Early psychotherapeutic empathy, alliance, and client outcome: Preliminary evidence of indirect effects.

The association between psychotherapeutic empathy and client outcome is well established, yet the mechanisms underlying this association remain poorly understood. We hypothesized that early experiences of empathy influence outcome through the working alliance. To test this hypothesis, we used archival data collected from 56 clients (mean [M] age = 19.5 years, 83.9% female, 76.8% White) who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments and then received five sessions of evidence-based psychotherapy. Therapists (M age = 26.0 years, 50% female, 100% White) were six students in a clinical psychology PhD program. Results of bootstrap analyses were consistent with the idea that early experiences of empathy strengthen the alliance (specifically the goals and tasks facets), which in turn facilitates improvements in depressive symptoms and psychological well-being. While preliminary, these results implicate a specific pathway of change in the treatment of depression.

Does the supervisor's teaching style influence the supervisee's learning prescribed techniques?

OBJECTIVES: This study examined the directive and non-directive supervisors' instructional styles, supervisees' interactive communications within supervision sessions as well as the relative success of supervisees' learning to apply specific techniques within psychotherapy. METHOD: The developers of Time-Limited Dynamic Psychotherapy (TLDP) provided the supervised training for 16 therapists as part of the "Vanderbilt II" psychotherapy project. Supervision sessions were rated for supervisors' adherence to TLDP content. Both supervisors and supervisee were rated for classroom interactive behaviors of "initiation" speech (e.g., introducing ideas) and "responsive" speech (e.g., amplifying the other speaker's topic). The third therapy session was targeted for discussion within supervision. Therapy sessions immediately before and after supervision were rated on TLDP adherence. RESULTS: One of the supervisors (Supervisor A) was found to use an instructional style of relatively more initiation-based speech, whereas the other (Supervisor B) used more response-based speech. Technical adherence for supervisees of Supervisor A was significantly higher than those assigned to Supervisor B. Supervisees' initiation-based speech during supervision predicted less use of TLDP techniques in the therapy session after supervision. Supervisors' interactive style was not associated with therapy adherence. CONCLUSIONS: Relatively more directive and structured supervision may influence the acquisition and use of manual-prescribed therapy techniques.

A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome.

OBJECTIVE: This study examined whether therapists' facilitative interpersonal skills (FIS) would prospectively predict the outcomes of therapies that occurred more than one year later. METHOD: Therapists were 44 clinical psychology trainees who completed the FIS performance task and a self-reported measure of social skills in the initial weeks of their training. In the FIS task, prospective therapists were presented with a standard set of videos portraying clients in therapy. Verbal responses to these therapeutic simulations were recorded and then rated by trained coders. More than one year later, the therapists began providing psychotherapy to clients in a psychology clinic. Clients completed a symptom measure before each therapy session. RESULTS: Using multilevel modeling, it was found that therapist FIS significantly predicted client symptom change. That is, higher FIS therapists were more effective than lower FIS therapists. However, subsequent analyses showed that this FIS effect was not uniform across all therapy durations; specifically, higher FIS therapists were more effective than lower FIS therapists over shorter durations (e.g., ≤8 sessions) but did not differ from lower FIS therapists in effectiveness for the small percentage of therapies that were longer-term (e.g., >16 sessions). CONCLUSIONS: Therapists' interpersonal characteristics may influence client progress in therapy.

Clients' pretreatment role expectations, the therapeutic alliance, and clinical outcomes in outpatient therapy.

OBJECTIVES: The present study examined the associations between pretreatment role expectations, working alliance, and therapy outcome. A mediational model was hypothesized wherein the therapeutic alliance mediates the relationship between clients' pretreatment role expectations and psychotherapy outcome. METHOD: Sixty-eight clients completed the Expectations About Counseling-Brief Form at pretreatment, the Working Alliance Inventory-Short Form Revised after Session 3, and the Outcome Questionairre-45 at both pretreatment and the final session. RESULTS: All 3 expectations factors (Personal Commitment, Facilitative Conditions, Counselor Expertise) were related to the alliance. However, only expectations for Counselor Expertise were related to outcome, although this relationship did not appear to be mediated by the alliance. CONCLUSIONS: Suggested research directions, clinical implications, and study limitations are discussed.

Factorial and predictive validity of the expectations about counseling-brief (EAC-B) with clients seeking counseling.

Our goals in this study were to define the factorial structure of treatment expectations for a sample of treatment-seeking clients and to understand the predictive validity of those expectations. A sample of 353 clients who were about to begin counseling at a university counseling center or at a psychology clinic completed the Expectations About Counseling-Brief form (EAC-B) and then completed measures of the working alliance, session quality, and symptom distress throughout the treatment. Principal components analysis resulted in a 3-factor solution of EAC-B treatment expectations, which accounted for 48.0% of the total variance. Consistent with previous research, the 3 factors were labeled client involvement, counselor expertise, and facilitative conditions. Among clients with prior treatment experience, a meaningful 4-factor solution was achieved; it involved the counselor expertise factor being split into 2 subgroups labeled "counselor directive helping" and "counselor subjective expertise." The predictive validity of these 3 factors found that each of the 3 EAC-B factor-derived scales, as well the total EAC-B score, was predictive of clients' (but not therapists') ratings of the therapeutic alliance as well as ratings of session depth, smoothness, and positivity. Client involvement, facilitative conditions, and EAC-B Total score (but not counselor expertise) predicted therapy outcome.

The influence of supervision on manual adherence and therapeutic processes.

OBJECTIVES: To identify the effectiveness of psychotherapy supervision on therapists' immediate (next session) and long-term (1 year) adherence to time-limited dynamic psychotherapy (TLDP). METHOD: Sixteen therapists from the Vanderbilt II psychotherapy project were assigned new cases in pretraining, training, and booster/posttraining year-long cohorts. Technical adherence to the manual, as well as general therapeutic relational processes, were rated for clinical supervisory sessions in which the third therapy session was discussed. The therapy sessions immediately before and after the supervisory sessions were also rated for technical adherence and relational processes. RESULTS: Postsupervision adherence increased from the presupervision session during the training cohort. In supervision, therapists' discussion of techniques and strategies from the manual in supervision was significantly related to technical adherence in the session prior to (but not after) supervision. However, supervisors' discussion of specific techniques predicted therapists' total technical adherence in the therapy session after (but not before) supervision. In terms of the type of techniques, supervisors' influenced postsupervision therapy adherence on TLDP's unique approach to formulation, the cyclical maladaptive pattern, but did not influence technical adherence on the therapeutic relationship. CONCLUSIONS: In supervision, therapists tend to focus on how they adhered to techniques from the previous session, whereas supervisors' comments about specific techniques predicted how the therapist would adhere to techniques in the next therapy session. The findings provide support for the immediate effects of supervision in shaping therapist techniques as well as highlighting the challenges of altering common relational processes through technical training.

Working alliance as a mediator of client attachment dimensions and psychotherapy outcome.

Studies that employ multidimensional attachment measures to explore the impact of attachment style on psychotherapy process and outcome are virtually absent in the literature. Further, the role of the working (therapeutic) alliance as a mediator of the influence of attachment on treatment outcome has not been formally investigated. In order to address these gaps in the research, archival data from 66 psychotherapy clients treated at a university graduate program training clinic were used to examine the influence of three adult attachment dimensions (Comfort with Closeness, Comfort Depending on Others, and Rejection Anxiety) on the therapeutic alliance and outcome, as well as to assess whether the alliance mediates the relationship between attachment and therapy outcome. Both Comfort with Closeness and Comfort Depending on Others were significantly related to alliance and outcome, whereas Rejection Anxiety was not significantly related to either variable. Alliance was a significant partial mediator of the effect of Comfort with Closeness on outcome. The results suggest that multidimensional measures of attachment capture important influences on alliance and psychotherapy and that Comfort with Closeness promotes successful outcome by virtue of its influence on alliance.

Therapist effects: facilitative interpersonal skills as a predictor of therapist success.

This study examined sources of therapist effects in a sample of 25 therapists who saw 1,141 clients at a university counseling center. Clients completed the Outcome Questionnaire-45 (OQ-45) at each session. Therapists' facilitative interpersonal skills (FIS) were assessed with a performance task that measures therapists' interpersonal skills by rating therapist responses to video simulations of challenging client-therapist interactions. Therapists completed the Social Skills Inventory (SSI) and therapist demographic data (e.g., age, theoretical orientation) were available. To test for the presence of therapist effects and to examine the source(s) of these effects, data were analyzed with multilevel modeling. Of demographic predictor variables, only age accounted for therapist effects. The analysis with age, FIS, and SSI as predictors indicated that only FIS accounted for variance in outcomes suggesting that a portion of the variance in outcome between therapists is due to their ability to handle interpersonally challenging encounters with 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).