Client,Treatment, and Therapist Variables Related To Outcome in Brief,Systems-Oriented Family Therapy

Client, therapist, and treatment characteristics were examined with respect to how much of the variance they could account for in a variety of outcome measures. Multiple regression analyses were used to examine relationships among each of the client, therapist, and treatment characteristics studied and the various outcome measures. For the 219 families that were treated with brief family therapy, only a relatively low amount of variance in any of the outcome measures could be accounted for. The amount of explained variance, however, varied considerably from one outcome measure to the other. When the more homogeneous groups of clients (single parents or adolescent identified patients) were considered, the amount of explained variance generally showed an increase. Different sets of client, therapist, and treatment variables accounted for the variance in these outcome measures across client groups, demonstrating both the complexities of the relationships and the relative independence of various outcome measures. New variables are suggested for future research.     

Therapist Perceptions of Client Reactions

This study examined therapist ability to identify client-reported reactions. Sixteen therapists each saw two volunteer clients for single counseling sessions. In postsession reviews, clients rated the helpfulness of, and indicated their reactions to, each therapist intervention. Therapists also rated the helpfulness of, and indicated their perceptions of client reactions to, each therapist intervention. In 50% of the instances therapists matched clients, that is, reported the same reaction cluster as the clients did. There were higher match rates on the reaction clusters of therapeutic work (62%), supported (54%), and no reaction (46%) than negative reaction (27%) and challenged (14%). When therapists matched on therapeutic work, helpfulness ratings for the following intervention were higher than when therapists did not match. In contrast, when therapists matched on negative reactions and no reaction, helpfulness ratings for the following intervention were lower than when they had not matched. Thus, therapists' ability to match client reactions was related to their ability to generate helpful interventions. Implications for practice and future research are discussed.     

Therapy Outcomes: Client Perception and Similarity with Therapist View

This study examined clients' perceptions of therapy outcome and how those perceptions related to therapist views. Additionally, the effects of client and therapist gender and ethnicity, and the match on these variables (e.g., female therapist-female client) were examined. Results showed that clients generally improved from both the client and therapist perceptions, although therapists' views were influenced by client ethnicity. There was no difference between gender or ethnicity matches on perception of outcome. Further examination showed that gender and ethnicity interacted to influence both client and therapist perceptions of outcome. The authors discuss the research and practice implications of these findings.     

Client Choice of Therapist or Therapy

This article presents a rationale for client choice of therapist or therapy as an alternative method of matching. It discusses implications for clients, therapists, and helping agencies and reviews the limited research on the topic.     

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.     

Impact of Co-Therapy Teams on Client Outcomes and Therapist Training in Marriage and Family Therapy

This study of 33 student therapists, 402 client systems, and three supervisors tested the efficacy of using student co-therapy teams as an aspect of clinical training in a marriage and family therapy program. This study utilizes both quantitative and qualitative methodology. Two research questions were addressed: “Do different pairings of co-therapists affect client outcomes?” and “Is co-therapy a viable option for a training program?” The results indicate that client outcomes using co-therapy are at least as effective as treatment using one therapist and in some circumstances produce more positive outcomes for both clients and student therapists.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

Therapist activities preceding therapy setbacks in a poor-outcome case

Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.     

‘Learning from research’: Therapist perspectives on the benefits and challenges of participating in a longitudinal,systematic case‐study

Objectives: In psychotherapy research we have often neglected to examine the impact of research procedures on therapy process and outcome. Such information is extremely important in helping us evaluate the validity of our findings, increase relevance of research for practice, and choose appropriate methods for future projects. The aim of this paper is to share the experience of six person‐centered therapists, who participated in a longitudinal, systematic study, and present their reflections about the impact of research on therapy process, therapeutic engagement and professional development. Methods: The findings have emerged from semi‐structured interviews that took place after the first, sixth (middle) and last therapy session. In total 18 interviews were conducted. These data were part of a much larger research protocol that included a number of outcome and process measures. Results & Conclusions: The analysis of therapist narratives revealed important benefits for those participating in systematic case study research. The use of Brief Structured Recall methods and qualitative interviewing was an important factor in promoting therapist reflexivity and professional development. The importance of a strong research alliance and the active involvement of the client in the research process is discussed.     

Interviewing a Therapist in the Presence of a Couple: A Description of the Therapeutic Process

A therapy research team interviewed a therapist in the presence of a couple. Following each of six consecutive sessions with a couple, an interviewer posed questions to the therapist and couple. While one question was standard to each interview, other questions were generated by team members who tracked the entire process via live observation. These questions were directed first at the therapist, then at the couple, and then focused on therapeutic process and outcome. Findings of this process for the therapy system included decreasing the hierarchy within the client/therapist relationship; increasing the client ownership and energy in the therapy process; discovering the presence of parallel processes between the systems; and informing the direction of future therapy sessions. Practical, clinical implications are discussed for a variety of therapy settings.     

Therapist responses to requests for disclosure of therapeutic records: An introductory study

This paper describes a questionnaire survey of therapists in the UK who have been subject to requests for disclosure of client records as part of a legal process. Therapist responses are outlined in terms of the perceived effect of such disclosure on the client, therapist and the therapeutic relationship. Negative effects included the experience of exposure of sensitive client material in an adversarial legal system, of powerful emotional responses by therapists, and a sense of feeling professionally de‐skilled in an unfamiliar and often challenging legal environment. Positive effects for the client included the achievement of valued outcomes such as compensation, and, for the therapist, the facilitation of support for the client in this process. These findings are discussed in terms of a contrast between therapist perceptions of consensual and contested disclosure. In the former, therapist and client are in agreement about the restorative value and outcome of disclosure. In contested disclosure, the process is experienced as disrupting therapeutic privacy, undermining professional self‐confidence and introducing an unwelcome element of critical re‐evaluation of client motives for undertaking therapy.     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

Therapist response modes in the exploration stage: timing and effectiveness

In an investigation of the exploration stage of single counselling sessions with 26 anxious female volunteer clients and 13 female doctoral student therapists, no overall association was found between client narrative processing modes and subsequent therapist verbal response modes. There was evidence in a third of the sample for an association between therapist response modes and subsequent client narrative modes, such that clients used more internal than external or reflexive narrative processing modes when therapists used open questions about feelings and reflections of feelings. Client and therapist helpfulness ratings did not differ for different therapist response modes or client narrative process modes. Hence, overall results suggested that all four therapist response modes (open questions about thoughts, open questions about feelings, restatements, reflections of feelings) are effective during the exploration stage.     

Themes in Therapist Development During the First Three Months of Clinical Experience

The results of a qualitative research study designed to better understand the developmental processes active in beginning therapists during the first three months of clinical contact is reported. Thirteen beginning therapists were asked to complete a monthly log describing experiences impacting their clinical work and themselves as therapists during their first three months of client contact. Data analysis revealed that the primary developmental theme active during this period of time is the development of therapist confidence. Two additional themes, the development of an internal gauge on which to evaluate current experiences and the development of boundaries around the self as a professional, were also found to be active during this time. These additional themes support the development of therapist confidence. Implications for training and research are identified.     

The Relationship Between Client Emotional Expressions, Therapist Interventions, and the Working Alliance: An Exploration of Eight Emotional Expression Events

The relationship between client emotional expression and therapist interventions was studied in two working alliance conditions. An events-focused methodology was used to examine a total of 8 events taken from a variety of therapeutic orientations. Results indicated that, in the presence of a good client–therapist relationship, therapists showed higher levels of empathy and effectively focused on the immediately expressed feelings; in turn, their clients were engaged in exploration of feelings. In poor-relationship dyads, clients expressed negative feelings toward the therapists. Interventions rated as effective by clinical judges were characterized by accurate therapist understanding of clients' emotional expressions and working with strains in the therapeutic relationship. Ineffective interventions were associated with inaccurate assessments of clients' emotional states. Intensive analysis of these sessions led to three distinct models of in-session emotional expression events. Theoretical and practical implications of these models will be discussed.     

The Influence of Parental Factors on Therapist Adherence in Multi-systemic Therapy

Therapist treatment adherence has received a great deal of attention in recent years, in part because of its relation to treatment outcomes. Although certain therapist behaviors have been found to be associated with treatment outcomes, little is known about client factors impacting on therapists’ ability to adhere to treatment protocols. In this study, we evaluated effects of parental beliefs, psychopathology, and interaction styles on therapists’ adherence to Multi-systemic Therapy (MST) principles. Eighty-two parents participating in a clinical trial of MST completed baseline measures assessing psychopathology, family functioning, and treatment expectations. Analyses indicated that parental perceptions of therapist adherence were established within the first 4 weeks of treatment, and that parental psychopathology, motivation, expectations, and child rearing practices were related to parental ratings of therapist adherence. Results were essentially unchanged when controlling for parental positive response style. Clinical and research implications of the findings are discussed.     

Therapist empathy,homework compliance,and outcome in cognitive behavioral therapy for generalized anxiety disorder: partitioning within- and between-therapist effects

Although client-perceived therapist empathy relates to positive therapy outcomes, including in cognitive behavioral therapy (CBT), little is known about how empathy exerts its ameliorative effect. One possible way is by promoting clients’ subsequent homework compliance, a variable that also predicts positive outcomes in CBT. The present study sought to investigate simultaneously, in the context of 43 therapist–client dyads receiving 15 sessions of CBT for generalized anxiety disorder, (1) the association of early client-perceived therapist empathy (averaged over sessions 1, 3, 5) with mid-treatment client homework compliance (averaged over sessions 6, 8, 10); (2) the association of mid-treatment homework compliance on client posttreatment worry severity; and (3) the indirect effect of early perceived therapist empathy on posttreatment worry through mid-treatment homework compliance. Given that clients were nested within therapists, we examined both within- and between-therapist differences in clients’ ratings of therapist empathy and homework compliance, and tested both of these indices as predictors of the relevant dependent variables in a multilevel model. At the within-therapist level (i.e., differences between clients within a given therapist’s caseload), greater early empathy was associated with greater mid-treatment homework compliance. At the between-therapist level (i.e., differences between therapists across all of their cases), greater between-therapist homework compliance was related to lower posttreatment worry. Finally, homework compliance was not found to mediate the relationship between empathy and posttreatment outcome. The results underscore the importance of parsing client and therapist effects, and are discussed with regard to their training and research implications.     

Client concealment and self-presentation in therapy: comment on Kelly (2000)

The authors disagree with A. E. Kelly's (2000) conclusions that clients conceal things from therapists primarily for self-presentational reasons and that client concealment is positively related to positive therapy process and outcome. They also disagree with A. E. Kelly regarding the implications of self-presentation theory for therapy. Their review of the research suggests that clients do not conceal much from therapists, that what they do conceal involves many different kinds of information hidden for many different reasons, that therapists have wide variability in being able to detect hidden client material, and that the relationship of client concealment and therapist awareness of client concealment with therapy process and outcome is not clear. Finally, the authors discuss their views about implications of client concealment and self-presentation for therapy.