UBC Theses and Dissertations

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UBC Theses and Dissertations

A study of the working alliance in psychotherapy Adler, Jean Vera 1988

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STUDY OF THE WORKING ALLIANCE IN PSYCHOTHERAPY by JEAN VERA ADLER B . A . , U n i v e r s i t y Of B r i t i s h C o l u m b i a , 1966 M . B . A . , York U n i v e r s i t y , 1976 M . A . , U n i v e r s i t y Of B r i t i s h C o l u m b i a , 1984 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION in THE FACULTY OF GRADUATE STUDIES C o u n s e l l i n g P s y c h o l o g y We a c c e p t t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA May 1988 © Jean Vera A d l e r , 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Counselling Psychology The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date May 26 th , 19 8 8 i i A b s t r a c t O r i g i n a l l y i d e n t i f i e d by Freud (1912, 1913), the t h e r a p e u t i c or working a l l i a n c e between c l i e n t and t h e r a p i s t has in the l a s t decade been proposed as the common f a c t o r tha t c o u l d account f o r p s y c h o t h e r a p e u t i c outcome r e g a r d l e s s of the t h e o r e t i c a l o r i e n t a t i o n s a n d / o r t e c h n i q u e s employed by t h e r a p i s t s . Psychotherapy r e s e a r c h e r s ( A l l e n , Newsom, Gabbard , & Coyne, 1984; H a r t l e y & S t r u p p , 1983; H o r v a t h , 1981; L u b o r s k y , 1976; M a r z i a l i , Marmar, & K r u p n i c k , 1981) have deve loped v a r i o u s s c a l e s f o r measur ing the a l l i a n c e and have q u i t e c o n s i s t e n t l y demonst ra ted an a l l i a n c e - o u t c o m e r e l a t i o n s h i p . The Working A l l i a n c e Inventory (Horva th , 1981, 1982) i s the f i r s t s e l f - r e p o r t ins t rument deve loped to measure the a l l i a n c e c o n s t r u c t . I t i s based on the theory proposed by B o r d i n (1975, 1979) tha t the a l l i a n c e i s the product of the s y n e r g i s t i c c o m b i n a t i o n of th ree h i g h l y r e l a t e d components—goa l m u t u a l i t y , agreement r e g a r d i n g r e l e v a n t t a s k s and r e s p o n s i b i l i t i e s , and the development of p e r s o n a l bonds or a t t a c h m e n t s . In the p r e s e n t s t u d y , the Working A l l i a n c e Inventory was a d m i n i s t e r e d a f t e r each of the f i r s t f i v e , the t e n t h , and the f i n a l s e s s i o n s of 44 psychotherapy c a s e s . It was found to be s t a t i s t i c a l l y s i g n i f i c a n t l y r e l a t e d to outcome by the t h i r d to f i f t h s e s s i o n on four of the s i x outcome measures employed. Another s e l f - r e p o r t measure, the H e l p i n g A l l i a n c e  Q u e s t i o n n a i r e (Luborsky , M c L e l l a n , Woody, O ' B r i a n , & A u e r b a c h , 1985) was a l s o a d m i n i s t e r e d at the t h i r d s e s s i o n , as w e l l as measures of t h e r a p i s t empathy, e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s . The H e l p i n g A l l i a n c e Q u e s t i o n n a i r e , which i s based on a c l i n i c a l l y - d e r i v e d d e f i n i t i o n of the a l l i a n c e , was found to be s t a t i s t i c a l l y s i g n i f i c a n t l y r e l a t e d to outcome on a l l s i x of the measures employed. S p e c u l a t i o n s c o n c e r n i n g the d i f f e r e n t i a l p a t t e r n s of r e s u l t s w i th the two a l l i a n c e measures a re o f f e r e d . i v T a b l e of Conten ts A b s t r a c t i i L i s t of T a b l e s v i i i Acknowledgement x Chapter I INTRODUCTION 1 1 . OVERVIEW 1 2. CURRENT PROPOSITIONS ABOUT THE WORKING ALLIANCE 4 3. DEFINITION OF TERMS 6 4. RESEARCH QUESTIONS 10 Chapter II REVIEW OF LITERATURE 11 1. THEORETICAL DEVELOPMENT OF THE ALLIANCE CONCEPT 11 1.1 P s y c h o a n a l y t i c F o r m u l a t i o n s 11 1.2 Other C o n c e p t u a l i z a t i o n s Of The R e l a t i o n s h i p 13 2. EMPIRICAL RESEARCH ON THE ALLIANCE 17 2.1 The Penn Research Group 17 2.2 The V a n d e r b i l t Research Group 21 2.3 The L a n g l e y P o r t e r Research Group 24 2.4 The Menninger Research Group 25 2.5 The B r i t i s h Columbia Research Group 27 2.6 The Involvement Dimension 30 3. SIGNIFICANCE OF THE PRESENT STUDY 31 4. RESEARCH HYPOTHESES 33 Chapter III METHODS AND PROCEDURES 37 1. DESIGN OF THE STUDY 37 2. POPULATION 38 3. DATA COLLECTION AND PREPARATION 40 4. RELATIONSHIP MEASURES 42 4.1 Working A l l i a n c e Inventory 42 4.2 C l i e n t Involvement S c a l e 45 4.3 R e l a t i o n s h i p Inventory 46 4.4 C o u n s e l o r Ra t ing Form 47 4.5 H e l p i n g A l l i a n c e Q u e s t i o n n a i r e 48 5. OUTCOME MEASURES 49 V 5.1 Ta rge t Compla in ts Improvement 49 5.2 Symptom C h e c k l i s t - 9 0 50 5.3 S e l f - E s t e e m Index 51 5.4 Inventory Of I n t e r p e r s o n a l Problems 52 5.5 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e 53 5.6 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e 54 5.7 T h e r a p i s t Demographic Data Sheet 54 Chapter IV RESULTS 56 1. RELATIONSHIP OF PERCEIVED ALLIANCE STRENGTH TO OUTCOME 58 1.1 Ta rge t Compla in ts Improvement . . . . 5 8 1.2 S e l f - E s t e e m Index 60 1.3 Symptom C h e c k l i s t - 9 0 60 1.4 Inventory Of I n t e r p e r s o n a l Problems 62 1.5 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e 63 1.5.1 S a t i s f a c t i o n 64 1.5.2 Change 64 1.5.3 Adjustment 64 1.6 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e 65 1.6.1 S a t i s f a c t i o n 65 1.6.2 Change 65 1.6.3 Adjustment 66 2. RELATIONSHIP OF PERCEIVED CHANGE IN ALLIANCE STRENGTH TO OUTCOME 66 3. RELATIONSHIPS OF CLIENT-PERCEIVED THERAPIST EMPATHY, EXPERTNESS, ATTRACTIVENESS, AND TRUSTWORTHINESS TO OUTCOME 68 3.1 R e l a t i o n s h i p Inventory 69 3.2 C o u n s e l o r R a t i n g Form 69 4. RELATIONSHIP OF CLIENT-PERCEIVED ALLIANCE STRENGTH AS MEASURED WITH THE HELPING ALLIANCE QUESTIONNAIRE TO OUTCOME 69 5. RELATIONSHIP OF PERCEIVED CLIENT INVOLVEMENT TO OUTCOME 70 6. RELATIONSHIP OF CONGRUENCE OF CLIENT-PERCEIVED AND THERAPIST-PERCEIVED ALLIANCE STRENGTH TO OUTCOME 73 7. POST HOC ANALYSES 76 7.1 A n a l y s i s Of T h e r a p i s t E f f e c t 76 7.2 A n a l y s i s Of E f f e c t Of T h e o r e t i c a l O r i e n t a t i o n s Of T h e r a p i s t s 77 7.3 C o r r e l a t i o n s Of The WAI With The Outcome Measures At The Seven O c c a s i o n s 79 7.4 R e l a t i o n s h i p s Between The WAI And The Other R e l a t i o n s h i p Measures 81 7.5 I d e n t i f i c a t i o n Of R e l a t i v e S t r e n g t h s Of Outcome v i P r e d i c t o r V a r i a b l e s 84 7.6 Comparison Of WAI Scores Of Completed And Premature ly Terminated Cases 88 Chapter V DISCUSSION 91 1. INTERPRETATION OF FINDINGS 91 1.1 R e l a t i o n s h i p Of P e r c e i v e d A l l i a n c e S t r e n g t h To Outcome 91 1.2 R e l a t i o n s h i p Of P e r c e i v e d Change In A l l i a n c e S t r e n g t h To Outcome 93 1.3 R e l a t i o n s h i p s Of C l i e n t - p e r c e i v e d T h e r a p i s t Empathy, E x p e r t n e s s , A t t r a c t i v e n e s s , And T r u s t w o r t h i n e s s To Outcome 94 1.4 R e l a t i o n s h i p Of C l i e n t - p e r c e i v e d A l l i a n c e S t r e n g t h As Measured Wi th The H e l p i n g A l l i a n c e Q u e s t i o n n a i r e To Outcome 96 1.5 R e l a t i o n s h i p Of P e r c e i v e d C l i e n t Involvement To Outcome 105 1.6 R e l a t i o n s h i p Of Congruence Of C l i e n t - p e r c e i v e d And T h e r a p i s t - p e r c e i v e d A l l i a n c e S t r e n g t h To Outcome . .106 1.7 Post Hoc A n a l y s e s 107 1.7.1 A n a l y s i s Of T h e r a p i s t E f f e c t 107 1.7.2 A n a l y s i s Of E f f e c t Of T h e o r e t i c a l O r i e n t a t i o n s Of T h e r a p i s t s 108 1.7.3 C o r r e l a t i o n s Of The WAIc With The Outcome Measures At The Seven O c c a s i o n s 109 1.7.4 R e l a t i o n s h i p s Between The WAI And The Other R e l a t i o n s h i p Measures 110 1 .7 .5 I d e n t i f i c a t i o n Of R e l a t i v e S t r e n g t h s Of Outcome P r e d i c t o r V a r i a b l e s 111 1.7.6 Comparison Of WAI Scores Of Completed And Premature ly Terminated Cases 111 2. LIMITATIONS OF THE STUDY 111 3. RECOMMENDATIONS FOR FUTURE RESEARCH 115 4. SUMMARY AND CONCLUSION 117 REFERENCES 119 APPENDIX 1 - LETTER OF INITIAL CONTACT TO SOCIAL SERVICE AGENCIES 129 APPENDIX 2 - LETTER OF INITIAL CONTACT TO PRIVATE PRACTITIONERS 130 APPENDIX 3 - THERAPIST CONSENT FORM 131 APPENDIX 4 - CLIENT CONSENT FORM 133 APPENDIX 5 - TARGET COMPLAINTS/DEMOGRAPHIC QUESTIONNAIRE 135 APPENDIX 6 - SYMPTOM CHECKLIST-90 136 APPENDIX 7 - SELF-ESTEEM INDEX 140 APPENDIX 8 - INVENTORY OF INTERPERSONAL PROBLEMS 141 APPENDIX 9 - WORKING ALLIANCE INVENTORY (CLIENT FORM) . . . 1 4 7 APPENDIX 10 - CLIENT INVOLVEMENT SCALE (CLIENT FORM) 152 APPENDIX 11 - WORKING ALLIANCE INVENTORY (THERAPIST FORM) 153 APPENDIX 12 - CLIENT INVOLVEMENT SCALE (THERAPIST FORM) .158 APPENDIX 13 - RELATIONSHIP INVENTORY - EMPATHY SUBSCALE .159 APPENDIX 14 - COUNSELOR RATING FORM 161 APPENDIX 15 - HELPING ALLIANCE QUESTIONNAIRE 164 APPENDIX 16 - STRUPP POSTTHERAPY QUESTIONNAIRE 165 APPENDIX 17 - TARGET COMPLAINTS IMPROVEMENT RATING FORM .168 APPENDIX 18 - THERAPIST DEMOGRAPHIC DATA SHEET 169 APPENDIX 19 - THERAPIST POSTTHERAPY QUESTIONNAIRE 170 APPENDIX 20 - LETTER OF THANKS TO CLIENTS 173 APPENDIX 21 - INSTRUMENT SCORING KEYS 174 APPENDIX 22 - ADDITIONAL INFORMATION COLLECTED ON THE SPQ AND THE TPQ 176 APPENDIX 23 - RELIABILITY ESTIMATES OF THE INSTRUMENTS . . 1 7 9 APPENDIX 24 - DEMOGRAPHIC ANALYSIS OF THE SAMPLE 184 APPENDIX 25 - ESTABLISHMENT OF THE ALLIANCE THROUGH EARLY SESSIONS 186 APPENDIX 26 - MAGNITUDE OF CHANGE ON THE OUTCOME MEASURES 187 v i i i L i s t of T a b l e s 1. I n t e r c o r r e l a t i o n of the WAI S u b s c a l e s at S e s s i o n Three 44 2. R e l a t i o n s h i p s between the WAIc and Targe t C o m p l a i n t s Improvement 59 3. R e l a t i o n s h i p s between the WAIc and the Inventory of  I n t e r p e r s o n a l Problems 62 4. R e l a t i o n s h i p s between the WAI and the SPQ and the TPQ 63 5. R e l a t i o n s h i p of Change in WAIc S t r e n g t h to Outcome . . . 6 7 6. R e l a t i o n s h i p s between Other P r o c e s s Measures and Outcome Measures 68 7. R e l a t i o n s h i p s between the C l i e n t Involvement S c a l e and the Outcome Measures 70 8. Summary of R e l a t i o n s h i p - O u t c o m e C o r r e l a t i o n s 71 9. Z - R a t i o s of D i f f e r e n c e s between WAIc-Outcome C o r r e l a t i o n s and Other R e l a t i o n s h i p Measures-Outcome C o r r e l a t i o n s 72 10. Congruence of the WAIc and the WAIt 73 11. WAIc-WAIt Congruence at the Seven O c c a s i o n s 74 12. C o r r e l a t i o n of Outcome w i th WAIc-WAIt Congruence at the Seven O c c a s i o n s 75 13. A n a l y s i s of T h e r a p i s t E f f e c t on Three Marker Outcome V a r i a b l e s 77 14. A n a l y s i s of E f f e c t of T h e o r e t i c a l O r i e n t a t i o n of T h e r a p i s t on WAIt 78 15. C o r r e l a t i o n s of the WAIc at Seven O c c a s i o n s w i th the Outcome Measures 80 16. R e l a t i o n s h i p s between the WAI and the Other P r o c e s s Measures 82 17. I n t e r c o r r e l a t i o n s of the C l i e n t - R a t e d P r o c e s s Measures 84 18. I n t e r c o r r e l a t i o n s of the Outcome Measures 85 ix 19. R e l a t i v e S t r e n g t h s of Outcome P r e d i c t o r V a r i a b l e s . . . . 8 7 20. Comparison of WAI Scores of Completed and Premature ly Termina ted Cases 89 21 . Means and Standard D e v i a t i o n s of R e l a t i o n s h i p Measures 180 22. R e l i a b i l i t y E s t i m a t e s of the Inst ruments 182 23. C a t e g o r i z a t i o n of T h e r a p i s t s 184 24. C a t e g o r i z a t i o n of C l i e n t s 185 25. I n t e r c o r r e l a t i o n s of the WAIc at the F i r s t F i v e S e s s i o n s 186 26. Magnitude of Change on Symptom C h e c k l i s t - 9 0 and Inventory of I n t e r p e r s o n a l Problems 188 X Acknowledgement I thank the members of my commit tee , D r s . L e s l i e G r e e n b e r g , Rober t To lsma , D a n i e l Per lman , and Robert C o n r y , f o r t h e i r c a r e f u l rev iews of my work and f o r t h e i r h e l p f u l s u g g e s t i o n s . I a l s o thank the p s y c h o t h e r a p i s t s and t h e i r c l i e n t s who gave me a c c e s s to t h e i r p e r s o n a l e x p e r i e n c e s i n therapy through the q u e s t i o n n a i r e s they c o m p l e t e d . F i n a l l y , I thank my f r i e n d s and f a m i l y who encouraged me w i t h t h e i r c o n f i d e n c e in my c a p a c i t y to complete t h i s p r o j e c t . 1 I. INTRODUCTION 1. OVERVIEW The concept of a t h e r a p e u t i c or working a l l i a n c e between c l i e n t and t h e r a p i s t r e p r e s e n t s the most c u r r e n t and p r o m i s i n g attempt in psychotherapy p r o c e s s r e s e a r c h to e x p l a i n the r e l e v a n c e of the r e l a t i o n s h i p to t h e r a p e u t i c outcome (Greenberg & P i n s o f , 1986; H a r t l e y & S t r u p p , 1983). I t seems to have s u p p l a n t e d R o g e r s ' (1957) " c o r e " or " n e c e s s a r y and s u f f i c i e n t " c o n d i t i o n s f o r change as a f e r t i l e source of r e s e a r c h and theory (Ge lso & C a r t e r , 1985). A number of s t u d i e s have in recent years begun to r e v e a l the na ture and s i g n i f i c a n c e of the a l l i a n c e (Gomes-Schwartz , 1978; H a r t l e y & S t r u p p , 1983; H o r v a t h , 1981; L u b o r s k y , 1976; M a r z i a l i , 1984; O ' M a l l e y , Suh, & S t r u p p , 1983). The p r e s e n t study has s u b j e c t e d some of the f i n d i n g s of these s t u d i e s to f u r t h e r examinat ion by drawing a sample from a p o p u l a t i o n of r e a l psychotherapy c a s e s conducted in n a t u r a l s e t t i n g s and implement ing an i n t e n s i v e measurement program. There has long been r e c o g n i t i o n tha t the r e l a t i o n s h i p between the person who seeks change , ( i . e . , the c l i e n t ) , and the one who o f f e r s to be a change a g e n t , ( i . e . , the t h e r a p i s t ) , i s an impor tant element of the t reatment s i t u a t i o n r e g a r d l e s s of the t h e r a p i s t ' s t h e o r e t i c a l o r i e n t a t i o n ( B o r d i n , 1975, 1976, 1979; F r a n k , 1971; F r e u d , 1913; R o g e r s , 1957; S t r u p p , 1973). Psychotherapy p r o c e s s r e s e a r c h e r s , a f t e r i n i t i a l l y f o c u s i n g on core c o n d i t i o n s and p r o d u c i n g i n c o n c l u s i v e f i n d i n g s t h e r e , have on ly r e l a t i v e l y r e c e n t l y begun to r e f o c u s away from " s p e c i f i c " , 2 ( i . e . , t e c h n i c a l or o r i e n t a t i o n ) , f a c t o r s and toward " g e n e r a l " or " g e n e r i c " , ( i . e . , r e l a t i o n s h i p ) , f a c t o r s and have begun to e m p i r i c a l l y demonstrate t h e i r importance (Gomes-Schwartz , 1978; L u b o r s k y , S i n g e r , & L u b o r s k y , 1975; S t r u p p & H a d l e y , 1979). Two o ther approaches to e x p l i c a t i n g the impact of the c l i e n t - t h e r a p i s t r e l a t i o n s h i p on t h e r a p e u t i c outcome, Rogers ' (1957) core c o n d i t i o n s and s o c i a l i n f l u e n c e t h e o r y , have a l s o been e m p i r i c a l l y demonstrated to have some r e l a t i o n s h i p to c l i e n t change . Rogers h y p o t h e s i z e d tha t the n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s f o r c l i e n t change were t h e r a p i s t - o f f e r e d , namely , empathy, u n c o n d i t i o n a l p o s i t i v e r e g a r d , and c o n g r u e n c e . S t r o n g ' s (1968) s o c i a l i n f l u e n c e theory r e l a t e d c l i e n t change to the ex tent to which the c l i e n t p e r c e i v e d the t h e r a p i s t as e x p e r t , a t t r a c t i v e , and t r u s t w o r t h y . The working a l l i a n c e i s an i n c o r p o r a t i v e and p r o m i s i n g a p p r o a c h . O r i g i n a l l y proposed by Freud in 1912, the concept of an a l l i a n c e between c l i e n t and t h e r a p i s t i s emerging as an approach to i n t e g r a t i n g s p e c i f i c and g e n e r a l f a c t o r s i n an o v e r a r c h i n g theory of t h e r a p e u t i c change . In p a r t i c u l a r , B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n of the a l l i a n c e as the p r o d u c t of the s y n e r g i s t i c c o m b i n a t i o n of th ree h i g h l y r e l a t e d components of the a l l i a n c e - - g o a l m u t u a l i t y , agreement r e g a r d i n g r e l e v a n t t a s k s and r e s p o n s i b i l i t i e s , and the development of p e r s o n a l bonds or a t t a c h m e n t s — h a s prompted i n v e s t i g a t o r s to b e g i n to at tempt to t r a c k and t o measure the s t r e n g t h and q u a l i t y of the a l l i a n c e in t h e r a p e u t i c engagements. G e l s o and C a r t e r (1985) have d e s c r i b e d the working 3 a l l i a n c e , in p a n t h e o r e t i c a l t e r m s , as e x i s t i n g when the c l i e n t ' s r e a s o n a b l e or " o b j e c t i v e l y " o b s e r v i n g s i d e a l i g n s w i th the c o u n s e l l o r ' s working s i d e c r e a t i n g the sense that the p a r t i c i p a n t s in the c o u n s e l l i n g r e l a t i o n s h i p are j o i n e d toge ther i n a shared e n t e r p r i s e , each making h i s or her c o n t r i b u t i o n to the work. Drawing on B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n , G e l s o and C a r t e r (1985) have suggested that the a l l i a n c e i s an e m o t i o n a l a l ignment tha t i s both f o s t e r e d and fed by the emot iona l bond or p o s i t i v e at tachment and by agreement on the a p p r o p r i a t e n e s s of g o a l s and t a s k s . T h e r a p i s t empathy, g e n u i n e n e s s , and r e s p e c t must be met by c l i e n t c a p a c i t y to t r u s t and to form at tachments to p e o p l e . Moreover , the c l i e n t p r o b a b l y needs to have a wor ld view s i m i l a r enough to the t h e r a p i s t ' s t h e o r e t i c a l s tance that the g o a l s and t a s k s of the c o u n s e l l i n g make sense to her or h im. Greenberg (1985) has noted tha t one of the s t r e n g t h s of B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n i s tha t i t h e l p s i n t e g r a t e views on the importance of the r e l a t i o n s h i p and t e c h n i q u e i n p s y c h o t h e r a p y . S p e c i f i c t e c h n i c a l o p e r a t i o n s that c o n s t i t u t e t a s k s are viewed as r e q u i r i n g p a r t i c u l a r types of r e l a t i o n a l bonds, w h i l e the c o m p l e t i o n of c e r t a i n r e l a t i o n s h i p t a s k s might i n v o l v e the use of t e c h n i c a l s k i l l s . It i s the c o r r e c t combina t ion of g o a l s , t a s k s , and bonds , or the s y n t h e s i s of d i f f e r e n t r e l a t i o n a l and t e c h n i c a l e l e m e n t s , tha t c o n s t i t u t e s a good o v e r a l l a l l i a n c e . Docher ty (1985) and H a r t l e y (1985) have s i m i l a r l y r e c o g n i z e d the i n t e g r a t i v e p o t e n t i a l of the a l l i a n c e c o n c e p t . 4 R e c e n t l y , r e s e a r c h e r s ( H a r t l e y & S t r u p p , 1983; H o r v a t h , 1981; L u b o r s k y , C r i t s - C r i s t o p h , A l e x a n d e r , M a r g o l i s , & Cohen, 1983; Marmar, M a r z i a l i , H o r o w i t z , & W e i s s , 1986; P i n s o f & C a t h e r a l l , 1984) have demonstrated that the a l l i a n c e has g rea t p o t e n t i a l as a potent p r e d i c t o r of outcome i n a f a i r l y wide v a r i e t y of s e t t i n g s and c o n t e x t s . Greenberg and P i n s o f (1986) have observed tha t i t i s p a r t i c u l a r l y impr&ss ive tha t the a l l i a n c e has been r e l a t e d to outcome when i t has been measured in many d i f f e r e n t ways at d i f f e r e n t r e s e a r c h c e n t r e s w i th d i f f e r e n t types of t h e r a p y . T h e s e , they s a y , a re u n u s u a l l y robust f i n d i n g s in psychotherapy r e s e a r c h . 2. CURRENT PROPOSITIONS ABOUT THE WORKING ALLIANCE The f i r s t three p r o p o s i t i o n s that f o l l o w are drawn from G e l s o and C a r t e r ' s (1985) recommendations f o r r e s e a r c h i n i t i a t i v e s : 1) R e g a r d l e s s of the d u r a t i o n of c o u n s e l l i n g , i t i s important tha t the a l l i a n c e be e s t a b l i s h e d r e l a t i v e l y e a r l y i f the t reatment i s to be s u c c e s s f u l . T h i s p r o p o s i t i o n i s suppor ted by the r e s e a r c h of H a r t l e y and S t rupp (1983) , Luborsky et a l . (1983) , and Horvath (1981) . 2) In terms of B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n , the bonding a s p e c t of the a l l i a n c e d e v e l o p s most s l o w l y , whereas, i f therapy i s to p roceed e f f e c t i v e l y , there must be at l e a s t g e n e r a l agreement e a r l y in the work about the g o a l s a p p r o p r i a t e f o r t reatment and the t a s k s tha t are n e c e s s a r y to a t t a i n those g o a l s . 5 3) In l i n e wi th G r e e n s o n ' s (1967) c o n c e p t u a l i z a t i o n , the importance of the working a l l i a n c e waxes and wanes d u r i n g the v a r i o u s phases of the psychotherapy i n t e r v e n t i o n . H a r t l e y and S t r u p p (1983) view t h e i r f i n d i n g s as c o n s i s t e n t w i th Langs ' (1973, 1974) n o t i o n tha t a s t r o n g a l l i a n c e a l l o w s the c l i e n t to f e e l t r u s t i n g enough to e x p e r i e n c e suppor t d u r i n g d i f f i c u l t t i m e s , and to m a i n t a i n f a i t h i n the t h e r a p i s t ' s e f f e c t i v e n e s s and good mot ives d u r i n g p e r i o d s of n e g a t i v e t r a n s f e r e n c e . In a s i m i l a r v e i n , B o r d i n (1983) has suggested that in the middle phase of t h e r a p y , the p r o c e s s of r e p a i r i n g the a l l i a n c e when i t i s weakened or d i s r u p t e d a c t u a l l y becomes the work of the t r e a t m e n t . The remain ing p r o p o s i t i o n s a re drawn from the g e n e r a l l i t e r a t u r e and rev iews of the a l l i a n c e : 4) Both H a r t l e y and S t rupp (1983) and O ' M a l l e y , Suh , and S t r u p p (1983) have observed from t h e i r s t u d i e s tha t outcome can be r e l a t e d t o the o c c u r r e n c e of an i n c r e a s e in a l l i a n c e s t r e n g t h over the e a r l y s e s s i o n s . In the H a r t l e y and S t rupp s t u d y , more s u c c e s s f u l dyads i n c r e a s e d t h e i r a l l i a n c e s peak ing at the f i r s t q u a r t i l e p o i n t in the t h e r a p y , w h i l e l e s s s u c c e s s f u l dyads t roughed at the c o r r e s p o n d i n g p o i n t . Suh , O ' M a l l e y and S t rupp (1986) l o o k e d f o r d i f f e r e n t i a l t h e r a p i s t behav iour to account f o r the changes in c l i e n t p a r t i c i p a t i o n a c r o s s e a r l y s e s s i o n s (which p r e d i c t e d outcome by the t h i r d s e s s i o n ) and r e l a t e d these changes to p a t t e r n s of change in t h e r a p i s t warmth and e x p l o r a t i o n . 5) Based on convergent r e s e a r c h from d i f f e r e n t o r i e n t a t i o n s 6 (R ice & K e r r , 1986; Sampson & W e i s s , 1986), Greenberg and P i n s o f (1986) have suggested t h a t involvement may be the most c r i t i c a l c l i e n t subdimension and i n d i c a t o r of the a l l i a n c e . A p p r o p r i a t e involvement i n t h e r a p e u t i c t a s k s i s e v i d e n c e d by such g e n e r a l i n d i c a t o r s as p a r t i c i p a t i o n , o p t i m i s m , p e r c e i v e d task r e l e v a n c e , r e s p o n s i b i l i t y , and by o r i e n t a t i o n - s p e c i f i c i n d i c a t o r s such as e x p e r i e n c i n g i n e x p e r i e n t i a l p s y c h o t h e r a p y , b o l d n e s s of e x p l o r a t i o n in p s y c h o a n a l y t i c t h e r a p y , i n s p e c t i o n of ev idence in c o g n i t i v e t h e r a p y , and c o m p l e t i o n of homework ass ignments in b e h a v i o u r a l t h e r a p y . Luborsky (1985) has s i m i l a r l y seen the a l l i a n c e as o n l y one of a f a m i l y of p o s i t i v e r e l a t i o n s h i p q u a l i t i e s i n c l u d i n g p o s i t i v e e v a l u a t i o n of o t h e r s , involvement in the therapy and f e e l i n g unders tood by the t h e r a p i s t , and o t h e r s , a l l of wh ich , he has o b s e r v e d , when taken t o g e t h e r have an amaz ing ly c o n s i s t e n t p r e d i c t i v e r e c o r d f o r the outcomes of p s y c h o t h e r a p y and imply that these q u a l i t i e s a re c r u c i a l l y i n v o l v e d in the c u r a t i v e p r o c e s s of t h e r a p y . 3. DEFINITION OF TERMS P s y c h o t h e r a p y : The t reatment of mental or emot iona l d i s o r d e r s or maladjustments by p s y c h o l o g i c a l means, e s p e c i a l l y i n v o l v i n g v e r b a l communica t ion . (Webster 's D i c t i o n a r y , T h i r d E d i t i o n ) Outcome; The p e r c e p t i o n s of the c l i e n t and the t h e r a p i s t r e g a r d i n g the s u c c e s s of p s y c h o t h e r a p y , p a r t i c u l a r l y as i t r e l a t e s to improvements i n t a r g e t c o m p l a i n t s , symptom r e d u c t i o n , i n c r e a s e i n s e l f - e s t e e m , r e s o l u t i o n of i n t e r p e r s o n a l p rob lems , 7 and c l i e n t ' s and t h e r a p i s t ' s p o s t t h e r a p y a s s e s s m e n t s . Outcome i s measured by Targe t Compla in ts Improvement, r e s i d u a l g a i n on the Symptom C h e c k l i s t - 9 0 , the S e l f - E s t e e m Index, and the Inventory of I n t e r p e r s o n a l P rob lems , and the S t rupp P o s t t h e r a p y  Q u e s t i o n n a i r e and the T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e . Working A l l i a n c e : The c l i e n t ' s and the t h e r a p i s t ' s awareness of a se t of agreements , u n d e r s t a n d i n g s , and bonds tha t were a r r i v e d at d u r i n g a sequence of p u r p o s i v e h e l p i n g i n t e r a c t i o n s . In p a r t i c u l a r , the f o l l o w i n g components a c c o r d i n g to B o r d i n (1979) d e f i n e a v i a b l e a l l i a n c e , r e g a r d l e s s of the s p e c i f i c t h e o r e t i c a l or t e c h n i c a l approach taken by the t h e r a p i s t : 1) The h e l p e r and the he lpee have a sense of agreement about the g o a l s of the h e l p i n g p r o c e s s . The he lpee has an awareness tha t these g o a l s are r e l e v a n t to h e r / h i m and f e e l s a degree of i d e n t i f i c a t i o n wi th the e x p l i c i t and i m p l i c i t aims of the p a r t i c u l a r h e l p i n g p r o c e s s in which h e / s h e i s engaged. The h e l p e r has some d i r e c t or i n d i r e c t ev idence tha t the g o a l s e s t a b l i s h e d in the therapy r e l a t i o n s h i p a re e x p l i c i t l y or i m p l i c i t l y shared and a c c e p t e d by the h e l p e e . 2) The h e l p e r and the he lpee have a sense of m u t u a l i t y (or agreement) tha t the t a s k s demanded of each of them in the h e l p i n g p r o c e s s are r e a s o n a b l e and w i t h i n t h e i r g l o b a l c a p a b i l i t i e s (or e x p e r t i s e ) , and r e l e v a n t i n a d i r e c t or i n d i r e c t way to the g o a l s of the h e l p i n g p r o c e s s upon which they have m u t u a l l y a g r e e d . 3) The h e l p e r and the he lpee e x p e r i e n c e a sense of a bond 8 between them. Some of the bases upon which such a t h e r a p e u t i c p a r t n e r s h i p are b u i l t are sense of mutual t r u s t i n g , l i k i n g , u n d e r s t a n d i n g , and c a r i n g . D i f f e r e n t t h e r a p e u t i c o r i e n t a t i o n s and s t r a t e g i e s make d i f f e r e n t demands on the p a r t i c i p a n t s in terms of each of these components. These unique demands c r e a t e a unique q u a l i t y f o r each s u c c e s s f u l a l l i a n c e . B o r d i n has m a i n t a i n e d , however, that a l l h e l p i n g dyads have to a c h i e v e a b a s i c q u a n t i t a t i v e l e v e l in each of the t h r e e a reas in o rder to produce the a l l i a n c e component n e c e s s a r y f o r a s u c c e s s f u l h e l p i n g r e l a t i o n s h i p . T h e r a p e u t i c A l l i a n c e ; The term employed by o b j e c t r e l a t i o n s t h e o r i s t s ( G i t e l s o n , 1962; Z e t z e l , 1956, 1970) f o r the a l l i a n c e c o n c e p t . H e l p i n g A l l i a n c e : L u b o r s k y ' s (1976) term f o r the a l l i a n c e c o n c e p t . Empathy: The a b i l i t y of the t h e r a p i s t a c c u r a t e l y and s e n s i t i v e l y to unders tand e x p e r i e n c e s and f e e l i n g s and  t h e i r meaning to the c l i e n t d u r i n g the moment-to-moment encounter of p s y c h o t h e r a p y . . . . [ I t ] means that the t h e r a p i s t i s c o m p l e t e l y at home in the u n i v e r s e of the p a t i e n t . . . . I t i s a s e n s i n g of the c l i e n t ' s inner wor ld . . . ' a s i f ' i t were the t h e r a p i s t ' s own . . . . The a b i l i t y and s e n s i t i v i t y r e q u i r e d to communicate these inner meanings back to the c l i e n t in a way tha t a l l o w s these e x p e r i e n c e s to be ' h i s ' i s the o ther major p a r t . . . . The t h e r a p i s t a t a h i g h l e v e l [of empathy] w i l l i n d i c a t e not o n l y a s e n s i t i v e u n d e r s t a n d i n g of the apparent f e e l i n g s but w i l l by h i s communicat ion c l a r i f y and expand the p a t i e n t ' s awareness of these f e e l i n g s and e x p e r i e n c e s . (Rogers , G e n d l i n , K i e s l e r , & T r u a x , 1967, p p . 104-105) P e r c e i v e d Empathy: The ex ten t to which a he lpee i s aware of the h e l p e r ' s empathy. 9 E x p e r t n e s s : A c o u n s e l l o r i s p e r c e i v e d as an exper t or knowledgeable person in h i s / h e r f i e l d i f s h e / h e has the f o l l o w i n g a t t r i b u t e s : 1) o b j e c t i v e ev idence of s p e c i a l i z e d t r a i n i n g or knowledge such as a d ip loma or d e g r e e ; 2) s u b j e c t i v e e v i d e n c e of r e c o g n i z e d a b i l i t y such as r e p u t a t i o n , fame, a n d / o r p h y s i c a l s i g n s a s s o c i a t e d w i t h s u c c e s s , ( e . g . , a f f l u e n c e ) ; and 3) b e h a v i o u r a l ev idence of e x p e r t i s e such as r a t i o n a l and knowledgeable arguments and c o n f i d e n c e i n p r e s e n t a t i o n ( S t r o n g , 1968). A t t r a c t i v e n e s s : The a t t r a c t i v e n e s s of a h e l p e r i s a f u n c t i o n of the f o l l o w i n g c o n d i t i o n s : 1) p h y s i c a l a t t r a c t i v e n e s s (Cash & S a l t z b a c h , 1978); 2) warmth or f r i e n d l i n e s s ( G o l d s t e i n , 1971); and 3) c o m p a t a b i 1 i t y in terms of a g r e e a b l e n e s s or l i k e n e s s of o p i n i o n ( S t r o n g , 1968). T r u s t w o r t h i n e s s : A h e l p e r i s p e r c e i v e d as t r u s t w o r t h y i f one or both of the f o l l o w i n g are p r e s e n t : 1) s o c i a l l y s a n c t i o n e d r o l e as a h e l p e r or l e g i t i m a t e source of i n f l u e n c e ( S t r o n g , 1968); and 2) s t e a d y , deep , and c o n s i s t e n t c o n c e r n fo r the c l i e n t ' s w e l f a r e ( F r a n k , 1973). S p e c i f i c F a c t o r : A f a c t o r or v a r i a b l e tha t i s s p e c i f i c to a t e c h n i q u e or procedure and a s s o c i a t e d w i th a s p e c i f i c approach to p s y c h o t h e r a p y . G e n e r a l or G e n e r i c F a c t o r : A f a c t o r or v a r i a b l e that i s 10 common to a l l of the d i f f e r e n t approaches to p s y c h o t h e r a p y , ( e g . , the c l i e n t - t h e r a p i s t r e l a t i o n s h i p ) . WAI; The acronym 'WAI' r e f e r s to the Working A l l i a n c e  Inventory ( H o r v a t h , 1981, 1982) in both c l i e n t (WAIc) and t h e r a p i s t (WAIt) fo rms . 4. RESEARCH QUESTIONS The p r e s e n t study was in tended to answer the f o l l o w i n g q u e s t i o n s : 1) Are c l i e n t - p e r c e i v e d and t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h s as measured by the Working A l l i a n c e Inventory p o s i t i v e l y r e l a t e d to outcome? 2) Are c l i e n t - p e r c e i v e d and t h e r a p i s t - p e r c e i v e d changes i n a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s as measured by the WAI p o s i t i v e l y r e l a t e d to outcome? 3) Is c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc more p o s i t i v e l y r e l a t e d to outcome than i s c l i e n t - p e r c e i v e d t h e r a p i s t empathy, e x p e r t n e s s , a t t r a c t i v e n e s s , or t r u s t w o r t h i n e s s ? 4) Is c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the H e l p i n g A l l i a n c e Q u e s t i o n n a i r e p o s i t i v e l y r e l a t e d to outcome? 5) Are c l i e n t - p e r c e i v e d and t h e r a p i s t - p e r c e i v e d c l i e n t involvement p o s i t i v e l y r e l a t e d to outcome? 6) Is congruence of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc and t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIt p o s i t i v e l y r e l a t e d to outcome? 11 I I . REVIEW OF LITERATURE 1. THEORETICAL DEVELOPMENT OF THE ALLIANCE CONCEPT 1.1 P s y c h o a n a l y t i c F o r m u l a t i o n s The concept of the working a l l i a n c e emerged i n i t i a l l y i n the p s y c h o a n a l y t i c l i t e r a t u r e as an a s p e c t of the t r a n s f e r e n c e . F reud (1912) d i s t i n g u i s h e d two types of t r a n s f e r e n c e — p o s i t i v e a f f e c t i o n a t e and n e g a t i v e h o s t i l e . He f u r t h e r d i v i d e d the former i n t o a c o n s c i o u s f r i e n d l y component and an u n c o n s c i o u s s e x u a l component. I f we ' remove' the t r a n s f e r e n c e by making i t c o n s c i o u s , we are d e t a c h i n g on ly these two components of the emot iona l a c t [ i . e . , the n e g a t i v e h o s t i l e and the u n c o n s c i o u s s e x u a l ] from the person of the d o c t o r ; the o t h e r component, which i s a d m i s s i b l e to c o n s c i o u s n e s s and u n o b j e c t i o n a b l e , p e r s i s t s and i s the v e h i c l e of s u c c e s s in p s y c h o a n a l y s i s e x a c t l y as i t i s i n o ther methods of t r e a t m e n t . (p . 105) In f a c t , F reud (1913) regarded the p o s i t i v e t r a n s f e r e n c e as a p r e r e q u i s i t e to t r e a t m e n t : When are we to beg in making our communicat ions to the p a t i e n t ? . . . Not u n t i l an e f f e c t i v e t r a n s f e r e n c e has been e s t a b l i s h e d in the p a t i e n t , a proper r a p p o r t w i th h im. I t remains the f i r s t aim of the t reatment to a t t a c h him to i t and to the person of the d o c t o r . To ensure t h i s , n o t h i n g need be done but to g i v e him t i m e . If one e x h i b i t s a s e r i o u s i n t e r e s t i n h im , c a r e f u l l y c l e a r s away the r e s i s t a n c e s that c r o p up at the b e g i n n i n g and a v o i d s making c e r t a i n m i s t a k e s , he w i l l of h i m s e l f form such an attachment and l i n k the d o c t o r up wi th one of the imagos of the peop le by whom he was accustomed t o be t r e a t e d wi th a f f e c t i o n . (pp. 139-40) Hence, F r e u d ' s c o n c e p t u a l i z a t i o n of the bond at t h i s p o i n t was l a r g e l y tha t of a l i b i d i n a l at tachment of p a t i e n t to p h y s i c i a n . S t e r b a (1934) and B i b r i n g (1937) as w e l l as Freud h i m s e l f 12 (1937) d e v e l o p e d a r e v i s e d c o n c e p t u a l i z a t i o n in which the c o n s c i o u s r a t i o n a l par t of the ego (the autonomous ego f u n c t i o n s ( L o e w e n s t e i n , 1954)) was seen as a l l y i n g i t s e l f w i th the a n a l y s t a g a i n s t the u n c o n s c i o u s . S u c c e s s f u l t reatment was r e l a t e d to the k ind of r e l a t i o n s h i p w i th the a n a l y s t tha t the p a t i e n t was c a p a b l e of s u s t a i n i n g , o r , in o ther words, the p a t i e n t and a n a l y s t s h a r i n g the same purposes (Fr iedman, 1969). Ob jec t r e l a t i o n s t h e o r i s t s b e g i n n i n g wi th Z e t z e l (1956) d i d not d i s t i n g u i s h the " t h e r a p e u t i c a l l i a n c e " from the t r a n s f e r e n c e n e u r o s i s , i n s t e a d r e g a r d i n g t r a n s f e r e n c e , ( i . e . , the r e v i v a l of the e a r l y m o t h e r - c h i l d r e l a t i o n s h i p in the t h e r a p e u t i c r e l a t i o n s h i p c u l m i n a t i n g in s u c c e s s f u l i n t r o j e c t i o n of the a n a l y s t as a good o b j e c t ) , as a b a s i s fo r the a l l i a n c e . Comparably , the a n a l y s t ' s empathic i m b r i c a t i o n wi th h i s p a t i e n t ' s emotions p r o v i d e s a s u s t a i n i n g g r i d of ' u n d e r s t a n d i n g ' (or ' r e s o n a n c e ' ) which l e a d s towards c o - o p e r a t i o n and i d e n t i f i c a t i o n , to the p a r t i a l r e l i n q u i s h m e n t of the a n a c l i t i c a t t i t u d e , and in the end t o a c o l l a b o r a t i o n which has [been] c a l l e d ' t h e r a p e u t i c a l l i a n c e ' . ( G i t e l s o n , 1962, p. 199) In t r a d i t i o n a l p s y c h o a n a l y s i s the t r a n s f e r e n c e i s i n t e r p r e t e d , whi le the r e a l o b j e c t r e l a t i o n s h i p i s o f t e n so secure tha t i t seldom needs e x p l i c i t r e i n f o r c e m e n t . . . . In most t h e r a p y , in c o n t r a s t , wh i le t r a n s f e r e n c e may be o b v i o u s to the t h e r a p i s t , i t i s the r e a l i t y of the r e l a t i o n s h i p which remains in the f o r e f r o n t . It i s the s t r e n g t h e n i n g of the r e a l o b j e c t r e l a t i o n s h i p which h o l d s the p o t e n t i a l f o r c o n s i d e r a b l y i n c r e a s i n g the p a t i e n t ' s i n s i g h t . ( Z e t z e l , 1970, p . 153) G r e e n s o n ' s (1965, 1967; Greenson & Wex le r , 1969) c o n c e p t u a l i z a t i o n of the a l l i a n c e i s s i m i l a r l y broad in s c o p e , encompassing v a r i o u s a s p e c t s of the t h e r a p e u t i c r e l a t i o n s h i p 1 3 a l o n g wi th the q u a l i t y of work the c l i e n t does in the t reatment p r o c e s s . H i s a n a l y s i s has been the s t i m u l u s f o r the c u r r e n t t h e o r e t i c a l and e m p i r i c a l focus on the a l l i a n c e as the key element i n the t h e r a p e u t i c r e l a t i o n s h i p . He i d e n t i f i e d th ree c o n t r i b u t i o n s to i t s a t t a i n m e n t : 1) the p a t i e n t ' s c a p a c i t y to o s c i l l a t e between m a i n t a i n i n g c o n t a c t w i th the r e a l i t y of the a n a l y t i c s i t u a t i o n and r i s k i n g r e g r e s s i n g i n t o h i s f a n t a s y wor ld ( i . e . , d e v e l o p i n g a t r a n s f e r e n c e n e u r o s i s ) ; 2) the a n a l y s t ' s humanness c o n s i s t i n g of u n d e r s t a n d i n g and i n s i g h t conveyed in an atmosphere of s e r i o u s work, s t r a i g h t f o r w a r d n e s s , compassion and r e s t r a i n t ; and 3) the c o n s t a n t s c r u t i n y of how the p a t i e n t and the a n a l y s t seem to be working t o g e t h e r , the mutual concern w i t h the working a l l i a n c e , which in i t s e l f s e r v e s to enhance i t . 1.2 Other C o n c e p t u a l i z a t i o n s Of The R e l a t i o n s h i p T h e o r i s t s of o ther s c h o o l s of therapy have a l s o s t r e s s e d the importance of the r e a l r e l a t i o n s h i p between t h e r a p i s t and c l i e n t and t h e i r working " c o n t r a c t " . Rogers (1951, 1957) took the most r a d i c a l r e l a t i o n s h i p -o r i e n t e d s tand when he argued tha t the t h e r a p i s t - o f f e r e d c o n d i t i o n s of empathy, u n c o n d i t i o n a l p o s i t i v e r e g a r d , and congruence were c o r e , ( i . e . , the n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s ) , f o r p s y c h o t h e r a p e u t i c b e n e f i t . H i s i d e a s have s t i m u l a t e d much r e s e a r c h which has produced c o n t r a d i c t o r y and u l t i m a t e l y i n c o n c l u s i v e f i n d i n g s (Gurman, 1977; Lamber t , 1 4 D e J u l i o , & S t e i n , 1978; M i t c h e l l , B o z a r t h & K r a u f t , 1977; P a r l o f f , Waskow & W o l f e , 1978; Watson, 1984). The most p r o m i s i n g ins t rument deve loped to measure the c o r e c o n d i t i o n s i s the R e l a t i o n s h i p Inventory ( B a r r e t t - L e n n a r d , 1962). B a r r e t t - L e n n a r d ' s assumpt ion in measur ing c l i e n t -p e r c e i v e d c o n d i t i o n s was tha t i t i s what the c l i e n t h e r s e l f / h i m s e l f e x p e r i e n c e s tha t a f f e c t s h im /her d i r e c t l y and thus i s the pr imary l o c u s of t h e r a p e u t i c i n f l u e n c e in the r e l a t i o n s h i p . Gurman (1977) compared c l i e n t , t h e r a p i s t and o b s e r v e r p e r c e p t i o n s of the t h e r a p e u t i c r e l a t i o n s h i p . In twenty of the 26 s t u d i e s of the r e l a t i o n s h i p between c l i e n t p e r c e p t i o n of r e l a t i o n s h i p (as a s s e s s e d p redominant ly w i th the RI) and outcome, p o s i t i v e f i n d i n g s were r e p o r t e d (and in t h r e e , mixed , but s u p p o r t i v e r e s u l t s were r e p o r t e d ) . T h i s was a more i m p r e s s i v e r e s u l t than tha t r e g i s t e r e d f o r s t u d i e s of o b s e r v e r -r a t e d empathy. E q u a l l y i m p o r t a n t l y , however, Gurman noted tha t l i k e o ther s t u d i e s based on the t h e r a p i s t - o f f e r e d c o n d i t i o n s , r e s u l t s tended to ' f a l l o f f when the s t u d i e s i n v o l v e d s u b j e c t s from non c l i e n t - c e n t e r e d t h e r a p i e s . In the p r e s e n t s t u d y , the r e l a t i o n s h i p of c l i e n t - r a t e d empathy to outcome i s compared w i th that of c l i e n t - r a t e d a l l i a n c e s t r e n g t h . Frank (1971) a l s o a t tempted to d e f i n e common or n o n s p e c i f i c f e a t u r e s of s u c c e s s f u l t h e r a p e u t i c engagements: 1) an e m o t i o n a l l y c h a r g e d , c o n f i d i n g r e l a t i o n s h i p , 2) a t h e r a p e u t i c r a t i o n a l e a c c e p t e d by p a t i e n t and t h e r a p i s t ; 15 3) p r o v i s i o n of new i n f o r m a t i o n by p r e c e p t , example, and s e l f - d i s c o v e r y ; 4) s t r e n g t h e n i n g of the p a t i e n t ' s e x p e c t a t i o n of h e l p ; 5) p r o v i d i n g the p a t i e n t w i th s u c c e s s e x p e r i e n c e s ; and 6) f a c i l i t a t i o n of emot iona l a r o u s a l . The f i r s t f e a t u r e , the p a t i e n t - t h e r a p i s t r e l a t i o n s h i p , was seen as a n e c e s s a r y but not s u f f i c i e n t c o n d i t i o n fo r a l l the other common f e a t u r e s . In h i s book, Frank (1973) viewed the p a t i e n t - t h e r a p i s t encounter as a system whose p r o p e r t i e s are determined not on ly by the c h a r a c t e r i s t i c s of the p r o t a g o n i s t s , but a l s o by the c o n t e x t in which the encounter o c c u r s . As the system d e v e l o p s , i t , i n t u r n , a f f e c t s c e r t a i n f e a t u r e s of both members. He c o n c l u d e d tha t the s u c c e s s of psychotherapy r e l a t e s not on ly to a convergence of the t h e r a p i s t ' s and p a t i e n t ' s v a l u e s , but a l s o to a s p e c t s of the p a t i e n t - t h e r a p i s t i n t e r a c t i o n tha t a f f e c t the t h e r a p i s t ' s z e a l and the p a t i e n t ' s c o n f i d e n c e in h i m / h e r . Research on what has become known as the s o c i a l i n f l u e n c e p r o c e s s and was o p e r a t i o n a l i z e d by S t rong (1968) as s u c c e s s f u l outcome be ing r e l a t e d to the c l i e n t p e r c e i v i n g the c o u n s e l l o r as e x p e r t , a t t r a c t i v e , and t r u s t w o r t h y has a l s o proved i n c o n c l u s i v e . On the b a s i s of t h e i r review of t h i s r e s e a r c h , C o r r i g a n , D e l l , Lewis and Schmidt (1980) c o n c l u d e d t h a t : A l t h o u g h i t i s important to unders tand the r e l a t i v e c o n t r i b u t i o n of p e r c e i v e d c o u n s e l o r a t t r i b u t e s to the v a r i o u s s t a g e s of a c o u n s e l i n g r e l a t i o n s h i p , i t may be even more important t o unders tand those even ts and c o u n s e l o r a t t r i b u t e s tha t f a c i l i t a t e the t r a n s i t i o n from f a v o u r a b l e f i r s t i m p r e s s i o n s to subsequent , presumably more p r o d u c t i v e , s t a g e s of a c o u n s e l i n g r e l a t i o n s h i p . (p . 437) 16 Barak and L a C r o s s e (1975) deve loped the C o u n s e l o r R a t i n g  Form to measure the c o u n s e l l o r ' s e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s as p e r c e i v e d by the c l i e n t . In the p r e s e n t s t u d y , the r e l a t i o n s h i p s of c l i e n t - r a t e d t h e r a p i s t e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s to outcome are compared w i th tha t of c l i e n t - r a t e d a l l i a n c e s t r e n g t h . A d i s t i n c t l y d i f f e r e n t approach was o f f e r e d by B o r d i n (1975, 1979). He at tempted to d e f i n e the working a l l i a n c e i n terms of the demands and agreements between the c l i e n t and the t h e r a p i s t . More s p e c i f i c a l l y , he p o s t u l a t e d t h a t : 1) d i f f e r e n t t h e r a p e u t i c t e c h n i q u e s would p l a c e d i f f e r e n t demands on both t h e r a p i s t and p a t i e n t ; 2) unique s t r a t e g i e s would imply d i f f e r e n t g o a l s and o b j e c t i v e s ; 3) a good t h e r a p e u t i c a l l i a n c e would demand an a c c e p t a n c e o f , and agreement on 1) and 2) between t h e r a p i s t and c l i e n t . In o ther words, these e lements would have to ' f i t ' c l i e n t and t h e r a p i s t needs and r e s o u r c e s and r e s u l t in mutual agreement between them r e g a r d i n g g o a l s and o b j e c t i v e s , and c o n s e q u e n t l y the c l i e n t would r e g a r d the therapy a c t i v i t i e s as r e l e v a n t to h i s / h e r g o a l s ; and 4) a r e a l r e l a t i o n s h i p , a ' b o n d ' , would have to d e v e l o p between c l i e n t and t h e r a p i s t , i n v o l v i n g t r u s t , a c c e p t a n c e , and l i k i n g . The f o r m u l a t i o n was unique from s e v e r a l p o i n t s of view (H or va th , 1981): 1) A l t h o u g h i t i n c o r p o r a t e d some of the b a s i c c o n c e p t s of 17 the a n a l y t i c stream of t h o u g h t , i t was o p e r a t i o n a l l y independent of t h e r a p e u t i c c o n s t r u c t s tha t were unique to a p a r t i c u l a r t h e o r e t i c a l o r i e n t a t i o n . 2) It d e f i n e d a g e n e r i c p r o c e s s v a r i a b l e tha t cut a c r o s s t h e o r e t i c a l s t r a t e g i e s , ( i . e . , agreement on g o a l s and t a s k s p l u s p e r s o n a l b o n d s ) , but at the same t ime s p e c i f i e d tha t d i f f e r e n t methods would produce unique t o p o l o g i e s w i t h i n these agreements . 3) The d e f i n i t i o n of the working a l l i a n c e c o u l d be e x p l i c a t e d i n terms of d i s c r e t e t h e r a p e u t i c o b j e c t i v e s . 2. EMPIRICAL RESEARCH ON THE ALLIANCE The p r e v i o u s d i s c u s s i o n of the working a l l i a n c e was based e x c l u s i v e l y on c l i n i c a l o b s e r v a t i o n s and l o g i c a l e x t r a p o l a t i o n s . D u r i n g the l a s t decade , v a r i o u s Nor th American r e s e a r c h groups have deve loped ins t ruments to measure the a l l i a n c e and have pursued the r e l a t i o n s h i p s between the a l l i a n c e as a p r o c e s s v a r i a b l e and a v a r i e t y of outcome v a r i a b l e s . 2.1 The Penn Research Group The e a r l i e s t e m p i r i c a l work was done by Luborsky and h i s c o l l e a g u e s a t the U n i v e r s i t y of P e n n s y l v a n i a on the Penn H e l p i n g  A l l i a n c e S c a l e s . Based on h i s c l i n i c a l o b s e r v a t i o n s , Luborsky (1976) composed a l i s t of seven s i g n s of two types of h e l p i n g r e l a t i o n s h i p s : Type 1: A t h e r a p e u t i c a l l i a n c e based on the p a t i e n t ' s e x p e r i e n c i n g the t h e r a p i s t as s u p p o r t i v e and h e l p f u l w i th h i m s e l f / h e r s e l f as the r e c i p i e n t . 18 Type 2: A t h e r a p e u t i c a l l i a n c e based on a sense of working t o g e t h e r or c o l l a b o r a t i n g in a j o i n t s t r u g g l e a g a i n s t what i s impeding the p a t i e n t , w i th the emphasis on shared r e s p o n s i b i l i t y . Luborsky (1976; L u b o r s k y , M i n t z , A u e r b a c h , C r i t s - C r i s t o p h , B a c h r a c h , T o d d , J o h n s o n , Cohen, & O ' B r i e n , 1980) had c l i n i c a l o b s e r v e r s r a t e the f i r s t twenty minutes of two e a r l y and two l a t e s e s s i o n s of the seven most improved and e i g h t l e a s t improved p a t i e n t s from a p o o l of 73 who had had at l e a s t 25 s e s s i o n s of p s y c h o a n a l y t i c a l l y - o r i e n t e d p s y c h o t h e r a p y . He found that s i x of seven of the improvers deve loped h e l p i n g r e l a t i o n s h i p s in the e a r l y s e s s i o n s , whereas none of the e i g h t nonimprovers d i d s o . More p r e c i s e l y , the occurence of Type 1 and 2 a l l i a n c e s c o r r e l a t e d .58 wi th outcome, ( i . e . , r e s i d u a l ga in on a composi te of four measures p r o v i d e d by p a t i e n t s and o b s e r v e r s ) . L u b o r s k y , C r i t s - C r i s t o p h , A l e x a n d e r , M a r g o l i s , and Cohen (1983) r e p o r t e d that the most f r e q u e n t l y observed s i g n s were those in which the p a t i e n t f e l t he lped or changed by the t h e r a p i s t or the t rea tment , ( i . e . , o b s e r v a t i o n s about p r o g r e s s toward g o a l s ) . The s i g n s were then c o n v e r t e d i n t o a more e f f i c i e n t r a t i n g s c a l e (14 i tems) and these were a p p l i e d to the same da ta (Morgan, L u b o r s k y , C r i t s - C r i s t o p h , C u r t i s , & Solomon, 1982). The r a t i n g method was shown to be more r e l i a b l e than the c o u n t i n g s i g n s method (r= .75 to .88 f o r i n t e r r a t e r r e l i a b i l i t y and £ = . 9 5 f o r i n t e r n a l r e l i a b i l i t y ( c o e f f i c i e n t a l p h a ) ) , and to 19 have a lmost e q u a l l y s i g n i f i c a n t p r e d i c t i v e power, a c c o u n t i n g f o r about 25% of the v a r i a n c e of v a r i o u s outcome measures . Only 6 of 57 pre t rea tment p r e d i c t o r s , ( i . e . , p e r s o n a l i t y c o r r e l a t e s ) , examined a c h i e v e d c o r r e l a t i o n s tha t were as h i g h . For example, improvement on the f i r s t t a r g e t c o m p l a i n t , ( i . e . , the s p e c i f i c symptom f o r which the c l i e n t came to t reatment ( B a t t l e , Imber, H o e h n - S a r i c , S t o n e , Nash , & F r a n k , 1966) ) , c o r r e l a t e d s i g n i f i c a n t l y w i th the e a r l y a l l i a n c e (r=.44 w i th the r a t i n g method and r=.59 w i th the c o u n t i n g s i g n s method) . As to the development of the h e l p i n g a l l i a n c e , the r e s e a r c h e r s c o n c l u d e d tha t i t was a l r e a d y p resen t at the t h i r d to f i f t h s e s s i o n s and showed a modest degree of c o n s i s t e n c y from the e a r l y to the l a t e s e s s i o n s (r=.57 wi th the r a t i n g method) . T h i s f i n d i n g was more e v i d e n t f o r more improved p a t i e n t s (whose s c o r e s i n c r e a s e d from e a r l y to l a t e s e s s i o n s ) than f o r l e s s improved p a t i e n t s (whose s c o r e s d e c r e a s e d ) . The a l l i a n c e was a l s o found to c o r r e l a t e modera te ly h i g h l y wi th the presence of o b s e r v e r - r a t e d t h e r a p i s t f a c i l i t a t i n g b e h a v i o u r , ( i . e . , e a r l y h e l p i n g a l l i a n c e r a t i n g s c o r r e l a t e d .55 wi th e a r l y t h e r a p i s t f a c i l i t a t i n g behav iour r a t i n g s ) , as w e l l as wi th ten s i m i l a r i t i e s of p a t i e n t and t h e r a p i s t ( £ = . 5 3 ) , e s p e c i a l l y age match and r e l i g i o u s a c t i v i t y match. A s e l f - r e p o r t , the 11- i tem H e l p i n g A l l i a n c e Q u e s t i o n n a i r e ( L u b o r s k y , M c L e l l a n , Woody, O ' B r i e n , & A u e r b a c h , 1985) which r o u g h l y p a r a l l e l s the r a t i n g s c a l e was a d m i n i s t e r e d to male o p i a t e - d e p e n d e n t p a t i e n t s who had r e c e i v e d s u p p o r t i v e e x p r e s s i v e p s y c h o t h e r a p y (n=32), drug c o u n s e l l i n g (n=39), or c o g n i t i v e -20 b e h a v i o u r a l psychotherapy (n=39). The s e l f - r e p o r t was g iven a f t e r the t h i r d s e s s i o n to e s t i m a t e the degree to which the p a t i e n t e x p e r i e n c e d the t h e r a p i s t and the therapy as h e l p f u l . T h e r a p i s t s completed a p a r a l l e l form of the q u e s t i o n n a i r e , the T h e r a p i s t F a c i l i t a t i n g B e h a v i o u r s Q u e s t i o n n a i r e (A lexander & L u b o r s k y , 1986). S c o r e s were c o r r e l a t e d w i th seven-month outcomes. The two forms produced s i m i l a r r e s u l t s — c o r r e l a t i o n s ranged from .51 to .72 w i th four outcome d i m e n s i o n s . In the p resen t s t u d y , the r e l a t i o n s h i p of a l l i a n c e s t r e n g t h as measured by the HAQ to outcome i s compared w i th that measured by the WAIc. T h e r a p i s t s ' e f f e c t i v e n e s s was a l s o examined by Luborsky et a l . (1985) by r a t i n g t h e i r per formance a g a i n s t s p e c i f i c t e c h n i q u e s d e f i n e d in manuals p r e p a r e d f o r the th ree types of t r e a t m e n t . Three de te rminan ts of t h e r a p i s t s u c c e s s were found to r e l a t e to outcome: p e r s o n a l q u a l i t i e s , p u r i t y of t e c h n i q u e , and h e l p i n g a l l i a n c e s c o r e s , w i th the l a s t measure c o r r e l a t i n g most h i g h l y . On the b a s i s of i n t e r c o r r e l a t i o n s of these d e t e r m i n a n t s ( t h e r a p i s t s ' p e r s o n a l q u a l i t i e s were most h i g h l y c o r r e l a t e d wi th the h e l p i n g a l l i a n c e measure, r= .74 ) , the r e s e a r c h e r s c o n c l u d e d tha t t h e r a p i s t s ' p e r s o n a l adjustment and i n t e r e s t i n h e l p i n g the p a t i e n t were c r i t i c a l to the fo rmat ion of a h e l p i n g a l l i a n c e : . . . the major agent of e f f e c t i v e psychotherapy i s the p e r s o n a l i t y of the t h e r a p i s t , p a r t i c u l a r l y the a b i l i t y to form a warm, s u p p o r t i v e r e l a t i o n s h i p . (p . 609) 21 2.2 The V a n d e r b i l t Research Group The V a n d e r b i l t Psychotherapy P r o j e c t (S t rupp & H a d l e y , 1979) i n v e s t i g a t e d the r e l a t i v e c o n t r i b u t i o n s to outcome of the t h e r a p i s t ' s t e c h n i c a l s k i l l s and the q u a l i t i e s inheren t in any good human r e l a t i o n s h i p . S i x t e e n c l i e n t s seen by e x p e r i e n c e d t h e r a p i s t s were compared wi th 15 seen by c o l l e g e p r o f e s s o r s s e l e c t e d fo r t h e i r u n t u t o r e d a b i l i t y to form warm, u n d e r s t a n d i n g , empathic r e l a t i o n s h i p s . P a t i e n t s in both groups showed on average equa l improvement. U s i n g the o b s e r v e r - r a t e d V a n d e r b i l t Psychotherapy P r o c e s s  S c a l e , Gomes-Schwartz (1978) examined the c o n s i d e r a b l e d i f f e r e n c e s in t h e r a p e u t i c r e l a t i o n s h i p s among i n d i v i d u a l d y a d s . She was a b l e to c o n t r i b u t e p r o v o c a t i v e e v i d e n c e tha t up to 38% of the v a r i a n c e in t reatment outcomes c o u l d be accounted f o r by the p a t i e n t ' s involvement in the t h e r a p e u t i c p r o c e s s . P a t i e n t Involvement was d e s c r i b e d as an index of a p a t i e n t ' s a c t i v e p a r t i c i p a t i o n , openness , t r u s t i n the t h e r a p y , and l a c k of h o s t i l i t y and n e g a t i v i s m in the t h e r a p e u t i c i n t e r a c t i o n . G iven an i n v o l v e d p a t i e n t , p r o f e s s i o n a l t h e r a p i s t s were a b l e to maximize t h e r a p e u t i c g a i n s . S t r u p p and Hadley (1979) c o n c l u d e d that t h e r a p e u t i c change seemed to o c c u r when there was a c o n j u n c t i o n between a p a t i e n t who was c a p a b l e of t a k i n g advantage of a benign human r e l a t i o n s h i p and a t h e r a p i s t whose i n t e r v e n t i o n s were e x p e r i e n c e d by the p a t i e n t as e x p r e s s i o n s of c a r i n g and genuine i n t e r e s t . Whi le the " t e c h n i q u e s " of p r o f e s s i o n a l t h e r a p i s t s d i d not seem to g i v e r i s e to measurably s u p e r i o r t reatment e f f e c t s , 22 these s k i l l s appeared to p o t e n t i a t e the n a t u r a l h e a l i n g p r o c e s s e s inheren t in a "good human r e l a t i o n s h i p " , p r o v i d e d the p a t i e n t was a b l e to f e e l c o m f o r t a b l e wi th and resonate to the t h e r a p i s t ' s g e n e r a l approach to t h e r a p y . Moras and S t rupp (1982) examined the pre t rea tment v a r i a b l e s , ( i . e . , p e r s o n a l i t y c o r r e l a t e s ) , i n the V a n d e r b i l t database in r e l a t i o n to both the a l l i a n c e s formed and the outcomes a c h i e v e d . C l i n i c a l assessments of i n t e r p e r s o n a l r e l a t i o n s p r e d i c t e d p a t i e n t s ' l e v e l s of involvement in the t h e r a p e u t i c r e l a t i o n s h i p , a c c o u n t i n g f o r up to 25% of the v a r i a n c e as r a t e d by o b s e r v e r s . S i n c e modera te ly to s e v e r e l y i m p a i r e d i n t e r p e r s o n a l r e l a t i o n s were l e s s r e l i a b l e p r e d i c t o r s than were b a s i c a l l y adequate r e l a t i o n s , the r e s e a r c h e r s c o n c l u d e d tha t t h e r a p i s t i n t e r v e n t i o n s or the p a r t i c u l a r p a t i e n t - t h e r a p i s t match p l a y a major r o l e i n the development of an a l l i a n c e , s p e c i f i c a l l y f o r p a t i e n t s who have d i f f i c u l t y i n i n t e r p e r s o n a l r e l a t i o n s . H a r t l e y and S t rupp (1983) c o n s t r u c t e d the o b s e r v e r - r a t e d V a n d e r b i l t U n i v e r s i t y T h e r a p e u t i c A l l i a n c e S c a l e (44 i tems) and a p p l i e d i t to samples of the V a n d e r b i l t p r o j e c t d a t a . A l t h o u g h t h e i r a n a l y s i s of v a r i a n c e i n d i c a t e d no s i g n i f i c a n t a s s o c i a t i o n between a l l i a n c e s c o r e s and outcome g r o u p s , they compared more and l e s s s u c c e s s f u l dyads and d i s c o v e r e d tha t the former i n c r e a s e d t h e i r a l l i a n c e i n the i n i t i a l p h a s e , peak ing a t the f i r s t q u a r t i l e p o i n t of therapy and then t r a i l i n g o f f a g a i n i n l a t e r s e s s i o n s . The p a t t e r n of s c o r e s f o r the l e s s s u c c e s s f u l g r o u p , on the o ther hand, was a m i r r o r image of t h a t . T h e i r 23 a l l i a n c e s c o r e s f e l l from t h e i r i n i t i a l e q u a l i t y w i th the o ther group and rose a g a i n at the midpoin t of t h e r a p y . However, they never a c h i e v e d s c o r e s as h i g h as the peak of the more s u c c e s s f u l g r o u p . In the l a t e r p h a s e s , there were no s u b s t a n t i a l d i f f e r e n c e s between groups and by the end of t h e r a p y , they once more were e s s e n t i a l l y e q u a l . H a r t l e y and S t r u p p noted tha t in the i n i t i a l phase of t h e r a p y , the two groups were s i g n i f i c a n t l y d i v e r g e n t on the R e s p o n s i b i l i t y and A n x i e t y f a c t o r s of t h e i r s c a l e . L i k e Gomes-Schwartz (1978) , they c o n c l u d e d tha t those p a t i e n t s who went on to a c h i e v e b e t t e r outcomes a c c e p t e d t h e i r own r o l e in b r i n g i n g about change , and they became more open and l e s s anx ious in the s e s s i o n s . O ' M a l l e y , Suh , and S t r u p p (1983) measured the r e l a t i o n s h i p s in the same data in each of the f i r s t t h r e e s e s s i o n s wi th a r e v i s e d V a n d e r b i l t Psychotherapy P r o c e s s S c a l e . They found a p a t t e r n of i n c r e a s e d a s s o c i a t i o n between p r o c e s s and outcome from which they c o n c l u d e d tha t Involvement i s not n e c e s s a r i l y an antecedent q u a l i t y of the p a t i e n t , but d e v e l o p s in the course of t h e r a p y . Moreover , change in p a t i e n t p a r t i c i p a t i o n over the f i r s t th ree s e s s i o n s c o r r e l a t e d more s t r o n g l y than a b s o l u t e p a t i e n t p a r t i c i p a t i o n in the t h i r d s e s s i o n wi th outcome ( £ = . 6 3 v s . . 4 6 ) . They (Suh, O ' M a l l e y , & S t r u p p , 1986) accounted f o r t h i s in terms of the p a t t e r n s of t h e r a p i s t a c t i v i t y in the e a r l y s e s s i o n s . I n c r e a s e s in T h e r a p i s t Warmth & F r i e n d l i n e s s and in T h e r a p i s t E x p l o r a t i o n r e s u l t e d in h i g h outcomes f o r low p r o g n o s i s p a t i e n t s . The r e l a t i o n s h i p of change in a l l i a n c e s t r e n g t h over e a r l y 24 s e s s i o n s to outcome i s f u r t h e r e x p l o r e d in the p r e s e n t s t u d y . 2.3 The L a n g l e y P o r t e r Research Group M a r z i a l i , Marmar and K r u p n i c k (1981) deve loped an o b s e r v e r -r a t e d T h e r a p e u t i c A l l i a n c e S c a l e to measure what they termed the a f f e c t i v e , a t t i t u d i n a l a s p e c t s of the t h e r a p e u t i c c l i m a t e . In a p i l o t s tudy w i th the f i v e most and f i v e l e a s t improved of 25 p a t i e n t s t r e a t e d in b r i e f dynamic therapy at the L a n g l e y P o r t e r I n s t i t u t e , the 21 - i tem P a t i e n t C o n t r i b u t i o n S c a l e d i s c r i m i n a t e d marked ly : p a t i e n t s r a t e d as making a s t r o n g p o s i t i v e c o n t r i b u t i o n to the t h e r a p e u t i c a l l i a n c e had good t reatment outcomes. P a t i e n t s r a t e d as c o n t r i b u t i n g n e g a t i v e l y had poor outcomes. In another study of 52 p a t h o l o g i c a l bereavement c a s e s , p a t i e n t s ' p o s i t i v e c o n t r i b u t i o n s d i d not p r e d i c t outcome, a l t h o u g h p a t i e n t s ' n e g a t i v e c o n t r i b u t i o n s d i d (r=.34 (2<.05); H o r o w i t z , Marmar, W e i s s , DeWi t t , & Rosenbaum, 1984). However, h i e r a r c h i c a l m u l t i p l e r e g r e s s i o n a n a l y s i s r e v e a l e d tha t i n i t i a l p a t i e n t m o t i v a t i o n i n t e r a c t e d w i th the a l l i a n c e s c a l e s in a mean ingfu l way to p r e d i c t outcome. M a r z i a l i (1984) compared three v i e w p o i n t s on the a l l i a n c e -p a t i e n t , t h e r a p i s t and n o n p a r t i c i p a n t judge r a t i n g s of the same s e s s i o n s . P a t i e n t and t h e r a p i s t - r a t e d s c a l e s p a r a l l e l e d the o r i g i n a l o b s e r v e r - r a t e d T h e r a p e u t i c A l l i a n c e S c a l e . The th ree measurement systems were t e s t e d on 42 p a t i e n t s in b r i e f dynamic psychotherapy in s e s s i o n s 1, 3, 5, 10, 15, and 20. There was s i g n i f i c a n t agreement between them in t h e i r e s t i m a t e s of the p a t i e n t s ' p o s i t i v e c o n t r i b u t i o n s , l e s s f o r the p a t i e n t s ' 25 n e g a t i v e c o n t r i b u t i o n s , and i n s i g n i f i c a n t i n t e r c o r r e l a t i o n s of r a t i n g s of t h e r a p i s t p o s i t i v e and n e g a t i v e c o n t r i b u t i o n s . The p a t i e n t c o n t r i b u t i o n s in each of the th ree r a t i n g systems were the best p r e d i c t o r s of outcome, b e i n g a s s o c i a t e d as e a r l y as the f i r s t and t h i r d s e s s i o n s . Hence, the s tudy c o n c l u d e d tha t P a t i e n t s ' and t h e r a p i s t s ' r a t i n g s of t h e i r own and the o t h e r ' s p o s i t i v e c o n t r i b u t i o n s to the t h e r a p e u t i c r e l a t i o n s h i p are power fu l p r e d i c t o r s of t h e r a p e u t i c change . . . equa l or b e t t e r . . . than the r a t i n g s p r o v i d e d by n o n p a r t i c i p a n t j u d g e s . I t may be that the t h e r a p e u t i c p a r t i c i p a n t s p r o v i d e the more a u t h e n t i c v e r s i o n s of the q u a l i t y of the t reatment r e l a t i o n s h i p , (p . 422) In the p r e s e n t s t u d y , the r e l a t i o n s h i p of congruence of c l i e n t and t h e r a p i s t r a t i n g s of a l l i a n c e s t r e n g t h to outcome i s e x p l o r e d . Marmar, M a r z i a l i , Horowi tz & Weiss (1986) a p p l i e d the o b s e r v e r - r a t e d s c a l e to 15 c a s e s (segments of the 2nd, 5 t h , 8 t h , 11th, and 12th hours of 12-hour t rea tments ) and s u b j e c t e d the r e s u l t s to a f a c t o r a n a l y s i s . Two p a t i e n t p o s i t i v e f a c t o r s e m e r g e d — s a t i s f a c t i o n w i th therapy and working c a p a c i t y and commitment. These r e s u l t s were c o n f i r m e d in a r e p l i c a t i o n w i t h 32 p a t i e n t s . 2.4 The Menninger Research Group The Menninger F o u n d a t i o n ' s Psychotherapy Research P r o j e c t ( H o r w i t z , 1974), a 20 -year l o n g i t u d i n a l s tudy of 42 c a s e s , i d e n t i f i e d the t h e r a p e u t i c a l l i a n c e as not o n l y a p r e r e q u i s i t e f o r t h e r a p e u t i c work, but o f t e n as the main v e h i c l e of change . However, the d e s i g n of the s tudy was n a t u r a l i s t i c and l o o s e 26 (Ge lso & C a r t e r , 1985) and , hence , i t s r e s u l t s c o u l d not be taken to be e m p i r i c a l l y s o u n d . The c u r r e n t Kansas measures of the t h e r a p e u t i c a l l i a n c e more nar rowly c o n f i n e the a l l i a n c e to the p a t i e n t ' s c o l l a b o r a t i v e behav iour wi th the t h e r a p i s t , ana logous to L u b o r s k y ' s (1976) Type 2 h e l p i n g a l l i a n c e . In o rder to s e p a r a t e the t h e r a p e u t i c a l l i a n c e from t h e r a p i s t t e c h n i q u e , F r i e s w y k , C o l s o n , & A l l e n (1984) d e f i n e d the a l l i a n c e e x c l u s i v e l y in terms of the p a t i e n t ' s a c t i v i t y . To a l s o s e p a r a t e i t from t r a n s f e r e n c e , they r e s t r i c t e d the d e f i n i t i o n to the p a t i e n t ' s c o l l a b o r a t i v e work i n p s y c h o t h e r a p y . A l l e n , Newsom, Gabbard , & Coyne (1984) then d e v i s e d an o b s e r v e r - r a t e d C o l l a b o r a t i o n S c a l e to a s s e s s the a l l i a n c e and f o u r s c a l e s to a s s e s s m e d i a t i n g p a t i e n t f a c t o r s — t r u s t i n the t h e r a p i s t ' s commitment, s k i l l and m o t i v e s ; sense of a c c e p t a n c e ; opt imism about the outcome of t h e r a p y ; and e x p r e s s i o n of a f f e c t . C o l l a b o r a t i o n was d e f i n e d as f o l l o w s : The i n t e n t of t h i s s c a l e i s to determine the ex ten t to which the p a t i e n t i s making o p t i m a l use of the t reatment as a r e s o u r c e f o r c o n s t r u c t i v e change . More s p e c i f i c a l l y , the s c a l e a s s e s s e s the degree to which the p a t i e n t a c t i v e l y p a r t i c i p a t e s i n the work, c o n c r e t e l y e v i d e n c e d i n h i s or her engagement i n the r e q u i s i t e t reatment t a s k s , whatever they may be . R a t e r s a re to a s s e s s the p a t i e n t ' s use of the t h e r a p y , t a k i n g i n t o account the degree to which he or she (a) works a c t i v e l y in the s e s s i o n , (b) b r i n g s s i g n i f i c a n t i s s u e s and m a t e r i a l i n t o the t rea tment , (c) open ly p r o v i d e s i n f o r m a t i o n and e x p r e s s e s f e e l i n g s , (d) makes good use of the t h e r a p i s t ' s t reatment e f f o r t s , (e) a p p l i e s the work done in therapy ( e . g . , i n s i g h t s and a d v i c e ) to l i f e o u t s i d e the t h e r a p y , and ( f ) adopts t h e r a p e u t i c f u n c t i o n s ( e . g . , s e l f - o b s e r v a t i o n ) to c a r r y the work forward i n d e p e n d e n t l y . (p . 386) R e l i a b i l i t y of the s c a l e s was demonstra ted u s i n g the 27 V a n d e r b i l t p r o j e c t d a t a . The component s c a l e s most h i g h l y c o r r e l a t e d w i t h o v e r a l l c o l l a b o r a t i v e r a t i n g s were: makes good use of t h e r a p i s t ' s e f f o r t s ( . 96 ) ; works a c t i v e l y ( . 92 ) ; shows r e s i s t a n c e ( - . 8 9 ) ; r e f l e c t s ( . 88 ) ; and i s m o t i v a t e d to change ( . 8 7 ) . The r e s e a r c h e r s a l s o found h i g h c o r r e l a t i o n s between the th ree m e d i a t i n g f a c t o r s a s s o c i a t e d wi th the p a t i e n t ' s e x p e r i e n c e of the r e l a t i o n s h i p . They s t r e s s e d , however, tha t t h e i r s c a l e s were s p e c i f i c a l l y d e s i g n e d to a s s e s s the a l l i a n c e r e q u i r e d f o r p s y c h o a n a l y t i c t h e r a p y . F r i e s w y k , A l l e n , C o l s o n , Coyne , Gabbard , H o r w i t z , & Newson (1986) p l a n t o employ t h e i r ins t rument in the i n t e n s i v e s tudy of s i n g l e c a s e s ( i n p a r t i c u l a r w i th b o r d e r l i n e p a t i e n t s ) i n order to t r a c k w i t h i n - s e s s i o n s h i f t s in the a l l i a n c e as they r e l a t e to v a r i o u s t y p e s of t h e r a p e u t i c i n t e r v e n t i o n s . 2 .5 The B r i t i s h Columbia Research Group Horvath (1981) employed the Working A l l i a n c e Inventory in c l i e n t and t h e r a p i s t s e l f - r e p o r t v e r s i o n s to p r e d i c t outcome a f t e r the t h i r d s e s s i o n f o r 29 c l i e n t s r e c e i v i n g psychotherapy based on a v a r i e t y of t h e o r e t i c a l o r i e n t a t i o n s . The WAI p r e d i c t e d p s y c h o t h e r a p y outcome as measured w i th the S t r u p p  P o s t t h e r a p y Q u e s t i o n n a i r e ( S t r u p p , W a l l a c h , & Wogan, 1964) more e f f i c i e n t l y than d i d the Empathy s u b s c a l e of the R e l a t i o n s h i p  Inventory ( B a r r e t t - L e n n a r d , 1962) or the C o u n s e l o r R a t i n g Form (Barak & L a C r o s s e , 1975). The Task s u b s c a l e was the most u s e f u l p r e d i c t o r of a l l a s p e c t s of therapy outcome based on c l i e n t s e l f - r e p o r t ( r= .57 ) . An overv iew of the r e s u l t s of the c o r r e l a t i o n a l da ta based on t h e r a p i s t r e p o r t (a m o d i f i e d v e r s i o n 28 of the S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e ) i n d i c a t e d that the Task domain was a l s o the most e f f e c t i v e in p r e d i c t i n g t h e r a p i s t -r e p o r t e d c l i e n t s a t i s f a c t i o n and adjustment (r=.68 and .32 r e s p e c t i v e l y ) . The t h e r a p i s t ' s p e r c e p t i o n of c l i e n t changes , however, most s t r o n g l y c o r r e l a t e d wi th the t h e r a p i s t - r e p o r t e d Bond component ( r= .47 ) . R e l a t i o n s h i p and outcome measures were o b t a i n e d from 36 s u b j e c t s i n v o l v e d i n a program i n which the g e s t a l t t w o - c h a i r method was used to h e l p r e s o l v e d e c i s i o n a l c o n f l i c t (Greenberg & Webster , 1982). The Task s u b s c a l e , the Empathy s u b s c a l e of the R e l a t i o n s h i p Inventory and the C o u n s e l o r R a t i n g Form s c a l e s were comple ted a f t e r the second s e s s i o n and a measure of c l i e n t v o i c e q u a l i t y ( R i c e , Koke, G r e e n b e r g , & W a g s t a f f , 1979) was taken in the f i r s t s e s s i o n . The Task s u b s c a l e c o n s i s t e n t l y r e l a t e d to a v a r i e t y of outcome i n d i c e s more h i g h l y than any of the o ther p r o g n o s t i c i n d i c a t o r s a c c o u n t i n g f o r between 30 to 46% of the outcome v a r i a n c e . I t i s important t o note tha t a l l the s u b j e c t s were engaged in a h i g h l y s i m i l a r , a c t i v e t h e r a p e u t i c t a s k , ( i . e . , g e s t a l t t w o - c h a i r d i a l o g u e ) , so tha t these r e s u l t s a p p l i e d to a s i t u a t i o n in which a d i r e c t e d t h e r a p e u t i c task was b e i n g u s e d . N o t i n g the h i g h c o r r e l a t i o n between Task and Empathy in t h i s and in t h e i r own s t u d y , Horvath and Greenberg (1986) c o n c l u d e d tha t u t i l i z a t i o n by the t h e r a p i s t of t a s k s which were p e r c e i v e d by the c l i e n t as r e l e v a n t may l e a d the c l i e n t to p e r c e i v e the t h e r a p i s t as e m p a t h i c . Task was p o s s i b l y more h i g h l y r e l a t e d to outcome by v i r t u e of i t be ing a more s p e c i f i c 29 and more i n t e r a c t i o n a l measure, i n d i c a t i n g tha t i f c l i e n t s p e r c e i v e t h e i r t h e r a p i s t s ' i n - s e s s i o n s u g g e s t i o n s or r e q u e s t s as r e l e v a n t to t h e i r g o a l s , they may p e r c e i v e the t h e r a p i s t as empathic even i f the s u g g e s t i o n s or r e q u e s t s are c h a l l e n g i n g or c o n f r o n t i n g . Moseley (1983) employed a r e v i s e d WAI (Horva th , 1982) w i th 25 c l i e n t s in b r i e f therapy from a v a r i e t y of o r i e n t a t i o n s . L i k e Horvath (1981), Moseley found a s t r o n g c o r r e l a t i o n between the G o a l and Task s u b s c a l e s s u g g e s t i n g tha t i s s u e s p e r t a i n i n g to therapy o b j e c t i v e s , ( i . e . , G o a l ) , and therapy a c t i v i t i e s , ( i . e . , T a s k ) , a re h i g h l y o v e r l a p p e d in the e a r l y phases of the a l l i a n c e . A g a i n , the WAI in g e n e r a l and the Task s u b s c a l e in p a r t i c u l a r were found to be r e l i a b l y c o r r e l a t e d w i th therapy outcome as measured by improvement in t a r g e t c o m p l a i n t s ( B a t t l e et a l . , 1966) and the S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e ( S t r u p p , W a l l a c h , & Wogan, 1964). No s i g n i f i c a n t r e l a t i o n s h i p was found between the a l l i a n c e measure and e i t h e r change i n s t a t e a n x i e t y ( S t a t e - T r a i t A n x i e t y I n v e n t o r y ; S p i e l b e r g e r , G o r s u c h , & Lushene , 1970) or change in s e l f - c o n c e p t (Tennessee S e l f - C o n c e p t  Q u e s t i o n n a i r e ; F i t t s , 1965). Moseley c o n c l u d e d tha t these f i n d i n g s on both s t a n d a r d i z e d p e r s o n a l i t y ins t ruments used in the s tudy suggested that the c o r r e l a t i o n between c l i e n t r e p o r t s at the end of the t h i r d s e s s i o n and at t e r m i n a t i o n on the S t rupp  P o s t t h e r a p y Q u e s t i o n n a i r e and improvement i n t a r g e t c o m p l a i n t s might s i m p l y have r e p r e s e n t e d a s a t i s f a c t i o n e f f e c t r a t h e r than a p r e d i c t i o n of change. A l t e r n a t i v e l y , the l a c k of r e l a t i o n s h i p s wi th the a n x i e t y and s e l f - c o n c e p t measures might 30 be e x p l a i n e d as a l a c k of f i t between these measures and the a c t u a l changes in the t r e a t m e n t , or a f u n c t i o n of the b r e v i t y of the t r e a t m e n t s . In the p r e s e n t s t u d y , the r e l a t i o n s h i p of the WAI to outcome i s examined employing a number of outcome measures tha t r e f l e c t the v a r i e t y c u r r e n t l y be ing u t i l i z e d in the f i e l d of psychotherapy r e s e a r c h . 2 .6 The Involvement Dimension One of the most c o n s i s t e n t f i n d i n g s of the working a l l i a n c e r e s e a r c h to date has been the s i g n i f i c a n t r e l a t i o n s h i p of c l i e n t involvement to t h e r a p e u t i c s u c c e s s ( A l l e n et a l . , 1984; Gomes-S c h w a r t z , 1978; Greenberg & P i n s o f , 1986; L u b o r s k y , 1976). The most r e c e n t l y r e p o r t e d e f f o r t s of the v a r i o u s r e s e a r c h groups have a c c o r d i n g l y been d i r e c t e d at d i s c o v e r i n g the t h e r a p i s t d e t e r m i n a n t s of c l i e n t involvement ( A l l e n et a l . , 1984; Horowi tz & Marmar, 1985; Luborsky et a l . , 1985). B e u t l e r , Dunbar , & Baer (1980) r e p o r t e d tha t more e f f e c t i v e t h e r a p i s t s (as r a t e d by t h e i r s u p e r v i s o r s ) p e r c e i v e d s i g n i f i c a n t l y more engagement, ( i . e . , i n v o l v e m e n t ) , i n t h e i r c l i e n t s . B a e r , Dunbar , Hami l ton I I , & B e u t l e r (1980) per formed a f a c t o r a n a l y s i s of a 74 - i tem p s y c h o t h e r a p e u t i c p r o c e s s i n v e n t o r y employed by 26 t h e r a p i s t s to r a t e t h e i r e x p e r i e n c e w i th 99 p a t i e n t s in a p s y c h i a t r i c c l i n i c . T h e r a p e u t i c P a r t i c i p a t i o n , ( i . e . , the ex tent to which the p a t i e n t p a r t i c i p a t e s p r o d u c t i v e l y in the t h e r a p e u t i c p r o c e s s by d e m o n s t r a t i n g s e l f - d i s c l o s u r e , s e l f - a w a r e n e s s , i n s i g h t , or behav iour c h a n g e ) , emerged as the 31 most s i g n i f i c a n t f a c t o r a c c o u n t i n g f o r 16.5% of the v a r i a n c e in the t h e r a p i s t s ' judgments of outcome of t r e a t m e n t . Remarking on the c o n s i s t e n c y of t h e i r f i n d i n g s w i th those of Gomes-Schwartz (1978) , Baer e t a l . suggested that Psychotherapy i s c h a r a c t e r i z e d by r e l a t i v e l y c o n s i s t e n t d imens ions of p r o c e s s and a c t i v i t y which vary in degree from t h e r a p i s t to t h e r a p i s t . (p . 569) U s i n g the same c l i n i c a l sample , K o l b , B e u t l e r , D a v i s , C r a g o , and S h a n f i e l d (1982) compared the i n f l u e n c e of p a t i e n t ' s p e r s o n a l i t y , l o c u s of c o n t r o l , p e r c e p t i o n of the q u a l i t y of the t h e r a p e u t i c r e l a t i o n s h i p and therapy involvement on the outcome of psychotherapy wi th 91 p a t i e n t s . P a t i e n t ' s involvement was the best p r e d i c t o r of o v e r a l l s u c c e s s , be ing a s s o c i a t e d w i th both p a t i e n t and t h e r a p i s t g l o b a l r a t i n g s of improvement and w i th d e c r e a s e s in somat ic and p a r a n o i d symptoms as measured wi th the Symptom C h e c k l i s t - 9 0 ( D e r o g a t i s , L ipman, & C o v i , 1973). Therapy dropout was a l s o found to be p r e d i c t a b l e from i n v o l v e m e n t . In the p resen t s t u d y , the r e l a t i o n s h i p s of e x p l o r a t o r y c l i e n t and t h e r a p i s t - r a t e d involvement measures to outcome are examined. 3. SIGNIFICANCE OF THE PRESENT STUDY D u r i n g the past d e c a d e , the f i e l d of a l l i a n c e r e s e a r c h has been a c t i v e l y g e n e r a t i n g f i n d i n g s and h y p o t h e s e s . The B r i t i s h Columbia Research Group has focused on the use of s e l f - r e p o r t a l l i a n c e measures based on B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n . H o r v a t h ' s (1981) e x p l o r a t o r y study of the 32 p r e d i c t i v e c a p a c i t y of the c l i e n t - r a t e d working a l l i a n c e has p r o v i d e d some ev idence tha t t h i s more s imp ly a d m i n i s t e r e d measure may be a t l e a s t as e f f e c t i v e as the r a t e r - r e p o r t e d measures deve loped by o ther r e s e a r c h g r o u p s . Greenberg and W e b s t e r ' s (1982) and M o s e l e y ' s (1983) s t u d i e s have c o r r o b o r a t e d t h i s e v i d e n c e . However, s m a l l and r e s t r i c t e d samples have l i m i t e d the g e n e r a l i z a b i l i t y of the r e s u l t s of these t h r e e s t u d i e s . Moreover , Horvath r e l a t e d the a l l i a n c e to outcome as measured wi th a c l i e n t r e p o r t of s a t i s f a c t i o n , ( i . e . , the S t r u p p  P o s t t h e r a p y Q u e s t i o n n a i r e ) . Hence, the q u e s t i o n may be p o s e d : Is the c o r r e l a t i o n s imply an a r t i f a c t of the c o n s t a n c y of c l i e n t s a t i s f a c t i o n through therapy r a t h e r than a t r u e measure of change ( G l a s s , 1984)? M o s e l e y ' s at tempt to examine t h i s w i th two s t a n d a r d i z e d p e r s o n a l i t y measures f a i l e d to demonstrate c o r r e l a t i o n s between them and the a l l i a n c e . F i n a l l y , a l l t h r e e s t u d i e s based t h e i r a n a l y s e s of c o r r e l a t i o n on o n l y a s i n g l e a d m i n i s t r a t i o n of the WAI, ( i . e . , at a s i n g l e p o i n t i n t h e r a p y ) . The p r e s e n t s tudy i s i n t e n d e d to more d e f i n i t i v e l y e s t a b l i s h the u t i l i t y of c l i e n t and t h e r a p i s t - r a t e d measures , both the WAI and the r e c e n t l y deve loped HAQ which i s based on L u b o r s k y ' s (1976) c o n c e p t u a l i z a t i o n of the a l l i a n c e . A number of outcome measures c u r r e n t l y be ing employed in the f i e l d of p s y c h o t h e r a p y r e s e a r c h are u t i l i z e d . The study a l s o s u b j e c t s some recent hypotheses r e g a r d i n g the r e l a t i o n s h i p of change i n a l l i a n c e s t r e n g t h to outcome ( H a r t l e y & S t r u p p , 1983; Suh et a l . , 1985) and the s i g n i f i c a n c e of c l i e n t involvement as a subdimension and i n d i c a t o r of the a l l i a n c e (Greenberg & P i n s o f , 33 1986) to e x a m i n a t i o n . 4. RESEARCH HYPOTHESES The p r e s e n t study was in tended to t e s t the f o l l o w i n g h y p o t h e s e s : H o - 1 : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the Working  A l l i a n c e Inventory and outcome. 1 Ho-1 a : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc and outcome. H o - 1 b : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIt and outcome. H a - 1 : There i s a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p or c o r r e l a t i o n between p e r c e i v e d a l l i a n c e s t r e n g t h  and outcome. H o - 2 : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between p e r c e i v e d change in a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s as measured by the Working A l l i a n c e Inventory and outcome. H o - 2 a : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between c l i e n t - p e r c e i v e d change in a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s as measured by the WAIc The s i x ins t ruments used to measure outcome are T a r g e t C o m p l a i n t s Improvement, r e s i d u a l g a i n on the Symptom C h e c k l i s t -90, the S e l f - E s t e e m Index, and the Inventory of I n t e r p e r s o n a l  P rob lems , and the S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e and the T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e . 34 and outcome. Ho-2b: There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between t h e r a p i s t - p e r c e i v e d change in a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s as measured by the WAIt and outcome. H a - 2 : There i s a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p or c o r r e l a t i o n between p e r c e i v e d change in a l l i a n c e  s t r e n g t h over the f i r s t f i v e s e s s i o n s and outcome. H o - 3 : There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc to outcome and the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d t h e r a p i s t empathy, a t t r a c t i v e n e s s , e x p e r t n e s s , or t r u s t w o r t h i n e s s to outcome. H o - 3 a : There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc to outcome and the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d empathy as measured by the Empathy s u b s c a l e of the R e l a t i o n s h i p Inventory to outcome. Ho -3b : There i s no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc t o outcome and the r e l a t i o n s h i p of c l i e n t - p e r c e i v e d t h e r a p i s t a t t r a c t i v e n e s s , e x p e r t n e s s , or t r u s t w o r t h i n e s s as measured by the C o u n s e l o r R a t i n g Form to outcome. H a - 3 : There i s a l a r g e r s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e  r e l a t i o n s h i p between c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h and  outcome than between c l i e n t - p e r c e i v e d t h e r a p i s t empathy, 35 a t r a c t i v e n e s s , e x p e r t n e s s , or t r u s t w o r t h i n e s s and outcome. H o - 4 : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between c l i e n t - p e r c i e v e d a l l i a n c e s t r e n g t h as measured by the H e l p i n g A l l i a n c e Q u e s t i o n n a i r e and outcome. H a - 4 ; There i s a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p or c o r r e l a t i o n between c l i e n t - p e r c e i v e d a l l i a n c e  s t r e n g t h as measured by the H e l p i n g A l l i a n c e Q u e s t i o n n a i r e and  outcome. H o - 5 ; There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between p e r c e i e d c l i e n t invo lvement as measured by the e x p l o r a t o r y C l i e n t Involvement S c a l e and outcome. H o - 5 a : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between c l i e n t - p e r c e i v e d c l i e n t involvement as measured by the CISc and outcome. Ho -5b : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between t h e r a p i s t - p e r c e i v e d c l i e n t involvement as measured by the CISt and outcome. H a - 5 : There i s a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p or c o r r e l a t i o n between p e r c e i v e d c l i e n t involvement  and outcome. H o - 6 : There i s no s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between congruence of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIc and t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured by the WAIt and outcome. Ha-61 There i s a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p or c o r r e l a t i o n between congruence of c l i e n t - p e r c e i v e d and t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h and outcome. 36 The r e s u l t s of the a n a l y s e s in the p resen t study have been i n t e r p r e t e d u s i n g the .05 p r o b a b i l i t y l e v e l of s t a t i s t i c a l s i g n i f i c a n c e . 37 I I I . METHODS AND PROCEDURES 1. DESIGN OF THE STUDY In the p resen t s t u d y , the development of working a l l i a n c e s has been examined through s e l f - r e p o r t q u e s t i o n n a i r e s completed by c l i e n t s and t h e r a p i s t s i n the course of t h e i r a c t u a l t h e r a p e u t i c engagements- t o g e t h e r . The e f f e c t i v e n e s s of these a l l i a n c e s has been a s s e s s e d by r e l a t i n g them to a v a r i e t y of s e l f - r e p o r t outcome measures . F o r t y - f o u r t h e r a p i e s were t r a c k e d from f i r s t to l a s t s e s s i o n , ( i . e . , working a l l i a n c e measures were taken a f t e r each of the f i r s t f i v e s e s s i o n s , the t e n t h s e s s i o n ( i f there was o n e ) , and the f i n a l s e s s i o n . In a l l , seven r e l a t i o n s h i p measures (which encompassed 18 s u b s c a l e s ) were employed to a s s e s s the t h e r a p e u t i c r e l a t i o n s h i p s that were formed, four measures (encompassing 12 s u b s c a l e s ) of which were a d m i n i s t e r e d as repea ted measures, ( i . e . , the WAIc, the C l i e n t Involvement  S c a l e ( C l i e n t Form) , the WAIt, and the C l i e n t Involvement S c a l e ( T h e r a p i s t Form) ) . A l l of the r e l a t i o n s h i p measures were c o r r e l a t e d w i th s i x outcome measures (which encompassed 29 s u b s c a l e s ) as w e l l as wi th one another in order to determine the na ture and e f f e c t i v e n e s s of the 44 working a l l i a n c e s . The independent v a r i a b l e s were: - c l i e n t r a t i n g s of the s t r e n g t h of WAI C o m p o s i t e , G o a l s , T a s k s , Bonds, and Involvement a f t e r each of the f i r s t f i v e , t e n t h , and f i n a l therapy s e s s i o n s . - t h e r a p i s t r a t i n g s of the s t r e n g t h of WAI C o m p o s i t e , G o a l s , 38 T a s k s , Bonds, and c l i e n t Involvement a f t e r each of the f i r s t f i v e , t e n t h , and f i n a l therapy s e s s i o n s . - c l i e n t r a t i n g of t h e r a p i s t Empathy a f t e r the t h i r d s e s s i o n ( R e l a t i o n s h i p Inventory ) - c l i e n t r a t i n g s of t h e r a p i s t E x p e r t n e s s , A t t r a c t i v e n e s s , and T r u s t w o r t h i n e s s a f t e r the t h i r d s e s s i o n (Counse lor R a t i n g  Form) - c l i e n t r a t i n g of the h e l p i n g a l l i a n c e a f t e r the t h i r d s e s s i o n ( H e l p i n g A l l i a n c e Q u e s t i o n n a i r e ) The dependent v a r i a b l e s were: - t a r g e t c o m p l a i n t s improvements - r e s i d u a l g a i n s in symptom r e d u c t i o n (Symptom C h e c k l i s t - 9 0 ) , s e l f - e s t e e m ( S e l f - E s t e e m I n d e x ) , and i n t e r p e r s o n a l problem r e s o l u t i o n ( Inventory of I n t e r p e r s o n a l Problems) - c l i e n t p o s t t h e r a p y assessment - t h e r a p i s t p o s t t h e r a p y assessment 2. POPULATION The p o p u l a t i o n from which the sample was drawn c o n s i s t e d of a c t u a l p s y c h o t h e r a p i e s be ing conduc ted in Vancouver and V i c t o r i a , B r i t i s h Columbia and at the York U n i v e r s i t y C o u n s e l l i n g C e n t r e in T o r o n t o , O n t a r i o d u r i n g F e b r u a r y , 1986 th rough May, 1987. The p o p u l a t i o n was r e s t r i c t e d as f o l l o w s : 1. The c l i e n t s were in therapy f o r the f i r s t t ime w i th the p a r t i c i p a t i n g t h e r a p i s t s . 2. The c l i e n t s were at l e a s t 18 y e a r s o l d . 3. The c l i e n t s were d i a g n o s e d as not p s y c h o t i c and not 39 s u i c i d a l by the p a r t i c i p a t i n g t h e r a p i s t s . 4 . The c l i e n t s were engaging in i n d i v i d u a l therapy r a t h e r than c o n j o i n t or f a m i l y t h e r a p y . A l t h o u g h some of the therapy s e s s i o n s may have i n v o l v e d t h e i r s p o u s e s , in the view of the p a r t i c i p a t i n g t h e r a p i s t s , i n d i v i d u a l therapy was the major s e r v i c e be ing p r o v i d e d to the c l i e n t s . 5. The c l i e n t s were w i l l i n g and a b l e to g i v e t h e i r in formed consent to p a r t i c i p a t e in the s t u d y . In B r i t i s h C o l u m b i a , about 40 s o c i a l s e r v i c e a g e n c i e s employ ing t h e r a p i s t s and about 60 t h e r a p i s t s i n p r i v a t e p r a c t i c e were a p p r o a c h e d , f i r s t by l e t t e r (Appendices 1 and 2) and then by t e l e p h o n e . When i n v i t e d , the r e s e a r c h e r a t t e n d e d agency s t a f f meet ings in o rder to review wi th the a g e n c i e s ' t h e r a p i s t s the nature and scope of the r e s e a r c h , the broad o u t l i n e of the s t u d y , the amount of t ime the p r o c e d u r e s would r e q u i r e , and the s a f e g u a r d s tha t had been d e s i g n e d to p r o t e c t c l i e n t and t h e r a p i s t c o n f i d e n t i a l i t y and anonymi ty . These s a f e g u a r d s a re d e t a i l e d be low. No i n f o r m a t i o n was, of c o u r s e , g i v e n r e g a r d i n g the h y p o t h e s i z e d s t r u c t u r e of the working a l l i a n c e . Indeed, the use of the term was a v o i d e d , the r e s e a r c h be ing d i s c u s s e d i n terms of an e x p l o r a t i o n of the na ture of the t h e r a p e u t i c r e l a t i o n s h i p . As w e l l , c l i n i c and p r a c t i c a s t u d e n t s in the masters and d o c t o r a l programs i n C o u n s e l l i n g P s y c h o l o g y at the U n i v e r s i t y of B r i t i s h Columbia were approached i n t h e i r c l i n i c and c o u r s e s e t t i n g s . In T o r o n t o , masters s t u d e n t s in Psycho logy at York U n i v e r s i t y were approached in t h e i r c l i n i c s e t t i n g . 40 From t h e r a p i s t s who agreed t o p a r t i c i p a t e in the s t u d y , the r e s e a r c h e r s reques ted t h e i r w r i t t e n consent (Appendix 3 ) , e x p l a i n e d the q u e s t i o n n a i r e a d m i n i s t r a t i o n p r o c e d u r e , and p r o v i d e d them wi th package(s ) of forms and q u e s t i o n n a i r e s . Each package was n u m e r i c a l l y coded and a l l forms (except the consent forms) and q u e s t i o n n a i r e s w i t h i n the package bore the code number so tha t data c o u l d be c o l l e c t e d and c o n t r o l l e d wh i le p r e s e r v i n g c l i e n t and t h e r a p i s t anonymi ty . In a l l , 252 packages were p r e p a r e d and d i s t r i b u t e d . C o n f i d e n t i a l i t y was o f f e r e d to c l i e n t s by p r o v i d i n g them w i th enve lopes a t t a c h e d to each of the q u e s t i o n n a i r e s that they were asked to c o m p l e t e , a l o n g w i th i n s t r u c t i o n s t o p l a c e t h e i r completed q u e s t i o n n a i r e s in these enve lopes and to s e a l them so that the i n f o r m a t i o n the c l i e n t had p r o v i d e d would be a v a i l a b l e o n l y to the r e s e a r c h e r and not to the p a r t i c i p a t i n g t h e r a p i s t or agency . 3. DATA COLLECTION AND PREPARATION T h e r a p i s t s s i g n e d the T h e r a p i s t Consent Form a t t a c h e d to an i n s t r u c t i o n sheet e n t i t l e d ' I n s t r u c t i o n s t o T h e r a p i s t s in the Psychotherapy Research P r o j e c t ' (Appendix 3 ) . They r e q u e s t e d p a r t i c i p a t i o n from t h e i r c l i e n t s a f t e r the f i r s t , s e c o n d , o r , in a few c a s e s , the t h i r d s e s s i o n o f f e r i n g to pay the c l i e n t a g r a t u i t y of $25 .00 . C o n s e n t i n g c l i e n t s s i g n e d the C l i e n t Consent Form (Appendix 4) and comple ted the Targe t Compla in ts /Demograph ic Q u e s t i o n n a i r e (Appendix 5 ) , the Symptom C h e c k l i s t - 9 0 (Appendix 6 ) , the S e l f - Esteem Index (Appendix 7 ) , and the Inventory of I n t e r p e r s o n a l  Problems (Appendix 8 ) . These measures are d e s c r i b e d in l a t e r 41 s e c t i o n s of t h i s c h a p t e r . T h i s t e s t b a t t e r y r e q u i r e d about 40 minutes of the c l i e n t s ' t i m e . The demographic d a t a , ( i . e . , c l i e n t age , gender , m a r i t a l s t a t u s , and e d u c a t i o n l e v e l ) c o l l e c t e d on the Ta rge t Compla in ts /Demograph ic Q u e s t i o n n a i r e were not a n a l y z e d s t a t i s t i c a l l y , but a summary of them i s c o n t a i n e d in Appendix 24, T a b l e 24. A f t e r each of the f i r s t f i v e therapy s e s s i o n s as w e l l as a f t e r the t e n t h s e s s i o n ( i f the re was one) and a f t e r the f i n a l s e s s i o n , both c l i e n t and t h e r a p i s t completed t h e i r r e s p e c t i v e v e r s i o n s of the WAI (Appendices 9 and 11). T h i s form i n i t i a l l y r e q u i r e d about f i v e minutes to c o m p l e t e . They a l s o both completed a s i x - i t e m C l i e n t Involvement S c a l e (Appendices 10 and 12) a t t a c h e d to the WAI. (In many of the c a s e s , the WAI was a c t u a l l y a d m i n i s t e r e d a f t e r s e s s i o n s 2 through 6 a n d , in a few c a s e s , a f t e r s e s s i o n s 3 th rough 7 s i n c e the f i r s t and o c c a s i o n a l l y the second s e s s i o n were c o n s i d e r e d by the t h e r a p i s t to be assessment s e s s i o n ( s ) r a t h e r than a c t u a l therapy s e s s i o n ( s ) , i . e . , the c l i e n t and t h e r a p i s t had not yet c o n t r a c t e d to work t o g e t h e r . ) A f t e r the t h i r d s e s s i o n o n l y , c l i e n t s comple ted t h r e e a d d i t i o n a l q u e s t i o n n a i r e s , the R e l a t i o n s h i p Inventory (Appendix 13) , the C o u n s e l o r R a t i n g Form (Appendix 14) , and the H e l p i n g  A l l i a n c e Q u e s t i o n n a i r e (Appendix 15) . Be fo re t h e i r 10th s e s s i o n s , the r e s e a r c h e r met w i th the t h e r a p i s t s to c o l l e c t the forms comple ted to tha t p o i n t and to p r o v i d e them w i th the 10th s e s s i o n q u e s t i o n n a i r e s and w i th the 42 t e r m i n a t i o n q u e s t i o n n a i r e packages as w e l l as w i th the g r a t u i t y cheque and a l e t t e r of thanks f o r the c l i e n t (Appendix 20 ) . At t h i s t i m e , t a r g e t c o m p l a i n t s were t r a n s f e r r e d from the form on which the c l i e n t had r e c o r d e d them (Appendix 5) to the T a r g e t Compla in ts Improvement R a t i n g Form (Appendix 17) . When therapy c o n c l u d e d , c l i e n t s a g a i n completed the i n i t i a l b a t t e r y of four q u e s t i o n n a i r e s as w e l l as the S t rupp P o s t t h e r a p y  Q u e s t i o n n a i r e (Appendix 16) . I n i t i a l t a r g e t c o m p l a i n t s were r a t e d for improvements (Appendix 17) . T h e r a p i s t s comple ted the T h e r a p i s t Demographic Data Sheet (Appendix 18) and the T h e r a p i s t  P o s t t h e r a p y Q u e s t i o n n a i r e (Appendix 19) . Q u e s t i o n n a i r e s r e t u r n e d from the f i e l d were keyed d i r e c t l y i n t o the UBC computer and a l l input was then v i s u a l l y e d i t e d by the r e s e a r c h e r . A l l subsequent data management and a n a l y s e s were per formed at t h i s computing f a c i l i t y . 4. RELATIONSHIP MEASURES 4.1 Working A l l i a n c e Inventory The Working A l l i a n c e Inventory (Horva th , 1981, 1982) (Appendices 9 and 11) i s a 36 - i tem s e l f - r e p o r t ins t rument d e s i g n e d to a s s e s s the s t r e n g t h and d imens ions of the a l l i a n c e as c o n c e p t u a l i z e d by B o r d i n (1975, 1979). Twelve i tems measure each c o m p o n e n t — g o a l s , t a s k s , and bonds . In o rder to ensure tha t the inst rument would not be governed by any s p e c i f i c t h e o r e t i c a l approach but would a p p l y a c r o s s o r i e n t a t i o n s , a l a r g e number of t h e r a p i s t s from d i f f e r e n t o r i e n t a t i o n s were i n v o l v e d in j u d g i n g i tem a p p r o p r i a t e n e s s . 43 U n l i k e most of the o ther ins t ruments deve loped t o measure the a l l i a n c e , the WAI i s based on c l i e n t (WAIc) and t h e r a p i s t (WAIt) p e r s p e c t i v e s r a t h e r than t h i r d p a r t y e v a l u a t i o n . . . . such o b s e r v e r s , no matter how w e l l t r a i n e d , can on ly respond to the b e h a v i o u r a l ev idence a v a i l a b l e to them. Important a f f e c t i v e and c o g n i t i v e components of the p s y c h o t h e r a p e u t i c p r o c e s s are e n t i r e l y u n a v a i l a b l e to such r a t e r s . (Horvath & G r e e n b e r g , 1986, p . 536) The m u l t i t r a i t - m u l t i m e t h o d mat r ix (Campbel l & F i s k e , 1959) was used to examine the c o n v e r g e n t - d i s c r i m i n a n t v a l i d i t y of the th ree d imens ions of the W A I - - G o a l , T a s k , and Bond—wi th some suppor t b e i n g o f f e r e d f o r the convergent v a l i d i t y of the th ree s u b s c a l e s and fo r the d i s c r i m i n a n t v a l i d i t y of the Goa l and Task s u b s c a l e s . A c c e p t a b l e s u b s c a l e and composi te r e l i a b i l i t i e s ( i n t e r n a l c o n s i s t e n c y and c o e f f i c i e n t a lpha r e s p e c t i v e l y ) were a l s o demonst ra ted : C l i e n t form: Goa l .88 Task .88 Bond .85 Composite .93 T h e r a p i s t form: Goa l .87 Task .82 Bond .68 Composite .87 The r e l i a b i l i t i e s d e r i v e d from the data of the p resen t s t u d y , ( i . e . , i n t e r n a l c o n s i s t e n c i e s and c o e f f i c i e n t s a l p h a ) , of the WAI and of the o ther r e l a t i o n s h i p measures d e s c r i b e d in the f o l l o w i n g s e c t i o n s a re p r e s e n t e d in Appendix 23, T a b l e 22. The c o e f f i c i e n t s were found to be s i m i l a r to those r e p o r t e d by o ther r e s e a r c h e r s as r e p o r t e d in t h i s c h a p t e r . The Horvath study p r o v i d e d ev idence which i s c o n f i r m e d in the p r e s e n t study tha t the WAI s u b s c a l e s are h i g h l y 44 i n t e r r e l a t e d . In the p r e s e n t s t u d y , the median C r o n b a c h ' s (1951) a lpha c o e f f i c i e n t , ( i . e . , the degree to which the s u b s c a l e s measured the same t h i n g ) , was .91 f o r the WAIc and .94 f o r the WAIt (Appendix 23, T a b l e 22) . These v a l u e s a re s i m i l a r to H o r v a t h ' s v a l u e s of .93 f o r the WAIc and .87 f o r the WAIt. Horvath v e r i f i e d t h i s h i g h degree of agreement among the s u b s c a l e s by i n t e r c o r r e l a t i n g them. H i s f i n d i n g s are p r e s e n t e d a l o n g wi th the c o r r e s p o n d i n g f i n d i n g s of the p r e s e n t s tudy in T a b l e 1. T a b l e 1 - I n t e r c o r r e l a t i o n of the WAI S u b s c a l e s a t S e s s i o n Three BOND;GOAL BOND:TASK GOAL:TASK WAIc .66 .76 .85 WAIc (Horva th , 1981) .84 .79 .88 WAIt .80 .77 .91 WAIt (Horva th , 1981) .69 .59 .83 These c o r r e l a t i o n c o e f f i c i e n t s i n d i c a t e a s t r o n g r e l a t i o n s h i p among the s u b s c a l e s . Horvath c o n c l u d e d t h a t : Whi le the re was e v i d e n c e p r e s e n t e d tha t the s c a l e s a re s t r o n g l y i n t e r r e l a t e d , the p o t e n t i a l v a l u e of u t i l i z i n g the unique i n f o r m a t i o n tha t may become a v a i l a b l e through the use of the s u b s c a l e s must weigh h e a v i l y i n the d e l i b e r a t i o n . The a c t u a l s t r u c t u r e of the Working A l l i a n c e between h e l p e r and he lpee i s an e m p i r i c a l q u e s t i o n wh ich , at t h i s t i m e , i s i n s e p a r a b l e from the p s y c h o m e t r i c q u a l i t i e s of the WAI. Much f u r t h e r r e s e a r c h i s c a l l e d fo r to r e s o l v e the b a s i c i s s u e s u n d e r l y i n g the p r o b l e m . (p . 117) H y p o t h e s i z i n g on the b a s i c i s s u e s u n d e r l y i n g the problem to which Horvath has r e f e r r e d above , Greenberg and P i n s o f (1986) have suggested that the a l l i a n c e i s a t r a n s a c t i o n a l v a r i a b l e 45 tha t o c c u r s at a l e v e l of a b s t r a c t i o n t h a t subsumes a c r i t i c a l c l i e n t v a r i a b l e which shou ld be the focus of the f u r t h e r r e s e a r c h fo r which Horvath has c a l l e d . As r e p o r t e d in S e c t i o n 2 of Chapter I, Greenberg and P i n s o f have noted the c o n s i s t e n t f i n d i n g from a l l i a n c e - r e l a t e d r e s e a r c h tha t c l i e n t p a r t i c i p a t i o n , o p t i m i s m , p e r c e i v e d task r e l e v a n c e , and r e s p o n s i b i l i t y are r e l a t e d to change , and they have h y p o t h e s i z e d tha t Involvement would emerge as the most c r i t i c a l c l i e n t subdimension and i n d i c a t o r of the a l l i a n c e . T h e r e f o r e , they have suggested that f u r t h e r r e s e a r c h be d i r e c t e d a t t h i s lower l e v e l of a b s t r a c t i o n toward the development of o r i e n t a t i o n - s p e c i f i c measures to u n r a v e l the i s s u e s i n v o l v e d in d i s c r i m i n a t i n g the d i f f e r e n t types of c l i e n t involvement tha t a re p r o d u c t i v e i n d i f f e r e n t t a s k s and t r e a t m e n t s . In the p r e s e n t s t u d y , the WAI s u b s c a l e s have been examined i n d i v i d u a l l y as Horvath has recommended above . As w e l l , a p r e l i m i n a r y measure of Involvement ( d e s c r i b e d in the f o l l o w i n g s e c t i o n ) has been employed and compared wi th the WAI (Ho-5 , S e c t i o n 5 of Chapter I V ) . 4.2 C l i e n t Involvement S c a l e Based on the c o n s i s t e n t f i n d i n g s of the v a r i o u s r e s e a r c h groups r e g a r d i n g the r e l a t i o n s h i p of c l i e n t involvement to t h e r a p e u t i c s u c c e s s ( S e c t i o n 2.6 of Chapter I I ) , a s i x - i t e m s c a l e (Appendices 10 and 11) was c r e a t e d to measure C l i e n t Invo lvement . I t was a d m i n i s t e r e d a l o n g wi th the WAI to both c l i e n t s (CISc) and t h e r a p i s t s (CI St ) as an e x p l o r a t o r y i n s t r u m e n t . I t i n c l u d e s two i tems t a p p i n g P a r t i c i p a t i o n (#1 and 46 #4), two t a p p i n g R e s p o n s i b i l i t y (#2 and #6), and two t a p p i n g C o l l a b o r a t i o n (#3 and #5). 4.3 R e l a t i o n s h i p Inventory The R e l a t i o n s h i p Inventory ( B a r r e t t - L e n n a r d , 1962) (Appendix 13) was d e s i g n e d to measure four d imens ions of the i n t e r p e r s o n a l r e l a t i o n s h i p from the c l i e n t ' s p e r s p e c t i v e — Empathy, U n c o n d i t i o n a l i t y , L e v e l of R e g a r d , and Congruence . These d imens ions are based on R o g e r s ' (1957) concept of n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s f o r t h e r a p e u t i c change ( S e c t i o n 1.2 of Chapter I I ) . The ins t rument has 16 i tems in each s u b s c a l e y i e l d i n g 64 i tems in t o t a l . Because the RI_ s c a l e s tend to be h i g h l y c o r r e l a t e d (Gurman, 1977), on ly the most r e p r e s e n t a t i v e of the f o u r , Empathy, was employed in the p r e s e n t s t u d y . S u b j e c t s respond to the RI_ by a s s i g n i n g a v a l u e of +3, +2, +1, - 1 , - 2 , or -3 to each i t e m . A response of +3 s i g n i f i e s s t r o n g agreement , and -3 s t r o n g d isagreement wi th the i t em. In the p r e s e n t s t u d y , the s c o r i n g a d a p t a t i o n employed by Horva th (1981) was employed, ( i . e . , a f t e r c o r r e c t i n g f o r p o l a r i t y , v a l u e s of 1 to 6 were a s s i g n e d to the responses wi th h i g h e r s c o r e s r e f l e c t i n g more p o s i t i v e p e r c e p t i o n s of the t h e r a p e u t i c r e l a t i o n s h i p ) . Gurman (1977) e v a l u a t e d 14 s t u d i e s of the i n t e r n a l c o n s i s t e n c y of the RI_ and 10 s t u d i e s of i t s t e s t - r e t e s t r e l i a b i l i t y and found tha t the mean i n t e r n a l r e l i a b i l i t y c o e f f i c i e n t f o r the Empathy s u b s c a l e was .84 . The mean t e s t -r e t e s t c o e f f i c i e n t for Empathy was . 8 3 . Horvath (1981) r e p o r t e d 47 a r e l i a b i l i t y e s t i m a t e f o r the RI Empathy s u b s c a l e of . 8 9 . 4.4 C o u n s e l o r R a t i n g Form The s o c i a l i n f l u e n c e theory of c o u n s e l l i n g ( S t r o n g , 1968) which t h i s measure r e f l e c t s was d e s c r i b e d in S e c t i o n 1.2 of Chapter I I . The C o u n s e l o r R a t i n g Form (Barak & L a C r o s s e , 1975; Appendix 14) c o n s i s t s of 36 i tems r e f e r e n c i n g t h e r a p i s t q u a l i t i e s tha t are r a t e d by the c l i e n t on a s e v e n - p o i n t b i p o l a r s c a l e . Each of the th ree d imens ions of s o c i a l i n f l u e n c e , ( i . e . , e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s ) , i s measured by 12 i tems y i e l d i n g th ree s u b s c a l e s . The i tems a r e a d j e c t i v e p a i r s of o p p o s i t e meaning, ( e g . , A t t r a c t i v e - R e p u l s i v e ) , w i th seven spaces s e p a r a t i n g them. The c l i e n t marks one of these spaces w i t h an ' X ' to i n d i c a t e h i s / h e r p e r c e p t i o n of the t h e r a p i s t . The c l o s e r the mark i s made to the l e f t or r i g h t a d j e c t i v e , the more the t h e r a p i s t i s i d e n t i f i e d wi th tha t d e s c r i p t o r . The CRF i s s c o r e d by a s s i g n i n g the i n t e g e r s 1 to 7 to the p o i n t s between the a d j e c t i v e s and summing the s c o r e s of the 12 i tems b e l o n g i n g to each s u b s c a l e ( a f t e r c o r r e c t i n g f o r p o l a r i t y ) . The range of s c o r e s on each s u b s c a l e v a r i e s from 12 to 84 wi th h i g h s c o r e s r e p r e s e n t i n g h i g h i n f l u e n c e on each d i m e n s i o n . R e l i a b i l i t y c o e f f i c i e n t s of .75 to .93 f o r the ins t rument were r e p o r t e d by L a C r o s s e (1977) in an a n a l o g c o u n s e l l i n g exper iment which i n v o l v e d s i m u l a t i o n of d i f f e r e n t t h e r a p e u t i c a p p r o a c h e s . The method of r e l i a b i l i t y assessment was not r e p o r t e d . D i s c r i m i n a n t v a l i d i t y w i t h i n c o u n s e l l o r s (Barak & D e l l , 1977) and between c o u n s e l l o r s ( L a C r o s s e , 1977) have a l s o 48 been d e m o n s t r a t e d . 4.5 H e l p i n g A l l i a n c e Q u e s t i o n n a i r e As r e p o r t e d in S e c t i o n 2.1 of Chapter I I , L u b o r s k y , M c L e l l a n , Woody, O ' B r i e n , and Auerbach (1985) have deve loped an 11- i tem s e l f - r e p o r t q u e s t i o n n a i r e (Appendix 15) which p a r a l l e l s t h e i r H e l p i n g A l l i a n c e R a t i n g S c a l e . I t has e i g h t HA (He lp ing A l l i a n c e ) Type 1 i tems (a t h e r a p e u t i c a l l i a n c e based on the p a t i e n t ' s e x p e r i e n c i n g the t h e r a p i s t as s u p p o r t i v e and h e l p f u l w i th h i m s e l f / h e r s e l f as the r e c i p i e n t ) and th ree HA Type 2 i tems (a t h e r a p e u t i c a l l i a n c e based on a sense of working t o g e t h e r or c o l l a b o r a t i n g in a j o i n t s t r u g g l e a g a i n s t what i s impeding the p a t i e n t , w i th the emphasis on shared r e s p o n s i b i l i t y ) . S u b j e c t s respond to the HAQ by a s s i g n i n g a v a l u e of +3, +2, +1, - 1 , - 2 , or -3 to each i tem. A response of +3 s i g n i f i e s s t r o n g agreement and -3 s t r o n g d isagreement wi th the i t e m . V a l u e s of 1 to 6 were a s s i g n e d to the responses in the p r e s e n t s t u d y , w i th h i g h e r s c o r e s r e f l e c t i n g more p o s i t i v e p e r c e p t i o n s of the t h e r a p e u t i c r e l a t i o n s h i p . A d m i n i s t e r e d a f t e r the t h i r d s e s s i o n to 110 drug -abuse p a t i e n t s , the t o t a l s c o r e was c o r r e l a t e d s i g n i f i c a n t l y (p_<.0l) w i th the p a t i e n t s ' seven-month outcomes on four measures at .51 to . 7 2 . A w a i t i n g the r e s u l t s of a " r e - p a i r i n g " s tudy employing the i n s t r u m e n t , A lexander and Luborsky (1986) s t a t e d that Because of i t s r e l a t i v e s i m p l i c i t y , i f the q u e s t i o n n a i r e method i s comparable to the o t h e r s p r e d i c t i v e l y , i t would become the f u t u r e method of c h o i c e in terms of e f f i c i e n c y and economy of t ime f o r measur ing h e l p i n g a l l i a n c e phenomena. (p . 354) Noth ing f u r t h e r has been r e p o r t e d by the Penn group on t h i s 49 i s s u e . 5. OUTCOME MEASURES S ix outcome measures were employed in the p r e s e n t s t u d y . Three of them were measures employed by Horva th (1981) and Moseley ( 1 9 8 3 ) - - T a r g e t C o m p l a i n t s Improvement, the S t r u p p  P o s t t h e r a p y Q u e s t i o n n a i r e , and the T h e r a p i s t P o s t t h e r a p y  Q u e s t i o n n a i r e — a n d t h e i r r e l a t i o n s h i p s w i th the WAI were v e r i f i e d i n the p r e s e n t s t u d y . The Symptom C h e c k l i s t - 9 0 , the S e l f - E s t e e m Index, and the Inventory of I n t e r p e r s o n a l Problems were a l s o employed in order to tap the domain of c l i e n t change i n p s y c h o t h e r a p y as b r o a d l y as p o s s i b l e . 5.1 Targe t C o m p l a i n t s Improvement Improvement in t a r g e t c o m p l a i n t s (Appendices 5 and 17) has been employed as an i n d i v i d u a l i z e d outcome measure in both the Penn (Luborsky et a l . , 1983; Morgan e t a l . , 1982) and V a n d e r b i l t (Gomes-Schwartz , 1978) s t u d i e s . M in tz and K i e s l e r (1982) d e s c r i b e d the p r i n c i p a l advantage of t h i s outcome measure: S i n c e they [ i n d i v i d u a l i z e d outcome measures] a re t a i l o r e d to the unique t reatment s i t u a t i o n of each p a t i e n t , they are p u r p o r t e d t o be of much g r e a t e r r e l e v a n c e and v a l i d i t y as outcome or program e v a l u a t i o n i n d e x e s , in c o n t r a s t to " a c r o s s the board" or s t a n d a r d i z e d group measures t a p p i n g d imens ions tha t may or may not be r e l e v a n t to a p a r t i c u l a r p a t i e n t , (p. 493) B a t t l e et a l . (1966) compared t a r g e t c o m p l a i n t s improvement w i th o ther outcome measures , ( i . e . , p a t i e n t s ' and t h e r a p i s t s ' r a t i n g s of o v e r a l l improvement, a s o c i a l i n e f f e c t i v e n e s s s c a l e , and a d i s c o m f o r t s c a l e ) , in a four -month 50 p s y c h o t h e r a p y s t u d y . The r e s e a r c h e r s found tha t t a r g e t c o m p l a i n t s c o r r e l a t e d s i g n i f i c a n t l y w i th these o ther measures . T a r g e t c o m p l a i n t s as an outcome measure seemed to respond d i f f e r e n t i a l l y to e x p e r i m e n t a l m a n i p u l a t i o n , were l e s s dependent on the p a t i e n t s ' t r a n s f e r e n c e s i t u a t i o n than g l o b a l improvement r a t i n g s , and were easy f o r p a t i e n t s to s t a t e . Rankings and s e v e r i t y r a t i n g s were shown to be . h i g h l y r e l i a b l e when r e p o r t e d b e f o r e and a f t e r an i n t e n s i v e p s y c h i a t r i c e v a l u a t i o n i n t e r v i e w . In the p r e s e n t s t u d y , c l i e n t s i d e n t i f i e d up to th ree c o m p l a i n t s on a q u e s t i o n n a i r e (Appendix 5) a d m i n i s t e r e d a t the b e g i n n i n g of t h e r a p y . At the c o n c l u s i o n of t h e r a p y , c l i e n t s were p r e s e n t e d wi th these c o m p l a i n t s and were i n s t r u c t e d to r a t e t h e i r improvement on each on a f i v e - p o i n t L i k e r t s c a l e coded 1 ( 'Worse ' ) to 5 ( 'A Lot B e t t e r ' ; Appendix 17) . The improvement r a t i n g s were a v e r a g e d . Any averaged score over 3.0 ( ' S l i g h t l y B e t t e r ' ) , t h e r e f o r e , r e p r e s e n t e d an improvement. 5.2 Symptom C h e c k l i s t - 9 0 The Symptom C h e c k l i s t - 9 0 ( D e r o g a t i s , L ipman, & C o v i , 1973; Appendix 6) i s compr ised of 90 i tems which r e f l e c t n ine pr imary symptom d i m e n s i o n s : s o m a t i z a t i o n , o b s e s s i v e - c o m p u l s i v e , i n t e r p e r s o n a l s e n s i t i v i t y , d e p r e s s i o n , a n x i e t y , h o s t i l i t y , phobic a n x i e t y , p a r a n o i d i d e a t i o n , and p s y c h o t i c i s m . Deve loped wi th p r imary emphasis on v a l i d i t y as a c r i t e r i o n measure in c l i n i c a l drug t r i a l s , the inst rument has a l s o been shown to be s e n s i t i v e to a wide v a r i e t y of nonpharmacologic f a c t o r s in the t reatment s e t t i n g . In a s tudy w i th 209 s u b j e c t s , D e r o g a t i s , R i c k e l s and Rock 51 (1976) compared the symptom d imens ions of the SCL-90 w i th MMPI s c a l e s which r e f l e c t e d ve ry h i g h convergent v a l i d i t y f o r the S C L - 9 0 . I n t e r n a l c o n s i s t e n c y c o e f f i c i e n t s f o r the n ine s c a l e s ranged from .77 to .90 and t e s t - r e t e s t r e l i a b i l i t i e s ranged from .78 to . 9 0 . Each i tem i s r a t e d on a f i v e - p o i n t s c a l e of d i s t r e s s r a n g i n g from 'Not at a l l ' to ' E x t r e m e l y ' . The SCL-90 takes 20 minutes to c o m p l e t e . Use of t h i s measure as an outcome assessment d e v i c e i s in a c c o r d w i th the recommendations of the N a t i o n a l I n s t i t u t e of Menta l H e a l t h ' s Outcome Measures P r o j e c t (Waskow & P a r l o f f , 1975) and i t has been u t i l i z e d by the Lang ley P o r t e r group in t h e i r a l l i a n c e r e s e a r c h ( S e c t i o n 2.3 of Chapter I I ) . 5.3 S e l f - E s t e e m Index Bachman and O ' M a l l e y (1977) r e p o r t e d b e i n g h e a v i l y i n f l u e n c e d by Rosenberg (1965) and Coopersmi th (1967) in t h e i r use of the term s e l f - e s t e e m to r e f e r to "an i n d i v i d u a l ' s s e l f -e v a l u a t i o n or judgment of h i s / h e r own worth" (p . 366) . The Bachman and O ' M a l l e y a d a p t a t i o n of the Rosenberg index (Appendix 7) was s t a n d a r d i z e d on a sample of 1608 young men. The SEI i s the unweighted mean of the 10 i tems wi th the f i v e - p o i n t L i k e r t s c a l e of r e s p o n s e s coded 1 to 5. I t i n c r e a s e d by one s t a n d a r d d e v i a t i o n over the e i g h t - y e a r span of Bachman and O ' M a l l e y ' s l o n g i t u d i n a l s t u d y . F a c t o r a n a l y s i s r e v e a l e d a s t r o n g f i r s t f a c t o r e x p l a i n i n g up to 69% of the common v a r i a n c e and i n t e r n a l r e l i a b i l i t y was found to be as h i g h as . 8 1 . C o n s t r u c t v a l i d i t y was demonstra ted by c o r r e l a t i o n s wi th o ther v a r i a b l e s such as 52 n e g a t i v e a f f e c t i v e s t a t e s ( r = - . 5 l ) and h a p p in e s s ( r= .54 ) . 5.4 Inventory Of I n t e r p e r s o n a l Problems H o r o w i t z , W e c k l e r , and Doren (1983) deve loped the Inventory  of I n t e r p e r s o n a l Problems in order to r e l a t e i n t e r p e r s o n a l d i f f i c u l t i e s to p s y c h i a t r i c c o m p l a i n t s . T w e n t y - e i g h t p a t i e n t s of a p s y c h i a t r i c c l i n i c were i n t e r v i e w e d b e f o r e b e g i n n i n g psychotherapy from which 100 i n t e r p e r s o n a l problems were i d e n t i f i e d . These were found to c o n s t i t u t e f i v e major c l u s t e r s of problem b e h a v i o u r s that g e n e r a l l y concerned i n t i m a c y , a g g r e s s i o n , c o m p l i a n c e , independence , and s o c i a l i z i n g (Horowi tz , 1979). One hundred s t u d e n t s Q - s o r t e d the i tems demonst ra t ing i n t e r n a l c o n s i s t e n c y , ( i . e . , c o r r e l a t i o n between problems w i t h i n a c l u s t e r (p_<.0l)). T e s t - r e t e s t r e l i a b i l i t y of .77 was a l s o demonst ra ted . The c u r r e n t v e r s i o n of the I IP (1986, p e r s o n a l c o r r e s p o n d e n c e , Appendix 8) c o n s i s t s of 127 i t e m s , 118 of which form 12 s u b s c a l e s . These are l i s t e d below a l o n g w i th t h e i r t e s t - r e t e s t r e l i a b i l i t i e s : Hard to be In t imate 1 1 i tems - .88 Hard to be A s s e r t i v e 17 i tems - .82 Hard to be Independent 9 i tems - .86 Hard to be S o c i a b l e 1 1 i tems - .90 Hard to f e e l S e l f - W o r t h - 6 i tems - .78 Hard to be S u p p o r t i v e 1 1 i tems - .76 Hard to be A g g r e s s i v e 5 i tems - .69 Too G i v i n g - 6 i tems - .80 53 Too A g g r e s s i v e - 13 i tems - .80 Too H y p e r s e n s i t i v e - 10 i tems - .85 Too Eager to P l e a s e - 10 i tems - .74 Too Dependent 9 i tems - .77 5 . 5 S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e The S t r u p p P o s t t h e r a p y Q u e s t i o n n n a i r e ( S t r u p p , W a l l a c h , & Wogan, 1964) (Appendix 16) i s a r e t r o s p e c t i v e measure a d m i n i s t e r e d at the end of t reatment to determine c l i e n t s ' e x p e r i e n c e of improvement and s a t i s f a c t i o n w i th t r e a t m e n t . The SPQ has shown p o s i t i v e c o r r e l a t i o n w i th o ther s o u r c e s of outcome measurement in s e v e r a l p r e v i o u s i n v e s t i g a t i o n s ( C a r t w r i g h t , K i r t n e r , & F i s k e , 1963). S t rupp et a l . showed tha t c l i e n t s ' r a t i n g s of change c o r r e l a t e d w i th t h e r a p i s t s ' o v e r a l l s u c c e s s r a t i n g s . T h u s , Waskow and P a r l o f f (1975) have c o n c l u d e d , v a l i d i t y appears to be s u b s t a n t i a l . Horvath (1981) l o g i c a l l y a n a l y z e d the 11 t h e r a p y - r e l a t e d i tems to i d e n t i f y th ree s u b s c a l e s : S a t i s f a c t i o n (3 i t e m s ) , Change (5 i t e m s ) , and Adjustment (3 i t e m s ) . He r e p o r t e d the f o l l o w i n g r e l i a b i l i t y e s t i m a t e s f o r the i n s t r u m e n t : E i g h t o t h e r i tems d e a l i n g wi th p r e t h e r a p y c o n d i t i o n s , the t h e r a p i s t ' s l e v e l of e x p e r t i s e , the t ime in therapy u n t i l change took p l a c e , and the d e c i s i o n to t e r m i n a t e the therapy were not a n a l y z e d s t a t i s t i c a l l y in the p resen t s t u d y . A summary of these da ta i s p r e s e n t e d in Appendix 22. S a t i s f a c t i o n .87 Change .88 Adjustment .77 Composite .65 54 5.6 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e The T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e was adapted by Horva th (1981; Appendix 19) from the S t r u p p P o s t t h e r a p y  Q u e s t i o n n a i r e d e s c r i b e d above in o rder to p r o v i d e an outcome i n d i c a t o r based on t h e r a p i s t ' s judgment. The r a t i o n a l e to i n c l u d e a t h e r a p i s t ' s e v a l u a t i o n among the outcome measures was based on f i n d i n g s that suggest tha t the t h e r a p i s t tends to c a p t u r e a p o r t i o n of the outcome v a r i a n c e t h a t i s q u i t e independent of the c l i e n t ' s p o i n t of view ( M i n t z , 1977). Horvath (1981) dropped one i n a p p r o p r i a t e i tem from the c l i e n t fo rm. He r e p o r t e d the f o l l o w i n g r e l i a b i l i t y e s t i m a t e s f o r the TPQ: S a t i s f a c t i o n .37 (2 i tems) Change .75 (5 i tems) Adjustment .81 (3 i tems) Composite .55 (10 i tems) Appendix 22 i n c l u d e s a summary of the data from the seven i tems that were not a n a l y z e d s t a t i s t i c a l l y in the p r e s e n t s t u d y . 5.7 T h e r a p i s t Demographic Data Sheet T h i s form (Appendix 18) , comple ted by the t h e r a p i s t at the end of t r e a t m e n t , was d e s i g n e d to gather the f o l l o w i n g i n f o r m a t i o n about the t h e r a p i s t : p r o f e s s i o n a l a f f i l i a t i o n , h i g h e s t degree e a r n e d , number of y e a r s of e x p e r i e n c e as a t h e r a p i s t / c o u n s e l l o r , and t h e o r e t i c a l o r i e n t a t i o n which most c h a r a c t e r i z e d the work w i th t h i s c l i e n t . With the e x c e p t i o n of t h e o r e t i c a l o r i e n t a t i o n , these da ta were not employed in the s t a t i s t i c a l a n a l y s e s , but a summary of them i s c o n t a i n e d in 55 Appendix 24, T a b l e 23. The r e l i a b i l i t i e s d e r i v e d from the data of the p r e s e n t s t u d y , ( i . e . , i n t e r n a l c o n s i s t e n c i e s and c o e f f i c i e n t s a l p h a ) , of a l l of the outcome measures d e s c r i b e d in the p r e c e d i n g s e c t i o n s are p r e s e n t e d in Appendix 23, T a b l e 22. Wi th one e x c e p t i o n , ( i . e . , the SPQ S a t i s f a c t i o n s u b s c a l e d i s c u s s e d in S e c t i o n 1.5.1 of Chapter I V ) , the c o e f f i c i e n t s were found to be s i m i l a r to those r e p o r t e d by o ther r e s e a r c h e r s as r e p o r t e d above . 56 IV. RESULTS Data were c o l l e c t e d from 44 therapy c a s e s i n i t i a t e d and completed d u r i n g the p e r i o d F e b r u a r y , 1986 to May, 1987. As w e l l , some data were c o l l e c t e d from 12 c a s e s tha t were t e r m i n a t e d premature ly by the c l i e n t s a f t e r l e s s than s i x s e s s i o n s . The 44 c a s e s have been c a t e g o r i z e d as to t h e i r s o u r c e s below: P r i v a t e p r a c t i t i o n e r s in G r e a t e r Vancouver and V i c t o r i a 22 c a s e s T h e r a p i s t s employed by s o c i a l s e r v i c e a g e n c i e s in G r e a t e r Vancouver 13 c a s e s Mas te rs and d o c t o r a l s t u d e n t s i n c l i n i c and p r a c t i c a s e t t i n g s in T o r o n t o , O n t a r i o and Vancouver ( i n c l u d i n g two demonst ra t ion c a s e s conducted by a c l i n i c s u p e r v i s o r ) 9 c a s e s 44 c a s e s In the l a r g e s t source g r o u p , p r i v a t e p r a c t i t i o n e r s , one t h e r a p i s t c o n t r i b u t e d four c a s e s to the sample , one c o n t r i b u t e d t h r e e , and two o t h e r s c o n t r i b u t e d two c a s e s e a c h . The c l i n i c s u p e r v i s o r mentioned above a l s o c o n t r i b u t e d a case from h i s p r i v a t e p r a c t i c e . Hence, 35 t h e r a p i s t s were r e p r e s e n t e d in the sample of 44 c a s e s . Case dependence r e s u l t i n g from t h i s t h e r a p i s t e f f e c t was examined s t a t i s t i c a l l y as a post hoc a n a l y s i s and the r e s u l t s the re f rom are r e p o r t e d in S e c t i o n 7 . 1 . No c l i e n t was r e p r e s e n t e d in more than one case i n the sample . A l l of the p r i v a t e p r a c t i t i o n e r s r e c e i v e d f i n a n c i a l compensat ion in whole or in p a r t d i r e c t l y from t h e i r c l i e n t s , wh i l e the t h e r a p i s t s employed by s o c i a l s e r v i c e a g e n c i e s r e c e i v e d s a l a r i e s from t h e i r a g e n c i e s , and the s tudent 57 t h e r a p i s t s were not f i n a n c i a l l y compensated. The 13 c a s e s c o n t r i b u t e d by t h e r a p i s t s employed in a g e n c i e s r e p r e s e n t e d seven d i f f e r e n t a g e n c i e s — f i v e were from an agency s p e c i a l i z i n g i n a l c o h o l and drug abuse c o u n s e l l i n g , four from c h u r c h - s p o n s o r e d c o u n s e l l i n g s e r v i c e s , two from community-based n o n - p r o f i t c o u n s e l l i n g c e n t r e s , one from a t h e r a p i s t working in a h o s p i t a l s e t t i n g , and one from a campus c o u n s e l l i n g s e r v i c e f o r women. The demographic a n a l y s i s of the sample of c l i e n t s and t h e r a p i s t s i s c o n t a i n e d i n Appendix 24, T a b l e s 23 and 24. In summary, the t h e r a p i s t sample c o n s i s t e d l a r g e l y of c o u n s e l l o r s in p r i v a t e p r a c t i c e hav ing between one and f i v e y e a r s of e x p e r i e n c e and working from a h u m a n i s t i c o r i e n t a t i o n . However, s e v e r a l t h e r a p i s t s , when asked to i d e n t i f y / d e s c r i b e t h e i r t h e o r e t i c a l o r i e n t a t i o n in the f i r s t pa r t of q u e s t i o n #5 on the Demographic Data Sheet (Appendix 18) , i n d i c a t e d tha t they had employed t e c h n i q u e s a s s o c i a t e d w i th an o r i e n t a t i o n o t h e r than tha t in which they had c a t e g o r i z e d t h e m s e l v e s . I t seems, t h e r e f o r e , tha t at l e a s t some of the t h e r a p i s t s in the sample were, in f a c t , e c l e c t i c i n o r i e n t a t i o n . Such a s p e c u l a t i o n i s c o n s i s t e n t w i th the f i n d i n g s of W a t k i n s , L o p e z , C a m p b e l l , and Hammil l (1986) who surveyed 716 c o u n s e l l i n g p s y c h o l o g i s t s and found tha t the m a j o r i t y , ( i . e . , 40.2%), i d e n t i f e d t h e i r p r imary o r i e n t a t i o n as e c l e c t i c and tha t the m a j o r i t y of t h o s e , ( i . e . , 36.4%), c l a s s i f i e d t h e i r e c l e c t i c o r i e n t a t i o n as h u m a n i s t i c - e x i s t e n t i a l e c l e c t i c i s m . I t seemed tha t h u m a n i s t i c o r i e n t a t i o n s tended to be absorbed i n t o 58 s y n t h e t i c e c l e c t i c i s m , ( i . e . , i n t e g r a t i o n of a d i v e r s i t y of contemporary a p p r o a c h e s ) , w h i c h , the r e s e a r c h e r s n o t e d , a l lowed p r a c t i t i o n e r s to use t e c h n i q u e s from d i f f e r e n t t h e o r i e s tha t seemed a p p r o p r i a t e f o r p a r t i c u l a r c l i e n t s . The c l i e n t sample c o n s i s t e d l a r g e l y of females between the ages of 26 and 35 hav ing at l e a s t some c o l l e g e e d u c a t i o n . The t h e r a p e u t i c dyads were l a r g e l y same-gender and the t h e r a p i e s would be c h a r a c t e r i z e d as b r i e f . 1. RELATIONSHIP OF PERCEIVED ALLIANCE STRENGTH TO OUTCOME The a l l i a n c e measure employed in t h i s and subsequent a n a l y s e s i s the average of the t h i r d , f o u r t h , and f i f t h s e s s i o n measures . The s e l e c t i o n of t h i s measure i s suppor ted by an a n a l y s i s of the i n t e r c o r r e l a t i o n s of the WAI s c o r e s of each of the f i r s t f i v e s e s s i o n s which i s p r e s e n t e d in Appendix 25, Tab le 25. The r e s u l t s of the a n a l y s i s of the r e l a t i o n s h i p of p e r c e i v e d a l l i a n c e s t r e n g t h to outcome a r e p r e s e n t e d by outcome measure. 1.1 Target Compla in ts Improvement Targe t c o m p l a i n t s improvement i s d e f i n e d as the average improvement . on the th ree or l e s s c o m p l a i n t s i d e n t i f i e d by the c l i e n t at the b e g i n n i n g of therapy (Appendix 5) and r a t e d by the c l i e n t at the end of therapy (Appendix 17) . C l i e n t s r a t e d t h e i r improvement on each compla in t on a f i v e - p o i n t L i k e r t s c a l e . The mean improvement was 4.07 (4 = 'Somewhat B e t t e r ' on the q u e s t i o n n a i r e ) w i th a s tandard d e v i a t i o n of . 5 9 . The f i n d i n g s 59 f o r t h i s outcome measure are p r e s e n t e d in T a b l e 2 a l o n g wi th the s i m i l a r r e s u l t s of Moseley (1983) . T a b l e 2 - R e l a t i o n s h i p s between the WAIc and Targe t C o m p l a i n t s Improvement Moseley (1983; n=19) r r GOAL TASK BOND COMPOSITE .25 . 34** . 4 0 * * .33 ** * S i g n i f i c a n t r e l a t i o n s h i p , 2<.05 * * S i g n i f i c a n t r e l a t i o n s h i p , .33 1 . 5 3 * * . 5 1 * The WAIc COMPOSITE s c a l e as w e l l as i t s BOND and TASK s u b s c a l e s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th t a r g e t c o m p l a i n t s improvement and the WAIc GOAL s u b s c a l e a l s o approached s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n wi th t h i s outcome measure (p_=.06). The magnitude of the c o r r e l a t i o n between the WAIt and t a r g e t c o m p l a i n t s improvement d i d not reach s t a t i s t i c a l s i g n i f i c a n c e , ( r= - . 08 , T a b l e 8 ) . 1 M o s e l e y ' s r e s u l t s were compared wi th the r e s u l t s of the p resen t s tudy by t e s t i n g the d i f f e r e n c e s between the c o r r e l a t i o n c o e f f i c i e n t s ( G l a s s & H o p k i n s , 1984, p p . 307-309) . The r ' s were t r a n s f o r m e d to F i s h e r Z ' s , the v a r i a n c e s of the Z / s computed, and the s t a n d a r d e r r o r s of the d i f f e r e n c e s d e t e r m i n e d . C o r r e l a t i o n s were found not to d i f f e r s t a t i s t i c a l l y s i g n i f i c a n t l y between the two s t u d i e s . 60 1.2 S e l f - E s t e e m Index The S e l f - E s t e e m Index, as w e l l as the Symptom C h e c k l i s t - 9 0 and the Inventory of I n t e r p e r s o n a l Problems whose r e l a t i o n s h i p s w i t h outcome are d i s c u s s e d in S e c t i o n s 1.3 and 1.4 r e s p e c t i v e l y , i n v o l v e d p r e t e s t s and p o s t t e s t s . R e s i d u a l g a i n s were c a l c u l a t e d u s i n g the REGRESSION procedure of SPSS:X to per form s e m i - p a r t i a l c o r r e l a t i o n s u s i n g the p r e t e s t s as the c o n t r o l s . The magnitude of change on these outcome measures was examined b e f o r e the r e l a t i o n s h i p s between the p r o c e s s and outcome measures were c o n s i d e r e d . For the S e l f - E s t e e m Index, a t - t e s t compar ing the means of the p r e t e s t and the p o s t t e s t , ( i . e . , 36.09 and 39.36 wi th s t a n d a r d d e v i a t i o n s of 6.72 and 5.51 r e s p e c t i v e l y ) , produced a t - v a l u e of 4.65 (p_<.00l). The s tandard e r r o r of the p a i r d i f f e r e n c e , ( i . e . , the p o o l e d w i t h i n -groups S . D . d i v i d e d by the square root of n) , was employed in computing the t - v a l u e . N e i t h e r the magnitude of the c o r r e l a t i o n between the WAIc and r e s i d u a l g a i n on the SEI nor the magnitude of the c o r r e l a t i o n between the WAIt and r e s i d u a l g a i n on the SEI reached s t a t i s t i c a l s i g n i f i c a n c e , ( £ = . 1 8 and .17 r e s p e c t i v e l y , T a b l e 8 ) . 1.3 Symptom C h e c k l i s t - 9 0 The magnitude of change on the Symptom C h e c k l i s t - 9 0 from p r e t e s t to p o s t t e s t was a n a l y z e d by s u b s c a l e . These r e s u l t s are p r e s e n t e d in Appendix 26, T a b l e 26. A l l of the s u b s c a l e s of the inst rument showed s t a t i s t i c a l l y s i g n i f i c a n t improvements, ( i . e . , r e d u c t i o n s ) , in symptoms from the p r e t e s t s to the p o s t t e s t s . 61 The F - v a l u e s ranged from 6.54 (2^.05) to 46.87 (2^ .001) . A n a l y s i s of the SCL-90 at the s u b s c a l e l e v e l was p r e s e n t e d up to t h i s p o i n t in the p resent s tudy fo r the purpose of d e s c r i p t i o n o n l y . S i n c e a n a l y s e s of the r e l a t i o n s h i p s between the r e l a t i o n s h i p measures and t h i s outcome measure were c o n s i d e r e d to be mean ingfu l on ly at the s c a l e t o t a l l e v e l and not at the s u b s c a l e l e v e l ( s i n c e c l i e n t s would be expected to r e g i s t e r change on o n l y some and not a l l of the s u b s c a l e s ) , a n a l y s e s at the s u b s c a l e l e v e l were d i s c o n t i n u e d at t h i s p o i n t . N e i t h e r the magnitude of the c o r r e l a t i o n between the WAIc and r e s i d u a l g a i n on the SCL-90 nor the magnitude of the c o r r e l a t i o n between the WAIt and r e s i d u a l ga in on the SCL-90 reached s t a t i s t i c a l s i g n i f i c a n c e , (r_=.05 and .07 r e s p e c t i v e l y , T a b l e 8 ) . 62 1.4 Inventory Of I n t e r p e r s o n a l Problems The magnitude of change on the Inventory of I n t e r p e r s o n a l  Problems from p r e t e s t to p o s t t e s t was a n a l y z e d by s u b s c a l e . These r e s u l t s a re p r e s e n t e d in Appendix 26, T a b l e 26. A l l of the s u b s c a l e s of the inst rument showed s t a t i s t i c a l l y s i g n i f i c a n t improvements, ( i . e . , r e d u c t i o n s ) , i n i n t e r p e r s o n a l problems from the p r e t e s t s to the p o s t t e s t s , ( i . e . , the F - v a l u e s ranged from 6.39 (2^.05) to 1148.48 ( g ^ . O O l ) , w i t h the e x c e p t i o n of the 'Too G i v i n g ' s u b s c a l e (F=2.86, 2 = ' 1 ° ) « A n a l y s i s of the I IP at the s u b s c a l e l e v e l was d i s c o n t i n u e d at t h i s p o i n t f o r the reason s t a t e d f o r the Symptom C h e c k l i s t - 9 0 in S e c t i o n 1 .3 . The f i n d i n g s fo r the IIP are p r e s e n t e d in T a b l e 3. T a b l e 3 - R e l a t i o n s h i p s between the WAIc and the Inventory of I n t e r p e r s o n a l Problems GOAL . 4 4 * * TASK . 4 5 * * BOND .23 COMPOSITE . 4 0 * * * * S i g n i f i c a n t r e l a t i o n s h i p , 2 - « 0 1 The WAIc COMPOSITE s c a l e as w e l l as i t s GOAL and TASK s u b s c a l e s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the I IP . The magnitude of the c o r r e l a t i o n between the WAIt and r e s i d u a l g a i n on the I IP d i d not r e a c h s t a t i s t i c a l s i g n i f i c a n c e 63 ( r= .02 , T a b l e 8 ) . 1.5 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e The f i n d i n g s f o r the SPQ and f o r the TPQ whose r e l a t i o n s h i p to outcome i s d i s c u s s e d in S e c t i o n 1.6 are p r e s e n t e d in T a b l e 4. Tab le 4 - R e l a t i o n s h i p s between the WAI and the SPQ and the TPQ GOAL TASK WAIc • BOND COMPOSITE S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e Change . 3 5 * * . 4 1 * * . 3 5 * * . 4 0 * * T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .33* . 3 4 * * .24 .32* Change . 27 * . 29* .22 .28* Adjustment .13 .14 .10 .13 TPQ T o t a l .28* .28* .22 .28* WAIt S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e Change .04 .12 .06 .07 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .24 .33* .22 .27* Change .17 .21 .08 .16 Adjustment .22 .19 .08 .17 TPQ T o t a l .24 .28* .15 .23 * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 5 * * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 1 64 1.5.1 S a t i s f a c t i o n S i n c e the r e l i a b i l i t y of the S a t i s f a c t i o n s u b s c a l e of the SPQ was found to be ex t remely low i n the p r e s e n t s tudy ( H o y t ' s (1941) c o e f f i c i e n t = . 2 5 , Appendix 23, T a b l e 22 ) , c o r r e l a t i o n of the WAI wi th i t was regarded as i n v a l i d . H o r v a t h ' s (1981) f i n d i n g of a H o y t ' s c o e f f i c i e n t of .37 f o r the TPQ S a t i s f a c t i o n s u b s c a l e ( S e c t i o n 5 .6 , Chapter I I I ) seems to c o r r o b o r a t e the c o n c l u s i o n tha t the th ree i tems tha t c o n s t i t u t e t h i s s c a l e a re p o o r l y c o n s t r u c t e d . 1.5.2 Change The WAIc COMPOSITE as w e l l as i t s GOAL, TASK, and BOND s u b s c a l e s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th SPQ Change ( r= .40 , . 3 5 , . 4 1 , and .35 r e s p e c t i v e l y ) . The magnitude of the c o r r e l a t i o n between the WAIt and SPQ Change d i d not reach s t a t i s t i c a l s i g n i f i c a n c e , ( r= .07 ) . 1 .5 .3 Adjustment The th ree i tems that c o n s t i t u t e t h i s s u b s c a l e probe the c l i e n t ' s assessment of h i s / h e r c a p a c i t y to cope at the t ime of t e s t c o m p l e t i o n r a t h e r than h e r / h i s assessment of change r e s u l t i n g from t h e r a p y , ( e g . , Item #15: How adequate ly do you f e e l you a re d e a l i n g wi th any p r e s e n t p r o b l e m ? ) . T h e r e f o r e , t h i s s u b s c a l e was judged i n v a l i d and c o r r e l a t i o n of the WAI w i t h i t was a l s o regarded as i n v a l i d . H e n c e f o r t h i n the p r e s e n t s t u d y , o n l y c o r r e l a t i o n s w i th the SPQ Change s u b s c a l e have been r e p o r t e d . 65 1.6 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e The magnitude of the c o r r e l a t i o n between the WAIt and the TPQ d i d not reach s t a t i s t i c a l s i g n i f i c a n c e , ( £ = . 2 3 ) . However, the WAIc COMPOSITE as w e l l as i t s GOAL and TASK s u b s c a l e s d i d c o r r e l a t e s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the TPQ, ( £ = . 2 8 f o r the f u l l s c a l e and a l s o £ = . 2 8 fo r each of the two s u b s c a l e s ) . 1.6.1 S a t i s f a c t i o n The WAIt COMPOSITE as w e l l as i t s TASK s u b s c a l e c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th TPQ S a t i s f a c t i o n ( £ = . 2 7 and .33 r e s p e c t i v e l y ) . As w e l l , the WAIc COMPOSITE and i t s GOAL and TASK s u b s c a l e s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th TPQ S a t i s f a c t i o n (r_ =.32, . 3 3 , and .34 r e s p e c t i v e l y ) , and the WAIc BOND s u b s c a l e a l s o approached s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n w i th i t ( £ = .24) . 1.6.2 Change The magnitude of the c o r r e l a t i o n between the WAIt and TPQ Change d i d not reach s t a t i s t i c a l s i g n i f i c a n c e , ( £ = . 1 6 ) . The WAIc COMPOSITE as w e l l as i t s GOAL and TASK s u b s c a l e s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th TPQ Change ( £ = . 2 8 , . 2 7 , and .29 r e s p e c t i v e l y ) . 66 1.6 .3 Adjustment N e i t h e r the magnitude of the c o r r e l a t i o n between the WAIt and TPQ Adjustment nor the magnitude of the c o r r e l a t i o n between the WAIc and TPQ Adjustment reached s t a t i s t i c a l s i g n i f i c a n c e , (r =.17 and .13 r e s p e c t i v e l y ) . 2. RELATIONSHIP OF PERCEIVED CHANGE IN ALLIANCE STRENGTH TO  OUTCOME Suh, O ' M a l l e y , and S t r u p p (1986) examined change in t h e r a p i s t behav iour over the f i r s t th ree s e s s i o n s of the rapy on the V a n d e r b i l t Psychotherapy P r o c e s s S c a l e . They found that t h i s change s c o r e c o r r e l a t e d s i g n i f i c a n t l y w i th v a r i o u s outcome measures wh i le the t h i r d s e s s i o n s c o r e i t s e l f d i d n o t . However, Suh et a l . ' s formula f o r d e r i v i n g t h i s change measure i n v o l v e d d i f f e r e n c e s c o r e s which are c o n s i d e r e d to be u n r e l i a b l e because of the compounded e r r o r inheren t i n t h e i r b e i n g based on m u l t i p l e p o i n t e s t i m a t e s ( S t a n l e y , 1971). Moreover , they summed the d i f f e r e n c e between S e s s i o n 3 and S e s s i o n 1 and the d i f f e r e n c e between S e s s i o n 2 and S e s s i o n 1, thereby d o u b l i n g the w e i g h t i n g of the l a t t e r d i f f e r e n c e i n t h e i r t o t a l d i f f e r e n c e wi thout p r o v i d i n g a r a t i o n a l e f o r t h i s w e i g h t i n g . In the p r e s e n t s t u d y , the WAIc COMPOSITE s c o r e s f o r the f i r s t f i v e s e s s i o n s were f i t t e d to a r e g r e s s i o n l i n e and the s l o p e of t h i s l i n e was then c o r r e l a t e d wi th the v a r i o u s outcome measures . A l t h o u g h an rj_ of .89 was computed fo r the s l o p e of the r e g r e s s i o n l i n e , ( i . e . , the r e g r e s s i o n l i n e accounted f o r 67 most of the v a r i a n c e , a n d , t h e r e f o r e , the p a t t e r n of WAIc development was indeed found to be l i n e a r ) , the magnitude of the c o r r e l a t i o n between the s l o p e , ( i . e . , the change i n a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s ) , and none of the outcome measures reached s t a t i s t i c a l l y s i g n i f i c a n c e . When a d i f f e r e n c e s c o r e was computed by s u b t r a c t i n g the S e s s i o n 5 WAIc COMPOSITE from the S e s s i o n 1 WAIc COMPOSITE s c o r e and t h i s d i f f e r e n c e was then c o r r e l a t e d w i th the outcome measures , one s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n d i d o c c u r . B e i n g one of s i x , t h i s was judged not to be s i g n i f i c a n t ev idence of a r e l a t i o n s h i p between change i n WAIc s t r e n g t h and outcome. The c o r r e l a t i o n s wi th the two methods a re p r e s e n t e d in Tab le 5. T a b l e 5 - R e l a t i o n s h i p of Change in WAIc S t r e n g t h to Outcome F i t t e d R e g r e s s i o n L i n e D i f f e r e n c e Score C o r r e l a t i o n Ta rge t Compla in ts .00 .20 Improvement I IP .15 .33* SCL-90 - . 0 4 .12 SPQ Change .02 .08 SEI .09 .21 TPQ .05 .04 * S i g n i f i c a n t d i f f e r e n c e , p^.05 68 S i n c e the WAIt d i d not c o r r e l a t e s t a t i s t i c a l l y s i g n i f i c a n t l y w i th outcome (Ho-1 , S e c t i o n 1) , no a n a l y s i s of the r e l a t i o n s h i p of change in a l l i a n c e s t r e n g t h as measured by the WAIt to outcome was p e r f o r m e d . 3. RELATIONSHIPS OF CLIENT-PERCEIVED THERAPIST EMPATHY,  EXPERTNESS, ATTRACTIVENESS, AND TRUSTWORTHINESS TO OUTCOME The f i n d i n g s r e l e v a n t to Ho-3 are p r e s e n t e d i n Tab le 6 and summarized in T a b l e 8 which c o n c l u d e s S e c t i o n 5. T a b l e 6 - R e l a t i o n s h i p s between Other P r o c e s s Measures and Outcome Measures EMPATHY EXPERT ATTRACT TRUST HA J_ HA 2 T a r g e t C o m p l a i n t s .03 .01 - . 1 3 - .09 .29* .22 Symptom C h e c k l i s t - 90 .16 . 3 9 * * . 3 6 * * . 4 2 * * . 4 3 * * . 3 6 * * S e l f - E s t e e m Index .04 . 3 7 * * . 29 * .27* .32* . 29 * Inventory of . 26* I n t e r p e r s o n a l Problems .28* .28* .28* . 4 1 * * .21 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e Change .15 .16 .13 .09 . 3 8 * * .17 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .16 .18 - . 0 4 .08 .28* . 3 1 * Change .24 .29* .14 .30* .28* .26* Adjustment .20 .28* .16 .16 .21 . 3 5 * * TPQ T o t a l .23 .29* .10 .20 .30* . 3 6 * * * S i g n i f i c a n t r e l a t i o n s h i p , g<.05 * S i g n i f i c a n t r e l a t i o n s h i p , £ ^ . 0 1 69 3.1 R e l a t i o n s h i p Inventory The Empathy s u b s c a l e of the RI_ c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i t h r e s i d u a l ga in on the I IP ( £ = . 2 6 ) but not w i th the o ther outcome measures . 3.2 C o u n s e l o r R a t i n g Form The CRF t o t a l s c o r e c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the SCL-90 ( £ = . 4 2 , T a b l e 8 ) , the SEI (r = .33) , and the I IP ( £ = . 3 0 ) . E x p e r t n e s s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l ga in on the SCL-90 ( £ = . 3 9 , Tab le 6 ) , the SEI_ ( £ = . 3 7 ) , and the I IP ( £ = . 2 8 ) . E x p e r t n e s s a l s o c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the TPQ ( £ = . 2 9 ) . Both A t t r a c t i v e n e s s and T r u s t w o r t h i n e s s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the SCL-90 ( £ =.36 and . 4 2 ) , the SEI ( £ = . 2 9 and . 2 7 ) , and the I IP ( £ = . 2 8 f o r both s u b s c a l e s ) . 4. RELATIONSHIP OF CLIENT-PERCEIVED ALLIANCE STRENGTH AS  MEASURED WITH THE HELPING ALLIANCE QUESTIONNAIRE TO OUTCOME The f i n d i n g s r e l e v a n t to Ho-4 were p r e s e n t e d in Tab le 6 in S e c t i o n 3 and a re summarized in T a b l e 8 which c o n c l u d e s S e c t i o n 5. The HAQ c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th a l l s i x of the outcome measures employed i n the p resen t study ( £ ranged from .29 to . 4 4 ) . Type 1 H e l p i n g A l l i a n c e a l s o c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th a l l of the outcome measures ( £ ranged from 70 .29 to . 4 3 ) , wh i l e Type 2 H e l p i n g A l l i a n c e c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the SCL-90 (r =.36) and the SEI (r=.29) and wi th the TPQ ( r= .36 ) . 5. RELATIONSHIP OF PERCEIVED CLIENT INVOLVEMENT TO OUTCOME The f i n d i n g s r e l e v a n t to Ho-5 are p r e s e n t e d in T a b l e 7. The e x p l o r a t o r y s i x - i t e m C l i e n t Involvement S c a l e was appended t o the WAI (both c l i e n t and t h e r a p i s t forms) in o r d e r to examine the r e l a t i o n s h i p of the h y p o t h e s i z e d "lower l e v e l " C l i e n t Involvement v a r i a b l e (Greenberg & P i n s o f , 1986) to outcome ( S e c t i o n 2 of Chapter I and S e c t i o n 4.1 of Chapter I I I ) . T a b l e 7 - R e l a t i o n s h i p s between the C l i e n t Involvement S c a l e and the Outcome Measures CISc C ISt Ta rge t C o m p l a i n t s Improvement . 3 9 * * .01 1 Symptom C h e c k l i s t - 9 0 - . 0 2 .06 S e l f - E s t e e m Index .21 .13 Inventory of I n t e r p e r s o n a l Problems .27* .10 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e Change . 3 9 * * .12 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n . 3 7 * * . 27 * Change .29* .23 Adjustment .16 . 25 * TPQ T o t a l .32* . 29 * * S i g n i f i c a n t r e l a t i o n s h i p , p_^.05 * * S i g n i f i c a n t r e l a t i o n s h i p , £ ^ . 0 1 1 The CIS s c o r e s were averaged over the t h i r d , f o u r t h , and f i f t h s e s s i o n s as were the WAI s c o r e s ( S e c t i o n 1 ) . 71 The CISc c o r r e l a t i o n s w i th outcome were s i m i l a r to those of the WAIc, ( i . e . , i t c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th t a r g e t c o m p l a i n t s improvement ( r= .39 ) , r e s i d u a l g a i n on the I IP ( r= .27 ) , SPQ Change ( r= .39 ) , and the TPQ ( r = . 3 2 ) ) . C o r r e l a t i o n of the CI St wi th outcome was s l i g h t l y s t r o n g e r than tha t of the WAIt w i th outcome, ( i . e . , the CI St c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y wi th the TPQ, ( r = . 2 9 ) ) , wh i l e the WAIt o n l y approached s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n w i th i t , (r =.23, T a b l e 4 ) . The r e l a t i o n s h i p s of the seven r e l a t i o n s h i p measures to the s i x outcome measures were compared at the s c a l e t o t a l l e v e l in T a b l e 8. T a b l e 8 - Summary of R e l a t i o n s h i p - O u t c o m e C o r r e l a t i o n s Targe t SCL-90 SEI I IP SPQ TPQ Compla in ts Chanqe WAIc . 3 3 * * .05 .18 . 4 0 * * . 4 0 * * .28* CISc . 3 9 * * .02 .21 .27* . 3 9 * * . 32 * CRF - . 0 7 . 4 2 * * . 3 3 * * .30* . 1 3 .21 Empathy .03 .16 .04 .26* .15 .23 HAQ .29* . 4 4 * * . 3 3 * * . 3 8 * * . 3 4 * * . 3 4 * * WAIt - . 0 8 .07 .17 .02 .07 .23 cist .01 .06 .13 .10 .12 . 29 * * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 5 * * S i g n i f i c a n t r e l a t i o n s h i p , p_<.0l The d i f f e r e n c e s between the WAIc c o r r e l a t i o n c o e f f i c i e n t s and the o t h e r r e l a t i o n s h i p measure c o r r e l a t i o n c o e f f i c i e n t s were 72 t e s t e d u s i n g the Z t r a n s f o r m a t i o n procedure d e s c r i b e d in S e c t i o n 1 .1 . The f i n d i n g s are p r e s e n t e d in Tab le 9. T a b l e 9 - Z - R a t i o s of D i f f e r e n c e s between WAIc-Outcome C o r r e l a t i o n s and Other R e l a t i o n s h i p Measures-Outcome C o r r e l a t ions T a r g e t SCL-90 SEI I IP SPQ TPQ C o m p l a i n t s Chanqe CISC .31 .14 .14 .67 .05 .20 CRF 1.88* 1 .81* .73 .52 1 .33 .34 Empathy 1 .42 .50 .65 .72 1 .62 .25 HAQ .25 1 . 9 6 * * .73 . 1 1 .32 .30 WAIt 1 .92* .09 .05 1 . 84* 1 .61 .25 CISt 1 .55 .05 .23 .46 1 .38 .05 * S i g n i f i c a n t r e l a t i o n s h i p , p_<.05 * S i g n i f i c a n t r e l a t i o n s h i p , p_<.0l The WAIc c o r r e l a t i o n s w i th outcome were found to d i f f e r s t a t i s t i c a l l y s i g n i f i c a n t l y from the CRF and WAIt c o r r e l a t i o n s w i th outcome on two measures, and from the HAQ c o r r e l a t i o n w i th outcome on one measure. In order to compare the o v e r a l l e f f e c t i v e n e s s of the WAIc and the HAQ, each was i n c l u d e d in a m u l t i p l e r e g r e s s i o n e q u a t i o n w i th a l l of the s i x outcome measures . The v a r i a n c e ( r 2 ) e x p l a i n e d by the WAIc was .31 and that f o r the HAQ was . 3 2 . Hence, on an o v e r a l l b a s i s , the two a l l i a n c e measures had equa l r e l a t i o n s h i p s w i th outcome. 73 6. RELATIONSHIP OF CONGRUENCE OF CLIENT-PERCEIVED AND  THERAPIST-PERCEIVED ALLIANCE STRENGTH TO OUTCOME For the purpose of t h i s s t u d y , congruence was d e f i n e d as c l i e n t s and t h e r a p i s t s r a t i n g t h e i r a l l i a n c e s s i m i l a r l y . The c o r r e l a t i o n s between the two forms of the WAI a re p r e s e n t e d in T a b l e 10. T a b l e 10 - Congruence of the WAIc and the WAIt C l i e n t Form  GOAL TASK BOND COMPOSITE T h e r a p i s t Form: GOAL .32* .32* .21 .30* TASK . 3 7 * * . 38** .29* . 37* * BOND .23 .28* .21 . 25 * COMPOSITE .32* . 3 3 * * .24 .32* * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 5 * * S i g n i f i c a n t r e l a t i o n s h i p , p_^.0l The two forms c o r r e l a t e d a t low but s t a t i s t i c a l l y s i g n i f i c a n t l e v e l s on both the COMPOSITE s c a l e and on the GOAL and TASK s u b s c a l e s . They d i d not c o r r e l a t e c o n s i s t e n t l y s t a t i s t i c a l l y s i g n i f i c a n t l y on the BOND s u b s c a l e . In the a n a l y s e s p r e s e n t e d in T a b l e s 10 and 11, an a p p r o x i m a t i o n of M a h a l a n o b i s ' d i s t a n c e (Bock, 1975, p. 399) , ( i . e . , c l i e n t ' s p e r c e p t i o n minus t h e r a p i s t ' s p e r c e p t i o n , s q u a r e d ) , was the measure t h a t was c o r r e l a t e d w i t h outcome. In o rder to reduce the skewness of the r e s u l t i n g d i s t r i b u t i o n to produce a more normal d i s t r i b u t i o n , a square root t r a n s f o r m a t i o n 74 was per formed on the congruence d a t a . N o r m a l i t y was then c o n f i r m e d w i th the Kolmogorow-Smirnov goodness of f i t t e s t ( H o l l a n d e r & W o l f e , 1971). Congruence was indeed found to i n c r e a s e somewhat over the seven o c c a s i o n s . The d e c r e a s i n g measures of d i s t a n c e a re p r e s e n t e d in T a b l e 11. T a b l e 11 - WAIc-WAIt Congruence at the Seven O c c a s i o n s Mean D i s t a n c e S . D . S e s s i o n 1 S e s s i o n 2 S e s s i o n 3 S e s s i o n 4 S e s s i o n 5 S e s s i o n 10 22.00 18.67 18.21 19.12 18.13 16.56 17.05 16.76 1 7.40 1 1 .37 13.52 15.02 12.68 1 3.05 F i n a l S e s s i o n The r e s u l t s of the a n a l y s i s of the c o r r e l a t i o n of congruence w i th outcome are p r e s e n t e d in T a b l e 12. 75 T a b l e 12 - C o r r e l a t i o n of Outcome wi th WAIc-WAIt Congruence at the Seven O c c a s i o n s S e s s i o n #1 #2 #3 #4 #5 #10 F i n a ! T a r g e t - . 2 0 1 - . 3 8 * * - . 1 2 - . 0 9 .13 .16 .14 Compla in ts SCL-90 - . 0 4 .23 .23 .09 .09 .08 - . 0 3 SEI - . 0 4 .18 .13 .26* .25* . 4 2 * * .20 I IP - . 1 6 .02 .06 .12 - . 0 3 - . 2 5 * - . 2 5 S t r u p p P o s t t h e r a p y Q u e s t i o n n a i r e Change - . 2 8 * - . 2 6 * .02 - . 1 0 - . 0 8 .07 - . 0 7 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .15 .18 . 1 4 .00 .13 .06 .07 Change - . 1 0 .00 - . 0 9 - .11 - . 0 5 - . 0 4 .05 Adjustment .13 .10 - .01 .01 .09 . 4 3 * * .14 TPQ T o t a l .08 .07 .02 - . 0 3 .07 .22 . 1 1 * S i g n i f i c a n t r e l a t i o n s h i p , p<.05 * * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 1 The r e s u l t s of the a n a l y s i s of the c o r r e l a t i o n of congruence w i th outcome were e q u i v o c a l . Congruence in l a t e r s e s s i o n s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the SEI and i t approached s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n in e a r l y s e s s i o n s w i th r e s i d u a l g a i n on the S C L - 9 0 . However, congruence c o r r e l a t e d n e g a t i v e l y w i th improvement in t a r g e t c o m p l a i n t s and w i th SPQ Change in e a r l y s e s s i o n s and S i n c e the congruence measure s h r i n k s as congruence i n c r e a s e s , the c o r r e l a t i o n s of t h i s measure wi th outcome would be expec ted t o be n e g a t i v e . The s i g n s of the c o r r e l a t i o n c o e f f i c i e n t s have , t h e r e f o r e , been r e v e r s e d . 76 n e g a t i v e l y w i th r e s i d u a l g a i n on the IIP i n l a t e r s e s s i o n s . Congruence was u n r e l a t e d t o outcome on the TPQ. 7. POST HOC ANALYSES 7.1 A n a l y s i s Of T h e r a p i s t E f f e c t As d e s c r i b e d at the b e g i n n i n g of t h i s c h a p t e r , 35 t h e r a p i s t s c o n t r i b u t e d the 44 c a s e s tha t c o n s t i t u t e d the sample . One t h e r a p i s t c o n t r i b u t e d four c a s e s , two c o n t r i b u t e d th ree c a s e s e a c h , and two c o n t r i b u t e d two c a s e s e a c h . T h i s r e p r e s e n t e d n e i t h e r a s i g n i f i c a n t t h e r a p i s t e f f e c t , ( i . e . , 30 or 86% of the t h e r a p i s t s c o n t r i b u t e d o n l y one c a s e ) , nor was i t a s y s t e m a t i c or b a l a n c e d e f f e c t tha t would l e n d i t s e l f to s t a t i s t i c a l c o n t r o l . T h e r e f o r e , s imple compar isons of the two groups of c a s e s , ( i . e . , one be ing the 14 c a s e s from the f i v e t h e r a p i s t s c o n t r i b u t i n g m u l t i p l e c a s e s and the o ther be ing the 30 c a s e s from the 30 t h e r a p i s t s c o n t r i b u t i n g one case e a c h ) , were per formed t o check f o r s i g n i f i c a n t d i f f e r e n c e s between the g r o u p s . A l t h o u g h i t was r e c o g n i z e d tha t dependency e f f e c t s c o u l d show in o ther ways, the s t a n d a r d d e v i a t i o n was used as the "check" i n d i c a t o r . Three "marker v a r i a b l e s " of c l i e n t change were chosen and t h e i r s t a n d a r d d e v i a t i o n s for each of the two groups were compared and a r e p r e s e n t e d i n T a b l e 13. 77 T a b l e 13 - A n a l y s i s of T h e r a p i s t E f f e c t on Three Marker Outcome V a r i a b l e s 14 c a s e s from 30 c a s e s from 5 t h e r a p i s t s S . D . 30 t h e r a p i s t s S . D . Improvement on Targe t Compla in ts .48 'Change ' S u b s c a l e of SPQ .74 S e l f - E s t e e m I n d e x — R e s i d u a l Ga in .89 .64 .72 1 .05 7.2 A n a l y s i s Of E f f e c t Of T h e o r e t i c a l O r i e n t a t i o n s Of T h e r a p i s t s Seven of the c a s e s were c h a r a c t e r i z e d by the four t h e r a p i s t s i n v o l v e d as o ther than h u m a n i s t i c i n t h e o r e t i c a l o r i e n t a t i o n - - f o u r as a n a l y t i c and th ree as l e a r n i n g . T h i s r e p r e s e n t e d n e i t h e r a s i g n i f i c a n t t h e o r e t i c a l o r i e n t a t i o n e f f e c t , ( i . e . , 31 or 89% of the t h e r a p i s t s c l a i m e d a h u m a n i s t i c o r i e n t a t i o n , th ree c l a i m e d an a n a l y t i c o r i e n t a t i o n , and o n l y one c l a i m e d a l e a r n i n g o r i e n t a t i o n ) , nor was i t a s y s t e m a t i c or ba lanced e f f e c t that would l e n d i t s e l f to s t a t i s t i c a l c o n t r o l . T - t e s t s of the d i f f e r e n c e s between these two g r o u p s , ( i . e . , the seven n o n - h u m a n i s t i c and the 37 h u m a n i s t i c ) , were performed on both c l i e n t and t h e r a p i s t forms of the WAI. No s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s were r e v e a l e d in compar isons based on the WAIc. The r e s u l t s of the WAIt compar isons are p r e s e n t e d in T a b l e 14. 78 T a b l e 14 - A n a l y s i s of E f f e c t of T h e o r e t i c a l O r i e n t a t i o n of T h e r a p i s t on WAIt Humanis t ic Non-Humanis t ic Mean S, . D . Mean S . D . t GOAL 67. 50 1 , .45 64 .67 1 .07 1 . .57 TASK 68. 22 1 , .95 65 .06 6 . 1 5 2. .45* BOND 74. 44 1 . .95 71 .52 6 .67 2, .16* COMPOSITE 210. 17 6, .21 201 .25 18 .65 2, .24* * S i g n i f i c a n t d i f f e r e n c e , p_^.05 The WAIt COMPOSITE as w e l l as i t s TASK and BOND s u b s c a l e s d i f f e r e d s t a t i s t i c a l l y s i g n i f i c a n t l y between the h u m a n i s t i c and n o n - h u m a n i s t i c g r o u p s . 79 7.3 C o r r e l a t i o n s Of The WAI With The Outcome Measures At The  Seven O c c a s i o n s The WAI was c o r r e l a t e d w i th outcome at each of the seven o c c a s i o n s at which i t was a d m i n i s t e r e d in o rder to examine f l u c t u a t i o n s over t ime . The mean WAI s c o r e s at the seven o c c a s i o n s at which the ins t rument was a d m i n i s t e r e d were examined and are p r e s e n t e d in Appendix 23, T a b l e 21 a l o n g w i th the r e l i a b i l i t y c o e f f i c i e n t s . The data r e v e a l that the a l l i a n c e s c o n t i n u e d to s t r e n g t h e n through the c o u r s e of t h e r a p y . The c o r r e l a t i o n s of each of the repeated WAIc measures wi th the outcome measures were examined to determine how the a l l i a n c e s ' r e l a t i o n s h i p s w i th outcome changed over the c o u r s e of t h e r a p y . These data are p r e s e n t e d in T a b l e 15. 80 T a b l e 15 - C o r r e l a t i o n s of the WAIc a t Seven O c c a s i o n s w i th the Outcome Measures Target SEI SCL-90 I IP SPQ TPQ C o m p l a i n t s Change COMPOSITE S e s s i o n 1 .19 - . 0 7 - . 0 2 .05 .30* .24 S e s s i o n 2 .24 .06 - . 0 5 .31* . 29 * .17 S e s s i o n 3 .27* .12 - . 1 0 .28* .24* .25* S e s s i o n 4 .29* . 25 * .14 . 3 6 * * . 4 0 * * .24 S e s s i o n 5 . 4 0 * * .18 . 1 1 . 4 7 * * . 4 6 * * . 31 * S e s s i o n 10 .38* .21 .09 . 5 5 * * . 4 8 * * . 4 1 * F i n a l S e s s i o n .21 .17 .06 .30* . 4 5 * * . 26* GOAL S e s s i o n 1 .04 - . 2 0 - . 0 5 - . 0 3 . 1 1 .12 S e s s i o n 2 .08 - . 0 9 - . 1 0 .21 . 1 1 .06 S e s s i o n 3 .16 .07 - . 0 4 . 3 6 * * .21 .20 S e s s i o n 4 .19 .17 .19 . 4 1 * * . 3 6 * * .32* S e s s i o n 5 . 31 * .12 .16 . 4 6 * * . 3 9 * * . 27 * S e s s i o n 10 .22 . 1 1 .21 . 6 5 * * .25 .34* F i n a l S e s s i o n .09 .22 .16 . 3 5 * * . 3 6 * * .30* TASK S e s s i o n 1 .24 .02 .03 .12 . 3 6 * * .28* S e s s i o n 2 .24 .12 .04 . 34 * * . 3 4 * * .17 S e s s i o n 3 .21 .07 - . 0 6 .30* .24* . 25 * S e s s i o n 4 .29* .26* .18 . 3 8 * * . 4 1 * * .21 S e s s i o n 5 . 4 4 * * .17 .16 . 5 6 * * . 47 * * .34* S e s s i o n 10 .35* .21 . 1 4 . 5 4 * * . 4 8 * * . 39 * F i n a l S e s s i o n .25* .27* . 1 3 . 3 6 * * . 5 4 * * . 27 * BOND S e s s i o n 1 .25* .00 - . 0 3 .06 . 3 5 * * . 26* S e s s i o n 2 . 3 6 * * .15 - . 0 7 .30* . 3 6 * * . 25 * S e s s i o n 3 . 3 5 * * .18 - . 1 6 . 1 1 .22 .22 S e s s i o n 4 .32* .25* .02 .21 . 3 4 * * .15 S e s s i o n 5 . 3 6 * * .19 .00 . 31 * . 4 0 * * .24 S e s s i o n 10 .42* .23 - .11 .27 . 5 2 * * . 35 * F i n a l S e s s i o n .22 .00 - .11 .14 . 3 3 * * .14 * S i g n i f i c a n t r e l a t i o n s h i p , p_^.05 * * S i g n i f i c a n t r e l a t i o n s h i p , p_<.01 81 A l though i t has been assumed that the a l l i a n c e was p r e d i c t i v e of outcome by the t h i r d s e s s i o n (Greenberg & P i n s o f , 1986), the da ta in the p r e s e n t s tudy i n d i c a t e d that the r e l a t i o n s h i p of the WAI to the outcome measures w i th which i t c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y c o n t i n u e d to s t r e n g t h e n through the c o u r s e of t h e r a p y . The a n a l y s i s a l s o r e v e a l e d , however, tha t the f i n a l s e s s i o n WAI's r e l a t i o n s h i p wi th outcome was u s u a l l y not as s t r o n g as tha t in e a r l i e r s e s s i o n s . The r e l a t i o n s h i p s of the WAI w i th r e s i d u a l g a i n on the SEI and on the S C L - 9 0 , both of which were not s t a t i s t i c a l l y s i g n i f i c a n t a t the t h i r d to f i f t h s e s s i o n ( S e c t i o n 1.2 and 1 .3 ) , were not o n l y lower at a l l seven o c c a s i o n s and sometimes n e g a t i v e , but they d i d not i n c r e a s e as c o n s i s t e n t l y as d i d the o ther WAI-outcome r e l a t i o n s h i p s through the c o u r s e of t h e r a p y . In p a r t i c u l a r , they were u n s t a b l e over the t h i r d , f o u r t h , and f i f t h s e s s i o n s , ( i . e . , lower in the t h i r d , r i s i n g i n the f o u r t h , and d r o p p i n g in the f i f t h ) . 7.4 R e l a t i o n s h i p s Between The WAI And The Other R e l a t i o n s h i p  Measures The r e l a t i o n s h i p s of the WAI w i th the four o ther r e l a t i o n s h i p measures i n c l u d e d in the p r e s e n t s tudy f o r the purpose of compar ison wi th i t a re p r e s e n t e d in T a b l e 16. 82 T a b l e 16 - R e l a t i o n s h i p s between the WAI and the Other P r o c e s s Measures GOAL TASK BOND COMPOSITE Working A l l i a n c e Inventory ( C l i e n t Form) C l i e n t Involvement S c a l e . 7 0 * * . 7 3 * * . 8 1 * * . 8 1 * * ( c l i e n t - r a t e d ) C l i e n t Involvement S c a l e .38* . 33 * .38* . 4 0 * * ( t h e r a p i s t - r a t e d ) Empathy . 6 8 * * . 6 9 * * . 5 7 * * . 6 9 * * C o u n s e l o r R a t i n g Form E x p e r t n e s s . 3 7 * * . 3 9 * * . 27 * . 3 6 * * A t t r a c t i v e n e s s . 3 9 * * . 3 9 * * . 3 5 * * . 4 2 * * T r u s t w o r t h i n e s s .30* . 27 * .17 .26* CRF T o t a l . 3 8 * * . 39 * * . 29 * . 38** H e l p i n g A l l i a n c e Q u e s t i o n n a i r e HA Type 1 . 6 0 * * . 6 2 * * . 4 0 * * . 5 8 * * HA Type 2 . 5 6 * * . 4 6 * * . 3 1 * . 4 7 * * HAQ T o t a l . 6 3 * * . 6 2 * * . 4 0 * * . 5 8 * * Working A l l i a n c e Inventory ( T h e r a p i s t Form) C l i e n t Involvement S c a l e . 3 7 * * . 5 0 * * . 3 7 * * . 4 3 * * ( c l i e n t - r a t e d ) C l i e n t Involvement S c a l e . 8 8 * * . 8 9 * * . 8 4 * * . 90* * ( t h e r a p i s t - r a t e d ) Empathy .22 .28* .07 .19 C o u n s e l o r R a t i n g Form E x p e r t n e s s .24 . 28 * .13 .22 A t t r a c t i v e n e s s .06 .06 - . 0 3 .06 T r u s t w o r t h i n e s s .06 .06 - . 0 8 .03 CRF T o t a l .13 .13 .01 . 1 1 83 T a b l e 16 ( C o n t ' d . ) GOAL TASK BOND COMPOSITE  H e l p i n g A l l i a n c e Q u e s t i o n n a i r e HA Type 1 . 3 7 * * . 4 1 * * .20 . 3 4 * * HA Type 2 .18 .22 .06 .16 HAQ T o t a l . 33* * . 38** .17 .30* * S i g n i f i c a n t r e l a t i o n s h i p , p_<.05 * S i g n i f i c a n t r e l a t i o n s h i p , p_<.0l The WAIc c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y wi th a l l of the o ther p r o c e s s measures employed in the s t u d y . The WAIt c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the c l i e n t - r a t e d and t h e r a p i s t - r a t e d C l i e n t Involvement S c a l e s and wi th the H e l p i n g  A l l i a n c e Q u e s t i o n n a i r e , but not w i th Empathy or wi th the Counse lo r R a t i n g Form. In o rder to a s s e s s the ex tent to which the f i v e c l i e n t -r a t e d p r o c e s s measures were t a p p i n g r e l a t e d or o v e r l a p p i n g c o n s t r u c t s , they were c o r r e l a t e d w i th one another at the s c a l e l e v e l . These c o r r e l a t i o n s are p r e s e n t e d in T a b l e 17. 84 T a b l e 17 - I n t e r c o r r e l a t i o n s of the C l i e n t - R a t e d P r o c e s s Measures WAIc Empathy CRF HAQ WAIC — Empathy . 6 9 * * — CRF . 3 8 * * . 6 8 * * — HAQ . 5 8 * * . 6 6 * * . 5 1 * * --CISC . 8 1 * * . 4 6 * * .17 . 4 7 * * * * S i g n i f i c a n t c o r r e l a t i o n , p_£. 01 With the e x c e p t i o n of the r e l a t i o n s h i p between the CISc and the CRF, a l l the r e l a t i o n s h i p measures were s t a t i s t i c a l l y s i g n i f i c a n t l y r e l a t e d . 7.5 I d e n t i f i c a t i o n Of R e l a t i v e S t r e n g t h s Of Outcome P r e d i c t o r  V a r i a b l e s In o rder to i n v e s t i g a t e which r e l a t i o n s h i p v a r i a b l e or combina t ion of v a r i a b l e s were the most u s e f u l p r e d i c t o r ( s ) of the v a r i o u s outcomes, a s e r i e s of m u l t i p l e forward s tepwise r e g r e s s i o n e q u a t i o n s was deve loped w i th the REGRESSION procedure of SPSStX u s i n g the s i x r e l a t i o n s h i p measures as the independent v a r i a b l e s and the s i x outcome measures as the dependent v a r i a b l e s . There i s the p o s s i b i l i t y of c o r r e l a t e d e r r o r s when a s e r i e s of m u l t i p l e r e g r e s s i o n a n a l y s e s a r e per formed w i th r e l a t e d outcome measures , { i . e . , the a n a l y s e s a re not r e a l l y i n d e p e n d e n t ) , and , t h e r e f o r e , the p r o b a b i l i t y of a Type I e r r o r i s h i g h e r than that set fo r each of the a n a l y s e s . Some of the 85 i n t e r c o r r e l a t i o n s of the s i x outcome measures as p r e s e n t e d in T a b l e 18 a re s t a t i s t i c a l l y s i g n i f i c a n t a n d , hence , the p r o b a b i l i t i e s set f o r the m u l t i p l e r e g r e s s i o n a n a l y s e s a r e , i n f a c t , somewhat u n d e r s t a t e d . T a b l e 18 - I n t e r c o r r e l a t i o n s of the Outcome Measures Targe t I IP SCL-90 SEI SPQ TPQ C o m p l a i n t s Change Targe t C o m p l a i n t s I IP .17 — SCL-•90 .18 . 4 2 * * — SEI . 4 0 * * .24 . 4 4 * * SPQ Change . 5 1 * * . 3 8 * * .23 . 27 * — TPQ . 3 5 * * .12 .24 . 31 * . 29 * * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 5 * S i g n i f i c a n t r e l a t i o n s h i p , £ < . 0 1 I t was noted that these r e g r e s s i o n e q u a t i o n s were u n s t a b l e , s i n c e a r a t i o of 30 c a s e s per independent v a r i a b l e i s d e s i r e a b l e to d e r i v e a s t a b l e e q u a t i o n ( K e r l i n g e r & Pedhazur , 1982), a c o n d i t i o n t h a t was not met in the p r e s e n t s t u d y . Hence, no i n t e r p r e t a t i o n was to be a p p l i e d from these a n a l y s e s beyond the sample in the s t u d y . The e x p l a i n e d v a r i a n c e s (rj_) were r e p o r t e d o n l y as i n d i c a t i o n s of the c o n t r i b u t i o n s of the independent v a r i a b l e s t o the v a r i a n c e s in t h i s s t u d y . For each of the s i x dependent outcome v a r i a b l e s , o n l y one independent r e l a t i o n s h i p v a r i a b l e e n t e r e d i n t o the e q u a t i o n at the p r o b a b i l i t y l e v e l of .05 or l e s s . I n t e r c o r r e l a t i o n s of the r e l a t i o n s h i p measures were found to be h i g h as were p r e s e n t e d in 86 S e c t i o n 7 . 3 , T a b l e 17. T h e r e f o r e , i t seemed tha t the o v e r l a p among the independent r e l a t i o n s h i p v a r i a b l e s was such t h a t combin ing them d i d not s i g n i f i c a n t l y improve upon t h e i r p r e d i c t i v e e f f i c a c y . The r e s u l t s a re p r e s e n t e d in T a b l e 19. The independent v a r i a b l e s which d i d not enter i n t o the e q u a t i o n s were l i s t e d w i th t h e i r beta weights a f t e r the e n t e r i n g v a r i a b l e s in o rder of t h e i r impact . 87 T a b l e 19 - R e l a t i v e S t r e n g t h s of Outcome P r e d i c t o r V a r i a b l e s Outcome V a r i a b l e P r e d i c t o r Beta Weights R Squared T a r g e t Compla in ts Improvement I IP CISc . 39 * ' . 1 5 SCL-90 SEI SPQ Change HAQ .13 WAIc .04 CRF - . 1 4 Empathy - . 1 9 WAIc . 4 0 * * CISC .15 Empathy .04 CRF - . 1 7 HAQ - . 2 2 HAQ . 4 4 * * WAIc .31 CISC .29 Empathy .23 CRF - . 2 6 HAQ .33* CRF .22 CISC .07 WAIc .00 Empathy - . 2 2 WAIc . 4 0 * * CISc .20 HAQ . 1 7 CRF - . 0 2 Empathy - . 2 5 . 1 6 .19 1 1 16 1 Not i n e q u a t i o n 2 The c o e f f i c i e n t s of d e t e r m i n a t i o n f o r SPQ Change and f o r the TPQ are lower than those r e p o r t e d in H o r v a t h ' s (1981) s t u d y , ( i . e . , .20 and .29 r e s p e c t i v e l y ) . I t was s p e c u l a t e d that the d i f f e r e n c e s might have been due to the s m a l l e r n , ( i . e . , 29 ) , of tha t s tudy which made f o r a h i g h e r chance of f T t t i n g the e r r o r , a n d , h e n c e , f o r d e f l a t i o n upon r e p l i c a t i o n w i th a l a r g e r sample s i z e . 88 T a b l e 19 ( C o n t ' d . ) Outcome V a r i a b l e P r e d i c t o r Beta Weights R Squared TPQ HAQ CISc WAIt WAIc CRF .34* .12 Empathy .19 .14 . 1 1 .06 .02 * S i g n i f i c a n t p r e d i c t o r , p_<.05 * * S i g n i f i c a n t p r e d i c t o r , 2^*01 The two c l i e n t - r a t e d measures of the a l l i a n c e , ( i . e . , the HAQ and the WAIc) , and the CISc were c o n s i s t e n t l y b e t t e r p r e d i c t o r s of outcome than were the CRF, Empathy, and the WAIt. 7.6 Comparison Of WAI Scores Of Completed And Premature ly  Termina ted Cases Some d a t a were c o l l e c t e d on 12 c a s e s that were p remature ly t e r m i n a t e d by c l i e n t s . The WAIc and the WAIt a f t e r the f i r s t and second s e s s i o n s were compared and the r e s u l t s a re p r e s e n t e d in T a b l e 20. 89 Tab le 20 - Comparison of WAI S c o r e s of Completed and Premature ly Terminated Cases n ( c ) / n ( t ) 1 Mean S . D. Mean S . D . WAIc F i r s t S e s s i o n : GOAL 66.59 8. 71 59.00 2 8 .43 2 .50* 44/10 TASK 66. 1 4 8. 62 60.80 1 1 .25 1 .67 BOND 70.25 8. 34 65.20 10 .33 1 .65 COMPOSITE 202.98 23. 67 185.00 28 .07 2 .10* Second S e s s i o n : GOAL 66. 19 7. 53 64.67 6 .48 .56 43/9 TASK 66.53 7. 10 64.44 8 .31 .78 BOND 70.81 6. 97 68.78 8 .09 .78 COMPOSITE 203.53 19. 71 197.89 20 .43 .78 WAIt F i r s t S e s s i o n : GOAL 61 .49 7. 68 62.33 7 .04 .34 43/1 2 TASK 63.49 6. 52 65.58 5 .87 1 .00 BOND 67.91 7. 17 67.58 8 .13 .13 COMPOSITE 192.88 19. 59 195.50 19 .31 .41 Second S e s s i o n : GOAL 63.05 7. 43 62.20 1 1 .08 .23 3 43/10 TASK 64.65 7. 31 62.70 8 .00 .75 BOND 70.09 7. 62 70.00 6 .90 .04 1 Based on 44 completed c a s e s and 10 p remature ly t e r m i n a t e d c a s e s (n(c)=number c o m p l e t e d ; n(t)=number p remature ly t e r m i n a t e d ) . 2 T - t e s t of the d i f f e r e n c e between the means of the two g r o u p s . F - t e s t s of the d i f f e r e n c e s between the v a r i a n c e s of the two groups r e v e a l e d in a l l but one case no s i g n i f i c a n t d i f f e r e n c e s a n d , hence , the t - v a l u e s were based on p o o l e d v a r i a n c e e s t i m a t e s . 3 A s i g n i f i c a n t d i f f e r e n c e between the v a r i a n c e s of the two groups was r e v e a l e d w i th t h i s F - t e s t and , h e n c e , the _t-value based on separa te v a r i a n c e e s t i m a t e s was p r e s e n t e d . 90 WAIc COMPOSITE s c o r e s as w e l l as WAIc GOAL s c o r e s , a f t e r the f i r s t s e s s i o n were s t a t i s t i c a l l y s i g n i f i c a n t l y d i f f e r e n t f o r those who t e r m i n a t e d t h e i r t h e r a p i e s than f o r those who c o n t i n u e d to c o m p l e t i o n . T h i s d i f f e r e n c e d i d not h o l d t r u e a f t e r the second s e s s i o n and d i d not a p p l y to WAIt s c o r e s . 91 V . DISCUSSION 1. INTERPRETATION OF FINDINGS 1.1 R e l a t i o n s h i p Of P e r c e i v e d A l l i a n c e S t r e n g t h To Outcome It was h y p o t h e s i z e d tha t p e r c e i v e d a l l i a n c e s t r e n g t h was p o s i t i v e l y r e l a t e d to outcome. T h i s was the case f o r c l i e n t -p e r c e i v e d a l l i a n c e s t r e n g t h , but not f o r t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h . The WAIc c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y wi th t a r g e t c o m p l a i n t s improvement ( £ = . 3 3 , T a b l e 2) as i t had as w e l l in the Moseley (1983) s t u d y . The BOND s u b s c a l e c o r r e l a t e d p a r t i c u l a r l y s t r o n g l y ( £ = . 4 0 ) w i th t a r g e t c o m p l a i n t s improvement i n the p r e s e n t s t u d y . The WAIc a l s o c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the I IP ( £ = . 4 0 , T a b l e 3 ) , a l t h o u g h t h i s was due to the per formance of the GOAL and TASK s u b s c a l e s ( £ = . 4 4 and .45) r a t h e r than to tha t of the BOND s u b s c a l e ( £ = . 2 3 ) . I t may be tha t c l i e n t s r e l a t e d t h e i r changes on t h i s more d i f f e r e n t i a t e d outcome inst rument to the more t e c h n i c a l d imens ions of t h e i r a l l i a n c e , ( i . e . , g o a l s and t a s k s ) , than they d i d t h e i r improvements on the more g l o b a l t a r g e t c o m p l a i n t s tha t they had themselves i d e n t i f i e d and d e s c r i b e d . The WAIc d i d not c o r r e l a t e wi th r e s i d u a l ga in on the SCL-90 or the SEI w h i l e o ther r e l a t i o n s h i p measures d i d s o . These f i n d i n g s r a i s e q u e s t i o n s about the v a l i d i t y of the WAIc which are a d d r e s s e d in S e c t i o n 1.4, the i n t e r p r e t a t i o n of the f i n d i n g s r e l e v a n t to the r e l a t i o n s h i p of the HAQ to outcome. 92 The WAIc d i d c o r r e l a t e s t a t i s t i c a l l y s i g n i f i c a n t l y w i th SPQ Change ( r= .40 , T a b l e 4 ) . In p a r t i c u l a r , the TASK s u b s c a l e c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y ( r= .4 l ) w i t h SPQ Change. T h i s was an expected f i n d i n g s i n c e i t was c o n s i s t e n t wi th that of Horvath (1981) . However, s i n c e the SPQ i s comple ted by the c l i e n t a f t e r therapy i s c o n c l u d e d , r a t h e r than i n v o l v i n g p r e t e s t s and p o s t t e s t s , i t i s s u b j e c t to the charge that i t i s not a t rue t e s t of outcome, ( i . e . , t h e r a p e u t i c c h a n g e ) , but r a t h e r a s a t i s f a c t i o n measure. The WAIc a l s o c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the TPQ ( r= .28 , T a b l e 4 ) . T h i s c o r r e l a t i o n of the c l i e n t - r a t e d p r o c e s s measure wi th the t h e r a p i s t - r a t e d outcome measure c o u n t e r s the c l a i m ( G l a s s , 1984) that the a l l i a n c e i s not an independent p r e d i c t o r of outcome, but r a t h e r an i n - p r o c e s s assessment of outcome which i s l a t e r i n e v i t a b l y c o n f i r m e d i n the manner of a s e l f - f u l f i l l i n g p r o p h e c y . F u r t h e r e v i d e n c e tha t the a l l i a n c e i s an independent p r e d i c t o r of outcome i s d i s c u s s e d in S e c t i o n 1 . 7 . 3 . The WAIt d i d not p r e d i c t outcome as a s s e s s e d by the c l i e n t on any of the f i v e measures employed. C o r r e l a t i o n w i th the t h e r a p i s t - r a t e d TPQ was a l s o not s t a t i s t i c a l l y s i g n i f i c a n t at the composi te l e v e l (Tab le 4 ) . The f a i l u r e of the WAIt to p r e d i c t outcome demonstrated i n the p r e s e n t s tudy sugges ts tha t the WAIt i s not an e f f e c t i v e measure of the a l l i a n c e . The r e l a t i v e l y weak c o r r e l a t i o n s of the WAIt w i th the WAIc (Tab les 10 and 16) and the s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between the c o r r e l a t i o n s of the WAIc 93 wi th t a r g e t c o m p l a i n t s improvement and w i th the I IP and the WAIt wi th t h e s e two outcome measures (Tab le 9) i n d i c a t e tha t the two i n s t r u m e n t s are not measur ing the same c o n s t r u c t , a l t h o u g h they both p u r p o r t to be measures of the a l l i a n c e . T h i s d i s p a r i t y sugges ts tha t the meaning of the a l l i a n c e c o n s t r u c t r e q u i r e s c l a r i f i c a t i o n . I t may be argued tha t s t r o n g e r c o r r e l a t i o n s of the WAI w i th outcome would have been a c h i e v e d had i n i t i a l WAI v a l u e s been p a r t i a l e d out of the t h i r d to f i f t h s e s s i o n average measures , thereby l i f t i n g the c e i l i n g imposed by the r e g r e s s i o n e f f e c t on i n i t i a l l y s t r o n g a l l i a n c e s . S i n c e the p o i n t spread over the f i v e s e s s i o n s was o n l y 7.77 out of 252 f o r the WAIc (Appendix 23, T a b l e 21) and 11.96 out of 252 f o r the WAIt, i n c l u s i o n of such a p rocedure would p r o b a b l y not have e f f e c t e d the study r e s u l t s s i g n i f i c a n t l y . 1.2 R e l a t i o n s h i p Of P e r c e i v e d Change In A l l i a n c e S t r e n g t h To  Outcome I t was h y p o t h e s i z e d tha t p e r c e i v e d change i n a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s of therapy was p o s i t i v e l y r e l a t e d to outcome. T h i s was found not to be the c a s e . Suh , O ' M a l l e y , & S t r u p p ' s (1986) r e s e a r c h has suggested tha t i n c r e a s e in t h e r a p i s t b e h a v i o u r s , ( i . e . , T h e r a p i s t Warmth and T h e r a p i s t E x p l o r a t i o n ) , i n the e a r l y p a r t of the rapy might be more c r i t i c a l to s u c c e s s f u l outcome than the a b s o l u t e l e v e l of such t h e r a p i s t b e h a v i o u r s in the t h i r d s e s s i o n . A l t h o u g h the a l l i a n c e d i d i n c r e a s e in the p r e s e n t s tudy (Table 14) , when Suh et a l . ' s p rocedure was a p p l i e d to the d a t a , 94 no r e l a t i o n s h i p between i n c r e a s e in a l l i a n c e s t r e n g t h over the f i r s t f i v e s e s s i o n s and outcome was found (Table 5 ) . S i n c e the r a t i o n a l e f o r t h e i r method of c a l c u l a t i n g the i n c r e a s e seems q u e s t i o n a b l e , ( S e c t i o n 2 of Chapter I V ) , i t may be that Suh et a l . ' s f i n d i n g was in f a c t a s t a t i s t i c a l a r t i f a c t . In a d d i t i o n , i t r e l a t e d to a subgroup of four of t h e i r 16 c a s e s , a subgroup which c o n s i s t e d of "low p r o g n o s i s " p a t i e n t s who a c h i e v e d "h igh outcomes" and may not app ly a c r o s s a t o t a l sample . 1.3 R e l a t i o n s h i p s Of C l i e n t - p e r c e i v e d T h e r a p i s t Empathy,  E x p e r t n e s s , A t t r a c t i v e n e s s , And T r u s t w o r t h i n e s s To Outcome I t was h y p o t h e s i z e d tha t c l i e n t - p e r c e i v e d t h e r a p i s t empathy, e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s were l e s s p o s i t i v e l y r e l a t e d to outcome than was c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h . T h i s was found to be the c a s e . The Empathy s u b s c a l e of the RI_ c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th on ly one of the outcome measures, r e s i d u a l g a i n on the I IP ( £ = . 2 6 , T a b l e 6 ) . T h i s poor r e s u l t may be a t t r i b u t a b l e to the l i m i t a t i o n s of the i n s t r u m e n t . Such an a t t r i b u t i o n would be c o n s i s t e n t w i th the c o n c l u s i o n s of G e l s o and C a r t e r (1985) and of Marks and Tolsma (1986) c o n c e r n i n g the c o n t r a d i c t o r y f i n d i n g s of p r o c e s s - o u t c o m e s t u d i e s w i th r e s p e c t to empathy ( S e c t i o n 1.2, Chapter I I ) . G e l s o and C a r t e r c o n c l u d e d tha t t h e r e i s not a s imp le l i n e a r r e l a t i o n s h i p , at l e a s t of any magni tude , between t h e r a p i s t - o f f e r e d c o n d i t i o n s and outcome and t h a t the r e l a t i o n s h i p i s p r o b a b l y best viewed as h i g h l y complex . Marks and Tolsma recommended that s i n c e empathy i s a complex c o n s t r u c t , i t s i n v e s t i g a t i o n r e q u i r e s s o p h i s t i c a t e d 95 s t u d i e s in which the d e t a i l s of the empathic p r o c e s s are c l o s e l y s c r u t i n i z e d . For example, such v a r i a b l e s as v a r i a t i o n s in the s u b j e c t p o p u l a t i o n and in the p r e s e n t i n g concern and the manner in which i t i s d i s c u s s e d , ( i . e . , l e v e l of emot iona l con ten t i n the p r e s e n t a t i o n ) , a f f e c t the s t r e n g t h of empathy r a t i n g s . S i n c e the p r e s e n t study drew upon a broad p o p u l a t i o n of r e a l c a s e s , no such s c r u t i n y of the empathic p r o c e s s was f e a s i b l e . The C o u n s e l o r R a t i n g Form was more c o n s i s t e n t l y r e l a t e d to outcome than was Empathy, c o r r e l a t i n g s t a t i s t i c a l l y s i g n i f i c a n t l y w i th th ree of the s i x outcome measures . I t c o r r e l a t e d w i th r e s i d u a l ga in on the SCL-90 ( r= .42 , T a b l e 7 ) , the SEI ( r= .33 ) , and the IIP ( r= .30 ) , but i t d i d not c o r r e l a t e w i th t a r g e t c o m p l a i n t s improvement, SPQ Change, and the TPQ. The WAIc d i d c o r r e l a t e s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the l a t t e r t h r e e . The C R F ' s c o r r e l a t i o n w i th t a r g e t c o m p l a i n t s improvement and w i th r e s i d u a l g a i n on the SCL-90 were s t a t i s t i c a l l y s i g n i f i c a n t l y d i f f e r e n t from those of the WAIc w i th these two outcome measures (Table 9 ) . That the WAIc would ou tper fo rm the CRF on t a r g e t c o m p l a i n t s improvement and SPQ Change (though not s t a t i s t i c a l l y s i g n i f i c a n t l y on the l a t t e r ) i s c o n s i s t e n t w i th H o r v a t h ' s (1981) and M o s e l e y ' s (1983) r e s u l t s . However, the s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n s of the CRF and of the HAQ ( d i s c u s s e d in S e c t i o n 1.4) w i th r e s i d u a l ga in on the SCL-90 and the SEI h i g h l i g h t the inadequacy of the WAIc as a comprehensive c o r r e l a t i v e measure. In p a r t i c u l a r , both of these r e l a t i o n s h i p measures ' c o r r e l a t i o n s wi th the SCL-90 were s t a t i s t i c a l l y 96 s i g n i f i c a n t l y s t r o n g e r than tha t of the WAIc w i th the S C L - 9 0 . 1.4 R e l a t i o n s h i p Of C l i e n t - p e r c e i v e d A l l i a n c e S t r e n g t h As  Measured With The H e l p i n g A l l i a n c e Q u e s t i o n n a i r e To Outcome It was h y p o t h e s i z e d t h a t c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h as measured wi th the H e l p i n g A l l i a n c e Q u e s t i o n n a i r e was p o s i t i v e l y r e l a t e d to outcome. T h i s was the c a s e . The HAQ proved to be a power fu l p r e d i c t o r of outcome in the p r e s e n t s t u d y , c o r r e l a t i n g s t a t i s t i c a l l y s i g n i f i c a n t l y w i th a l l s i x of the outcome measures (Table 8 ) . T h i s 11- i tem s c a l e i s more e f f i c i e n t l y a d m i n i s t e r e d than the 36 - i tem WAIc and seems to be at l e a s t as e f f e c t i v e . The t h r e e - i t e m H e l p i n g A l l i a n c e Type 2 s u b s c a l e c o r r e l a t e d l e s s s t r o n g l y , though not s t a t i s t i c a l l y s i g n i f i c a n t l y s o , than the e i g h t - i t e m H e l p i n g A l l i a n c e Type 1 s u b s c a l e (Table 6 ) , but t h i s seemed to be a t t r i b u t a b l e to one i t em, ( i . e . , #11: I f e e l now tha t I can unders tand myse l f and d e a l w i th myse l f on my own ( that i s , even i f t h i s t h e r a p i s t and I were no longer meet ing f o r t reatment a p p o i n t m e n t s ) . ) , which c o n s i s t e n t l y e l i c i t e d r e s p o n s e s tha t were d i s p a r a t e from those to the o ther i t e m s . In t h e i r c o n c e p t i o n s , the HAQ i s an e m p i r i c a l l y - d r i v e n ins t rument whereas the WAI i s c o n c e p t u a l l y - d r i v e n . A lexander and Luborsky (1986) r e p o r t e d that the HAQ was d e r i v e d from the Penn H e l p i n g A l l i a n c e S c a l e tha t was in tu rn deve loped from L u b o r s k y ' s s tudy of c l i n i c a l t r a n s c r i p t s . Examinat ion of i t s i tems sugges ts tha t they r e f l e c t a p o s i t i v e or opt imism f a c t o r , r e q u i r i n g the c l i e n t to e v a l u a t e the ex tent to which she /he f e e l s good because h e / s h e b e l i e v e s s h e / h e i s be ing or w i l l be 97 h e l p e d by the t h e r a p i s t . The importance of t h i s p o s i t i v e c l i e n t a t t i t u d e was a f f i r m e d by the f i n d i n g of Marmar, M a r z i a l i , H o r o w i t z , and Weiss (1986) that the p a t i e n t f e e l i n g h e l p e d and h o p e f u l was an important f a c t o r b e i n g tapped by t h e i r a l l i a n c e s c a l e . The HAQ i tems may be grouped by con ten t as f o l l o w s : Two of the 11 i tems probe the ex ten t of c l i e n t - p e r c e i v e d t h e r a p e u t i c p r o g r e s s : #3-1 have o b t a i n e d some new u n d e r s t a n d i n g . #4-1 have been f e e l i n g b e t t e r r e c e n t l y . Four i tems probe the ex tent of c l i e n t op t im ism: #1-1 b e l i e v e that my t h e r a p i s t i s h e l p i n g me. #2-1 b e l i e v e that the t reatment i s h e l p i n g me. #5-1 can a l r e a d y see tha t I w i l l e v e n t u a l l y work out the problems I came to t reatment f o r . #11-1 f e e l now that I can unders tand mysel f and d e a l wi th myse l f on my own ( that i s , even i f t h i s t h e r a p i s t and I were no longer meet ing f o r t reatment a p p o i n t m e n t s ) . Three i tems probe the extent of c l i e n t c o n f i d e n c e in the t h e r a p i s t : #6-1 f e e l I can depend upon the t h e r a p i s t . #7-1 f e e l the t h e r a p i s t unders tands me. #8-1 f e e l the t h e r a p i s t wants me to a c h i e v e my g o a l s . Two i tems probe the ex tent of c l i e n t - p e r c e i v e d c l i e n t c o l l a b o r a t i o n w i th the t h e r a p i s t : 98 #9-1 f e e l I am working t o g e t h e r w i th the t h e r a p i s t in a j o i n t e f f o r t . #10-1 b e l i e v e we have s i m i l a r ideas about the na ture of my p rob lems . With the e x c e p t i o n of i tems #9 and #10, t h e n , the HAQ i s a measure of c l i e n t a t t i t u d e . F r i eswyk et a l . (1986) have c r i t i c i z e d such measures of the a l l i a n c e as h a v i n g " f a i l e d to d i s t i n g u i s h u n d e r l y i n g and c o n t r i b u t i n g p a t i e n t a t t i t u d e s and c h a r a c t e r i s t i c s from the p a t i e n t ' s a c t i v e c o l l a b o r a t i o n i n the t h e r a p e u t i c p r o c e s s " (p . 35 ) . It i s t h i s a c t i v e c o l l a b o r a t i o n which they regard as the w i t h i n - p r o c e s s v a r i a b l e which may be u t i l i z e d as a barometer of change which r e f l e c t s i n i t s v a r i a t i o n s both the s h o r t - t e r m and l o n g - t e r m impact of v a r i o u s c l a s s e s of t h e r a p e u t i c i n t e r v e n t i o n . T h i s c o n c e p t u a l b a s i s of the HAQ i s d i f f e r e n t from tha t of the WAI which i s based on B o r d i n ' s (1975, 1979) theory c o n c e r n i n g the s t r u c t u r e of the a l l i a n c e and which f o c u s e s in t w o - t h i r d s of i t s i tems on c l a r i t y of g o a l s and task r e l e v a n c e . The WAI demands of the c l i e n t , t h e r e f o r e , more d i f f e r e n t i a t e d , c o n c e p t u a l responses to i t s i t e m s . Such responses may be d i f f i c u l t f o r l e s s i n t e l l e c t u a l l y - a d r o i t c l i e n t s to make and t h i s d i f f i c u l t y may r e s u l t i n more v a r i a t i o n or e r r o r in t h e i r responses a n d , hence , i n l e s s c o n s i s t e n t c o r r e l a t i o n s w i th outcome. The WAI items probe a broader range of v a r i a b l e s than do the HAQ i t e m s . Seven i tems probe c l i e n t b e h a v i o u r s and c l i e n t -p e r c e i v e d t h e r a p i s t b e h a v i o u r s : 99 #2- and I agree about the t h i n g s I w i l l need to do i n therapy to h e l p improve my s i t u a t i o n . #4-What I am d o i n g in therapy g i v e s me new ways of l o o k i n g at my p rob lem. #5- and I unders tand each o t h e r . #6- p e r c e i v e s a c c u r a t e l y what my g o a l s a r e . #22- and I a re working towards m u t u a l l y agreed upon g o a l s . #30- and I c o l l a b o r a t e on s e t t i n g g o a l s f o r my t h e r a p y . #32-We have e s t a b l i s h e d a good u n d e r s t a n d i n g of the k i n d s of changes tha t would be good fo r me. One i tem probes the extent of c l i e n t m o t i v a t i o n : #14-The g o a l s of these s e s s i o n s are important to me. One i tem probes the extent of c l i e n t - p e r c e i v e d t h e r a p e u t i c p r o g r e s s : #25-As a r e s u l t of these s e s s i o n s , I am c l e a r e r as to how I might be a b l e to change . One i tem probes the extent of c l i e n t o p t i m i s m : #16-1 f e e l that the t h i n g s I do in therapy w i l l h e l p me to a c c o m p l i s h the changes tha t I want. One i tem probes the ex ten t of c l i e n t c o n f i d e n c e in the t h e r a p i s t : #21-1 am c o n f i d e n t i n ' s a b i l i t y to h e l p me. One i tem probes the extent of c l i e n t c o n f i d e n c e in the t h e r a p y : 100 #35-1 b e l i e v e the way we are working wi th my problem i s c o r r e c t . Three i tems probe the ex tent of c l i e n t o r i e n t a t i o n toward c o l l a b o r a t i o n : #13-1 am c l e a r on what my r e s p o n s i b i l i t i e s are i n t h e r a p y . #18-1 am c l e a r as to what wants me to do in these s e s s i o n s . #24-We agree on what i s important f o r me to work o n . Seven i tems probe the s t r e n g t h of the i n t e r p e r s o n a l bond between c l i e n t and t h e r a p i s t : #8-1 b e l i e v e l i k e s me. #17-1 b e l i e v e i s g e n u i n e l y concerned f o r my w e l f a r e . #19- and I r e s p e c t each o t h e r . #23-1 f e e l that a p p r e c i a t e s me. #26- and I t r u s t one a n o t h e r . #28-My r e l a t i o n s h i p wi th i s ve ry important to me. #36-1 f e e l c a r e s about me even when I do t h i n g s tha t h e / s h e does not approve o f . As w e l l , the WAI i n c l u d e s a l a r g e number of n e g a t i v e l y -s t a t e d i t e m s , ( i . e . , 13 of 36 ) , which e l i c i t c l i e n t doubt r a t h e r than c l i e n t op t im ism: #1-1 f e e l uncomfor tab le w i th . #3-1 am w o r r i e d about the outcome of these s e s s i o n s . #7-1 f i n d what I am d o i n g i n therapy c o n f u s i n g . 101 #9-1 wish and I c o u l d c l a r i f y the purpose of our s e s s i o n s . #11-1 b e l i e v e the time and I a re spending t o g e t h e r i s not spent e f f i c i e n t l y . #12- does not unders tand what I am t r y i n g to a c c o m p l i s h in t h e r a p y . #15-1 f i n d what and I a re do ing in therapy i s u n r e l a t e d to my c o n c e r n s . #20-1 f e e l tha t i s not t o t a l l y honest about h i s / h e r f e e l i n g s toward me. #27- and I have d i f f e r e n t i d e a s on what my problems a r e . #29-1 have the f e e l i n g that i f I say or do the wrong t h i n g s , w i l l s t o p working w i th me. #31-1 am f r u s t r a t e d by the t h i n g s I am d o i n g in t h e r a p y . #33-The t h i n g s that i s a s k i n g me to do d o n ' t make s e n s e . #34-1 d o n ' t know what to expect as the r e s u l t of my t h e r a p y . T h i s heterogeneous measure of the a l l i a n c e which probes c l i e n t a c t i v i t y , c l i e n t - p e r c e i v e d t h e r a p i s t a c t i v i t y , c l i e n t a t t i t u d e s and c h a r a c t e r i s t i c s , c l i e n t d o u b t s , and c l i e n t f e e l i n g s about the t h e r a p i s t and the r e l a t i o n s h i p w i th the t h e r a p i s t i s a l s o v u l n e r a b l e to the charge tha t i t r enders the impact of s p e c i f i c c l a s s e s of t h e r a p i s t i n t e r v e n t i o n s on the d e v e l o p i n g a l l i a n c e and i t s subsequent r e l a t i o n to outcome d i f f i c u l t to e v a l u a t e (Fr ieswyk et a l . , 1986). The d i v e r s i t y of v a r i a b l e s be ing probed by the WAI i s e v i d e n c e d i n the d i s t i n c t i v e , though not s t a t i s t i c a l l y s i g n i f i c a n t l y d i f f e r e n t , per formance of i t s BOND s u b s c a l e , both in r e l a t i o n to the o ther r e l a t i o n s h i p v a r i a b l e s and a l s o i n i t s 102 r e l a t i o n s h i p to outcome. A l t h o u g h the WAIc c o r r e l a t e d at .58 w i th the HAQ (Table 17) , the WAIc BOND s u b s c a l e c o r r e l a t e d l e s s s t r o n g l y a t . 4 0 . The BOND s u b s c a l e a l s o c o r r e l a t e d l e s s s t r o n g l y both wi th the CRF ( £ = . 2 9 , T a b l e 16) than d i d the WAIc COMPOSITE ( £ = . 3 8 ) and wi th Empathy ( £ = . 5 7 f o r the BOND s u b s c a l e and £ = . 6 9 f o r the WAIc COMPOSITE). The BOND s u b s c a l e was more s t r o n g l y r e l a t e d to t a r g e t c o m p l a i n t s improvement than the WAI and the HAQ ( £ = . 4 0 v s . .33 (Tab le 2) and .29 (Table 6) r e s p e c t i v e l y ) . I t was l e s s s t r o n g l y r e l a t e d to r e s i d u a l ga in on the I IP than were the WAIc and the HAQ ( £ = . 2 3 v s . .40 (Table 3) and .38 (Table 6) r e s p e c t i v e l y ) . T h i s d i s t i n c t i v e per formance of the BOND s u b s c a l e seems c o n s i s t e n t w i th G e l s o and C a r t e r ' s (1985) p r o p o s i t i o n tha t the bonding a s p e c t of the a l l i a n c e d e v e l o p s somewhat i n d e p e n d e n t l y of the o t h e r a s p e c t s (Chapter I, S e c t i o n 2 ) . The charge that the a l l i a n c e measure i s , in f a c t , an e a r l y e v a l u a t i o n of outcome which i s i n e v i t a b l y c o r r o b o r a t e d as a s e l f - f u l f i l l i n g prophecy seems to a p p l y to the HAQ, ( i . e . , t h i s " a l l i a n c e " measure q u e s t i o n s whether the c l i e n t b e l i e v e s that the therapy i s h e l p i n g ; the outcome measures q u e s t i o n whether the c l i e n t b e l i e v e s tha t the therapy has h e l p e d ) . U n l i k e the WAI, the HAQ p r o v i d e s l i t t l e i n f o r m a t i o n that would a s s i s t the c l i n i c i a n i n c o n s t r u c t i n g an a l l i a n c e w i th a p a r t i c u l a r c l i e n t . These c o n c e p t u a l d i f f e r e n c e s between the HAQ and the WAI, both of which p u r p o r t to measure the a l l i a n c e , seem to support the c o n c e r n e x p r e s s e d by Greenberg and P i n s o f (1986) r e g a r d i n g the c o n s t r u c t v a l i d i t y of the v a r i o u s a l l i a n c e measures . 103 A l t h o u g h the o v e r a l l e f f e c t i v e n e s s of the HAQ and the WAIc in a c c o u n t i n g f o r outcome v a r i a n c e was e q u a l , the HAQ was s t a t i s t i c a l l y s i g n i f i c a n t l y more s t r o n g l y r e l a t e d to the SCL-90 than was the WAIc. V a r i o u s s p e c u l a t i o n s may be o f f e r e d c o n c e r n i n g the compara t ive weakness of the WAIc i n r e l a t i o n s h i p to the SCL-90 a n d , to a l e s s e r and not s t a t i s t i c a l l y s i g n i f i c a n t e x t e n t , to the S E I . A c l u e to tha t weakness seems to l i e in the f a c t tha t the CRF as w e l l as the HAQ c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i t h the SCL-90 and the SEI (r=.42 and .33 r e s p e c t i v e l y f o r the CRF and r=.44 and .33 r e s p e c t i v e l y f o r the HAQ, Tab le 8 ) . None of the o ther r e l a t i o n s h i p measures c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th these two outcome measures . The CRF i s a measure of the c l i e n t ' s e v a l u a t i o n of the t h e r a p i s t ' s e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s . The HAQ in 6 of i t s 11 i tems a l s o measures the c l i e n t ' s assessment of the t h e r a p i s t i n h i s / h e r r o l e as t h e r a p i s t (as d i s t i n c t from h e r / h i s p a r t i c i p a t i o n i n the p e r s o n a l r e l a t i o n s h i p between them). These two outcome measures are d i f f e r e n t from the o t h e r s in tha t they demand that the c l i e n t e v a l u a t e h i m / h e r s e l f , ( i . e . , p a t h o l o g i c a l symptoms and s e l f - e s t e e m ) , as opposed to h e r / h i s c o m p l a i n t s , h i s / h e r r e l a t i o n s h i p s w i th o t h e r s , or h e r / h i s e x p e r i e n c e i n t h e r a p y . The changes measured wi th the SCL-90 and the SEI seem to be dependent upon the c l i e n t ' s p e r c e i v i n g the t h e r a p i s t as competent . Such an i n t e r p r e t a t i o n seems c o n s i s t e n t w i th the emphasis p l a c e d by B u t l e r and S t r u p p (1986) upon the t h e r a p i s t r a t h e r 104 than the therapy as the change a g e n t : . . . The purpose of psychotherapy r e s e a r c h i s to u n d e r s t a n d how one person (the t h e r a p i s t ) i n f l u e n c e s or f a i l s to i n f l u e n c e another person (the p a t i e n t ) w i t h i n a t h e r a p e u t i c c o n t e x t . T h e r a p e u t i c c o n t e x t , in t u r n , can be f u r t h e r d e f i n e d as a p a r t i c u l a r i n t e r p e r s o n a l c o n t e x t in which one person (the p a t i e n t ) seeks some b e n e f i t from another (the t h e r a p i s t ) . I m p l i c i t i n these s ta tements i s the assumpt ion that i t i s the t h e r a p i s t , not "the t h e r a p y " , which i s the ins t rument of t h i s b e n e f i c i a l i n f l u e n c e . (p . 37) A f u r t h e r p o s s i b l e e x p l a n a t i o n of the d i f f e r e n t i a l per formance of the two a l l i a n c e measures r e l a t e s to t h e i r d i f f e r e n t a d m i n i s t r a t i o n s . The WAI was a d m i n i s t e r e d at each of the f i r s t f i v e s e s s i o n s whereas the HAQ and the CRF were a d m i n i s t e r e d o n l y once at the t h i r d s e s s i o n and p e r h a p s , t h e r e f o r e , r e c e i v e d more c l i e n t c o n s i d e r a t i o n at t h i s c r i t i c a l p o i n t . In f a c t , the i n s t a b i l i t y of the c o r r e l a t i o n s of the WAIc over the t h i r d , f o u r t h , and f i f t h s e s s i o n s wi th the SCL-90 and the SEI (Tab le 15) , ( i . e . , the lower c o r r e l a t i o n s of the t h i r d s e s s i o n WAIc, the r i s e i n the f o u r t h , and the drop in the f i f t h ) , sugges ts the p o s s i b i l i t y t h a t repea ted measures may be i n t r u s i v e and c a u s i n g an e f f e c t . F i n a l l y , the sample i n the p r e s e n t study c o n s i s t e d l a r g e l y of h u m a n i s t i c / e x p e r i e n t i a l / e c l e c t i c c a s e s (Appendix 24, T a b l e 23) in which g o a l s and t a s k s a re not e x p l i c i t l y a r t i c u l a t e d a t the o u t s e t of t h e r a p y , but a re r a t h e r i d e n t i f i e d by the c l i e n t in the c o u r s e of h e r / h i s becoming aware of h i s / h e r p r o c e s s . The h u m a n i s t i c t h e r a p i s t does not c o n c e i v e of h e r / h i s f u n c t i o n as be ing to a n a l y z e or r e s o l v e a problem or a d i s o r d e r , but i n s t e a d 105 as be ing to f a c i l i t a t e the c l i e n t ' s e x i s t e n t i a l " u n f o l d i n g " in the c o n t e x t of a d i a l o g i c encounter or an " I -Thou" r e l a t i o n s h i p (Buber , 1970). Hence, i tems in the GOAL and TASK s u b s c a l e s are p o s s i b l y more l i k e l y to r e c e i v e u n c e r t a i n and perhaps noncommit ta l or n e g a t i v e responses from c l i e n t s in t h i s sample than from c l i e n t s in a sample which i n c l u d e d more l e a r n i n g -o r i e n t e d c a s e s or c e r t a i n p s y c h o a n a l y t i c c a s e s . There may have been a mismatch w i th t h i s sample between the assumpt ions u n d e r l y i n g h u m a n i s t i c psychotherapy and the c o n c e p t u a l b a s i s of the WAI. A l l of the f a c t o r s d i s c u s s e d a b o v e - - t h e s i g n i f i c a n c e of the t h e r a p i s t as e x p e r t , the repea ted a d m i n i s t r a t i o n e f f e c t , and the b i a s of the sample toward h u m a n i s t i c cases—may have c o n t r i b u t e d to the weakness of the WAIc r e l a t i v e to the HAQ in i t s r e l a t i o n s h i p to some of the outcome measures i n the p r e s e n t s t u d y . 1.5 R e l a t i o n s h i p Of P e r c e i v e d C l i e n t Involvement To Outcome It was h y p o t h e s i z e d tha t c l i e n t - p e r c e i v e d c l i e n t involvement and t h e r a p i s t - p e r c e i v e d c l i e n t involvement were p o s i t i v e l y r e l a t e d to outcome. I t was found to be the case tha t c l i e n t - p e r c e i v e d c l i e n t involvement was p o s i t i v e l y r e l a t e d to outcome, but that t h e r a p i s t - p e r c e i v e d c l i e n t involvement was n o t . The e x p l o r a t o r y C l i e n t Involvement S c a l e was i n c l u d e d in the p r e s e n t s tudy in o rder to p r o v i d e data r e l e v a n t to Greenberg and P i n s o f ' s (1986) s u g g e s t i o n tha t Involvement i s the c r i t i c a l c l i e n t v a r i a b l e a s s o c i a t e d w i th the fo rmat ion of the a l l i a n c e . 106 The CIS appended to both forms of the WAI per formed s i m i l a r l y to the WAIc and the WAIt in r e l a t i o n s h i p to the outcome measures (Table 7 ) . A l t h o u g h Greenberg and P i n s o f s s u g g e s t i o n i m p l i e s that the CIS would c o r r e l a t e more s t r o n g l y than the WAI, the f a c t tha t t h i s s i x - i t e m s c a l e demonstrated comparable p r e d i c t i v e c a p a c i t y w i th the WAI sugges ts tha t i t s u n d e r l y i n g c o n c e p t u a l b a s i s m e r i t s f u r t h e r e x a m i n a t i o n . 1.6 R e l a t i o n s h i p Of Congruence Of C l i e n t - p e r c e i v e d And  T h e r a p i s t - p e r c e i v e d A l l i a n c e S t r e n g t h To Outcome It was h y p o t h e s i z e d tha t congruence of c l i e n t - p e r c e i v e d a l l i a n c e s t r e n g t h and t h e r a p i s t - p e r c e i v e d a l l i a n c e s t r e n g t h was p o s i t i v e l y r e l a t e d to outcome. T h i s was found not to be the c a s e . No r e s e a r c h has as yet been p u b l i s h e d on the congruence of c l i e n t and t h e r a p i s t p e r s p e c t i v e s on t h e i r working a l l i a n c e as i t r e l a t e s to outcome. However, H i l l , Helms, T i c h e n o r , S p i e g e l , O ' G r a d y , and P e r r y ( i n p r e s s ) found that c l i e n t and t h e r a p i s t r a t i n g s of t h e r a p i s t i n t e r v e n t i o n s were more congruent at h i g h e r l e v e l s of c l i e n t e x p e r i e n c i n g , the measure of t h e r a p e u t i c e f f e c t i v e n e s s in e x p e r i e n t i a l t h e r a p y , than a t lower l e v e l s of c l i e n t e x p e r i e n c i n g . Congruence of r a t i n g s of the a l l i a n c e by c l i e n t s and t h e r a p i s t s would c o n s t i t u t e " o b j e c t i v e " e v i d e n c e of the p resence of that a l l i a n c e . A s i g n i f i c a n t r e l a t i o n s h i p between congruence and outcome would p r o v i d e s t r o n g suppor t fo r the h y p o t h e s i z e d s i g n i f i c a n c e of the a l l i a n c e in p s y c h o t h e r a p y ( B o r d i n , 1975, 1 07 1979) . In the p r e s e n t s t u d y , the two forms of the WAI were found to be weakly but s t a t i s t i c a l l y s i g n i f i c a n t l y c o r r e l a t e d except on the BOND s u b s c a l e s of both (Tab le 10) , and t h e i r congruence was found to i n c r e a s e somewhat over the seven o c c a s i o n s a t which they were a d m i n i s t e r e d (Table 11). However, the r e s u l t s of the p resen t s tudy a re e q u i v o c a l w i th r e s p e c t to the p r e d i c t i v e e f f i c a c y of congruence of c l i e n t and t h e r a p i s t r a t i n g s of the a l l i a n c e (Table 12) . Congruence in l a t e r s e s s i o n s c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th r e s i d u a l g a i n on the SEI and i t approached s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n i n e a r l y s e s s i o n s w i th r e s i d u a l g a i n on t n e S C L - 9 0 . However, i t c o r r e l a t e d n e g a t i v e l y w i th improvement in t a r g e t c o m p l a i n t s and wi th SPQ Change in e a r l y s e s s i o n s and wi th r e s i d u a l g a i n on the IIP in l a t e r s e s s i o n s . Congruence was u n r e l a t e d to outcome on the TPQ. These f i n d i n g s on the v a r i o u s outcome measures are i n c o n s i s t e n t a n d , hence , no i n t e r p r e t a t i o n c o u l d be drawn from them. 1.7 Post Hoc A n a l y s e s 1.7.1 A n a l y s i s Of T h e r a p i s t E f f e c t S i n c e the e f f e c t of some t h e r a p i s t s h a v i n g c o n t r i b u t e d m u l t i p l e c a s e s to the sample was n e i t h e r s i g n i f i c a n t nor s y s t e m a t i c , s i m p l e compar isons of the s t a n d a r d d e v i a t i o n s of the group of 14 c a s e s c o n t r i b u t e d by f i v e t h e r a p i s t s and the group of 30 c a s e s c o n t r i b u t e d by 30 t h e r a p i s t s were made on th ree marker outcome v a r i a b l e s (Tab le 13). S i n c e the s t a n d a r d 108 d e v i a t i o n s of the two groups were not ext remely d i f f e r e n t on any of the marker v a r i a b l e s , ( i . e . , one be ing not more than twice as l a r g e as the o t h e r ) , a l l 44 c a s e s in the sample were t r e a t e d as i n d e p e n d e n t . 1.7.2 A n a l y s i s Of E f f e c t Of T h e o r e t i c a l O r i e n t a t i o n s Of  T h e r a p i s t s The data were inadequate to a n a l y z e a p o s s i b l e e f f e c t of t h e o r e t i c a l o r i e n t a t i o n on the a l l i a n c e . Only four of the 35 t h e r a p i s t s c a t e g o r i z e d themselves as o ther than h u m a n i s t i c . However, s imp le compar isons of the WAI s c o r e s of the two groups were p e r f o r m e d . No d i f f e r e n c e s were r e v e a l e d in the c l i e n t s ' p e r c e p t i o n s of t h e i r a l l i a n c e s between the two g r o u p s . However, the t h e r a p i s t s ' p e r c e p t i o n s d i d d i f f e r s t a t i s t i c a l l y s i g n i f i c a n t l y (Tab le 14). The n o n - h u m a n i s t i c c a s e s had weaker a l l i a n c e s than d i d the h u m a n i s t i c c a s e s . The n o n - h u m a n i s t i c c a s e s a l s o showed g r e a t e r v a r i a b i l i t y on the TASK and GOAL components of the a l l i a n c e s . T h i s a n a l y s i s was of q u e s t i o n a b l e v a l i d i t y , however, s i n c e on ly four t h e r a p i s t s were r e p r e s e n t e d in the n o n - h u m a n i s t i c g r o u p . Moreover , s e v e r a l t h e r a p i s t s , when asked to i d e n t i f y / d e s c r i b e t h e i r t h e o r e t i c a l o r i e n t a t i o n in the f i r s t p a r t of the q u e s t i o n (#5 on the T h e r a p i s t Demographic Data S h e e t , Appendix 18) , i n d i c a t e d tha t they had employed t e c h n i q u e s a s s o c i a t e d w i th an o r i e n t a t i o n o t h e r than that in which they had c a t e g o r i z e d t h e m s e l v e s . T h i s would presumably r e s u l t i n i n c o n s i s t e n t a p p l i c a t i o n of the t h e o r e t i c a l o r i e n t a t i o n . Hence, i t seems l i k e l y tha t t h i s d i f f e r e n c e a c t u a l l y r e f l e c t s a 109 t h e r a p i s t e f f e c t on the t h e r a p i s t - r a t e d a l l i a n c e r a t h e r than a t r u e e f f e c t of t h e o r e t i c a l o r i e n t a t i o n . 1 .7 .3 C o r r e l a t i o n s Of The WAIc With The Outcome Measures At The  Seven O c c a s i o n s It has been assumed t h a t the a l l i a n c e " g e l s " by the t h i r d to f i f t h s e s s i o n ( S t r u p p , 1980) and then remains c o n s t a n t throughout the t h e r a p e u t i c engagement. S a l t z m a n , L u e t g e r t , R o t h , C r e a s e r , and Howard (1976) p r o v i d e d e m p i r i c a l e v i d e n c e t h a t t h i s assumpt ion was a r e a s o n a b l e one in that t h e i r 91 s u b j e c t c l i e n t s and 19 s u b j e c t t h e r a p i s t s r e f l e c t e d widespread s e n s i t i v i t y to numerous cues tha t d e f i n e d the s t a t e of t h e i r a l l i a n c e s by the t h i r d s e s s i o n . Morgan, L u b o r s k y , C r i t s -C r i s t o p h , C u r t i s , and Solomon (1982) compared t h e i r t h i r d and f i f t h s e s s i o n a l l i a n c e r a t i n g s w i th the r a t i n g s done on the s e s s i o n at which 90% of the t reatment (which c o n s i s t e d of at l e a s t 25 s e s s i o n s ) had been c o m p l e t e d . They found no s i g n i f i c a n t d i f f e r e n c e s between e a r l y and l a t e s e s s i o n r a t i n g s and c o n c l u d e d t h a t the a l l i a n c e remains s t a b l e over the c o u r s e of t r e a t m e n t . However, B o r d i n (1983) p o s t u l a t e d tha t a " t e a r - r e p a i r " phenomenon o c c u r s which c o n s t i t u t e s the c r i t i c a l t h e r a p e u t i c e x p e r i e n c e . Heppner and Heesacker (1982) have a l s o sugges ted t h a t the r e l a t i o n s h i p changes over the c o u r s e of t h e r a p y . The seven repea ted measures taken in the p resen t s tudy r e v e a l a t r e n d of i n c r e a s i n g s t r e n g t h of the a l l i a n c e (Tab le 21) and when c o r r e l a t e d wi th each of the outcome measures a l s o r e v e a l a t r e n d of i n c r e a s i n g s t r e n g t h of c o r r e l a t i o n through the 110 c o u r s e of therapy (Table 15) . However, t h i s c o r r e l a t i o n w i th outcome drops o f f q u i t e c o n s i s t e n t l y at the f i n a l s e s s i o n , presumably because c l i e n t and t h e r a p i s t have t e r m i n a t e d t h e i r r e l a t i o n s h i p . T h i s c o n s t i t u t e s f u r t h e r e v i d e n c e to tha t p r e s e n t e d in S e c t i o n 1.1 tha t what i s b e i n g measured by the WAIc i s an independent v a r i a b l e r a t h e r than an i n - p r o c e s s assessment of outcome. 1.7.4 R e l a t i o n s h i p s Between The WAI And The Other R e l a t i o n s h i p  Measures Based on t h e i r s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s w i th one a n o t h e r , i t appears from T a b l e s 16 and 17 tha t the c l i e n t -r a t e d r e l a t i o n s h i p measures are indeed t a p p i n g o v e r l a p p i n g c o n s t r u c t s , w i th the CRF b e i n g the most d i s p a r a t e of the f i v e . Greenberg and P i n s o f (1986) have q u e s t i o n n e d the c o n s t r u c t v a l i d i t y of the v a r i o u s a l l i a n c e measures , ( i . e . , whether the d i f f e r e n t r e s e a r c h groups a re d e f i n i n g the a l l i a n c e i n the same way) . The c o r r e l a t i o n of .58 (Tab le 17) between the WAIc and the HAQ, a l t h o u g h s t a t i s t i c a l l y s i g n i f i c a n t , means tha t one of the measures accounted f o r 34% of the v a r i a n c e in the o t h e r . T h i s i s s m a l l , c o n s i d e r i n g tha t the two ins t ruments p u r p o r t to be measur ing the same c o n s t r u c t . 111 1.7 .5 I d e n t i f i c a t i o n Of R e l a t i v e S t r e n g t h s Of Outcome P r e d i c t o r  V a r i a b l e s In the s tepwise m u l t i p l e r e g r e s s i o n a n a l y s i s per formed f o r each of the s i x outcome measures (Tab le 19) , o n l y one of the s i x r e l a t i o n s h i p measures ( e i t h e r the HAQ, the WAIc, or the CISc) e n t e r e d i n t o each of the e q u a t i o n s tha t was deve loped at the .05 p r o b a b i l i t y l e v e l or l e s s . T h i s i s c o n s i s t e n t w i th the c o n c l u s i o n t h a t most of the r e l a t i o n s h i p measures are t a p p i n g o v e r l a p p i n g c o n s t r u c t s tha t was drawn in S e c t i o n 1 .7 .4 . 1.7.6 Comparison Of WAI S c o r e s Of Completed And Premature ly  Terminated Cases The l i m i t e d p r o c e s s data c o l l e c t e d from premature ly t e r m i n a t e d t h e r a p i e s r e v e a l e d a s i g n i f i c a n t d i f f e r e n c e between c l i e n t r a t i n g s of the a l l i a n c e a f t e r the f i r s t s e s s i o n of those who c o n t i n u e d to c o m p l e t i o n v e r s u s those who dropped o u t . C l i e n t s who s u b s e q u e n t l y dropped out r a t e d the Goa l subdimension of t h e i r a l l i a n c e s i g n i f i c a n t l y lower than c l i e n t s who c o n t i n u e d to c o m p l e t i o n (t=2.50 (p<.05) , T a b l e 20 ) . S i n c e t h i s d i f f e r e n c e d i d not r e c u r on the second s e s s i o n and i s based on o n l y ten c l i e n t r a t i n g s , f u r t h e r r e s e a r c h seems n e c e s s a r y b e f o r e any c o n c l u s i o n s may be drawn. 2. LIMITATIONS OF THE STUDY T h i s s tudy has a t tempted to overcome some of the d e s i g n l i m i t a t i o n s of p r e v i o u s s t u d i e s of the a l l i a n c e : 1) I t i s based on more r e a l i s t i c outcome d a t a , ( i . e . , d a t a were c o l l e c t e d in a lmost a l l the c a s e s when therapy was 1 1 2 t e r m i n a t e d , r a t h e r than a f t e r an a r b i t r a r y ten s e s s i o n s , as was the case in the Horvath (1981) and Moseley (1983) s t u d i e s . 2) The problem of confounded s o u r c e s of a l l i a n c e and outcome d a t a , ( i . e . , both be ing s e l f - r e p o r t s of c l i e n t and t h e r a p i s t ) , i s i n h e r e n t i n t h i s s tudy as i t was i n the Horvath and Moseley s t u d i e s . In a f i e l d s t u d y , i t i s not f e a s i b l e to i n t r o d u c e t h i r d p a r t y s c r u t i n y of e i t h e r p r o c e s s or outcome. However, a v a r i e t y of outcome measures commonly used in psychotherapy r e s e a r c h was employed, a l l of which r e f l e c t e d some r e l a t i o n s h i p w i th the a l l i a n c e measures . M o r e o v e r , some c r o s s -c o r r e l a t i o n between c l i e n t - r a t e d a l l i a n c e measures and t h e r a p i s t - r a t e d outcome measures ( S e c t i o n 1.1 of t h i s c h a p t e r ) was demonstrated as w e l l as a " d r o p p i n g o f f " of the a l l i a n c e -outcome r e l a t i o n s h i p a t the f i n a l s e s s i o n ( S e c t i o n 1.7.3 of t h i s c h a p t e r ) . These f i n d i n g s seem to counter the c l a i m that the a l l i a n c e - o u t c o m e r e l a t i o n s h i p r e p r e s e n t s s imply a demonst ra t ion of the " s e l f - f u l f i l l i n g p r o p h e c y " . However, some f a c t o r s l i m i t the g e n e r a l i z a b i l i t y of the f i n d i n g s of the p r e s e n t s tudy beyond the sample upon which i t i s b a s e d . That sample c o n s i s t e d of v o l u n t e e r p a r t i c i p a n t s r e s p o n d i n g to the q u e s t i o n n a i r e s in the course of r e a l t h e r a p i e s in t h e i r r e a l s e t t i n g s . Some l i m i t a t i o n s seem i n h e r e n t in t h i s s e l e c t i o n p r o c e s s : 1) T h e r a p i s t s who v o l u n t e e r e d to p a r t i c i p a t e r e p r e s e n t a subset who f e l t c o n f i d e n t enough of t h e i r t h e r a p e u t i c s k i l l s to be w i l l i n g to have t h e i r c l i e n t s ' p e r c e p t i o n s of them r e v e a l e d to r e s e a r c h e r s through q u e s t i o n n a i r e responses tha t were not 113 seen by the t h e r a p i s t s t h e m s e l v e s . 2) These t h e r a p i s t s s e l e c t e d the c l i e n t s whom they i n v i t e d to p a r t i c i p a t e in the study w i th them--presumably c l i e n t s wi th whom they f e l t c o n f i d e n t tha t they would be a b l e to c o n t i n u e working over the p e r i o d of t ime that the s tudy r e q u i r e d , ( i . e . , at l e a s t s i x s e s s i o n s ) , and w i th whom they f e l t c o m f o r t a b l e enough to p r o f e r the i n v i t a t i o n to p a r t i c i p a t e i n i t w i th them. 3) A p p r o p r i a t e c l i e n t s had to be educated enough to be a b l e to read and complete the q u e s t i o n n a i r e s , s o p h i s t i c a t e d enough to not f i n d t h r e a t e n i n g the idea of r e s e a r c h e r s who were s t r a n g e r s to them examining t h e i r responses to the very p e r s o n a l e x p e r i e n c e of t h e r a p y , and m o t i v a t e d enough to complete q u e s t i o n n a i r e s a f t e r t h e i r s e s s i o n s . C l i e n t s b e g i n n i n g t h e r a p y , f o r example, i n c r i s e s would not have been s u i t a b l e p a r t i c i p a n t s . Hence, the sample i s b i a s e d by a l l these s e l e c t i o n f a c t o r s toward more s u c c e s s f u l t h e r a p i e s . The r e l a t i v e homogeneity of the s u b p o p u l a t i o n r e f l e c t e d in the sample may have been a moderat ing f a c t o r a f f e c t i n g the s t r e n g t h of the p ro c e s s - o u t c o me r e l a t i o n s h i p s the study demonst ra ted . As w e l l , the study f i n d i n g s may not app ly to l e s s s u c c e s s f u l t h e r a p i e s , and to t h e r a p i e s wi th l e s s e d u c a t e d , s o p h i s t i c a t e d , and m o t i v a t e d c l i e n t s , as w e l l as w i th those in c r i s e s . 4) Few of the t h e r a p i e s i n the study were a c t u a l l y t e r m i n a t e d upon agreement by both p a r t i c i p a n t s tha t the work had been s u c c e s s f u l l y c o m p l e t e d . In most c a s e s , e x t e r n a l c i r c u m s t a n c e s — g e o g r a p h i c r e l o c a t i o n of a p a r t i c i p a n t , f i n a n c i a l 1 1 4 r e s t r i c t i o n s , t h e r a p i s t reass ignment to o ther r e s p o n s i b i l i t i e s , end of u n i v e r s i t y semeste r , and onset of summer v a c a t i o n — determined the p o i n t of t e r m i n a t i o n of t h e r a p y . A l though these e x t e r n a l l y - i m p o s e d t e r m i n a t i o n s may a c c u r a t e l y r e f l e c t the r e a l i t y of how t h e r a p e u t i c engagements end , they d i s t o r t the r e l a t i o n s h i p between a l l i a n c e development and t h e r a p e u t i c change tha t was be ing examined in t h i s s t u d y , ( i . e . , these are not i d e a l c a s e s in which the r e l a t i o n s h i p - o u t c o m e r e l a t i o n s h i p can be assumed to have f u l l y d e v e l o p e d and , h e n c e , to be r e l i a b l y d e m o n s t r a b l e ) . 5) A l though c l i e n t s were a s s u r e d in the p r e l i m i n a r y w r i t t e n i n f o r m a t i o n p r o v i d e d to them tha t t h e i r r e s p o n s e s would be t r e a t e d c o n f i d e n t i a l l y and anonymously , t h i s a s s u r a n c e cannot be assumed to e n t i r e l y e l i m i n a t e t h e i r i n c l i n a t i o n in t h e i r q u e s t i o n n a i r e responses u s u a l l y to want to r e f l e c t f a v o u r a b l y upon t h e i r t h e r a p i s t s and upon t h e i r own p r o g r e s s and s a t i s f a c t i o n w i th t h e i r t h e r a p i e s . C o n v e r s e l y and o c c a s i o n a l l y , c l i e n t s may have been e x p r e s s i n g r e s i d u a l r e s e n t m e n t s , e i t h e r w i th t h e i r t h e r a p i s t s or w i th o t h e r s in t h e i r l i v e s , through t h e i r n e g a t i v e l y - b i a s e d q u e s t i o n n a i r e r e s p o n s e s . I t i s , i n f a c t , i n h e r e n t l y i m p o s s i b l e to be who l ly o b j e c t i v e or u n b i a s e d i n r e p o r t i n g a s u b j e c t i v e e x p e r i e n c e such as tha t of be ing in t h e r a p y , p a r t i c u l a r l y when the r e p o r t must be reduced to the form of q u a n t i t a t i v e l y - s c a l e d responses to q u e s t i o n n a i r e i t e m s . 6) The sample c o n s i s t e d l a r g e l y of c a s e s conducted by t h e r a p i s t s who i d e n t i f i e d t h e i r t h e o r e t i c a l o r i e n t a t i o n as h u m a n i s t i c and , hence , may have y i e l d e d d i f f e r e n t r e s u l t s than a 115 sample which i n c l u d e d more l e a r n i n g and some a n a l y t i c a l l y -o r i e n t e d c a s e s . 7) The s i g n i f i c a n t a l l i a n c e - o u t c o m e c o r r e l a t i o n c o e f f i c i e n t s found i n the p r e s e n t s tudy account f o r o n l y 7 to 25% of outcome v a r i a n c e . In c o n s i d e r i n g whether such c o e f f i c i e n t s i n d i c a t e t h a t the t h e o r i z e d s i g n i f i c a n c e of the a l l i a n c e f o r outcome s h o u l d be reexamined, the example produced by R o s e n t h a l and Rubin (1979) i s r e l e v a n t . They showed tha t " s m a l l " p e r c e n t a g e s of v a r i a n c e may be important and tha t e f f e c t s i z e e v a l u a t i o n s s h o u l d be s e n s i t i v e to the c o n t e x t of the d a t a , i n t h i s case the c o n t e x t b e i n g the l i m i t e d e m p i r i c a l e f f i c a c y of psychotherapy r e s e a r c h and theory a t the p r e s e n t t i m e . 3. RECOMMENDATIONS FOR FUTURE RESEARCH The f o l l o w i n g recommendations f o l l o w from the f i n d i n g s of the p r e s e n t s t u d y : 1) Based on i t s f a i l u r e to p r e d i c t outcome: That the u t i l i z a t i o n of the WAIt as a r e s e a r c h inst rument be d i s c o u r a g e d . 2) Based on the d i f f e r e n t i a l per formance of the WAI and the HAQ: tha t the concern e x p r e s s e d by Greenberg and P i n s o f (1986) r e g a r d i n g the c o n s t r u c t v a l i d i t y of the v a r i o u s a l l i a n c e measures be s u b j e c t e d to e m p i r i c a l i n v e s t i g a t i o n . 3) Based on the e a r l y s t r e n g t h of the BOND s u b s c a l e measures in t h i s sample of b r i e f psychotherapy c a s e s : That B o r d i n ' s (1975, 1979) p r o p o s i t i o n ( S e c t i o n 2, Chapter I) that the bonding a s p e c t of the a l l i a n c e d e v e l o p s s l o w l y be m o d i f i e d to e x c l u d e b r i e f therapy c a s e s in which the data in the p r e s e n t s tudy suggest the bond must be e s t a b l i s h e d prompt ly i f the 1 16 therapy i s to be s u c c e s s f u l . 4) Based on the i n c r e a s i n g r e l a t i o n s h i p of a l l i a n c e to outcome up to the t e n t h s e s s i o n and the drop o f f i n f i n a l s e s s i o n a l l i a n c e - o u t c o m e r e l a t i o n s h i p : That the a l l i a n c e be t r a c k e d s e s s i o n by s e s s i o n employing a s i n g l e - c a s e r e s e a r c h d e s i g n , such tha t d e t a i l e d e v a l u a t i o n of f l u c t u a t i o n s i n the s t a t e of the a l l i a n c e may be a s s o c i a t e d w i th t reatment i n t e r v e n t i o n s (Fr ieswyk et a l . , 1986). Such examina t ion would h e l p to c l a r i f y the r e l a t i o n s h i p s of the h y p o t h e s i z e d d imens ions of the a l l i a n c e to the events in t h e r a p y . 5) Based on the h i g h i n t e r c o r r e l a t i o n s of the WAI s u b s c a l e s and the f a c t tha t the e x p l o r a t o r y C l i e n t Involvement S c a l e c o r r e l a t e d as s t r o n g l y wi th outcome as d i d the WAI: That f u r t h e r r e s e a r c h be d i r e c t e d at the c l i e n t subdimension of Involvement tha t Greenberg and P i n s o f (1986) have suggested i s subsumed by the t r a n s a c t i o n a l a l l i a n c e v a r i a b l e toward the development of o r i e n t a t i o n - s p e c i f i c measures to u n r a v e l the i s s u e s i n v o l v e d in d i s c r i m i n a t i n g the d i f f e r e n t types of c l i e n t involvement that a re p r e d i c t i v e in d i f f e r e n t t a s k s and t r e a t m e n t s . Such a recommendation i s c o n s i s t e n t wi th the c o n c l u s i o n drawn by S t i l e s , S h a p i r o , and E l l i o t t (1986) from t h e i r review of p r o c e s s - o u t c o m e r e s e a r c h : The a l l i a n c e c o n s t r u c t i s r e a l l y o n l y a c o n c e p t u a l u m b r e l l a f o r u n i t i n g a number of c l i e n t and t h e r a p i s t c o n t r i b u t i o n s ; the exact o p e r a t i o n of these c o n s t i t u e n t f a c t o r s remains to be c l a r i f i e d . A l t h o u g h a t t e m p t i n g to be i n c l u s i v e , the a l l i a n c e concept i s v u l n e r a b l e to c r i t i c i s m a l s o lodged a g a i n s t the g e n e r a l t h e r a p i s t f a c t o r s : I t l o c a t e s the common c o r e at too h i g h a l e v e l of a b s t r a c t i o n . (p. 174) 1 1 7 4. SUMMARY AND CONCLUSION In the p r e s e n t s t u d y , the working a l l i a n c e was measured w i th a s e l f - r e p o r t i n s t r u m e n t , the Working A l l i a n c e Inventory (H or va th , 1981, 1982), based on B o r d i n ' s (1975, 1979) c o n c e p t u a l i z a t i o n of the a l l i a n c e as c o n s i s t i n g of r e l a t i o n a l bonds and the t a s k s and g o a l s of p s y c h o t h e r a p y . T h i s inst rument was a d m i n i s t e r e d to c l i e n t s and t h e r a p i s t s a f t e r each of the f i r s t f i v e , the t e n t h , and the f i n a l s e s s i o n s of 44 therapy c a s e s . For compara t ive p u r p o s e s , another a l l i a n c e measure, as w e l l as measures of t h e r a p i s t empathy, e x p e r t n e s s , a t t r a c t i v e n e s s , and t r u s t w o r t h i n e s s , were a l s o a d m i n i s t e r e d a f t e r the t h i r d s e s s i o n . The WAI and the o ther f i v e measures were c o r r e l a t e d w i th outcome as measured by s i x i n s t r u m e n t s : Targe t Compla in ts Improvement, the Symptom C h e c k l i s t - 9 0 , the S e l f - E s t e e m Index, the Inventory of I n t e r p e r s o n a l P r o b l e m s , the S t rupp P o s t t h e r a p y  Q u e s t i o n n a i r e , and the T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e . The WAIc was found to c o r r e l a t e s t a t i s t i c a l l y s i g n i f i c a n t l y w i th four of the s i x i n s t r u m e n t s , wh i l e the WAIt d i d not c o r r e l a t e w i th any of them. T h e r a p i s t empathy, a t t r a c t i v e n e s s , e x p e r t n e s s , and t r u s t w o r t h i n e s s c o r r e l a t e d l e s s c o n s i s t e n t l y s t a t i s t i c a l l y s i g n i f i c a n t l y than d i d the WAIc wi th outcome, wh i le the HAQ c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y wi th a l l s i x of the outcome measures . I t was c o n c l u d e d tha t the two in s t ru me n t s tha t purpor t to measure the a l l i a n c e , the HAQ, which has a phenomenolog ica l response s e t , and the WAI, which has a more b e h a v i o u r a l response 118 s e t , a re a c t u a l l y measur ing o v e r l a p p i n g but d i f f e r e n t c o n s t r u c t s . Moreover , i t was c o n c l u d e d tha t the a l l i a n c e c o n s t r u c t i s l o c a t e d at too h i g h a l e v e l of a b s t r a c t i o n . An e x p l o r a t o r y measure of c l i e n t i n v o l v e m e n t , a h y p o t h e s i z e d subdimension subsumed by the a l l i a n c e v a r i a b l e was found to c o r r e l a t e comparably to the WAI w i th outcome a n d , t h e r e f o r e , to m e r i t f u r t h e r i n v e s t i g a t i o n . The repea ted measures of the a l l i a n c e r e v e a l e d that the a l l i a n c e c o n t i n u e d to s t r e n g t h e n in i t s r e l a t i o n s h i p to outcome beyond the t h i r d s e s s i o n , d r o p p i n g o f f o n l y a t the c o n c l u s i o n of t h e r a p y . T h i s f i n d i n g a l o n g wi th the f i n d i n g t h a t the c l i e n t -r a t e d a l l i a n c e measure, the WAIc, c o r r e l a t e d s t a t i s t i c a l l y s i g n i f i c a n t l y w i th the t h e r a p i s t - r a t e d outcome measure , the TPQ, sugges ted tha t the s e l f - r e p o r t e d a l l i a n c e measures a re t a p p i n g a c o n s t r u c t tha t i s d i s t i n c t from an i n - p r o c e s s e v a l u a t i o n of s a m e - s e l f - r e p o r t e d outcome. As one phase of the B . C . Research G r o u p ' s a l l i a n c e r e s e a r c h program, the p resen t s tudy has c o n t r i b u t e d important f i n d i n g s w i th r e s p e c t to the compara t ive e f f i c a c i e s of d i f f e r e n t i n s t r u m e n t s tha t p u r p o r t to measure the a l l i a n c e , the i s s u e of changes in the a l l i a n c e over the c o u r s e of t h e r a p y , and the argument r e g a r d i n g whether a c l i e n t - r e p o r t e d a l l i a n c e measure i s a " t r u e " a l l i a n c e measure. 1 19 REFERENCES A l e x a n d e r , L . B . & L u b o r s k y , L . (1986) . The Penn H e l p i n g A l l i a n c e S c a l e s . In L . S . Greenberg & W.M. P i n s o f ( E d s . ) , The p s y c h o t h e r a p e u t i c p r o c e s s : A r e s e a r c h handbook. New Y o r k : G u i l f o r d . A l l e n , J . G . , Newsom, G . E . , Gabbard , G . O . , & Coyne, L . (1984) . 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The c a p a c i t y f o r emot iona l g rowth . London: H o g a r t h . 132 THERAPIST CONSENT FORM I hereby v o l u n t a r i l y consent to p a r t i c i p a t e i n the psychotherapy r e s e a r c h s t u d y . The na tu re of t h i s r e s e a r c h has been e x p l a i n e d to me and I unders tand tha t I w i l l be r e q u i r e d to complete some q u e s t i o n n a i r e s . I have been in formed tha t the responses on the q u e s t i o n n a i r e s w i l l be t r e a t e d anonymously and c o n f i d e n t i a l l y and tha t the r e s e a r c h e r s w i l l not know my name nor w i l l they have any i d e n t i f y i n g i n f o r m a t i o n about me. I have e x p l a i n e d the nature of the r e s e a r c h to my c l i e n t ( s ) and I am aware tha t I am f r e e to withdraw from t h i s s tudy at any t i m e . S igned Date 1 33 APPENDIX 4 - CLIENT CONSENT FORM INFORMATION ABOUT THE PSYCHOTHERAPY RESEARCH PROJECT T h i s s tudy i s d e s i g n e d to genera te i n f o r m a t i o n about the k i n d s of i n t e r a c t i o n s tha t h e l p peop le s o l v e p r o b l e m s , change , or l e a r n about t h e m s e l v e s . The i n f o r m a t i o n tha t i s b e i n g ga thered w i l l enable t h e r a p i s t s t o d e v e l o p more e f f e c t i v e ways to f a c i l i t a t e change . There a re many d i f f e r e n t k i n d s of e f f e c t i v e i n t e r a c t i o n s . We would l i k e to know some of your i d e a s , o p i n i o n s , and f e e l i n g s about your i n t e r a c t i o n s w i th your h e l p e r . Your c o o p e r a t i o n w i th the r e s e a r c h p r o j e c t i s important and we would l i k e to have the b e n e f i t of your e x p e r i e n c e . Your r e s p o n s e s to the q u e s t i o n n a i r e s are c o m p l e t e l y c o n f i d e n t i a l . The r e s e a r c h e r s w i l l not know who you are nor w i l l your t h e r a p i s t / c o u n s e l l o r see your q u e s t i o n n a i r e . Your p a r t in the r e s e a r c h i n v o l v e s the f i l l i n g out of some q u e s t i o n n a i r e s . The f i r s t se t of q u e s t i o n n a i r e s w i l l take about 40 minutes to c o m p l e t e . You w i l l be asked to respond to another q u e s t i o n n a i r e a f t e r each of the f i r s t f i v e ' o f your therapy s e s s i o n s (which w i l l take about 5 minutes) as w e l l as a f t e r the t e n t h s e s s i o n ( i f the re i s one) and a f t e r the f i n a l s e s s i o n . Then , at the end of your t h e r a p y , we would l i k e you to complete some more q u e s t i o n n a i r e s (which w i l l take another 40 m i n u t e s ) . Thank-you f o r your c o o p e r a t i o n . 1 34 CONSENT FORM I hereby v o l u n t a r i l y consent to p a r t i c i p a t e in the psychotherapy r e s e a r c h s t u d y . The na tu re of t h i s r e s e a r c h has been e x p l a i n e d to me and I unders tand tha t I w i l l be r e q u i r e d to complete some q u e s t i o n n a i r e s . I have been in formed tha t the responses on the q u e s t i o n n a i r e s w i l l be t r e a t e d anonymously and c o n f i d e n t i a l l y and the r e s e a r c h e r s w i l l not know my name nor w i l l they have any i d e n t i f y i n g i n f o r m a t i o n about me. I f I do not wish to p a r t i c i p a t e i n t h i s s t u d y , I unders tand that my d e c i s i o n w i l l i n no way a f f e c t the s t a n d a r d or the a v a i l a b i l i t y of the s e r v i c e I w i l l r e c e i v e , and tha t my wi thdrawal would a l s o in no way a f f e c t the s tandard of s e r v i c e I w i l l r e c e i v e . S igned Date Wi tness ( T h e r a p i s t ) 1 35 APPENDIX 5 - TARGET COMPLAINTS/DEMOGRAPHIC QUESTIONNAIRE PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #1A The e n c l o s e d q u e s t i o n n a i r e s are pa r t of a r e s e a r c h p r o j e c t to s tudy how c l i e n t s f e e l about t h e i r t h e r a p y / c o u n s e l l i n g e x p e r i e n c e s . P l e a s e t r y to answer a l l q u e s t i o n s as c o m p l e t e l y and a c c u r a t e l y as you c a n . Rep lace the completed q u e s t i o n n a i r e s in the enve lope p r o v i d e d and s e a l i t . Your c o o p e r a t i o n in t h i s r e s e a r c h i s very much a p p r e c i a t e d . Age: Sex (check o n e ) : M F M a r i t a l S t a t u s : S i n g l e M a r r i e d D i v o r c e d Widowed E d u c a t i o n (check h i g h e s t l e v e l and complete q u e s t i o n ) : E lementary s c h o o l ( i n d i c a t e number of y e a r s : ) H igh s c h o o l ( i n d i c a t e number of y e a r s : ) H igh s c h o o l graduate C o l l e g e ( i n d i c a t e number of y e a r s : ) C o l l e g e graduate Graduate study or p r o f e s s i o n a l t r a i n i n g (k ind of e t c . : d e g r e e , ) P l e a s e name the th ree problems or d i f f i c u l t i e s you most want h e l p w i th in p s y c h o t h e r a p y / c o u n s e l l i n g : F i r s t Prob lem: Second Prob lem: T h i r d Prob lem: 1 36 APPENDIX 6 ~ SYMPTOM CHECKLIST-90 PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #2 Below i s a l i s t of problems and c o m p l a i n t s tha t peop le sometimes have . P l e a s e read each one c a r e f u l l y . A f t e r you have done s o , p l e a s e c i r c l e the number to the r i g h t that best d e s c r i b e s HOW MUCH DISCOMFORT THAT PROBLEM HAS CAUSED YOU DURING  THE PAST WEEK INCLUDING TODAY. Mark on ly one numbered space f o r each problem and do not s k i p any i t e m s . C i r c l e the a p p r o p r i a t e number: 0 - Not a t a l l 1 - A l i t t l e b i t 2 - Modera te ly 3 - Q u i t e a b i t 4 - Ex t remely HOW MUCH WERE YOU BOTHERED BY: 1 . Headaches 0 1 2 3 4 2. Nervousness or s h a k i n e s s i n s i d e 0 1 2 3 4 3. Unwanted t h o u g h t s , words, or i d e a s that won' t l e a v e your mind 0 1 2 3 4 4. F a i n t n e s s or d i z z i n e s s 0 1 2 3 4 5. L o s s of sexua l i n t e r e s t or p l e a s u r e 0 1 2 3 4 6. F e e l i n g c r i t i c a l of o t h e r s 0 1 2 3 4 7. The idea that someone e l s e can c o n t r o l your thoughts 0 1 2 3 4 8. F e e l i n g o t h e r s are to blame f o r most of your t r o u b l e s 0 1 2 3 4 9. T r o u b l e remembering t h i n g s . 0 1 2 3 4 10. W o r r i e d about s l o p p i n e s s or c a r e l e s s n e s s 0 1 2 3 4 11. F e e l i n g e a s i l y annoyed or i r r i t a t e d 0 1 2 3 4 12. P a i n s in hear t or c h e s t 0 1 2 3 4 13. F e e l i n g a f r a i d in open spaces or on the s t r e e t s . 0 1 2 3 4 14. F e e l i n g low in energy or slowed down 0 1 2 3 4 15. Thoughts of ending your l i f e 0 1 2 3 4 1 37 16. Hear ing v o i c e s that o ther peop le do not h e a r . . . . 0 1 2 3 4 17. T r e m b l i n g 0 1 2 3 4 18. F e e l i n g tha t most peop le cannot be t r u s t e d 0 1 2 3 4 19. Poor a p p e t i t e 0 1 2 3 4 20. C r y i n g e a s i l y 0 1 2 3 4 21. F e e l i n g shy or uneasy w i th the o p p o s i t e sex 0 1 2 3 4 22. F e e l i n g of be ing t rapped or caught 0 1 2 3 4 23. Suddenly s c a r e d f o r no reason 0 1 2 3 4 24. Temper o u t b u r s t s tha t you c o u l d not c o n t r o l 0 1 2 3 4 25. F e e l i n g a f r a i d to go out of your house a l o n e . . . . 0 1 2 3 4 26. Blaming y o u r s e l f f o r t h i n g s 0 1 2 3 4 27. P a i n s in lower back 0 1 2 3 4 28. F e e l i n g b l o c k e d in g e t t i n g t h i n g s done 0 1 2 3 4 29. F e e l i n g l o n e l y 0 1 2 3 4 30. F e e l i n g b lue 0 1 2 3 4 31. Worry ing too much about t h i n g s 0 1 2 3 4 32. F e e l i n g no i n t e r e s t in t h i n g s 0 1 2 3 4 33. F e e l i n g f e a r f u l 0 1 2 3 4 34. Your f e e l i n g s be ing e a s i l y hur t 0 1 2 3 4 35. Other peop le be ing aware of your p r i v a t e thoughts 0 1 2 3 4 36. F e e l i n g o t h e r s do not unders tand you or a re unsympathet ic 0 1 2 3 4 37. F e e l i n g tha t peop le a re u n f r i e n d l y or d i s l i k e you 0 1 2 3 4 38. Having to do t h i n g s very s l o w l y to i n s u r e c o r r e c t n e s s 0 1 2 3 4 39. Heart pounding or r a c i n g 0 1 2 3 4 40. Nausea or upset stomach 0 1 2 3 4 41. F e e l i n g i n f e r i o r to o t h e r s 0 1 2 3 4 138 42. Soreness of your musc les 0 1 2 3 4 43. F e e l i n g that you a re watched or t a l k e d about by o t h e r s 0 1 2 3 4 44. T r o u b l e f a l l i n g a s l e e p 0 1 2 3 4 45. Hav ing to check and doublecheck what you do 0 1 2 3 4 46. D i f f i c u l t y making d e c i s i o n s 0 1 2 3 4 47. F e e l i n g a f r a i d to t r a v e l on b u s e s , subways, or t r a i n s 0 1 2 3 4 48. T r o u b l e g e t t i n g your b r e a t h 0 1 2 3 4 49. Hot or c o l d s p e l l s . . . 0 1 2 3 4 50. Hav ing to a v o i d c e r t a i n t h i n g s , p l a c e s , or a c t i v i t i e s because they f r i g h t e n you 0 1 2 3 4 51. Your mind goes b lank 0 1 2 3 4 52. Numbness or t i n g l i n g in p a r t s of your body 0 1 2 3 4 53. A lump in your t h r o a t 0 1 2 3 4 54. F e e l i n g h o p e l e s s about the f u t u r e 0 1 2 3 4 55. T r o u b l e c o n c e n t r a t i n g 0 1 2 3 4 56. F e e l i n g weak in p a r t s of your body 0 1 2 3 4 57. F e e l i n g tense or keyed up 0 1 2 3 4 58. Heavy f e e l i n g s in your arms or l e g s 0 1 2 3 4 59. Thoughts of death or d y i n g 0 1 2 3 4 60. O v e r e a t i n g 0 1 2 3 4 61. F e e l i n g uneasy when peop le a re watch ing or t a l k i n g about you 0 1 2 3 4 62. Hav ing thoughts tha t are not your own 0 1 2 3 4 63. Having urges to b e a t , i n j u r e , or harm s o m e o n e . . . 0 1 2 3 4 64. Awakening in the e a r l y morning 0 1 2 3 4 65. Having to repeat the same a c t i o n s such as t o u c h i n g , c o u n t i n g , washing 0 1 2 3 4 66. S l e e p tha t i s r e s t l e s s or d i s t u r b e d 0 1 2 3 4 1 39 67. Having urges to break or smash t h i n g s 0 1 2 3 4 68. Having i d e a s or b e l i e f s tha t o t h e r s do not share 0 1 2 3 4 69. F e e l i n g ve ry s e l f - c o n s c i o u s w i th o t h e r s 0 1 2 3 4 70. F e e l i n g uneasy in c rowds , such as shopping or at a movie 0 1 2 3 4 71. F e e l i n g e v e r y t h i n g i s an e f f o r t 0 1 2 3 4 72. S p e l l s of t e r r o r or p a n i c 0 1 2 3 4 73. F e e l i n g uncomfor tab le about e a t i n g or d r i n k i n g i n p u b l i c 0 1 2 3 4 74. G e t t i n g i n t o f requent arguments 0 1 2 3 4 75. F e e l i n g nervous when you are l e f t a lone 0 1 2 3 4 76. Others not g i v i n g you proper c r e d i t f o r your achievements 0 1 2 3 4 77. F e e l i n g l o n e l y even when you are w i th p e o p l e . . . . 0 1 2 3 4 78. F e e l i n g so r e s t l e s s you c o u l d n ' t s i t s t i l l 0 1 2 3 4 79. F e e l i n g s of w o r t h l e s s n e s s 0 1 2 3 4 80. F e e l i n g tha t f a m i l i a r t h i n g s are s t range or u n r e a l 0 1 2 3 4 81. Shout ing or throwing t h i n g s 0 1 2 3 4 82. F e e l i n g a f r a i d you w i l l f a i n t in p u b l i c 0 1 2 3 4 83. F e e l i n g tha t peop le w i l l take advantage of you i f you l e t them 0 1 2 3 4 84. Having thoughts about sex tha t bother you a l o t . 0 1 2 3 4 85. The idea tha t you s h o u l d be p u n i s h e d f o r your s i n s . . . 0 1 2 3 4 86. F e e l i n g pushed to get t h i n g s d o n e . . . 0 1 2 3 4 87. The idea tha t something s e r i o u s i s wrong wi th your body 0 1 2 3 4 88. Never f e e l i n g c l o s e to another person 0 1 2 3 4 89 . F e e l i n g s of g u i l t 0 1 2 3 4 90. The idea that something i s wrong w i th your mind . 0 1 2 3 4 140 APPENDIX 7 - SELF-ESTEEM INDEX PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #3 P l e a s e i n d i c a t e how o f t e n each of the f o l l o w i n g s ta tements i s t r u e f o r you by c h e c k i n g the a p p r o p r i a t e word: 1. I f e e l that I am a person of wor th , at l e a s t on an equa l p lane wi th o t h e r s . Never Seldom Sometimes Of ten Almost Always 2. I f e e l tha t I have a number of good q u a l i t i e s . Never Seldom Sometimes Of ten Almost Always 3. I am a b l e to do t h i n g s as w e l l as most o ther p e o p l e . Never Seldom Sometimes Of ten Almost Always 4. I f e e l I do not have much to be proud o f . Never Seldom Sometimes Of ten 5. I take a p o s i t i v e a t t i t u d e toward m y s e l f . Never Seldom Sometimes Of ten 6. Sometimes I t h i n k I am no good at a l l . Never Seldom Sometimes Of ten _ 7. I am a u s e f u l person to have a r o u n d . Never Seldom Sometimes Of ten _ 8. I f e e l tha t I c a n ' t do a n y t h i n g r i g h t . Never Seldom Sometimes Of ten _ 9. When I do a j o b , I do i t w e l l . Never Seldom Sometimes Of ten _ 10. I f e e l tha t my l i f e i s not very u s e f u l . Never Seldom Sometimes Of ten Almost Always Almost Always Almost Always Almost Always Almost Always Almost Always Almost Always 141 APPENDIX 8 - INVENTORY OF INTERPERSONAL PROBLEMS PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #4 Here i s a l i s t of problems that peop le r e p o r t in r e l a t i n g to o ther p e o p l e . P l e a s e read the l i s t below, and f o r each i t em, s e l e c t the number that d e s c r i b e s how d i s t r e s s i n g tha t problem has been f o r y o u . Then c i r c l e that number. 0 = Not at a l l 1 = A l i t t l e 2 = Modera te ly 3 = Q u i t e a b i t 4 = Ext remely Par t I. The f o l l o w i n g a r e t h i n g s you f i n d hard to do w i th o ther p e o p l e . I t i s hard f o r me t o : 1 . 2. 3. 4, 5. 6, 7, 8, 9, t r u s t o t h e r people 0 say "no" to other peop le j o i n in on groups keep t h i n g s p r i v a t e from o ther p e o p l e l e t o t h e r people know what I want t e l l a person to s t o p b o t h e r i n g me i n t r o d u c e mysel f to new peop le c o n f r o n t peop le wi th problems tha t come up . be a s s e r t i v e wi th another person 10. make f r i e n d s , 1 1 , 12, 13, 14, 15, 16, 17, e x p r e s s my a d m i r a t i o n f o r another p e r s o n . . have someone dependent on me d i s a g r e e w i th o ther peop le l e t o t h e r people know when I am angry 0 0 0 0 0 0 0 0 0 0 0 0 0 make a l o n g - t e r m commitment to another person 0 s t i c k t o my own p o i n t of view and not be swayed by other p e o p l e 0 be another p e r s o n ' s boss 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 2 3 3 4 4 142 18. do what another person wants me t o do 0 19. get a l o n g w i th peop le who have a u t h o r i t y over me 0 20. be a g g r e s s i v e toward o ther p e o p l e when the s i t u a t i o n c a l l s f o r i t 0 21. compete a g a i n s t o ther peop le 0 22. make r e a s o n a b l e demands of o t h e r p e o p l e . . . . 0 2 3 . . s o c i a l i z e wi th o ther people 0 24. get out of a r e l a t i o n s h i p tha t I d o n ' t want to be in . 0 25. take charge of my own a f f a i r s wi thout h e l p from o ther peop le 0 26. show a f f e c t i o n to o ther peop le 0 27. f e e l c o m f o r t a b l e around o ther p e o p l e 0 28. get a l o n g w i th o ther people 0 29. unders tand another p e r s o n ' s p o i n t of v i e w . . 0 30. t e l l p e r s o n a l t h i n g s to o ther p e o p l e 0 31. b e l i e v e that I am l o v a b l e to o t h e r p e o p l e . . 0 32. express my f e e l i n g s to o ther p e o p l e d i r e c t l y 0 33. be f i r m when I need to be 0 34. e x p e r i e n c e a f e e l i n g of l o v e f o r another person 0 35. be c o m p e t i t i v e when the s i t u a t i o n c a l l s f o r i t 0 36. se t l i m i t s on o ther peop le 0 37. be honest w i th o ther peop le 0 38. be s u p p o r t i v e of another p e r s o n ' s g o a l s in l i f e 0 39. f e e l c l o s e to o ther people 0 40. r e a l l y c a r e about o ther p e o p l e ' s p r o b l e m s . . 0 1 43 41. argue w i th another person 0 1 2 3 4 42. r e l a x and enjoy mysel f when I go out w i th o ther peop le 0 1 2 3 4 43. f e e l s u p e r i o r to another person 0 1 2 3 4 44. become s e x u a l l y a roused toward the person I r e a l l y c a r e about 0 1 2 3 4 45. f e e l t h a t I deserve another p e r s o n ' s a f f e c t i o n 0 1 2 3 4 46. keep up my s i d e of a f r i e n d s h i p 0 1 2 3 4 47. spend t ime a lone 0 1 2 3 4 48. g i v e a g i f t to another person 0 1 2 3 4 49. have l o v i n g and angry f e e l i n g s towards the same person 0 1 2 3 4 50. m a i n t a i n a working r e l a t i o n s h i p wi th someone I d o n ' t l i k e 0 1 2 3 4 51. se t g o a l s f o r mysel f wi thout o ther p e o p l e ' s a d v i c e 0 1 2 3 4 52. a c c e p t another p e r s o n ' s a u t h o r i t y over m e . . 0 1 2 3 4 53. f e e l good about winning 0 1 2 3 4 54. i g n o r e c r i t i c i s m from other peop le 0 1 2 3 4 55. f e e l l i k e a separa te person when I am in a r e l a t i o n s h i p 0 1 2 3 4 56. a l l o w mysel f to be more s u c c e s s f u l than o ther peop le 0 1 2 3 4 57. f e e l or ac t competent i n my r o l e as p a r e n t . 0 1 2 3 4 58. l e t myse l f f e e l angry at somebody I l i k e . . . 0 1 2 3 4 59. respond s e x u a l l y to another person 0 1 2 3 4 60. a c c e p t p r a i s e from another person 0 1 2 3 4 61. put somebody e l s e ' s needs b e f o r e my o w n . . . . 0 1 2 3 4 62. g i v e c r e d i t to another person f o r d o i n g something w e l l 0 1 2 3 4 63. s t a y out of o ther p e o p l e ' s b u s i n e s s 0 1 2 3 4 1 44 64. take i n s t r u c t i o n s from p e o p l e who have a u t h o r i t y over me 0 1 2 3 4 65. f e e l good about another p e r s o n ' s h a p p i n e s s . 0 1 2 3 4 66. get over the f e e l i n g of l o s s a f t e r a r e l a t i o n s h i p has ended 0 1 2 3 4 67. ask o ther peop le to get t o g e t h e r s o c i a l l y w i th me 0 1 2 3 4 68. f e e l angry a t o ther peop le 0 1 2 3 4 69. g i v e c o n s t r u c t i v e c r i t i c i s m to another person 0 1 2 3 4 70. e x p e r i e n c e s e x u a l s a t i s f a c t i o n 0 1 2 3 4 71. open up and t e l l my f e e l i n g s to another person 0 1 2 3 4 72. f o r g i v e another person a f t e r I ' ve been angry 0 1 2 3 4 73. a t t e n d to my own w e l f a r e when somebody e l s e i s needy 0 1 2 3 4 74. be a s s e r t i v e wi thout w o r r y i n g about h u r t i n g the o ther p e r s o n ' s f e e l i n g s 0 1 2 3 4 75. be i n v o l v e d wi th another pe rson wi thout f e e l i n g t rapped 0 1 2 3 4 76. do work f o r my own sake i n s t e a d of f o r someone e l s e ' s a p p r o v a l . . . 0 1 2 3 4 77. be c l o s e to somebody wi thout f e e l i n g tha t I'm b e t r a y i n g somebody e l s e 0 1 2 3 4 78. be s e l f - c o n f i d e n t when I am w i th o ther p e o p l e . . . 0 1 2 3 4 Par t I I . The f o l l o w i n g are t h i n g s tha t you do too much. 79. I f i g h t w i th o ther peop le too much 0 1 2 3 4 80. I am too s e n s i t i v e to c r i t i c i s m 0 1 2 3 4 81. I f e e l too r e s p o n s i b l e f o r s o l v i n g o ther p e o p l e ' s problems 0 1 2 3 4 82. I get i r r i t a t e d or annoyed too e a s i l y 0 1 2 3 4 83. I am too e a s i l y persuaded by o ther p e o p l e . . 0 1 2 3 4 1 45 84. I want p e o p l e to admire me too much 0 1 2 3 4 85. I ac t l i k e a c h i l d too much 0 1 2 3 4 86. I am too dependent on o ther peop le 0 1 2 3 4 87. I am too s e n s i t i v e to r e j e c t i o n 0 1 2 3 4 88. I open up to peop le too much 0 1 2 3 4 89. I am too independent 0 1 2 3 4 90. I am too a g g r e s s i v e toward o ther p e o p l e . . . . 0 1 2 3 4 91. I t r y to p l e a s e o ther peop le too much 0 1 2 3 4 92. I f e e l a t t a c k e d by o ther peop le too m u c h . . . 0 1 2 3 4 93. I f e e l too g u i l t y f o r what I have done 0 1 2 3 4 94. I c lown around too much 0 1 2 3 4 95. I want to be n o t i c e d too much 0 1 2 3 4 96. I c r i t i c i z e o ther peop le too much 0 1 2 3 4 97. I t r u s t o t h e r people too much 0 1 2 3 4 98. I t r y to c o n t r o l o ther peop le too much 0 1 2 3 4 99. I a v o i d o ther people too much 0 1 2 3 4 100. I am a f f e c t e d by another p e r s o n ' s moods too much 0 1 2 3 4 101. I put o ther p e o p l e ' s needs b e f o r e my own too much 0 1 2 3 4 102. I t r y to change o ther peop le too much 0 1 2 3 4 103. I am too g u l l i b l e 0 1 2 3 4 104. I am o v e r l y generous to o ther peop le 0 1 2 3 4 105. I am too a f r a i d of o ther peop le 0 1 2 3 4 106. I worry too much about o ther p e o p l e ' s r e a c t i o n s to me 0 1 2 3 4 107. I am too s u s p i c i o u s of o ther peop le 0 1 2 3 4 108. I am i n f l u e n c e d too much by another p e r s o n ' s thoughts and f e e l i n g s 0 1 2 3 4 1 46 109. I compliment other peop le too much 0 1 2 3 4 110. I worry too much about d i s a p p o i n t i n g o ther people 0 1 2 3 4 111. I man ipu la te o ther peop le too much to get what I want 0 1 2 3 4 112. I l o s e my temper too e a s i l y 0 1 2 3 4 113. I t e l l p e r s o n a l t h i n g s t o o ther people too much 0 1 2 3 4 114. I blame myse l f too much f o r c a u s i n g other p e o p l e ' s problems 0 1 2 3 4 115. I am too e a s i l y bo thered by o ther peop le making demands of me 0 1 2 3 4 116. I argue w i th o ther peop le too much 0 1 2 3 4 117. I am too env ious and j e a l o u s of o ther people 0 1 2 3 4 118. I keep o t h e r people at a d i s t a n c e too much 0 1 2 3 4 119. I worry too much about my f a m i l y ' s r e a c t i o n s to me 0 1 2 3 4 120. I l e t o ther people take advantage of me too much 0 1 2 3 4 121. I too e a s i l y l o s e a sense of mysel f when I am around a s t r o n g - m i n d e d person 0 1 2 3 4 122. I f e e l too g u i l t y f o r what I have f a i l e d to do 0 1 2 3 4 123. I f e e l c o m p e t i t i v e even when the s i t u a t i o n does not c a l l f o r i t 0 1 2 3 4 124. I f e e l embarrassed in f r o n t of o ther people too much 0 1 2 3 4 125. I f e e l too anx ious when I am i n v o l v e d w i th another person 0 1 2 3 4 126. I am a f f e c t e d by another p e r s o n ' s misery too much 0 1 2 3 4 127. I want to get revenge a g a i n s t peop le too much 0 1 2 3 4 APPENDIX 9 - WORKING ALLIANCE INVENTORY (CLIENT FORM)  PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #11 INSTRUCTIONS On the fo l lowing pages there are sentences that describe some of the d i f f e ren t ways a person might think or feel about h is or her therapist (counse l lor ) . As you read the sentences, mentally insert the name of your therapist (counsel lor ) in place of in the text. Below each statement ins ide , there is a seven-point s c a l e : 1 Never 2 Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways If the statement descr ibes the way you a1 ways feel (or th ink) , c i r c l e the number ' 7 ' ; i f i t never app l ies to you, c i r c l e the number ' 1 ' . Use the numbers in between to describe the var ia t ions between these extremes. Thi s quest ionnai re i s CONFIDENTIAL; nei ther your therapist nor the agency wi l l see your answers. Work f a s t ; your f i r s t impressions are the ones we would l i ke to see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM.) Thank you for your cooperat ion. © A. 0. Horvath, 1981, 1982. Session : Date: I feel uncomfortable with 1 2 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 A1 ways and I agree about the things I w i l l need to do in therapy to help improve 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often my s i t u a t i o n . 6 Very Often 7 A1 ways I am worried about the outcome of these sessions. 1 2 3 Never Rarely Occasional ly Somet i mes 5 Often Very Often 7 Always 4. What I am doing in therapy gives me new ways of looking at my problem. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 5. and I understand each other. 1 2 3 Never Rarely Occasional ly Somet i mes 5 Often Very Often 7 A1 ways CO perceives accurate ly what my goals are. 1 2 3 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 A1 ways I f i n d what I am doing in therapy confusing. 1 2 3 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 Always 8. I be 1i eve 1 Never 1i kes me. 2 Rarely Occasional ly Somet i mes 5 Often Very Often 7 A1 ways I wi sh 1 Never and I could c l a r i f y the purpose of our sessions. 2 3 4 5 Rarely Occasional ly Sometimes Often Very Often 7 Always 10. I d isagree with about what I ought to get out of therapy. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often 6 Very Often 7 A1 ways 11. I be l i eve the time 1 2 Never Rarely and I are spending together is not spent e f f i c i e n t l y . 3 4 5 6 Occasional ly Sometimes Often Very Often 7 Always 12. does not understand what I am t ry ing to accomplish in therapy. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 13. I am c lea r on what my r e s p o n s i b i l i t i e s are in therapy. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 14. The goals of these sessions are important to me. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 15. I f i n d what and I are doing in therapy is unrelated to my concerns. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often 6 Very Often 7 Always 16. I fee l that the things I do in therapy wi l l help me to accomplish the changes 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often that I want. 6 Very Often 7 A1 ways 17. I be l ieve 1 Never is genuinely concerned for my welfare. 2 3 4 Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 18. I am c l e a r as to what 1 2 Never Rarely wants me to do in these sess ions . 3 4 5 Occasional ly Sometimes Often Very Often 7 Always 19. 1 Never and I respect each other. 2 3 Rarely Occasional ly Somet i mes 5 Often Very Often 7 Always 20. I feel that 1 Never is not t o t a l l y honest about h is /he r fee l ings toward me. 2 3 4 5 Rarely Occasional ly Sometimes Often Very Often 7 Always 21. I am conf ident in 1 2 Never Rarely 's a b i l i t y to help me. 3 4 Occasional ly Sometimes 5 Often Very Often 7 A1 ways 22. and I are working towards mutually agreed upon goals . 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 23. I feel that appreciates me. 1 2 3 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 A1 ways O 24. We agree on what is important for me to work on. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often 6 Very Often A1 ways 25. As a resu l t of these sess ions , I am c learer as to how I might be able to change. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often 6 Very Often 7 Always 2G. and I trust one another. 1 2 3 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 A1 ways 27. and I have d i f f e ren t ideas on what my problems are. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 28. My r e l a t i o n s h i p with 1 2 Never Rarely is very important to me. 3 4 Occas i ona11y Somet i mes 5 Often Very Often 7 Always 29. I have the f e e l i n g that i f I say or do the wrong th ings, 1 2 3 4 Never Rarely Occasional ly Sometimes wi l l stop working with me. 5 6 Often Very Often 7 A1 ways 30. and I co l laborate on se t t ing goals for my therapy. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 31. I am f r u s t r a t e d by the things I am doing in therapy. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 Always 32. We have estab l ished a good understanding of the kind of changes 1 2 3 4 Never Rarely Occasional ly Sometimes that would be good for me. 5 6 Often Very Often 7 A1 ways 33.The things that 1 Never Rarely _ is asking me to do don't make sense. 2 3 4 Occasional ly Sometimes 5 Often Very Often 7 Always 34. I don' t know what to expect as the resu l t of my therapy. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 35. I be l ieve the way we are working with my problem is cor rec t . 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 36. I feel 1 Never cares about me even when I do things that he/she does not approve o f . 2 3 4 5 6 Rarely Occasional ly Sometimes Often Very Often 7 Always APPENDIX K> - CLIENT INVOLVEMENT SCALE (CLIENT FORM) 1. I feel that I am f r e e l y , openly and honestly expressing my thoughts and fee l ings and o f f e r i n g information about my behaviour in t h i s therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always I feel that I am a c t i v e l y working toward the success of th is therapy. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 3. I am working together with my therapist to make changes I need to make. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 4. I am f u l l y involved in the process of th is therapy. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 5. I feel that I am making the best use of th is therapy in order to help me make changes. 1 2 3 4 5 6 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 6. I feel a good deal of r e s p o n s i b i l i t y for making th is therapy work. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 Always PLEASE BE SURE TO PLACE THE COMPLETED QUESTIONNAIRE IN THE ATTACHED ENVELOPE AND SEAL THE ENVELOPE APPENDIX 1J. - WORKING ALLIANCE INVENTORY (THERAPIST FORM)  PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #11 (THERAPIST FORM) INSTRUCTIONS On the fo l lowing pages there are sentences that describe some of the d i f f e r e n t ways a person might think or feel about h is or her c l i e n t . As you read the sentences, mentally insert the name of your c l i e n t in place of in the text . Below each statement ins ide , there is a seven-point s c a l e : 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always If the statement descr ibes the way you a1 ways feel (or th ink) , c i r c l e the number 'T; i f i t never app l ies to you, c i r c l e the number ' 1 ' . Use the numbers in between to describe the var ia t ions between these extremes. This quest ionnai re is CONFIDENTIAL; nei ther your c l i e n t nor the agency w i l l see your answers. Work f a s t ; your f i r s t impressions are the ones we would l i ke to see. (PLEASE DON'T FORGET TO RESPOND TO EVERY ITEM.) Thank you for your cooperat ion. ® A. 0. Horvath, 1981, 1984. Session #: Date: 1. I fee l uncomfortable with . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 2. and I agree about the steps to be taken to improve h i s / h e r s i t u a t i o n . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 3. I have some concerns about the outcome of these sess ions . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often • Very Often Always 4. and I both feel confident about the usefulness of our current a c t i v i t y in therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 5. and I have a common perception of her /h is goals . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 6. I feel I r e a l l y understand 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 7. f inds what we are doing in therapy confusing. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 8. I be l ieve l i kes me. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 9. I sense a need to c l a r i f y the purpose of our session(s) for . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 10. I have some disagreements with about the goals of these sess ions . 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often 6 Very Often 7 A1 ways 11. I be l ieve that the time 1 2 Never Rarely and I are spending together is not spent e f f i c i e n t l y . 3 4 5 6 Occasional ly Sometimes Often Very Often 7 Always 12. I have doubts about what we are t ry ing to accomplish in therapy. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 A1 ways 13. I am c lear and e x p l i c i t about what 1 2 3 Never Rarely Occasional ly 's r e s p o n s i b i l i t i e s are in therapy. 4 5 6 Sometimes Often Very Often 7 Always 14. The current goals of these sessions are important for 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 Always 15. I f i n d what and I are doing in therapy is unrelated to he r /h is current concerns. 1 2 3 4 5 6 Never Rarely Occasional ly Sometimes Often Very Often 7 Always 16. I feel confident that the things we do in therapy wi l l help des i res . 1 2 3 4 Never Rarely Occasional ly Sometimes to accomplish the changes that he/she 5 Often Very Often 7 A1 ways 17. I am genuinely concerned for 1 2 3 Never Rarely Occasional ly s welfare. Somet imes 5 Often 6 Very Often 7 Always 18. I am c lea r as to what I expect 1 2 Never Rarely Occasional ly to do in these sess ions . 3 4 5 Sometimes . Often Very Often 7 Always 19 . 1 Never and I respect each other. 2 3 Rarely Occasional ly Somet imes 5 Often Very Often 7 A1 ways 20. I fee l that I am not t o t a l l y honest about my fee l ings toward 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 21. I am confident in my a b i l i t y to help 1 2 3 Never Rarely Occasional ly Somet i mes 5 Often Very Often 7 A1 ways 22. We are working towards mutually agreed upon goals . 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 23. I appreciate 1 Never as a person. 2 3 Rarely Occasional ly Somet i mes 5 Often Very Often A1 ways ON 24. We agree on what is important for to work on. 1 2 3 4 Never Rarely Occasional ly Sometimes 5 Often Very Often 7 A1 ways 25. As a resu l t of these sess ions , 1 2 Never Rarely Occasional ly is c learer as to how she/he might be able to change. 3 4 5 6 Sometimes Often Very Often 7 A1 ways 26. and I have b u i l t a mutual t rus t . 1 2 3 Never Rarely Occasional ly Somet imes 5 Often Very Often 7 Always 27. and I have d i f f e ren t ideas on what h is /her real problems are. 1 2 3 4 5 Never Rarely Occasional ly Sometimes Often Very Often 7 A1 ways 28. Our r e l a t i o n s h i p is important to 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 29. has some fears that i f she/he says or does the wrong th ings, I w i l l stop working with him/her. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 30. and I have col laborated in se t t ing goals for these sess ions . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 31. is f rus t ra ted by what I am asking her/him to do In therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 32. We have estab l ished a good understanding between us of the kind of changes that would be good for . ^ 1 2 3 4 5 6 7 vj-v Never Rarely Occasional ly Sometimes Often Very Often Always 33. The things that we are doing in therapy don't make much sense to . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 34. doesn't know what to expect as the resul t of therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 35. be l ieves the way we are working with her /h is problem is cor rec t . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 36. I respect even when he/she does things that I do not approve o f . 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always APPENDIX J_2 - CLIENT INVOLVEMENT SCALE (THERAPIST FORM) 1. is f r e e l y , openly and honestly expressing h is /he r thoughts and fee l ings and o f f e r i n g information about h i s / h e r behaviour in th is therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 2. is a c t i v e l y working toward the success of th is therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 3. is working together with me to make changes he/she needs to make. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 4. is f u l l y involved in the process of th is therapy. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 5. is making the best use of th is therapy in order to help him/her make changes. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 6. seems to feel a good deal of r e s p o n s i b i l i t y for making th is therapy work. 1 2 3 4 5 6 7 Never Rarely Occasional ly Sometimes Often Very Often Always 159 APPENDIX 13 - RELATIONSHIP INVENTORY - EMPATHY SUBSCALE PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #12 Below are l i s t e d a v a r i e t y of ways tha t one person may f e e l or behave in r e l a t i o n to another p e r s o n . P l e a s e c o n s i d e r each numbered statement w i th r e f e r e n c e to your p r e s e n t r e l a t i o n s h i p w i th your c o u n s e l l o r , m e n t a l l y add ing h i s or her name i n the space p r o v i d e d . For example, i f the o ther p e r s o n ' s name was J o h n , you would read statement #1, as ' John wants to unders tand how I see t h i n g s . ' Mark each statement in the answer column on the r i g h t , a c c o r d i n g to how s t r o n g l y you f e e l that i t i s t r u e , or not t r u e , in t h i s r e l a t i o n s h i p . P l e a s e be sure to mark every one . Wr i te in +3, +2, +1, or - 1 , - 2 , - 3 , to s tand f o r the f o l l o w i n g answers : +3: Y e s , I s t r o n g l y f e e l tha t i t i s t r u e . +2: Y e s , I f e e l i t i s t r u e . +1: Y e s , I f e e l tha t i t i s p r o b a b l y t r u e , or more t r u e than u n t r u e . - 1 : No, I f e e l that i t i s p r o b a b l y u n t r u e , or more untrue than t r u e . - 2 : No, I f e e l i t i s not t r u e . - 3 : No, I s t r o n g l y f e e l that i t i s not t r u e . 1. wants to unders tand how I see t h i n g s _ 2. may unders tand my words but h e / s h e does not see the way I f e e l _ 3. n e a r l y a lways knows e x a c t l y what I mean _ 4. l o o k s at what I do from h i s / h e r own p o i n t of view 5. u s u a l l y senses or r e a l i z e s what I am f e e l i n g . . . . 6. I f e e l that what says u s u a l l y e x p r e s s e s e x a c t l y what h e / s h e i s f e e l i n g and t h i n k i n g at tha t moment . . . 7. ' s own a t t i t u d e s toward some of the t h i n g s I do or say prevent h im /her from u n d e r s t a n d i n g me 160 8. wants me to t h i n k tha t h e / s h e l i k e s me or unders tands me more than h e / s h e r e a l l y does _ 9. Sometimes t h i n k s tha t I_ f e e l a c e r t a i n way, because t h a t ' s the way h e / s h e f e e l s _ 10. u s u a l l y unders tands the whole of what I m e a n . . . . _ 11. j u s t takes no n o t i c e of some t h i n g s tha t I t h i n k or f e e l _ 12. a p p r e c i a t e s e x a c t l y how the t h i n g s I e x p e r i e n c e f e e l to me _ 13. At t imes t h i n k s tha t I f e e l a l o t more s t r o n g l y about a p a r t i c u l a r t h i n g than I r e a l l y do _ 14. unders tands me _ 15. ' s response to me i s u s u a l l y so f i x e d and automat ic tha t I d o n ' t r e a l l y get through to h im/her _ 16. When I am hur t or upset can r e c o g n i z e my f e e l i n g s e x a c t l y , wi thout becoming upset too _ 161 APPENDIX 14 - COUNSELOR RATING FORM PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #13 L i s t e d below are s e v e r a l s c a l e s which c o n t a i n word p a i r s a t e i t h e r end of the s c a l e and seven spaces between the p a i r s . P l e a s e ra te the c o u n s e l o r you j u s t saw on each of the s c a l e s . If you f e e l tha t the c o u n s e l o r very c l o s e l y resembles the word at one end of the s c a l e , p l a c e a check mark as f o l l w s : f a i r : : : : : : _X u n f a i r OR f a i r _ X : : : : : : u n f a i r If you t h i n k tha t one end of the s c a l e q u i t e c l o s e l y d e s c r i b e s the c o u n s e l o r then make your check mark as f o l l o w s : rough : _X : : : : : smooth OR rough : : : : ! _X : smooth If you f e e l tha t one end of the s c a l e o n l y s l i g h t l y d e s c r i b e s the c o u n s e l o r , then check the s c a l e as f o l l o w s : a c t i v e : : : s • * p a s s i v e OR a c t i v e : : : ' p a s s i v e If both s i d e s of the s c a l e seem e q u a l l y a s s o c i a t e d w i th your i m p r e s s i o n of the c o u n s e l o r or i f the s c a l e i s i r r e l e v a n t , then p l a c e a check mark in the middle s p a c e : hard : : : X : : : s o f t Your f i r s t i m p r e s s i o n i s the best answer . PLEASE NOTE: PLACE CHECK MARKS IN THE MIDDLE OF THE SPACES C o p y r i g h t c , M.B. L a C r o s s e and A . B a r a k , 1974, 1975. Not to be reproduced wi thout p e r m i s s i o n . 162 a g r e e a b l e : : : _ u n a l e r t : : : a n a l y t i c : : : u n a p p r e c i a t i v e : : : a t t r a c t i v e : : : c a s u a l : : : c h e e r f u l : : : u n c l e a r : : : d i s t a n t : : : c o m p a t i b l e : : : unsure : : : s u s p i c i o u s : : : undependable : : : ; i n d i f f e r e n t : : : : i n e x p e r i e n c e d : : : : i n e x p e r t : : : : u n f r i e n d l y : : : : honest : : : : in formed : : : : i n s i g h t f u l : : : : s t u p i d : : : : u n l i k e a b l e : : : : l o g i c a l : : : : open : : : : p r e p a r e d : : : : u n r e l i a b l e : : : : d i s r e s p e c t f u l : ' d i s a g r e e a b l e a l e r t d i f f u s e a p p r e c i a t i v e u n a t t r a c t i v e fo rmal d e p r e s s e d c l e a r c l o s e i n c o m p a t i b l e c o n f i d e n t b e l i e v a b l e _ dependable _ e n t h u s i a s t i c _ e x p e r i e n c e d exper t f r i e n d l y d i s h o n e s t i g n o r a n t i n s i g h t l e s s i n t e l l i g e n t l i k e a b l e i l l o g i c a l c l o s e d unprepared r e l i a b l e r e s p e c t f u l 163 i r r e s p o n s i b l e : : : s e l f l e s s : : : s i n c e r e : : i s k i l l f u l : : : _ s o c i a b l e : t • d e c e i t f u l : : : _ t r u s t w o r t h y : : : _ genuine : : v _ warm : : ' _ r e s p o n s i b l e s e l f i s h i n s i n c e r e u n s k i l l f u l u n s o c i a b l e s t r a i g h t f o r w a r d u n t r u s t w o r t h y phony c o l d 164 APPENDIX 15 - HELPING ALLIANCE QUESTIONNAIRE PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #14 Below are l i s t e d a v a r i e t y of ways tha t one person may f e e l or behave in r e l a t i o n to another p e r s o n . P l e a s e c o n s i d e r each statement w i th r e f e r e n c e to your p resen t r e l a t i o n s h i p wi th your t h e r a p i s t . Mark each statement a c c o r d i n g t o how s t r o n g l y you f e e l that i t i s t r u e , or not t r u e , in t h i s r e l a t i o n s h i p . P l e a s e mark  every one . Wr i te in +3, +2, +1 or - 1 , - 2 , - 3 , to s tand f o r the f o l l o w i n g answers : +3. Y e s , I s t r o n g l y f e e l that i t i s t rue +2. Y e s , I f e e l i t i s t rue +1. Y e s , I f e e l tha t i t i s p r o b a b l y t r u e , or more t r u e than unt rue - 1 . No, I f e e l tha t i t i s p r o b a b l y u n t r u e , or more unt rue than t r u e - 2 . No, I f e e l i t i s not t r u e - 3 . No, I s t r o n g l y f e e l that i t i s not t r u e 1. I b e l i e v e that my t h e r a p i s t i s h e l p i n g me. 2. I b e l i e v e that the t reatment i s h e l p i n g me. 3. I have o b t a i n e d some new u n d e r s t a n d i n g . 4. I have been f e e l i n g b e t t e r r e c e n t l y . 5. I can a l r e a d y see that I w i l l e v e n t u a l l y work out the problems I came to t reatment f o r . 6. I f e e l I can depend upon the t h e r a p i s t . 7. I f e e l the t h e r a p i s t unders tands me. 8. I f e e l the t h e r a p i s t wants me to a c h i e v e my g o a l s . 9. I f e e l I am working toge ther wi th the t h e r a p i s t in a j o i n t e f f o r t . 10. I b e l i e v e we have s i m i l a r ideas about the na ture of my p r o b l e m s . 11. I f e e l now tha t I can unders tand myse l f and d e a l w i th myse l f on my own ( that i s , even i f t h i s t h e r a p i s t and I were no l o n g e r meet ing f o r t reatment a p p o i n t m e n t s ) . 165 APPENDIX 16 - STRUPP POSTTHERAPY QUESTIONNAIRE PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #5 1. How much in need of f u r t h e r t h e r a p y / c o u n s e l l i n g do you f e e l now? No need at a l l S l i g h t need C o u l d use more C o n s i d e r a b l e need Very g rea t need 2. What has l e d to the t e r m i n a t i o n of your t h e r a p y / c o u n s e l l i n g ? My d e c i s i o n My t h e r a p i s t ' s d e c i s i o n Mutua l agreement E x t e r n a l f a c t o r s 3. How much have you b e n e f i t t e d from your t h e r a p y / c o u n s e l l i n g ? A g r e a t d e a l A f a i r amount To some ex tent Very l i t t l e Not at a l l 4. E v e r y t h i n g c o n s i d e r e d , how s a t i s f i e d are you w i th your t h e r a p y / c o u n s e l l i n g e x p e r i e n c e ? Ex t remely d i s s a t i s f i e d M o d e r a t e l y d i s s a t i s f i e d F a i r l y d i s s a t s i f e d F a i r l y s a t i s f i e d M o d e r a t e l y s a t i s f i e d H i g h l y s a t i s f i e d Ex t reme ly s a t i s f i e d 5. Was your t h e r a p i s t of the same sex as you? Yes No 6. What i m p r e s s i o n d i d you have of h i s / h e r l e v e l of e x p e r i e n c e as a t h e r a p i s t / c o u n s e l l o r ? Ex t reme ly i n e x p e r i e n c e d Rather i n e x p e r i e n c e d Somewhat i n e x p e r i e n c e d F a i r l y e x p e r i e n c e d H i g h l y e x p e r i e n c e d E x c e p t i o n a l l y e x p e r i e n c e d 7. At the b e g i n n i n g of t h e r a p y , how w e l l d i d you f e e l you were g e t t i n g a long? Very w e l l F a i r l y w e l l N e i t h e r w e l l nor p o o r l y F a i r l y p o o r l y Very p o o r l y Ex t remely p o o r l y 1 66 8. How l o n g b e f o r e e n t e r i n g therapy d i d you f e e l in need of p r o f e s s i o n a l he lp? L e s s than 1 year 1-2 y e a r s 3-4 y e a r s 5-10 y e a r s 11-15 y e a r s 16-20 y e a r s y e a r s ( s p e c i f y ) 9. How s e v e r e l y d i s t u r b e d d i d you c o n s i d e r y o u r s e l f a t the b e g i n n i n g of your t h e r a p y / c o u n s e l l i n g ? Ext remely d i s t u r b e d Very much d i s t u r b e d Modera te ly d i s t u r b e d Somewhat d i s t u r b e d Very s l i g h t l y d i s t u r b e d 10. How much a n x i e t y d i d you f e e l at the t ime you s t a r t e d t h e r a p y / c o u n s e l l i n g ? A tremendous amount A g rea t d e a l A f a i r amount Very l i t t l e None at a l l 11. How grea t was the i n t e r n a l " p r e s s u r e " to do something about these problems when you e n t e r e d t h e r a p y / c o u n s e l l i n g ? Ext remely g rea t Very g rea t F a i r l y g rea t R e l a t i v e l y s m a l l Very s m a l l Ex t remely s m a l l 12. How much do you f e e l you have changed as a r e s u l t of t h e r a p y / c o u n s e l l i n g ? A g r e a t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l 13. How much of t h i s change do you f e e l has been apparent to o t h e r s ? (a) People c l o s e s t to you (husband, w i f e , e t c . ) A g rea t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l (BT C l o s e f r i e n d s A g rea t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l (cT C o - w o r k e r s , a c q u a i n t a n c e s , e t c . A g rea t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l 167 14. On the whole , how w e l l do you f e e l you are g e t t i n g a l o n g now? Ext remely w e l l Very w e l l F a i r l y w e l l N e i t h e r w e l l nor p o o r l y F a i r l y p o o r l y Very p o o r l y Ext remely p o o r l y 15. How a d e q u a t e l y do you f e e l you are d e a l i n g wi th any p resen t problem? Very a d e q u a t e l y F a i r l y a d e q u a t e l y N e i t h e r a d e q u a t e l y nor i n a d e q u a t e l y Somewhat a d e q u a t e l y Very i n a d e q u a t e l y 16. To what ex tent have your c o m p l a i n t s that brought you to t h e r a p y / c o u n s e l l i n g changed as a r e s u l t of t rea tment? Comple te ly d i s a p p e a r e d Very g r e a t l y improved C o n s i d e r a b l y improved Somewhat improved Not at a l l improved Got worse 17. How soon a f t e r e n t e r i n g t h e r a p y / c o u n s e l l i n g d i d you f e e l any marked change? hours of therapy (approx imate ly ) 18. How s t r o n g l y would you recommend t h e r a p y / c o u n s e l l i n g to a c l o s e f r i e n d w i th emot iona l problems? Would s t r o n g l y recommend i t Would m i l d l y recommend i t Would not recommend i t Would a d v i s e a g a i n s t i t 19. P l e a s e i n d i c a t e the adequacy of t h i s q u e s t i o n n a i r e in d e s c r i b i n g your therapy e x p e r i e n c e . G ive any a d d i t i o n a l da ta which you f e e l are r e l e v a n t to an u n d e r s t a n d i n g of your e x p e r i e n c e . THANK-YOU FOR YOUR PARTICIPATION IN THIS PROJECT 168 APPENDIX 17 - TARGET COMPLAINTS IMPROVEMENT RATING FORM PSYCHOTHERAPY RESEARCH QUESTIONNAIRE #1B We are i n t e r e s t e d in how much the f o l l o w i n g problems or d i f f i c u l t i e s of yours have changed s i n c e the b e g i n n i n g of t h e r a p y . P l e a s e c i r c l e the words tha t d e s c r i b e your p o s i t i o n . A w o r s e . . . s a m e . . . s l i g h t l y b e t t e r . . . somewhat b e t t e r . . . a l o t b e t t e r B w o r s e . . . s a m e . . . s l i g h t l y b e t t e r . . . somewhat b e t t e r . . . a l o t b e t t e r C w o r s e . . . s a m e . . . s l i g h t l y b e t t e r . . . somewhat b e t t e r . . . a l o t b e t t e r 169 APPENDIX 18 - THERAPIST DEMOGRAPHIC DATA SHEET THERAPIST DEMOGRAPHIC DATA SHEET 1. P r o f e s s i o n a l a f f i l i a t i o n : P s y c h o l o g i s t S o c i a l Worker C o u n s e l l o r P s y c h i a t r i s t Other ( p l e a s e s p e c i f y ) 2 . H ighes t degree c o m p l e t e d : B . A . M.D. PhD. E d . D . M . E d . B .S .W. M.S.W. Other (p lease s p e c i f y ) 3. Number of y e a r s e x p e r i e n c e as a t h e r a p i s t / c o u n s e l l o r : None 1 - 5 6 - 1 0 1 1 - 1 5 More 4. Sex (check o n e ) : M F 5. I d e n t i f y / d e s c r i b e the t h e o r e t i c a l o r i e n t a t i o n which most c h a r a c t e r i z e s your work wi th t h i s p a r t i c u l a r c l i e n t : I f you had to p l a c e y o u r s e l f i n one of the f o l l o w i n g t h r e e c a t e g o r i e s , which would you choose? (check one) a n a l y t i c l e a r n i n g h u m a n i s t i c 170 APPENDIX 19 - THERAPIST POSTTHERAPY QUESTIONNAIRE THERAPIST POSTTHERAPY QUESTIONNAIRE 1. How much more therapy do you f e e l your c l i e n t needs now? No need at a l l S l i g h t need C o u l d use more C o n s i d e r a b l e need Very g r e a t need 2. What determined t h i s c h o i c e to t e rmina te w i th your c l i e n t now? C l i e n t ' s d e c i s i o n T h e r a p i s t ' s d e c i s i o n Mutual agreement E x t e r n a l f a c t o r s 3. How much has your c l i e n t b e n e f i t t e d from therapy? A g rea t d e a l A f a i r amount To some ex ten t Very l i t t l e Not at a l l 4. E v e r y t h i n g c o n s i d e r e d , how s a t i s f i e d are you w i th the r e s u l t s of your c l i e n t ' s psychotherapy e x p e r i e n c e ? Ext remely d i s s a t i s f i e d M o d e r a t e l y d i s s a t i s f i e d F a i r l y d i s s a t s i f e d F a i r l y s a t i s f i e d M o d e r a t e l y s a t i s f i e d H i g h l y s a t i s f i e d Ex t remely s a t i s f i e d 5. As a t h e r a p i s t / c o u n s e l l o r , how would you d e s c r i b e y o u r s e l f ? Ex t remely i n e x p e r i e n c e d Rather i n e x p e r i e n c e d Somewhat i n e x p e r i e n c e d F a i r l y e x p e r i e n c e d H i g h l y e x p e r i e n c e d E x c e p t i o n a l l y e x p e r i e n c e d 6. At the b e g i n n i n g of t h e r a p y , how w e l l d i d you f e e l your c l i e n t was g e t t i n g a l o n g ? Very w e l l F a i r l y w e l l N e i t h e r w e l l nor p o o r l y F a i r l y p o o r l y Very p o o r l y Ex t remely p o o r l y 171 7. How s e v e r e l y d i s t u r b e d was your c l i e n t at the b e g i n n i n g of therapy? Ex t remely d i s t u r b e d Very much d i s t u r b e d Modera te ly d i s t u r b e d Somewhat d i s t u r b e d Very s l i g h t l y d i s t u r b e d 8. How much a n x i e t y d i d your c l i e n t e x p e r i e n c e at the b e g i n n i n g of therapy? A tremendous amount A g rea t d e a l A f a i r amount Very l i t t l e None at a l l 9 . How much i n t e r n a l " p r e s s u r e " d i d your c l i e n t e x p e r i e n c e about these problems when h e / s h e en te red p s y c h o t h e r a p y ? Ex t remely g rea t Very g r e a t F a i r l y g rea t R e l a t i v e l y s m a l l Very s m a l l Ex t remely s m a l l 10. How much do you f e e l you c l i e n t has changed as a r e s u l t of therapy? A grea t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l 11. How much of t h i s change do you f e e l has been apparent to o t h e r s ? (a) People c l o s e s t to h im/her (husband, w i f e , e t c . ) A grea t d e a l A f a i r amount Somewhat Very l i t t l e Not a t a l l (BT C l o s e f r i e n d s A g rea t d e a l A f a i r amount Somewhat Very l i t t l e Not at a l l (cT C o - w o r k e r s , a c q u a i n t a n c e s , e t c . A g rea t d e a l A f a i r amount Somewhat Very l i t t l e Not a t a l l 12. On the whole , how w e l l do you f e e l your c l i e n t i s g e t t i n g a l o n g now? Ex t remely w e l l Very w e l l F a i r l y w e l l N e i t h e r w e l l nor p o o r l y F a i r l y p o o r l y Very p o o r l y Ex t remely p o o r l y 172 13. How a d e q u a t e l y do you f e e l your c l i e n t i s d e a l i n g w i t h any p r e s e n t problem? Very a d e q u a t e l y F a i r l y adequa te ly N e i t h e r adequa te ly nor i n a d e q u a t e l y Somewhat i n a d e q u a t e l y Very i n a d e q u a t e l y 14. To what ex tent has your c l i e n t ' s c o m p l a i n t ( s ) or symptom(s) tha t brought h im/her to therapy changed as a r e s u l t of t rea tment? Comple te ly d i s a p p e a r e d Very g r e a t l y improved C o n s i d e r a b l y improved Somewhat improved Not at a l l improved Got worse 15. How soon a f t e r e n t e r i n g therapy d i d you f e e l tha t marked changes had taken p l a c e in your c l i e n t ? hours of therapy (approx imate ly ) THANK-YOU FOR YOUR PARTICIPATION IN THIS PROJECT 1 73 APPENDIX 20 - LETTER OF THANKS TO CLIENTS THE UNIVERSITY OF BRITISH COLUMBIA F a c u l t y of E d u c a t i o n Department of C o u n s e l l i n g P s y c h o l o g y 5780 T o r o n t o Road Vancouver , B . C . V6T 1L2 Dear P a r t i c i p a n t , Thank you f o r h e l p i n g us w i th the Psychotherapy Research P r o j e c t by c o m p l e t i n g our q u e s t i o n n a i r e s . In a p p r e c i a t i o n of your p a r t i c i p a t i o n , we are e n c l o s i n g a cheque f o r $25.00 . S i n c e r e l y , Jean A d l e r P r o j e c t C o o r d i n a t o r 174 APPENDIX 21 - INSTRUMENT SCORING KEYS Symptom C h e c k l i s t - 9 0 .1 S o m a t i z a t i o n - 1 , 4, 12, 27, 40, 42, 48, 49, 52, 53, 56, 58 O b s e ^ s s i v e - C o m p u l s i v e - 3 , 9, 10, 28, 38, 45, 46, 51, 55, 65 I n t e r p e r s o n a l S e n s i t i v i t y - 6 , 21, 34, 36, 37, 41, 61 , 69, 73 D e p r e s s i o n - 5 , 14, 15, 20, 22, 26, 29, 30, 31, 32, 54, 71, 79 A n x i e t y - 2 , 17, 23, 33, 39, 57, 72, 78, 80, 86 A n g e r - H o s t i l i t y - 1 1 , 24, 63, 67, 74, 81 Phobic A n x i e t y - 1 3 , 25, 47, 50, 70, 75, 82 P a r a n o i d I d e a t i o n - 8 , 18, 43, 68, 76, 83 P s y c h o t i c i s m - 7 , 16, 35, 62, 77, 84, 85 , 87, 88, 90 A d d i t i o n a l S c a l e s - 1 9 , 44, 59, 60, 64, 66, 89 S e l f - E s t e e m Index 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , J_0 1  Inventory of I n t e r p e r s o n a l Problems Hard to be I n t i m a t e - 1 , 11, 26, 30, 34, 37, 39, 44, 70, 71, 72 Hard to be A s s e r t i v e - 2 , 5, 6, 8, 9 , 13, 17, 22, 32, 33, 35, 36, 43, 57, 69, 74, 78 Hard to be Independent -4 , 16, 25, 47, 51, 54, 55, 56, 66 Hard to be S o c i a b l e - 3 , 7, 10, 23, 27, 28, 42, 46, 48, 62, 67 Hard to f e e l S e l f - W o r t h - 2 1 , 31, 45, 53, 60, 76 Hard to be S u p p o r t i v e - 1 2 , 18, 19, 29, 38, 40, 50, 52, 61 , 64, 65 Hard to be A g g r e s s i v e - 1 4 , 20, 41, 58, 68 Not Members of H s u b s c a l e s - 1 5 , 24, 49, 59, 63, 73, 75 , 77 Too G i v i n g - 8 8 , 97, 101, 104, 109, 113 Too A g g r e s s i v e - 7 9 , 82, 90, 96, 98, 102, 111, 112, 115, 116, 117, 123, 127 Too H y p e r s e n s i t i v e - 8 0 , 92, 99, 105, 106, 107, 108, 118, 124, 125 Too Eager to P l e a s e - 8 1 , 83, 91, 93, 103, 110, 114, 120, 122, 126 Too Dependent -84 , 85, 86, 87, 94, 95 , 100, 119, 121 Not Member of T s u b s c a l e s - 8 9 Working A l l i a n c e Inventory ( C l i e n t Form) GOAL: 3 , 6 , 9 , U> , J_2 , 14 , 22 , 25 , 27 , 30 , 32 , 34 TASK: 2 , 4 , 7 , 11, 1 3 , 1 5 , 1 6 , 18 , 24 , 3J. , 33 , 35 BOND: J _ , 5 , 8 , 17 , 19 , 20 , 21 , 23 , 26 , 28 , 29 , 36 1 R e v e r s e - w e i g h t e d i tems are u n d e r l i n e d . 175 Working A l l i a n c e Inventory ( T h e r a p i s t Form) GOAL: 3 , 5 , 9 , 10 , 12 , 14 , 22 , 25 , 27 , 30 , 32 , 34 TASK: 2 , 4 11 , 13 , 15 , 16 , 18 , 24 , 31 , 33 , 35 BOND: 1 , 6 , 8 , 17 , 19 , 20 , 21 , 23 , 26 , 28 , 29 , 36 R e l a t i o n s h i p Inventory (Empathy S u b s c a l e ) 1, 2 , 3, 4 , 5, 6, 7 C o u n s e l o r R a t i n g Form E x p e r t n e s s - 2 , 3 , 8 11 T r u s t w o r t h i n e s s - 12 , 33 , 34 , 35 A t t r a c t i v e n e s s - 1 , 4 36 H e l p i n g A l l i a n c e Q u e s t i o n n a i r e HA Type 1 - 1, 2, 3, 4, 5, 6, 7, 8 HA Type 2 - 9 , 10, 11 S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n - 3 , 4, 18 Change - J_2 , 13a , 13b , 13c , 16 Adjustment - 1 , 1 4 , 1 5 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n - 3 , 4 Change - j_0 , H a , 1 1b , 1 1c , V4 Adjustment - 1 , 1 2 , 1 3 , 8 , 9 , 10, 12, 12 , 14, 15 , 16 , 1 1 , 15 , 16 , j_9 , 20 , 21 , 23 , 25 , 13 , J_8 , 24 , 26 , 27 , 28 , 29 , 3_0 , , 5 , 6 , 7 , 9, 10 , 14 , 17 , 22 , 32 , 176 APPENDIX 22 - ADDITIONAL INFORMATION COLLECTED ON THE SPQ AND THE TPQ On the S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e (Appendix 16) , the f o l l o w i n g q u e s t i o n s were not i n c l u d e d in the a n a l y s e s of the p r e s e n t s t u d y . The numbers r e c o r d e d f o r each i tem response are the number of r e s p o n d e n t s . 2. What has . l e d to the t e r m i n a t i o n of your t h e r a p y / c o u n s e l l i n g ? My d e c i s i o n - 4 My t h e r a p i s t ' s d e c i s i o n - 2 Mutual agreement -15 E x t e r n a l f a c t o r s -23 6. What i m p r e s s i o n d i d you have of [your t h e r a p i s t ' s ] l e v e l of e x p e r i e n c e ? Ext remely i n e x p e r i e n c e d - 2 Rather i n e x p e r i e n c e d - 0 Somewhat i n e x p e r i e n c e d - 4 F a i r l y e x p e r i e n c e d -10 H i g h l y e x p e r i e n c e d -20 E x c e p t i o n a l l y e x p e r i e n c e d - 7 No response - 1 7. At the b e g i n n i n g of t h e r a p y , how w e l l d i d you f e e l you were g e t t i n g a long? Very w e l l -17 F a i r l y w e l l -16 N e i t h e r w e l l nor p o o r l y - 5 F a i r l y p o o r l y - 1 Very p o o r l y - 3 Ext remely p o o r l y - 2 8. How l o n g b e f o r e e n t e r i n g therapy d i d you f e e l in need of p r o f e s s i o n a l he lp? L e s s than T year -16 1-2 yea rs - 8 3-4 y e a r s - 5 5-10 y e a r s - 9 11-15 y e a r s - 3 16-20 y e a r s - 1 Over 20 years - 2 9. How s e v e r e l y d i s t u r b e d d i d you c o n s i d e r y o u r s e l f at the b e g i n n i n g of your t h e r a p y / c o u n s e l l i n g ? 177 Ext remely d i s t u r b e d - 4 Very much d i s t u r b e d -16 Modera te ly d i s t u r b e d -12 Somewhat d i s t u r b e d - 8 Very s l i g h t l y d i s t u r b e d - 4 10. How much a n x i e t y d i d you f e e l at the t ime you s t a r t e d t h e r a p y / c o u n s e l l i n g ? A tremendous amount -15 A g r e a t d e a l -15 A f a i r amount - 9 Very l i t t l e - 5 None at a l l - 0 11. How grea t was the i n t e r n a l " p r e s s u r e " to do something about these problems when you e n t e r e d t h e r a p y / c o u n s e l l i n g ? Ext remely grea t -15 Very grea t -13 R e l a t i v e l y s m a l l -12 Very s m a l l - 4 Ex t remely s m a l l - 0 17. How soon a f t e r e n t e r i n g t h e r a p y / c o u n s e l l i n g d i d you f e e l any marked change? A f t e r l e s s than 5 hours of the rapy -19 a f t e r 5-10 hours of therapy -16 A f t e r more than 10 hours of therapy - 6 No response - 3 On the T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e (Appendix 19), the f o l l o w i n g q u e s t i o n s were not i n c l u d e d in the a n a l y s e s of the p r e s e n t s t u d y . 2. What determined t h i s c h o i c e to t e r m i n a t e wi th your c l i e n t now? C l i e n t ' s d e c i s i o n - 8 T h e r a p i s t ' s d e c i s i o n - 0 Mutual agreement -17 E x t e r n a l f a c t o r s -19 5. As a t h e r a p i s t / c o u n s e l l o r , how would you d e s c r i b e y o u r s e l f ? Ex t remely i n e x p e r i e n c e d - 1 Rather i n e x p e r i e n c e d - 0 Somewhat i n e x p e r i e n c e d - 5 F a i r l y e x p e r i e n c e d -20 H i g h l y e x p e r i e n c e d -16 178 E x c e p t i o n a l l y e x p e r i e n c e d - 1 No response - 1 6. At the b e g i n n i n g of t h e r a p y , how w e l l d i d you f e e l your c l i e n t was g e t t i n g a long? Very w e l l - 2 F a i r l y w e l l -10 N e i t h e r w e l l nor p o o r l y - 4 F a i r l y p o o r l y -15 Very p o o r l y -10 Ex t remely p o o r l y - 2 No response - 1 7. How s e v e r e l y d i s t u r b e d was your c l i e n t a t the b e g i n n i n g of therapy? Ex t remely d i s t u r b e d - 5 Very much d i s t u r b e d - 4 M o d e r a t e l y d i s t u r b e d -18 Somewhat d i s t u r b e d -11 Very s l i g h t l y d i s t u r b e d - 5 No response - 1 8. How much a n x i e t y d i d your c l i e n t e x p e r i e n c e at the b e g i n n i n g of the rapy? A tremendous amount - 4 A g r e a t d e a l -15 A f a i r amount -21 Very l i t t l e - 3 None at a l l - 0 No response - 1 9. How much i n t e r n a l " p r e s s u r e " d i d your c l i e n t e x p e r i e n c e about these problems when h e / s h e e n t e r e d p s y c h o t h e r a p y ? Ex t remely g rea t - 6 Very g rea t -13 F a i r l y g rea t -20 R e l a t i v e l y s m a l l - 3 Very s m a l l - 0 Ex t remely s m a l l - 0 No response - 2 15. How soon a f t e r e n t e r i n g therapy d i d you f e e l tha t marked changes had taken p l a c e in your c l i e n t ? A f t e r l e s s than 5 hours of therapy -13 A f t e r 5-10 hours of therapy -23 A f t e r more than 10 hours of therapy - 6 No response - 2 179 APPENDIX 23 - RELIABILITY ESTIMATES OF THE INSTRUMENTS The computer package LERTAP ( L a b o r a t o r y of E d u c a t i o n a l Research Tes t A n a l y s i s Package; N e l s o n , 1974) was used to e s t i m a t e the r e l i a b i l i t y of each of the ins t ruments employed in the s t u d y . LERTAP uses H o y t ' s (1941) a n a l y s i s of v a r i a n c e a l g o r i t h m to compute c o e f f i c i e n t s of i n t e r n a l c o n s i s t e n c y . I n t e r n a l c o n s i s t e n c y i s an e s t i m a t e of the extent to which s u b s c a l e i tems a l l tap the same c o n s t r u c t . LERTAP can be used to c a l c u l a t e C r o n b a c h ' s (1951) c o e f f i c i e n t a l p h a , a measure of t o t a l t e s t r e l i a b i l i t y , or the degree to which the s u b s c a l e s of the t e s t tend to measure the same t h i n g . When s u b s c a l e s measure q u i t e d i s t i n c t or u n r e l a t e d c o n s t r u c t s , the t o t a l s c a l e r e l i a b i l i t y i s expected to be l e s s than the r e l i a b i l i t y found in each of the s u b s c a l e s . Cronbach suggested tha t t h i s c o e f f i c i e n t a lpha i s an index of how much the t o t a l s c a l e score r e f l e c t s "common e lements r a t h e r than a hodgepodge of e lements each s p e c i f i c to one s u b t e s t " (Cronbach , quoted by N e l s o n , 1974, p. 280) . A l l of the p r o c e s s and outcome measures employed i n the s tudy were a n a l y z e d w i th LERTAP and the r e s u l t s are p r e s e n t e d i n T a b l e 22. The means and s t a n d a r d d e v i a t i o n s of the r e l a t i o n s h i p measures are p r e s e n t e d in T a b l e 21. The means and s t a n d a r d d e v i a t i o n s of the outcome measures a re p r e s e n t e d in S e c t i o n s 1.1 and 1.2 of Chapter IV ( t a r g e t c o m p l a i n t s improvement and the SEI ) , in Appendix 26, Tab le 26 (SCL-90 and I I P ) , and in T a b l e 22 ( SPQ and TPQ) . 180 Tab le 21 - Means and S tandard D e v i a t i o n s of R e l a t i o n s h i p Measures S e s s i o n  #1 #2 #3 #4 #5 #10 F i n a l Working A l l i a n c e Inventory ( C l i e n t Form) Goal 68. ,50 69. .02 70. .43 71 , .05 70. .63 72. 65 72, .05 10. ,62 8. .82 8. ,40 7. .88 7. .77 7. 19 7, .45 Task 69. .36 70, .02 71 . .05 72, .02 72, .07 71 . 92 72, .02 9. .86 8, .52 7. .76 7, .48 7, .60 7. 1 1 7, .35 Bond 70. .25 70, .81 72. .55 72, .81 73. .07 75. 19 73, .82 8. .34 6, .97 6. .93 7, .49 8. .00 6. 09 7, .55 Composite 208. . 1 1 209, .86 214. .02 215, .88 215. .78 219. 77 217, .89 26. .95 22, .47 21 . .17 21 , .06 21 . .21 17. 96 20, .50 Working A l l i a n c e Inventory ( T h e r a p i s t Form) Goal 63. 53 65. 19 66. 91 68 .23 68. 19 66 .96 70 .17 8. 66 9.03 8. 09 7 .83 9. 37 8 .12 7 .81 Task 65. 58 67.07 67. 70 68 .95 68. 48 67 .00 69 .57 7. 37 8.20 7. 63 6 .77 8. 77 6 .66 8 .43 Bond 67. 91 70.09 71 . 63 71 .77 72. 31 72 .12 73 .36 7. 17 7.62 5. 85 7 .25 7. 36 5 .88 6 .25 Composite 197. 02 202.35 206. 23 208 .95 208. 98 206 .08 213 .10 21 . 29 23.44 20. 35 20 .64 24. 31 19 .28 21 .48 ' l i e n t Involvement ( C l i e n t Form) P a r t i c i p a t ' n 12. 61 12.65 12. 41 12 .61 12. 49 12 .69 12 .21 1 . 78 1 .51 1 . 58 1 .50 1 . 91 1 .19 1 .62 R e s p o n s i b ' t y 12. 89 12.67 12. 59 1 2 .86 12. 83 12 .92 12 .61 1 . 69 1 .48 1 . 45 1 .37 1 . 45 1 .09 1 .22 C o l l a b o r a t ' n 12. 30 12.19 12. 1 1 12 .21 12. 05 12 .35 12 .09 2. 05 1 .93 1 . 60 1 .81 2. 02 1 .41 1 .64 Composite 37. 73 37.51 37. 1 1 37 .67 37. 37 37 .96 37 .91 5. 03 4.51 4. 35 4 .42 5. 10 3 .41 4 .19 ! l i e n t Involvement ( T h e r a p i s t Form) P a r t i c i p a t ' n 1 1 . 37 1 1 .67 1 1 . 84 1 2 .09 1 1 . 86 1 1 .88 1 1 .88 1 . 81 1 .99 1 . 94 1 .53 1 . 95 1 .64 1 .69 R e s p o n s i b ' t y 10. 91 1 1 .44 1 1 . 51 1 1 .70 1 1 . 79 1 1 .36 11 .76 1 . 99 2.11 1 . 83 1 .78 2. 08 2 .16 2 .08 C o l l a b o r a t ' n 10. 88 1 1 .40 1 1 . 58 1 1 .84 1 1 . 57 1 1 .48 1 1 .62 1 . 98 1 .95 1 . 65 1 .76 1 . 64 1 .83 2 . 1 1 Composite 33. 16 34.51 34. 93 35 .63 35. 21 34 .72 35 .24 5. 35 5.89 5. 1 4 4 .81 6. 1 1 5 .47 5 .75 181 T a b l e 21 ( C o n t ' d . ) S e s s i o n #!_ #1_ #3 #4 #5 #10 F i n a l R e l a t i o n s h i p Inventory (Empathy s u b s c a l e ) 75.21 9.30 C o u n s e l o r R a t i n g Form E x p e r t n e s s 74.91 7.32 A t t r a c t i v e n e s s 72.91 7.27 T r u s t w o r t h i n e s s 78.05 6.32 Composite 225.86 19.57 H e l p i n g A l l i a n c e Q u e s t i o n n a i r e HA Type 1 41.32 4.68 HA Type 1 13.83 1 .96 Composite 55.15 6.18 182 T a b l e 22 - R e l i a b i l i t y E s t i m a t e s of the Inst ruments H o y t ' s C o e f f i c i e n t C r o n b a c h ' s A lpha R e l a t i o n s h i p Measures Working A l l i a n c e Inventory ( C l i e n t Form) G o a l .87 (.84 to .89) Task .87 (.77 to .90) Bond .81 (.75 to .85) .91 (.85 to .92) Working A l l i a n c e Inventory ( T h e r a p i s t Form) Goa l .92 (.88 to .95) Task .91 (.84 to .93) Bond .82 (.72 to .88) .94 (.90 to .94) C l i e n t Involvement ( C l i e n t Form) .79 (.68 to .85) .72 (.51 to .84) .85 (.73 to .89) P a r t i c i p a t i o n R e s p o n s i b i l i t y C o l l a b o r a t i o n C l i e n t Involvement ( T h e r a p i s t Form) P a r t i c i p a t i o n .80 (.74 to .87) R e s p o n s i b i l i t y .88 (.83 to .94) C o l l a b o r a t i o n .92 (.86 to .98) .92 (.89 to .93) .96 (.92 to .97) R e l a t i o n s h i p Inventory (Empathy s u b s c a l e ) .81 C o u n s e l o r R a t i n g Form E x p e r t n e s s A t t r a c t i v e n e s s T r u s t w o r t h i n e s s .84 .80 .82 H e l p i n g A l l i a n c e Q u e s t i o n n a i r e HA HA Type Type .84 71 N/A .88 .61 1 The median f i g u r e and the range a re r e p o r t e d fo r the repeated measures . 183 Tab le 22 ( C o n t ' d . ) Outcome Measures Targe t C o m p l a i n t s Symptom C h e c k l i s t - 9 0 S o m a t i z a t i o n O b s e s s i v e - C o m p u l s i v e I n t e r p e r s o n a l S e n s i t i v i t y D e p r e s s i o n A n x i e t y H o s t i l i t y Phobic A n x i e t y P a r a n o i d I d e a t i o n Psychot i c ism S e l f - E s t e e m Index H o y t ' s C o e f f i c i e n t C r o n b a c h ' s A lpha N/A ,81 / .84 81 / . 86 ,75 / .82 ,85 / .86 ,77 / .86 ,66 / .58 ,64 / .84 ,65 / .82 ,75/ .81 ,90 / .87 N/A , 94 / .95 Inventory of I n t e r p e r s o n a l Problems Hard to be In t imate . 7 8 / . 8 3 Hard to be A s s e r t i v e . 8 7 / . 9 0 Hard to be Independent . 7 5 / . 7 5 Hard to be S o c i a b l e . 8 7 / . 8 9 Hard to f e e l S e l f - W o r t h . 5 7 / . 4 8 Hard to be S u p p o r t i v e . 7 0 / . 6 0 Hard to be A g g r e s s i v e . 6 7 / . 7 4 Too G i v i n g . 7 0 / . 8 0 Too A g g r e s s i v e . 8 5 / . 8 3 Too H y p e r s e n s i t i v e .81/ .91 Too Eager to P l e a s e . 7 5 / . 8 6 Too Dependent . 8 8 / . 8 3 S t rupp P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .25 Change .62 Adjustment .74 S . D . .69 .72 .82 T h e r a p i s t P o s t t h e r a p y Q u e s t i o n n a i r e S a t i s f a c t i o n .66 .89 Change .85 .78 Adjustment .87 .90 8 7 / . 8 7 S . D . 70 .58 77 .74 2 P r e t e s t / p o s t t e s t c o e f f i c i e n t s . 3 Means are not r e p o r t e d f o r the number of p o s s i b l e r e s p o n s e s ins t ruments a n d , hence , i tem s u b s c a l e s c o r e s were computed. SPQ and fo r the TPQ because the per i tem v a r i e d on these s c o r e s were s t a n d a r d i z e d b e f o r e 184 APPENDIX 24 - DEMOGRAPHIC ANALYSIS OF THE SAMPLE T h e r a p i s t s : In order to d e s c r i b e the sample , the t h e r a p i s t s have been c a t e g o r i z e d in v a r i o u s ways from the demographic da ta tha t they p r o v i d e d at the end of t h e i r engagements (Appendix 18) . These c a t e g o r i z a t i o n s are p r e s e n t e d in T a b l e 23. T a b l e 23 - C a t e g o r i z a t i o n of T h e r a p i s t s P r o f e s s i o n a l a f f i l i a t i o n R e g i s t e r e d P s y c h o l o g i s t s 2 U n r e g i s t e r e d P s y c h o l o g i s t s 1 S o c i a l Workers 9 C o u n s e l l o r s 23 H i g h e s t degree completed P h . D . 3 M.S.W. 5 B .S .W. 4 M . A . / M . E d . 17 B . A . 6 E x p e r i e n c e as a t h e r a p i s t More than 15 years 3 11-15 y e a r s 6 6-10 y e a r s 7 1-5 y e a r s 18 L e s s than 1 year 1 T h e o r e t i c a l o r i e n t a t i o n A n a l y t i c 1 4 (wi th t h i s c l i e n t ) L e a r n i n g 3 Humanis t ic 37 Gender Female 21 Male 14 1 G e l s o and C a r t e r (1985) have d e f i n e d the th ree o r i e n t a t i o n s as f o l l o w s : A n a l y t i c : Approaches tha t p l a c e a premium on making the u n c o n s c i o u s c o n s c i o u s and that at l e a s t use F r e u d i a n p e r s o n a l i t y t h e o r y as a b a s i c s t a r t i n g p o i n t . L e a r n i n g : Approaches based on or h i g h l y c o m p a t i b l e w i th p r i n c i p l e s of c l a s s i c a l or i n s t r u m e n t a l c o n d i t i o n i n g , and , most r e c e n t l y , c o g n i t i v e m e d i a t i o n a l p r o c e s s . H u m a n i s t i c : The p e r s p e c t i v e tha t pays g r e a t e s t a t t e n t i o n to the c l i e n t ' s (and the t h e r a p i s t ' s ) "here-and-now" f u n c t i o n i n g , to the c l i e n t ' s i n h e r e n t t r u s t w o r t h i n e s s and c a p a c i t y f o r a c t u a l i z a t i o n . (pp. 196-197) 185 C l i e n t s : The c l i e n t s have a l s o been c a t e g o r i z e d in v a r i o u s ways as p r e s e n t e d in T a b l e 24 from the data they p r o v i d e d at the b e g i n n i n g of t h e i r t h e r a p i e s (Appendix 5 ) . T a b l e 24 - C a t e g o r i z a t i o n of C l i e n t s Age 18-25 y e a r s 11 26-35 y e a r s 18 36-45 y e a r s 9 Over 45 y e a r s 6 Gender Female 29 Male 15 M a r i t a l S t a t u s S i n g l e 17 M a r r i e d 1 3 D i v o r c e d 14 E d u c a t i o n L e v e l Some h i g h s c h o o l 4 High s c h o o l g raduates 5 Some c o l l e g e 1 5 C o l l e g e graduates 10 Some graduate s t u d i e s 10 T h i r t y - t h r e e of the t h e r a p e u t i c dyads were same-gender , ( i . e . , c l i e n t and t h e r a p i s t both female or both m a l e ) , and 11 were c r o s s - g e n d e r . A l though p r e c i s e i n f o r m a t i o n was not c o l l e c t e d on the number of s e s s i o n s c o n s t i t u t i n g each c a s e , i t was e s t i m a t e d that they ranged from 6 to 25 s e s s i o n s and in d u r a t i o n from s i x weeks to seven months. The average number of s e s s i o n s per case was e s t i m a t e d to be 12. 186 APPENDIX 25 - ESTABLISHMENT OF THE ALLIANCE THROUGH EARLY SESSIONS It has been h y p o t h e s i z e d tha t the a l l i a n c e i s e s t a b l i s h e d by a p p r o x i m a t e l y the t h i r d to f i f t h s e s s i o n (Horvath & G r e e n b e r g , 1986). In o rder to t e s t t h i s h y p o t h e s i s , the f i r s t f i v e r e p e a t e d measures of the WAIc were c o r r e l a t e d w i th one a n o t h e r . The data p r e s e n t e d i n T a b l e 25 suggested tha t the a l l i a n c e d i d indeed become more s t a b l e from S e s s i o n 3 o n . Tab le 25 - I n t e r c o r r e l a t i o n s of the WAIc at the F i r s t F i v e S e s s i o n s S e s s i o n  #1 #2 #3 #4 #5 S e s s i o n 1 S e s s i o n 2 .71 S e s s i o n 3 .55 S e s s i o n 4 .61 S e s s i o n 5 .52 The p r e s e n t s t u d y , t h e r e f o r e , has employed as i t s measure of the a l l i a n c e the average of the t h i r d , f o u r t h , and f i f t h s e s s i o n measures . .78 .79 .86 .73 .80 .81 187 APPENDIX 26 - MAGNITUDE OF CHANGE ON THE OUTCOME MEASURES A n a l y s e s of the magnitude of change from p r e t e s t to p o s t t e s t on the Symptom C h e c k l i s t - 9 0 and the Inventory of  I n t e r p e r s o n a l Problems were per formed as repea ted measures ( i . e . , p r e t e s t and p o s t t e s t ) MANOVAs u s i n g S P S S : X . The r e s u l t s are p r e s e n t e d in T a b l e 26. 188 T a b l e 26 - Magnitude of Change on Symptom C h e c k l i s t - 9 0 and Inventory of I n t e r p e r s o n a l Problems N of Items Mean S . D. F 1 2 Symptom C h e c k l i s t - 9 0 Somat i z a t i o n - p r e - p o s t 12 9.03 5.68 8. 6. 46 50 8. 3 9 * * O b s e s s i v e - C o m p u l s i v e - p r e - p o s t 10 16.92 8.66 7. 6. 98 77 45. 5 4 * * * I n t e r p e r s o n a l S e n s i t i v i t y -- p r e - p o s t 9 13.90 8.88 6. 6. 95 42 26. 3 6 * * * Depress i o n - p r e - p o s t 1 3 25.53 1 2.78 1 1 . 8. 01 95 46. 8 7 * * * A n x i e t y - p r e - p o s t 10 1 3.53 8.43 7. 7. 30 48 19. 3 4 * * * H o s t i l i t y - p r e - p o s t 6 6.05 3.52 5. 4. 45 29 20. 7 3 * * * Phobic A n x i e t y - p r e - p o s t 7 3.45 2.15 4. 3. 06 36 6. 54* P a r a n o i d I d e a t i o n - p r e - p o s t 6 7.07 4.09 4. 4. 60 25 25. 1 3 * * * P s y c h o t i c i s m - p r e - p o s t 1 0 8.75 4.56 6. 6. 99 12 21 . 3 4 * * * SCL-90 T o t a l - p r e - p o s t 90 114.50 64.82 54. 50. 26 30 3 4. g O * * * 1 U n i v a r i a t e F - t e s t s are r e p o r t e d f o r the s u b s c a l e s . H o t e l l i n g s (1951) m u l t i v a r i a t e t e s t of s i g n i f i c a n c e i s r e p o r t e d f o r the s c a l e t o t a l s . 2 The s t a n d a r d e r r o r of the p a i r d i f f e r e n c e , ( i . e . , the p o o l e d w i t h i n - g r o u p s S . D . d i v i d e d by the square root of n ) , was employed in computing the F - v a l u e . 3 The mean t o t a l pa tho logy p r e s c o r e of 1.27 (S .D.= .60) i s a lmost i d e n t i c a l to the p r e s c o r e of 1.25 ( S . D . = .3.9) r e p o r t e d by D e r o g a t i s , R i c k e l s , and Rock (1976) i n t h e i r v a l i d a t i o n s tudy of the S C L - 9 0 . 189 T a b l e 26 ( C o n t ' d . ) N of Items Mean S . D . F Inventory of I n t e r p e r s o n a l Problems Hard to be I n t i m a t e - p r e 1 1 15 .28 8. 00 - p o s t 10 .61 7. 18 25. 3g*** Hard to be A s s e r t i v e - p r e 17 36 .31 1 1 . 83 - p o s t 30 .70 13. 57 15. 1 g * * * Hard to be Independent -pre 9 16 .66 6. 44 - p o s t • 1 3 .09 5. 89 21 . 3 ^ *** Hard to be S o c i a b l e - p r e 1 1 40 .98 8. 12 - p o s t 12 .01 8. 39 1 1 48. 4 8 * * * Hard to f e e l S e l f - W o r t h - p r e 6 9 .80 4. 91 - p o s t 8 .31 3. 98 6. 39* Hard to be S u p p o r t i v e - p r e 1 1 13 .34 6. 60 - p o s t 9 .97 6. 58 17. 74*** Hard to be A g g r e s s i v e - p r e 5 10 . 1 5 4. 15 - p o s t 8 .77 4. 87 6. 49* Too G i v i n g - p r e 6 7 .91 4. 65 - p o s t 6 .99 4. 75 2. 86 Too A g g r e s s i v e - p r e 13 14 .88 8. 84 - p o s t 1 1 .72 8. 55 8. 57* * Too H y p e r s e n s i t i v e - p r e 10 17 .56 8. 53 - p o s t 1 4 .19 8. 94 13. 7 2 * * * Too Eager t o P l e a s e - p r e 10 18 .16 8. 94 - p o s t 1 5 .03 7. 58 10. 50* * Too Dependent -pre 9 1 5 .56 6. 45 - p o s t 12 .05 6. 52 17. 3 6 * * * T o t a l I l P - p r e 1 27 231 .51 67. 84 - p o s t 164 .68 72. 93 1 78. 37*** * S i g n i f i c a n t d i f f e r e n c e , pj^.05 * * S i g n i f i c a n t d i f f e r e n c e , p_^.0l * * * S i g n i f i c a n t d i f f e r e n c e , p_<.00l 

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