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Therapeutic relationship and its association with outcome Moseley, Douglas Charles 1983

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THE THERAPEUTIC RELATIONSHIP AND ITS ASSOCIATION WITH OUTCOME by DOUGLAS CHARLES MOSELEY B.A., U n i v e r s i t y Of A l b e r t a , 1978 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department Of 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 c o n f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1983 © Douglas C h a r l e s Moseley, 1983 In presenting t h i s thesis in p a r t i a l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t freely available for reference and study. I further agree that permission for extensive copying of t h i s 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 t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Counselling Psychology The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date: 25 A p r i l 1983 i i Abstract This study investigated the association between general re l a t i o n s h i p factors and outcome in short .term counselling. Twenty five c l i e n t s who were seeking counselling at various settings in the lower mainland of B r i t i s h Columbia completed instruments that were designed to quantify aspects of their r e l a t i o n s h i p with the therapist. Three models of the therapeutic r e l a t i o n s h i p were examined: Strong's s o c i a l influence theory; Roger's core conditions; and Bordin's working a l l i a n c e . It was hypothesized that the three dimensions of Bordin's Working Alliance (bond, task, and goal) would correlate s i g n i f i c a n t l y with four outcome measures. Two of the outcome measures u t i l i z e d did not correlate with any of the relationship variables. Task and Bond correlated s i g n i f i c a n t l y (p<.0l and p<.05 respectively) with two indices of outcome and Goal had a 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) with one of the outcome measures. Of the other four relationship variables that were included in t h i s study, only the s o c i a l influence variable of c l i e n t perceived counsellor attractiveness correlated with outcome measures beyond chance l e v e l s . i i i Tables of Contents Abstract i i L i s t of Tables iv Acknowledgement v Chapter I Introduction and Rationale 1 Background of the problem 1 Statement of the problem 4 Hypotheses 6 D e f i n i t i o n of terms 8 Significance of the study 10 Chapter II Review of the Literature 11 General vs. s p e c i f i c factors in counselling 11 Therapist-offered f a c i l i t a t i v e conditions 13 Social influence model 14 Working a l l i a n c e model 16 Contrast and comparison of the three models 19 Chapter III Methodology 21 Sample 21 Procedure 22 Data analysis 24 Instrumentation 25 State T r a i t Anxiety Inventory 25 Tennessee Self Concept Scale 26 Target Complaints 26 Relationship Inventory 27 Counselor Rating Form 28 Working A l l i a n c e Inventory.. 28 Strupp Posttherapy Questionnaire 29 Chapter IV Results 31 Client demographic c h a r a c t e r i s t i c s 31 Therapist demographic c h a r a c t e r i s t i c s 32 R e l i a b i l i t i e s of instruments 33 Relationship between predictor variables 38 Relationship between predictors and outcome measures 39 Chapter V Discussion 45 Summary and conclusions..... 45 Limitations and implications for future research 52 L i s t of References 55 Appendix A - Instructions to therapists and c l i e n t s 60 L i s t of Tables Table 4.1 Means, Standard Deviations, and R e l i a b i l i t i e s of the State T r a i t Anxiety Inventory 33 Table 4.2 Means, Standard Deviations, and R e l i a b i l i t i e s of the Tennessee Self Concept Scale (Total 'P') 34 Table 4.3 Mean, Standard Deviation, and R e l i a b i l i t y of the Strupp Posttherapy Composite Score 35 Table 4.4 Mean, Standard Deviation, and R e l i a b i l i t y of the Empathy Scale 36 Table 4.5 Means, Standard Deviations, and R e l i a b i l i t i e s of the Counselor Rating Form (CRF) 36 Table 4.6 Intercorrelation Coefficients of the CRF 36 Table 4.7 Means, Standard Deviations, and R e l i a b i l i t i e s of the Working All i a n c e Inventory (WAI) 37 Table 4.8 Intercorrelation C o e f f i c i e n t s of the WAI 37 Table 4.9 Relationships Between Predictor Measures 38 Table 4.10 Relationship Between Outcome and Predictor Variables 40 Table 4.11 Stepwise Regression Analysis: Strupp Composite 42 Table 4.12 Stepwise Regression Analysis: Target Complaints.... 42 Table 4.13 Relationship of Tr a i t Anxiety to Outcome 44 V Acknowledgement I would l i k e to thank my committee members for their contributions. In p a r t i c u l a r , Les Greenberg gave me personal support and helped to educate me about the process of producing a thesis. I would also l i k e to express my deepest appreciation to my wife, Diane, for her patience and loving support. 1 Chapter I_ Introduction and Rationale BACKGROUND OF THE PROBLEM Psychotherapy is a very complex phenomena and there are many unanswered questions concerning the process of c l i e n t change. Some theorists believe that therapeutic e f f e c t s are mainly the result of s p e c i f i c techniques employed by the therapist. Another group of theorists believe that the effects of therapy can be traced to certain general process factors that are e f f e c t i v e between c l i e n t and therapist over the course of treatment. 'Specific factor' approaches look for pa r t i c u l a r therapeutic techniques that can best account for therapeutic outcome. A large body of research in psychotherapy has been generated by proponents of various 'schools* of therapy each attempting to demonstrate that the techniques generated from their philosophy are best able to eff e c t therapeutic success This approach has been complicated by the fact that similar b e n e f i c i a l therapeutic gains have been associated with a great variety of therapeutic strategies each with i t s own set of techniques. Furthermore, in real l i f e counselling therapists w i l l often e c l e c t i c a l l y mix and modify a variety of therapeutic strategies to best suit their c l i e n t . It i s acknowledged that s p e c i f i c factor research can contribute a great deal to an understanding of psychotherapy but the fact remains that researchers have not successfully isolated these factors. 2 Psychotherapeutic change can also be conceptualized from a more global point of view where the focus i s on key factors that are common to therapeutic situations in general. These factors are thought to be inherent to a l l helping relationships. Whereas the s p e c i f i c factor approach tends to compare one form of therapy with another, the general factor approach focuses on the q u a l i t i e s of the psychotherapeutic relationship, in order to discover the means through which constructive therapeutic change occurs. The main problem in general factor research i s developing a systematic theory that adequately describes the process of helping. In the past two decades, several investigators have developed theoretical frameworks that emphasize general factors in the process of psychotherapy and t h i s study w i l l focus on three prevailing formulations. One of the best known counselling models was presented by Rogers (1957,1967). He postulated that three conditions -empathy, genuineness, and unconditional p o s i t i v e regard - were necessary and s u f f i c i e n t to produce therapeutic e f f e c t s . In other words, therapeutic change w i l l occur to the degree that the c l i e n t experiences these q u a l i t i e s in the therapist. Rogers work has stimulated a great deal of research in the l a s t three decades. In an extensive review of the l i t e r a t u r e , Gurman (1977) concluded that there i s a relationship between c l i e n t perceived therapeutic conditions and outcome in therapy. Strong's (1968) Social Influence model of psychotherapy has also stimulated a large body of research. This model stems from 3 attitude change research in s o c i a l psychology and e s s e n t i a l l y views psychotherapy as a an interpersonal attitude change process. The therapist i s likened to a communicator who has a discrepant message to convey to an audience. Extrapolating from the work of Hovland, Janis, and Kelly (1953), Strong postulated that the extent to which counsellors are perceived as a t t r a c t i v e , expert, and trustworthy, the less l i k e l y the c l i e n t w i l l be able to d i s c r e d i t the counsellor's message. More s p e c i f i c a l l y , Strong stated that c l i e n t s who perceive high leve l s of counsellor expertness, attractiveness and trustworthiness w i l l be more l i k e l y to react to counsellor influence attempts and thus to experience successful therapeutic outcomes. Another general factor t h e o r i s t , Bordin (1979), has reformulated the concept of the Therapeutic Working A l l i a n c e , which focuses on s p e c i f i c components of the r e l a t i o n s i p between therapist and c l i e n t . He suggests that any therapeutic relationship can be viewed in terms of three essential components: the personal bond between c l i e n t and therapist; a common understanding regarding the relevance of the tasks undertaken in therapy; and an agreeement on therapeutic goals . Each psychotherapeutic relationship w i l l d i f f e r somewhat in composition of bonds, tasks and goals but a l l successful therapies w i l l have a strong a l l i a n c e and thus outcome can be associated with these three dimensions. Each of the aforementioned models of therapy focus on the rela t i o n s h i p between c l i e n t and therapist as the basis for 4 therapeutic change. Bordin's Working A l l i a n c e conceptualization appears to offer a more comprehensive view of the psychotherapeutic relationship than those of Rogers or Strong. His model emcompasses an interactional component between c l i e n t and therapist whereas Rogers and Strong focus only on the q u a l i t i e s of the therapist. Furthermore, i t seems l o g i c a l l y evident that any productive relationship w i l l devote some consideration to the delineation of goals and the formulation of tasks which w i l l f a c i l i t a t e accomplishment of those goals. STATEMENT OF THE PROBLEM The aim of t h i s study i s to examine the relationship between the so-called general factors and therapeutic outcome. More s p e c i f i c a l l y , are the variables generated by the theories of Rogers, Strong, and Bordin correlated with outcome and i f so, which ones are most useful in predicting outcome variance? Can the variables from the Working All i a n c e model (Bond, Task, and Goal), which incorporate reciprocal aspects between therapist and c l i e n t , better account for outcome variance than the variables generated from the models of Rogers and Strong (Empathy, Attractivenss, Expertness, and Trustworthiness)? Part of this study w i l l attempt to replicate some of the findings reported by Horvath, 1 9 8 1 . As part of his study, Horvath examined the relationship of the seven aforementioned process variables to outcome. He reported that the Task dimension of the Working Alliance was correlated with the composite score of the outcome measure beyond chance leve l s at 5 the p<.05 l e v e l of significance. In order to more f u l l y explore the relationship between the general factors and outcome, he computed a multiple stepwise regression equation with the composite outcome measure as the dependent variable and general process measures as independent, (predictor) variables. He suggested that the Task component of the working a l l i a n c e might be the most e f f i c i e n t predictor of c l i e n t reported outcome in short term therapy. Goal and Attractiveness also entered the regression equation at the p<.05 l e v e l of significance after the ef f e c t s due to Task had been removed. Whereas Horvath's study used a c l i e n t perceived retrospective survey, the Strupp Posttherapy Questionnaire (Strupp, Wallach, & Wogan, 1964) to measure outcome, the present study w i l l more thoroughly explore the rel a t i o n s h i p between outcome and the general variables by u t i l i z i n g three additional measures of outcome: Target Complaints (Battle et. a l . , 1966); State T r a i t Anxiety Inventory (Spielberger et. a l . , 1970); and the Tennessee Self Concept Scale ( F i t t , 1965). The Target Complaints (TC) was used to get the c l i e n t ' s rating of improvement on concerns that he or she presented at the beginning of treatment. The Tennesse Self Concept Scale (TSC) and State T r a i t Anxiety Inventory (STAI) were administered twice in an attempt to measure change of 'state' anxiety and self concept over the course of therapeutic treatment. 6 HYPOTHESES In the hypotheses that follow, subheadings marked 'a' w i l l be r e p l i c a t i o n s of procedures in Horvath's study and 'b','c*, and 'd' w i l l be extentions of his research. Statements of s t a t i s i c a l significance w i l l assume the p<.05 le v e l unless quali f ied. 1. The f i r s t set of hypotheses i s concerned with the relationship between the variable of Task, as measured by the Working A l l i a n c e Inventory (Horvath, 1981) and therapeutic outcome: a. Task w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the Strupp Posttherapy Questionnaire (SPQ) composite score. b. Task w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the Target Complaints (TC). c. Task w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in state anxiety between posttest and pretest on the STAI. d. Task w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in se l f concept between posttest and pretest on the TSC. 7 2. The next set of hypotheses is concerned with the relat i o n s h i p between the variable of Goal, as measured by the WAI, and therapeutic outcome: a. Goal w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the SPQ composite score. b. Goal w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the TC. c. Goal w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in state anxiety between posttest and pretest on the STAI. d. Goal w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in self concept between posttest and pretest on the TSC. 3 . The last set of hypotheses is concerned with the relationship between the variable of Bond, as measured by the WAI, and therapeutic outcome: a. Bond w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the SPQ composite score. b. Bond w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the TC. c. Bond w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in state anxiety between posttest and pretest on the STAI. d. Bond w i l l correlate s i g n i f i c a n t l y with therapeutic outcome as measured by the residual change in self concept between posttest and pretest on the TSC. 8 In addition to these hypotheses t h i s study w i l l explore several research questions. What are the relationships between the predictor variables? How do the s o c i a l influence and core condition variables relate to outcome? How does pretherapy t r a i t anxiety relate with outcome? Which relationship variable is the most e f f i c i e n t predictor of outcome variance for each outcome measure and can any of the other predictors account for outcome variance after the e f f e c t s due to the primary predictor have been removed? DEFINITION OF TERMS Therapist: An individual who i s s k i l l e d in a method of treatment that is designed to a l l e v i a t e a c l i e n t ' s psychological stress. Therapists in t h i s study were eit h e r : doctoral l e v e l Psychologists; advanced Masters l e v e l students; or employed counsellors. C l i e n t : A nonpsychotic person over the age of 18 who i s undergoing treatment with a therapist to relieve psychological stress. Working A l l i a n c e : A close association between c l i e n t and therapist that i s formed to relieve the c l i e n t ' s psychological d i s t r e s s . Bordin's working a l l i a n c e consists of three functional components: personal bonds between c l i e n t and therapist; shared agreement on therapeutic goals; and shared understanding that the tasks demanded of each of them are reasonable and relevant to the c l i e n t ' s d i f f i c u l t i e s . 9 Empathy: Empathy i s defined as: 'The extent to which one person i s conscious of the immediate awareness of another ... It is an active process of desiring to know the f u l l present and changing awareness of another person, of reaching out to receive his communication and meaning that at least those aspects of his awareness that are most important to him at the moment. It i s an experiencing of the consciousness "behind" another's outward communication (Rogers et a l . , 1967, p.103). Perceived Expertness: Perceived expertness has been defined as the " c l i e n t ' s b e l i e f that the counsellor possesses information and means of interpreting information which allows the c l i e n t to obtain v a l i d conclusions about and to deal e f f e c t i v e l y with his or her problems" (Strong and Dixon, 1971, p.562). Perceived Attractiveness: A counsellor is perceived as at t r a c t i v e when the c l i e n t experiences l i k i n g , admiration and compatibility for him or her; desire for approval from him or her and desire to be more similar to him or her (Schmidt and Strong, 1971). Perceived Trustworthiness: A c l i e n t perceives a counsellor as trustworthy i f he believes him to be sincere, open and without motive for personal gain (Barak and Lacrosse, 1975). SIGNIFICANCE OF THE STUDY The general factor approach in psychotherapeutic research warrants closer examination. Recent studies have indicated that the interaction between c l i e n t and therapist in early treatment sessions may have predictive value for therapeutic outcome (Morgan et. a l . , 1982; Heppner and Heesacker, 1983). Bordin's Working A l l i a n c e model provides a framework for studying t h i s 1 0 interaction and offers variables that can be quantified. This study attempted to empirically examine Bordin's conceptualization. If a simple, empirical measure of the Working Alliance can be proven to be v a l i d , the implications are wide ranging. Most importantly, the process of psychotherapy would be better understood and outcome for any given therapeutic relationship could be predicted at an early stage of therapy regardless of the therapist's p a r t i c u l a r theoretical orientation. The Working All i a n c e model offers a more comprehensive view of the process of therapy; i t offers a way of conceptualizing the c l i e n t ' s input into the therapy whereas other general factor models focus on the therapist's contribution. If the findings from Horvath's study are supported, and the variables generated by the Working A l l i a n c e (bond,task, and goal) are important therapy prognosticators, therapists would be able to have early, e a s i l y obtained, information about the types of approaches that would increase of p r o b a b i l i t y of therapeutic gain for the c l i e n t . Programs for counsellor t r a i n i n g could also use this information to f a c i l i t a t e instruction of individuals who are planning to enter the helping profession. 11 Chapter 11  Review of the Literature GENERAL VERSUS SPECIFIC FACTORS IN PSYCHOTHERAPY Eysenck's (1952) often quoted challenge that psychotherapy may not be more e f f e c t i v e than chance remission has stimulated a large body of research on therapeutic outcomes. If one could draw a generalized finding from the therapeutic research that has been done, the most that one could say would be that a l l forms of psychotherapy are somewhat more e f f e c t i v e than no planned help (Frank, 1979; Smith and Glass, 1977). Assuming that t h i s reasonably established generalization i s true, the question arises as to which elements of therapy can most account for p o s i t i v e outcomes. One way to approach the question therapeutic effectiveness is to examine s p e c i f i c therapist behaviors or therapy situations and attempt to discover factors that are v i t a l to successful outcomes. Studies of this nature attempt to control for a l l the variables in the design except for the ones being examined . Often s p e c i f i c techniques from one therapeutic approach w i l l be compared to the techniques from other approaches. The major d i f f i c u l t y with the single factor appraoch i s that psychotherapy i s a complex phenomena and the task of i s o l a t i n g and measuring s p e c i f i c , independent variables in any given therapeutic approach can be an extremely d i f f i c u l t , i f not impossible, task. In order to prove the e f f i c a c y of a s p e c i f i c 1 2 psychotherapeutic technique, control procedures would have to be developed that would rule out nonspecific treatment effects such as expectancy for improvement or f a i t h in the ef f i c a c y of psychotherapy (Kazdin and Wilcoxin, 1976). Even i f a s p e c i f i c factor was determined, i t would not help to explain the findings that similar gains have resulted from a wide variety of therapeutic appraoches (Luborsky, Singer, & Luborsky, 1975; Smith and Glass, 1977). It may be that research methods and instruments currently being employed in outcome research are not yet refined enough, but the fact remains that there i s no conclusive evidence that s p e c i f i c therapeutic ingrediants can be causally linked to therapeutic change (Kazdin and Wilcoxin, 1976; Strupp and Hadley, 1979). A number of theorists have been working for a number of years on an alternative approach to psychotherapeutic research (Bordin, 1979; Frank, 1972; Rogers, 1951,1957; Strupp, 1978). Their aim i s to delineate common elements in therapeutic behaviors or situations and then attempt to li n k these factors with therapeutic outcomes. Using t h i s approach, researchers must f i r s t formulate a conceptual framework for psychotherapy that w i l l enable them to define the general variables that are expected to influence outcome. Once these variables have been defined and ways have been found to quantify them in the context of a variety of therapeutic settings, an attempt can be made to relate them to v a r i a b i l i t y in therapeutic success. A description of three such conceptualizations w i l l be presented in the next sections. 1 3 THERAPIST-OFFERED FACILITATIVE CONDITIONS Rogers (1951,1957) was one of the f i r s t theoreticians to present a conceptual framework for psychotherapy that incorporated general process variables which could be defined in functional terms. He stated that three conditions -empathy, genuineness, and unconditional positive regard were necessary and s u f f i c i e n t to produce constructive personality change. In th i s model, the therapist's primary task i s to provide an atmosphere where the c l i e n t can experience these core conditions. It i s assumed that each individual has the inherent capacity to move towards a state of psychological health and the primary r e s p o n s i b i l i t y for the di r e c t i o n of therapy i s placed on the c l i e n t . In the present study, empathy was chosen for examination because i t appeared to be the most studied and best understood of the core conditions. It has been shown that empathy i s strongly correlated with the other core conditions which suggests that a therapist who conveys empathy i s also expressing the other two conditions (Gurman, 1977; M i t c h e l l , Bozarth, and Krauft, 1977). In a review of 23 studies using c l i e n t perceived empathy as a process variable, Gurman (1977) reported that there was substantial evidence supporting the relationship between c l i e n t perceived core conditions and outcome. Rogers defined empathy as: "The a b i l i t y of the therapist (to) accurately and se n s i t i v e l y understand experiences and feelings and their meaning to the c l i e n t during the moment to moment encounter of psychotherapy...The a b i l i t y and s e n s i t i v i t y required to communicate these inner meanings back to the c l i e n t in a 1 4 way that allows these experiences to be ' h i s ( R o g e r s et. a l . , 1967, pp. 104-105). Empathy can measured from three points of view: the therapist's; the c l i e n t ' s ; and from that of an independent observer. L o g i c a l l y , i t seems evident that the c l i e n t i s ultimately the most competent judge of whether or not he or she experienced the empathy of the therapist. It follows from t h i s that the c l i e n t ' s experience of the therapeutic rel a t i o n s h i p w i l l be most c r u c i a l l y related to outcome. The Relationship Inventory (Rl), developed by Barrett-Lennard (1962), has been used to measure the c l i e n t ' s perception of the core condtions (Gurman, 1977). It consists of 64 items, 16 of which r e f l e c t the c l i e n t ' s experience of therapist empathy. The psychometric properties have been summarized by Gurman (1977) and found to be s a t i s f a c t o r y . SOCIAL INFLUENCE MODEL OF PSYCHOTHERAPY Jerome Frank (1961) was one of the f i r s t theoreticians to focus on the s o c i a l influence elements in the realm of psychotherapy when he wrote about the role of persuasion in widely divergent approaches to helping. He suggested that psychotherapy i s a process wherein the therapist exerts his s o c i a l l y derived influence or power to help the c l i e n t move towards psychological health. Goldstein (1966) elaborated on th i s theme by extrapolating research findings from s o c i a l psychology to counselling psychology. These findings suggested that a communicator's a b i l i t y to induce attitude change depended 1 5 on his capacity to convey c r e d i b i l i t y (expertness and trustworthiness) and attractiveness (Hovland, Janis & Kelly, 1953). Expanding on Goldstein's idea, Strong (1968) has developed a model of psychotherapy which hypothesizes that the therapist can be likened to an opinion changer and that his influence i s related to the c l i e n t ' s perception of his or her attractiveness, expertness, and trustworthiness. He suggested that t h i s interpersonal influence process occurs in two phases. In the f i r s t phase the therapist establishes a power base with c l i e n t and in the second phase the counsellor draws on t h i s power base to help the c l i e n t change toward more constructive ways of thinking and acting. Once a c l i e n t has become involved in therapy, the p r o b a b i l i t y of therapeutic change w i l l be maximized when the therapist i s perceived as a t t r a c t i v e , expert, and trustworthy. In order to measure the s o c i a l influence variables suggested by Strong, Barak and LaCrosse (1975) have developed the Counselor Rating Form (CRF) which yields scores on each of the aforementioned three dimensions as perceived by the c l i e n t . Three therapists (each representing d i f f e r e n t therapeutic viewpoints) were rated on 36 bipolar scales and the subsequent factor analysis supported the hypothesis that the three dimensions could be measured. The r e l i a b i l i t y of the CRF has been supported in analog counselling studies (see Corrigan et. a l . , 1980 for a comprehensive review). LaCrosse (1980) used the CRF to test the effect of the 1 6 s o c i a l influence variables on psychotherapeutic outcome in a f i e l d setting with c l i e n t s at a drug abuse c l i n i c . In thi s study, the CRF and Goal Attainment Scaling (GAS) was used to obtain pre and postcounselling scores for 36 c l i e n t s who were seeking help with drug abuse problems. A regression analysis was done and i t was found the CRF variables accounted for 35% of the outcome variance as measured by GAS. Of the variables studied, i n i t i a l perceived expertness was the most powerful outcome predictor (accounting for 31% of the t o t a l outcome variance). Heppner and Heesacker (1983) examined the rel a t i o n s h i p between the s o c i a l influence variables and c l i e n t s a t i s f a c t i o n within real l i f e counselling. In t h i s study, 72 c l i e n t s at a university counselling centre completed the Counseling Evaluation Inventory (CEI) and the CRF after several weeks in therapy. The results indicated that c l i e n t perceptions of attractiveness, expertness, and trustworthiness were correlated with c l i e n t s a t i s f a c t i o n . In the subsequent regression analysis, expertness was the best predictor of the CEI scores. WORKING ALLIANCE MODEL Although the concept of the therapeutic working a l l i a n c e stems back to (Freud, 1913), i t has only been in recent years that researchers have attempted to u t i l i z e the concept to generate general process variables. Greenson (1965) was one of the f i r s t authors to suggest that the working a l l i a n c e was a quali t y that was crafted by the therapist, as opposed to an 17 accidental byproduct of the therapeutic relationship . He suggested that a mutually positive regard between c l i e n t and therapist i s an important component of the a l l i a n c e but i s not s u f f i c i e n t , in i t s e l f , to achieve the aims of therapy. The therapist must also be constantly attuned to the dyadic processes that are occuring with the c l i e n t and endeavor to ensure that he and the c l i e n t are working together in constructive ways to reach psychotherapeutic goals. In the l a s t few years, several investigators have attempted to relate the working a l l i a n c e to psychotherapeutic outcome (Luborsky, 1976; Strupp, 1974). These early investigations were limited by the lack of c l a r i t y in the d e f i n i t i o n of working a l l i a n c e and the subsequent d i f f i c u l t y in quantifying i t . A major e f f o r t to relate components of the therapeutic a l l i a n c e to outcome has been undertaken by members of the Penn Psychotherapy Project. In recent years t h i s group has been developing measures which u t i l i z e independent raters to quantify the helping a l l i a n c e concept. Two types of scales, based on c l i e n t s ' statements, have been developed: Type 1 refers to indications that the c l i e n t i s receiving help or experiencing a helpful attitude from the therapist and Type 2 refers to indications that the c l i e n t and therapist are working in a joint e f f o r t to help the c l i e n t . In a recent study (Morgan, Luborsky, Crits-Christoph, Curtis & Solomon, 1982), ten most improved and ten least improved c l i e n t s (of 73 in an outpatient c l i n i c ) who experienced at least 25 psychoanalytically oriented therapy sessions were 18 rated over four 20 minute intervals during sessions at the beginning and at the end of therapy. It was reported that s i g n i f i c a n t correlations (ranging from .44 to .58) were found between a l l i a n c e ratings and the outcome measures. Bordin (1976,1979) has also offered a promising d e f i n i t i o n of the working a l l i a n c e . He postulated that the a l l i a n c e in psychotherapy has three functioanl components: the personal bonds between c l i e n t and therapist; therapeutic goals that are formed by mutual agreement; and the development of tasks that are perceived by the c l i e n t to be relevant to his (her) d i f f i c u l t i e s . Bordin suggested that a l l successful therapies w i l l have strong a l l i a n c e s although the emphasis on the three factors w i l l vary depending on the pa r t i c u l a r therapeutic approach that i s being employed. If Bordin's view of the working a l l i a n c e i s v a l i d , i t should be possible to demonstrate a strong relationship between the three dimensions and psychotherapeutic outcome. Horvath (1981) has recently developed an instrument to measure the working a l l i a n c e as defined by Bordin. The Working Alliance Inventory (WAI) was developed on the basis of results from an analogue p i l o t study and a f i e l d study with real c l i e n t s . It consists of 36 bipolar items which give scores for each of the c l i e n t perceived dimensions of Bordin's working a l l i a n c e . Early indications were that the WAI appeared to have acceptable psychometric properties. Horvath also examined the relationship of the Working 19 A l l i a n c e to outcome. In that study, the WAI along with the CRF (LaCrosse, 1977) and the RI (Barrett-Lennard, 1962) were administered in the t h i r d session to real l i f e c l i e n t s who were p a r t i c i p a t i n g in a variety of therapies in the lower mainland of B r i t i s h Columbia. A retrospective outcome measure was completed after ten sessions and i t was reported that the Task dimension of the Working Alliance correlated s i g n i f i c a n t l y with most of the outcome scales while Bond and Goal correlated with some of the outcome indicators. Horvath also did a multiple regression analysis using the general process variables of Empathy, Trustworthiness, Expertness, Attractiveness, Bond, Task, and Goal to predict therapeutic outcome. The results of his analysis suggested that the Task variable of Bordin's model may be the most e f f i c i e n t therapy outcome prognosticator. COMPARISON AND CONTRAST BETWEEN THE CONCEPTS OF THE WORKING ALLIANCE, THERAPIST-OFFERED FACILITATIVE CONDITIONS, AND SOCIAL INFLUENCE THEORY The aforementioned conceptualizations a l l agree that there are general factors in psychotherapy and that the q u a l i t i e s of the r e l a t i o n s h i p between c l i e n t and therapist are related to outcomes. The Rogerian approach assumes that c l i e n t change is i n i t i a t e d by being exposed to a therapist with the q u a l i t i e s of empathy, genuineness, and unconditional positive regard. Strong's conceptualization assumes that c l i e n t s change because of the therapist's influence or power - the power base being 20 established by the c l i e n t ' s perception of the therapist's trustworthiness, attractiveness, and expertness. Bordin suggests that potential c l i e n t change i s maximized when there i s a good ' f i t ' between the c l i e n t , therapist, and the nature of the tasks that both c l i e n t and counsellor believe to be appropriate to the goals that are decided upon in therapy. Rogers and Strong focus on q u a l i t i e s offered by the therapist whereas Bordin's working a l l i a n c e emphasizes the interaction between c l i e n t and therapist. The salient q u a l i t i e s offered by the therapists are d i f f e r e n t in Rogers' and Strong's models. In Roger's model the therapist's role is to be without roles; he is nonjudgemental and demonstrates unconditional acceptance. He functions, e s s e n t i a l l y , to provided an environment wherein the c l i e n t i s able to explore aspects of his personal world that are now either denied or distorted. In Strong's model, the therapist establishes a d e f i n i t e role in order to create an influence base to help the c l i e n t change maladaptive attitudes and actions. Outcome depends on how well the therapist i s able to convey trustworthiness, expertness and attractiveness. Bordin's model does not specify the necessity of any p a r t i c u l a r role for the therapist. It i s assumed that d i f f e r e n t therapeutic situations w i l l place d i f f e r e n t demands on c l i e n t and therapist. Regardless of these differences, however, the common elements of bond, task, and goal must exist i f therapy i s to be e f f e c t i v e . 21 Chapter III  Methodology SAMPLE The sample for this study was drawn from a population of c l i e n t s , eighteen years or older, who were seeking i n d i v i d u a l , verbally oriented, short term psychotherapeutic help in the lower mainland of B r i t i s h Columbia. C l i e n t s who were currently using prescribed psychoactive medications were excluded from the study. The researcher approached agencies and ind i v i d u a l counsellors in the Lower Mainland of B r i t i s h Columbia to ask for their cooperation with the study. Therapists were given general information about the study and i t s requirements but did not receive p a r t i c u l a r s about the hypotheses. Those therapists who were w i l l i n g to cooperate were asked to approach new c l i e n t s in the f i r s t session and s o l i c i t t heir p a r t i c i p a t i o n in the study. If the c l i e n t agreed to p a r t i c i p a t e , he or she was asked by the therapist to f i l l out the f i r s t battery of instruments immediately after the f i r s t session. Participants were assured of anonymity and advised of their right to withdraw at any time without jeopardizing treatment. They were told that the purpose of the study was to examine the therapeutic r e l a t i o n s h i p but no information was given about the process variables that were be measured. A participant's data was not included in the analysis i f they discontinued therapy before the seventh session. If the 22 c l i e n t was s t i l l in treatment after fourteen sessions, the posttest was administered after that session. Samples of the instructions to the therapist and information given to the c l i e n t are included in Appendix A. PROCEDURE This study had three data c o l l e c t i o n points. When therapy began the c l i e n t was asked to complete a battery of pretest questionnaires . This battery consisted of: Spielberger State T r a i t Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970); Tennessee Self Concept Scale ( F i t t , 1965); and Target Complaints (Battle, Imber, Hoehn-Saric, Stone, Nash, & Frank, 1966). The f i r s t two questionnaires were selected on the basis of the assumption that state anxiety and se l f concept would be expected to change as the c l i e n t progressed in psychotherapy. The Target Complaints was administered so that a record of the concerns that the c l i e n t hoped to resolve would be available at the end of therapy. Immediately after the t h i r d session, the c l i e n t s were asked to complete a second battery of tests which were selected to measure the relationship variables that were included in t h i s study. This battery consisted of: the Relationship Inventory (Barrett-Lennard, 1962); the Counselor Rating Form (Barak and LaCrosse, 1975); and the Working A l l i a n c e Inventory (Horvath, 1981). After termination of therapy or the fourteenth session, whichever came f i r s t , t he.clients were asked to f i l l out the 23 same battery of tests given out in the pretest situation plus two additional instruments. The Strupp Posttherapy Questionnaire (Strupp, Wallach, and Wogan, 1964) is a posttherapy evaluation instrument that i s designed to measure c l i e n t perceived change. A scale for the Target Complaints was also included so that c l i e n t s could rate improvement on concerns that they had presented at the beginning of treatment. A l l the materials were completed pr i v a t e l y and sealed in individual envelopes for return to the investigator. C l i e n t s were advfsed that their therapists did not have access to their responses on the questionnaires. Following i s a summary of tests administered in each session: Session 1 Pretest Anxiety Inventory Tennessee Self Con. Target Complaints Session 3 Relationship Measures Relationship Inventory -Empathy Counselor Rating Form -Expertness -Trustworthiness -Attractiveness Working Al l i a n c e In. -Bond -Task -Goal Last or Session 14 Postest Anxiety Inventory Tennessee Self Con. Target Complaints Strupp Posttherapy 24 DATA ANALYSIS In th i s study, two types of therapy outcome measures were u t i l i z e d . Self concept and state anxiety were measured twice, pre and post therapy. Changes in scores were treated as indices of therapeutic outcome. In order to eliminate the s t a t i s t i c a l dependence of the raw change scores on the pretest scores for any given c l i e n t , residual gain scores were calculated for each of these t r a i t s (Linn and Slinde, 1977). Residualizing the gain scores has the effect of i d e n t i f y i n g individuals whose scores changed more than expected. The other type of outcome measures yielded a single score which represented the the c l i e n t ' s view of treatment effectiveness at posttest. The general relationship variables that were measured after the t h i r d session (empathy, expertness, attractiveness, trustworthiness, bond, task and goal) were correlated with each of the therapeutic outcome measures yi e l d i n g Pearson's product-moment co r r e l a t i o n c o e f f i c i e n t s . In addition, stepwise multiple regression equations were calculated using the seven r e l a t i o n s h i p measures as independent (predictor) variables and the outcome measures as dependent variables. In t h i s type of procedure, the independent variable with the highest zero order c o r r e l a t i o n with the dependent variable i s entered into the regression on the f i r s t step. If any of the other predictors can account for a ' s i g n i f i c a n t ' portion of the variance of the dependent variable after the ef f e c t s due to the f i r s t variable i s removed, the next most e f f i c i e n t predictor is entered into the equation. This process 25 is repeated u n t i l none of the remaining predictors can account for s i g n i f i c a n t , unique outcome variance. INSTRUMENTATION State-Trait Anxiety Inventory (STAI) The STAI purports to measure two types of anxiety (Spielberger, Gorsuch, Lushene, 1970). The f i r s t twenty items assess 'state' anxiety which i s viewed as changing with the immediate condition of perceived tension. The second twenty items measure ' t r a i t ' anxiety which is considered to be a more stable condition of anxiety proneness that tends to be c h a r a c t e r i s t i c of the i n d i v i d u a l . Each item has four response options and items were coded so that high scores represent greater lev e l s of anxiety. Scores range from a minimum of 20 to a maximum of 80 on both scales. In the STAI manual, test - r e t e s t r e l i a b i l i t i e s for state and t r a i t anxiety are reported separately for males and females. Over an one hour i n t e r v a l , r e l i a b i l i t y c o e f f i c i e n t s were quoted as .33 (males) and .16 (females) for state, and .84 and .76 respectively for t r a i t . At twenty days, c o e f f i c i e n t s were .54 and .27 for state verses .86 and .76 for t r a i t . After 104 days r e l i a b i l i t i e s were .33 and .31 for state and .73 and .77 for t r a i t . Construct v a l i d i t y for t r a i t scores were obtained by c o r r e l a t i n g t r a i t scores with the IPAT Anxiety Scale, Manifest Anxiety Scale and Affect Adjective Checklist. The c o e f f i c i e n t s for a group of 125 college women were .75, .80, and .52 26 respectively (Spielberger et. a l . , 1970). Tennessee Self Concept Questionnaire (TSC) The TSC (Fitt,l965) i s a widely used, 100 item test which purports to measure a person's image of s e l f . According to the test's author, the 'Total Positive' scale is the most important single indicator of o v e r a l l self esteem in the test. This scale i s made up of ninety 5-point items. People with low scores have doubts about their self worthiness and tend to be anxious, depressed, and unhappy. High scorers l i k e themselves and are confident of their own value and worth. In the manual the author reports t e s t - r e t e s t r e l i a b i l i t i e s of .88 and .92 for the 'Total P' scale. In order to demonstrate construct v a l i d i t y of his instrument, F i t t reports that the TSC subscales correlate with MMPI subscales in ways that one would expect. No data i s presented in the manual to support t h i s statement. Target Complaints (TC) Target Complaints (Battle et a l . , 1966) was included in the f i r s t battery of tests so that the c l i e n t was able to specify from one to three concerns that he or she hoped to resolve during counselling. In the post test battery, a copy of their o r i g i n a l concerns was returned to the c l i e n t along with a 5-point scale on which the c l i e n t was asked to rate the amount of change for each concern. Options available were: Worse; No Change; A L i t t l e Better; Somewhat Better; and A Lot Better 27 (scored 1-5). Scores were summed and then divided by the number of target complaints rated in order to generate an index of outcome. In order to test the v a l i d i t y of the TC, Battle et a l . (1966) compared mean TC improvement scores with outcome scores from four other measures including: the Social Ineffectiveness Scale and Discomfort Scale (Stone, Frank, Nash, and Imber, 1961); the c l i e n t ' s o v e r a l l rating of outcome; and the therapist's rating of the patient's overa l l improvement. Although s p e c i f i c data was not included, the authors reported that the TC correlated s i g n i f i c a n t l y with a l l four measures. Relationship Inventory (RI) The RI (Barrett-Lennard, 1962) was designed to measure the c l i e n t ' s perception of the core conditions of therapy as formulated by Rogers (1957). This study used a shortened version which consisted of 64, 6-point bipolar items which generated four subscales (Empathy, Genuineness, Unconditional Positive Regard, and Respect). Only the Empathy subscale was used in the analysis. The scoring range for each item on the o r i g i n a l test form i s -3 to +3 (ranging from most negative to most posit i v e perceptions); in order to eliminate negative scores, the items were recoded from +1 to +6 with higher scores r e f l e c t i n g more posit i v e perceptions of the therapeutic r e l a t ionship. Gurman (1977, p.508) evaluated 14 studies of internal consistency r e l i a b i l i t y and 10 studies of test-retest 28 r e l i a b i l i t y and found that the mean internal r e l i a b i l i t y c o e f f i c i e n t for Empathy was .84. The mean test- r e t e s t c o e f f i c i e n t for Empathy was .83. These findings would seem to indicate that the c l i e n t ' s perceptions of the therapist's relationship q u a l i t i e s remain stable over time. Counselor Rating Form (CRF) The CRF (Barak and LaCrosse, 1975) consists of 36, 7-point items that r e f l e c t the three s o c i a l influence dimensions of counsellor behavior (expertness, attractiveness, and trustworthiness) as perceived by the c l i e n t . The range of scores on each dimension varies from 12 to 84 with high scores representing high influence on each dimension. Evidence for the instrument's v a l i d i t y i s based on the factor analysis done by the test authors. LaCrosse and Barak (1976) reported s p l i t - h a l f r e l i a b i l i t y c o e f f i c i e n t s of .87 for Expertness, .85 for attractiveness and .90 for trustworthiness. In that study, intercorrelations among the scales within each counsellor tended to be high but the authors concluded that the dimensions appeared to be unique enough to be of the o r e t i c a l and p r a c t i c a l use. 29 Working Alliance Inventory (WAI) The WAI (Horvath, 1981) was designed to measure the c l i e n t ' s perception of three functional components of the Working All i a n c e (bond,task, and goal) as conceptualized by Bordin (1979). The instrument used in t h i s study was a s l i g h t l y revised version and consisted of 36, 7-point bipolar itmes. The scores for each scale of WAI could range from 12 to 84 with high scores representing greater emphasis on that component. A composite was also calculated by t o t a l i n g a l l three scales. Validation of t h i s instrument i s s t i l l in the preliminary stages. The fact that Horvath's study was able to show that there was a rel a t i o n s h i p between the WAI (Composite and Task scales) and outcome i s c i t e d as supporting evidence of construct v a l i d i t y . The results of a multi t r a i t multi method matrix were interpreted as being supportive of the v a l i d i t y of the Goal scale. Horvath analyzed the scales for r e l i a b i l i t y using Hoyt's ANOVA procedure and reported c o e f f i c i e n t s of .85 for Bond, .88 for Task, .88 for Goal, and .93 'for the Composite score. Intercorrelations between the scales tended to be high which indicated that some of the scales are strongly i n t e r r e l a t e d Strupp Posttherapy Questionnaire (SPQ) The SPQ (Strupp et a l . , 1964) is a retrospective measure of the c l i e n t ' s perception of therapy. It consists of 23 items, 11 of which s o l i c i t the c l i e n t ' s reaction to therapy (questions 5,7,8,16,17a,17b,17c,18,19,20, and 22). The other 12 items were not included in the analysis. Items had 5 to 7 response 30 alternatives and were coded so that high scores re f l e c t e d greater change and s a t i s f a c t i o n with therapy. The Composite index of psychotherapeutic outcome was arrived at by t o t a l i n g the scores on the 11 items. The SPQ was included in the outcome battery for the following reasons: 1. One of the major aims of t h i s study was to replicate the findings of Horvath (1981) and t h i s instrument was the main measure of outcome in that study. 2. The c l i e n t ' s retrospective views of therapy should be included in an outcome research battery (Waskow and P a r l o f f , 1975) . 3. The v a l i d i t y of the SPQ has been supported by i t s high cor r e l a t i o n with other recognized outcome measurements (Cartwright et a l . , 1963). 31 Chapter IV Results CLIENT DEMOGRAPHIC CHARACTERISTICS Process and outcome data were returned from a t o t a l of 26 c l i e n t s . One subject-client was excluded from the study when the experimenter was advised by the subject's therapist that the c l i e n t had been coming to therapy as part of a requirement for receiving other a i d . It was decided that t h i s subject did not meet the d e f i n i t i o n of ' c l i e n t ' outlined in Chapter I. Of the remaining 25 subjects, the Target Complaints outcome measure was not completed by six c l i e n t s and three of these six submitted Strupp Posttherapy Questionnaires that were incomplete. The 25 subjects ranged from 23 to 53 years with mean age of 33.1. Females outnumbered males 19 to 6. Of the 24 c l i e n t s who responded to the question of marital status, eight were single; six were married; five were divorced; and five were separated. The majority of respondents were college graduates (13) or had one to three years of college experience (8); three categorized themselves as high school graduates. 32 THERAPIST DEMOGRAPHIC CHARACTERISTICS When more than one protocol was returned from a p a r t i c u l a r agency, there was no provisio to determine the exact number of therapists involved. In thi s s i t u a t i o n , a therapist may have contributed more than one c l i e n t and thus i t i s possible that the therapist's demographic data includes some duplications. Therapists came from a variety of settings in B r i t i s h Columbia representing the following agencies: Govt. Mental Health Centres 4 Drug and Alcohol C l i n i c s 4 University Counseling C l i n i c 2 University Psychiatric C l i n i c 3 Private Counseling Agencies 5 Private Practitioners 7 Educational level and experience of therapists was not col l e c t e d . Therapists were asked to categorize the predominant therapeutic orientation used with the c l i e n t in t h i s study and were given seven choices: Client Centred; Psychodynamic; Behavioral; Cognitive Behavioral; Gestalt; Rational Emotive; and Other. Those who checked only one orientation c l a s s i f i e d themselves as Gestalt (3), Client Centered (2), Cognitive Behavioral (2), Psychodynamic (1), and Rational Emotive (1). The remaining therapists (11) who responded checked two or more categories and a summary of their responses follows: Client Centered 8 Cognitive Behavioral 5 Rational Emotive 4 Behavioral 3 Psychodynamic 3 Transactional Analysis 1 33 RELIABILITIES OF MEASURING INSTRUMENTS Test r e l i a b i l i t y can be estimated by examining the internal consistency of the items. Internal consistency is an estimate of item homogeneity. In this study, internal consistency estimates of test subscales were calculated by using Hoyt's ANOVA procedure (Hoyt, 1941). An id e a l l y consistent scale, where every item i s accurately measuring the same desired construct, would have a Hoyt's value of 1.00. Estimates of the item homogeneity for the t o t a l instrument were obtained by cal c u l a t i n g Cronbach's Alpha (Cronbach, 1951). The corr e l a t i o n c o e f f i c i e n t s between subscales and summaries of the raw data w i l l be reported where pertinent. The outcome instruments w i l l be l i s t e d f i r s t followed by the predictor variable inventories. State T r a i t Anxiety Inventory (STAI) The r e l i a b i l i t y c o e f f i c i e n t s l i s t e d in Table 4.1 indicate Table 4.1 Means, Standard Deviations, & R e l i a b i l i t i e s of State T r a i t Anxiety Inventory N=25 Dimension I terns Mean S. .D. Hoyt Pre Post Pre Post Pre Post State 20 44. 2 39.2 13.2 11.0 .95 .94 T r a i t 20 47. 5 45. 1 10.1 9.7 .91 .91 that the subscales of 'state' and ' t r a i t ' anxiety were in t e r n a l l y consistent. The manual for thi s test (Spielberger et a l . , 1970), reports test retest r e l i a b i l i t i e s ranging from .73 34 to .86 for T r a i t . The magnitude of the State anxiety raw scores did, on the average, diminish over the course of therapy although the change was less than one half standard deviation. As expected, the T r a i t scores changed less, on the average, than the State scores. Tennessee Self Concept Scale (TSC) Only the 'Total P' was score used in t h i s study. The r e l i a b i l i t y c o e f f i c i e n t s for t h i s scale were consistently high at pre and post t e s t . In the manual for t h i s instrument, test retest r e l i a b i l i t i e s ranging from .88 to .92 are reported ( F i t t , 1965). The r e l i a b i l i t i e s l i s t e d in Table 4.2 indicate that the scale functioned as expected. Table 4.2 Means, Standard Deviations & R e l i a b i l i t i e s of The Total 'P' Scale N=25 Items Mean S.D. Hoyt Pre Post Pre Post Pre Post Total 'P' Score 90 320.2 332.4 39.2 35.3 .95 .94 The self concept raw score did on the average, increase moderately over the course of therapy. The change of means between pretest and posttest was approximately one t h i r d of a standard deviation. 35 Strupp Posttherapy Questionnaire (SPQ) As discussed in Chapter 3, a composite index of outcome was derived from the SPQ and the data i s l i s t e d in Table 4.3. Table 4.3 Mean, Standard Deviation & R e l i a b i l i t y of Strupp Composite Score N=22 Items Mean S.D. Hoyt Strupp Composite 11 43.5 5.9 .85 Score The Hoyt's ANOVA was .85 which suggests that the SPQ items tended toward homogeneity. The Target Complaints was also administered in the post test battery but due to the ind i v i d u a l i z e d nature of the items, r e l i a b i l i y c o e f f i c i e n t s were not calculated. Relationship Inventory (RI) Table 4.4 summarizes the raw score data for the RI and l i s t s a Hoyt's value of .87. It appears the items measuring Empathy were i n t e r n a l l y consistent. The r e l i a b i l i t y compares favorably with the test retest r e l i a b i l i t y of .83 for Empathy reported by Gurman (1977) after an analysis of ten studies using the RI. Table 4.4 Mean, Standard Deviation & R e l i a b i l i t y of the Empathy Scale N=25 Items Mean S.D. Hoyt Empathy 16 77.3 7.8 .87 Table 4.5 Means, Standard Deviations, & R e l i a b i l i t i e s of the Counselor Rating Form N=25 Dimension I terns Mean S.D. Hoyt Attract iveness 1 2 73.6 6.9 .87 Expertness 1 2 76.7 5.4 .88 Trustworthiness 1 2 78.2 5.4 .85 Table 4.6 Intercorrelation Coefficients of the CRF Dimensions N=25 Attract Expert Expert .71 Trust .77 .60 37 Counselor Rating Form (CRF) Table 4.5 presents the r e l i a b i l i t y c o e f f i c i e n t s for the three dimensions of the CRF and Table 4.6 contains the int e r c o r r e l a t i o n c o e f f i c i e n t s of the subscales. The Hoyt values obtained suggest that items measuring the subscales are int e r n a l l y consistent and are comparable with the s p l i t half r e l i a b i l i t i e s ranging from .85 to .90 reported by LaCrosse and Barak (1976). The correlation c o e f f i c i e n t s between the subscales suggest that the constructs of Attractiveness, Expertness, and Trustworthiness are int e r r e l a t e d . Working Alli a n c e Inventory (WAI) The r e l i a b i l i t y estimates and in t e r c o r r e l a t i o n c o e f f i c i e n t s for the WAI subscales are reported in Tables 4.7 and 4.8. Table 4.7 Means, Standard Deviations, & R e l i a b i l i t i e s the Working Alliance Inventory N=25 Dimension I terns Mean S.D. Hoyt Cronbach Bond Task Goal 12 12 12 36 69.6 68.6 67.3 205.5 10.1 9.8 11.1 28.9 .92 .92 .89 Composite .93 Table 4.8 Intercorrelation C o e f f i c i e n t s of the WAI Dimensions N=25 Task Bond Bond Goal .78 .92 .69 38 The Hoyt values indicated strong internal consistencies of items within subscales and are comparable to the r e l i a b i l i t i e s of the RI and CRF. For the c l i e n t form of the WAI, Horvath (1981) reported Hoyt values ranging from .85 to .88 and Cronbach's Alpha in his study was .93. The high values for Cronbach's Alpha suggest that these scales may be measuring strongly related underlying concepts. There apppears to be a p a r t i c u l a r l y strong overlap between the Goal and Task dimensions. RELATIONSHIP BETWEEN PREDICTOR MEASURES The correlations between the relationship variables used in th i s study are shown in Table 4.9 . With t h i s number of correlations, the 'significance' of single correlations must be interpreted with caution. Table 4.9 Relationship Between the Predictor Variables N=25 Empathy Attract Expert Trust Bond Task Goal Attract .76 Expert .63 .71 Trust .75 .77 .60 Bond .76 .73 .66 .72 Task .70 .65 .69 .53 .78 Goal .70 .59 .69 .41 .69 Anxiety 1 -.35 -.14 -.20 -.20 -.32 1 'Trait' Anxiety measured at pretest. 39 Taken one pair at a time, correlations above .35 would occur by chance alone five times out of a hundred (p<.05). Si m i l a r l y , correlations above .48 would be ' s i g n i f i c a n t ' at the p<.01 l e v e l correlations above .59 would be greater than chance expectation at the p<.0C)1 l e v e l of sig n i f i c a n c e . It can be seen that the subscales within the WAI are strongly correlated (ranging from .69 to .92) as i s the case with the subscales for the CRF (ranging from .63 to .76). The lowest correlations are between Trustworthiness and Task. The correlations between T r a i t anxiety at pretest and the relationship predictors are weaker than the correlations between the relationship variables but t r a i t anxiety might have a n o n t r i v i a l association with some of the predictors. In p a r t i c u l a r , t r a i t anxiety seems to have a strong negative cor r e l a t i o n with Task, Goal and Empathy. RELATIONSHIP BETWEEN OUTCOME AMD PREDICTOR MEASURES The correlations between the relationship variables and outcome measures are shown in Table 4.10. Once again a caveat regarding the i n t e r p r e t a b i l i t y of a large number of correlations from small sample must be made. Given the number of correlations in this matrix, i t would be expected that a number of ' s i g n i f i c a n t ' correlations would occur by chance alone. There does, however, appear to be a pattern of correlations that might be c l i n i c a l l y meaningful to explore and compare with 40 findings from a similar study previous study (Horvath, 1981). Table 4.10 Relationship Between Outcome and Predictor Variables N=25 'State' Anxiety Self Concept Target Strupp Residual Score Residual Score Complaints Composite N=25 N=25 N= 1 9 N=22 Empathy .06 -.15 .23 .27 Attract .10 -.03 .39* .52** Expert .20 -.19 .35 .31 Trust .23 -.16 .08 .22 Bond -.16 . 1 1 .51* .46* Task -.13 .21 .53** .50** Goal -.04 -.02 .33 .37* * p<.05 ** p<.0l The three sets of hypotheses, l i s t e d in Chapter 1, stated that the three Working All i a n c e dimensions w i l l correlate s i g n i f i c a n t l y , at the p<.05 l e v e l , with four outcome measures. In each set, subhypotheses 'a' attempted to repl i c a t e the findings of a study done by Horvath who used the Strupp Posttherapy Questionnaire (SPQ) to measure outcome. Subhypotheses 'b', 'c', and 'd' extend from 'a' and each pertains to additional indices of outcome included in thi s study: Target Complaints (TC), state anxiety change, and self concept change (respectively). In Table 4.10, i t can be seen that there were no s i g n i f i c a n t correlations between the predictor variables and the residual change scores on se l f concept or state anxiety. On the basis of t h i s data, the n u l l hypotheses cannot be rejected for each subhypotheses 'c' and *d' . 41 The f i r s t set of hypotheses stated that Task would correlate s i g n i f i c a n t l y at the p<.05 l e v e l with each of the outcome measures. The n u l l hypotheses for 1(a) and 1(b), Ho: r(xy)=0 were rejected in favour of the alternative hypotheses, H1: r(xy)*0 on the basis of the obtained correlations of correlations of .50 and .53 with the SPQ and the TC respectively. These correlations occured beyond chance at the p<.01 l e v e l . The correlation of .50 between Task and the SPQ composite score compares with the correlation of .57 reported by Horvath which was s i g n i f i c a n t at the p<.05 l e v e l . The second set of hypotheses stated that Goal would correlate s i g n i f i c a n t l y at p<.05 with the outcome measures. The n u l l hypothesis was rejected for 2(a) but the data f a i l s to lend support for rejection of the n u l l hypothesis for 2(b). In other words, Goal correlated s i g n i f i c a n t l y with the Strupp composite (.37) but not with Target Complaints (.33). Horvath reported a cor r e l a t i o n of .30 between Goal and SPQ composite which was not signicant. The t h i r d set of hypotheses stated that Bond would correlate s i g n i f i c a n t l y at the p<.05 level with the measures of outcome. The n u l l hypothesis for 3(a) and 3(b) were rejected in favour of the alternative hypothesis, H1: r(xy)*0. The cor r e l a t i o n of Bond with SPQ was .46 and with TC was .51. Horvath reported a correlation of .31 between Bond and the SPQ composite score which was not s i g n i f i c a n t . In order to explore the rel a t i o n s h i p between the relati o n s h i p factors and outcome, multiple stepwise regression 42 equations were calculated with the outcome measures as dependent variables. Since the zero order Pearson correlations between the relationship variables and the residualized change scores of anxiety and self concept were not s i g n i f i c a n t , multiple regression equations were not calculated for those two scores. The results for the SPQ and TC as dependent variables are summarized in Tables 4.11 and 4.12. Table 4.11 Stepwise Regression Analysis Dependent variable: Strupp Composite N=22 P. to enter=.05 R2=.27 F probability=.014 Variables Entered F r a t i o Attractiveness 7.3 Variables Remaining Empathy Expertness Trustworthiness Bond Task Goal P a r t i a l Correlation -.22 -.08 -.31 . 1 0 .26 . 1 1 T-prob .35 .74 .18 .65 .25 .62 Table 4.12 Stepwise Regression Analysis Dependent variable: Target Complaints N=1 9 P. to enter=.05 R2=.45 F probability=.007 Variables Entered F r a t i o Task Goal 6.8 6.8 Variables Remaining Empathy Attractiveness Expertness Trustworthiness Bond P a r t i a l Correlation -.14 .18 .06 -.35 .03 T-prob .59 .50 .81 . 1 6 .89 43 With the SPQ as the dependent variable, perceived Attractiveness was the most e f f i c i e n t predictor of outcome and accounted for 27% of the variance. After the variance due to Attractiveness was 'removed* no other rel a t i o n s h i p variable accounted for a s i g n i f i c a n t portion of the variance at the p<.05 l e v e l . Horvath found that Task was the most powerful predictor of outcome as measured by the SPQ. The second factor in that study was Goal. He also reported that Attractiveness contributed s i g n i f i c a n t l y to the explanation of SPQ variance after the variance due to Task and Goal had been removed. The multiple regression analysis for Target Complaints i s shown in Table 4.12. In th i s equation, the Task variable i s the most e f f i c i e n t predictor of c l i e n t reported outcome. The Goal dimension also contributed to prediction of the outcome measure after the variance due to Task had been removed. The underlying premise of this study has been that aspects of the c l i e n t and therapist interaction in early treatment are related to and perhaps can be used as a basis for prediction of psychotherapeutic outcome. It is also possible that pretreatment c l i e n t variables also have some r e l a t i o n to outcome. One of the pretreatment variables, ' t r a i t ' anxiety, was correlated with the outcome measures in order to v i s u a l l y compare the magnitude of the co r r e l a t i o n c o e f f i c i e n t s against those of the relat i o n s h i p variables with outcome. These correlations are presented in Table 4.13. 44 Table 4.13 Relationship of T r a i t Anxiety to Outcome Residualized Residualized Target Strupp 'State' Anxiety Self Concept Complaints Composite Change Score Change Score N=25 N=25 N=19 N=22 T r a i t Anxiety (at pretest) .19 -.22 -.31 -.27 Although there i s a trend toward an inverse relationship between anxiety and outcome, the magnitudes of the correla t i o n s , taking them one pair at a time, were not s i g n i f i c a n t at the p<.05 l e v e l . Chapter V Di scussion 45 SUMMARY AND CONCLUSIONS The main purpose of thi s study was to examine the relationship of Bordin's Working All i a n c e dimensions to psychotherapeutic outcome. In addition to Bond, Task, and Goal, four other so c a l l e d general process factors (Empathy, Attraction, Expertness, and Trustworthiness), generated by two di f f e r e n t conceptualizations of the therapeutic relat i o n s h i p , were examined with respect to four measures of therapeutic outcome. Hypothesis about the relationship between the Working Alli a n c e dimensions and outcome were formed on the basis of findings reported by Horvath (1981). Three sets of hypotheses were formulated. The f i r s t hypothesis in each set were formulated as attempts to rep l i c a t e findings from Horvath's study and concerned the relat i o n s h i p of the Working All i a n c e dimensions to outcome as measured by the Strupp Posttherapy Questionnaire composite score. The remaining hypotheses in each set pertained to the relationship of the Working All i a n c e dimensions with three additional indices of outcome: the Target Complaints; change on se l f concept over the course of treatment as measured by the Tennessee Self Concept Scale (TSC) and change of anxiety as measured by the State T r a i t Anxiety Inventory (STAI). Multiple stepwise regression equations were calculated with the outcome measures as the dependent variables and the seven rel a t i o n s h i p variables as 46 predictors. The major findings of the study were: 1. ) The Working All i a n c e dimensions did seem to relate to two measures of outcome in a way that might have c l i n i c a l s i g n i f i c a n c e . A) Strupp Posttherapy Questionnaire (SPQ) Using the SPQ as the outcome measure, i t was found that Task correlated s i g n i f i c a n t l y (p<.0l) with therapeutic outcome as did Bond and Goal (p<.05). B) Target Complaints (TC) Using the TC as the outcome measure, Task (p<.0l) and Bond (p<.05) correlated s i g n i f i c a n t l y with outcome. In the subsequent multiple regression analysis, outcome was best predicted by the Task dimension of the working a l l i a n c e which accounted for 28% of the variance. The Goal dimension also contributed to the prediction of outcome after the variance due to Task had been removed. Task and Goal together accounted for 46% of outcome variance. 2. ) Of the other relationship variables, only perceived Attractiveness correlated with measures of outcome beyond chance levels (p<.0l with SPQ and p<.05 with TC). When a multiple stepwise regression equation was calculated with the SPQ as the dependent variable, Attractiveness entered the equation as the 47 most e f f i c i e n t predictor of outcome, accounting for 27% of the variance. The co r r e l a t i o n c o e f f i c i e n t of Attractiveness with SPQ was .52 as compared with .50 with Task and i t appears as though these scales might account for an overlapping portion of the outcome variance. 3.) None of the relationship variables correlated s i g n i f i c a n t l y with outcome as measured by the residualized change scores on s e l f concept and state anxiety. In a study that correlated the same rel a t i o n s h i p variables with outcome, Horvath reported that the Task dimension had the strongest c o r r e l a t i o n with the SPQ composite score and was the best predictor of outcome variance on this measure. In the present study, the Task dimension was the only relationship variable to correlate with both the the SPQ and TC at the p<.0l l e v e l . It was also the most e f f i c i e n t predictor of outcome variance for the TC. The data in t h i s study, in conjunction with the findings reported by Horvath, provides evidence for the role of Task in therapy. It suggests that c l i e n t s who report, at an early stage of therapy, that the a c t i v i t i e s undertaken in therapy are appropriate and relevant to their problems w i l l be more l i k e l y to experience p o s i t i v e outcomes. If the c l i e n t understands c l e a r l y what is going on in therapy and has confidence that the tasks w i l l help him (or her) to achieve the therapeutic goals, therapeutic effectiveness w i l l be maximized. Goal correlated s i g n i f i c a n t l y (p<.05) with the SPQ and accounted for a s i g n i f i c a n t portion of the variance for the TC 48 a f t e r the e f f e c t s due t o Task had been removed. T h i s would seem t o i n d i c a t e t h a t the s u c c e s s f u l n e g o t i a t i o n of g o a l s i n the e a r l y s tage of t h e r a p y may a l s o enhance the p r o b a b i l i t y of s u c c e s s f u l outcome. H o r v a t h had a l s o r e p o r t e d t h a t Goal a c c o u n t e d f o r a s i g n i f i c a n t p o r t i o n of the SPQ v a r i a n c e a f t e r the e f f e c t s due t o Task were removed. Task and Goal seem t o c o - r e l a t e w i t h outcome. The c o r r e l a t i o n between th e s e d i m e n s i o n s i s v e r y s t r o n g (.93) which s u g g e s t s t h a t t h e s e two s c a l e s a r e t a p p i n g i n t o a s i n g l e u n d e r l y i n g component of the a l l i a n c e and, l o g i c a l l y , t h e s e c o n c e p t s a r e r e l a t e d . Once g o a l s have been e s t a b l i s h e d , the next s t e p i s t o d e l i n e a t e the t a s k s which must be performed i n o r d e r t o r e a c h the g o a l s . S i m i l a r l y , i t i s d i f f i c u l t t o f o r m u l a t e t a s k s w i t h o u t a t l e a s t i m p l i c i t r e f e r e n c e t o t h e g o a l s of t h e r a p y . These two v a r i a b l e s do not o v e r l a p c o m p l e t e l y however. In b o t h the r e g r e s s i o n a n a l y s i s done by H o r v a t h and the p r e s e n t s t u d y , Task and Goal a c c o u n t e d f o r s e p a r a t e a s p e c t s of outcome v a r i a n c e . I t may be t h a t t h e s e two s c a l e s a r e t a p p i n g i n t o two a s p e c t s or s t a g e s of a common u n d e r l y i n g p r o c e s s - l i t e r a l l y a 'working' a l l i a n c e . I f the t h e r a p i e s i n t h i s s tudy had been p r i m a r i l y problem s o l v i n g , b e h a v i o r a l l y o r i e n t e d t r e a t m e n t s , the importance of the Task and Goal d i m e n s i o n s would have been s e l f e v i d e n t . However i n t h i s study a wide spectrum of t h e r a p e u t i c approaches was r e p r e s e n t e d which i n d i c a t e s t h a t t h e s e d i m e n s i o n s a r e i m p o r t a n t a c r o s s approaches. The Bond dimens i o n of the Working A l l i a n c e had s i g n i f i c a n t c o r r e l a t i o n s (p<.05) w i t h both of the outcome measures. T h i s 49 would seem to indicate that the quality of the personal relationship between c l i e n t and therapist i s also p o s i t i v e l y related with outcome. Though Bond is highly correlated with Empathy (r=.76), the fact that Empathy did not correlate s i g n i f i c a n t l y with the outcome measures seems to indicate that Bond was more e f f e c t i v e in t h i s study at capturing the 'personal' component of the relationship. The scales of Bond and perceived Attractiveness are also related conceptually as i s evidenced by the c o r r e l a t i o n of .73 between the two scales. Both scales correlated s i g n i f i c a n t l y with two outcome measures but judging from the multiple regression analyses, i t appears as though Attractiveness might be better able to account for outcome variance of at least one measure. It i s interesting to speculate about the role of perceived Attractiveness in rel a t i o n to outcome. Even though Attractiveness had s i g n i f i c a n t l y contributed to outcome variance (as measured by the SPQ) in Horvath's study, the emergence of th i s variable in the present study as the best predictor of the SPQ was unexpected. In the f i e l d studies that have used the s o c i a l influence variables as predictors of outcome (LaCrosse, 1980; Heppner and Heesacker, 1983), perceived expertness has been found to be the best predictor of outcome v a r i a b i l i t y . In order to get a better understanding of the i n t e r r e l a t i o n between Attractiveness and outcome, the items contributing to the Attractiveness score were inspected. E s s e n t i a l l y the items can be grouped into three broad categories: warmth and 50 f r i e n d l i n e s s ; compatability and closeness; and enthusiasm. In other words, the findings for Attractiveness suggest that the c l i e n t s are more l i k e l y to experience positive outcomes when they report experiences of warmth, closeness, l i k i n g and enthusiasm. The c o r r e l a t i o n s of Task, Goal, Bond, and Attractiveness with outcome suggests that a 'successful' a l l i a n c e has two major aspects. One component consists of the 'working' a l l i a n c e where tasks and goals contribute to outcome. The importance of t h i s component was r e f l e c t e d by the data on the i n t e r r e l a t e d scales of Task and Goal. The other aspect consists of a 'therapeutic' a l l i a n c e where the personal relationship between the c l i e n t and therapist i s central to e f f e c t i v e psychotherapy (which was re f l e c t e d by the data on perceived Attractiveness and Bond). The fact that none of the predictors correlated with the outcomes based on change of anxiety and s e l f concept was perplexing. These outcome measures were incorporated into t h i s study in an attempt to navigate around the possible confounding e f f e c t that could occur when c l i e n t s d i r e c t l y rate both process and outcome. Inspection of the data revealed that anxiety decreased and s e l f concept increased for the majority of c l i e n t s . Eighteen subjects moved favorably on both these dimensions and three c l i e n t s either moved on only one scale or showed l i t t l e change for both. The c l i e n t s from two therapists (two c l i e n t s each) however appeared to deteriorate in that they showed a r e l a t i v e l y high increase in anxiety (average of 10 points or about one 51 standard deviation) and a corresponding decrease in self concept (average of 18 points or about one half of a standard deviation). When these four subjects were removed from the data, Task correlated s i g n i f i c a n t l y (p<.05) with both residualized change scores (the d i r e c t i o n with anxiety was inverse). Whatever happened with these four c l i e n t s i s unknown. It is possible that these two therapists were i n e f f e c t i v e in these situations or i t may be that factors outside of therapy precluded therapeutic gain during treatment. In any case i t i s interesting to note that i f the cases where obvious deterioration i s evident are eliminated, the Task dimension correlated s i g n i f i c a n t l y with a l l four measures of outcome. It could be that the Working Al l i a n c e model i s most applicable with c l i e n t s who, at the start of therapy, are amenable to therapeutic gain. Some recent research has focused on the role of pretreatment variables in psychotherapeutic treatment (Luborsky et. a l . , 1980; LaCrosse, 1980) and an a u x i l i a r y aim of this study was to explore relationship of pretreatment anxiety to outcome. It was found that the c l i e n t ' s i n i t i a l l e v e l of ' t r a i t ' anxiety had comparatively low correlations with the outcome measures, although i t appears that the d i r e c t i o n of the associations was consistently inverse i . e . the c l i e n t s with higher i n i t i a l anxiety tended towards lower outcome scores. A vi s u a l comparison of the correlations suggests that the relationship variables are more strongly correlated with outcome 52 than an individual difference variable such as anxiety. LIMITATIONS AND IMPLICATIONS FOR FUTURE RESEARCH Any conclusions drawn from a data base of n=25 must be considered tentative and statements about s t a t i s i c a l significance have been frequently q u a l i f i e d . Ideally, future studies concerning the therapeutic relationship should have a larger sample of c l i e n t s who are experiencing a wide variety of problems and treatment orientations. In addition, procedures should be available to obtain follow up scores. Aside from the size of the N, the major d i f f i c u l t y with th i s study i s the reliance on c l i e n t ratings for both relationship variables and outcome measures. For example, the c l i e n t who tends to rate a dimension of the therapeutic r e l a t i o n s h i p highly may also have tendencies to rate outcome in a p a r t i c u l a r way. Ideal ways to avoid t h i s problem would be to have nonparticipant judges rate the relationship dimensions and then attempt to correlate these scores to outcome or to have outcome rated by an independent observer. In t h i s study, the intention was to examine the c l i e n t ' s perception of the therapeutic relationship in a context of a variety of therapeutic orientations that are commonly available in the community. The only alternative would have been to have an independent observer rate outcome and, outside of the c l i n i c s i t u a t i o n , t h i s approach tends to be impractical. Future studies of t h i s nature might focus on ways of getting therapist ratings of outcome. 53 A number of i m p l i c i t assumtions were made in th i s study that might be questioned. It was assumed that the therapeutic relationship would be established by the t h i r d session. Strupp (1980) has suggested that the therapeutic relationship i s established by the end of the t h i r d session and evidence has been presented that the helping a l l i a n c e i s stable over treatment (Morgen et. a l . , 1982). However, at least one s o c i a l influence study has suggested that the relationship changes over the course of therapy (Heppner and Heesacker, 1982). This area needs further exploration. The findings from this study can only be generalizable to to short term therapies. It may be that the dynamics of therapeutic change are dif f e r e n t in long term therapy. For example, the Working Alliance dimensions could be c r i t i c a l to change in the e a r l i e r stages of therapy but other, more a f f e c t i v e , components of the relationship might become more dominent in r e l a t i o n to the therapeutic change in l a t e r stages. The use of c l i e n t s who agree to part i c i p a t e in a study such as this one, might also l i m i t the g e n e r a l i z a b i l i t y of these findings. Clients who agree to donate some time and e f f o r t to research may experience therapy d i f f e r e n t l y than c l i e n t s who would refuse to p a r t i c i p a t e . The findings of this study in conjunction with the results reported by Horvath (1981) support the usefulness of Bordin's Working Al l i a n c e model as a conceptualization of the c l i e n t change process in short term therapy. It also provided support 54 for the v a l i d i t y of the Working All i a n c e Inventory as a research instrument with c l i n i c a l u t i l i t y . 55 L i s t of References Barak, A. & LaCrosse, M.B. Multidimensional perception of counselor behavior. Journal of Counseling Psychology, 1975, 22, 471-476. Barrett-Lennard, G.T. Dimensions of therapist response as causal factors in therapeutic change. 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Psychotherapeutic A t t r a c t i o n . New York: Pergamon Press, 1971. Greenson, R.R. The working a l l i a n c e and the transference neurosis. The Psychoanalytic Quarterly, 1965, 34.' 155-181. Gurman, A.S. The patient's perception of the therapeutic rel a t i o n s h i p . In A.S. Gurman & A.M. Razin (Eds.), E f f e c t i v e Psychotherapy: A handbook of research. New York: Pergamon Press, 1977, 503-543. Heppner, P.P., and Heesacker, M. Interpersonal influence process in r e a l - l i f e counseling: Investigating c l i e n t perceptions, counselor experience l e v e l , and counselor power over time. Journal of Counseling Psychology, 1982, 29, 219-223. Heppner, P.P., and Heesacker, M. Perceived counselor c h a r a c t e r i s t i c s , c l i e n t expectations, and c l i e n t s a t i s f a c t i o n with counseling. Journal of Counseling  Psychology, 1983, 30, 31-39. Horvath, A. An exploratory study of the concept of therapeutic  a l l i a n c e and i t s measurement. Unpublished doctoral d i s s e r t a t i o n : University of B r i t i s h Columbia, 1981. 57 Hovland, C.I., Janis, I.L. & Kelley, H.H. Coummunicat ions and  persuasion: Psychological studies of opinion change. New Haven: Yale University Press, 1 9 5 3 . Hoyt, C L . Test r e l i a b i l i t y estimated by analysis of variance. Psychometika, 1 9 4 1 , 6, 1 5 3 - 1 6 0 . Kazdin, A.E., & Wilcoxin, L.A. Systematic desensitization and nonspecific treatment e f f e c t s : A methodological evaluation. Psychological B u l l e t i n , 1 9 7 6 , 8J3, 7 2 9 - 7 5 8 . Lacrosse, M.B. Comparative perceptions of counselor behavior: A r e p l i c a t i o n and extention. Journal of Counseling  Psychology, 1 9 7 7 , 24, 4 6 4 - 4 7 1 . LaCrosse, M.B. Perceived counselor s o c i a l influence and counseling outcomes: V a l i d i t y of the Counselor Rating Form. Journal of Counseling Psychology, 1 9 8 0 , 2 7 , 3 2 0 - 3 2 7 . LaCrosse, M.B., & Barak, A. D i f f e r e n t i a l perception of counselor behavior. Journal of Counseling Psychology, 1 9 7 6 , 2 3 , 1 7 0 - 1 7 2 . Linn, R.L., and Slinde, J.A. The determination of the significance of change between pre- and posttesting periods. Review of Educational Research, 1 9 7 7 , 47 1 2 1 - 1 5 0 . Luborsky, L. Helping a l l i a n c e s in psychotherapy. In J.L. Claghorn, (Ed.), Successful Psychotherapy. New York: Brunner/Mazel, 1 9 7 6 . Luborsky, L., Singer, B. & Luborsky, L. Comparative studies of psychotherapies: Is i t true that "Everybody Has Won and A l l Must Have Prizes"? Archives of General Psychiatry, 1 9 7 5 , 3 2 , 9 9 5 - 1 0 0 8 . Luborsky, L., Mintz, J., and Auerbach, A. Predicting the outcome of psychotherapy: Findings of the Penn Psychotherapy Project. Archives of General Psychiatry, 1 9 8 0 , 3 7 , 4 7 1 - 4 8 1 . 58 M i t c h e l l , K.M., Bozarth, J.D., & Krauft, C C . A reappraisal of the therapeutic effectiveness of accurate empathy, non-possessive warmth and genuineness. In A.S. Gurman and A.M. Razin (Eds.), E f f e c t i v e Psychotherapy: A handbook of research. New York: Pergamon Press, 1 9 7 7 , 4 8 2 - 5 0 2 . Morgan, R., Luborsky, L., Crits-Christoph, P., Curtis, H., Solomon, J. Predicting the outcomes of psychotherapy by the Penn Helping A l l i a n c e Rating Method. Archives of  General Psychiatry, 1 9 8 2 , 3 9 , 3 9 7 - 4 0 2 . Rogers, CR. Client Centered Therapy. Cambridge, Mass: Riverside Press, 1 9 5 1 . Rogers, CR. The necessary and s u f f i c i e n t conditions of therapeutic personality change. Journal of Consulting  Psychology, 1 9 5 7 , 2 2 , 9 5 - 1 0 3 . Rogers, CR., Gendlin, G.T., Kies l e r , D.V., & Truax, L.B. The  therapeutic relationship and i t s impact: A study of  psychotherapy with schizophrenics• Madison, Wisconsin: U n i v e r i s i t y of Wisconsin Press, 1 9 6 7 . Schmidt, L.D. & Strong, S.R. Attractiveness and influence in counseling. Journal of Counseling Psychology, 1 9 7 1 , 1 8 , 3 4 8 - 3 5 1 . — Smith, M.L. & Glass, G.V. Meta-analysis of psychotherapy outcome studies. American Psychologist, 1 9 7 7 , 3 2 , ( 9 ) , 7 5 2 - 7 6 0 . — Spielberger, CD., Gorsuch, R.L., & Lushene, R.E. Manual for the State-Trait Anxiety Inventory. Palo Alto, C a l i f o r n i a : Consulting Therapists Press, 1 9 7 0 . Strong, S.R. Counseling: An interpersonal influence process. Journal of Counseling Psychology, 1 9 6 8 , J_5, 2 1 5 - 2 2 4 . Strupp, H.H. On basic ingrediants of psychotherapy. Psychotherapy and Psychosomatics, 1 9 7 4 , _24, 2 4 9 - 2 6 0 . Strupp, H.H. Success and f a i l u r e in time-limited psychotherapy: A systematic comparison of two cases: Comparison 2 . Archives of General Psychiatry, 1 9 8 0 , 3J7, 7 0 8 - 7 1 6 . 59 Strupp, H.H., Wallach, M.S., & Wogan, M. Psychotherapy experience in retrospect: Questionnaire survey of former patients and their therapists. Psychological Monographs, 1964, 78, (Whole No. 588). Strupp, H.H., and Hadley, S.W. Specific verses nonspecific factors in psychotherapy. Archives of General Psychiatry, 1979, 36, 1125-1136. Waskow, I.E., and Pa r l o f f , M.B. (Eds.) Psychotherapy change  measures. Rockville, Md.: National Institute of Mental Health, 1975. 60 APPENDIX A - INSTRUCTIONS AND INFORMATION FOR THERAPISTS AND CLIENTS 61 Information about the T h e r a p e u t i c R e l a t i o n s h i p P r o j e c t This study i s designed t o generate i n f o r m a t i o n about the k i n d s of r e l a t i o n -s h i p s that help people s o l v e problems, change, or l e a r n about themselves. The i n f o r m a t i o n t h a t i s being gathered w i l l enable t h e r a p i s t s to develop more e f f e c t -i v e ways to f a c i l i t a t e change. Your c o o p e r a t i o n w i t h the r e s e a r c h p r o j e c t i s important and we would v e r y much a p p r e c i a t e having the b e n e f i t of your e x p e r i e n c e . I f you agree to p a r t i c i p a t e i n the study, you w i l l be asked t o f i l l out three q u e s t i o n n a i r e s . The f i r s t instrument w i l l take about 45 minutes t o complete. I n the next weeks, you w i l l be asked t o complete a s h o r t form and another ques-t i o n n a i r e r e q u i r i n g a p p r o x i m a t e l y 45 minutes. Your responses to the q u e s t i o n n a i r e w i l l be kept s t r i c t 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 a r e , n e i t h e r w i l l your t h e r a p i s t see your q u e s t i o n n a i r e . When t h i s study i s completed, i n d i v i d u a l d e b r i e f i n g w i l l be a v a i l a b l e and o v e r a l l f i n d i n g s w i l l be a c c e s s i b l e t o those who are i n t e r e s t e d . 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 h e l p i n g r e l a t i o n s h i p r e s e a r c h study. The na t u r e of t h i s r e s e a r c h has been e x p l a i n e d t o me and I understand t h a 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 informed t h a 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 n o t 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 w i s h to p a r t i c i p a t e i n t h i s study, I understand t h a t my d e c i -s i o n w i l l i n no way a f f e c t the standard 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 . I understand t h a t I am f r e e t o withdraw from t h i s study a t any time, and that my w i t h d r a w a l w i l l i n no way a f f e c t the standard of s e r v i c e I w i l l r e c e i v e . Signed_ Date Witness ( T h e r a p i s t ) 62 INSTRUCTIONS TO PARTICIPANTS IN THE PSYCHOTHERAPY RELATIONSHIP RESEARCH PROJECT This p r o j e c t i s designed to explore the d i f f e r e n t kinds of h e l p i n g r e l a t i o n s h i p s that develop i n counselling/psychotherapy. Your p a r t i c i p a t i o n i s v i t a l l y important to the p r o j e c t and your g e n e r o s i t y w i t h your time and energy i s much app r e c i a t e d . The procedure we are using i s designed to ensure complete c o n f i d e n t i a l i t y . Please f o l l o w the steps o u t l i n e d below: 1. Ask your c l i e n t to vo l u n t e e r to p a r t i c i p a t e i n the p r o j e c t . Read and e x p l a i n , i f necessary, the consent form. Have your c l i e n t s i g n the form and s i g n i t y o u r s e l f as witness. Place the consent form i n the sm a l l white envelope marked "consent" and m a i l i t to the re s e a r c h e r . 2. Open packet ' I ' and ad m i n i s t e r q u e s t i o n n a i r e s A,B, & D before the f i r s t s e s s i o n (should take about 25 minutes to f i l l o u t ) . I f time permits, administer questionnaire C (which takes about 30 minutes) before the f i r s t s e s s i o n as w e l l ; otherwise, please encourage your c l i e n t to complete 'C immediately a f t e r the i n t e r v i e w . A f t e r the c l i e n t has l e f t , please t r a n s f e r the data from questionnaire D onto the appropriate l i n e s of q u e s t i o n n a i r e L and put 'L' i n t o packet I I I so that i t w i l l be a v a i l a b l e f o r f u t u r e r e f e r e n c e . Please h o l d the completed questionnaires A,B,C, and D i n the ' : k i t " . 3. Make a note on your calendar to remind y o u r s e l f to ad m i n i s t e r packet ' I I ' a f t e r the t h i r d s e s s i o n . h. A f t e r the t h i r d i n t e r v i e w , ask the c l i e n t to complete the q u e s t i o n n a i r e s i n packet I I (E,F,G which w i l l take about 25 minutes). Please encourage your c l i e n t to f i l l them out r i g h t a f t e r the s e s s i o n . Have your c l i e n t s e a l these forms, plus the q u e s t i o n n a i r e s from the f i r s t s e s s i o n , i n t o the s e l f addressed envelope (marked packet I I ) and m a i l to res e a r c h e r . 5. Please make another note on your calendar to ad m i n i s t e r the forms i n packet ' I I I ' a f t e r the 14 th s e s s i o n . I f therapy terminates before 1'4 s e s s i o n s , administer t h i s packet a f t e r the l a s t s e s s i o n . 6. A f t e r the 14th or l a s t s e s s i o n , give your c l i e n t the q u e s t i o n n a i r e s marked 'PC' from packet I I I to f i l l out and s e a l i n the packet I I I envelope (takes about one hour). The t h e r a p i s t should f i l l out the q u e s t i o n n a i r e marked 'PT' from packet I I I . Place a l l the completed q u e s t i o n n a i r e s i n the l a r g e m a n i l l a envelope and r e t u r n i t to the researcher. 7. Should you have more than one c l i e n t p a r t i c i p a t i n g i n the p r o j e c t , please f o l l o w the complete procedure each time, using a new k i t . 8. Each q u e s t i o n n a i r e i n a gi v e n k i t has the same 3 d i g i t code so that the c l i e n t ' s responses can be kept together. To assure c o n f i d e n t i a l i t y , there i s no record of which c l i e n t r e c e i v e s which code. I f a c l i e n t wishes to r e c e i v e d e t a i l e d d e b r i e f i n g on h i s or her p a r t i c u l a r responses, they should be a d i v i s e d to record t h e i r code number and c a l l researcher at the number below a f t e r t e r m i n a t i o n of therapy. 9. Thankyou f o r your c o o p e r a t i o n ! I f you have any q u e s t i o n s , c a l l Doug Moseley at 

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