A pan-theoretical conceptualization of client involvement in psychotherapy

Objective: The present paper attempts to differentiate client involvement from other, similar process variables and presents a pan-theoretical conceptualization of client involvement. Method: A modified Delphi poll was conducted with 20 experienced clinicians and researchers. In two rounds of data collection, the experts completed a questionnaire designed to elicit their feedback on whether a variety of involvement items were representative of our pan-theoretical definition of client involvement. Results: The results of the survey provide insight into which types of client activities are good representations of client involvement. Conclusion: We propose that client involvement can be understood as being comprised of behavioral, cognitive, and emotional elements, and we provide concrete examples of these activities.     

An investigation of client mood in the initial and final sessions of cognitive-behavioral therapy and psychodynamic-interpersonal therapy

Objective: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes. Methods: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P). Results: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments. Conclusions: These results suggest different change processes are at work in CBT and PIT.     

Therapist strategies early in therapy associated with good or poor outcomes among clients with low proactive agency

Objective: Within a mixed methods program of research the present study aimed at expanding knowledge about interactions in the initial therapeutic collaboration by combining focus on client interpersonal style and therapist contribution. Method: The study involves in-depth analyses of therapist–client interactions in the initial two sessions of good and poor outcome therapies. Based on interpersonal theory and previous research, the Inventory of Interpersonal Problems (IIP-64-C) was used to define poor outcome cases, that is, low proactive agency cases. To compare good and poor outcome cases matched on this interpersonal pattern, cases were drawn from two different samples; nine poor outcome cases from a large multi-site outpatient clinic study and nine good outcome cases from a process-outcome study of highly experienced therapists. Results: Qualitative analysis of therapist behaviors resulted in 2 main categories, fostering client’s proactive agentic involvement in change work and discouraging client’s proactive agentic involvement in change work, 8 categories and 22 sub-categories. Conclusion: The findings revealed distinct and cohesive differences in therapist behaviors between the two outcome groups, and point to the particular therapist role of fostering client agency through engagement in a shared work on change when clients display strong unassertiveness and low readiness for change.

Clinical or Methodological Significance Summary: The present analysis combines focus on client interpersonal style, therapist strategies/process and outcome. The categories generated from the present grounded theory analysis may serve as a foundation for identifying interactions that are associated with agentic involvement in future process research and practice, and hence we have formulated principles/strategies that were identified by the analysis.     

Efficacy of client feedback in group psychotherapy with soldiers referred for substance abuse treatment

Abstract

This study investigated whether routine monitoring of client progress, often called “client feedback,” via an abbreviated version of the Partners for Change Outcome Management System (PCOMS) resulted in improved outcomes for soldiers receiving group treatment at an Army Substance Abuse Outpatient Treatment Program (ASAP). Participants (N = 263) were active-duty male and female soldiers randomized into a group feedback condition (n = 137) or a group treatment-as-usual (TAU) condition (n = 126). Results indicated that clients in the feedback condition achieved significantly more improvement on the outcome rating scale (d = 0.28), higher rates of clinically significant change, higher percentage of successful ratings by both clinicians and commanders, and attended significantly more sessions compared to the TAU condition. Despite a reduced PCOMS protocol and a limited duration of intervention, preliminary results suggest that the benefits of client feedback appear to extend to group psychotherapy with clients in the military struggling with substance abuse.     

Client reflections on confirmation and disconfirmation of expectations in cognitive behavioral therapy for generalized anxiety disorder with and without motivational interviewing

Objective: Addressing methodological shortcomings of prior work on process expectations, this study examined client process expectations both prospectively and retrospectively following treatment. Differences between clients receiving cognitive behavioral therapy (CBT) versus motivational interviewing integrated with CBT (MI-CBT) were also examined. Method: Grounded theory analysis was used to study narratives of 10 participants (N?=?5 CBT, 5 MI-CBT) who completed treatment for severe generalized anxiety disorder as part of a larger randomized controlled trial. Results: Clients in both groups reported and elaborated expectancy disconfirmations more than expectancy confirmations. Compared to CBT clients, MI-CBT clients reported experiencing greater agency in the treatment process than expected (e.g., that they did most of the work) and that therapy provided a corrective experience. Despite nearly all clients achieving recovery status, CBT clients described therapy as not working in some ways (i.e., tasks did not fit, lack of improvement) and that they overcame initial skepticism regarding treatment. Conclusions: Largely converging with MI theory, findings highlight the role of key therapist behaviors (e.g., encouraging client autonomy, validating) in facilitating client experiences of the self as an agentic individual who is actively engaged in the therapy process and capable of effecting change.     

Improving the efficiency of cognitive-behavioural therapy by using formal client feedback

Objective: Feedback from clients on their view of progress and the therapeutic relationship can improve effectiveness and efficiency of psychological treatments in general. However, what the added value is of client feedback specifically within cognitive-behavioural therapy (CBT), is not known. Therefore, the extent to which the outcome of CBT can be improved is investigated by providing feedback from clients to therapists using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Method: Outpatients (n?=?1006) of a Dutch mental health organization either participated in the “treatment as usual” (TAU) condition, or in Feedback condition of the study. Clients were invited to fill in the ORS and SRS and in the Feedback condition therapists were asked to frequently discuss client feedback. Results: Outcome on the SCL-90 was only improved specifically with mood disorders in the Feedback condition. Also, in the Feedback condition, in terms of process, the total number of required treatment sessions was on average two sessions fewer. Conclusion: Frequently asking feedback from clients using the ORS/SRS does not necessarily result in a better treatment outcome in CBT. However, for an equal treatment outcome significantly fewer sessions are needed within the Feedback condition, thus improving efficiency of CBT.     

Testing a mediation model of psychotherapy process and outcome in psychodynamic psychotherapy: Previous client distress,psychodynamic techniques,dyadic working alliance,and current client distress

To test a sequential model of psychotherapy process and outcome, we included previous client distress, therapist psychodynamic techniques, dyadic working alliance, and current client distress. For 114 sets of eight-session segments in 40 cases of psychodynamic psychotherapy, clients completed the Outcome Questionnaire-45 and Inventory of Interpersonal Problems-32 after the first and final session, judges reliably coded one middle sessions on the Psychodynamic subscale of the Multitheoretical List of Therapeutic Interventions, and clients and therapists completed the Working Alliance Inventory after every session. Results indicated that higher use of psychodynamic techniques was associated with higher levels of the working alliance, which in turn was associated decreased client distress; and working alliance was higher later in psychotherapy. There was a significant indirect effect of psychodynamic techniques on decreases in distress mediated by the working alliance. Implications for theory, practice, and research are provided.

Clinical or methodological significance of this article: Conducted a longitudinal, latent variable examination of the relationships of psychodynamic techniques and working alliance on client distress. Psychodynamic techniques have an indirect effect on decreases in client distress through the dyadic working alliance.     

The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process

Objective: The experiencing scale (EXP) is an often used measure of client's depth of processing and meaning-making in-session. While research suggests that “client experiencing” predicts psychotherapy outcomes, this relationship has never been summarized in a meta-analysis. We examine this specific client factor as an in-session process predictor of good treatment outcomes. Method: A meta-analysis quantified the relationship between client experiencing and therapy outcomes using a total of 10 studies and 406 clients. Results: Analysis indicated that client experiencing is a small to medium predictor of standardized symptom improvements at final treatment outcomes with an effect of r?=??.19 (95% CI ?.10 to ?.29), which we consider a “best estimate” for robustly quantifying the association between EXP and self-reported clinical outcomes. However, effects were higher (i.e., r?=??.25) when observational measures of outcome were also included: Subgroup analyses indicated that EXP effects were moderated by the modality of outcome measurement (i.e., symptom reports vs. observational measures). On the other hand, statistical index, treatment phase, or treatment approach did not have significant impacts, which addresses some perennial questions in the EXP literature. Conclusions: Client experiencing is a small to medium predictor of treatment outcomes and a probable common factor.     

Characteristics of client-identified helpful events in emotion-focused therapy for child abuse trauma

Abstract

This study investigated the characteristics of client-identified helpful events (n=29) in emotion-focused therapy for child abuse trauma (EFTT). Helpful events (HE) were identified on the Helpful Aspects of Therapy Questionnaire and in Post Therapy Interviews, located in video-taped therapy sessions, and compared to researcher-defined control events (CE) for each client. Results indicated a greater focus on childhood abuse (particularly during the imaginal confrontation procedure), higher levels of emotional arousal, and comparable alliance quality in HE compared to CE. HE contained deeper levels of experiencing compared to CE, but only for clients who achieved the greatest depth of experiencing. Client perspectives converged with theory and research on change processes in EFTT and have implications for practice and training.     

Pseudosecure vs. individuated-secure client attachment to therapist: Implications for therapy process and outcome†

Objective: We differentiated two hypothesized client subtypes: (a) Pseudosecure clients have high Client Attachment to Therapist Scale (CATS) Secure and high CATS Preoccupied scores, tend to idealize their therapist, and exhibit maladaptive dependency; (b) Individuated-secure clients combine high Secure with low Preoccupied scores and function more autonomously. Clients who, despite insecure attachment to others, “earn” individuated-secure attachment to their therapist benefit most from therapy. Method: We examined regression suppressor effects by reanalyzing raw data from four published studies. If pseudosecure attachment is present, when covariance between CATS Secure and Preoccupied scores is removed, residual Secure scores should be significantly better predictors of process/outcome indicators than raw Secure scores. Results: Suppressor effects were observed in eight of nine analyses. Two were statistically significant. Earned individuated-secure attachment predicted improvement in interpersonal relationship symptoms, but only for clients with Avoidant pre-therapy attachment patterns. Finally, significant meta-analytic effect size estimates were obtained for CATS subscales, Secure r?=?.274 (95% CI?=?.177, .366), Avoidant, r?=??.296 (95% CI?=??.392, ?193), and Preoccupied, r?=??.192 (95% CI?=??.289, ?.092). Conclusions: Clients with pre-therapy Avoidant attachment who nevertheless “earn” individuated-secure attachment to their therapist appear to benefit more from therapy.     

A time-series analysis of therapeutic alliance,interventions, and client’s clinical status in an evidence-based single-case study: Evidence for establishing change mechanisms in psychotherapy

Objective: The goal of this study was to analyze the time-series of alliance, interventions, and client’s post-sessions clinical status, to establish if alliance and adherence to cognitive-behavioral interventions preceded improvement in psychotherapy Method: A single-case study of a complete Cognitive-Behavioral treatment of a 27-year-old male diagnosed with Generalized Anxiety Disorder treatment was conducted. Alliance, adherence to cognitive-behavioral interventions, and client’s therapeutic condition were assessed every two sessions during the entire treatment. Results: After controlling for the effect of autocorrelations, the transfer functions showed that alliance predicted client’s clinical condition with a lag of two sessions throughout the entire treatment. However, the inverse relationship was not observed. Conclusions: Results support the hypothesis of a time-lagged association between alliance and subsequent client’s changes in their clinical condition in single case of a cognitive-behavioral treatment.     

A meta-analysis of the effect of therapist experience on outcomes for clients with internalizing disorders

Abstract

Objective: This meta-analysis synthesized the literature regarding the effect of therapist experience on internalizing client outcomes to evaluate the utility of lay providers in delivering treatment and to inform therapist training. Method: The analysis included 22 studies, contributing 208 effect sizes. Study and client characteristics were coded to examine moderators. We conducted subgroup meta-analyses examining the relationship of therapist experience across a diverse set of internalizing client outcomes. Results: Results demonstrated a small, but significant relationship between therapist experience and internalizing client outcomes. There was no relationship between therapist experience and outcomes in clients with primary anxiety disorders. In samples of clients with primary depressive disorders and in samples of clients with mixed internalizing disorders, there was a significant relationship between experience and outcomes. The relationship between therapist experience and outcomes was stronger when clients were randomized to therapists, treatment was not manualized, and for measures of client satisfaction and “other” outcomes (e.g., dropout). Conclusions: It appears that therapist experience may matter for internalizing clients under certain circumstances, but this relationship is modest. Continuing methodological concerns in the literature are noted, as well as recommendations to address these concerns.     

Client Involvement,Working Alliance,and Type of Therapy Termination

The study investigated the relationship of therapist-rated client and therapist involvement and client relatedness in the first session to strength of working alliance, measured after the third session, and type of client termination. Ten therapists and their 109 college student clients participated. How well the client related at intake was positively associated with client and therapist alliance scores. Client intake involvement was positively associated with client alliance assessment. Unilateral client terminations were related to weaker client and therapist working alliance evaluations. Results indicate the importance of building a strong alliance in the early phases of counseling.     

Therapist and relationship factors influencing dropout from individual psychotherapy: A literature review

Abstract

Among potential predictors of dropout, client variables are most thoroughly examined. This qualitative literature review examines the current state of knowledge about therapist, relationship and process factors influencing dropout. Databases searches identified 44 relevant studies published January 2000–June 2011. Dropout rates varied widely with a weighted rate of 35%. Fewer than half of the studies directly addressed questions of dropout rates in relation to therapist, relationship or process factors. Therapists' experience, training and skills, together with providing concrete support and being emotionally supportive, had an impact on dropout rates. Furthermore, the quality of therapeutic alliance, client dissatisfaction and pre-therapy preparation influenced dropout. To reduce dropout rates, therapists need enhanced skills in building and repairing the therapeutic relationship.     

Understanding the process of motivational interviewing: A review of the relational and technical hypotheses

Objective: The current study systematically reviews evidence for a causal chain model suggested by Miller and Rose to account for the efficacy of Motivational Interviewing (MI). Method: Literature searches were conducted to identify studies delivering MI in an individual format to treat various problem areas. Results: Thirty-seven studies met inclusion criteria. The results suggest that when clinicians utilise MI consistent behaviours, clients are more likely to express language in favour of change. Furthermore, this client language was consistently related to positive client outcome across studies. Conclusions: While the results support some parts of the Miller and Rose model, additional research is needed to confirm the findings in diverse populations. Understanding the mechanisms of MI's effectiveness may maximise the implementation of MI, potentially contributing to better client outcomes.     

Counselors’ attachment anxiety and avoidance and the congruence in clients’ and therapists’ working alliance ratings

Objective: To determine how counselors’ attachment anxiety and avoidance related to congruence between counselors’ and clients’ Working alliance (WA) ratings. Congruence strength was defined as the regression coefficient for clients’ WA ratings predicting counselors’ WA ratings. Directional bias was defined as the difference in level between counselors’ and clients’ WA ratings. Method: Twenty-seven graduate student counselors completed an attachment measure and they and their 64 clients completed a measure of WA early in therapy. The truth-and-bias analysis was adapted to analyze the data. Results: As hypothesized counselors’ WA ratings were significantly and positively related to clients’ WA ratings. Also as hypothesized, counselors’ WA ratings were significantly lower than their clients’ WA ratings (directional bias). Increasing counselor attachment anxiety was related to increasing negative directional bias; as counselors’ attachment anxiety increased the difference between counselors and clients WA ratings became more negative. There was a significant interaction between counselor attachment anxiety and congruence strength in predicting counselor WA ratings. There was a stronger relationship between client WA ratings and counselor WA ratings for counselors low versus high in attachment anxiety. Conclusion: Counselors’ attachment anxiety is realted to their ability to accurately percieve their clients’ WA.