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.     

Client and therapist variability in clients' perceptions of their therapists' multicultural competencies

This study examined therapist differences in their clients' ratings of their therapists' multicultural competencies (MCCs) as well as tested whether therapists' who were rated as exhibiting more MCCs also had clients who had better therapy outcomes (N = 143 clients and 31 therapists). All clients completed at least 3 sessions. Results demonstrated that therapists accounted for less than 1% of the variance in their clients' Cross-Cultural Counseling Inventory–Revised (CCCI-R; T. D. LaFromboise, H. L. K. Coleman, & A. Hernandez, 1991) scores, suggesting that therapists did not differ in terms of how clients rated their MCCs. Therapists accounted for approximately 8.5% of the variance in therapy outcomes. For each therapist, their clients' CCCI-R scores were aggregated to provide an estimate of therapists' MCCs. Therapists' MCCs, based on aggregate CCCI-R scores, did not account for the variability in therapy outcomes that were attributed to them. Additionally, clients' race/ethnicity, therapists' race/ethnicity, or the interaction of clients'–therapists' race/ethnicity were not significantly associated with clients' perceptions of their therapists' MCCs.     

Working through: in-session processes that promote between-session thoughts and activities

This study examined whether clients' ratings of the working alliance as well as their perception of cognitive-behavioral (CB) and psychodynamic-interpersonal (PI) techniques (delivered by therapists who used both) were associated with clients' intersession processes (i.e., their thoughts about therapy and therapeutic activity between sessions). Seventy-five clients who were currently in therapy at a large university counseling center participated in the current study. Multilevel regression analyses demonstrated that alliance and clients' perceptions of their therapists' use of PI techniques were positively associated with clients' general thoughts about therapy between sessions. Also, stronger alliances were associated with more therapeutic activities between sessions and more positive (and less negative) thoughts about therapy between sessions. In addition, clients at later sessions who described their therapists as using more PI techniques also reported engaging in more therapeutic activities between sessions (after controlling for the variance in the other variables, such as use of CB techniques). Clients' perceptions of their therapists' use of CB techniques in the most recent session were not related to thinking about therapy or therapeutic activities after controlling for the variance in the other variables.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

Clients' Experiences of Obstructive Silence: Integrating Conscious Reports and Analytic Theories

The psychodynamic literature has associated clients' silences in psychotherapy sessions with a variety of processes. These processes include wishes to merge with the therapist, to gain control in session, to communicate the unsayable, to express helplessness and, most frequently, the intertwined processes of resistance and regression. Experiences of obstructive silence—that is, moments in which clients detached from the process of therapeutic inquiry—were examined in this study. A grounded theory analysis was used to explore clients' experiences of silences in psychotherapy across psychotherapeutic modalities. Two types of obstructive pausing processes, Disengaged pauses and Interactional pauses, were identified. The implications of delineating conscious aspects of these complex experiences are stressed and techniques are suggested for therapeutic intervention in moments of experienced threat.     

Vivid RET II: Disputing methods

Summary In this article, I have outlined a variety of ways in which therapists can make the disputing process more vivid and memorable for clients. I have underlined that tailoring interventions to fit clients' idiosyncracies is most important and have suggested ways of doing this. The point was made that what might work for one client may very well not work for another. In conclusion, I would encourage therapists to adopt an experimental attitude toward their interventions and to continually monitor the effect of them by requesting feedback from clients as Beck et. al. (1979) advocate. This would help therapists to construct, for each client, a profile of the types of disputing tactics that are effective and the types that prove ineffective.     

Valuing clients' perspective and the effects on the therapeutic alliance: a randomized controlled study of an adjunctive instruction

The patterns of growth and development of the therapeutic alliance over the course of therapy have been of continued interest to psychotherapy researchers. The purpose of this study was to investigate whether a simple institutional metacommunication intervention with clients had an effect on the development of the alliance. This adjunctive instruction involved inviting therapy clients to take a proactive role in their treatment by encouraging feedback to their therapist about various aspects of the therapy process. In this randomized controlled study (N = 94), clients were assigned to 1 of 2 conditions: (a) an institutional adjunctive instruction condition in which patients were contacted by clinic personnel at the beginning of the remediation phase (Session 5) and encouraged to take a proactive role in their treatment and (b) a control condition that contained no institutional adjunctive instruction. Between-condition differences in the alliance were tested, controlling for baseline influences and the early therapeutic alliance. Clients' postsession reports from Sessions 1 to 24 indicated that the adjunctive instruction increased the alliance over the course of therapy vis-à-vis the control condition. The adjunctive instruction appeared to have fostered clients' evaluation of their therapists' interest in their welfare. The results indicate that interventions, even brief or subtle, can produce lasting benefits in the alliance when targeted at specific psychological processes. Systematic metacommunication from the institutional level appeared to reinforce clients' therapeutic alliance with their therapists in individual treatment.     

An innovative cognitive strategy to assist problem gamblers

The clinical and research literature suggests that cognitive and behavioural therapies are particularly helpful in assisting clients overcome problem gambling behaviour. Several articles have described the efficacy of a range of cognitive interventions, especially provision of information regarding rates of return and the odds of games and the exploration of irrational beliefs and myths and misconceptions regarding gambling activity. This paper describes in detail an innovative cognitive strategy which focuses on problem gambling clients' financial status. The strategy incorporates the use of illustrations, generally using a whiteboard, to highlight how problem gambling behaviour negatively impacts on financial wealth over time. Step by step instructions are provided, together with illustrations, to allow clinicians to incorporate the strategy in treatment with their own clients.     

Clients' pretreatment counseling expectations as predictors of the working alliance

Because research suggests that counseling expectations are malleable and that alliance ratings predict clinical outcomes, the relationship between this pretreatment client characteristic (expectations) and the quality of the alliance early in treatment deserves further attention. This study examined the relationships between 57 clients' pretreatment role expectations and 3rd-session client-rated alliance in a naturalistic setting. Prior to intake, clients completed the Expectations About Counseling-Brief Form (H. E. A. Tinsley, 1982), and clients completed the Working Alliance Inventory-Short Form Revised (R. L. Hatcher & J. A. Gillaspy, 2006) following the 3rd therapy session. Results indicate that clients' expectations for personal commitment predicted the task, bond, and goal dimensions of the alliance. Expectations for facilitative conditions and counselor expertise did not predict clients' perceptions of the alliance. Clinical implications and research directions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Clients' treatment expectations at a community mental health center

Clients' expectations about mental health care, particularly differences in these expectations as a function of social class, and the relationship of discrepancies between expectations and perceptions to treatment outcome, is examined in this study with 317 Caucasian clients. In contrast to the majority of studies, no differences in treatment expectations relating to clients' social class, sex, or marital status were found. Nor were discrepancies related to course or outcome of therapy. Discussion focuses around explanation and interpretation of these findings. Particularly relevant is the need to determine the extent to which nonusers in the community share the attitudes and expectations of clients.     

Client experience of gender in therapeutic relationships: an interpretive ethnography.

The purpose of this study was to explore clients' experiences of gender in therapeutic relationships in order to inform therapists of critical issues from clients' perspectives. To capture clients' views, the researchers chose an interpretive ethnographic design that used unstructured, collaborative interviews with clients who had worked with both female and male therapists. The interviews were analyzed using procedures developed by Kvale (1996), who emphasizes the importance of including the client's voice in data gathering, analysis, and final presentation. The results were reviewed with the clients to insure accurate presentation of their views. The final results were organized into six themes: client-therapist connection, male therapists, female therapists, topics discussed, effectiveness, and confounding factors. Researchers discuss the implications of gender-stereotyped behavior in therapy, the relationship between therapist gender and therapeutic alliance, and recommendations for practicing gender-sensitive therapy.     

Collaboration and a Self-Help Orientation in Therapy with Suicidal Clients

Working with suicidal clients historically has placed a heavy burden of responsibility on the therapist for a successful outcome. This orientation generally has left clinicians feeling stressed and in need of controlling their clients' behavior; clients, in turn, often have developed unrealistic expectations of therapy or resistance of the therapist's interventions. In this context, the chance for a potentially valuable collaboration between client and therapist is often lost. This paper builds on previous work that has introduced the notion of a collaborative working relationship with suicidal clients. It is argued that the therapeutic process ideally should not only utilize the therapist's knowledge and skills in treating suicidal clients, but also cultivate self-efficacy by encouraging the client to adopt a self-help orientation to therapy. Several general principles of a collaborative/self-help orientation to working with suicidal clients are discussed and a variety of specific therapeutic strategies consistent with this orientation are described.     

The Effect of Therapist–Client Racial Similarity on Client Satisfaction and Therapist Evaluation of Treatment

Client satisfaction with therapy services and therapists' perspectives of treatment evaluation were examined in relation to therapist and client racial similarity. Secondary data from a university marriage and family therapy clinic located in the southeast was used to pair therapists and clients on racial similarity or difference. Statistical analyses revealed no major differences in clients' perceptions of satisfaction based on similarity to therapists' race. Therapists indicated some differences in their perceptions of the success of services provided to clients based on similarity to client's race. Implications for researchers, clinicians, and educators are included.     

Helping construct desirable identities: a self-presentational view of psychotherapy

The author reviews the research demonstrating not only that clients withhold personal information and reactions from their therapists but also that such discretion is associated with positive therapy process ratings and outcomes. These results run counter to traditional approaches to psychotherapy, which demand a high degree of openness from clients. These puzzling findings can be explained by conceptualizing psychotherapy as a self-presentational process, wherein clients come to benefit from therapy by perceiving that their therapists have favorable views of them. Creating these favorable impressions can involve clients' hiding some undesirable aspects of themselves from their therapists. The author offers findings from the psychotherapy and social-psychology literatures in support of this view and makes suggestions concerning what clients and therapists might optimally reveal in therapy.     

Incidence of critical events in professional practice: a statewide survey of psychotherapy providers

The goal was to tabulate the incidences of clients' suicide, attack by a client, and sexual contact with clients in an Alaskan sample of masters and doctoral-level psychotherapy providers (excluding psychiatrists) and to assess which, if any, demographic or professional characteristics were associated with each critical event. Results from 151 respondents (response rate 43.5%) indicated that 42.7% of providers had experienced at least one client's suicide, 28% had been physically attacked by a client, 4% reported having had sexual contact with a then current client, and 6% reported sexual contact with a former client. Areas for research are outlined, specifically the importance of using methods other than surveys and exploring variables other than standard demographic data.     

Individual differences in client reactions to counseling and psychotherapy: A challenge for research

Recent research is reviewed that suggests extensive individual differences in how clients respond to therapeutic interventions and therapist response modes. Three research strategies are proposed as parts of a therapeutic science that aims at both nomothetic generalizations and explications of idiographic meanings, while simultaneously confronting conceptual and methodological complexities arising from client individual differences in response to counseling.     

Organizing awareness and increasing emotion regulation: revising chair work in emotion-focused therapy for borderline personality disorder

Emotion-focused therapy (EFT) is an empirically supported treatment that may have potential as a stage-two treatment for borderline personality disorder (BPD). Specific aspects of BPD--the tendency to experience fluctuating self-states; weakness in meta-cognitive or reflective functioning; and the tendency for self-states to be organized by presently occurring interpersonal processes--present challenges to applying some EFT interventions with this population. In particular, even within a highly attuned, validating and accepting empathic relationship, clients with BPD may have difficulty with the usual manualizations of chair work interventions. This is because these interventions often employ polarization and intensification of experience in order to activate adaptive alternate emotional resources and self organizations. For the client with borderline personality disorder, these interventions may be counter-productive, emotionally dysregulating and disorganizing. EFT chair work, however, also has the potential to provide structure to the borderline clients experience of self, to stimulate metacognitive awareness, provide an alive experience of the process of polarization, attenuate emotional activation, and increase the experience of self-coherence. This article describes the development of stepwise approximations of EFT two-chair intervention for self-critical splits. It outlines potential stages of two-chair work as well as intervention principles important for productive chair work with this population. The EFT change principles of awareness, expression regulation, reflection, transformation, and corrective experience still centrally apply. However, several additional strategies are discussed to scaffold clients' capacity to both experience and regulate emotion.     

Healthy and unhealthy forms of religiousness manifested by psychotherapy clients: An empirical investigation

This study investigated whether 49 Mormon psychotherapy clients and 51 Mormon nonclients differed on a number of religious and psychological variables. The data were analyzed using analysis of covariance, controlling for social desirability, education level, and occupation status. Clients scored higher than nonclients on shame and lower on existential well-being. There were no significant differences between clients and nonclients on religious orientation, religious wellbeing, moral reasoning, and guilt. Females scored much higher on guilt, and female clients scored much higher on shame; there were no other gender differences. Subjects showed a preference for Stage 4 moral reasoning, and 92% were intrinsically motivated in their religious worship. The psychotherapy clients' religious beliefs and motivations appeared healthy and functional and could be an asset during therapy. The clients manifested some psychological issues which could predispose them to unhealthy reactions to some of the doctrines and influences of their religion. The gender differences observed were also discussed.     

Clients' attributions of recalled important or helpful events in a counseling interview

Clients' causal explanations for recalled important or helpful events between those of early and of late sessions of counseling interview have been examined. We predicted that (a) for clients' recalled important or helpful events, there will be more internal attribution in late than in early sessions and (b) clients' evaluation of counseling sessions would be positively related to their internal attribution of the recalled important or helpful events. Data were generated from 84 sessions of therapy, with 12 counselor-client dyads conducting seven sessions of therapeutic interviews each. Immediately after each interview, clients were requested to recall and explain the most important or helpful events that happened during the session. Clients' causal explanations of the events were analyzed by two trained judges. Results showed no statistically significant differences in frequencies of internal attribution. Similarly, internal attribution did not covary with clients' evaluation of counseling sessions. The implications of the results are discussed.