863 0.0075 57.17 22 < .001 Slope 0.0021 0.0000 46.77 22 .002 Level 3 Intercept 0.0522 0.0027 50.92 42 0.163 Slope 0.00481 0.00002 64.28 41 0.012
296
CTPS: Rational - Intuitive Fixed effect Coefficient SE t-ratio df p value Intercept 1.6564 0.0160 103.31 49 < .001 Slope 0.0057 0.0014 4.04 48 < .001 Rational - Intuitive 0.00007 0.00008 0.86 48 0.397 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0827 0.0068 Level 2 Intercept 0.0871 0.0076 57.01 25 < .001 Slope 0.0020 0.0000 46.53 25 0.006 Level 3 Intercept 0.0483 0.0023 50.52 39 0.102 Slope 0.00487 0.00002 65.41 38 0.004
CTPS: Objective - Subjective Fixed effect Coefficient SE t-ratio df p value Intercept 1.6589 0.0170 97.10 49 < .001 Slope 0.0059 0.0015 3.91 48 < .001 Objective- Subjective 0.00005 0.00008 0.67 48 0.509 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0819 0.0067 Level 2 Intercept 0.0862 0.0074 57.49 25 < .001 Slope 0.00249 0.00001 47.33 25 0.005 Level 3 Intercept 0.0545 0.0030 51.26 39 0.09 Slope 0.00475 0.00002 61.01 38 0.009
297
ASQ: Avoidance Fixed effect Coefficient SE t-ratio df p value Intercept 1.6564 0.0161 102.76 49 < .001 Slope 0.0057 0.0014 4.02 48 < .001 Avoidance 0.0010 0.0019 0.51 48 0.614 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0822 0.0068 Level 2 Intercept 0.0855 0.0073 57.19 21 < .001 Slope 0.0021 0.0000 46.90 21 0.001 Level 3 Intercept 0.0522 0.0027 51.33 43 0.180 Slope 0.00492 0.00002 53.61 42 0.014
ASQ: Anxiety Fixed effect Coefficient SE t-ratio df p value Intercept 1.6553 0.0162 102.14 49 < .001 Slope 0.0058 0.0014 4.03 48 < .001 Anxiety -0.0008 0.0016 -0.51 48 0.612 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0824 0.0068 Level 2 Intercept 0.0864 0.0075 57.12 20 < .001 Slope 0.00224 0.00001 46.85 20 0.001 Level 3 Intercept 0.0526 0.0028 50.92 44 0.220 Slope 0.00477 0.00002 63.20 43 0.024
298
YSQ-S3: Punitiveness (square-root) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6567 0.0162 102.40 49 < .001 Slope 0.0057 0.0014 3.96 48 < .001 Punitiveness -0.0016 0.0034 -0.47 48 0.640 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0825 0.0068 Level 2 Intercept 0.0867 0.0075 57.21 25 < .001 Slope 0.0018 0.0000 46.63 25 0.006 Level 3 Intercept 0.0504 0.0025 50.73 39 0.099 Slope 0.00492 0.00002 66.43 41 0.003
YSQ-S3: Entitlement (log) Fixed effect Coefficient SE t-ratio df p value Intercept 1.6562 0.0164 101.04 49 < .001 Slope 0.0057 0.0014 4.01 48 < .001 Entitlement -0.0026 0.0054 -0.49 48 0.628 Random effect Variance component SD χ2 df p value Level 1 Error variance 0.0825 0.0068 Level 2 Intercept 0.0859 0.0074 57.14 26 0.001 Slope 0.0019 0.0000 46.66 26 0.008 Level 3 Intercept 0.0522 0.0027 51.04 38 0.077 Slope 0.00499 0.00002 66.97 37 0.002 Note. Number of therapists / clients for each analysis was as follows: CAMS-R 43/65; CTPS-Rational, NEO-A and YSQ-S3 Punitiveness 40/65; CTPS-Objective, NEO-N, NEO-O, Avoidance andYSQ-S3 Entitlement 39/65; NEO-E 42/65; Anxiety 45/65.