Gay and bisexual male clients' perceptions of counseling: the role of perceived sexual orientation similarity and counselor universal-diverse orientation

A recurring question in multicultural counseling is whether client-counselor similarity on sociodemographic characteristics benefits counseling. A related issue is how counselor orientation to diversity relates to counseling process and outcome, both as a main effect and in interaction with counselor-client sociodemographic match. This cross-sectional study investigated these questions in relation to gay and bisexual male clients' counseling experiences by examining clients' perceived similarity to their counselor in sexual orientation, as well as counselors' self-reported orientation to diversity (assessed in terms of level of universal-diverse orientation [UDO]). Data were from 83 male-male client-counselor dyads recruited from lesbian/gay/bisexual-affirming counseling practices, where clients identified as gay or bisexual and counselors identified as gay, bisexual, or heterosexual. Counselor UDO was positively and uniquely associated with client ratings of the working alliance, session depth, and session smoothness. Perceived sexual orientation similarity was not directly related to any of the counseling-related criterion variables. Moreover, when counselors reported low levels of UDO, perceived similarity was negatively associated with the client-rated alliance and perceived improvement. Client religious commitment-a control variable in all analyses--was uniquely and negatively associated with client ratings of perceived improvement in counseling.     

Real relationship,working alliance,transference/countertransference and outcome in time-limited counseling and psychotherapy

Six client/therapist dyads (three therapists each working with two clients) were studied to determine how the real relationship unfolds over the course of time-limited treatment and how this unfolding relates to the development of the client/therapist working alliance, client transference, and therapist countertransference. We also examined how these indices of the relationship fluctuate as a function of treatment outcome. Results indicate that in general for all six dyads, therapists’ and clients’ ratings of the real relationship and working alliance were strong throughout treatment. However, patterns of real relationship and working alliance over the course of treatment varied between dyads categorized as more vs. less successful. Therapists’ countertransference was low, as was client transference, but differences in ratings were evident when the dyads were classified by outcome.     

The helping alliance and premature termination

The study was conducted to determine the relationship between strength of the helping alliance and type of client termination (premature or with mutual knowledge of client and counselor). Participants were 102 client-counselors dyads at a university counseling center. After an average of 8 sessions, clients and couneselors completed Alexander & Luborsky's (1986) Helping Alliance Questionnaires. Clients terminated after an average of 19 sessions. Clients who later terminated with mutual knowledge of their counselors gave significantly higher strength of helping alliance ratings than did clients who later terminated unilaterally and prematurely. Counselors' ratings of strength of helping alliance were only modestly related to clients' ratings and unrelated to type of client termination.     

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.     

Counseling Canadian Indigenous Peoples: The Therapeutic Alliance and Outcome

The aim of this study was to determine whether client therapeutic alliance ratings and client symptom severity were predictors of counseling outcomes among Canadian Indigenous clients. Participants included 179 Canadian Indigenous clients who completed an outcome measure at the 1st and last sessions and an alliance measure at both the 2nd and 3rd sessions. Results indicated that higher client alliance ratings at Sessions 2 and 3 and baseline client symptom severity were significant predictors of outcome. El objetivo de este estudio fue determinar si las valoraciones del cliente de la alianza terapéutica y la severidad de los síntomas del cliente fueron indicadores de los resultados de la consejería entre clientes indígenas canadienses. Los participantes incluyeron 179 clientes indígenas canadienses que completaron una medida de resultados en la primera y última sesión, además de una medida de la alianza en la segunda y tercera sesión. Los resultados indicaron que unas valoraciones del cliente más altas de la alianza en las sesiones 2 y 3 y la severidad preliminar de los síntomas del cliente fueron indicadores significativos del resultado.     

The Effect of Nonverbal Skills Training on Counselor Trainee Nonverbal Sensitivity and Responsiveness and on Session Impact and Working Alliance Ratings

Counselor trainees (N = 18) were randomly assigned to treatment (nonverbal sensitivity) or control (empathy training) conditions. Trainees saw a recruited client before (first 2 weeks) and after (last 2 weeks) a 15-week counseling methods class. Trainees rated their sensitivity to nonverbal behaviors, counseling self-efficacy, and the extent to which they focused on client nonverbal behavior. Clients filled out the Session Evaluation Questionnaire and Working Alliance Inventory at pre- and posttesting. Trained raters viewed videotapes of the counseling sessions and rated the extent that counselors focused on client nonverbal behavior. As hypothesized, trainees in the treatment condition, when compared with those in the control condition, increased their focus on client nonverbal behaviors. In addition, clients of treatment condition counselors showed significant differences in working alliance ratings. Trainees in both conditions increased their rating of nonverbal sensitivity and self-efficacy from pre- to posttesting. Implications are discussed.     

Experiences of Christian clients in secular psychotherapy: a mixed-methods investigation

Eleven Christian former clients were sampled to uncover factors contributing to positive versus negative experiences in secular psychotherapy. The qualitative results indicated that although many participants felt hesitant to discuss their faith due to uncertainty about their therapists' reactions, positive experiences were reportedly facilitated by therapists' openness to understanding clients' faith and giving clients control over how much, when, and how to discuss their religious beliefs and practices. Dissatisfied clients reported that their therapists expressed opposing religious views or avoided discussing religious or spiritual issues. Participants' self-reports of the working alliance and of their therapists' expertness, attractiveness, and trustworthiness were largely consistent with the narrative data, but the alliance scores were somewhat more sensitive to participants' positive versus negative evaluations of their therapy experience. That is, several participants rated their therapists' personal characteristics quite favorably but indicated poor agreement with their therapists on the goals or tasks of treatment.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

Session helpfulness and session evaluation in short‐term counselling

The relationship between perceived session helpfulness and session evaluation was examined in 11 dyads during eight sessions of short‐term counselling. Results based on the Session Evaluation Questionnaire (Stiles, 1980) showed that, for clients, while depth, arousal, and positivity correlated with perceived session helpfulness, only depth and positivity entered a stepwise regression, yielding a multiple correlation of 0.76. For counsellors, while depth and positivity correlated with session perceived helpfulness, only depth entered the stepwise regression analysis, with a correlation of 0.70. Session depth also consistently correlated with change in perceptions of helpfulness from one session to another. Clients had higher depth scores for sessions that both participants rated as helpful. They had lower depth scores for sessions rated as less helpful by both participants or for sessions where participants disagreed in their helpfulness ratings. The centrality of counselling depth in affecting experiences of counselling helpfulness is discussed.     

Predictors and consequences of sudden gains in transdiagnostic cognitive-behavioural therapy for anxiety disorders

Sudden gains—substantial stable symptom improvements between consecutive therapy sessions—are a common phenomenon. As condensed points of change, examination of sudden gains can provide insight into mechanisms of therapeutic change. This study investigated the association between sudden gains and cognitive change, therapeutic alliance, and/or client engagement in transdiagnostic group cognitive-behavioural therapy for anxiety disorders. Of 58 treatment initiators, 21% (n = 12) exhibited a sudden gain. Consistent with previous research, sudden gainers demonstrated significantly greater pre- to post-treatment symptom improvement than non-sudden gainers. Observational coding of therapy sessions found that sudden gains were associated with elevated levels of cognitive change and client engagement in the pre-gain session, and elevated levels of cognitive change and therapeutic alliance in the post-gain session. However, these results varied by use of within- and between-subject control comparisons, highlighting the value using a dual control methodology. In context of previous research, the results on cognitive change replicate previous findings in depressive populations, and clarify mixed findings in anxiety populations. The results on therapeutic alliance replicate previous findings for the first time in an anxiety sample, although the between-subject control comparisons revealed complexity previously undetected. This study was also the first to investigate and thus establish the relation between client engagement and sudden gains.     

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.     

Counselor Sex Role Orientation,Flexibility, and Working Alliance Formation

The authors examined the hypothesized relationship among counselor androgyny, counselor flexibility, and the establishment of client-rated working alliances. In Study 1, 41 counseling students completed the Bem Sex-Role Inventory (BSRI; Bem, 1981a) and the Counselor Behavior Analysis Inventory (Gabbard, Howard, & Dunfee, 1986). Contrary to the hypothesis, there was no relationship between androgyny and counseling flexibility. In Study 2, 42 counseling students completed the BSRI and videotaped counseling sessions with a recruited client. Analyses revealed a significant relationship between counselor flexibility and client ratings of working alliance, but no relationship between counselor androgyny and counselor flexibility. Research and clinical implications are discussed.     

Physical therapists' nonverbal communication predicts geriatric patients' health outcomes

Two studies explored the link between health care providers' patterns of nonverbal communication and therapeutic efficacy. In Study 1, physical therapists were videotaped during a session with a client. Brief samples of therapists' nonverbal behavior were rated by naive judges. Judges' ratings were then correlated with clients' physical, cognitive, and psychological functioning at admission, at discharge, and at 3 months following discharge. Therapists' distancing behavior was strongly correlated with short- and long-term decreases in their clients' physical and cognitive functioning. Distancing was expressed through a pattern of not smiling and looking away from the client. In contrast, facial expressiveness, as revealed through smiling, nodding, and frowning, was associated with short- and long-term improvements in functioning. In Study 2, elderly subjects perceived distancing behaviors of therapists more negatively than positive behaviors.     

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.     

Counseling dropout relative to client attractiveness,disturbance, and expected number of sessions

Participants were 12 counseling center psychologist and thir 257 college-student clients. Immediately after intake, clients indicated whether or not they would make an additional appointment, their reasons for not making another appointment, and the estimated number of sessions they would attend. Counselors rated clients' attractiveness and disturbance and estimated the number of sessions they would have with each client. Clients who did not make a second appointment were generally satisfied with the help they received in one session. Client estimates were more predictive than counselor estimates of actual number of sessions. Relative to less attractive and disturbed clients, more attractive and disturbed clients made and kept post-intake appointments.     

工作同盟和领悟对咨询效果的影响

为了解短程咨询中工作同盟和领悟对咨询效果的影响,以12个个案94次会谈为对象,考察工作同盟、领悟分别与会谈效果、治疗效果的关系,并考察二者共同作用于效果的方式。结果表明,咨访双方评定的工作同盟都可以正向预测会谈效果,但不能预测治疗效果;领悟与会谈有效性正相关,领悟正向预测治疗效果;咨询师评定的同盟的三个维度以领悟为中介影响其对会谈效果的评价。     

Emotion in an alliance rupture and resolution sequence: A theory‐building case study

Aims: Alliance rupture and resolution processes are occasions for the client to have his or her core interpersonal patterns activated in the here and now of the therapy and to negotiate them with the therapist. So far, no studies have been conducted on emotional processing, from a sequential perspective using distinct emotion categories, in alliance rupture and resolution therapy sessions. This is the objective of this theory‐building case study. Method: This client underwent a 34‐session long, psychodynamic psychotherapy within the context of an open trial. An alliance rupture‐resolution sequence of two subsequent sessions, along with a third control session, was selected from this case and these sessions were rated using the Classification of Affective‐Meaning States (CAMS), an observer‐rated method to classify distinct emotions, according to current emotion‐focused models. Results: The results indicate that the rupture session was associated, above all, with core maladaptive fear, evoked in the actual here and now of the therapeutic relationship, whereas the resolution session was associated with the expression and experience of adaptive hurt as regards biographical issues of the client. Discussion: These results are discussed with regard to the alliance rupture and resolution model and the exploration of integrating client's emotional processing in the model.     

Exploring actor-partner interdependence in family therapy: whose view (parent or adolescent) best predicts treatment progress?

Predictions of family therapy outcome consistently vary depending on which client rates the alliance. We used the actor-partner interdependence model (Kenny, Kashy, & Cook, 2006) to test the interdependence of parents' and adolescents' ratings of alliance, session depth/value, and improvement-so-far after Sessions 3, 6, and 9. Initial analyses found trivial between-therapists variance; therefore, a 3-level hierarchical model partitioned the variance in these variables into between families, between family members, and between session components. For alliance and session depth, results showed a significant parent actor effect and a significant adolescent partner effect. Specifically, when parents saw a stronger alliance, they also saw the session as more valuable, but when adolescents saw a stronger alliance, their parents saw the session as less valuable. Both the parents' and the adolescents' improvement scores showed significant linear growth over time, and adolescents' alliance ratings were positively associated with their own and their parents' views of therapeutic progress.     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

Transference,Insight, and the Counselor's Intentions During a Counseling Hour

The interactive effects of transference and client insight on session quality, and the relationship between transference and counselor intentions, were studied within the context of a single counseling session. Thirty-eight experienced counselors audiotaped one counseling session and rated their intentions for each intervention. Counselors also rated transference, insight, and session quality. As hypothesized, when transference was high, client insight was positively related to session quality. Furthermore, negative transference was related to several counselor intentions. Negative transference may signal counselors to focus on the relationship and underlying client issues, and to avoid structuring and directing behavior change.