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An exploratory study of the working alliance : its measurement and relationship to therapy outcome Horvath, Adam O. 1981

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An E x p l o r a t o r y Study o f the working A l l i a n c e : I t s Measurement and R e l a t i o n s h i p to Therapy Outcome by Adam 0. Horvath B»A. S i r George Williams U n i v e r s i t y fl.S.W. .. M c G i l l U n i v e r s i t y A THESIS SOEMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION i n THE FACULTY OF GRADUATE STUDIES COUNSELLING PSYCHOLOGY We accept t h i s t h e s i s as conforming to the r e q u i r e d standard A p r i l , 1981 THE UNIVERSITY OF BRITISH COLUMBIA © A. ,0. florvath, 1981 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t 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 f r e e l y a v a i l a b l e 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 i s understood that copying or pu b l i c a t i o n 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 L n u ^ c e i f i u t ^ T g ^ c l o t o The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 K-6 .2/79} ABSTRACT i i Research supervisor: L.S. Greenberg The purpose of t h i s exploratory study was to develop a paper-and-penci1 inventory to measure the strength and qu a l i t y of the Therapeutic Working A l l i a n c e . This instrument, the Working All i a n c e Inventory (WAI), was based on the conceptualization of a Working All i a n c e developed by Bordin (1975,1976). According to Bordin, the Working All i a n c e has three components: Bond, Goal, and Task. The WAI was designed to tap the c l i e n t ' s and therapist's perceptions of these components of a therapeutic relationship after the t h i r d therapy interview. An item pool was developed for the WAI, based upon a survey of the l i t e r a t u r e . The items formulated were refined and c u l l e d on the basis of two successive ratings by groups of expert raters. Following these ratings, the WAI was p i l o t tested in an analog environment using graduate students in counselling psychology as subjects. F i n a l l y , the WAI along with two e x i s t i n g tests, the Counselor Rating Form (CRF) (LaCrosse, 1977) and the Relationship Inventory (R-I) (Barrett-Lennard, 1962), were administered to c l i e n t - t h e r a p i s t dyads representing a variety of theore t i c a l approaches to psychotherapy. Psychotherapy outcome was measured by adaptations of the Client Posttherapy Questionnaire (Strupp et a l . , 1964). i i i The results indicated that the WAI had adequate r e l i a b i l i t y , and evidence was gathered supporting the instrument's construct v a l i d i t y . The analysis of the data suggests that there i s a strong c o r r e l a t i o n a l r e l a t i o n s h i p between Empathy and the a l l i a n c e dimension of Bond, and a moderate rela t i o n s h i p between Empathy and Goal. The Task dimension was reasonably independent of Empathy. A l l of the WAI dimensions had low correlations with the concepts measured by the CRF. The c l i e n t reported Working Al l i a n c e Task dimension correlated s i g n i f i c a n t l y with s a t i s f a c t i o n , change, and composite outcome, while the Goal dimension correlated s i g n i f i c a n t l y with s a t i s f a c t i o n . A l l of the therapist reported a l l i a n c e dimensions correlated s i g n i f i c a n t l y with s a t i s f a c t i o n and change as well as the composite outcome score. Multiple regression analysis using a l l of the c l i e n t predictor variables (Empathy, Trustworthiness, Expertness, Attractiveness, Bond, Task, Goal) suggested that the Task scale of the WAI, which was designed to measure the perceived relevance of therapy events, may be the most e f f i c i e n t therapy outcome prognosticator of the variables investigated. The nature of the sample and the low subject-to-variable r a t i o in this research suggested that the study -must be replicated in order to more firmly e s t a b l i s h the s t a b i l i t y and g e n e r a l i z a b i l i t y of the findings. ACKNOWLEDGMENTS This di s s e r t a t i o n is dedicated to the twenty-nine individuals and their counsellors, who donated their time and energy and allowed me a glimpse into the private world of the relationship between therapist and c l i e n t . Their anonymity prevents me from expressing my gratitude personally. I can only hope that the small contribution t h i s research w i l l make to the science of psychotherapy w i l l be of some repayment for their e f f o r t . The research was supported in part by a B.C. Health Care Research grant. I wish to acknowledge their assistance and thank them for their confidence in the project. A d i s s e r t a t i o n is a product of a c o l l e c t i v e e f f o r t . As the doctoral candidate, only my name appears on the t i t l e ; I wish to express my indebtedness to the members of my d i s s e r t a t i o n committee (Drs. Allan, Marks and Rogers), each of whom contributed generously to the research from their own f i e l d of expertise. My p a r t i c u l a r appreciation goes to my research supervisor, Dr. Les Greenberg, not only for his i n t e l l e c t u a l stimulation and guidance, but also for his sense of perspective and humor. Throughout my work on this research, I have had the exceptional good fortune of being helped --substantively and emotionally-- by a distinguished group of friends. I wish to express my gratitude to Dr. O'Shea, Dr. Hoover, Dr. Newman, V Dr. G. Holmes, Dr. Bonny, Ted Truman and Sharon Mclnnis. To have discovered the quality of their friendship, in i t s e l f , would have made the work worthwhile. My greatest debt is to my wife Barbara for her fortitude and forbearance through the trying times. With those named and those omitted, I wish to share some of the c r e d i t ; the errors, of course, are mine. v i TABLE OF CONTENTS Abstract i i Acknowledgments iv Table of contents vi L i s t of tables xi Chapter I: Introduction and rationale 1 Background of the problem 1 Statement of the problem 4 Def i n i t i o n of terms 5 Chapter I I : Review of the l i t e r a t u r e 10 General versus s p e c i f i c factors in psychotherapy 10 The Therapist-Offered F a c i l i t a t i v e Conditions 14 Assessment of observed Empathy 17 Perceived Empathy 19 Social psychological approach to the therapy process: Interpersonal influence conceptualizations 22 The measurement of perceived s o c i a l influence dimensions . 23 The concept of Working All i a n c e 25 C l a s s i c a l analytic formulations 25 The revised c l a s s i c a l approach 27 The object relationship approach 28 Current extrapolations of the concept of Al l i a n c e ... 30 Comparisons and contrasts among the concepts of Working Al l i a n c e , Therapist-Offered F a c i l i t a t i v e Conditions, and Social Influence Theory 35 v i i Major differences between Therapist-Offered F a c i l i t a t i v e Conditions and Working All i a n c e 36 Major differences between Social Influence concepts and Working Alliance 37 Major s i m i l a r i t i e s among the concepts of Working Al l i a n c e , Social Influence, and Therapist-Offered F a c i l i t a t i v e Conditions 37 Chapter I I I : The development of the Working Al l i a n c e Inventory - - l o g i c a l analysis 38 Item generation 39 Rating of the item pool 41 Phase I construct validation 42 Instrumentation 42 Sample 43 Phase I rating results 43 Phase II construct val i d a t i o n 48 Instrumentation 48 Sampling 49 Phase II rating results 50 Analysis of phase II ratings 50 Chapter IV: The p i l o t study and the design of the c l i n i c a l study 56 Instrumentation 56 Working Alliance Inventory - - c l i e n t form (WAIc) 57 Working Alliance Inventory --therapist form (WAIt) .. 57 The Relationship Inventory (R-I) 58 Scoring of the R-I '. 59 v i i i Counselor Rating Form (CRF) 59 Client Posttherapy Questionnaire (CPQ) 60 Scoring of the CPQ 61 The Therapist Posttherapy Questionnaire (TPQ) 62 Scoring of the TPQ 63 Demographic data sheet 63 The p i l o t study 64 Subjects of the p i l o t study 64 Pi l o t study procedures 65 Results of the p i l o t testing phase 66 Revision of the instrumentation and procedures 69 The c l i n i c a l study 70 Design of the c l i n i c a l study 70 The sample 70 Client selection c r i t e r i a 73 Data preparation and analysis 73 Data preparation 73 Analysis 74 Chapter V: Results 75 Demographic c h a r a c t e r i s t i c s of the subjects 75 Therapists 75 Clients 77 R e l i a b i l i t y estimates of the measuring instruments 77 Working Alliance 77 Counselor Rating Form (CRF) 79 Empathy 80 The outcome measurements 81 Convergent v a l i d i t y of the Working Alliance Inventory .. 84 The relationship between the Working Alliance dimensions and Attractiveness, Trustworthiness, Expertness, and Empathy 87 The relationship between the outcome c r i t e r i a and the relationship measures 89 Clien t s 90 Therapist 91 Regression analysis 92 Client data 94 Therapist data 99 Chapter VI: Conclusions and discussion 104 Summary of the major conclusions 106 The pschychometric properties of the WAI 106 R e l i a b i l i t y 106 V a l i d i t y 107 Expert rating 108 The m u l t i t r a i t multimethod matrix 109 Comparison of expected and obtained relationships between the WAI dimensions and Empathy 110 Comparison of expected and obtained relationships between the Working A l l i a n c e , the CRF subscales, and Empathy 112 The structure of the Working Alliance . 113 The WAI's efficacy in predicting outcome 118 Limitations of the design 122 Implications for future research 124 o X L i s t of references 127 Appendix A: Material used in construct v a l i d a t i o n Phase I. 148 Appendix B: Material used in construct v a l i d a t i o n Phase I I . 163 Appendix C: Material used in the p i l o t testing of the WAI.. 174 Appendix D: Item level analysis of the p i l o t data 199 Appendix E: Material used in the c l i n i c a l study 221 x i LIST OF TABLES 2.1 Studies r e l a t i n g observed Empathy and therapy outcome ...19 2.2 Intercorrelations of the R-I subscales 21 2.3 R e l i a b i l i t y c o e f f i c i e n t s of the Counselor Rating Form (CRF) in three d i f f e r e n t analog therapy environments 24 2.4 Summary of the l i t e r a t u r e on the Working A l l i a n c e : C l a s s i c a l a n a l y t i c a l position 26 2.5 Summary of the l i t e r a t u r e on the Working A l l i a n c e : The revised c l a s s i c a l formulations 28 2.6 Summary of the l i t e r a t u r e on the Working A l l i a n c e : The object relations approach 29 2.7 Summary of the l i t e r a t u r e on the Working A l l i a n c e : The current conceptualizations 32 2.8 Summary of studies using concepts related to Bordin's d e f i n i t i o n of the Working Alliance 34 3.1 Phase I item rating results and item di s p o s i t i o n 45-47 3.2 Phase I item rating summary: A l l items 47 3.3 Phase I item rating summary: Retained items 48 3.4 Phase II item rating results and item disposition ....51-52 3.5 Phase II item rating summary: A l l items 53 3.6 Phase II item rating summary: Retained items 55 4.1 Hoyt's r e l i a b i l i t y c o e f f i c i e n t s of the WAI 67 4.2 Location of sample sources and number of therapists 72 5.1 R e l i a b i l i t y estimates of the Working Alliance Inventory .78 5.2 Intercorrelation c o e f f i c i e n t s of the WAI 79 xi i 5.3 R e l i a b i l i t y estimates of the Counselor Rating Form (CRF).80 5.4 Intercorrelation c o e f f i c i e n t s of the CRF dimensions 80 5.5 R e l i a b i l i t y estimate of the Empathy scale as measured by the R-I 81 5.6 R e l i a b i l i t y estimates of the c l i e n t outcome measures ....82 5.7 Adjusted means (X*) of the outcome instruments 83 5.8 M u l t i t r a i t multimethod matrix of the rel a t i o n s h i p variables 85 5.9 Relationship between the WAIc and the CRF dimensions and Empathy 87 5.10 Relationship between the therapist Working Al l i a n c e domains and therapist reported Empathy 88 5.11 Zero order correlation c o e f f i c i e n t s of the c l i e n t r elationship and outcome variables 90 5.12 Zero order correlation c o e f f i c i e n t s of the therapist relationship and outcome variables 92 5.13 Stepwise regression analyses ( c l i e n t data) Working All i a n c e variables 95 5.14 Stepwise regression analyses ( c l i e n t data) a l l process variables 97-98 5.15 Stepwise regression analyses (therapist data) Working All i a n c e variables 100 5.16 Stepwise regression analyses (therapist data) a l l variables 102 6.1 The zero order and squared i n 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 of the WAI 116 Chapter I_ Introduction and Rationale BACKGROUND OF THE PROBLEM During the last decade psychotherapy research has focused on the exploration of the sp e c i f i c factors associated with p a r t i c u l a r treatment approaches. The explication of the 'non s p e c i f i c ' or general factors that seemed to contribute to therapeutic e f f i c a c y (Beutler, 1979; Wilkins, 1979a) has been, by comparison, neglected. Often the factors cutting across s p e c i f i c models of intervention have been mistakenly grouped together with 'random variables' or unknown factors (Wilkins, 1979b). More recently there have been signs of renewed interest in the nature of the therapeutic variables that are not unique to a given mode of intervention ( Bordin, 1975, 1976, 1980; Frank, 1972, 1973; Kazdin, 1979; Luborsky, 1976).. There are at least two reasons that favor the exploration of these general process variables. In the f i r s t place, a number of researchers have concluded that the majority of 'effects' in many di f f e r e n t helping situations are common to several therapeutic methodologies and diverse strategies (Frank, 1971, 1972; Gomes-Schwartz, 1978; Snyder & Snyder, 1961). Secondly, although most 's p e c i f i c factor' research has been based on the model of contrasting two mutually exclusive, well defined, clear al t e r n a t i v e strategies, the r e a l i t y of the c l i n i c a l situation i s 2 a much more complex one. In the real therapy environment various therapeutic techniques based on a variety of theoreti c a l constructs are often mixed e c l e c t i c a l l y . Consequently the search for variables that contribute to positive therapy outcome must examine the commonalities as well as the differences among the various therapy approaches. Among the different investigators examining the issue of general versus s p e c i f i c factors, several (e.g., Bordin, 1975, 1976, 1980; Frank, 1972, 1973; Luborsky, 1976; Rogers, 1951, 1957; Rogers & Dymond, 1954; Strong, 1978) have developed theories of helping that emphasize significance of general factors in psychotherapy. Bordin's taxonomy of a general factor, which he c a l l e d Working A l l i a n c e , is based on s p e c i f i c q u a l i t i e s of the relationship between helpee and helper. In his presentation "The Working A l l i a n c e : A Basis for a General Theory of Psychotherapy" Bordin (1976) defined the essential components of the therapeutic rel a t i o n s h i p that related to successful psychotherapeutic results regardless of the theo r e t i c a l basis of the therapy used. These were: 1) a personal bond between therapist and c l i e n t (Bond), 2) agreement between therapist and c l i e n t on the goals of the therapy (Goal), and 3) shared understandings regarding the relevance of the tasks undertaken in therapy (Task) (Bordin, 1975, 1976). According to this model, the building and maintenance of these three elements is a common essential factor in a l l forms of 3 e f f e c t i v e psychotherapy. By the same token he suggested that the r e l a t i v e importance of these components may vary amongst therapies of d i f f e r e n t orientation. Although a number of investigators (e.g., Barrett-Lennard, 1962; Carkhuff, 1969a; Rogers, 1951, 1957; Saranat, 1975) have attempted to examine the rela t i o n s h i p of the general factors to psychotherapy outcome, to date there has been no attempt to develop an instrument s p e c i f i c a l l y designed to measure the Working Alli a n c e based upon the participants' perception of the therapeutic process. Furthermore, there has been no attempt .to delineate empirically the rela t i o n s h i p of the proposed a l l i a n c e dimensions to one another or the relationship between Bordin's Working Alliance dimensions and generic psychotherapy factors proposed by other theoreticians. Bordin's model of the Working Alli a n c e was chosen for investigation because i t appeared to offer a breadth of conceptualization of the therapeutic relationship that was superior to the most frequently used alternative model of a general relationship factor in psychotherapy. The alternative schema, the 'Therapist Offered F a c i l i t a t i v e Conditions' was developed by Rogers and his co-workers (Barrett-Lennard, 1962; Carkhuff, 1969a; Rogers-, 1951, 1957). While the models of both Bordin and Rogers took into account the quality of the personal relationship between c l i e n t and therapist, Bordin's Working Alliance focused on two q u a l i t i e s of the c l i e n t - t h e r a p i s t interaction that have been neglected by both empirical and theoreti c a l investigators. F i r s t , i t is important that the therapist and the c l i e n t have a shared and common understanding 4 of the goals of the therapy. This proposition i s l o g i c a l l y evident; i t would be, in fact, d i f f i c u l t to imagine a productive relationship in which existed a cross purpose of goals between the helper and helpee, or in which the therapist was ignorant of what the c l i e n t wanted to achieve. Second, there appears to be a sound and l o g i c a l basis for the notion that the c l i e n t ' s gains are related to the degree to which he/she finds the a c t i v i t i e s engaged in during therapy relevant (Task). STATEMENT OF THE PROBLEM The main purpose of the present study was to operationalize the Working Alliance and i t s dimensions by developing a v a l i d and r e l i a b l e instrument to measure i t . In addition the study also examined the relationship of the Working Al l i a n c e components—Goal, Task, and Bond--to other general process var iables. Two methodological problems were addressed in developing the Working Al l i a n c e Inventory. F i r s t , the question of the most appropriate technique of assessment had to be resolved; which of the available methods of c o l l e c t i n g data on the Working Alliance was most suitable? Some of the alternatives considered were: content analysis, interviewing techniques, summary ratings, and questionnaires. The second problem was the selection of the most r e l i a b l e and e f f i c e n t referent for the source of the assessment. That i s , from whose point of view - - c l i e n t , therapist or independent judge--should the Working Alliance be assessed? As part of the validation of the Working Alliance measuring instrument, four questions were addressed: 1) Did the Working Alliance Inventory measure the concepts of the Working Alliance as defined by Bordin (1975, 1976)? 2) To what extent did the components of the Working Alliance dimensions represent unique variables previously untapped by other instruments based on alternative relationship taxonomies? 3) How did the Working Alliance relate to other general process variables that were known to have a relat i o n s h i p to psychotherapy outcome? 4) How eff i c a c i o u s was the Working Alliance --as i t was measured by the instrument developed in this study-- in predicting psychotherapy outcome? This last question was further explored by analysing the predictive e f f i c a c y of the Working Alliance compared to other generic process variables. DEFINITION OF TERMS Therapist: A person trained in some method(s) of therapy or counselling which endeavors to reli e v e a c l i e n t ' s psychological d i s t r e s s . (The terms counsellor, helper, and therapist are used synonymously in this study.) CIient: A person over the age of 16 who sought out, or was directed to seek out, a therapist or counsellor for the purpose of r e l i e v i n g some f e l t d i s t r e s s . (The term helpee and c l i e n t are used synonymously.) 6 Working A l l i a n c e : The complex understandings, attachments, and agreements that are formed by the therapist and c l i e n t at the conscious l e v e l during their joint e f f o r t to eliminate the c l i e n t ' s psychological d i s t r e s s . The Working All i a n c e consists of: a set of personal bonds between the c l i e n t and the helper; shared understandings between the c l i e n t and the therapist regarding what are the appropriate goals for therapy; and the consensual understanding between therapist and c l i e n t of the relevance of the tasks undertaken in therapy for the c l i e n t ' s r e l i e f of suf f e r i n g . In this study Working Alliance refers to the c l i e n t ' s and the therapist's awareness of a set of agreements,-understandings, and bonds that were arrived at during a sequence of purposive .helping interactions. In p a r t i c u l a r , the following components define a viable a l l i a n c e regardless of the sp e c i f i c t h e o r e t i c a l or technical approach taken by the therapist: 1) The helper and the helpee have a sense of agreement about the goals of the helping process. The helpee w i l l have an awareness that these goals are relevant to him/her and feels a degree of i d e n t i f i c a t i o n with the e x p l i c i t and i m p l i c i t aims of the particular helping process he/she i s engaged i n . The helper has some direct or indirect evidence that the goals established in the therapy relationship are e x p l i c i t l y or i m p l i c i t l y shared and accepted by the c l i e n t . 7 2) The helper and the helpee have a sense of mutuality (agreement) that the tasks demanded of each of them in the helping process are reasonable and within their global c a p a b i l i t i e s (or expertise), and relevant in a dir e c t or indirect way to the goals of the helping process upon which they have mutually agreed. 3) The helper and the helpee experience a sense of a bond between them. Some of the bases on which such a therapeutic partnership are b u i l t are sense of mutual trusting, l i k i n g , understanding, and caring. Different therapeutic orientations and strategies make diff e r e n t demands on the participants in terms of each of these components. These unique demands create a unique quality for each successful a l l i a n c e . It is expected, however, that a l l helping dyads w i l l have to achieve a basic quantitative l e v e l in each of the three areas in order to provide the a l l i a n c e component necessary for a successful helping relationship. Empathy: Empathy was defined as: The extent to which one person is 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 makes at least those aspects of his awareness that are most important to him at the moment. It is an experiencing of the consciousness "behind" another's outward communication.(Rogers, Gendlin, K i e s l e r , & Truax, 1967, p.103) Perceived Empathy: Perceived Empathy is the extent to which a helpee is aware of the helper's empathy. Expertness: A counsellor is perceived as an expert or knowledgeable person in his/her f i e l d i f she/he has the following a t t r i b u t e s : 8 1) objective evidence of specialized training or knowledge such as a diploma or degree, 2) subjective evidence of recognized a b i l i t y such as reputation, fame, and/or physical signs associated with success (e.g., affluence); and 3) behavioural evidence of expertise such as rational and knowledgeable arguments and confidence in presentation (cf. Strong, 1968). Attract iveness: The attractiveness of a therapist is a function of the following conditions: 1) physical attractiveness (Cash, Begley, McCowan, & Wiese, 1975; Cash & Saltzbach, 1978), 2) warmth or fr i e n d l i n e s s (Goldstein, 1971; Greenberg, 1969), and 3) compatibility in terms of agreeableness, likeness of opinion. (Beutler, Johnson, N e v i l l e , Elkins, & lobe, 1975; Mann & Murphy, 1975; Strong, 1968) Trustworthiness: A helper is perceived as trustworthy i f one or both of the following are present: 1) s o c i a l l y sanctioned- role as a helper or legitimate source of influence (Strong, 1968), and 2) steady, deep, and consistent concern for the c l i e n t ' s welfare (Frank, 1973). Spec i f ic Factor: A factor or variable that is spec i f ic to a technique or procedure and associated with a s p e c i f i c approach to psychotherapy. 9 G e n e r a l or G e n e r i c F a c t o r : A f a c t o r or v a r i a b l e t h a t i s common to a l l of the d i f f e r e n t approaches t o p s y c h o t h e r a p y . WAI: The acronym 'WAI' r e f e r s t o the Working A l l i a n c e I n v e n t o r y i n both c l i e n t (WAIc) and t h e r a p i s t (WAIt) forms. WAIc: The c l i e n t form of the Working A l l i a n c e I n v e n t o r y . WAIt: The t h e r a p i s t form of the Working A l l i a n c e I n v e n t o r y . The d i s s e r t a t i o n was w r i t t e n i n s i x c h a p t e r s : the f i r s t c h a p t e r p r e s e n t e d the problem and i t s background, Chapter I I c o n t a i n s the review of the l i t e r a t u r e , and the t h i r d c h a p t e r p r e s e n t s the development of the Working A l l i a n c e I n v e n t o r y , Chapter IV d e a l s w i t h the d e s i g n of the c l i n i c a l study and the p i l o t i n g of the WAI, Chapter V p r e s e n t s the r e s u l t s of the c l i n i c a l e v a l u a t i o n of the i n v e n t o r y , and the d i s s e r t a t i o n i s c o n c l u d e d w i t h d i s c u s s i o n of the r e s u l t s i n Chapter V I . 10 Chapter 11 Review of the Literature GENERAL VERSUS SPECIFIC FACTORS IN PSYCHOTHERAPY Psychotherapy research in the past twenty-five years has been heavily committed to the question of the effectiveness of therapy ( Eysenck, 1952, 1959; Fiske, Cartwright, & Kirtner, 1964; Luborsky, Singer, & Luborsky, 1975). The most dramatic example of the importance of this issue has been the attention paid to the research published by Eysenck (1952, 1961) and the subsequent response in the l i t e r a t u r e that has attempted to refute the challenge by Eysenck that psychotherapy could not claim effectiveness beyond chance remission (Bergin, 1963, 1966, 1971; Bergin & Lambert, 1978; Bergin & Suinn, 1975; Cartwright, 1956; Luborsky, 1954, 1972; Smith & Glass, 1977; Strupp, 1963; Strupp, 1973a). It has been th i s focus on e f f i c a c y , in part, that distinguished the f i e l d of psychotherapy research from other studies in psychology. Whilst the l a t t e r i s often involved with the examination of theories and constructs without concern for immediate application, the psychotherapy researcher is continually s t r i v i n g to evaluate and improve a very p r a c t i c a l and s o c i a l l y essential endeavour (Strupp & Hadley, in press). Questions regarding the ef f i c a c y of the helping process can ' be asked in one of two ways: which s p e c i f i c therapist behaviour or therapy situation result in what s p e c i f i c benefit to the c l i e n t ? ; or, what are the common elements in therapeutic situations or behaviours of therapists that result in positive outcomes (Kazdin, 1979; Strupp, 1973a; Wilkins, 1979)? Each of these approaches has s p e c i f i c t h e o r e t i c a l and research design implicat ions. The f i r s t approach leads to a molecular view that w i l l induce the researcher to identif y small, closely defined variables that are - - i d e a l l y - - independent from a l l other factors. The i s o l a t i o n of these variables may lead to the delineation of s p e c i f i c factors causally linked to change (Kazdin & Wilcoxson, 1976). The investigator within this conceptual framework attempts to control, that i s , hold constant, a l l the variables in the design except the one under scrutiny. Due to the m u l t i p l i c i t y of events and circumstances that appear to influence the helping process, t h i s task can be extremely d i f f i c u l t . The alternative approach begins by taking account of the fact that a great variety of therapies using many d i f f e r e n t methods appear to produce b e n e f i c i a l results (Smith & Glass, 1977). It attempts to look at the commonalities amongst ef f e c t i v e therapeutic situations. The researcher in this l a t t e r case monitors, in a variety of therapy situations, the variable that was believed to be a 'general factor' and attempts to relate the v a r i a b i l i t y in therapeutic success to th i s factor. 12 During the last three decades there has been a considerable bias toward the f i r s t of these approaches. The general, or as i t was sometimes referred to, 'common', factor has often been erroneously treated as a nuisance variable to be purged from the experimental si t u a t i o n in order to allow the ' s p e c i f i c ' variable to emerge (Botzin & Lick, 1979; Wilkins, 1979b). The term 'non-specific variable' has been applied to the general fa c t o r ( s ) , and i m p l i c i t assumptions regarding i t s nature crept into the l i t e r a t u r e (Kazdin, 1979). These assumptions linked the common factor with the 'halo e f f e c t ' , general expectations, the placebo e f f e c t , and even ' f a i t h healing' (Kazdin, 1979). Wilkins (1979a) pointed out that the lack of c l a r i t y and the paucity of research in the area led to the lumping together of the general (or non-theory s p e c i f i c ) factors with non-treatment events that included: a) events external to therapy, b) events that are inherent in therapy but are not true variables (e.g., v i s i t i n g the therapist, placebo effect ), and c) events that may be common to many c l i e n t s ' experiences but are not part of therapy (e,g., l i f e experiences outside of therapy). Since c l a s s i c a l experimental designs aim to reduce the effect of these types of variables (Campbell & Stanley, 1963), true therapy-related general factors —mistakenly associated with those above-- were either ignored or minimized. Added to these considerations is the p r a c t i c a l r e a l i t y that, in the f i e l d of psychotherapy research, investigators are often practicing psychotherapists, counsellors, or individuals linked to in s t i t u t i o n s providing c l i n i c a l service. This situation has encouraged the evaluation of the effectiveness of the s p e c i f i c model the researcher was associated with rather than the exploration of the commonalities between that method and competing techniques. The rekindled interest in the general factor received impetus from two sources. F i r s t , a number of theoreticians (Bordin, 1975, 1976, 1980; Frank, 1972, 1973; Luborsky, 1976; Rogers, 1951, 1957; Strupp, 1978) have been reconsidering the value of the general factor in conceptualising the process of psychotherapy. Second, recent re-analysis of the results of the studies accumulated during the l a s t twenty-five years (Bergin & G a r f i e l d , 1971; Luborsky, Singer, & Luborsky, 1975; Smith & Glass, 1977) have indicated that a great variety of therapy and counselling methods have produced e s s e n t i a l l y similar gains across a variety of situations. It now appears that the term 'non-specific factors' was unfortunate and that, in fact, the general factor(s) are concrete variables that may be responsible for a considerable portion of outcome v a r i a b i l i t y (Kazdin, 1979). The emerging conceptualization of the general factor does not negate the import of s p e c i f i c techniques, nor does i t minimize the v a l i d i t y of s p e c i f i c approaches with pa r t i c u l a r problems. The model implies that the s p e c i f i c factors function within, and are enhanced by, an environment that i s influenced by variables that are common to a variety of approaches. 14 THE THERAPIST-OFFERED FACILITATIVE CONDITIONS Although most 'schools' of psychotherapy ascribe to the notion that some kind of positive relationship between c l i e n t and counsellor i s , at least, helpful in the therapeutic endeavour, Rogers' conclusion 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 (Rogers, 1951, 1957) was a uniquely bold hypothesis. The three concepts (core conditions) i d e n t i f i e d by Rogers were believed to be present in a l l successful therapies and became the cornerstones of the Client Centered approach to counselling. One of the unique attributes of the c l i e n t centered approach was the e f f o r t Rogers and his colleagues invested in defining these core conditions in functional terms. These endeavours gave ri s e to some of the most intensive systematic empirical investigations of therapist behaviour with respect to therapeutic outcome. Of the therapist offered core conditions, Empathy was chosen for examination in d e t a i l in the present study because i t is the best understood, accepted, and studied of the core conditions. Empathy has also been shown to be highly correlated with the other core conditions (Gurman, 1977), suggesting that i t s presence indicates the a v a i l a b i l i t y of the other two conditions (Mitchell, Bozarth, & Krauft, 1977). In essence, empathy according to Rogers, is 15 The a b i l i t y of the therapist ... Accurately and se n s i t i v e l y [to] understand experiences and feelings and their meaning to the c l i e n t during the moment to moment encounter of psychotherapy ... ( i t ) means that the therapist is completely at home in the universe of the patient ... It i s a sensing of the c l i e n t ' s inner world .. 'as i f ' i t were the therapist's own ... 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 way that allows these experiences to be 'his' is the other major point .... A high l e v e l (of empathy) w i l l indicate not only a sensitive understanding of the apparent feelings but ... by i t s communication c l a r i f y and expand the patient's awareness of these feelings or experiences (Rogers et a l . , 1967, pp. 104-105.) It is important to note that the concept of Empathy or, the other core conditions do not require the c l i e n t to accept the usefulness of this condition or to agree that his/her plight w i l l be diminished by receiving communications about his/her feelings and experiences. It is assumed that an atmosphere of empathic understanding is- perceived as relevant and he l p f u l , and that the process of providing such conditions co-opts the c l i e n t to u t i l i z e such an opportunity. Rogers et a l . (1967) go even further to suggest that, although accuracy of perception is important, the communication of [the] intent to understand can i t s e l f be of value ....[The] i n a r t i c u l a t e or bizarre i n d i v i d u a l , i f he perceives that the therapist is trying to understand hrs meanings, w i l l be helped because he w i l l be encouraged to communicate more of his s e l f . (p.105). 16 The essential features of the c l i e n t centered concept of Empathy are: 1) to communicate an eff o r t to 'understand' (both cognitively and a f f e c t i v e l y ) , 2) to be able to perceive accurately ('as i f ' c f . Rogers et a l . , 1967, p.104) the c l i e n t ' s message of content and context, and 3) to be able to r e f l e c t to the c l i e n t (on a moment by moment basis) the therapist's accurate appreciation of the c l i e n t ' s feelings and thoughts. The condition of Empathy may be evaluated from three discrete points of view: the therapist's, the c l i e n t ' s , and independent observers'. Each of those points of observation offers unique perspectives. The therapist is the 'locus' of the condition; i t is his/her 'experiencing' in the 'as i f ' mode and his/her communication of the intent and fact of perception that defines the substance of Empathy. In some essential sense, the therapist is the primary source of information especially in terms of the necessary preconditions of e f f o r t and intent. The c l i e n t on the other hand is in a position to give first-hand information on whether the condition of Empathy was available or perceived to be available to him/her. The t h i r d point of view, that of an independent judge, represents an 'objective' assessment of Empathy summarized from second-hand ( i . e . , non participant) experience. Third party judgments have the following advantages: 17 1) They are free from 'transference' or other conscious or unconscious sources of bias. 2) They can be assessed across several therapists or c l i e n t s by the same rater increasing between-rating r e l i a b i l i t y . 3) They are methodologically better contr o l l e d . 4) They are capable of recording moment-to-moment judgments. Judges' ratings, on the other hand, obviously suffer from the handicap of having to make 'as i f ' judgments about therapist's intents as well as c l i e n t s ' perceptions --often on the basis of reduced information. The evidence of published research appears to indicate that each of the above three sources of Empathy might be sensitive to a number of d i f f e r e n t and independent factors. (Mitchell, Bozarth, & Krauft, 1977; Pa r l o f f , Waskow, & Wolfe, 1978). There is a substantial body of l i t e r a t u r e which examines the v a l i d i t y of the claim that the degree of Empathy present in a therapeutic relationship is related to successful therapy. Because of the extensiveness of this l i t e r a t u r e , and the particular interest in the methodology of the assessment of relationship factors, the empirical aspects of th i s core condition are discussed under two headings: Observed Empathy and Perceived Empathy. Assessment of Observed Empathy The t h i r d party rating scale used in the studies reviewed below was based on the work of Truax (1962) and Truax and Carkhuff (1967). Mit c h e l l et a l . (1977) summarized their operational d e f i n i t i o n of Empathy this way: 18 The extent to which the therapist (1) is sensitive to both current feelings and thoughts of the helpee (both those in and those o,ut of awareness), (2) has the a b i l i t y to communicate his understanding of his c l i e n t ' s feelings and thinking, and (3) has the a b i l i t y to use language attuned to that of the c l i e n t , (p. 483). In the Carkhuff and Truax studies the raters or judges were trained to identif y levels and occurrences of Empathy, and either a moment, to moment or global rating was made on a five point scale. On the revised form (Carkhuff,1969a) of the Truax and Carkhuff scale a rating of 3 is usually considered the benchmark for minimal therapeutic effectiveness. The results of the early . studies were highly promising, generating optimism about the predictive power of Empathy: Therapists or counselors who are accurately empathic ... are indeed e f f e c t i v e ... These findings seem to hold with a wide variety of therapists and counselors regardless of their training or theoretic orientation and with a wide variety of c l i e n t s ... The evidence suggests that these findings hold in a variety of therapeutic contexts ... (Truax & Mi t c h e l l , 1971, p. 310). However, subsequent researchers (e.g., Meltzoff & Kornreich, 1970; Matarazzo, 1971) began to raise both methodological and substantive questions about these findings. The more recent studies that meet some rigorous experimental c r i t e r i a are summarized in Table 2.1 . These studies indicate modest relationships between Empathy and outcome in c l i e n t centered therapy. This relationship, however, seems to weaken or disappear in other therapeutic environments. 19 TABLE 2.1 Studies Relating Observed Empathy and Therapy Outcome Author Year No. of Subjects R e l i a b i l i t y 1 Hypotheses Si g n i f i c a n t N.S Altmann 1973 19 7 1 0 Beutler et a l . 1973 49 .49 0* 2* Bozarth & Rubin 245 .84 15 90 Ga r f i e l d & Bergin 1971 38 .91 0 90 Kurtz & Grummon 1972 25 .96 - -Mintz et a l . 1971 27 .89 0 2 Mitch e l l et a l . 1973 120 .67 2 560 Mullen & Abeles 1971 36 .76 1 0 Siegel 1972 8 .81 5* 64* Sloane et a l . 1975 92 ? 0 1 Truax 1970 31 .82 1* 3* Truax et a l . 1971 160 .81 3 24 Truax & Wittmer 1971 40 .63 2 3 xThe methods of estimating the r e l i a b i l i t y c o e f f i c i e n t s were not reported. * Used composite therapist s k i l l s . (Data based on M i t c h e l l et a l . , 1977) Perceived Empathy Although Truax and Carkhuff (1967) o r i g i n a l l y rejected the notion of the c l i e n t ' s perception as a v a l i d source of assessment of Empathy on the grounds that c l i e n t s would d i s t o r t their perception of their therapist or misinterpret the 20 therapist's interventions, there were strong t h e o r e t i c a l and empirical reasons to u t i l i z e the c l i e n t ' s experience of Empathy as a base of measurement. On theoretical grounds, i t was evident that Rogers' concept of Empathy involved the a b i l i t y of the therapist to communicate his/her understanding (Rogers et a l . , 1967, p. 483). Therefore, the c l i e n t ' s experience of the counsellor's behaviour and communication is prima facie evidence of communicated Empathy. In practice, the question of the v a l i d i t y of the measurements must rest with the rela t i o n s h i p of c l i e n t perceived Empathy and therapy outcome. Gurman (1977) reviewed 23 studies using c l i e n t perceived Empathy as a process variable. These studies spanned approximately 20 years (1954-1974) of research. Although the quality of these studies varied greatly, Gurman f e l t that they showed "substantial evidence in support of the relationship between patient perceived therapeutic conditions and outcome" (Gurman, 1977, p. 523). In reviewing Gurman's findings however, others (Lambert & DeJulio, 1977; Parloff et a l . , 1978) found the relationship less impressive, though generally more encouraging than the relationship between outcome and rated (observed) Empathy. Equally important is the conclusion that, l i k e other studies based on the therapist offered conditions, results tend to ' f a l l o f f ' when the studies involved subjects from non-client centered therapies. The studies reviewed below used the Relationship Inventory (R-I) of Barrett-Lennard (1962) and i t s subsequent revisions as the measuring instrument of Empathy. This instrument is based on the hypothesis that: "the c l i e n t ' s experience of his 21 therapist's responses is the primary locus of therapeutic influence in the relationship" (Barrett-Lennard, 1962, p. 2). Although cert a i n d i s t o r t i o n s by the c l i e n t are possible, or indeed probable, the author of the instrument contended that i t is the therapist's a b i l i t y to communicate his/her perceptions to the c l i e n t that is the f i n a l mediator of the condition of Empathy. Gurman's 1977 review of 23 studies using the R-I found substantial i n t e r c o r r e l a t i o n s among the four subscales of the instrument (See Table 2.2). The same reviewer summarized the TABLE 2.2 Intercorrelations of the R-I Subscales (Based on the 23 a r t i c l e s reviewed by Gurman 1977.) C LR U Total Empathy .62 .53 .28 .72 Congruence .67 .36 .81 Level of Regard .26 '.77 Uncondi t i o n a l i ty .48 C=Congruence LR=Level of Regard U=Uncondi t i o n a l i ty 13 studies available with both c l i e n t and therapist ratings of Empathy (Gurman, 1977). The range of correlations (r) was between .02 and .46 with only three out of 13 studies demonstrating s i g n i f i c a n t relationships ( H i l l , 1974, p.< .01; Lietaer, 1974a, p.< .001; and Lietaer, 1974b, p.< .01). The results indicate that the therapist's and the c l i e n t ' s version of the R-I may be measuring d i f f e r e n t aspects of the 22 relat ionship. SOCIAL PSYCHOLOGICAL APPROACH TO THE THERAPY PROCESS: INTERPERSONAL INFLUENCE CONCEPTUALIZATIONS There is a well established body of l i t e r a t u r e l i n k i n g counselling and psychotherapy research with s o c i a l psychology. H i s t o r i c a l l y this association began with Carl Hovland's exploration of the dynamics of propaganda and persuasion (Hovland, Janis, & Kelley, 1953) and Kurt Lewin's phenomenological examination of the process of group influence (Lewin, 1948). Social psychologists were also responsible for some of the e a r l i e s t explorations of the role of goals in opinion and attitude changes (Lewin, 1935). More recently, Goldstein (1962) and Goldstein, Heller, and Sechrest(1966) wrote extensively on psychotherapy in terms of expectations and power to influence. Along similar l i n e s , Frank (1973) suggested that eff i c a c y in psychotherapy is related to the strength of the patient's expectancy and the s i m i l a r i t y of the status of the therapist and c l i e n t . Using experimental evidence gleaned from opinion change research, Strong (1968) distinguished five factors c r i t i c a l to counsellor effectiveness. These were: 1) communication discrepancy, 2) perception of communicator expertness, 3) perception of communicator trustworthiness 4) perception of communicator attractiveness, and 5) involvement. These five variables were in turn refined and sharpened on the basis of empirical evidence (Barak & LaCrosse, 1975; Cash, Kerr, & Saltzbach, 1978; Heppner & Dixon, 1978; 23 LaCrosse, 1977; Strong & Dixon,1971) and t h e o r e t i c a l considerations (Strong & Matross, 1973). The majority of work related to s o c i a l influence today involves three variables: a) Perceived Expertness, b) Trustworthiness, and c) Attractiveness. These three concepts are believed to account for the helper's a b i l i t y to influence his/her c l i e n t ' s perception and cognition and explain some of the v a r i a b i l i t y in the c l i e n t ' s posttherapy behaviour. The theoretical construct used by the s o c i a l influence theorists to explain the process of therapeutic change is 'persuasion' or, more tech n i c a l l y , the reduction of cognitive dissonance (Patton, 1969). Cartwright (1965) postulated a model that stated that therapist power is a function of the congruence of the c l i e n t ' s perception of his or her need and the therapist's resources. This theoretical position states that there is a c o n f l i c t between the c l i e n t ' s cognition and behaviour, and the therapist's opinion of how the c l i e n t 'ought to be'. This dissonance is resolved in the therapist's favor only i f his/her 'power' is s u f f i c i e n t to dislodge the c l i e n t ' s 'status quo' (Johnson & Matross, 1977; Strong, 1978). The Measurement of Perce ived Soc i a l Influence Dimensions Empirical measurement of the s o c i a l influence concepts can be accomplished by the Counselor Rating Form (CRF) developed by Barak and LaCrosse (1975). The CRF consists of 36 items referencing therapist q u a l i t i e s that are rated on a seven point bipolar scale by the c l i e n t . Each of the three dimensions (Expertness, Attractiveness, Trustworthiness) i s measured by 12 24 items, y i e l d i n g three subscores. Data supporting the r e l i a b i l i t y of the CRF in an analog counselling experiment simulating three dif f e r e n t therapeutic approaches has been published by Barak and LaCrosse (1975) and LaCrosse (1977). TABLE 2.3 R e l i a b i l i t y C o e f f i c i e n t s 1 of the Counselor Rating Form (CRF) in Three Different Analog Therapy Environments* N=40 Client Centered Gestalt Rational Expertness .92 .83 .85 Attractiveness .88 .89 .75 Trustworthiness .91 .93 .89 1 The method of r e l i a b i l i t y assessment was not reported. * LaCrosse 1977. There have been several reports supporting some degree of discriminating v a l i d i t y within counsellors (Barak & D e l l , 1977; LaCrosse & Barak, 1976) and two studies supporting between-counsellor discrimination (Barak & LaCrosse, 1975; LaCrosse, 1977) Additional support for the general functioning of the scale within i t s own theoretical domain i s provided by Cash et a l . (1978) and Heppner and Dixon (1978). The r e l i a b i l i t y estimates of the CRF based on a publication by LaCrosse (1977) are summarized in Table 2.3. 25 THE CONCEPT OF WORKING ALLIANCE C l a s s i c a l Analytic Formulations The concept of the a l l i a n c e (or Working Alliance) was f i r s t described by Freud as the be n e f i c i a l attachment of the analysand to the doctor. The mechanics of this attachment involved the spontaneous and unconscious linkage by the patient of the analyst with "the images of the people by whom he was accustomed to be treated with a f f e c t i o n " (Freud, 1913, p. 139-140). Thus, at least i n i t i a l l y , the motivation for 'positive' attachment was l i b i d i n a l --much l i k e negative transference-- and i t r e l i e d for i t s strength on the patient's i n f a n t i l e f r u s t r a t i o n for t o t a l love and acceptance (Freud, 1913, p. 99-108). Although 'positive transference', l i k e i t s negative counterpart, was the target of analysis and interpretation, some of the friendly cathexis formed between therapist and patient would remain aft e r the i n f a n t i l e erotic attachments were removed, and form the core of the essential treatment promoting rapport: the a l l i a n c e . This would, "Clothe the doctor with authority and is transformed into b e l i e f in his communications and explanations" (Freud, 1913, p. 445). This early conceptualization f i t s well with the an a l y t i c a l cosmology of the psyche and Freud's basic view of the in s t i n c t u a l basis of relationships. The c l a s s i c a l stance was reiterated by Freud himself (Freud, 1937) and later endorsed by Greenacre (1954) and Anna Freud (1954). The weaknesses of this version of the concept of the a l l i a n c e are twofold: 1) The theoretical linkage between the 'positive transference' that is l i b i d i n a l in nature, and 'rapport' or 'alli a n c e ' is weak; there is c e r t a i n l y no p a r a l l e l mechanism in existence for 'negative transference' or 'counter transference'. The notion of a conscious 'standby' of a resolved unconscious complex is at odds with the a n a l y t i c a l concepts of neurotic mechan i sms. 2) The a l l i a n c e , as i t was o r i g i n a l l y postulated, arose spontaneously out of the somewhat suspect 'positive transference' (also autogenetic). Thus stated, there was no need, or room, for the therapist to foster or guide the development of the rapport, a notion that was unacceptable even to Freud himself (Freud, 1937). The major contributions to the c l a s s i c a l a n a l y t i c a l position are summarized in Table 2.4. TABLE 2.4 Summary of the Literature on the Working A l l i a n c e : C l a s s i c a l A n a l y t i c a l Position. Author T i t l e Year Measure Freud Dynamics of Transference 1912 None Freud On Beginning Treatment 1913 None Greenacre The Role of Transference 1954 None Freud The Widening Scope of Indications for Psychoanalysis. 1954 None 27 The Revised C l a s s i c a l Approach In 1937 Freud postulated that a portion of the Ego may s p l i t off from i t s e l f and could observe and relate to the Ego as a 'quasi object'. This mechanism permitted Sterba (1934) to develop the notion of 'therapeutic ego-dissociation'. This hypothesized s a t e l l i t e of the Ego came about through a mechanism similar to the superego's development. However, instead of identifying with the authority figure of the parent, i t a l l i e d i t s e l f with the therapist in a therapeutic a l l i a n c e . The cleaved off portion of the Ego was not only capable of forming a conscious and r e a l i s t i c bond with the analyst, but also become a sort of internalized therapist that enabled the patient to make therapeutic progress outside the a n a l y t i c a l hour. Sterba's concept of a l l i a n c e , being mostly conscious, is amenable to development and strengthening by the analyst. This proposition was supported by Freud in 1940: ...[The analyst ] and the patient's weakened ego, basing themselves on the external worId, have to band themselves together ... This pact constitutes the analytic s i t u a t i o n . (p. 173) The Ego-Object relation concept of the a l l i a n c e was further developed by Loewenstein (1954), and more recently, by Greenson (1965, 1967). Greenson suggested that the analyst's attitudes and actions v i s - a - v i s the c l i e n t strengthen the Working All i a n c e . He also developed the notion that successful therapy e n t a i l s the patient o s c i l l a t i n g between transference neurosis and Working All i a n c e (Greenson & Wexler, 1969); that i s , the catharsis of experiencing of the neurosis,, followed by the 'working through' u t i l i z i n g the rational portion of the ego. Thus conceptualized, the r a t i o n a l , object r e l a t i n g Ego not only 28 TABLE 2.5 Summary of the Literature on the Working A l l i a n c e : The Revised C l a s s i c a l Formulations. Author T i t l e Year Measure Sterba Freud The Fate of the Ego in Analytic Therapy. The Technique of Psychoanalysis. 1934 None 1940 Loewenstein Some Remarks on Defences, Autonomous 1954 Ego and Psychoanalytic Techniques. Greenson The Working Alliance and the Transference Neurosis. Greenson The Technique and Practice of Psychoanalys i s. 1965 1967 None None None None provides a reasonable partner for the therapist in building the Working All i a n c e , but also offers an explanation of f a i l u r e in some of the analytic attempts ( i . e . , i n a b i l i t y of the Ego to form a relationship with a good object). A summary of the major contributions to the Revised C l a s s i c a l Position is provided in Table 2.5. The Object Relationship Approach Several analysts developed a taxonomy of Ego development fundamentally di f f e r e n t from the c l a s s i c a l Freudian position. Notable amongst these were the Kleinians and Fairbairn and his student Winnicott. Both of these 'schools' f e l t that the Ego was shaped by i t s e a r l i e s t object relations and thereafter remained quite impervious to a l t e r a t i o n s . S p e c i f i c a l l y , they maintained that neurotic (or transference) relationships re-activate i n f a n t i l e Ego associations and the Ego (depending on the unconscious object attachments, that i s , whether the object i s fantasized as good or bad) either ingests the relationship (good object) or attempts to repel or excrete i t (bad object). Accordingly, Bibring (1937), Gitelson (1962) and, more recently, Horwitz (1974) conceptualized the a l l i a n c e as a 'new-object relationship' not based on previous ( i n s t i n c t i v e ) patterning, but comprising a new class of events in the c l i e n t ' s experience. It was the task of the therapist to.offer a need-gratifying experience that is not allowed to be ingested or rejected according to old-object patterns but, with the help of the therapist, becomes the model of reality-based g r a t i f i c a t i o n s . This model is d i f f e r e n t i a t e d from the previous two conceptualizations in that i t is based on a real relationship. The major contributions to the Object Relation approach to the Working Alliance are summarized in Table 2.6. TABLE 2.6 Summary of the Literature on the Working A l l i a n c e : The Object Relations Approach. Author T i t l e Year Measure Bibring On the Theory of the Results of Psychoanalysis Zetzel Current Concepts of Transference Gitelson The Curative Functions in Psychotherapy 1937 None 1956 1962 None None Horwitz C l i n i c a l Predictions in Psychotherapy 1974 Indirect 30 Current Extrapolations of the Concept of Alli a n c e The previous discussion of the Working Alliance was based exclusively on c l i n i c a l observations and l o g i c a l extrapolations. The current proponents of the concept distinguish themselves from these not only on theoreti c a l grounds but also, more importantly, because empirical data have influenced their formulations. Luborsky (19*76) and Strupp (1974) have broadened the d e f i n i t i o n of the ' c l a s s i c a l ' and 'revised c l a s s i c a l ' school to include a l l 'non transference' types of relationship dynamics between therapist and patient.- Without specifying the identity of the a l l i a n c e in more e x p l i c i t terms, but relying on the de f i n i t i o n s of Greenson (1965) and Horwitz (1974) these two investigators, as well as Hartley (1978) and Morgan (1977), attempted to quantify the Working Alliance either by content analysis or by tape-rating techniques. In a l l these studies an attempt was made to relate the strength of a l l i a n c e to some measure of therapeutic success. The c r i t e r i o n of success ranged from length in therapy (remaine'rs vs. quitters) to changes in MMPI scores. The size of the c o r r e l a t i o n a l relationships have been, on the whole, somewhat uneven (See Table 2.7). A d i s t i n c t l y different approach to the concept of a l l i a n c e was offered by Bordin (1975, 1976, 1980). He has attempted to define the Working Alliance on the basis of his extensive review of the l i t e r a t u r e as well as on his own experience, in terms of the demands and agreements between the c l i e n t and the therapist. More s p e c i f i c a l l y , he postulated that: 1) d i f f e r e n t therapeutic techniques would place d i f f e r e n t 31 demands on both therapist and patient, 2) unique strategies would imply d i f f e r e n t goals and objectives, 3) a good therapeutic a l l i a n c e would demand an acceptance of, and agreement on a) and b) between therapist and c l i e n t . In other words, these elements would have to ' f i t ' c l i e n t and therapist needs and resources and result in mutual agreement between them regarding goals and objectives, and consequently the c l i e n t would regard the therapy a c t i v i t i e s as relevent to his/her goals, and 4) a real relationship, 'bond' would have to develop between c l i e n t and therapist, involving trust, acceptance, and l i k i n g . The formulation was unique from several points of view: 1) Although i t incorporates some of the basic concepts of the analytic stream of thought, i t is operationally independent of therapeutic constructs that are unique to a p a r t i c u l a r theoretical orientation. 2) It defines a generic process variable that cuts across theoretical strategies (agreement on goals and tasks; personal bonds), but at the same time, s p e c i f i e s that d i f f e r e n t methods w i l l produce unique topologies within these agreements. 3) The d e f i n i t i o n of the Working All i a n c e can be explicated in terms of discrete therapeutic objectives. There has been some interest in recent years in the empirical validation of Bordin's concept of a l l i a n c e (Lehrke, 1978; Ryan, 1973; Saranat, 1975). 32 TABLE 2.7 Summary of the Literature on the Working A l l i a n c e : The Current Conceptualizations Author Outcome C r i t e r i a Method of Significance Measurement Luborsky Third Party Global Assessment Content (a) p^.05 (1976) Based on Audiotapes Analysis (b) p<.01 Strupp MMPI Scores and Therapist's Content p<.05 (1974) Judgements Analytic Morgan Therapist's Judgement Global Rating p<.05 (1977) Scale Hartley MMPI Scores and Therapist's Rating Scales n.s. (1978) Judgement (V.T.A.S) (a) Phase I a l l i a n c e (b) Phase II a l l i a n c e Although Ryan's (1973) study preceded Bordin's formal d e f i n i t i o n of the a l l i a n c e , his research is germaine because of his close association with Bordin. Furthermore, his instrumentation and data base were used for two subsequent studies by Saranat (1975) and Lehrke (1978). E s s e n t i a l l y , Ryan's focal interest was the correlaton of conditions he considered prerequisite to a l l i a n c e (Object Relations Capacity, Hope, and Form Level) to the measure Quality of Allia n c e (QA) he developed. QA was rated on the basis of two 4-minute interview segments per c l i e n t per interview taken at the beginning, middle, and end of the sessions. The ratings (by psychology students) were based on the global question: To what extent is the patient w i l l i n g to " a l l y himself with the therapist and to 33 p a r t i c i p a t e in a more d i r e c t l y collaborative way?" (Ryan, 1973, p. 83). He found only weak correlations among his variables, perhaps not unexpectedly in view of the remoteness of his concepts from the dependent variable. Saranat (1975) reanalysed Ryan's data using additional demographic information, as well as a follow-up outcome measurement based on a global therapist report. Her results showed s l i g h t l y improved corre l a t i o n s , but s t i l l r e l a t i v e l y few s i g n i f i c a n t relationships. Lehrke (1978) yet again reanalysed the Ryan-Saranat data and re-rated the tape segments using the Alliance Related Communication Instrument (ARC) that she developed based on Bordin's (1975, 1976) concept of a l l i a n c e . Her approach was e s s e n t i a l l y content analytic, y i e l d i n g 13 categories, most of which turned out to be somewhat redundant. Of the scales she retained for analysis, three had moderate relationship to Saranat's outcome data, the same number of scales correlated with the QA, and two scales related s i g n i f i c a n t l y with Al l i a n c e Related Preconditions. The l i t e r a t u r e on the current conceptualizations is summarized in Table 2.8. The results of these studies are not conclusive. It i s reasonable to expect that i f the Working Alliance is an important general process factor, then more powerful relationships ought to be demonstrable. One of the problems plaguing these studies appears to be the vagueness or imprecision surrounding the d e f i n i t i o n of a l l i a n c e . Another d i f f i c u l t y could be related to the problem of measurement. A l l of these studies attempted to examine the strength or presence Table 2.8 Summary of S t u d i e s U s i n g Concepts R e l a t e d to Bo r d i n ' s D e f i n i t i o n of the Working A l l i a n c e . Author No. of A l l i a n c e Measure Dependent V a r i a b l e Date S u b j e c t s D e f i n e d ? Ryan 40 No Inte r v i e w * 1973 Rorschach * Glo b a l R a t i n g Luborsky 10 No Content A n a l y s i s R e s i d u a l Gain on 1975 P a t i e n t ' s and T h e r a p i s t ' s R a t i n g Saranat 40 No See Ryan Follow up Q u e s t i o n n a i r e 1975 sent to T h e r a p i s t . Lehrke 39 Yes A l l i a n c e R e l a t e d See Ryan & Saranat 1978 Commun i c a t i ons H a r t l e y 11 Yes R a t i n g S c a l e Change Score on 1978 (VTAS) the MMPI, C l i e n t Rated Improvement T h e r a p i s t Rated Improvement Observer Rated Improvement * A l l i a n c e ' p r e - c o n d i t i o n s ' of the a l l i a n c e based on external evaluations of the content of the therapy. This process required a level of inference that may be unnecessarily high. There appears to be a more direct way of assessing the al l i a n c e through the experience of the therapist and the c l i e n t . It seems l i k e l y that Perceived Working All i a n c e s h a l l prove to be a more powerful general process variable than Rated Working Al l i a n c e , just as Perceived Empathy proved.to be a more useful measure than Rated Empathy. COMPARISONS AND CONTRASTS AMONG THE CONCEPTS OF WORKING ALLIANCE, THERAPIST-OFFERED FACILITATIVE CONDITIONS, AND SOCIAL INFLUENCE THEORY In the ongoing search to locate powerful general process variables that account for d i f f e r e n t degrees of success in therapy and counselling, three d i s t i n c t alternatives are represented by the Working Alliance conceptualizations, Therapist-Offered F a c i l i t a t i v e Conditions, and the Social Influence theory. Social Influence theory, based on so c i a l psychology, sees the helping process as one of influencing the c l i e n t to change his/her cognitions, perceptions, and actions. The therapist's a b i l i t y to accomplish these changes depends on how the c l i e n t perceives the therapist in terms of Expertness, Attractiveness, and Trustworthiness (Strong, 1968). A high rating on these components enhances the helper's 'interpersonal influence'. The theory of Therapist-Offered F a c i l i t a t i v e Conditions i s based upon the necessary and s u f f i c i e n t conditions (as defined by C. Rogers and his followers) that the helper offers to the helpee. These Therapist-Offered F a c i l i t a t i v e Conditions (Accurate Empathy, Congruence, Level of Regard, Unconditionality,) strengthen in the c l i e n t his/her innate regenerative powers, and psychic growth occurs. Working Alliance (as defined by Bordin, 1975, 1976) assumes that di f f e r e n t helping situations place unique demands on the helper and the helpee. Notwithstanding the differences, however, certain common elements must exist for a working relationship (alliance) to develop: the c l i e n t and his/her helper have to be in agreement as to the goals of treatment, the c l i e n t must perceive the tasks involved as relevant to those goals, and close personal bonds must develop between therapist and c l i e n t . Major differences between Therapist-Qffered F a c i l i t a t i v e  Condi t ions and Work ing Alliance 1. Therapist-Offered F a c i l i t a t i v e Conditions are dependent only on the therapist; Working All i a n c e is dependent on mutuality. 2. Therapist-Offered F a c i l i t a t i v e Conditions disregard differences or preferences of c l i e n t s ; Working All i a n c e expects a successful therapy to be a ' f i t ' among c l i e n t , therapist, and method. 3. Therapist-Offered F a c i l i t a t i v e Conditions require a non-judgmental 'unconditional' stance on the part of the helper; Working Alliance does not assume the necessity of a single s p e c i f i c attitude toward the c l i e n t . 3 7 Major di f ferences between Soc i a l Influence concepts and Working  Al1iance 1. Social Influence specifies that the helper should be perceived as 'expert, trustworthy, and a t t r a c t i v e ' ; Working Alli a n c e does not specify personal a t t r i b u t e s . 2 . Social Influence does not specify mutuality among patient and c l i e n t ; Working Alliance does emphasize such mutuality. 3 . Social Influence assumes that c l i e n t s improve because of therapist 'influence'; Working A l l i a n c e does not suggest assumptions regarding the 'mechanics' of helping. Major s i m i l a r i t i e s among the concepts of Work ing A l l i a n c e , Soc i a l Influence, and Therapist-Of fered Fac i 1 i tat ive Condi t ions 1. Each assumes that there are generic factors in therapy. 2 . Each places emphasis on a good relationship and attachments between helper and helpee. 3 . The three conceptualizations agree that the c l i e n t ' s perceptions mediate the meaning of the helper's actions. Chapter III The Development of the Working Alliance Inventory -- Logical Analysis This study was designed to explore the concept of Working Alliance and i t s relationship to alternative conceptualizations of generic process variables and therapy outcome. The task necessitated the development of an instrument capable of measuring the degree of Working Alliance that was present in a therapeutic relationship. This instrument, the Working Alliance Inventory (WAI), consisted of a questionnaire that assessed the c l i e n t ' s and therapist's awareness of q u a l i t i e s in the r e l a t i o n s h i p that were related to the dimensions of Working Alliance as defined by Bordin (1975, 1976). These a l l i a n c e dimensions (Task, Bond, and Goal) were c o n s t i t u t i v e l y defined in Chapter I. The inventory (WAI) was validated through l o g i c a l procedures and empirical analyses. The study consisted of four steps, each building on the results and findings of the previous step. The four steps were: 1) Item generation and construct va l i d a t i o n by selected experts, hereafter referred to as Phase I construct v a l i d a t i o n , 2) Additional item evaluation by a new group of experts, hereafter referred to as Phase II construct v a l i d a t i o n , 3) P i l o t testing of the Working Alli a n c e Inventory and the empirical procedures, and 4) Empirical or c r i t e r i o n - r e l a t e d v a l i d a t i o n . 39 Chapter III deals with the f i r s t two steps of the study, including a description of the design and discussion of the findings, under the general heading of Logical Analysis. Chapter IV contains the methodology and results of the p i l o t study as well as the design of the fourth ( c l i n i c a l ) phase of the research. Chapter V is devoted to the results of the c l i n i c a l explorations, and Chapter VI contains the discussion and interpretation of a l l the findings presented in the previous chapters. ITEM GENERATION The goal of this step of the study was the development of three item pools of approximately 30 items each. Each of the item pools referenced one of the three dimensions of the Working Al l i a n c e . The items were formulated to meet the following object ives: 1) Each pool of items should f a i r l y represent the universe of concepts related to one of the Working All i a n c e dimensions. 2) The individual items should be s p e c i f i c a l l y related (referenced) to the concepts and q u a l i t i e s embedded in the notions of the a l l i a n c e dimensions of Goal, Bond, or Task as defined by Bordin (1975, 1976). 3) Satisfactory items should discriminate between absence and presence of a construct to which they were referenced. 4 0 The following guidelines were observed in the formulation of the items: 1) Simple and straightforward phrasing of items. It was recognized that the adoption of th i s guideline would lead to items with a 'lower level of subtlety' (transparency). However, the value of the gain in relevance, r e a d a b i l i t y , and face v a l i d i t y attained by the use of simpler structures as opposed to more subtle ones has been supported in the l i t e r a t u r e (Holden & Jackson, 1979). 2) Several items were written referencing the same construct. It was considered desirable to allow the subsequent l o g i c a l analysis to select the most suitable items from these overlapping units. 3) An equal number of items was generated indicating strength and lack of A l l i a n c e . Preliminary to the actual generation of items the l i t e r a t u r e was reviewed in search of the kinds of items and methods of presentation that s a t i s f i e d these objectives. P a r t i c u l a r attention was paid to the items developed by Orlinsky and Howard (1966); Saltzman, Luetgert, Roth, Creaser, and Howard, (1976); Barrett-Lennard (1978); and Hartley (1978). The items found in the l i t e r a t u r e were used as models for the generation of the Working Alliance items. Items developed were c r i t i q u e d by two experienced psychotherapists and two senior doctoral students in counselling psychology. These psychologists, representing four d i f f e r e n t theoretical orientations (Gestalt, Behaviour Modification, Client Centered, and E c l e c t i c ) , permitted the evaluation of the 41 items' a c c e p t a b i l i t y in d i f f e r e n t therapeutic contexts. Particular attention was paid to the wording of the items. It was essential that, in keeping with the notion of a general factor, items should not contain words, expressions, or constructs which were unique to a pa r t i c u l a r treatment orientation or which had a connotation unique to a single therapeutic framework (e.g., transference, reinforcement). Each of the items was designed to capture a fe e l i n g , sensation, or attitude in the c l i e n t ' s f i e l d of awareness that would be present or absent depending on the strength of that p a r t i c u l a r relationship. For example, i f the c l i e n t decided that the statement "I f e e l uncomfortable with " described his or her feelings toward the therapist, this would imply a lack of a l l i a n c e in general, and poor personal bonds between helper and helpee in p a r t i c u l a r . Following the procedures and guidelines outlined above, 38 items were formulated referencing the Bond dimension, 30 items referencing the Goal dimension, and 23 items relevant to the Task dimension. The t o t a l number of items was 91. RATING OF THE ITEM POOL The item pool was rated by two groups of experts. The purpose of these ratings was to gather evidence for the construct v a l i d i t y of the items in the Working A l l i a n c e Inventory. The ratings were sequential, permitting the elimination and modification of items that were found to be unsatisfactory by the f i r s t group of raters. 42 Phase I_ Construct Validation The i n i t i a l pool of 91 items was rated in two ways: f i r s t , the raters were asked to indicate on a scale of one to f i v e , the degree of relevance of the items to the concept of Working All i a n c e ; second, they were asked to indicate which of the three components of the al l i a n c e (Goal, Task, or Bond) the item referenced. Instrumentat ion. In order to f a c i l i t a t e the rating procedure, the 91 items in the combined item pool were arranged on a form, with a five point Likert scale below each item (l=Not Related to A l l i a n c e ; 5=Alliance Item). In addition, the l e t t e r s 'B', 'G', and 'T' were printed to the right of each item. The rating package consisted of the following materials. 1) A l e t t e r explaining the research and s o l i c i t i n g the potential raters cooperation. 2) An instruction sheet explaining the procedure the raters were to follow. 3) Defi n i t i o n s of the Working Alliance and i t s components. 4) The 'face sheet' of the proposed Working All i a n c e Inventory. 5) The rating form. 6) Self-addressed stamped envelope for the return of the rating. The Phase I rating package i s presented in Appendix A. 43 The instruction sheet (item 2 ) explaining the rating procedures invited the raters to make comments or suggestions on the items in the questionnaire or on the scales in general. Preliminary drafts of the rating package were administered to four graduate students (two Doctoral, two Masters) in the Department of Counselling Psychology. Their comments provided valuable assistance toward the improvement o-f the f i n a l package. In addition the penultimate draft was c r i t i q u e d by two members of the Faculty of Education (U.B.C) with expertise in the f i e l d of testing and measurement. Sample. For the Phase I rating procedure a group of highly q u a l i f i e d experts was sought. An expert, for this part of the study, was defined as one who had authored a scholarly publication on the topic of the Working A l l i a n c e . A review of the l i t e r a t u r e covering the past ten years yielded the names of ten such scholars. Each of these individuals (one in Canada, nine in the United States) was sent an item rating package. One person could not be located; of the remaining nine, seven completed and returned usable questionnaires. Phase I_ Rat ing Results. Two summary s t a t i s t i c s were computed for each item: 1) The mean rating (M.R.) of the item, which equalled the arithmetic mean of the ratings assigned by the raters in response to the question 'Is t h i s item relevant to the Working Alliance?' Each respondent used a fiv e point scale defined as:'l=Not related to a l l i a n c e , . . . . 5=Alliance item.' 44 2) Percent agreement on dimension (P.A.), defined as the percentage of raters who c l a s s i f i e d an item in the 'correct' category. The correct category in th i s instance meant the Task, Bond, or Goal dimension to which the item i n i t i a l l y was referenced. P.A. was calculated by dividing the sum of correct ratings by the number of ratings received. The c r i t e r i a for the retention, rephrasing, or elimination of an item were decided on the basis of l o g i c a l considerations developed prior to the analyses of the returns. These c r i t e r i a were: An itern was retained 'as i s ' i f i t s M.R. was >4.0 and i t s P.A. was >70%. An itern was re-phrased i f i t met the f i r s t c r i t e r i o n , but two or more raters suggested improvements in phrasing of the item, or i f two or more raters categorised the item as f i t t i n g into more than one dimension. An item was rejected i f i t had a M.R. of <4.0 or P.A. <70%. Application of the above c r i t e r i a resulted in the retention of 59 items 'as i s ' , the rephrasing of 11 items, and the elimination of 21 items. Table 3.1 shows the actions taken with respect to each of the 91 items in the o r i g i n a l data bank. In the right hand column of the table the new item numbers are l i s t e d for the items retained for Phase II of the item rating procedure. 45 TABLE 3.1 Phase I Item Rating Results & Item Disposition (n of Raters= 7) I tern Domain Mean Agreement on Act ion New Item # Ra t i n g Dimension (%) Taken Number 1 G 4.8 85 Reta i ned 1 2 G 4.4 57 Deleted 3 G 4.0 85 Reta ined 2 4 G 4.8 71 Retained 3 5 G 4.8 100 Reta ined 4 6 G 4.2 85 Reta ined 5 7 B 4.2 100 Retained 6 8 B 4.7 85 Reta ined 7 9 B 4.7 85 Retained 8 10 T 3.9 42 Deleted 11 G 4.5 71 Reta ined g* 12 G 4.4 71 Retained 10* 13 G 4.2 83 Retained 11 14 G 4.0 71 Retained 12* 15 G 4.7 71 Retained 13 16 T 4.0 71 Reta i ned 14* 17 G 4.1 71 Reta ined 64* 18 T 4.0 71 Retained 68* 19 G 3.8 42 Deleted 20 T 4.2 85 Retained 15 21 T 4.7 71 Retained 16 22 T 4.5 85 Retained 17 23 T 4.2 '85 Retained 18 24 B 4.5 85 Retained 19 25 B 4.8 85 Reta i ned 20 26 T 4.1 71 Reta ined 21 27 G 4.8 71 Reta ined 22 28 B 4.6 83 Reta ined 23 29 T 4.8 85 Retained 24 30 T 4.8 71 Retained 25 31 T 4.7 71 Retained 26 32 T 4.5 83 Reta ined 27 33 T 4.6 85 Reta ined 28 '> 34 B 4.0 57 Deleted 35 T 4.8 71 Retained 29 36 T 4.2 71 Reta ined 30* 37 B 3.2 44 Deleted 38 T 4.7 71 Retained 31* * Items re-phrased. TABLE 3.1 CONTINUED Item Domain Mean Agreement on Action New Item # Rating Dimension (%) Taken Number 39 G 4.0 57 Deleted 40 T 3.7 57 Deleted 41 G 4.0 44 Deleted 42 • B 4.8 71 Retained 32 43 B 4.7 71 Reta i ned 33 44 B 4.7 100 Reta ined 34 45 B 3.6 57 Deleted 46 B 4.5 51 ' Deleted 47 B 4.8 66 Deleted 48 B 3.8 71 Deleted 49 G 4.5 66 Deleted 50 B 4.6 74 Retained 35 51 B 4.0 71 . Reta ined 36 52 B 4.8 ' 68 Deleted 53 T 4.2 71 Reta i ned 37 54 B 4.2 71 Retained 38 55 G 4.5 71 Reta ined 39 56 B 4.8 75 Reta ined 40 57 B 4.0 71 Reta i ned 66 58 B 4.0 71 Reta ined 41 59 B 3.8 57 Deleted 60 B 4.0 85 Reta ined 42 61 B 4.8 57 Deleted 62 G 4.6 85 Retained 67 63 B 4.2 57 Deleted 64 B 4.5 85 Reta ined 43 65 T 4.5 71 Retained 44 66 B 4.7 100 Reta ined 45 67 B 3.4 44 Deleted 68 G 4.0 66 Deleted 69 B 4.2 71 Retained 46 70 T 4.5 44 Deleted 71 T 4.5 71 Retained 47 72 B 4.0 57 Deleted 73 B 5.0 71 Retained 48 74 B 4.2 78 Retained 49 75 B 4.8 78 Retained 50 76 ; B 4.8 78 Retained 51 77 B 4.8 71 Retained 52 78 G 4.5 78 Retained 53 79 T 4.8 78 Retained 54 80 G 4.2 71 Retained 63* 81 G 4.2 76 Retained 55 * Items re-phrased. 47 TABLE 3.1 CONTINUED I tem # Doma in Mean Rat ing Agreement on Dimension (%) Act ion Taken New Item Number 82 G 4.0 78 Reta ined 69 83 G 4.2 71 Reta ined 56 84 G 4.5 71 Reta ined 57* 85 T 4.1 78 Reta i ned 58 86 G 4.0 71 Reta i ned 59 87 B 4.2 78 Reta i ned 60 88 B 4.5 78 Reta ined 61 89 G 4.4 71 Retained 62 90 G 4.0 71 Reta ined 65* 91 G 4.8 78 Reta i ned 70 * Items re-phrased. Table 3.2 Phase I Item Rating Summary: A l l Items (n of Ra t e r s = 7 ) Domain Number of items Mean Rat ing Standard Deviat ion Percent Agreement Goal Bond Task 30 38 23 4.33 4.36 4.39 .31 .44 .33 70.1 73.0 74.6 Total 91 4.36 37 72.4 Table 3.2 shows the summary s t a t i s t i c s for a l l the items in the o r i g i n a l item pool while Table 3.3 displays the same information for the 70 items remaining in the item bank at the end of Phase I. 48 The f i r s t phase of Construct Validation appeared successful: Table 3.3 Phase I Item Rating Summary: Retained Items (n of Raters= 7) Domain Number Mean of items Rating Standard Deviation Percent Agreement Goal Bond Task 24 26 20 4.38 4.50 4.45 30 31 29 76.1 80.0 75.8 Total 70 4.44 30 77.5 weak items were i d e n t i f i e d and eliminated, phrases that appeared to be ambiguous were detected, and helpful expert advice was obtained for their improvement. On the whole, the average M.R. of 4.44 for the retained items gave support to the v i a b i l i t y of the instrument, while the average P.A. of 77.5% indicated that experts were capable of distinguishing items among the three target domains. Phase 11 Construct Validation Instrumentation. Experience gained in Phase I suggested the need for some changes in the instrumentation. S p e c i f i c a l l y three al t e r a t i o n s were made: 1) instructions to raters were c l a r i f i e d regarding the items that were negatively worded with respect to the Al l i a n c e ; 49 2) i t was found that the 'face sheet' of the proposed instrument did not contain any information that was essential to the raters, and therefore t h i s material was omitted from the Phase II mailing; and 3) the anchor points for the raters, displayed on the top margin of each page of the rating form were extended from: '1=N0T RELATED TO ALLIANCE.... 5=ALLIANCE ITEM' to '1=N0T RELEVANT TO ALLIANCE. 2=SLIGHTLY RELEVANT. 3=S0MEWHAT RELEVANT. 4=RELEVANT. 5=HIGHLY RELEVANT TO ALLIANCE'. The last a l t e r a t i o n was made to f a c i l i t a t e more precise location of the rating points. The Phase II Item Rating protocol contained: 1) a personalized l e t t e r , signed by the researcher and the chairman of the dissertation committee, s o l i c i t i n g the co-operation of the raters, 2) instructions for completing the questionnaire, 3) d e f i n i t i o n s of the Working Alliance and i t s dimensions, 4) the 70 item rating form, and 5) a self-addressed stamped return envelope. A copy of the Phase II protocol is provided in Appendix B. Sampling. Subjects for the second phase of the construct validation were practicing c l i n i c a l or counselling psychologists registered with the B r i t i s h Columbia Psychological Association (B.C.P.A.). These subjects were expected to have some f a m i l i a r i t y with the concept of Working A l l i a n c e . They represented a population which, given the d e f i n i t i o n of the a l l i a n c e and i t s components, was believed to be able to u t i l i z e their training and expertise to render q u a l i f i e d judgments with 50 respect to the v a l i d i t y of the items. From the current (1979) membership l i s t of the B.C.P.A., 215 psychologists who met the c r i t e r i a were i d e n t i f i e d . Of this population 100 were randomly selected. Fifteen individuals were eventually eliminated because they had been exposed to some aspects of th i s research (n=8); were known to be r e t i r e d or no longer p r a c t i c i n g (n=4); or had moved out of the country (n=3). The remaining 85 individuals were sent item rating material early in June 1979. Phase 11 Rating Results. The subjects were requested to return their questionnaires within a week. Fourteen days after the material was sent, 15 responses were received. In order to ascertain the reason for the low rate of return and to improve the response rate, a 100% telephone follow-up of the non-responding subjects was undertaken. Fifty-one successful contacts were made over the next ten days. These phone c a l l s resulted in an additional 6 returns. Evidence from the follow-up procedure indicated that the reason for the r e l a t i v e l y poor response was that a large proportion of the subjects were either just going or were away on vacation. The t o t a l number of responses for Phase II was 21, or 24.7% of the sample. A l l the returns were usable. Analysis of Phase 11 Rat ings. The analysis of Phase II was designed to produce a penultimate version of the Working Alliance Inventory. Individual item s t a t i s t i c s , based on the ratings of the 21 respondents are presented in Table 3.4. 51 TABLE 3.4 Phase II Item Rating Results & Item Disposition (N. of Raters=21) I tem Domain Mean Agreement on Action New Item # Rat ing Dimension (%) Taken Number 1 G 4 . 52 95 Retained 30 2 G 4.57 86 Deleted 3 G 4.13 81 Deleted 4 G 4.67 95 Retained 22 5 G 4.52 100 Reta ined 27 6 B 4.43 76 Deleted 7 B 4.52 86 Reta ined 19 8 B 4.57 81 Retained 21 9 G 4.61 43 Deleted 10 G 4.33 33 Deleted 11 G 4.00 62 Deleted 12 G 4.38 54 Deleted 13 G 4.29 71 Deleted 14 T 4.10 71 Deleted 15 T 4 . 25 53 Deleted 16 T 4.48 88 Reta ined 24 17 T 4.33 94 Retained 2 18 T 4.10 76 Retained 31* 19 B 4 . 38 94 Retained 8 20 B 4.24 100 Retained 23 21 T 3.81 47 Deleted 22 G 4.19 88 Retained 9 23 B 4.33 100 Retained 28 24 T 4.12 100 Retained 4 25 T 3.87 71 Deleted 26 T 4.15 76 Retained 16* 27 T 4.38 76 Retained 15 28 T 4.11 85 Retained 11 29 T 4 . 05 95 Deleted 30 T 4 .14 95 Retained 6 31 T 4 . 57 72 Retained 13 32 B 4.57 100 Deleted 33 B 4.61 90 Deleted 34 B 4.56 100 Retained 17 35 B 4.33 95 Deleted 36 B 4.43 76 Deleted 37 T 3.62 38 Deleted 38 B 4.24 95 Retained 1 39 G 4.48 81 Retained 14 40 B 4.38 95 Retained 29 * Items re-phrased. 52 TABLE 3.4 CONTINUED Item Domain Mean Agreement on Action New Item # Rating Dimension (%) Taken Number 41 B 4.00 85 Deleted 42 B 3.48 76 Deleted 43 B 4.14 90 Deleted 44 T 4.12 81 Retained 35 45 B 4.31 95 Retained 26 46 B 4.10 81 Deleted 47 T 4.29 43 Deleted 48 B 4.29 71 Deleted 49 B 4.14 100 Deleted 50 B 4.28 100 Deleted 51 B 4.48 95 Reta ined 36 52 B 4.57 81 Deleted 53 G 4.14 70 Reta i ned 25* 54 T 3.75 95 Deleted 55 G 4.48 72 Reta ined 7 56 G 4.00 62 Deleted 57 G 4.24 81 Retained 34 58 T 4.19 91 Retained 33 59 G 4.19 47 Deleted 60 B 4.29 95 Deleted 61 B 4.62 95 Retained 5 62 G 4.28 47 Deleted 63 G 4.52 86 Retained 10 64 G 4.38 58 Deleted 65 G 4.24 76 Retained 12 66 B 4. 57 100 Retained 20 67 G 4.25 57 Deleted 68 T 4.10 100 Retained 18 69 G 4.10 94 Retained 3 70 G 4.50 85 Reta ined 32 : Items re -phrased. Summary s t a t i s t i c s of the Phase II ratings for a l l items are shown in Table 3.5 . Phase II results were generally consistent with the results obtained from the f i r s t phase, providing additional confidence in the v a l i d i t y of the items. The decrease in the v a r i a b i l i t y of the items supported the notion that each successive rating of 53 the item pool would eliminate ambiguous items. Table 3.5 Phase II Item Rating Summary: A l l Items (n of Raters=21) Domain Number Mean Standard Percent of items Rating Deviation Agreement Goal 24 4.33 .19 73.5 Bond 26 4.34 .25 87.4 Task 20 4.13 .23 78.7 Total 70 4.27 .24 79.9 The application of the o r i g i n a l item c r i t e r i a (discussed under Phase I construct validation) resulted in the elimination of 15 items (9, 10, 11, 12, 15, 21, 25, 37, 42, 47, 54, 59, 62, 64, 67) and the re-phrasing of three items (18, 26, 33). The remaining 55 items constituted the f i n a l item pool from which the actual items for the Working All i a n c e Inventory were selected. There were several conditions which had to be considered in designing the f i n a l instrument. In order to provide s u f f i c i e n t r e l i a b i l i t y scales of 10 items or more were desirable. P r a c t i c a l considerations c a l l e d for a questionnaire of 45 items or less which would keep the administration time below 30 minutes. The above constraints suggested an inventory of between 30 and 45 items or 10 to 15 items per domain. 54 Some of the items on the rating form referenced very similar concepts due to the provision of item overlap in the item generation phase. A selection procedure was designed to reduce redundancy (overlap) and at the same time maximize construct v a l i d i t y . The items in each of the three item pools were separated into 'content a f f i n i t y c l u s t e r s ' . These clusters consisted of items that o r i g i n a l l y referenced the same or clos e l y related concepts. The sorting was done by the researcher, based on the c r i t e r i a used at the item generation phase. The l i s t was then referred to a practicing psychotherapist to v e r i f y the researcher's judgments. There were 13 clusters in the Bond dimension, 12 in the Task dimension, and 12 in the Goal dimension. The 13 clusters in the Bond dimension were re-examined and the two clusters with the most similar content were pooled resulting in an equal number of cl u s t e r s in each of the three subscales (12). The 'best' item from each of the clusters was chosen to represent the underlying concept. The judgment of which item was the 'best' in each cluster was based on the P.A. values. The P.A. values were used at this stage in preference to the M.R. figures based on the rationale that a high P.A. value indicated an item that was referencing a construct that was unique to that p a r t i c u l a r scale. At this stage of the vali d a t i o n process the P.A. figure was seen as the more discriminating indicator of construct v a l i d i t y . The summary s t a t i s t i c s for the f i n a l 36 items selected for inclusion in the Working Al l i a n c e Inventory are presented in Table 3.6. Table 3.6 Phase II Item Rating Summary: Retained Items (n of Raters=21) Domain Number Mean Standard Percent of items Rating Deviation Agreement Goal 12 4.38 .19 85.3 Bond 12 4.43 .14 94.8 Task 12 4.23 .16 86.2 Total 36 4.35 .18 88.7 The items were arranged in random order in the Inventory. Under each item a five point Likert-type scale was printed to enable the respondents to indicate the degree to which they f e l t that the item described their relationship to the therapist. The use of the five point scale was explained on the 'face sheet' of the Working Alliance Inventory. In addition, anchor statements defining the meaning of each of the scale points were printed on the top margin of each page of the questionnaire. This version of the Working All i a n c e Inventory is presented in Appendix C. 56 Chapter IV The P i l o t Study and the Design of the C l i n i c a l Study This step in the investigation consisted of two parts: 1. The p i l o t study. This study had two objectives: a) to p i l o t test the Working Alliance Inventory, and b) to f i e l d test the procedures to be used in the f i n a l , c l i n i c a l study. 2. The c l i n i c a l study. This portion of the study also had two objectives: a) to explore the relat i o n s h i p between Working Alliance and the concepts of Empathy, Attractiveness, Trustworthiness, and Expertness, and b) to investigate the effica c y of the Working Alliance Inventory as a predictor of therapeutic success. In this chapter the instruments used in the remainder of the study are described. This is followed by the presentation of the design and findings of the p i l o t study. The chapter concludes with the description of the design and analysis for the c l i n i c a l study, the results of which are presented and discussed in Chapter V. INSTRUMENTATION The instruments discussed below were used in both the p i l o t and the c l i n i c a l phases of the study. Minor changes and refinements made to the instruments between these two parts of the research are s p e c i f i c a l l y noted under the heading 'Revisions of the Instrumentation and Procedures' in the penultimate section of t h i s chapter. Copies of a l l the instruments 57 discussed in this section are contained in Appendix C. Working All i a n c e Inventory --Client Form (WAIc) The development of the Working Alliance Inventory was described e a r l i e r in Chapter I I I . The f i n a l form of the instrument consisted of 36 items, 12 items per domain. Each of the items was a statement referencing an aspect of the cl i e n t - t h e r a p i s t relationship. Below each item there was a five point Likert scale. The meaning of each point on the Likert scale was defined on the face sheet of the inventory and repeated on the top margin of each page. The subjects were asked to indicate the degree to which the statement characterized their relationship by c i r c l i n g the appropriate number below the item. Working All i a n c e Inventory --Therapist Form (WAIt) In preparation for the c l i n i c a l study a therapist version of the Working Alliance Inventory was developed. The inclusion of the therapist's point of view of the al l i a n c e was important for several reasons: f i r s t , to permit an examination of the s i m i l a r i t i e s and differences between the therapist's and the c l i e n t ' s perception of the a l l i a n c e ; second, to f a c i l i t a t e the comparison of the relationship of the a l l i a n c e components and Empathy from the therapist's and c l i e n t ' s points of view; and l a s t l y , to f a c i l i t a t e the evaluation of the convergent v a l i d i t y of the WAI instruments. The WAIt was developed from the WAIc by re-phrasing the individual items of the WAIc. There were three possible points of reference that might have been used to re-formulate the items: 58 1) the therapist's b e l i e f s or experiences in therapy, 2) the therapist's impression of the c l i e n t ' s b e l i e f s or experiences, or 3) the therapist's impression of the c l i e n t ' s impression of the therapist's experience or b e l i e f s . I n i t i a l l y the approach was to adopt one of the above three alternatives and use i t exclusively throughout the instrument. However, attempts to use one option exclusively resulted in some awkward items. Therefore the f i r s t alternative (therapist's experience) was used wherever feasible in order to obtain direct 'first-hand' evidence. However other points of reference were also used when the therapist-referenced statement would have resulted in awkward items, or would have altered the focus of the item. The f i n a l wording of the items was v e r i f i e d for c l a r i t y and parallelism with the source items from the WAIc by two experienced psychotherapists. The Relationship Inventory (R-I) The Relationship Inventory (Barrett-Lennard, 1962) was designed to measure four dimensions of the interpersonal relationship --Empathy, Unconditionality, Level of Regard, and Congruence. These dimensions are based on Rogers's (1957) concepts of necessary conditions for therapeutic change. The instrument has 16 items in each subscale y i e l d i n g 64 items in t o t a l . The background of t h i s instrument and a summary of the subsequent empirical investigations of the R-I scale were discussed in Chapter II (Table 2.1) along with data indicating the rel a t i o n s h i p of Empathy with the other f a c i l i t a t i v e conditions and outcome research. Because the R-I scales tend 59 to be highly correlated, only the most 'representative' of the four scales --Empathy-- was analysed in this study. (A more detailed exposition of the rationale for choosing Empathy to represent the concepts measured by the R-I is presented in Chapter II.) Scoring of the R-I. The subjects responded to the R-I by assigning a value of +3, +2, +1, -1, -2, or -3 to each item. A response of +3 s i g n i f i e d strong agreement, whereas the response of -3 indicated strong disagreement with the item. The R-I is normally scored by multiplying the value assigned to the negatively worded items by -1, and summing the scores of a l l of the items in a given scale. This method of scoring results in a discontinuous scale (without '0' values) which proved to be inconvenient in some aspects of the numerical analysis. It was decided, therefore, to recode the subjects' responses (after correcting for polarity) by assigning the value of 1 to the -3 responses, 2 to the -2 responses, 3 to -1, 4 to +1, 5 to +2 and 6 to the +3 responses. This procedure s i m p l i f i e d the analysis without loss of information. Throughout the text, Empathy scores refer to scores derived by this transformation. In the tables and in certain parts of the text, the abbreviation EMPH is used for Empathy. Counselor Rat ing Form (CRF) The Counselor Rating Form (LaCrosse, 1977) measures the dimensions of Attractiveness (ATTRACT), Trustworthiness (TRUST), and Expertness (EXPERT). These dimensions and their theoretical foundation in Social Psychology were discussed in some d e t a i l in Chapter II. Empirical evidence of the 6 0 r e l i a b i l i t y of the CRF was discussed in Chapter II and summarized in Table 2.3. The Counselor Rating Form consists of 36 items with 12 items referencing each of the dimensions of Attractiveness, Trustworthiness, and Expertness. The items of the CRF are adjective pairs of opposite meaning (e.g., Attractive Repulsive). Between each of these pairs of adjectives there are seven spaces indicated. The subject responded to the rating form by selecting one of these spaces and marking i t with an 'X'. The position of the 'X' indicated the respondent's perception of the therapist. For example, i f the subject's response appeared as: Attractive _X Repulsive th i s would indicate that this person's therapist was perceived as more repulsive than a t t r a c t i v e . The closer the mark is made to the l e f t or right adjective, the more the therapist is i d e n t i f i e d with that descriptor. The CRF is scored by assigning the integers 1-7 to the points between the adjectives and summing the scores of the 12 items (after correction for pola r i t y ) belonging to each scale. Client Posttherapy Questionnaire (CPQ) The Client Posttherapy Questionnaire (Strupp et a l . , 1964) is a retrospective measure of c l i e n t perceived change. It contains 23 items, 11 of which pertain d i r e c t l y to therapy outcome (Questions 5, 7, 8, 16, 17a, 17b, 17c, 18, 19, 20, 22). The other 12 items relate to demographic information and pre-treatment status; only the 11 therapy outcome oriented questions were used in the analysis. 61 A retrospective evaluation instrument was chosen in preference to other alternatives for the following reasons: 1) The c l i e n t ' s (and the therapist's) view of outcome i s prima facie evidence of change (Cartwright, 1975); 2) Empirically, the CPQ has adequate correlations with other recognized outcome measurements (Cartwright, Kirtner, & Fiske, 1963; Klein, 1960; Nichols & Beck, 1960); 3) Evidence has been accumulating that an underlying homogeneous composite index of improvement was captured by retrospective measurements (Cartwright et a l . , 1963; Nichols & Beck, 1960; Strupp, Wallach, & Wogan, 1964); 4) The instrument appeared suitable for adaptation for therapist use; and 5) Cartwright, in his analysis of outcome assessments recommended that: Since the patient's o v e r a l l retrospective views of treatment success appear to be a very necessary part of appraisal, some verson of the Client Posttherapy Questionnaire should d e f i n i t e l y be included in a research battery (1975, p. 58). Scoring of the CPQ. The items referencing psychotherapy outcome were examined with a view to extracting a smaller number of factors underlying these 11 items. There were two possible methodologies to accomplish t h i s : an empirical approach, using one of the factor analytic data reduction techniques, or a l o g i c a l approach based on judgments of item content. Because the r a t i o of subjects to variables was low, the factor analytic procedures would have yielded an unstable solution, hence the l o g i c a l approach was chosen. A panel of five psychotherapists (including the researcher) independently sorted the items into 62 groups each referencing a single construct. Four of the five raters agreed on the following groupings: Group 1: Items 5, 18, 19 Group 2: Items 7, 8, 22 Group 3: Items 16, 17a, 17b, 17c, 20 The concept underlying group 1 was named Adjustment, group 2 S a t i s f a c t i o n , and group 3 Change. In the view of the panel of raters the sorting resulted in subgroups which were c l i n i c a l l y meaningful. Subsequent numerical analysis of outcome data in this study is presented in terms of the three subscores derived from the Posttherapy Questionnaires: Adjustment (ADJ), Satisfaction (SAT), and Change (CHG). In the computational procedures (except in the c a l c u l a t i o n of the internal consistency indi c i e s where raw scores were used) the subjects' scores on each scale were standardized (Mean=0, S.D.=1). The formula used for standardization was Zi=(Xi-X)/S.D.x where Zi is the standardized score for subject i on scale X, Xi is the subject's corresponding raw score, X is the subscale mean, and S.D.x is the standard deviation for scale X. In addition to the three subscale scores, a Composite score --the sum of the three standardized subscale scores-- was also used in the analysis. The Therapist Posttherapy Questionnaire (TPQ) The Therapist Posttherapy Questionnaire was an adaptation of the CPQ constructed to provide a p a r a l l e l outcome indicator based on the therapist's judgment. The rationale to include a therapist's evaluation amongst the outcome measures was based on the findings that suggested that the therapist tends to capture 63 a portion of the outcome variance that is quite independent of the c l i e n t ' s point of view (Garfield et a l . , 1971; Luborsky, 1971; Mintz, 1977; Strupp, 1978). Since the non therapy-related (demographic) CPQ items were redundant on the TPQ form, they were omitted. In addition CPQ item #22 (How strongly would you recommend psychotherapy/counselling to a close friend?) was not suitable for a therapist oriented questionnaire. It too was omitted. As the result of these deletions, the TPQ questionnaire had 15 items in t o t a l in contrast to the CPQ's 23 items, and the TPQ form had 10 outcome related items, whereas the CPQ form had 11. (The remaining five items dealt with pre-therapy conditions; these were not analysed.) Scoring of the TPQ. The scoring procedures used for the TPQ form were i d e n t i c a l to those for the CPQ. Demographic Data Sheet This questionnaire, completed by the therapist, was designed to gather the following information on the therapists: professional a f f i l i a t i o n , highest degree earned, number of years of experience, and theoretical orientation used with this c l i e n t . 64 THE PILOT STUDY Subjects of the P i l o t Study The subjects for this phase of the study were graduate students enrolled in a course in basic c l i n i c a l s k i l l s in the Department of Counseling Psychology at The University of B r i t i s h Columbia. In the summer of 1979 three sections of th i s course were offered. Two of the three sections were using the model developed by Egan (1975) as the basis of their training and student dyads formed c l i e n t - t h e r a p i s t pairs to practice counselling s k i l l s . During the course these dyads participated in over 10 one-hour interviews. The t h i r d section also used the Egan training method but changed ' c l i e n t ' and 'counsellor' pairs on a weekly basis. The stucture of the f i r s t two sections was closely analogous to short term counselling or psychotherapy. Although there are obvious differences between a counselling relationship that i s established as part of a training program and the relationship established between a professionally trained helper interacting with a c l i e n t seeking help, i t has been observed by the instructors teaching this course that the student ' c l i e n t s ' often risk dealing with some of their real personal concerns during these sessions. It has also been noted that the students performing the counselling role appeared highly motivated to respond in a very r e a l i s t i c and professional manner. Although each student in these two sections acted both as counsellor and c l i e n t , they did not interchange roles 65 within the same relationship. To reduce the p o s s i b i l i t y of contamination, each student was a subject only once in the p i l o t study; either as a c l i e n t or as a counsellor. After securing the instructors' cooperation, the classes were approached and the general nature of the research was explained to them. The researcher emphasized that the responses would be anonymous and c o n f i d e n t i a l , and that no questionnaire response would be shared with the instructor of the c l a s s . Of the 30 students in the two sections approached, 29 agreed to p a r t i c i p a t e in the research. P i l o t Study Procedures The p i l o t study had two data c o l l e c t i o n points, one after the t h i r d and one after the tenth session of an analog counselling s i t u a t i o n . After the t h i r d session, each subject-pair (subject-pair refers to a 'counsellor' and a ' c l i e n t ' dyad) completed the appropriate form of the Working Alli a n c e Inventory and the Relationship Inventory. In addition, c l i e n t s were administered the Counselor Rating Form and the therapists responded to the Demographic Data Sheet. The order in which the subjects responded to these questionnaires was specified in the instructions, and the response orders were randomized over the subject population. A l l the materials were completed p r i v a t e l y , and c o n f i d e n t i a l i t y was guaranteed to each respondent. The research material was sealed in individual envelopes and returned to the researcher by the counsellor. 66 Following the tenth session the subjects were asked to respond to the appropriate outcome assessment instrument (CPQ or TPQ). After the therapists and c l i e n t s p r ivately completed the forms, these were sealed in self addressed envelopes and returned to the researcher. The inventories had no personal i d e n t i f i c a t i o n of the c l i e n t or the therapist ensuring t o t a l anonymity of the subjects. The testing material was coded, however, to permit the i d e n t i f i c a t i o n of a l l the materials obtained from a p a r t i c u l a r c1ient-therapist pa i r . RESULTS OF THE PILOT TESTING PHASE The 29 subjects provided 14 completed protocols. Although the subjects responded to a l l the instruments used in the study only the responses to the WAIt (Therapist) and WAIc (Client) forms of the Working A l l i a n c e Inventory were analysed. The aim of this analysis was to estimate r e l i a b i l i t y of the inventory and i t s subscales, and to examine individual item correlations with t o t a l questionnaire and subscale scores. The method of estimating r e l i a b l i t y in this study was based on the c r i t e r i o n of item homogeneity. The actual analysis was ca r r i e d out using the LERTAP (Nelson, 1974) program on the AHMDAL II computer at the University of B r i t i s h Columbia. Item le v e l results of t h i s analysis are presented in Appendix D. The program uses Hoyt's (1941) method of c a l c u l a t i n g an index of r e l i a b i l i t y based on internal consistency. The generic term ' r e l i a b i l i t y estimates' in t h i s and a l l further discussion, refers to r e l i a b i l i t y  estimates based on internal consistency. 67 Estimates of the composite r e l i a b i l i t y were based on Cronbach's (1951) procedure. The value that was derived, Cronbach's Alpha, is an index of the degree to which the di f f e r e n t subtests measure similar underlying constructs. Table 4.1 Hoyt's R e l i a b i l i t y C o e f f i c i e n t s of the WAI n = 14 Dimension N of Items Mean S.D. Hoyt Cronbach Goal (C) 1 12 43.86 5.30 . 63 (T) 2 12 40.00 4.90 .68 Task (C) 12 46.46 4.01 . 51 (T) 12 44 . 29 4.12 . 57 Bond (C) 12 48.29 4.84 . 77 (T) 12 43.36 4 .62 .72 Composite (C) 36 138.86 11.92 (T) 36 127.64 10.29 C l i e n t s ' data (WAIc). t h e r a p i s t s ' data (WAIt). Table 4.1 summarizes the results of this stage of analysis. In the review of the subtest r e l i a b i l i t y of the Working All i a n c e Inventory, the effect of the homogenous therapeutic orientation of the p i l o t sample (cf. p. 68) was taken into account. It was expected that t h i s factor would r e s t r i c t the v a r i a b i l i t y of the subjects' responses and therefore lower the r e l i a b i l i t y estimates. The decision was made to proceed with the WAI without major revisions with the expectation that with the more varied sample of the c l i n i c a l study, the r e l i a b i l i t y would improve. This decision was supported by the results of the 68 c l i n i c a l portion of the study (cf. Table 5.1). The next stage of the analysis involved an examination of item l e v e l data. S p e c i f i c a l l y , individual item correlations with subscale and t o t a l inventory scores were evaluated. Theoretically, a good item would display a moderate correlation with the t o t a l test and a strong correlation with i t s own subtest. The reversal of this pattern ( i . e . , low correlaton with the subtest) would indicate a p o s s i b i l i t y that the item was sampling a construct that is di f f e r e n t from the other items in the subtest. Items with low correlation or having patterns of correlation markedly d i f f e r e n t from the ideal described before were evaluated. As a result of this evaluation two items in the Task domain were substantially revised (Nos. 3, 24). In several other cases minor grammatical changes were made. The researcher decided that the revisions at this stage should be conservative. This decision was influenced by the nature of the population of the p i l o t study. Twelve out of the 14 'therapists' in the sample indicated that they were using a c l i e n t centered model. The ' c l i e n t s ' also received the same training program as the therapists and, presumably, had 'client centered expectations' of the therapy process. It was f e l t that, under these circumstances, some items would exhibit low item subtest correlation as an a r t i f a c t of sample bias with respect to theoretical orientation. In p a r t i c u l a r , the items in the Task and Goal dimensions might have appeared to the p i l o t sample as less relevant or germane.to the kind of helping process in which they were engaged. Additionally i t was 69 probable that the r e s t r i c t e d nature of the sample also limited the v a r i a b i l i t y of the responses. In addition to the item analysis of the WAI, the returns were scrutinized for evidence of procedural d i f f i c u l t i e s with the other measuring instruments and the administration procedure 1. As a result, a few grammatical changes were made in the TPQ form of the Posttherapy Questionnaire and, in addition, the instructions to the therapist that accompanied the instruments were s l i g h t l y revised. It was noted at the same time that the general response to the procedure was highly favorable. The only negative comments received were in response to items in the outcome measuring instrument that were not relevant to the analog s i t u a t i o n , (e.g. Whose decision was i t to terminate these sessions?). Revision of the Instrumentation and Procedures The following changes were made to the instruments as a result of the p i l o t testing experience. Items 3 and 24 of the Task scale were revised, as discussed under the heading 'Results of the P i l o t Study'. The wording of two questions on the TPQ form was s i m p l i f i e d . Procedures outlined on the cover sheet that accompanied the testing material were revised and clar i f ied. JDuring the i n i t i a l discussion with the student subjects, remarks and comments on the procedures and/or d i f f i c u l t i e s with any of the tests were s p e c i f i c a l l y requested. 7 0 The f i n a l form of a l l the instruments used in the c l i n i c a l study constitutes Appendix E. THE CLINICAL STUDY Design of the C l i n i c a l Study The design of thi s phase of the investigation was b a s i c a l l y i d e n t i c a l to the design of the p i l o t study. The important d i s t i n c t i o n between these two phases of the investigation was that, while the p i l o t study used an analog counselling s i t u a t i o n , the subjects in the c l i n i c a l study participated in genuine psychotherapy. In addition, the c l i n i c a l study was based on therapy experiences that encompassed the broad variety of psychotherapy applications and a variety of therapy orientations. The widened scope of the c l i n i c a l study permitted the exploration of the a l l i a n c e components in a variety of psychotherapy experiences. The Sample Twenty-three potential sample sources were approached and asked to participate in the study. Some of these sources were agencies, others were individual therapists or counsellors. In each of these cases the researcher made a personal presentation that covered the nature and scope of the research, the broad outline of the study, the amount of time the procedures would take, and the safeguards on c o n f i d e n t i a l i t y and anonymity. The 15 sources that indicated interest or willingness to par t i c i p a t e in the project received instructions regarding the subject 71 selection c r i t e r i a . During the research no information was given to the potential subjects regarding the hypothesized structure of the Working A l l i a n c e . Indeed, the use of the term Working Al l i a n c e was avoided. The research was discussed in terms of an exploration of the structure of the therapeutic relationship. Because of the anonymity guaranteed to the agencies as well as the subjects, the geographical d i s t r i b u t i o n of the sample can only be approximated in terms of potential sources. The data that follow are based on sources agreeing to cooperate with the project. Not a l l of these sources contributed subjects. Thirteen of the 15 sources were located in the lower mainland of B r i t i s h Columbia, two on Vancouver Island, and one in the United States. Table 4.2 displays the location of the sources and the number of therapists within each source who volunteered to participate in the research. Note again that not a l l of the therapists who agreed to cooperate became part of the sample. The research design permitted a therapist to appear in the sample more than once, however n_o c l i e n t appears in the sample on more than one occasion. The 15 data sources covered a broad range of therapy services; fi v e of the sources were individual psychotherapists or counsellors and 10 were agencies. The fiv e individuals each provided a wide range of therapy services; three of these five received f i n a n c i a l compensation in whole or part d i r e c t l y from their c l i e n t s . The others, as well as a l l the agencies involved, were funded by t h i r d p a r t i e s . Three of the agencies served a university population, two specialized in problems related to drug-abuse, one was in the f i e l d of forensic psychiatry, one specialized in treating c l i e n t s suffering from phobic disorders, and three were Mental Health Centers with s p e c i f i c geographical catchment areas. The remaining three agencies provided a broad range of mental health services. Table 4.2 Location of Sample Sources and Number of Therapists Source # Locat ion No. of Therapists Volunteer ing 1 Vancouver B.C. 1 2 Port Coquitlam B.C. 3 3 Burnaby B.C. 3 4 Surrey B.C. 5 5 Vancouver B.C. 4 6 Vancouver B.C. 2 7 Vancouver B.C. 1 8 Vancouver B.C. 1 9 V i c t o r i a B.C. .4 10 Portland U.S.A. 2 11 Surrey B.C. 1 12 Vancouver B.C. 1 13 Vancouver B.C. 1 14 Vancouver B.C. 2 15 North Vancouver B.C. 1 Total=15 Total=32 7 3 Client Selection C r i t e r i a . C l i e n t s were e l g i b l e to participate in the research project i f they met the following c r i t e r i a : 1) The primary service received by the c l i e n t from the pa r t i c i p a t i n g agency or therapist was, at the time of the research, individual psychotherapy or counselling. Although a c l i e n t may have received adjunctive therapies of d i f f e r e n t kinds (occupational therapy, vocational counselling or the l i k e ) in each instance - - i n the view of the person in charge of the c l i e n t ' s case-- individual therapy was the major service offered to the subject. 2) The c l i e n t had to be age 16 or over. 3) The c l i e n t was not diagnosed as psychotic. 4) The c l i e n t - t h e r a p i s t r e l a t i o n s h i p was a 'new' relationship. That i s , the c l i e n t did not receive therapy from his/her therapist during the 12 months preceding this relat ionship. 5) The c l i e n t was able and w i l l i n g to give informed consent to participate in the project. DATA PREPARATION AND ANALYSIS Data Preparation Questionnaires returned from the f i e l d were coded and keypunched. Prior to analysis a 17% random error check was carri e d out on the coding process; the error rate was 0.6%. The keypunching of the coded data was 100% v e r i f i e d . A l l 7 4 subsequent data analyses and management were handled via the computing f a c i l i t i e s of The University of B r i t i s h Columbia. Analysi s The analysis of the results of the c l i n i c a l study focused on two major areas: 1) The r e l i a b i l i t y of the instruments used in the study. 2) The construct v a l i d i t y of the WAI. The r e l i a b i l i t y of the WAI scales was estimated through the calc u l a t i o n of internal consistency c o e f f i c i e n t s . The construct v a l i d i t y of the WAI was assessed by: 1) a m u l t i t r a i t multimethod matrix, and 2) the examination of the extent to which the WAI measurements were predictive of psychotherapy outcome. In addition, the r e l a t i v e e f f i c a c y of the predictor variables (GOAL, TASK, BOND, EMPH, TRUST, EXPERT, ATTRACT) when used in combination was explored. This l a s t analysis was carried out using stepwise multiple regression analysis. 7 5 Chapter V Results This chapter begins with a description of the demographic c h a r a c t e r i s t i c s of the sample, followed by an examination of the r e l i a b i l i t y of the instruments used in the study. Next, evidence pertaining to the convergent and divergent v a l i d i t y of the WAI i s introduced. This section is followed by the presentation of the c o r r e l a t i o n a l relationships of the Working Alliance dimensions with the other process variables monitored in the study. The chapter concludes with an examination of the relationship of the Working All i a n c e Inventory dimensions to outcome. DEMOGRAPHIC CHARACTERISTICS OF THE SUBJECTS The results of this study are based on the 29 protocols that were completed by the data c o l l e c t i o n deadline. It should be noted that, since a therapist may have participated in the study more than once, and since there was no way of id e n t i f y i n g a therapist on the basis of the returns, the therapist data includes some duplications. There are no duplications in the c l i e n t data. Therapi sts The following professions were represented in the sample: Counsellors (n=16), Psychologists (n=10), Social Workers (n=2). One therapist did not report t h i s information. These descriptors represent either the t i t l e assigned to a therapist . 76 by an agency or the therapist's own statement of professional ident i ty. Ten therapists had doctoral degrees, eight had masters degrees, while seven l i s t e d the highest degree completed at the bachelors l e v e l . Education l e v e l was not reported in four cases. Of the ten therapists with a doctorate, six had Ph.D.'s and four had Ed.D.'s. The masters l e v e l subjects could be further subdivided into M.A.'s (3), M.Ed.'s (2), M.S.W.'s (2), and M.Sc.'s (1). At the baccalaureate l e v e l 1 there were four B.A.'s and three B.Ed.'s. Four therapists did not report their l e v e l of t r a i n i n g . Ten therapists had between one and five years of experience; eleven had six to ten years of experience; and three had more than 15 years of experience. Data were not reported in fiv e cases. The therapists were asked to indicate the therapy orientation they used with their c l i e n t . Of the 29 persons who completed this part of the questionnaire, ten categorised their therapy orientation as Client Centered; eight as Behaviour Modification; four as E c l e c t i c ; three as Gestalt; two as Analytic; and one each as Jungian and E x i s t e n t i a l . Sundland and Barker (1962) has cautioned against the use of therapist self report as an indication of therapeutic orientation; nonetheless, the above information may provide a general index of the degree of d i v e r s i t y amongst therapies offered to the c l i e n t s . 1 The baccalaureate level therapists were students enrolled in a graduate program f u l f i l l i n g practicum or residency requi rements. 77 Cli e n t s The mean age of the c l i e n t sample was 34.6 years. The youngest c l i e n t was 19 years of age, the oldest 65. There were more female c l i e n t s (17) than male (12). Most of the c l i e n t s were married (15); of the remaining, six were single, seven divorced, and one separated. The majority of the c l i e n t s (17) had completed a university degree, five were in university, and four were high school graduates. Educational data were incomplete on three subjects. RELIABILITY ESTIMATES OF THE MEASURING INSTRUMENTS Work ing Alliance Psychological inventories used in the f i e l d have reported r e l i a b i l i t y c o e f f i c i e n t s ranging from .61 to .93 (LaCrosse, 1977; Barrett-Lennard, 1962; Dahlstrom, Welch, & Dahlstrom, 1975). The internal consistency estimates of the WAI subscales, calculated using Hoyt's (1941) paradigm, are shown in Table 5.1. An inspection of Table 5.1 reveals that a l l but one of the WAI scales' r e l i a b i l i t i e s compare favorably with those reported for similar inventories in the f i e l d . The exception is the Therapist's Bond scale. The lower internal consistency of this scale of the WAIt may be attributed, in part, to the r e l a t i v e l y lower v a r i a b i l i t y of the therapists' responses on this scale (S.D.=5.10). 78 Table 5.1 R e l i a b i l i t y Estimates of The Working All i a n c e Inventory n = 29 Dimension N of Items Mean S.D. Hoyt 1 Cronbach 2 Client Form (WAIc) GOAL 12 45.21 9.14 .88 TASK 12 45.10 8.85 .88 BOND 12 49.07 7.02 .85 COMPOSITE 36 139.38 23.63 .93 Therapist Form (WAIt) GOAL 12 44.86 8.03 .87 TASK 12 45.03 6.83 .82 BOND 12 47.59 5.10 . 68 COMPOSITE 36 137.48 18.05 .87 hoyt's estimate of r e l i a b i l i t y (Hoyt, 1941). 2Cronbach's Alpha for composite (Cronbach, 1951). The Cronbach's Alphas reported in Table 5.1 are indices of homogeneity of the to t a l inventory. A high value indicates that subscales of an instrument measure closely related concepts. The obtained Alpha c o e f f i c i e n t s of .93 and .87 for the WAIc and WAIt respectively raise the p o s s i b i l i t y that the three subscales within each of the instruments were measuring a uni-dimensional underlying concept. This finding together with other results pertaining to thi s issue are discussed in the next chapter. 79 Table- 5.2 displays the inter-scale correlations of the WAIc and the WAIt r e s p e c t i v e l y 1 . These correlation c o e f f i c i e n t s indicated a very strong rel a t i o n s h i p amongst these scales, in agreement with the high Cronbach's Alpha noted above. The Table 5.2 Intercorrelation Coefficients of the WAI. GOAL TASK TASK (Therapist) .83 (Client) .88 BOND (Therapist) . 69 .59 (Client) .84 . 79 interscale correlations were higher in the case of the c l i e n t s ' instrument (WAIc) than the therapists' (WAIt), though the correlation between the Goal and Task scales of the l a t t e r was also high. These findings also pertain to the question of the unidimensionality of the WAI, and are evaluated in the next chapter. Counselor Rating Form (CRF) Hoyt's r e l i a b i l i t y c o e f f i c i e n t s of the CRF are presented in Table 5.3. The values in Table 5.3 compare s a t i s f a c t o r i l y with the values reported by LaCrosse (1977) (cf. Table 2.3). The high Cronbach's Alpha of .88 indicates that the CRF may be measuring a u n i f a c t o r i a l underlying concept. 1 C u r v i l i n e a r i t y of these and a l l subsequent correlations discussed in thi s chapter were evaluated by inspection of the scatterplots. 80 Table 5.3 R e l i a b i l i t y Estimates of the Counselor Rating Form (CRF) n = 29 Dimension N of Items Mean S.D • Hoyt 1 Cronbach 2 ATTRACTIVENES 12 74 .07 7. 34 .86 EXPERTNESS 12 71 .34 8. 27 .84 TRUSTWORTHINESS 12 75 .17 8. 24 .87 COMPOSITE 36 220 .59 21. 52 .88 'Hoyt's estimate of r e l i a b i l i t y (Hoyt, 1941). 2Cronbach's Alpha for composite (Cronbach, 1951). Table 5.4 Intercorrelation C o e f f i c i e n t s of the CRF Dimensions n = 29 ATTRACT EXPERT .72 .61 .69 Table 5.4 contains the correlation c o e f f i c i e n t s among the CRF subscales. The correlation c o e f f i c i e n t s obtained also suggest a strong relationship among the concepts measured by these scales. Empathy Table 5.5 summarizes the internal consistency (Hoyt's r e l i a b i l i t y ) estimates of the R-I Empathy scale. The values obtained were comparable to those found by previous investigators using this instrument (see Table 2.1). EXPERT TRUST 81 Table 5.5 R e l i a b i l i t y Estimate of the Empathy Scale as Measured By The R-I n = 29 Dimension N of Items Mean1 S.D. Hoyt 2 EMPATHY c l i e n t therapi st 16 16 40.86 39. 57 12.94 10.72 .89 .88 'For the procedure used to score the R-I see Chapter IV.-2Hoyt's estimate of r e l i a b i l i t y (Hoyt, 1941). The Outcome Measurements Table 5.6 presents the internal consistency estimates of the CPQ and TPQ versions of the outcome questionnaire. As discussed in the previous chapter, the outcome instrument was subdivided into three subscales based on a l o g i c a l evaluation of the items. Internal consistency estimates are reported for each of the three subscales: S a t i s f a c t i o n , Adjustment, and Change, as well as Cronbach's Alpha for the composite outcome score. In evaluating the estimates of the r e l i a b i l i t y , the number of items in each of the scales must be kept in mind, since r e l i a b i l i t y estimation is affected by the length of the scale (Cronbach, 1970). A scale with fewer items i s l i k e l y to have a lower Hoyt value than a similar scale of greater length. For example, the low Hoyt value of .37 for the TPQ S a t i s f a c t i o n scale is probably partly due to the fact that this scale had only two items. However, the fewer items in the S a t i s f a c t i o n scale do not e n t i r e l y account for the low r e l i a b i l i t y . The data available are i n s u f f i c i e n t to explain the remaining discrepancy. Overall, with the exception noted above, the 82 outcome scales appeared to have sati s f a c t o r y internal consistency. Table 5.6 R e l i a b i l i t y Estimates of the C l i e n t N = 29 Outcome Measures. Dimension N of Items Mean S.D. Hoyt 1 Cronbach 2 Client form (CPQ) SATISFACTION 3 5.83 2.83 .87 CHANGE 5 13.26 5.00 .88 ADJUSTMENT 3 7.38 2.'.60 .77 COMPOSITE 11 26.47 8.40 .65 Therapist form (TPQ) SATISFACTION 2 5.83 1.77 .37 CHANGE 5 15.74 3.84 .75 ADJUSTMENT 3 7.86 2.61 .81 COMPOSITE 10 29.43 6.30 .55 'Hoyt's estimate of r e l i a b i l i t y (Hoyt, 1941). 2Cronbach's Alpha for composite (Cronbach, 1951). The Cronbach's Alphas of .65 and .55 for the CPQ and the TPQ, respectively, indicate that the outcome subscales probably represented more than one underlying factor. This finding supports the approach taken e a r l i e r on l o g i c a l grounds of subdividing the outcome questionnaire into components representing d i f f e r e n t aspects of outcome. The comparison of the Cronbach values across the two di f f e r e n t forms of the instrument suggests the p o s s i b i l i t y that the therapist version of the instrument (TPQ) or the therapists themselves, were more discriminating than the c l i e n t s ' form (CPQ) and/or the c l i e n t s 83 themselves. One additional set of data i s presented in this section, although these findings do not bear d i r e c t l y on the question of the instrument's r e l i a b i l i t y . The subscale means, as presented in Table 5.6, are not readily interpretable because the values are dependent on the numbers of items in the scale and on the di f f e r e n t number of response a l t e r n a t i v e s . For the purpose of inter-scale comparison the formula ^ 1 X i / y , * " N was developed. In this formula X* represents the adjusted mean, Xi i s the raw score 1 on question i , Yi is the number of alternative responses in question i , M is the number of items in the scale, and N is the number of individuals. The values derived from this transformation range from 1.0 for the highest posi t i v e outcome to 0.0 for the most negative outcome. Adjusted Means (X*) Table 5.7 of the Outcome n = 29 Instruments CPQ TPQ ADJUSTMENT .69 .64 SATISFACTION .83 .62 CHANGE .63 .48 COMPOSITE .71 . 58 Inspection of these values (presented in Table 5.7) shows that 1 The items were scored by assigning positive sequential integers to the response alternatives, s t a r t i n g with 1 for most negative outcome option. the 84 the therapist rated outcomes of therapy were somewhat less positive than the c l i e n t s ' rating. This trend is in agreement with the findings of LaCrosse (1977) and Mintz (1977).' In addition there appears to be some indication that both c l i e n t s and therapists rated the l e v e l of Change lower than either Satisfaction or Adjustment. CONVERGENT VALIDITY OF THE WORKING ALLIANCE INVENTORY Evidence of convergent and discriminant v a l i d i t y of the WAI was evaluated using the m u l t i t r a i t , multimethod matrix procedure developed by Campbell and Fiske (1959). The m u l t i t r a i t , multimethod matrix i s presented in Table 5.8. This matrix can be subdivided into four conceptually meaningful components: 1) the r e l i a b i l i t y diagonal (figures in bracket), 2) the heterotrait monomethod triangles (enclosed in broken l i n e s ) , 3) the heteromethod heterotrait triangles (enclosed in s o l i d l i n e s ) , and 4) the v a l i d i t y diagonal (values underlined). The r e l i a b i l i t y diagonal and the adjacent heterotrait monomethod tria n g l e make up a monomethod block. A heteromethod block is made up of the v a l i d i t y diagonal and the heterotrait heteromethod triangles lying on either side of i t . 85 Campbell & Fiske (1959) specified four conditions that bear on the question of an instrument's v a l i d i t y : 1) The items on the [ v a l i d i t y ] diagonal should be s i g n i f i c a n t l y d i f f e r e n t from zero and s u f f i c i e n t l y large to encourage further examination of v a l i d i t y . 2) [ The value on the] v a l i d i t y diagonal should be higher than the values lying on i t s column and row in the heterotrait heteromethod t r i a n g l e . 3) A variable [should] correlate higher with an independent e f f o r t to measure the same t r a i t than with measures designed to get at di f f e r e n t t r a i t s which happen to employ the same method... This involves comparing i t s values in the v a l i d i t y diagonals with i t s values in the heterotrait monomethod tri a n g l e s . 4) A fourth desideratum i s that the same pattern of t r a i t i n t e r r e l a t i o n s h i p be shown in a l l of the heterotrait triangles of both the monomethod and heteromethod blocks. (p. 82-83). Table 5.8. M u l t i t r a i t Multimethod Matrix of the Relationship Variables C L I E N T Bond Task Goal Emph CLIENT Bond Task Goal Emph ( .85) I .79\ ( .88) .84 83 .88"^  J .88) 63 .62" ( .89) THERAPIST Bond Task Goal Emph T H E R A P I S T Bond \.4 3 .50 .55 J .68) Task .46s- ^.66 .33 | .59^ Goal .55 . 7 5 s s.48 1 ( .69 Emph .53 .32 .48 s 1 .74 4^.82) .83\ ( .87) .49 60^^.88) 86 The ' t r a i t s ' in Table 5.8 were the three Working All i a n c e domains 'and Empathy. (The l a t t e r was included because of i t s close theoretical a f f i n i t y to the Working All i a n c e Bond dimension.) The 'methods' were the source of data ( i . e . , therapist and-client). The f i r s t of these four conditions pertains to the convergent v a l i d i t y of a test, the l a s t three bear on the discriminant v a l i d i t y of the instrument. Analysis of Table 5.8 indicates that: 1) The v a l i d i t y c o e f f i c i e n t s of the Working A l l i a n c e Inventory were s i g n i f i c a n t l y d i f f e r e n t from zero. 2) The Task and Goal scales s a t i s f i e d the second c r i t e r i o n proposed by Campbell & Fiske. It was noted, however, that the c o r r e l a t i o n between the therapist Goal and the c l i e n t Task scales was only .01 less than the corresponding v a l i d i t y c o e f f i c i e n t ( Task r= .76). 3) None of the WAI dimensions met the t h i r d Campbell & Fiske c r i t e r i o n . 4) A l l three of the WAI domains met the c r i t e r i o n of similar patterns of i n t e r r e l a t i o n s h i p s in the heterotrait triangles (condition four). In summary, there is evidence supporting the convergent v a l i d i t y of the WAI scales. These findings also offer some support of the discriminant v a l i d i t y of the WAI Goal scale. There is also some evidence supporting the discriminant v a l i d i t y of the scale measuring the Task domain. Evidence regarding the discriminant v a l i d i t y of the Bond scale is equivocal; while the elevated c o r r e l a t i o n between Bond and Empathy was explicable on the basis of the s i m i l a r i t y of the underlying constructs, the 87 strong relationship between c l i e n t ' s Bond and therapist's Goal scales suggests the p o s s i b i l i t y that the concepts underlying these two scales were conceptually d i f f i c u l t to d i f f e r e n t i a t e . THE RELATIONSHIP BETWEEN THE WORKING ALLIANCE DIMENSIONS AND ATTRACTIVENESS, TRUSTWORTHINESS, EXPERTNESS, AND EMPATHY Table 5.9 presents the values of the correlations among the relationship variables based on the c l i e n t reported data. Inspection of these values reveals that the Working Alliance dimensions have a stronger rel a t i o n s h i p to Empathy than to any of the social-psychological dimensions measured by the CRF. Table 5.9 Relationship Between the WAIc and Empathy n = 29 the CRF Dimensions and GOAL TASK BOND EMPATHY ATTRACTIVENESS .22 . 33 .38 .38 EXPERTNESS .29 .39 .28 .29 TRUSTWORTHINESS .08 .23 .05 .09 EMPATHY . 63 .63 .83 1.00 Of the CRF dimensions, Trustworthiness appeared to be unrelated to a l l the other variables except for a low-moderate relationship to the WAIc Task dimension (r= .23). The Expertness scale i s moderately related to a l l of the other scales, with a stronger relationship to the WAIc Task domain. Attractiveness had the least correlation with Goal and a moderate relationship with a l l of the other scales. 88 The correlations between Empathy and the WAI indicate that the Alliance dimensions and Empathy share some common variance, with Empathy and Bond showing a strong relationship. The strong c o r r e l a t i o n between Empathy and Bond was expected on the basis of the l o g i c a l structure of these concepts. Empathy, on the other hand, appeared unrelated to Trustworthiness and showed a stronger a f f i n i t y to Attractiveness. Expertness and Attractiveness share approximately the same amount of common variance with Empathy and the Working Alli a n c e dimensions. It is possible that a minimum l e v e l of a l l of these attributes are common to a l l therapeutic relationships. The independence of the Trustworthiness scale from a l l but the Task dimension may indicate that the therapist was judged Trustworthy on the basis of perceptions and feelings r e l a t i v e l y independent of Goals and Bond but perhaps related somewhat more to s p e c i f i c therapy events. Table 5.10 Relationship Between the Therapist Working Alli a n c e Domains and Therapist Reported Empathy n = 29 GOAL : TASK BOND EMPATHY .60 .49 .74 Table 5.10 presents the relationship of the therapist reported Working Alliance dimensions and Empathy. The highest correlation found was between Bond and Empathy. This c relationship was expected to be strong because of the s i m i l a r i t y of the concepts underlying these two scales. The weakest relationship was between Task and Empathy; th i s too was 89 expected, since the Task domain is the most 'behavioural' of the Working All i a n c e dimensions whereas the Empathy scale is designed to capture mostly the a f f e c t i v e components of the relationship (Rogers et a l . , 1967). Inspection of the correlations (Table 5.9) among the relationship dimensions appears to support the notion that the Working Alliance domains are d i s t i n c t from the soc i a l psychological dimensions measured by the CRF. The observed relationships further suggest that Empathy and the Working All i a n c e domains are more related to one another than to the CRF scales. Amongst the Working Alliance dimensions Bond was perceived by both therapists and c l i e n t s as most nearly i d e n t i c a l to Rogers's concept of Empathy, while the Task dimension was seen as the most d i s t i n c t . THE RELATIONSHIP BETWEEN THE OUTCOME CRITERIA AND THE RELATIONSHIP MEASURES The co r r e l a t i o n between each of the process variables and the outcome is presented in Table 5.11 for the c l i e n t s and Table 5.12 for the therapists. To provide protection against an elevated experiment-wise error that would accrue through testing each of the correlation c o e f f i c i e n t s separately, Steiger's (1980) X s t a t i s t i c was used to test the hypotheses whether, in each matrix, a l l population c o e f f i c i e n t s were equal to zero. In both instances, these hypotheses were rejected at the .05 le v e l of significance. 90 Clients The zero order correlations between the c l i e n t reported outcome and the c l i e n t reported relationship variables are shown in Table 5.11. Table 5.11 Zero Order Correlation Coefficients of the Client Relationship and Outcome Variables n = 29 SAT CHNG ADJ COMP WAIc .50* . 33* .22 .42* TASK .65* .45* .31 .57* BOND .32 .23 .21 .31 GOAL .40* .24 .09 .30 EMPH .11 .05 .26 .15 ATTRACT -.07 -.06 .03 -.05 TRUST .02 -.10 .16 .01 EXPERT .15 .09 .14 .15 * p<.05 An overview of the results leads to the following general observations: 1) The composite a l l i a n c e score (as measured by the WAIc) was s i g n i f i c a n t l y related to the composite outcome score. Additionally, the composite a l l i a n c e score was s i g n i f i c a n t l y correlated with the Satisfaction and Change outcome subscales; however, the correlation between the composite a l l i a n c e measure and the Adjustment component of the outcome is not s i g n i f i c a n t . 91 2) The Alliance dimensions Task, Bond, and Goal, though highly correlated amongst themselves, appeared to relate to the outcome scales d i f f e r e n t i a l l y . The Task dimension of the al l i a n c e correlated s i g n i f i c a n t l y with a l l but the Adjustment outcome subscales --though to d i f f e r e n t degrees-- whereas the Bond dimension did not correlate s i g n i f i c a n t l y with the outcome scores, and the Goal dimensions had s i g n i f i c a n t zero order cor r e l a t i o n only with the Sat i s f a c t i o n outcome scale. 3) In this study Empathy f a i l e d to correlate s i g n i f i c a n t l y with any of the outcome scales. 4) None of the s o c i a l psychological dimensions (Attractiveness, Trustworthiness, Expertness) measured by the CRF correlated beyond chance levels with the outcome scales at the p<.05 level of si g n i f i c a n c e . Therapists Table 5.12 displays the zero order correlations of the therapist reported relationship dimensions and the therapist reported outcome. The findings may be summarised thus: 1) The composite Working Alliance score, Empathy, and the a l l i a n c e dimension scores a l l correlated s i g n i f i c a n t l y with the composite outcome score. 2) A l l of the above relationship variables also correlated s i g n i f i c a n t l y with the Sa t i s f a c t i o n outcome subscale. 3) The composite Al l i a n c e score and two of the Alli a n c e dimensions —Bond and Task-- correlated s i g n i f i c a n t l y (p<.05) with the Change outcome subscale. 92 4) None of the Working Al l i a n c e scores had a s i g n i f i c a n t zero order correlation with Adjustment. Table 5.12 Zero Order Correlation C o e f f i c i e n t s of the Therapist Relationship and Outcome Variables n = 29 SAT CHNG ADJ COMP WAI t .66* .38* .27 . 52* TASK .68* .37* . 32 . 54* BOND .48* .47* .16 .48* GOAL .60* .22 .25 . 39* EMPH .54* .31 .03 . 34* * p<.05 Regression Analysis In spite of the evidence of high i n t e r c o r r e l a t i o n amongst the a l l i a n c e dimensions, the examination of the relati o n s h i p of these variables with the outcome subscales suggested that there may be c l i n i c a l usefulness in the exploration of d i f f e r e n t i a l predictive e f f i c a c y amongst the al l i a n c e dimensions. In order to investigate which variable, or combination of variables, would be the most useful outcome predictors, a set of multiple stepwise regression equations was developed using the relationship variables as independent variables to predict each of the outcome dimensions. Additionally, these equations were used to examine the relationship among the variables to discover i f any overlap existed in terms of the explained variance referenced by these variables. 93 It was noted that these regression equations are subject to 'shrinkage'. Upon r e p l i c a t i o n , the predicted portion of the variance is expected to diminish in proportion to the r a t i o of the number of cases to the number of independent variables. The lower the cases to variable r a t i o , the greater the expected 'shrinkage' in predicted variance (Kerlinger & Pedhazur, 1973). Normally, a r a t i o of 30 subjects per independent variable is desirable to derive a 'stable' equation; this condition was not met in this investigation. The analyses presented in this chapter, however, were implemented in the context of an exploratory investigation. No interpretation can be drawn from these analyses beyond the sample in the study. The p r o b a b i l i t y l e v e l of .05 for entry or deletion of a variable into the regression equation was set only in order to select a parsimonious subset of variables. S i m i l a r l y , the increment of explained variance (R 2) associated with the independent variables was reported only as an indication of the r e l a t i v e contribution of the variables to the explained variance i_n this  study. Two sets of equations were generated for each of the c l i e n t and therapist reported data. The f i r s t set of equations explored the questions pertaining to the relationship of the Alliance domains and used the Bond, Goal, and Task scales as independent variables. The second set of equations dealt with a l l of the relationship measures used in the study. The computations presented in the remainder of this chapter were carried out on the computing f a c i l i t i e s at the University of B r i t i s h Columbia using the regression analysis program *TRP (Lee 94 & Teni c i , 1979) . Client Data A summary of the stepwise regression equations based on the Alliance domains and c l i e n t data i s presented in Table 5.13. These equations were generated using the composite outcome and each of the outcome variable subscales in turn as dependent variables, and a l l of the a l l i a n c e dimensions as potential independent variables. No regression equation was generated using the Adjustment scale as the dependent variable since none of the a l l i a n c e dimensions correlated s i g n i f i c a n t l y at the p < .05 l e v e l with this variable. A review of Table 5.13 suggests that, of the three Alliance Dimensions, the Task domain was the most e f f i c i e n t predictor of c l i e n t reported outcome. In addition, i t was noted that while the Bond dimension contributed s i g n i f i c a n t l y to the prediction of the c l i e n t ' s s a t i s f a c t i o n (after the variance due to.Task had been removed), i t did not enter into the equation predicting the Composite outcome or Change scores. Similarly the Goal dimension made s i g n i f i c a n t contribution to the explanation of the variance in the Composite outcome score (Equation I) but did not enter into the equations using the other outcome subscores as dependent variables. Given the high i n t e r - c o r r e l a t i o n among the dependent variables, these regression equations must be interpreted with caution (Kerlinger & Pedhazur, 1973). Nonetheless i t appears that the meaningfulness of the a c t i v i t i e s engaged in during therapy as seen from the c l i e n t ' s point of view, and reflected by the WAIc Task scale, is related beyond chance le v e l to some 95 Table 5.13 Stepwise Regression Analyses (Client Data) Working All i a n c e Variables Equation I Dependent variable: Composite outcome n = 29 P to enter/delete=.05 R2=.48 F probability= .000 Variables Entered Increment in R2 Task .33 Goal .15 Variables Remaining F-prob Bond .60 Equation II Dependent variable: S a t i s f a c t i o n n = 29 P to enter/delete=.05 R2=.53 F probability= . 000 Variables Entered Increment in R2 Task .43 Bond .10 Variables Remaining F-prob Goal .17 Equation III Dependent variable: Change n = 29 P to enter/delete=.05 R2=.20 F probability= .013 Variables Entered Increment in R2 Task .20 Variables Remaining F-prob Bond .26 Goal .09 96 aspects of therapy outcome (as reported by the c l i e n t after the tenth session) in this study. In p a r t i c u l a r such relationships appear to exist with composite outcome scores, scores measuring c l i e n t perceived Change and, most notably, S a t i s f a c t i o n . On the basis of this sample, there were some tentative indications that, in addition to Task, the Bond dimension might be useful in predicting c l i e n t s a t i s f a c t i o n . In addition, the Working Alliance Goal domain seems to be linked to a portion of the Composite outcome score that is independent of the Variance predicted by Task. F i n a l l y , i t was noted that the proportion of variance (R 2) predicted in Change was small in comparison to the amount of variance predicted in the Sa t i s f a c t i o n and Composite outcome scores. The regression equations generated using a l l of the relationship variables are presented in Table 5.14. These equations were developed to select the most e f f i c i e n t predictors of outcome from a l l of the process variables. The results of Equation VI were i d e n t i c a l to Equation III, suggesting that the social-psychological variables and Empathy did not improve s i g n i f i c a n t l y the accuracy of predicting c l i e n t change compared to the prediction based on Task alone in this study. Equation V suggests that, although the zero order correlation between Satisfaction and Bond (r= .32) was greater than between Sa t i s f a c t i o n and Empathy (r= .11), Empathy appeared to be more independent of the factor referenced by Task than Bond. As a result of the greater portion of unique variance related to i t , Empathy displaced Bond as the second variable in the equation predicting S a t i s f a c t i o n . 97 Table 5.14 Stepwise Regression Analyses (Client Data) A l l Process Variables Equation IV Dependent variable: Composite outcome n = 29 p. to enter=.05 R2=.56 F probability=.000 Variables Entered Task Goal Attract iveness Increment in Rz .33 .14 .08 Variables Remaining Bond Empathy Trustworthiness Expertness F-prob .94 .38 .95 .25 Equation V Dependent variable: S a t i s f a c t i o n n = 29 p. to enter=.05 Variables Entered Task Empathy R2=.57 F probability=.000 Increment in R2 .43 .15 Variables Remaining Bond Goal Attractiveness Trustworthiness Expertness F-prob .64 .07 .09 .21 .49 98 TABLE 5.14 CONTINUED.. Equation VI Dependent variable: Change n = 29 p. to enter=.05 R2=.20 F probability=.013 Variables Entered Increment in R2 Task .20 Variables Remaining F-prob Bond .25 Goal .09 Empathy .07 Attractiveness .20 Trustworthiness .24 Expertness .59 Equation IV, on the other hand i s somewhat unusual. The f i r s t two variables entering the equation correspond to the results of Equation I using only the Working All i a n c e variables; however, although the variable Attractiveness had a neg l i g i b l e zero order correlation (r=-.05) with the dependent variable, i t contributes s i g n i f i c a n t l y to the explanation of the variance remaining after the variance due to the Task and Goal dimensions has been removed. It appears that Attractiveness was functioning as a supressor variable in this system (Cohen & Cohen, 1976). As noted before, these equations were developed for the purpose of exploration, not explanation, and therefore the interpretations attached to them must be treated as highly tentat ive. 99 Therapist Data Tables 5.15-5.16 summarize the regression analysis using the therapist reported data. No analysis using the Adjustment outcome subscale is reported, since none of the therapist reported a l l i a n c e dimensions correlated s i g n i f i c a n t l y with that outcome at the p<.05 l e v e l of significance (See Table 5.12). In each of the six stepwise regression equations calculated, only one independent variable entered into the equation. That is to say, after the variance due to the independent variable with the highest zero order correlation with the dependent variable had been removed, none of the remaining variables 'explained' a s i g n i f i c a n t proportion of the variance remaining. The Alliance dimension of Task accounted for approximately 29% of the variance in the therapist reported composite outcome (Eq. VII) and approximately 47% of the therapists' estimation of c l i e n t s a t i s f a c t i o n (Eq. VIII). In th i s study the Bond dimension of the Alli a n c e scale accounted for 22% of the variance in the therapist estimate of c l i e n t change (Eq. IX). Introduction of the other therapist reported process variable --Empathy-- did not alter the result of the regression equations (Table 5.16). This can be interpreted to mean that therapist reported Empathy did not s i g n i f i c a n t l y enhance the prediction of any of the outcome variables. 1 0 0 Table 5.15 Stepwise Regression Analyses (Therapist Data) Working Alliance Variables Equation VII Dependent variable: Composite outcome n = 29 P- to enter/delete=.05 R2=.29 F probability=. 002 Variables' Entered Increment in R2 Task .29 Variables Remaining F-prob Bond Goal .24 . 61 Equation VIII Dependent variable: S a t i s f a c t i o n n = 29 P- to enter/delete=.05 R2=.47 F probability=. 000 Variables Entered Increment in R2 Task .47 Variables Remaining F-prob Bond Goal . 53 .61 Equation IX Dependent variable: Change n = 29 P- to enter/delete=.05 R2=.22 F probability=. 009 Variables Entered Increment in R2 Bond .22 Variables Remaining F-prob Task Goal .53 .53 101 Comparison of the regression equations based on Client (Eq. I-VI) and Therapist data (Eq. VII-XII) suggests that: 1. The c l i e n t reported independent variables were more efficac i o u s predictors of c l i e n t based Composite outcome than the therapist reported independent variables in predicting therapist reported Composite outcome. 2. The c l i e n t reported variables predicted a s l i g h t l y higher proportion of the s a t i s f a c t i o n outcome than the variables based on the therapist report. 3 . In general, the Task dimension of the Working Alliance Inventory tended to be the most e f f i c i e n t predictor of outcome of brief psychotherapy. The one exception to this trend was the therapist's estimate of c l i e n t change; this outcome was most e f f i c i e n t l y predicted by the Bond dimension of the WAI. 4. The amount of variance predicted in the Change outcome component was r e l a t i v e l y small. 5. No combination of therapist or c l i e n t reported Alliance dimensions correlated s i g n i f i c a n t l y with the Adjustment subscale of the outcome instrument. 102 Table 5.16 Stepwise Regression Analyses (Therapist Data) A l l Variables Equation X Dependent variable: Composite outcome n = 29 p. to enter=.05 R2=.29 F probabi1ity=. 002 Variables Entered Increment in R2 Task .29 Variables Remaining F-prob Bond Goal Empathy .23 .61 .59 Dependent Equation XI variable: S a t i s f a c t i o n n = 29 p. to enter=.05 R2=.47 F probability=. 000 Variables Entered Increment in R2 Task .47 Variables Remaining F-prob Bond Goal Empathy . 53 .61 .10 Equation XII Dependent variable: n = 29 Change p. to enter=.05 R2=.22 F probability=. 009 Variables Entered Increment in R2 Bond .22 Variables Remaining F-prob Task Goal Empathy .53 .52 .72 103 A special note of caution must be repeated regarding the values associated with R2 or 'explained variance' in the equations reproduced in thi s section (Tables 5.13-5.16). Due to the size of the sample, the expected 'shrinkage' of these values on re p l i c a t i o n would be high (Kerlinger & Pedhazur, 1973). These calculations, and indeed the conclusions drawn from them in this and the following chapter, are used in the context of an exploratory study. The aim of these explorations was to investigate some broad questions r e l a t i n g to the measurabi1ity and structure of the Working A l l i a n c e . Inasmuch as ' s i g n i f i c a n t relationships' were found between some of the all i a n c e dimensions and some of the outcome indicators, these can be considered positive signs pointing to areas for further exploration. The size or strength of the relationships found by this study needs to be confirmed by future investigations. 104 Chapter VI Conclusions and Discussion The major focus of the study was the construction and vali d a t i o n of a paper-and-penci1 instrument to measure the concept of Working Alliance as defined by Bordin (1975, 1976). After a review of the l i t e r a t u r e on the measurement of therapy process variables, 91 items were generated. T h i r t y - f i v e of these items referenced the Bond, 33 referenced the Goal, and 23 items referenced the Task dimension of the Working Alliance Inventory. (The d e f i n i t i o n s of the Working All i a n c e dimensions are provided on page six of t h i s document). A two step rating procedure was devised to v e r i f y the construct v a l i d i t y and refine these items: 1) A group of seven expert raters evaluated: a) the relevance of the items to the Working All i a n c e Inventory, and b) categorized the items as referencing either the Bond, Task, or Goal component of the A l l i a n c e . Items that did not meet pre-defined c r i t e r i a of v a l i d i t y (mean rating and percent agreement) were eliminated. 2) The remaining 70 items were re-rated by a d i f f e r e n t group of 21 raters. Unsatisfactory items were eliminated,, using the c r i t e r i a specified in step 1. The 55 items remaining in the item pool were then sorted into 12 groups of highly similar items within each Alliance dimension, and from each group the item with the best percentage agreement rating was selected for inclusion in the Working 105 Alliance Inventory. A therapist version of the Working Alliance Inventory was developed by re-phrasing each of the items to r e f l e c t the therapist's perception of the A l l i a n c e . Empirical validation of the Working Al l i a n c e Inventory consisted of the administration of the appropriate version of the instrument to therapist and c l i e n t dyads after the t h i r d therapy interview. At t h i s time, subjects also completed two other instruments: the Empathy scale of the Relationship Inventory (Barrett-Lennard, 1962) and the Counselor Rating Form (LaCrosse, 1977). Seven therapy sessions l a t e r , an outcome questionnaire (an adaptation of the Client Posttherapy Questionnaire (Strupp et a l . , 1964)) was administered to the therapists and the c l i e n t s . The procedure and the instruments were f i r s t p i l o t tested in an analog environment. After evaluation of the results of the p i l o t test and f i n a l refinements of the WAI, the c l i n i c a l study was conducted with 29 therapist c l i e n t dyads representing a variety of therapeutic orientations. The results of the c l i n i c a l study were evaluated for evidence of the r e l i a b i l i t y and construct v a l i d i t y of the Working Al l i a n c e Inventory. This evaluation was based on c o r r e l a t i o n a l evidence among the process variables and the evaluation of the relationship of the Working Alliance Inventory variables with outcome. In addition, the data were explored for evidence pertaining to the taxonomy of the Working Alliance dimensions. 106 SUMMARY OF THE MAJOR CONCLUSIONS The results of this study indicate that progress has been made toward the development of an instrument (WAI) that measures the participants' perception of the therapeutic Working A l l i a n c e . There is s u f f i c i e n t evidence for the v a l i d i t y and r e l i a b i l i t y of the Working All i a n c e Inventory to consider the instrument suitable for research use. Although the question of the uniqueness of the individual a l l i a n c e domains (Bond, Goal, and Task) has not been resolved, i t appears that at least one of the subscales (Task) is s u f f i c i e n t l y linked to therapy outcome to warrant exploration of i t s c l i n i c a l u t i l i t y . In addition, i t was found that, in this study, the WAI was a more e f f i c i e n t outcome predictor than perceived Empathy or the Social Influence dimensions of Attractiveness, Trustworthiness, and Expertness. THE PSCHYCHOMETRIC PROPERTIES OF THE WAI R e l i a b i l i t y The adequacy of the WAI's r e l i a b i l i t y was examined to determine whether reasonable progress had been made toward development of an instrument that would be useful in research and perhaps a limited c l i n i c a l a p p l i c a t i o n . To this end the internal consistency ( r e l i a b i l i t y ) values were evaluated in comparison to other c l i n i c a l l y similar psychometric tools. 107 Examination of other self-report inventories (cf. Dahlstrom et a l . , 1975; Gurman, 1977) indicated that the WAI's composite r e l i a b i l i t i e s of .93 and .83 (Cronbach's Alpha) for the WAIc and the WAIt forms respectively were within the range expected for this kind of an instrument. Five out of the six subscales also compared favorably to subscales of similar length and subject matter (Gurman, 1977). The sixth --WAIt Bond-- scale, had a somewhat lower r e l i a b i l i t y . A possible reason for the r e l a t i v e l y lower r e l i a b i l i t y (Hoyt= .68) of this scale was the lack of v a r i a b i l i t y of the subjects' responses to this scale. Inspection of the scale mean and standard deviation suggested that one or a l l of three alternatives might be true: (1) therapists within the sample tended to see their personal attachments (Bonds) to c l i e n t s in stereotypic terms; (2) the therapist's version of the Bond scale could not distinguish fine gradations or shadings of personal attachments between therapist and c l i e n t ; and/or (3) the items in the therapist's Bond scale were not adequate to describe the relationship. Available data were i n s u f f i c i e n t to determine which one or combination of these alternatives was more l i k e l y true. V a l i d i t y While i t was recognized that i t was beyond the scope of t h i s research to undertake a l l of the tasks necessary to provide s u f f i c i e n t evidence for the construct v a l i d i t y of the'WAI for c l i n i c a l use, certain i n i t i a l steps, seen as part of an ongoing validation process, were taken. 108 Expert Rating. I n i t i a l l y , the construct v a l i d i t y of the items was examined from two separate conceptual points of view: Are these items relevant to the Working Alliance as defined by Bordin?; and, are the items intended for the three Working Alli a n c e domains distinguishable from one another? Evaluation and rating of the potential items by two successive groups of 'experts' gave some assurance that the items presented in the inventory provided v a l i d representation of the construct of Working Alliance generally, and of the s p e c i f i c Working Alliance dimensions in p a r t i c u l a r . The question of whether these item pools provided a s u f f i c i e n t l y r i c h and f a i r sampling of a l l the possible ways of assessing the constructs underlying the Working A l l i a n c e was not d i r e c t l y evaluated. Part of the future research on the WAI w i l l have to focus on the issue of whether a l l the Working Alliance concepts were ' f a i r l y ' and exhaustively tapped by the inventories (Cronbach, 1970, p. 124). The interscale correlations were examined from two points of view for evidence of construct v a l i d i t y : (1) examination of a m u l t i t r a i t , multimethod matrix contrasting the c l i e n t s ' and the therapists' rating of the process variables and, (2) comparison of the r e l a t i v e strengths of the relationships of variables t h e o r e t i c a l l y closely related to one another, and those t h e o r e t i c a l l y more independent. 109 The M u l t i t r a i t Multimethod Matrix. Campbell and Fiske's (1959) paradigm provided four c r i t e r i a for the evaluation of the m u l t i t r a i t multimethod matrix. These were: 1) Evaluation of the size and significance of the entries oh the v a l i d i t y diagonal, providing evidence of convergent v a l i d i t y . 2) Comparison of the values on the v a l i d i t y diagonal with the corresponding entries on the same row and column of the heterotrait heteromethod trian g l e s . 3) Comparison of the entries on the v a l i d i t y diagonal with the corresponding values on.the heterotrait monomethod triangl e s . 4) S i m i l a r i t y of t r a i t i nterrelationships patterns in a l l of the heterotrait t r i a n g l e s . The last three c r i t e r i a were evidence of discriminant v a l i d i t y . The results of this investigation suggested that a l l of the WAI subscales have s a t i s f i e d the requirements of the f i r s t c r i t e r i a . The values on the v a l i d i t y diagonal (cf. Table 5.8) were s i g n i f i c a n t at the p<.05 l e v e l and the magnitude of the v a l i d i t y c o e f f i c i e n t s exceeded the examples of sat i s f a c t o r y values suggested by Campbell and Fiske (1959, p. 82-83). Although a l l of these values met the minimum requirements of convergent v a l i d i t y , i t was noted that the c o e f f i c i e n t associated with the Bond scale was less than the values associated with the other Working Alli a n c e domains. This discrepancy in size was probably due, in part, to the lower r e l i a b i l i t y of the WAIc Bond dimension. 110 Both the Goal and Task scales showed evidence of discriminant v a l i d i t y based on the second Campbell and Fiske c r i t e r i o n . The Bond scale did not s a t i s f y this c r i t e r i o n . While none of the Working A l l i a n c e domains s a t i s f i e d the th i r d c r i t e r i o n of discriminant v a l i d i t y , a l l of the variables met the fourth condition proposed by Campbell and Fiske. With respect to this last condition, i t was noted that not only did the Working All i a n c e domains show similar patterns of correlations in the heterotrait t r i a n g l e s , but the r e l a t i v e magnitude of these relationships were as expected on the basis of theoretical analysis. (This finding is examined in greater d e t a i l in the following section.) In summary, the analysis of the m u l t i t r a i t multimethod matrix supported the convergent v a l i d i t y of the WAI scales. Although none of the Working All i a n c e Inventory scales met a l l of the discriminant v a l i d i t y c r i t e r i a , there is evidence indicating that two of the scales (Goal and Task) had some claim to discriminant v a l i d i t y . Comparison of expected and obtained relationships between  the WAI dimensions and Empathy. The r e l a t i v e sizes of the co r r e l a t i o n a l relationships of the Working Alliance dimensions were also examined in comparison to the expected h i e r a r c h i c a l relationships based on theoretical analysis. Correspondence of the experimental data and the hypothetical hierarchy was considered supporting evidence of the instrument's construct v a l i d i t y . I l l Logical analysis of the Working Alliance dimensions suggested that the strongest relationship amongst the component dimensions would exist between Goal and Task. Examination of the d e f i n i t i o n and explication of Bordin's (1976) concepts showed that the assessment of the strength of the Task element in the Working Alliance cannot be approached without e x p l i c i t or i m p l i c i t reference to the goals of the therapy. It appeared l o g i c a l and reasonable that the goals would constitute a point of reference in a r r i v i n g at some agreements and understandings regarding the relevance and pertinence of a c t i v i t i e s directed towards those goals. The working d e f i n i t i o n used in t h i s study has, in fact, stated that the '[tasks w i l l be] relevant... to the goals of the helping process...' (see p. 8). The Bond dimension, on the other hand, was not d i r e c t l y predicated on either of the two other Working Alliance components. Although i t is conceivable that the development of a cert a i n degree of caring and appreciation of one another by therapist and c l i e n t may be influenced by the quality or quantity of the Goal or Task dimension of their relationship, such contingency was not i n i t i a l l y thought to be basic to the structure of the Working Alliance conceptualization. Bordin's development of the concept of Bond and Rogers' concept of Empathy, seem to have a number of common themes (Bordin, 1976, 1980; Rogers, 1951, 1957). Both of these concepts involve such elements as the pr i z i n g of one another, caring, and respect. Based on these considerations i t was l o g i c a l l y expected that there would be a strong relationship between subject reported Empathy and subject reported Bond. 112 Based on the foregoing arguments, i t was believed that amongst the process dimensions measured in this research, the highest correlation would be between Task and Goal followed by a strong relationship between Bond and Empathy. Task and Bond were expected to show a lesser relationship. S i m i l a r l y , lower correlation indices were expected between Task and Empathy. The empirical findings (summarized in Table 5.8) correspond to the expected in t e r r e l a t i o n s h i p s , providing some ind i r e c t support for the WAI's construct v a l i d i t y . Comparison of expected and obta ined r e l a t ionships between  the Working Al l i a n c e , the CRF subscales, and Empathy. The concept of perceived Expertness, perceived Trustworthiness and perceived Attractiveness were d i f f i c u l t to link conceptually to either the Working Alliance dimensions or Empathy. The stumbling block appeared to be related to the d i f f e r e n t points of view implied in this concept with regard to the unit of interaction which was used as a primary reference. The soc i a l psychologists.who developed the concepts of Expertness, Trustworthiness, and Attractiveness were focusing on the c l i e n t ' s perception of. the therapist's appearance, his/her action, and even the therapist's physical surroundings (Cash et a l . , 1975;. Smith & Strong, 1970; Spigel, 1976). This conceptualization implied the c l i e n t ' s selective and subjective evaluation of the therapist's attributes as 'stimulus'. In contradistinction, Rogers' concepts were based on attitudes and behaviours of the therapist while Bordin's emphasis was on the interactive element between therapist and c l i e n t . On l o g i c a l consideration, i t was evident that the concepts developed by the 113 s o c i a l psychologists required a d i f f e r e n t l e v e l of inference or a t t r i b u t i o n from those used by- the client-centered theorists and Bordin. In terms of degrees of inference, both the Working Alliance dimensions and the therapist-offered conditions may be considered as being closer to the actual phenomena of therapy, while the q u a l i t i e s ascribed to the therapists by the c l i e n t s were seen as more distant. In summary, i t was expected that the s o c i a l psychological concepts would be r e l a t i v e l y independent of the Working All i a n c e dimensions and Empathy. These predictions were borne out by the empirical data: the correlation c o e f f i c i e n t s between the s o c i a l psychological dimensions and the Working Alliance scales were approximately .30 lower than the interscale correlations of the WAIc. The highest correlations between the WAIc and the CRF were between Attractiveness and Bond, and Expertness and Task. These results may r e f l e c t the fact that the former pair measures an a f f e c t i v e component of the relationship while the l a t t e r focuses on the cognitive or technical aspects. These findings contribute to the evidence supporting the construct v a l i d i t y of the WAI. THE STRUCTURE OF THE WORKING ALLIANCE The issue of the taxonomy of the constructs measured by the WAI scales was the second major focus of exploration of t h i s research. In the preceding section a strong r e l a t i o n s h i p between two of the WAI scales and between Empathy and Bond was predicted. The empirical evidence for the existence of these 114 patterns of relationship was used to support the construct v a l i d i t y of the WAI. The obverse of this issue is the question of whether the dimensions measured by the Working Alliance Inventory were referencing one and the same underlying construct. In formulating a decision rule appropriate for the resolution of this problem, two competing factors must be considered. Cronbach (1970) refers to t h i s issue as the 'bandwidth-fidelity dilemma' (p. 180). By grouping scale scores together the researcher improves his or her degree of assurance that a l l the information of interest has been captured. This increased r e l i a b i l i t y (bandwith), however, is purchased at the loss of d e t a i l information ( f i d e l i t y ) (Cronbach & Glesser, 1964). In the present study i t was possible to look at the Cronbach Alpha of .79 and .98 yielded by the WAIc and WAIt respectively and reach a decision that the three Working All i a n c e dimensions should be pooled and treated as a uni-dimensional scale. However, important c l i n i c a l information regarding the nature of the a l l i a n c e would be lost i f this assumption were made prematurely. From the l o g i c a l point of view the construct of personal bonds is c l e a r l y d i s t i n c t from, and at least p o t e n t i a l l y independent of, the other two hypothesized dimensions. None of the concepts used by Bordin in his development of the dimension of Bond, nor the elements constituting the working d e f i n i t i o n of Bond in this research, were l o g i c a l preconditions of the other two A l l i a n c e components. E a r l i e r , when the r e l a t i o n s h i p between Goal and Task was discussed, i t was suggested that these 115 two dimensions were l o g i c a l l y related. This theore t i c a l relationship, however, seems causally linked only in one dir e c t i o n . It appeared reasonable that the existence of a degree of agreement on goals is essential before the subject could decide whether the tasks in therapy were relevant and s i g n i f i c a n t . The existence of a strong mutuality with respect to the goals of therapy did not, on the other hand, guarantee the relevance of the therapeutic tasks. Another possible relationship that might explain the high i n t e r c o r r e l a t i o n among the WAI scales takes into account the temporal relationship of the Working Alliance domains. Bordin (1976) and Mann (1973) have suggested that the Working Alliance is b u i l t and re b u i l t several times during the course of therapy. It i s possible that this hypothesis can be extended to include the notion that the Working Alliance dimensions themselves are sequentially interrelated. More p a r t i c u l a r l y , a helper/helpee dyad f i r s t seeks an agreement regarding the therapeutic goals. Once concensus has been reached regarding these desirable outcomes, the therapist selects a sequence of purposeful strategies (tasks) applicable to the problem. If the therapy is to be successful the helper secures the c l i e n t ' s co-operation with these tasks and the c l i e n t begins to see the therapy related a c t i v i t i e s as meaningful, relevant, and p o t e n t i a l l y successful. Concurrent with these two steps personal bonds develop between therapist and c l i e n t , strengthening and reinforcing the c l i e n t ' s willingness to see the v a l i d i t y of the therapist's approach to his/her problem. If this (untested) hypothesis is tenable, the self reported Working All i a n c e 116 components that reflected summative impressions accumulated over time, would tend to be highly intercorrelated. The empirical evidence concerning the in t e r r e l a t i o n s h i p s within the Working Alli a n c e Inventory was presented in Table 5.2. This table is reproduced here with some additional information as Table 6.1. The degree of overlap amongst the dimensions measured by the WAI may be estimated by squaring the zero order correlations. The 'overlap' amongst the subscales Table 6.1 The Zero Order and Squared Intercorrelation Coefficients of the WAI N=29 GOAL TASK r r 2 r r TASK (Therapist) .83 .69 (Client) .88 .77 BOND (Therapist) .69 .48 .59 .34 (Client) .84 .70 .79 .62 of the therapists' Working Alliance Inventory, while substantial, was not out of lin e for an instrument in this f i e l d (Orlinsky & Howard, 1977). The commonality among the c l i e n t s ' perception was high (average 70%). Compared to other cli e n t - r e p o r t based inventories, however, these results were not unusual. For example, Kiesler et a l . (1967) reported intercorrelations for the Relationship-Inventory ranging from a low of r= .39 to a high of r= .83 (15% to 69%). Gurman (1977), in his summary of intercorrelations of various c l i e n t reported variables, has found that the 'average (across studies) in t e r c o r r e l a t i o n between R-I subscales ranged from r= .26 (S.D.= .32) to r= .67 (S.D.= .19). 117 The issue of d i f f e r e n t i a l v a l i d i t y cannot be resolved solely on the basis of determining the shared information amongst subscales. There are several alternative hypotheses that can be generated to f i t the data presently available: 1) The Working Alliance dimensions exist as separate and quasi-independent factors, but the Working All i a n c e Inventory is inadequate to capture the distinguishing features of the d i f f e r e n t dimensions. 2) The Working Alliance dimensions exist as separate and quasi-independent factors, however, the dimensions are causally linked in such way as to render the technology used in t h i s study incapable of detecting each as a separate e n t i t y . 3) The three Working All i a n c e dimensions exist as separate and quasi-independent factors, however, these factors were overwhelmed by some other factor(s) systematically related to outcome. 4) The Working Alliance is u n i f a c t o r i a l . While there was evidence presented that the scales are strongly interrelated, the potential value of u t i l i z i n g the unique information that may become available through the use of the subscales must weigh heavily in the d e l i b e r a t i o n . The actual structure of the Working All i a n c e between helper and helpee is an empirical question which, at t h i s time, is inseparable from the psychometric q u a l i t i e s of the WAI. Much further research is c a l l e d for to resolve the basic issues underlying the problem. THE WAI'S EFFICACY IN PREDICTING OUTCOME 118 From the c l i n i c i a n ' s point of view the most interesting aspect of thi s exploratory research may be the investigation of the relationship between the Working Alliance and therapy outcome. Within the li m i t a t i o n s of the research design and the instrument i t s e l f the researcher sought to explore the u t i l i t y of an a l l i a n c e inventory based on self-report to predict successful outcome in a variety of psychotherapies. The question of the instrument's predictive e f f i c a c y was of important p r a c t i c a l significance in and of i t s e l f , as well as providing evidence of construct v a l i d i t y for the WAI as discussed e a r l i e r . The results showed a positive and s i g n i f i c a n t relationship between both c l i e n t s ' and therapists' reports of the quality of Working Alli a n c e as measured by the WAI composite score, and the composite outcome as measured by the Posttherapy questionnaire. This finding was encouraging and the data were further explored to discern the sp e c i f i c predictive e f f i c a c y associated with each of the All i a n c e domains with respect to each of the outcome components. The o v e r a l l performance of the Task domain in rel a t i o n to both c l i e n t and therapist reported outcome was sa t i s f a c t o r y . There were some empirical data suggesting that, i f the a c t i v i t i e s undertaken in therapy were appreciated as appropriate and germaine to the problems being worked on, then the outcome of the session, at least in the short term, was l i k e l y p o s i t i v e . It i s l o g i c a l that c l i e n t s ' s a t i s f a c t i o n would be strongly 119 related to their response to Task items. From the c l i e n t ' s point of view, the value of the a c t i v i t i e s in therapy relate to the quality of the therapy i t s e l f . If what one is doing in therapy is perceived as relevant then i t is also perceived as at least p o t e n t i a l l y e f f e c t i v e , that i s , 'the right thing to do for me', and therefore a potent intervention. From the therapist's point of view, the Task items probably relate to a degree of assurance and s a t i s f a c t i o n with the strategy chosen for a particular c l i e n t . The therapist who feels s a t i s f i e d with the a c t i v i t i e s chosen has found a sense of dir e c t i o n or assurance of what w i l l 'work' with this c l i e n t . It is l i k e l y that a good therapist makes such a judgment on the basis of a variety of empirical and subjective data c o l l e c t e d either formally or informally. If there were reasonable evidence that therapy was not moving with optimal effectiveness, there would be a degree of searching, questioning, and testing on the therapist's part which, in turn, would be reflected in a lower rating of the Task items. The relationship of the Task scale to the Change outcome items probably depends on a l o g i c a l chain similar to the one discussed above. The lesser strength of the Task-Change relationship could be the result of the r e l a t i v e l y short lapse of time between the process and outcome measurements. The degree of change was probably also dependent on the a c q u i s i t i o n of s k i l l s to implement new behaviors or develop new responses, as well as emotional and cognitive factors. In addition,the behaviors and events associated with the Change items (in contradistinction to Satisfaction which i s an intra-subject 120 phenomenon) involve a network of 'others' who may not immediately a l t e r their habitual responses to the c l i e n t . For these reasons concepts associated with the Change outcome may be: a) slower to respond to c l i e n t improvement or, b) to some degree, confounded by variables outside the therapeutic sphere of influence. The lack of a strong rel a t i o n s h i p of the Task scale to Adjustment outcome items appeared related to the sequential relationship between S a t i s f a c t i o n , Change, and Adjustment. It appears l o g i c a l that s a t i s f a c t i o n with therapy would precede actual change, which in turn was seen as prerequisite to adjustment. Providing t h i s sequential hypothesis is tenable, the last step in the chain would be predicated on the preceding two, and Adjustment would be, temporally, the most distant outcome component. The performance of the other two Al l i a n c e dimensions in this study was less s a t i s f a c t o r y . The c l i e n t s ' Bond scale did not correlate with a s i g n i f i c a n t portion of the outcome v a r i a b i l i t y that was d i s t i n c t from the v a r i a b i l i t y associated with Task (except in the case of c l i e n t reported S a t i s f a c t i o n ) . As noted in Chapter V, however, the conclusions regarding the Working Alliance domains unique contribution to the explained outcome variance were based on the multiple regression analyses; these  results must be replicated before any inference can be drawn  beyond the sample in this study. 121 There was evidence of high co r r e l a t i o n between the Bond dimension and i t s c l i e n t centered counterpart, Empathy. Although a strong relationship was expected due to some s i m i l a r i t y in the underlying conceptualization, i t was o r i g i n a l l y hoped that a degree of difference might also be captured due to the di f f e r e n t (interactional) focus of the Allia n c e dimension. On the positive side, the Alli a n c e Bond dimension did correlate more substantially with the outcome measurement than Empathy, offering some hope of the scale's p o t e n t i a l . It is conceivable that, in spite of the high correlation between c l i e n t s ' Bond and Empathy, the former might be capturing t h i s facet of the relationship more e f f i c a c i o u s l y amongst the behavioural-cognitive therapists. Although such increased a p p l i c a b i l i t y was one of the o r i g i n a l design goals, the present study cannot support or reject t h i s hypothesis. Sa t i s f a c t i o n and the Goal dimensions appear to be linked to a s i g n i f i c a n t degree. It was suggested e a r l i e r that Sa t i s f a c t i o n might be the outcome component most l i k e l y to respond f i r s t to therapy events. S i m i l a r l y , the setting or negotiation of goals would be one of the f i r s t items on the therapy agenda. Further research might test the hypothesis li n k i n g both of these variables to the beginning phase of psychotherapy. The only instance the Goal scale captured outcome variance independent of the Task domain was with respect to the c l i e n t s ' composite outcome score. Similar patterns were not observed in rel a t i o n to the therapists' scale, nor did the Goal scale capture an independent portion of the variance with respect to 122 any other outcome scale. Consequently there was very limited support to indicate that t h i s scale was systematically contributing to the explanation of therapy outcome at the tenth sess ion. LIMITATIONS OF THE DESIGN Some factors l i m i t i n g the generalizabi1ity of these findings beyond the sample under investigation were inherent in the design of the study. The research c a l l e d for subject reported data for the evaluation of both the therapy process (WAI, CRF, R-I) and therapy outcome (CPQ, TPQ). Inherent d i f f i c u l t i e s in this strategy were e x p l i c i t l y recognized (e.g., process and outcome variables were to some degree confounded because they derive from the same source). It was reasonable to suppose, that the effect of such confounding would primarely elevate the c o r r e l a t i o n between Bond and S a t i s f a c t i o n . The superior performance of the Task domain with respect to the Sa t i s f a c t i o n outcome component indicates that factors beyond 'self f u l f i l l i n g prophesy' were operative. The nature of the concept of the Working All i a n c e raised some additional design considerations. Bordin's (1976, 1980) conceptualization of Working All i a n c e has, as one of i t s distinguishing features, the notion of g e n e r a l i z a b i l i t y across the variety of theoretical spectra. Working All i a n c e is a meta-concept focusing on the common features of the human helping process. This theory reconceptualizes the differences in approaches to psychotherapy in terms of patterns of a l l i a n c e 123 building and rebuilding cycles (Bordin, 1976). Consequently, i t was f e l t that the data should r e f l e c t the variety of therapies used in the c l i n i c a l community. Since there was no guarantee that the development and maintenance of the Working All i a n c e would be approximated in an analog therapy environment, i t was decided that the subjects should be drawn from a 'real' rather than an 'analog' therapy s i t u a t i o n . These design considerations both enhanced and r e s t r i c t e d the v a l i d i t y and g e n e r a l i z a b i l i t y of t h i s exploratory research. The face value and c l i n i c a l c r e d i b i l i t y of the study, i t was believed, benefitted from conducting the research 'in the f i e l d ' and including a cross-section of therapeutic methods. At the same time, however, the factor of d i f f e r e n t i a l therapeutic stances probably confounded the therapists' responses to the a l l i a n c e questionnaire. Unfortunately, the number of subjects was too small to permit separate analyses and comparison of outcome scores of the d i f f e r e n t therapeutic orientations. By accepting a variety of treatments applied to c l i e n t s with problems of d i f f e r e n t severity, two assumptions had to be made. F i r s t , regardless of the methodology followed, a l e v e l of a l l i a n c e , t y p i c a l of that relationship, w i l l be developed by the t h i r d to f i f t h session. In fact, there was some empirical support that this assumption was a reasonable one in a variety of situations (Saltzman et a l . , 1976). The second, more arbi t r a r y , assumption concerned the time required to develop a measurable effect resulting from the therapy intervention. In p r a c t i c a l terms the researcher had to reconcile in the design divergent 'expected treatment durations' amongst the variety of 124 therapies in the sample. Although a l l of the treatment situations f i t the d e f i n i t i o n of 'short term psychotherapy' (Butcher & Koss, 1978) the more behavioural approaches generally have a shorter treatment expectation than the more dynamically oriented therapies (Marks, 1978). The treatment period selected (10 sessions) was a compromise figure based on information collected from therapists regarding their expectation for the length of treatment. IMPLICATIONS FOR FUTURE RESEARCH As noted e a r l i e r , the present study was exploratory in nature, designed to evaluate the f e a s i b i l i t y of developing a self-report inventory to assess the strengths of the Alliance dimensions proposed by Bordin (1975, 1976). A f i r s t attempt to measure a theoretical concept faces some special d i f f i c u l t i e s . In the areas where the instrument has shown evidence of empirical v a l i d i t y , that i s , evidence of relationship to a c r i t e r i o n variable, a l l is well, and the u t i l i t y of both construct and instrument is supported. On the other hand, when parts of instruments show less than clear-cut evidence of v a l i d i t y , one of two solutions might be appropriate: further refinement of the instrument can be undertaken, or the concepts underlying the instrument can be reconsidered. In the case of the WAI Task dimension, preliminary evidence was supportive of the construct and the instrument measuring i t . Further improvement of this scale might involve some refinements in wording of the items, the lengthening of the scale to improve 125 r e l i a b i l i t y (Cronbach, 1970), and the p o s s i b i l i t y of increasing the number of rating points from fiv e to seven in search of finer discriminations. With respect to the Bond scale, i t appeared reasonable to suppose that the construct sought was l o g i c a l l y clear and measurable. Although the scale developed was reasonably r e l i a b l e and there was some evidence of construct v a l i d i t y , Bond f a i l e d to account for a s u f f i c i e n t amount of outcome variance independent of the other dimensions to give firm assurance of i t s existence as an independent therapy variable. As noted before the study must be replicated before the present findings can be extended beyond the sample. Further research is also required to improve and refine the Bond items to capture the d i s t i n c t i o n s ( i f they exist) between Bond and Empathy. Additional research on the Goal dimension should explore i t s relationship to the Task domain as an independent factor and investigate the d i f f e r e n t i a l temporal emphasis on those two aspects of the Working Alliance in d i f f e r e n t phases of therapy. The question of d i f f e r e n t i a l quality and quantity of Alliance amongst diverse therapy approaches requires a major investigative e f f o r t focusing on: a) comparing the r e l a t i v e strengths of the Working Alliance components amongst successful therapies of di f f e r e n t orientation, and b) comparing the Working Alliance's e f f i c a c y in predicting outcome across d i f f e r e n t therapeutic modalities. In order to confirm the importance of the Working Alliance throughout the length of therapy a somewhat d i f f e r e n t l i n e of investigation is required involving the evaluation of the 126 Working Al l i a n c e ' s e f f i c a c y of predicting outcome at termination of therapy and at different post-therapy i n t e r v a l s . Lastly, investigation of the c y c l i c a l building and rebuilding of the Working Alliance along the lines suggested by Bordin (1975, 1976, 1980) and Mann (1973) may be evaluated. 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On the relationship of c l i e n t s a t i s f a c t i o n to c l i e n t c h a r a c t e r i s t i c s and outcome of treatment. Journal of C l i n i c a l Psychology, 1978, 3_4 (1), 157-160. Winnicott, D. W. Metapsychological and c l i n i c a l aspects of  regression within the psychoanalytical set-up. New York: Basic Books, 1955. Wolf, S., & Montrose, M. Social v a l i d i t y : The case for subjective measurement. Journal of Applied Behaviour  Analysis, 1978, 11 (2). Zetzel, E. R. Current concepts of transference. International  Journal of Psychoanalysis, 1956, 37, 369-376. Zetzel, E. R. The capacity for emotional growth. London: Hogarth Press, 1970. Appendix A Material used in construct v a l i d a t i o n : Phase 150 Dear PS. I would appreciate your help i n developing an instrument that assesses the c l i e n t ' s perception of the forking A l l i a n c e . Kould. you rate the items on the following pages two ways: 1) Indicate the degree to which each statement taps any 2.L the dimensions of the Working All ia n c e by c i r c l i n g a number below the sentence. { 1 for an item not representing the Alli a n c e to any degree, 5 f c r a statement highly relevent to the Working A l l i a n c e ) (Feel free to make notes or suggestions underneath the items.) 2) Indicate which of the three components of the Working Alliance the sentence seems most relevant to by checking a code to the r i g h t of the item. (G=Goals; T=Tasks; B=Bonds. For the d e f i n i t i o n cf the Working Alliance and i t s components see Section I.) Plese read the d e f i n i t i o n s f i r s t , (section I ) before preceding with your r a t i n g of the items. (A sample cf the in s t r u c t i o n s to the c l i e n t s that w i l l accompany the f i n a l insrtrument i s included i n Appendix A. ) I w i l l appreciate a l l comments - s p e c i f i c or general - that you might have to offer-Thank you for your co-operation. Adam. 0- Horvath 151 I. Defin.ition Of The Perceived j£orkin£ A l l i a n c e The following d e f i n i t i o n i s based on Dr. £. Bordin's papers on "The G e n e r a l i z a b i l i t y of the Psychoanalytic Concept of Working Alliance " {1975) and "The working A l l i a n c e : Basis For A General Theory Of Psychotherapy" (1976). The changes made are an attempt to reconceptualize the a l l i a n c e in terms of the participant's perception of i t . All i a n c e r e f e r s to a set of agreements, understandings, and bonds that are arrived at during a sequence of purtcsive i n t e r a c t i o n s between helper and helpee. In p a r t i c u l a r , the following components w i l l earmark a viable a l l i a n c e regardless of the s p e c i f i c t h e o r e t i c a l or te c h n i c a l approach taken by the therapist. 1) The (helper/helpee) w i l l have a sense of agreement about the aoals of the helping process. The helpee w i l l have an awareness that these goals are relevant to him/her and f e e l a degree of i d e n t i f i c a t i o n with the e x p l i c i t and i m p l i c i t aims of the p a r t i c u l a r helping process he/she i s engaged i n . The helper w i l l have some di r e c t or i n d i r e c t evidence that his/her goals with the helpee are t a c i t l y or i m p l i c i t l y shared and accepted. 2) The (helper/helpee) w i l l have a sense of mutuality (agreement) that the tasks demanded of each of them i n the helping process i s a) reasonable and within t h e i r global c a p a b i l i t i e s (or expertise); b) Relevant in a dir e c t or i n d i r e c t way tc the goals of the helping process that they mutually agreed to ,152 3) The (helper/helpee) w i l l experience a sense of a bona between them. Seme of the bases on which such therapeutic partnership w i l l be b u i l t are sense of mutual t r u s t i n g , l i k i n g , understanding, and caring. Different therapeutic o r i e n t a t i o n s and strategies w i l l make d i f f e r e n t demands on the pa r t i c i p a n t s in terms cf each of these categories thereby having a unique quality to t h e i r successful a l l i a n c e s . I t i s expected, however, that a l l helping dyads w i l l have to achieve a basic quantitative l e v e l i n each of those three areas i n order to provide the a l l i a n c e component necessary for successful helping r e l a t i o n s h i p . 1=not related to A l l i a n c e . ... 5=Allianee item 153 We agree on the things I should get out of my therapy . 1 2 3 4 5 We share the same ideas on what i s needed to be changed in my l i f e . G T B 1 2 3 4 5 3 and I are working towards the same goals. G T B 1 2 3 4 5 4 and I have d i f f e r e n t ideas cf how my l i f e should change. G T B 1 2 3 4 5 5 We work towards mutually agreed upon goals. G T B 1 2 3 4 5 6 and I have d i f f e r e n t ideas on what I should be aiming for. G T B 1 2 3 4 5 7 I think I am working with a therapist who i s i d e a l l y suited to my needs r i g h t now. G T E 1 2 3 4 5 I respect as a highly capable and s k i l l f u l i n d i v i d u a l . 1 2 3 4 5 I am confident i n 's a b i l i t y to help me through my present d i f f i c u l t i e s . G I B 1 2 3 4 5 10 I wonder how wants me to change. G T B 1 2 3 4 5 1=not r e l a t e d to A l l i a n c e . . . „5=Alliance item 154 11 does not understand how I want my l i f e changed. G T B 1 2 3 4 5 12 I find myself resenting the way my therapist would l i k e me to change. G T B 1 2 3 4 . 5 13 I'm happy with myself but wants me to change. G T B 1 2 3 4 5 14 I'm unhappy about myself but does hot r e a l i z e t h i s . G T B 1 2 3 4 5 15 Se are in agreement as to where these sessions should be heading. G T B 1 2 3 4 5 16 wants to explore things deeper than I think i t i s njecessary. G T B 1 2 3 4 5 17 We are i n good agreement on what i s important and what i s not. G T B 1 2 ; 3 4 . 5 18 I believe we are beginning to understand what i s to be accomplished in these sessions. G T 3 1 2 3 4 5 19 and I agree on the cause of my d i s t r e s s . G !T B 1 2 3 4 5 20 I f e e l what we are doing together i s useful to me. G T B 1 2 3 .4 5 1=D0t related to Alliance.-..5=Alliance item 2 1 I don't know what wants me to do. G I B 1 2 3 4 5 and 1 agree about the steps t c be taken to improve my s i t u a t i o n . G T B 1 2 3 4 5 23 wants me to do too much too f a s t . G T B 1 2 3 4 5 24 My time with i s important. G T B 1 2 3 4 5 25 I f e e l that appreciates me. G T B 1 2 3 4 5 26 I find that the things that I discuss with are u s e f u l l . G T B 1 2 3 4 5 27 I wish uould c l a r i f y the purpose of our sessions. G T B 1 2 3 4 5 28 My r e l a t i o n s h i p with i s very important to me. G I B 1 2 3 4 5 29 I f e e l we are approaching my problems the r i g h t way. G T E 1 2 3 4 5 30 I f e e l that the way approaches things w i l l help me. G T B 1 2 3 4 5 155 31 I t i s unclear to rae how what and I are doing i s supposed to help me. G T B 1 2 3 4 5 1=aot r e l a t e d to .Alliance.... 5=Alliance item 156 32 I f i n d what ana I are doing f a r removed from my concerns. 1 2 3 4 5 33 I believe that the time and I are spending together i s not spent e.f f i c i e n t l y . 1 2 3 4 5 34 I l i k e the way my therapist helps me to chanqe. 1 2 3 4 5 35 I am confused about what to do i n my therapy sessions. 1 2 3 4 5 36 I f i n d therapy strange and -confusing. G T 3 1 2 3 4 5 37 does not decide on things without my agreement. G T B 1 2 3 4 5 38 I am clear on what my r e s p o n s i b i l i t i e s are i n therapy. G T B 1 2 3 4 5 39 gives me a better idea of the things that I need to change in my l i f e . G T B 1 2 3 4 5 4 0 often agrees with me on how I should change things. 1 2 3 4 5 4 1 I often find that has a good idea of what I'd l i k e to do. 1 2 3 4 5 42 I f e e l my therapist respects me. G !I B 1 2 3 4 5 ' 1=not related to A l l i a n ce.. 5 = Alli a n c e item 157 43 I trust *s judgement- G 1 3 1 2 " 3" 4 5 44 I belive i s genuinely concerned for my welfare- G T B 1 2 3 4 5 45 I think some of my problems reach deeper than r e a l i z e s - G T E 1 2 3 4 5 46 I think that understands and appreciates how I f e e l - G I B ' 1 2 3 4 5 47 I believe we work well together. G T B 1 2 3 4 5 48 My r e l a t i o n s h i p to — i s d i f f e r e n t from any other r e l a t i o n s h i p s . G T B 1 2 3 4 5 49 Sometimes i t seems that and I are f i g h t i n g over what i s r e a l l y important. G T B 1 2 3 4 5 50 My re l a t i o n s h i p to my therapist i s very important to me. 1 2 3 4 5 51 I can discuss d i f f i c u l t t o p i c s with r e l a t i v e l y e a s i l y . G T B 1 2 3 4 5 52 I usually look forward to my therapy time. G 1 B 1 2 3 4 5 53 I have confidence in what and I are doing together. . G T B 1 2 3 4 . 5 1=not rel a t e d to Alliance....5=Alliance item 158 54 I • often f e e l uncomfortable with * 1 2 3 4 5 55 Ihe goals of these sessions are meaningful to me. 1 2 3 4 5 56 I have the feeling that i f I say or do the wrong things, w i l l step working with me. 1 2 3 4 5 57 I f e e l that i s not t o t a l l y honest about his/her f e e l i n g s toward me. 1 2 3 4 5 58 My present therapist i s the best person to help me with my problem. 1 2 3 4 5 59 This i s the r i g h t time for me to work on my problem. G T B 1 2 3 4 5 60 I could egually well work on my concerns with another therapist . 1 2 3 4 5 61 I am not sure that is the r i g h t person to help me through ray present predicament. G 1 2 3 4 5 62 I f e e l comfortable with the d i r e c t i o n we are moving. G T B 1 2 3 4 5 63 I am convinced that and I w i l l work together well. G T B 1 2 3 4 5 1=not related to A l l i a n c e - - 5 = A l l i a n c e item 159 64 Sometimes I wonder whether I came to the r i a n t person for help. 1 2 3 4 5 65 I believe that ' s way of working with my concern i s correct-1 2 3 4 5 66 I trust . G T E 1 2 3 4 5 I sense that and I are working together on my problems. 1 2 3 4 5 68 I am wondering whether can appreciate what I want out of these sessions. G T B 1 2 3 4 5 6 9 I am not sure whether I w i l l continue therapy with my present therapist. 1 2 * 3 4 5 7 0 I am cl e a r as to what wants me to do. G T B 1 2 3 4 5 71 I sometimes wonder whether knows what he/she i s doing. 1 2 3 4 7 2 I have a f e e l i n g that understands parts of my problem that are yet unclear to me. G T B 1 2 3 4 5 7 3 I f e e l I have a strong commitment to work through my problem with to the end. G T B 1 2 3 4 5 1=not related to Alliance-. ... 5= A l l i a n c e item 160 74 I l i k e as a person. G T B 1 2 3 4 5 75 I beleive appreciates me as a person. 1 2 3 4 5 76 I f e e l respects me even when I do things that he/she does not approve of. G T E 1 2 3 4 5 77 T f e e l that has made a commitment to work my problem through with me. G T B 1 2 3 4 5 78 we agree on what needs to change to make my s i t u a t i o n better. 1 2 3 4 5 79 I f e e l that we are doing the r i g h t things during these sessions- G I B 1 2 3 4 5 80 Therapy tends to go slowly because I don't agree with what i s trying to do- G T B 1 2 3 4 5 81 perceives accurately what my goals are. 1 2 3 4 5 82 I worry about the outcome of these sessions. G T B 1 2 3 4 5 83 Sometimes I fin d myself wondering j u s t where mv therapist tr y i n g to get us? 1' 2 3 4 5 1=not related to Alliance....5=Alliance item l 161 84 I would l i k e to knew i f I am r e a l i s t i c about what I expect to get out cf therapy. G T E 1 2 3 4 5 85 The things that I am doing here don't make much sense to me. G I B 1 2 3 4 5 86 has u n r e a l i s t i c ideas about my capacity to chanae. G T E 1 2 " 3 4 5 87 appreciates what my l i f e i s a l l about. G T B 1 2 3 4 5 88 I f e e l r e a l l y understood. G T B 1 2 3 4 5 89 r e a l l y appreciates my p r i o r i t i e s . G T B 1 2 3 4 5 90 I don't understand what therapy i s a l l about. G T B 1 2 3 4 5 91 We have established a gocd understanding for the d i r e c t i o n of changes that would be good for me. G T B 1 2 3 4 5 THANK YOU FOE YOUE HELP AND CO-OPERATION. 162 H i Instructions to CLIENTS Below are some sentences that describe seme of the d i f f e r e n t ways a c l i e n t might think or f e e l about his or her therapist (counsellor) -As you read the sentences mentally i n s e r t the name of your therapist (counsellor) i n the place of the in the text. Below each sentence there i s a seven point scale: 1 2 3 4 5 6 7 Always Sometimes Never If the sentence describes the way that you alvays f e e l (or think) c i r c l e number 1; i f i t never applies t c you c i r c l e the number 7. Use the points i n between to describe the variations between these extremes. This questionnaire i s c o n f i d e n t i a l , NEITEEE YOUR TH3 E API ST NOE THE AGSNCT WILL SEE YGU 5 ANSWERS. Please work f a s t , your f i r s t impressions are the ones we would l i k e to get. (Please don't forget to respond to every item.) Thank you for your co-operation! 163 Appendix B Material used in construct v a l i d a t i o n : Phase II T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A 2075 WESISROOK MALL VANCOUVER. B.C., C A N A D A V6T 1W5 FACULTY OF EDUCATION Dear C o l l e a g u e I would a p p r e c i a t e your h e l p i n d e v e l o p i n g an i n s t r u m e n t t h a t a s s e s s e s the c l i e n t ' s p e r c e p t i o n o f the Working A l l i a n c e . The Working A l l i a n c e I n v e n t o r y w i l l e n a b l e p s y c h o l o g i s t s to a s s e s s the q u a l i t y o f the t h e r a p e u t i c r e l a t i o n s h i p i n i t s e a r l y s t a g e s and to make some p r o g n o s i s r e g a r d i n g the outcome o f t h e r a p y . Your h e l p i s needed to e v a l u a t e the it e m p o o l t h a t w i l l be the base o f t h i s i n s t r u m e n t . The d e f i n i t i o n s o f t h e t h r e e d i m e n s i o n s o f t h e Working A l l i a n c e — g o a l s , t a s k s and bonds (based on the t h e o r y d e v e l o p e d by B o r d i n 1975, 1 9 7 6 ) — a r e a t t a c h e d (Appendix A ) . Would you r a t e the i t e m s on th e f o l l o w i n g pages two ways: 1) I n d i c a t e the degree to which each s t a t e m e n t t a p s any of t h e d i m e n s i o n s o f the Working A l l i a n c e by c i r c l i n g a number below t h e s e n t e n c e . C i r c l e 1 f o r an item not  r e p r e s e n t i n g the A l l i a n c e t o any d e g r e e , 5 f o r a st a t e m e n t h i g h l y r e l e v a n t to the Working A l l i a n c e . The f a c t t h a t some i t e m s a r e " p o s i t i v e l y " worded ( i . e . t h e y r e p r e s e n t a t t r i b u t e s o f a good r e l a t i o n s h i p ) and o t h e r s a r e " n e g a t i v e " ( i . e . u n d e s i r a b l e from the p o i n t o f v i e w o f the a l l i a n c e ) s h o u l d not i n f l u e n c e your r a t i n g . What i s i m p o r t a n t i s whether the st a t e m e n t t a p s t h e elem e n t s o f the Working A l l i a n c e o r i s i r r e l e v e n t t o i t . ( F e e l f r e e t o make n o t e s o r s u g g e s t i o n s u n d e r n e a t h the items . ) 166 1 = N0T KELEVEN T TO ALUfiNCE .. 2=SLIGHTIY RELEVENT -. 3=SC.1E»HAT RELEVANT 4=EELEVENT ... 5= HIGHLY EE.LEVENT TO ALLIANCE 1 We agree on the things I should get out of my therapy . G T E 2 and I are working towards the same goals. G T B 1 2 3 4 5 3 and I have d i f f e r e n t ideas of how my l i f e should change. G T B 1 2 3 4 5 4 We work towards mutually agreed upon goals- G T B 1 , 2 3 4 5 5 and I have di f f e r e n t ideas cn what I should be aiming f o r . G T B 1 2 3 4 5 6 I think I am working with a therapist who i s i d e a l l y suited to my needs r i g h t now- G T E 1 2 3 4 5 7 I respect as a highly capable and s k i l l f u l i n d i v i d u a l - G T B 1 2 3 4 5 8 I am confident i n ' s a b i l i t y to help me through my present d i f f i c u l t i e s - G T B 1 2 3 4 5 9 does not seem to understand what are the changes that I need. G T B 1 2 3 4 5 10 Sometimes I resent the way my therapist would l i k e me to change. G T B 1 2 3 4 5 1 6 7 1=N0T EELEVENT TO ALLIANCE 2=SLIGHTXY EELEV.E ET 3-SC MEV.'H AT EELEV ANT 4 = EELEVENT ... 5= HIGHLY EELEVENT TO ALLIANCE 11 I'm happy with myself but wants me to change. 1 2 3 4 5 does not seem to be aware cf the extent of my d i f f i c u l t i e s . 1 2 3 4 5 13 We are in agreement as to where these sessions should be heading. 1 2 3 4 5 14 — wants to explore things deeper than I think i t i s necessary. G T E 1 2 3 4 5 15 I f e e l what we are doing together i s useful to me. G T B 1 2 3 4 5 16 I don't know what wants me t c do. G T E 1 2 3 4 5 17 and I agree about the steps to be taken to improve my s i t u a t i o n . G T B 1 2 3 4 5 18 wants me to change too much too fa s t . G T B 1 2 3 4 5 19 My time with i s important. 1 2 3 4 5 20 I f e e l that appreciates me. 1 2 3 4 5 21 I find that the things that I discuss with are useful. 1 2 3 4 5 G T B 168 1 = N0T ESLSVENT TO ALLIANCE ... 2=SL IGHTLY EELEVERT .-3=SOMEWHAT RELEVANT 4=RELE VENT 5=HIGHLY EELEVENT TO ALLIANCE 22 I wish would c l a r i f y the purpose cf our sessions. G T E 1 2 3 4 5 23 My r e l a t i o n s h i p with i s very important to me. G T B 1 2 3 4 5 24 I f e e l we are approaching my problems the r i g h t way. G T B 1 2 3 4 5 25 I f e e l that the way approaches things w i l l help me. G T B 1 2 3 4 5 26 I t i s unclear to me how what and I are doing i s supposed to help me. G T E 1 2 3 4 5 27 I fi n d what and I are doing f a r removed from my concerns. G T B 1 2 3 4 5 28 I believe that the time and I are spending together i s not spent e f f i c i e n t l y . G T B 1 2 3 4 5 29 I am confused about what to do in my therapy sessions. 1 2 3 4 5 30 I fi n d what we do therapy strange and confusing. 1 2 3 4 5 31 I am c l e a r on what my r e s p o n s i b i l i t i e s are in therapy. 1 2 3 4 5 . 169 1=N0T R ELEVEN T TO ALLIANCE 2=SLIGHTLY BELEVEBT 3= SC KE wH AT EELEV ANT 4 = HELEV ENT 5=H.IGHLI EELEVENT TO ALLIANCE 32 I f e e l my therapist respects me- G T B 1 2 3 4 5 33 I tr u s t ~'s judgement. G T B 1 2 3 4 5 34 I believe i s genuinely concernecl f o r my welfare- G I B 1 2 3 4 5 35 My r e l a t i o n s h i p tc my therapist i s very important to me- G T B 1 2 3 4 5 36 I can discuss d i f f i c u l t t o p i c s with r e l a t i v e l y e a s i l y . G T B 1 2 3 4 5 37 I have confidence i n what — and I are doing together- G 1 2 3 4 5 38 I often f e e l uncomfortable with 1 2 3 4 5 G T B 39 The goals of these sessions are meaningful to me. G T B 1 2 3 4 5 40 I have the f e e l i n g that i f I say or do the wrong things, w i l l stop working with me- G T B 1 2 3 4 5 41 My present t h e r a p i s t i s the best person to help me with my problem. G T B 1 2 3 4 5 42 I could equally well work on my concerns with another therapist . G T B 1 2 3 4 5 170 1=NOT EELEVENT TO ALLIANCE 2=SLIGHTLY BELEVEHT 3=SCMESHAT RELEVANT 4=EELEV ENT . 5=RIGHLY RELEVENT . TO ALLIANCE 4 3 Sometimes I sender whether I came to the r i g h t person f o r help- G T B 1 2 3 4 5 44 I believe that the way we are working with my problem i s correct. G T B 1 2 3 4 5 45 I trust G T B 1 2 3 4 5 46 I am not sure whether I w i l l continue therapy with my present t h e r a p i s t . G I B 1 2 3 4 5 47 I sometimes wonder whether knows what he/she i s doing. G T B 1 2 3 4 5 48 I f e e l I have a strong commitment to work through my problem with to the end. G T B 1 2 3 4 5 49 I l i k e as a person. G T B 1 2 3 4 5 50 I believe appreciates me as a person. G T B 1 2 3 4 5 51 I f e e l respects me even when I do things that he/she does not approve of. * G T B 1 2 3 4 5 52 I f e e l that has made a commitment to work my problem through with me. G T B 1 2 3 4 5 1 7 1 1 = K 0 T EELEVENT TO ALLIANCE 2=SLIGHTLY EELEVENT .. 3=SCMEKHAT RELEVANT 4=EELEVENT --. 5=HIGHLI EELEVENT TO ALLIANCE 5 3 Ke agree on what. needs to change tc make my s i t u a t i o n better. 1 2 3 4 5 5 4 I f e e l that we are doing the r i g h t things during these sessions. G T B 1 2 3 4 5 i5 — perceives accurately what my goals are. G T B 1 2 3 4 5 56 Sometimes I f i n d myself wondering just where my therapist i s trying to get us? 1 2 3 4 5 5 7 I don't know what to expect as the re s u l t of my therapy. 1 2 3 4 5 5 8 The things that I am doing here don't make much sense to me. G T B 1 2 3 4 5 59 jjas u n r e a l i s t i c ideas about my capacity to change. G T B 1 2 3 4 5 6 0 appreciates what my l i f e i s a l l about. G T B 1 2 3 4 5 61 I f e e l r e a l l y understood. G T B 1 2 3 4 5 6 2 r e a l l y appreciates my p r i o r i t i e s . 1 2 3 4 5 6 3 I often disagree with about my goals. 1 2 3 4 5 172 1=K0T EELEVENT TO ALLIANCE .. 2=SLIGHT1Y RELEVEKT 3=SCHEHHAT RELEVANT 4=RELEVENT ... 5=HIGHLY R ELEVEN T TO ALLIANCE 64 we generally agree on what i s important for me to work on. G T B 1 2 3 4 5 65 I don't know what we are t r y i n g to accomplish in therapy. G T B 1 " 2 3 4 5 66 I f e e l that i s not t o t a l l y honest about his/her f e e l i n g s toward me. G T B 1 2 3 4 5 67 I f e e l comfortable with the d i r e c t i o n we are moving. G T B 1 2 .3 4 5 68 I am clear as to what wants me to do i n these sessions. G T B 1 2 3 4 5 69 I worry about the outcome of these sessions. G T B 1 2 3 4 5 7C We have established a good understanding f o r the d i r e c t i o n of changes that would be good f o r me. G T B 1 2 3 4 5 THANK YOU FOR YOUR HELP AND CO—OPEE ATI ON. Appendix C Materia1 used in the p i l o t testing of the WAI PSYCHOTHERAPY RELATIONSHIP RESEARCH PROJECT TO THE PARTICIPANT: PLEASE COMPLETE THE ATTACHED QUESTIONNAIRES IN THE  ORDER GIVEN AND SEAL THE COMPLETED FORMS IN THE ENVELOPE PROVIDED, YOUR THERAPIST (COUNSELLOR) WILL RETURN THESE ALONG WITH HER/HIS QUESTIONNAIRE TO THE RESEARCHERS, PLEASE MAKE SURE YOU RESPOND TO EVERY ITEM, THANK YOU. 176 ,INSTRUCTIONS TO PARTICIPANTS IN THE PSYCHOTHERAPY RELATIONSHIP RESEARCH PROJECT T h i s p r o j e c t i s d e s i g n e d t o e x p l o r e t h e d i f f e r e n t k i n d s o f h e l p i n g r e l a t i o n s h i p s t h a t d e v e l o p i n c o u n s e l l i n g / p s y c h o t h e r a p y . Y o u r p a r t i c i p a t i o n i s v i t a l l y i m p o r t a n t t o t h e p r o j e c t a nd y o u r g e n e r o s i t y w i t h y o u r t i m e and e n e r g y i s much a p p r e c i a t e d . P l e a s e f o l l o w t h e s t e p s o u t l i n e d b e l o w e x a c t l y : ( 1 ) Ask y o u r c l i e n t t o v o l u n t e e r t o p a r t i c i p a t e i n t h e p r o j e c t . Read and e x p l a i n , i f n e c e s s a r y , t h e c o n s e n t f o r m . Have y o u r c l i e n t s i g n t h e f o r m and s i g n i t y o u r s e l f as w i t n e s s . S i g n t h e t h e r a p i s t c o n s e n t f o r m . P l a c e t h e c o m p l e t e d f o r m i n t h e 1 a r g e s e l f - a d d r e s s e d m a n i l l a e n v e l o p e . ( 2 ) A f t e r t h e 3 r d s e s s i o n w i t h t h i s c l i e n t p l e a s e g i v e h i m / h e r t h e p a c k e t a n d m a t e r i a l s m a r k e d "C". P l e a s e e n c o u r a g e y o u r c l i e n t t o c o m p l e t e i t - ( i t t a k e s 30 m i n u t e s ) and h a v e h i m / h e r s e a l t h e f i l l e d - o u t , f o r m s i n t h e e n v e l o p e p r o v i d e d . C o m p l e t e y o u r q u e s t i o n n a i r e s m a r k e d "T " , and s e a l a l l t h e m a t e r i a l ( y o u r s a n d y o u r c l i e n t ' s ) i n t h e l a r g e s e l f -a d d r e s s e d m a n i l l a e n v e l o p e . (3) S e n d t h e m a n i l l a e n v e l o p e b a c k t o t h e r e s e a r c h e r . ( 4 ) P l e a s e make a n o t e on y o u r c a l e n d a r t o r e m i n d y o u r s e l f t o a d m i n i s t e r t h e s e c o n d p a r t o f t h e q u e s t i o n n a i r e 7 s e s s i o n s a f t e r t h i s s e s s i o n o r a t t h e l a s t i n t e r v i e w y o u w i l l h a v e w i t h t h i s c l i e n t . Use t h e memo p r o v i d e d i f y o u w i s h . ( 5 ) A f t e r t h e 1 0 t h i n t e r v i e w ( a p p r o x i m a t e l y ) , o r a t t h e l a s t s e s s i o n , g i v e y o u r c l i e n t t h e p a c k e t m a r k e d "PC" t o f i l l o u t and s e a l i t i n t h e e n v e l o p e p r o v i d e d . P l e a s e f i l l o u t t h e m a t e r i a l m a r k e d "PT" a n d s e a l i t i n t h e e n v e l o p e . P l a c e a l l t h e c o m p l e t e d q u e s t i o n n a i r e s i n t h e l a r g e w h i t e e n v e l o p e a n d r e t u r n i t t o t h e r e s e a r c h e r . ( 6 ) S h o u l d y o u h a v e more t h a n one c l i e n t p a r t i c i p a t i n g i n t h e r e s e a r c h , p l e a s e f o l l o w t h e c o m p l e t e p r o c e d u r e e a c h t i m e , u s i n g a c o m p l e t e new " k i t " . 177 W o r k i n g A l l i a n c e I n v e n t o r y I n s t r u c t i o n s B e l o w a r e some s e n t e n c e s t h a t d e s c r i b e some o f t h e d i f f e r e n t ways a p e r s o n m i g h t t h i n k o r f e e l a b o u t h i s o r h e r t h e r a p i s t ( c o u n s e l l o r ) . As y o u r e a d t h e s e n t e n c e s m e n t a l l y i n s e r t t h e name o f y o u r t h e r a p i s t ( c o u n s e l l o r ) i n t h e p l a c e o f t h e i n t h e t e x t . B e l o w e a c h s e n t e n c e t h e r e i s a f i v e p o i n t s c a l e : 1 2 3 4 5 N e v e r S o m e t i m e s A l w a y s I f t h e s e n t e n c e d e s c r i b e s t h e way t h a t y o u a l w a y s f e e l ( o r t h i n k ) c i r c l e no. 5; i f i t n e v e r a p p l i e s t o y o u c i r c l e t h e number 1. U s e t h e p o i n t s i n b e t w e e n t o d e s c r i b e t h e v a r i a t i o n s b e t w e e n t h e s e e x t r e m e s . T h i s q u e s t i o n n a i r e i s c o n f i d e n t i a l ; NEITHER YOUR THERAPIST OR THE AGENCY  WILL SEE YOUR ANSWERS. P l e a s e work f a s t , y o u r f i r s t i m p r e s s i o n s a r e t h e o n e s we w o u l d l i k e t o g e t . ( P l e a s e d o n ' t f o r g e t t o r e s p o n d t o e v e r y i t e m . ) T h a n k y o u f o r y o u r c o o p e r a t i o n 178 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 1. I o f t e n f e e l u n c o m f o r t a b l e w i t h . 1 2 3 4 5 2. and I a g r e e a b o u t t h e s t e p s t o be t a k e n t o i m p r o v e my s i t u a t i o n . 1 2 3 4 5 3. I w o r r y a b o u t t h e o u t c o m e o f t h e s e s e s s i o n s . 1 2 3 4 5 4. I f e e l we a r e a p p r o a c h i n g my p r o b l e m s t h e . r i g h t way. 1 2 3 4 5 5. I f e e l r e a l l y u n d e r s t o o d . 1 2 3 4 5 6. I f i n d what we do i n t h e r a p y c o n f u s i n g . 1 2 3 4 5 7. p e r c e i v e s a c c u r a t e l y what my g o a l s a r e . 1 2 3 4 5 3> My t i m e w i t h i s i m p o r t a n t t o me. 1 2 3 4 5 9. I w i s h w o u l d c l a r i f y t h e p u r p o s e o f b u r s e s s i o n s . 1 2 3 4 ; 5 10. I o f t e n d i s a g r e e w i t h a b o u t my g o a l s . 1 2 3 4 5 11. I b e l i e v e t h a t t h e t i m e a n d I a r e s p e n d i n g t o g e t h e r i s n o t s p e n t e f f i c i e n t l y . 1 2 3 4 . 5 \ 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 12. I d o n ' t know what we a r e t r y i n g t o a c c o m p l i s h i n t h e r a p y . 1 2 3 4, 5 13. I am c l e a r on what my r e s p o n s i b i l i t i e s a r e i n t h e r a p y . 1 2 3 4 5 14. The g o a l s o f t h e s e s e s s i o n s a r e m e a n i n g f u l t o me. 1 2 3 4 5 15. I f i n d what a n d I a r e d o i n g f a r r e m o v e d f r o m my c o n c e r n s . 1 2 3 4 5 16. I f e e l t h a t what I do h e r e w i l l h e l p me t o a c c o m p l i s h t h e c h a n g e s t h a t I want. 17. I b e l i e v e i s g e n u i n e l y c o n c e r n e d f o r my w e l f a r e . 1 2 3 4 5 18. I am c l e a r a s t o what w a n t s me t o do i n t h e s e s e s s i o n s , 1 2 3 4 5 19. I r e s p e c t as a h i g h l y c a p a b l e a nd s k i l l f u l i n d i v i d u a l . 1 2 3 4 5 20. I f e e l t h a t i s n o t t o t a l l y h o n e s t a b o u t h i s / h e r f e e l i n g s t o w a r d me. 1 2 3 4 5 21. I am c o n f i d e n t i n 's a b i l i t y t o h e l p me t h r o u g h my p r e s e n t d i f f i c u l t i e s . 1 2 ' 3 4 5 22. We work t o w a r d s m u t u a l l y a g r e e d upon g o a l s . 1 2 3 4 . 5 1 8 0 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 23. I f e e l t h a t a p p r e c i a t e s me. 1 2 3 4 5 24. I d o n ' t know what w a n t s me t o do i n t h e s e s e s s i o n s . 1 2 3 4 5 25. As a r e s u l t o f t h e s e s e s s i o n s I am c l e a r e r as t o what I n e e d t o c h a n g e . 1 2 3 4 '5 26. I t r u s t 1 2 3 4 5 27. a nd I ha v e d i f f e r e n t i d e a s on what I s h o u l d be a i m i n g f o r . 1 2 3 4 5 28. My r e l a t i o n s h i p w i t h i s v e r y i m p o r t a n t t o me. 1 2 3 4 5 29. I h a v e t h e f e e l i n g t h a t i f I s a y o r do t h e w r o n g t h i n g s , w i l l s t o p w o r k i n g w i t h me. 1 2 3 4 . 5 30. We a g r e e on t h e t h i n g s I s h o u l d g e t o u t o f my t h e r a p y . 1 2 3 4 5 31. w a n t s me t o c h a n g e t o o f a s t . 1 2 3 4 . 5 32; We h a v e e s t a b l i s h e d a g o o d u n d e r s t a n d i n g f o r t h e d i r e c t i o n o f c h a n g e s t h a t w o u l d be g o o d f o r me. 33. The t h i n g s t h a t I am d o i n g h e r e d o n ' t make much s e n s e t o me. 1 2 3 4 5 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s I d o n ' t know w h a t t o e x p e c t a s t h e r e s u l t o f my t h e r a p y . 1 2 3 4 5 I b e l i e v e t h a t t h e way we a r e w o r k i n g w i t h my p r o b l e m i s c o r r e c t . 1 2 3 4 5 1 f e e l r e s p e c t s me e v e n w h e n I d o t h i n a s t h a t h e / s h e d o e s n o t a p p r o v e o f . 1 W o r k i n g A l l i a n c e I n v e n t o r y I n s t r u c t i o n s B e l o w a r e some s e n t e n c e s t h a t d e s c r i b e some o f t h e d i f f e r e n t ways p e o p l e i n t h e r a p y ( c o u n s e l l i n g ) may f e e l o r t h i n k a b o u t e a c h o t h e r . As y o u r e a d t h e s e n t e n c e s m e n t a l l y i n s e r t t h e name o f y o u r c l i e n t i n t h e p l a c e o f t h e i n t h e t e x t . B e l o w e a c h s e n t e n c e t h e r e i s a f i v e p o i n t s c a l e : 1 2 3 4 5 N e v e r S o m e t i m e s A l w a y s I f t h e s e n t e n c e d e s c r i b e s t h e way t h a t y o u a l w a y s f e e l ( o r t h i n k ) c i r c l e No. 5; i f i t n e v e r a p p l i e s t o y o u c i r c l e t h e number 1. U s e t h e p o i n t s i n b e t w e e n t o d e s c r i b e t h e v a r i a t i o n s b e t w e e n t h e s e e x t r e m e s . T h i s q u e s t i o n n a i r e i s c o n f i d e n t i a l ; NEITHER YOUR C L I E N T OR THE AGENCY  WILL SEE YOUR ANSWERS. P l e a s e work f a s t , y o u r f i r s t i m p r e s s i o n s a r e t h e o n e s we w o u l d l i k e t o g e t . ( P l e a s e d o n ' t f o r g e t t o r e s p o n d t o e v e r y i t e m . ) T h a n k y o u f o r y o u r c o o p e r a t i o n . 183 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 1. I o f t e n f e e l u n c o m f o r t a b l e w i t h . 1 2 3 4 5 2. a n d I a g r e e a b o u t t h e s t e p s t o be t a k e n t o i m p r o v e h i s / h e r s i t u a t i o n . 1 2 3 4 5 3. I w o r r y a b o u t t h e o u t c o m e o f t h e s e s e s s i o n s . 1 2 3 4 5 4. I f e e l we a r e a p p r o a c h i n g h i s / h e r p r o b l e m s t h e r i g h t way. 1 2 3 4 5 5. I f e e l I r e a l l y u n d e r s t a n d . 1 2 3 4 5 6. I f i n d what we do i n t h e r a p y c o n f u s i n g . 1 2 3 4 5 7. I h a v e an a c c u r a t e p e r c e p t i o n o f 's g o a l s . 1 2 3 4 5 s p e n d s w i t h me i s i m p o r t a n t f o r h i m / h e r . 2 3 4 5 9. I n e e d t o c l a r i f y f o r t h e p u r p o s e o f o u r s e s s i o n s . 1 2 3 4 5 10. I o f t e n d i s a g r e e w i t h a b o u t o u r g o a l s , i 1 2 3 4 5 11. I b e l i e v e t h a t t h e t i m e a n d I a r e s p e n d i n g t o g e t h e r i s n o t s p e n t e f f i c i e n t l y . 1 2 3 4 5 T h e t i m e 1 184 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 12. I d o n ' t know what we a r e t r y i n g t o a c c o m p l i s h i n t h e r a p y . 1 2 3 4 5 13. I am c l e a r on w h at 's r e s p o n s i b i l i t i e s a r e i n t h e r a p y . 1 2 . 3 4 5 14. T h e g o a l s o f t h e s e s e s s i o n s a r e m e a n i n g f u l t o _ . 1 2 3 4 5 15. I f i n d what a n d I a r e d o i n g f a r r e m o v e d f r o m s c o n c e r n s . 1 2 3 4 5 16. I f e e l w h a t we do h e r e w i l l h e l p t o a c c o m p l i s h t h e c h a n g e s t h a t h e / s h e w a n t s . 1 2 3 4 5 17. I am g e n u i n e l y c o n c e r n e d f o r 1 s w e l f a r e . 1 2 3 4 5 18. I am c l e a r a s t o w h at s h o u l d do i n t h e s e s e s s i o n s . 1 2 3 4 5 19. r e s p e c t s me a s a h i g h l y c a p a b l e a n d s k i l l f u l i n d i v i d u a l . 1 2 3 4 5 2 0 . I f e e l t h a t I am n o t t o t a l l y h o n e s t a b o u t my f e e l i n g s t o w a r d . 1 2 3 4 5 2 1 . I b e l i e v e i s c o n f i d e n t i n my a b i l i t y t o h e l p h i m / h e r t h r o u g h h i s / h e r p r e s e n t d i f f i c u l t i e s . 1 2 3 4 5 22. We work t o w a r d s m u t u a l l y a g r e e d upon g o a l s . 1 2 3 4 5 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 23. I a p p r e c i a t e . . 1 2 3 4 5 24. d o e s n ' t know what h e / s h e s h o u l d do i n t h e s e s e s s i o n s . 1 2 3 4 5 25. As a r e s u l t o f t h e s e s e s s i o n s i s c l e a r e r a s t o w h a t h e / s h e n e e d s t o c h a n g e . 1 2 3 4 5 26. I f e e l t h a t t r u s t s me. 1 2 3 4 5 27. and I h a v e d i f f e r e n t i d e a s on what h e / s h e s h o u l d be a i m i n g f o r . 1 2 3 4 5 28. My r e l a t i o n s h i p w i t h i s v e r y i m p o r t a n t t o h i m / h e r . 1 2 3 4 5 29. has t h e f e e l i n g t h a t i f h e / s h e s a y s o r d o e s t h e w r o n g t h i n g s , I w i l l s t o p w o r k i n g w i t h h i m / h e r . 1 2 3 . 4 5 30. We a g r e e on t h e t h i n g s s h o u l d g e t o u t o f t h e r a p y . 1 2 3 4 5 31. f e e l s t h a t I want h e r / h i m t o make c h a n g e s t o o f a s t . 1 2 3 4 5 32. We ha v e e s t a b l i s h e d a g o o d u n d e r s t a n d i n g f o r t h e d i r e c t i o n o f c h a n g e s t h a t w o u l d be good f o r . 1 2 3 4 5 33. T h e t h i n g s t h a t we a r e d o i n g h e r e d o n ' t make much s e n s e t o 1 2 3 4 5 186 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 34. d o e s n ' t know what t o e x p e c t as t h e r e s u l t o f t h e r a p y . 1 2 3 4 5 35. b e l i e v e s t h a t t h e way we a r e w o r k i n g w i t h h i s / h e r p r o b l e m i s c o r r e c t . 1 2 3 4 5 36. f e e l s t h a t I r e s p e c t h i m / h e r e v e n when h e / s h e d o e s t h i n g s t h a t I do n o t a p p r o v e o f . 1 2 3 4 5 C l i e n t Form ftP o s 11h e r a p y Q u e s t i o n n a i r e T h i s s u r v e y i s p a r t o f a ' r e s e a r c h p r o j e c t t o s t u d y how c l i e n t s f e e l about t h e i r t h e r a p y e x p e r i e n c e s . P l e a s e t r y t o answer a l l q u e s t i o n s as c o m p l e t e l y and a c c u r a t e l y as you can. R e t u r n y o u r c o m p l e t e d q u e s t i o n n a i r e i n t h e e n v e l o p e p r o v i d e d . Your c o o p e r a t i o n i n t h i s r e s e a r c h i s v e r y much a p p r e c i a t e d . *Adopted f r o m t h e q u e s t i o n n a i r e d e v e l o p e d by Dr. H. S t r u p p e t a l . 188 1. Age: 2. Sex ( c i r c l e one): M F 3 . Marital status: Single Married Divorced Widowed 4. Education (check highest le v e l and complete question): Elementary school (indicate number of years: ) High school (indicate number of years: ) High school graduate College (indicate number of years: ) College graduate Graduate study or professional training (kind, degree, etc.) 5 . How much in need of further therapy/counselling do you feel now? No need at a l l Slight need Could use more Considerable need Very great need 6. If this i s your last session, what led to the termination of your therapy/ counselling? My decision My therapist's decision Mutual agreement External factors 7. How much have you benefitted from your therapy/counselling? A great deal A f a i r amount __ To some extent Very l i t t l e Not at a l l 189 8. E v e r y t h i n g c o n s i d e r e d , how s a t i s f i e d are you w i t h the r e s u l t s o f your t h e r a p y / c o u n s e l l i n g e x p e r i e n c e ? E x t r e m e l y d i s s a t i s f i e d ; M o d e r a t e l y d i s s a t i s f i e d F a i r l y d i s s a t i s f i e d F a i r l y s a t i s f i e d M o d e r a t e l y s a t i s f i e d H i g h l y s a t i s f i e d E x tremely s a t i s f i e d 9. Was your t h e r a p i s t of the same sex? Yes No 10. What i m p r e s s i o n d i d you have of h i s / h e r l e v e l oi" e x p e r i e n c e as a t h e r a p i s t / c o u n s e l l o r ? Extremely i n e x p e r i e n c e d Rather i n e x p e r i e n c e d Somewhat e x p e r i e n c e d F a i r l y e x p e r i e n c e d H i g h l y e x p e r i e n c e d E x c e p t i o n a l l y e x p e r i e n c e d 1 1 . At the b e g i n n i n g of your t h e r a p y how w e l l d i d you f e e l you were g e t t i n g along? Very w e l l F a i r l y w e l l N e i t h e r w e l l nor p o o r l y F a i r l y p o o r l y Very p o o r l y Extremely p o o r l y 190 .12. How l o n g b e f o r e e n t e r i n g therapy d i d you f e e l i n need o f p r o f e s s i o n a l help? __ l e s s than 1 y e a r 1 - 2 y e a r s 3 - 4 y e a r s 5 - 1 0 y e a r s 11 - 15 y e a r s 1 6 - 2 0 y e a r s y e a r s ( s p e c i f y ) 13. How s e v e r e l y d i s t u r b e d d i d you c o n s i d e r y o u r s e l f at the b e g i n n i n g o f your t h e r a p y / c o u n s e l l i n g ? E x t r e m e l y Very much M o d e r a t e l y Somewhat Very s l i g h t l y d i s t u r b e d d i s t u r b e d d i s t u r b e d d i s t u r b e d d i s t u r b e d 14. How much a n x i e t y d i d you f e e l at the time you s t a r t e d t h e r a p y / c o u n s e l l i n g ? A tremendous A g r e a t A f a i r ' V e r y None a t amount d e a l amount l i t t l e a l l 15. How g r e a t was the i n t e r n a l " p r e s s u r e " t o do something about these problems when you e n t e r e d t h e r a p y / c o u n s e l l i n g ? E x t r e m e l y g r e a t Very g r e a t •_ F a i r l y g r e a t R e l a t i v e l y s m a l l Very s m a l l E x t r e m e l y s m a l l .16. How much do you f e e l you have changed as a r e s u l t of t h e r a p y / c o u n s e l l i n g ? A g r e a t d e a l A f a i r amount Somewhat Very l i t t l e Not a t a l l How m u c h o f t h i s c h a n g e do y o u f e e l h a s b e e n a p p a r e n t t o o t h e r s ? ( a ) P e o p l e c l o s e s t t o y o u ( h u s b a n d , w i f e , e t c . ) A g r e a t d e a l A f a i r a m o u n t Somewhat V e r y l i t t l e N o t a t a l l ( b ) C l o s e f r i e n d s A g r e a t A f a i r S o m e w h a t V e r y N o t a t d e a l a m o u n t l i t t l e a l l ( c ) C o - w o r k e r s , a c q u a i n t a n c e s , e t c . A g r e a t d e a l A f a i r a m o u n t Somewhat V e r y l i t t l e N o t a t a l l On t h e w h o l e how w e l l do y o u f e e l y o u a r e g e t t i n g a l o n g now? E x t r e m e l y w e l l V e r y w e l l F a i r l y w e l l N e i t h e r w e l l n o r p o o r l y F a i r l y p o o r l y V e r y p o o r l y E x t r e m e l y p o o r l y How a d e q u a t e l y d o . y o u f e e l y o u a r e d e a l i n g w i t h a n y p r e s e n t p r o b l V e r y a d e q u a t e l y F a i r l y a d e q u a t e l y N e i t h e r a d e q u a t e l y n o r i n a d e q u a t e l y S o mewhat i n a d e q u a t e l y V e r y i n a d e q u a t e l y T o w h n t e x t e n t h a v e y o u r c o m p l a i n t s o r s y m p t o m s t h a t b r o u g h t y o u t o t h e r a p y / c o u n s e l l i n g c h a n g e d a s a r e s u l t o f t r e a t m e n t ? C o m p l e t e l y d i s a p p e a r e d V e r y g r e a t l y i m p r o v e d C o n s i d e r a b l e i m p r o v e d Somewhat i m p r o v e d N o t a t a l l i m p r o v e d G o t w o r s e How s o o n a f t e r e n t e r i n g t h e r a p y d i d y o u f e e l a n y m a r k e d c h a n g e ? h o u r s o f t h e r a p y ( a p p r o x i m a t e l y ) How s t r o n g l y w o u l d y o u r e c o m m e n d t h e r a p y / c o u n s e l l i n g t o a c l o s e f r i e n d w i t h e m o t i o n a l p r o b l e m s ? \ / W o u l d s t r o n g l y r e c o m m e n d i t i t w i t h some r e s e r v a t i o n s W o u l d n o t r e c o m m e n t i t W o u l d a d v i s e a g a i n s t i t P l e a s e i n d i c a t e t h e a d e q u a c y o f t h i s q u e s t i o n n a i r e i n d e s c r i b i n g y o u r t h e r a p y e x p e r i e n c e . G i v e a n y a d d i t i o n a l d a t a w h i c h y o u f e e l a r e r e l e v a n t t o a n u n d e r s t a n d i n g o f y o u r e x p e r i e n c e . W o u l d m i l d l y r e c o m m e n d W o u l d r e c o m m e n d i t b u t THANK YOU FOR YOUR COOPERATION T h e r a p i s t Form *Posttheranv Questionnaire T h i s survey i s part of a research p r o j e c t to study how t h e r a p i s t s assess therapy experiences. Please t r y to answer a l l questions as a c c u r a t e l y as you can. Return your completed questionnaire i n the envelope provided. Your cooperation i n t h i s research i s very much appreciated. *Adopted form the questionnaire developed by Dr. H. Strupp et a l . 1. How much m o r e t h e r a p y d o y o u f e e l y o u r c l i e n t n e e d s now? No n e e d a t a l l S l i g h t n e e d C o u l d u s e m o r e C o n s i d e r a b l e n e e d V e r y g r e a t n e e d 2. I f y o u a r e t e r m i n a t i n g w i t h t h i s c l i e n t now, w h a t d e t e r m i n e d t h i s c h o i c e ? C l i e n t ' s d e c i s i o n T h e r a p i s t ' s d e c i s i o n M u t u a l a g r e e m e n t E x t e r n a l f a c t o r s 3 . How much h a s y o u r c l i e n t b e n e f i t t e d f r o m t h e r a p y ? A g r e a t d e a l A f a i r a m o u n t T o some e x t e n t V e r y l i t t l e N o t a t a l l i . E v e r y t h i n g c o n s i d e r e d , how s a t i s f i e d a r e y o u w i t h t h e r e s u l t s o f h i s / h e r p s y c h o t h e r a p y e x p e r i e n c e ? E x t r e m e l y d i s s a t i s f i e d M o d e r a t e l y d i s s a t i s f i e d • F a i r l y d i s s a t i s f i e d F a i r l y s a t i s f i e d M o d e r a t e l y s a t i s f i e d H i g h l y s a t i s f i e d E x t r e m e l y s a t i s f i e d A s a t h e r a p i s t ( c o u n s e l l o r ) how w o u l d y o u d e s c r i b e y o u r s e l f ? E x t r e m e l y i n e x p e r i e n c e d R a t h e r i n e x p e r i e n c e d Somewhat e x p e r i e n c e d F a i r l y e x p e r i e n c e d H i g h l y e x p e r i e n c e d E x c e p t i o n a l l y e x p e r i e n c e d A t t h e b e g i n n i n g o f t h e r a p y how w e l l d i d y o u f e e l y o u r c l i e n t was g e t t i n g a l o n g ? V e r y w e l l F a i r l y w e l l N e i t h e r w e l l n o r p o o r l y F a i r l y p o o r l y V e r y p o o r l y E x t r e m e l y p o o r l y How s e v e r e l y d i s t u r b e d was y o u r c l i e n t a t t h e b e g i n n i n g o f t h e r a p y ? E x t r e m e l y V e r y m u c h M o d e r a t e l y Somewhat V e r y s l i g h t l y d i s t u r b e d d i s t u r b e d d i s t u r b e d d i s t u r b e d d i s t u r b e d How m u c h a n x i e t y d i d y o u r c l i e n t e x p e r i e n c e a t t h e b e g i n n i n g o f t h e r a p y ? A t r e m e n d o u s A g r e a t A f a i r V e r y N o n e a t a m o u n t d e a l a m o u n t l i t t l e a l l How m u c h i n t e r n a l " p r e s s u r e " d i d y o u r c l i e n t e x p e r i e n c e a b o u t t h e s e p r o b l e w h e n h e / s h e e n t e r e d p s y c h o t h e r a p y ? E x t r e m e l y g r e a t V e r y g r e a t F a i r l y g r e a t / R e l a t i v e l y s m a l l V e r y s m a l l E x t r e m e l y s m a l l How much do y o u f e e l h e / s h e h a s c h a n g e d a s a r e s u l t o f t h e r a p y ? A g r e a t d e a l A f a i r a m o u n t S o m e w h a t V e r y l i t t l e N o t a t a l l How m u c h o f t h i s c h a n g e do y o u f e e l h a s b e e n a p p a r e n t t o o t h e r s ( a ) P e o p l e c l o s e s t t o h i m / h e r ( h u s b a n d , w i f e , e t c . ) A g r e a t A f a i r S o mewhat d e a l a m o u n t V e r y l i t t l e N o t a t a l l ( b ) C l o s e f r i e n d s . A g r e a t d e a l A f a i r a m o u n t Somewhat V e r y ' l i t t l e N o t a t a l l ( c ) C o - w o r k e r s , a c q u a i n t a n c e s , e t c . A g r e a t A f a i r S o mewhat V e r y N o t a t d e a l a m o u n t l i t t l e a l l On t h e w h o l e how w e l l do y o u f e e l h e / s h e i s g e t t i n g a l o n g now? E x t r e m e l y w e l l V e r y w e l l F a i r l y w e l l N e i t h e r w e l l n o r p o o r l y F a i r l y p o o r l y V e r y p o o r l y E x t r e m e l y p o o r l y How a d e q u a t e l y do y o u f e e l h e / s h e i s d e a l i n g w i t h a n y p r e s e n t p r o b l e m s ? V e r y a d e q u a t e l y F a i r l y a d e q u a t e l y N e i t h e r a d e q u a t e l y n o r i n a d e q u a t e l y Somewhat i n a d e q u a t e l y V e r y i n a d e q u a t e l y T o w h a t e x t e n t h a s h i s / h e r c o m p l a i n t s o r s y m p t o m s t h a t b r o u g h t h i m / h e r t o t h e r a p y c h a n g e d a s a r e s u l t o f t r e a t m e n t ? C o m p l e t e l y d i s a p p e a r e d V e r y g r e a t l y i m p r o v e d C o n s i d e r a b l y i m p r o v e d Somewhat i m p r o v e d N o t a t - a l l i m p r o v e d G o t w o r s e How s o o n a f t e r e n t e r i n g t h e r a p y d i d y o u f e e l t h a t m a r k e d c h a n g e s h a d t a k e n p l a c e i n h i m / h e r ? h o u r s o f t h e r a p y ( a p p r o x i m a t e l y ) THANK YOU FOR YOUR P A R T I C I P A T I O N I N T H I S P R O J E C T 198 ,a, '. ^ . S ^ A r i n ^ the CP? iiusiber -the items from 1 .to 36. Score the ansxver tc' each item from 1 t c 7. The l e f t - m o s t srace s i t h s r 1 or 7 as f o l l o w s • 1. - 7 . ' ' . 13. _ T 25. _ 7 z. - 1 14. - 1 26. 1 3. - 7 15. - 1 27. — 1 k. - 1 16. - 1 28. — 1 5- - 7 17. - 1 29. — 7 0. - 7 18. - 7 30. — 7 7. - 7 ' 19. - 7 31. 7 8. - 1 20. - 7 32. - 7 9. - 1 21. - 1 33- — 1 10. - 7 22. - 1 3^. — 7 11. - 1 23. - 7 35. — 7 12. - 1 24. - 7 36.. - 7 Determine f a c t o r scores E, T, A, by adding the scores of the 12 items i n each f a c t o r as f o l l o w s : Exnertness Trastworthinegs A t t r a c t I r e n e 3 s 2 12 1 3 13- k 8 •13 5 11 . , 2k 6 15 26 7 16 27 9 19" 23 10 20 29 14 21 30 17 23 33 22 25 3k 32 31 35 36 199 Appendix D Item level analysis of the p i l o t data 200 This Appendix contains a p a r t i a l output of the computer program LERTAP (Nelson, 1974). The inerpretation of the symbols are as follows: Option= the altenative on the Likert scale below each item. WGT = item p o l a r i t y ( i . e . adjustment for negatively or p o s i t i v e l y worded items). N = the number of subjects selecting each response altenat ive. P = percent. Mean = mean score for the item. S.D. = standard deviation of the item. S.T. = item-subtest c o r r e l a t i o n . T.T. = item-total test c o r r e l a t i o n . LERTAP numbers the items sequentally within each subtest. The item equvivalences are: Domain LERTAP # WAI # Bond 1 1 2 5 3 8 4 17 5 19 6 20 7 21 8 23 201 Domain LERTAP # WAI # Bond 9 26 10 28 11 29 12 36 Task 1 2 2 4 . 3 6 4 11 5 13 6 15 7 16 8 18 9 24 10 31 11 33 12 35 Goal 1 3 2 7 3 9 4 10 5 12 6 14 7 21 8 25 Doma i n Goal LERTAP # 9 10 11 12 WAI 27 30 32 34 LERTAP 2.0 TEST NO 1 W.A.I . FORM C o 00 ITEM NUMBER 1 OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 .0 3 3.0 9 G4 .3 4 4 .0 4 28.G 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 2 OPTION WGT 1 1.0 0 O.O 2 2.0 0 0 .0 3 3.0 4 28.6 4 4 .0 10 71.4 5 5.0 O 0 .0 TOTAL 14 ITEM NUMBER 3 OPTION WGT 1 5.0 3 21.4 2 4 .0 8 57. 1 3 3.0 2 14.3 4 2.0 1 7.1 5 1.0 O 0 .0 TOTAL 14 ITEM NUMBER 4 OPTION WGT 1 5.0 5 35.7 2 4 .0 8 57 . 1 3 3.0 1 7.1 4 2.0 O 0 .0 5 1.0 0 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK C ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.429 0.G4G 0.341 0.532 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.7 14 0.469 0.703 0.566 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 0.829 - 0 .099 0.014 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.286 0.611 0.613 0.516 LERTAP 2.0 TEST NO 1 W.A. ITEM NUMBER 5 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 6 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 7 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 8 OPTION 1 2 3 4 5 TOTAL FORM C WGT N P 1.0 O 0 .0 2.0 O 0 . 0 3.0 3 21.4 4.0 7 50 .0 5.0 4 28. G 14 WGT N P 5.0 5 35.7 4.0 6 42.9 3.0 2 14.3 2.0 1 7.1 1.0 0 O.O 14 WGT N P 1.0 0 0 .0 2.0 2 14.3 3.0 6 42.9 4.0 4 28.6 5.0 2 14.3 14 WGT N P 1.0 O 0 . 0 2.0 1 7.1 3.0 2 14.3 4.0 10 71.4 5.0 1 7.1 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK C ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.730 -0 .145 -0 .192 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.917 0.754 0.747 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.429 0.938 0.036 0.339 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.786 0.699 0.438 0.262 LERTAP 2.0 TEST NO 1 W.A.I . FORM C ITEM NUMBER 9 O OPTION WGT CM 1 5.0 3 21.4 2 4 .0 8 57 . 1 3 3.0 3 21.4 4 2.0 0 0 .0 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 10 OPTION WGT 1 5.0 8 57.1 2 4 .0 5 35.7 3 3.0 0 0 .0 4 2.0 1 7.1 5 1.0 O 0 .0 TOTAL 14 ITEM NUMBER 11 OPTION WGT 1 5.0 6 42.9 2 4.0 4 28.G 3' 3.0 3 21.4 4 2.0 O 0 .0 5 1.0 O 0 .0 OTHER 0 .0 1 7.1 TOTAL 14 ITEM NUMBER 12 OPTION WGT 1 1.0 1 7.1 2 2.0 1 7.1 3 3.0 2 14.3 4 4 .0 9 G4.3 5 5.0 1 7.1 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK C ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.000 O.G79 0.208 0 .000 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.429 0.852 0.111 0.358 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 1.385 -0 .246 0.274 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 1.016 0 .550 0.741 LERTAP 2.0 TEST NO 1 W.A. I . FORM C ITEM NUMBER 1 O CM OPTION WGT 1 5.0 4 28.6 2 4 .0 8 57.1 3 3.0 1 7.1 4 2.0 1 7.1 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 2 OPTION WGT 1 1.0 O 0 .0 2 2.0 1 7.1 3 3.0 3 21.4 4 4 .0 10 71.4 5 5.0 0 0 .0 TOTAL 14 ITEM NUMBER 3 OPTION WGT 1 1.0 0 0 .0 2 2.0 1 7.1 3 3.0 3 21.4 4 4 .0 9 64.3 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 4 OPTION WGT 1 1.0 O 0 .0 2 2.0 O 0 .0 3 3.0 1 7.1 4 4 .0 7 50.0 5 5.0 6 42.9 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 2 WAI BOND C ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.829 0.035 -0 .022 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.633 0.579 0 .600 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.714 0.726 0.695 0.765 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.357 0.633 0.704 0.632 LERTAP 2.0 TEST NO 1 W.A. I . FORM C ITEM NUMBER 5 OPTION WGT 1 1.0 0 0 . 0 2 2.0 0 O.O 3 3.0 3 21.4 4 4.0 8 57. 1 5 5.0 3 21.4 TOTAL 14 ITEM NUMBER 6 OPTION WGT 1 5.0 2 14.3 2 4 .0 9 64.3 3 3.0 2 14.3 4 2.0 1 7.1 5 1.0 0 0 . 0 TOTAL 14 ITEM NUMBER 7 OPTION WGT 1 1.0 0 0 .0 2 2.0 1 7.1 3 3.0 4 28.6 4 4 .0 8 57.1 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 8 OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 . 0 3 3.0 0 0 .0 4 4 .0 8 57.1 5 5.0 6 42.9 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 2 WAI BOND C ITEM STATS CORRELATIONS MEAN S.D. ST TT 1.000 0.679 0.647 0.731 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.857 0.770 0.191 -0 .045 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.745 0.650 0.562 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.429 0.514 0.251 0.406 LERTAP 2.0 TEST NO 1 W.A. I . FORM C „ ITEM NUMBER 9 s C\J OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 .0 3 3.0 0 0 .0 4 4:0 6 42.9 5 5.0 8 57. 1 TOTAL 14 ITEM NUMBER 10 OPTION 1 2 3 4 5 OTHER TOTAL WGT N P 1.0 1 7.1 2.0 1 7.1 3.0 4 28.G 4 .0 6 42.9 5.0 1 7.1 0 .0 1 7.1 14 ITEM NUMBER 11 OPTION WGT 1 5.0 11 78.6 2 4 .0 3 21.4 3 3.0 0 0 .0 4 2.0 0 0 .0 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 12 OPTION WGT 1 1.0 0 0 .0 2 2.0 1 7.1 3 3.0 2 14.3 4 4 .0 6 42.9 5 5.0 5 35.7 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 2 WAI BOND C ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.571 0.514 0.433 0.298 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.143 1.351 O.246 O.566 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.78G 0.426 0.249 0.248 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.917 0.589 0.698 LERTAP 2.0 TEST NO 1 W.A. I . FORM C c r > O ITEM NUMBER 1 OPTION WGT 1 5.0 7 50 .0 2 4 . 0 . 2 14.3 3 3.0 2 14.3 4 2.0 3 21.4 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 2 OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 .0 3 3.0 6 42.9 4 4 .0 8 57.1 5 5.0 0 0 .0 TOTAL 14 ITEM NUMBER 3 OPTION 1 2 3 4 5 OTHER TOTAL WGT N P 5.0 4 28.6 4.0 9 64.3 3.0 O 0 .0 2.0 0 0 .0 1.0 O 0 .0 0 .0 1 7.1 14 ITEM NUMBER 4 OPTION WGT 1 5.0 4 28.6 2 4 .0 6 42.9 3 3.0 4 28.6 4 2.0 O 0 .0 5 1.0 O 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL C ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 1.269 -0 .224 -0 .072 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 0.514 0.374 0.511 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.000 1.240 0.269 0.192 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.000 0.784 0.293 0.395 LERTAP 2.0 TEST NO 1 W.A. ITEM NUMBER 5 OPTION 1 2 3 4 5 OTHER TOTAL ITEM NUMBER 6 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 7 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 8 OPTION 1 2 3 4 5 TOTAL FORM C WGT N P 5.0 4 28.6 4.0 5 35.7 3.0 2 14.3 2.0 2 14.3 1.0 0 0 .0 0 .0 1 7.1 14 WGT N P 1.0 O 0.0 2.0 0 0 .0 3.0 4 28.6 4.0 5 35.7 5.0 5 35.7 14 WGT N P 1.0 1 7.1 2.0 1 7.1 3.0 3 21.4 4 .0 8 57.1 5.0 1 7.1 14 WGT N P 1.0 0 0 .0 2.0 0 0 .0 3.0 6 42.9 4 .0 7 50. 0 5.0 1 7.1 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL C ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 1.453 0.527 0.572 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.829 -0.031 O.103 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.500 1.019 0.417 0.719 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.633 0 . 4 6 5 ' 0 .560 LERTAP 2.0 TEST NO 1 W.A. I . FORM C ITEM NUMBER 9 OPTION WGT 1 5.0 2 14.3 2 4 .0 10 71.4 3 3.0 1 7.1 4 2.0 1 7.1 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 10 OPTION WGT 1 1.0 1 7.1 2 2.0 2 14.3 3 3.0 6 42.9 4 4 .0 5 35.7 5 5.0 0 0 .0 TOTAL 14 ITEM NUMBER 1 1 OPTION WGT 1 1 .0 1 7 2 2 .0 1 7 3 3 .0 7 50 4 4 .0 4 28 5 5 .0 0 0 OTHER 0 .0 1 7 TOTAL 14 ITEM NUMBER 12 OPTION WGT 1 5.0 3 21.4 2 4 .0 5 35. 7 3 3.0 5 35.7 4 2.0 1 7.1 5 1.0 O 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL C ITEM STATS . CORRELATIONS MEAN S.D. ST TT 3.929 0.730 0.121 0.537 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.071 0.917 0.819 0.775 ITEM STATS CORRELATIONS MEAN S.D. ST TT 2.857 1.167 0.614 0.523 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.7 14 0.914 0.058 0.001 LERTAP 2.0 w TEST NO 1 W.A. I . FORM T ITEM NUMBER 1 OPTION WGT 1 1 .0 0 0. .0 2 2 .0 1 7 . 1 3 3 .0 3 21 .  4 4 4 .0 8 57 .  1 5 5 .0 1 7 . 1 OTHER 0. .0 1 7 . 1 TOTAL 14 ITEM NUMBER 2 OPTION WGT 1 5.0 0 0 . 0 2 4 .0 0 O.O 3 3.0 8 57. 1 4 2.0 6 42.9 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 3 OPTION WGT 1 5.0 2 14.3 2 4 .0 7 50 .0 3 3.0 5 35.7 4 2.0 O 0 . 0 5 1.0 O 0 .0 TOTAL 14 ITEM NUMBER 4 OPTION WGT 1 5.0 2 14.3 2 4 .0 7 50 .0 3 3.0 3 21.4 4 2.0 2 14.3 5 1.0 0 O.O TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK T ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.429 1.223 0.257 0.392 ITEM STATS CORRELATIONS MEAN S.D. ST TT 2.571 0.514 0.31G 0.114 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.786 0.699 0.651 0.598 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.929 0.110 0.404 LERTAP 2.0 TEST NO 1 W.A. I . FORM T ^ ITEM NUMBER 5 OPTION WGT 1 1.0 O 0 .0 2 2.0 O 0 .0 3 3.0 1 7.1 4 4.0 8 57. 1 5 5.0 5 35.7 TOTAL 14 ITEM NUMBER G OPTION WGT 1 5.0 5 35.7 2 4.0 7 50.0 3 3.0 2 14.3 4 2.0 O 0 .0 5 1.0 O 0 .0 TOTAL 14 ITEM NUMBER 7 OPTION WGT 1 1.0 O 0 .0 2 2.0 2 14.3 3 3.0 2 14.3 4 4 .0 9 G4.3 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 8 OPTION WGT 1 1.0 0 0 .0 2 2.0 3 21.4 3 3.0 4 28. G 4 4 .0 7 50 .0 5 5.0 0 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK T ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.28G 0.G11 0.223 0.28G ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.214 0.G99 0.431 0.621 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.842 0.074 0 .490 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.286 0.825 0.217 0.339 LERTAP 2.0 TEST NO 1 W.A. I . FORM T _,_ ITEM NUMBER 9 <M OPTION WGT 1 5.0 2 14.3 2 4 .0 7 50.0 3 3.0 4 28.G 4 2.0 O 0 .0 5 1.0 0 0 .0 OTHER 0 .0 1 7.1 TOTAL 14 ITEM NUMBER 10 OPTION WGT 1 5.0 2 4 .0 3 3.0 4 2.0 5 1.0 TOTAL N P 7 50.0 4 28.6 3 21.4 0 0 .0 0 0 .0 14 ITEM NUMBER 1 1 OPTION WGT 1 5.0 2 4 .0 3 3.0 4 2.0 5 1.0 TOTAL N P 1 7.1 11 78.6 2 14.3 O 0 .0 0 0 .0 14 ITEM NUMBER 12 OPTION WGT 1 1.0 2 2.0 3 3.0 4 4 .0 5 5.0 TOTAL N P 0 0 .0 0 0 .0 6 42.9 7 50.0 1 7.1 14 SUMMARY ITEM STATISTICS SUBTEST 1 WAI TASK T ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 1.223 -0.011 -0 .062 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.286 0.825 0.217 0.221 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 0.475 0.475 0.561 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.633 0.353 0.569 TEST NO 1 W.A. I . FORM T ITEM NUMBER 1 OPTION WGT N P Lf\ 1 5 . 0 2 14.3 ^ 2 4 .0 6 42.9 3 3.0 4 28.G 4 2.0 O 0 .0 5 1.0 2 14.3 TOTAL 14 ITEM NUMBER 2 OPTION WGT N P 1 1.0 0 0 .0 2 2.0 O 0 .0 3 3.0 5 35.7 4 4 .0 9 G4.3 5 5.0 0 0 .0 TOTAL 14 ITEM NUMBER 3 OPTION WGT 1 1.0 1 7.1 2 2.0 1 7.1 3 3.0 G 42.9 4 4 .0 5 35.7 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 4 OPTION WGT 1 1.0 O 0 .0 2 2.0 0 0 .0 3 3.0 1 7.1 4 4 .0 4 28.6 5 5.0 9 64.3 TOTAL 14 SUBTEST 2 WAI BOND T ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.429 1.223 -0 .022 0.221 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.643 0.497 0.122 0.184 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.286 0.994 O.407 0.394 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.571 0.646 0.291 0.241 LERTAP 2.0 TEST NO 1 W.A. I . FORM T ITEM NUMBER 5 OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 .0 3 3.0 9 64.3 4 4.0 4 28.6 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 6 OPTION WGT 1 5.0 5 35.7 2 4 .0 6 42.9 3 3.0 2 14.3 4 2.0 1 7.1 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 7 OPTION WGT 1 1.0 0 0 .0 2 2.0 O 0 . 0 3 3.0 7 50 .0 4 4 .0 6 42.9 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 8 OPTION WGT 1 1.0 0 0 .0 2 2.0 0 0 .0 3 3.0 1 7.1 4 4 .0 5 35.7 5 5.0 8 57.1 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 2 WAI BOND T ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.429 0.646 0.546 0.719 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.917 O.396 O.199 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 0.646 0.495 0.565 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.500 0.650 0.44 1 0.327 LERTAP 2.0 TEST NO 1 W.A. I . FORM T ITEM NUMBER 9 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 10 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 1 1 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 12 OPTION 1 2 3 4 5 TOTAL WGT N P 1.0 0 0 .0 2.0 0 0 .0 3.0 3 21.4 4.0 7 50 .0 5.0 4 28.6 14 WGT N P 1.0 0 0 .0 2.0 2 14.3 3.0 6 42.9 4.0 6 42.9 5.0 O 0 .0 14 WGT N P 1.0 9 64.3 2.0 4 28.6 3.0 0 0 .0 4 .0 1 7.1 5.0 O 0 .0 14 WGT N P 1.0 0 0 .0 2.0 0 0 . 0 3.0 2 14.3 4.0 10 71.4 5.0 2 14.3 14 SUMMARY ITEM STATISTICS SUBTEST 2 WAI BOND T ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.071 0.730 0.718 0.475 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.286 0.726 0 .550 0.509 ITEM STATS CORRELATIONS MEAN S.D. ST TT 1 .500 0.855 0.407 O. 170 ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.000 0.555 0.186 - 0 . 0 4 0 LERTAP 2.0 TEST NO 1 W.A. ITEM NUMBER 1 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 2 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 3 OPTION 1 2 3 4 5 TOTAL ITEM NUMBER 4 OPTION 1 2 3 4 5 TOTAL FORM T WGT N P 5.0 1 7.1 4 . 0 1 7.1 3.0 6 42.9 2.0 6 42.9 1.0 0 0 .0 14 WGT N P 1.0 O 0 .0 2.0 3 21.4 3.0 6 42 .9 4..0 5 35.7 5.0 O 0 .0 14 WGT N P 5.0 5 -35.7 4.0 G 42.9 3.0 1 7.1 2.0 1 7.1 1.0 1 7.1 14 WGT N P 1.0 7 50.0 2.0 7 50.O 3.0 O 0 .0 4.0 0 0 .0 5.0 O 0 .0 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL T ITEM STATS CORRELATIONS MEAN S.D. ST TT 2.786 0.893 - 0 .245 -0 .084 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.143 0.770 0.572 0.599 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 1.207 0.669 0.648 ITEM STATS CORRELATIONS MEAN S.D. ST TT 1.500 0.519 0.266 0.554 LERTAP 2.0 TEST NO 1 W.A. I . FORM T ITEM NUMBER 5 OPTION WGT 1 5.0 4 28.6 2 4.0 6 42.9 3 3.0 3 21.4 4 2.0 1 7.1 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 6 OPTION WGT 1 1.0 O 0 .0 2 2.0 1 7.1 3 3.0 5 35.7 4 4 .0 7 50 .0 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 7 OPTION WGT 1 1.0 0 0 .0 2 2.0 2 14.3 3 3.0 3 21.4 4 4 .0 6 42.9 5 5.0 3 21.4 TOTAL 14 ITEM NUMBER 8 OPTION WGT 1 1.0 0 0 .0 2 2.0 2 14.3 3 3.0 6 42.9 4 4 .0 6 42.9 5 5.0 O 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL T ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.929 0.917 0.001 0.152 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 0.756 0.615 0.473 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.714 0.994 0.585 0.590 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.286 0.726 0.137 0.303 LERTAP 2.0 TEST NO 1 W.A. I . FORM T CM C\J ITEM NUMBER 9 OPTION WGT 1 5.0 5 35.7 2 4.0 7 50 .0 3 3.0 2 14.3 4 2.0 0 0 .0 5 1.0 0 0 .0 TOTAL 14 ITEM NUMBER 10 OPTION WGT 1 1.0 1 7.1 2 2.0 O 0 .0 3 3.0 4 28.6 4 4 .0 8 57.1 5 5.0 1 7.1 TOTAL 14 ITEM NUMBER 11 OPTION WGT 1 1.0 1 7.1 2 2.0 2 14.3 3 3.0 6 42.9 4 4 .0 5 35.7 5 5.0 0 0 .0 TOTAL 14 ITEM NUMBER 12 OPTION WGT 1 5.0 1 7.1 2 4 .0 5 35.7 3 ' 3.0 5 35.7 4 2.0 3 21.4 5 1.0 0 0 .0 TOTAL 14 SUMMARY ITEM STATISTICS SUBTEST 3 WAI GOAL T ITEM STATS CORRELATIONS MEAN S.D. ST TT 4.214 0.699 -0 .206 0 .140 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.571 0.938 0.672 0.541 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.071 0.917 0.698 0.598 ITEM STATS CORRELATIONS MEAN S.D. ST TT 3.286 0.914 0.128 0.044 221 Appendix E Materia1 used in the c l i n i c a l part of the study 222 INSTRUCTIONS TO PARTICIPANTS IN THE PSYCHOTHERAPY RELATIONSHIP RESEARCH PROJECT T h i s p r o j e c t i s d e s i g n e d t o e x p l o r e t h e d i f f e r e n t k i n d s o f h e l p i n p r e l a t i o n s h i p s t h a t d e v e l o p i n c o u n s e l l i n g / p s y c h o t h e r a p y . Y o u r p a r t i c i p a t i o n i s v i t a l l y i m p o r t a n t t o t h e p r o j e c t and y o u r g e n e r o s i t y w i t h y o u r t i m e and e n e r g y i s much a p p r e c i a t e d . The p r o c e d u r e we a r e u s i n g i s d e s i g n e d t o e n s u r e c o m p l e t e c o n f i d e n t i a l i t y . P l e a s e f o l l o w t h e s t e p s o u t l i n e d b e l o w : (1) Ask y o u r c l i e n t t o v o l u n t e e r t o p a r t i c i p a t e i n t h e p r o j e c t . Read and e x p l a i n , i f n e c e s s a r y , t h e c o n s e n t form. Have y o u r c l i e n t s i g n t h e f o r m a n d s i g n i t y o u r s e l f as w i t n e s s . S i g n t h e t h e r a p i s t c o n s e n t f o r m . P l a c e b o t h c o n s e n t f o r m s i n t h e s m a l l w h i t e e n v e l o p e marked " c o n s e n t " and m a i l i t t o t h e r e s e a r c h e r . ( 2 ) A f t e r t h e 3 r d s e s s i o n w i t h t h i s c l i e n t p l e a s e g i v e h i m / h e r t h e p a c k e t and m a t e r i a l s marked "C". P l e a s e e n c o u r a g e y o u r c l i e n t t o c o m p l e t e i t ( i t t a k e s 30 m i n u t e s ) and h ave h i m / h e r s e a l t h e f i l l e d - o u t f o r m s i n t h e e n v e l o p e p r o v i d e d . C o m p l e t e y o u r Questionnaires m a r k e d "T", a n d s e a l a l l t h e m a t e r i a l ( y o u r s and y o u r c l i e n t ' s ) i n one o f t h e l a r g e s e l f - a d d r e s s e d m a n i l l a e n v e l o p e s . (3) M a i l t h e m a n i l l a e n v e l o p e b a c k t o t h e r e s e a r c h e r . (4) P l e a s e make a n o t e on y o u r c a l e n d a r t o r e m i n d y o u r s e l f t o a d m i n i s t e r t h e s e c o n d p a r t o f t h e o u e s t i o n n a i r e 7 s e s s i o n s a f t e r t h i s s e s s i o n o r a t t h e l a s t i n t e r v i e w y o u w i l l have w i t h t h i s c l i e n t . Use t h e memo p r o v i d e d i f y o u w i s h . (5) A f t e r t h e 1 0 t h i n t e r v i e w ( a p p r o x i m a t e l y ) , o r a t t h e l a s t s e s s i o n , g i v e y o u r c l i e n t t h e p a c k e t marked "PC" t o f i l l o u t and s e a l i t i n t h e e n v e l o p e p r o v i d e d . P l e a s e f i l l o u t t h e m a t e r i a l marked "PT" and s e a l i t i n t h e e n v e l o p e . P l a c e a l l t h e c o m p l e t e d Q u e s t i o n n a i r e s i n t h e l a r g e m a n i l l a e n v e l o p e and r e t u r n i t t o t h e r e s e a r c h e r . (6) S h o u l d y o u h ave more t h a n one c l i e n t o a r t i c i o a t i n g i n t h e r e s e a r c h , p l e a s e f o l l o w t h e c o m p l e t e p r o c e d u r e e a c h t i m e , u s i n g a c o m p l e t e new " k i t " . T hank y o u Information about the Therapeutic Relationship Research Project This study i s designed to generate information about the kinds of r e l a t i o n -ships that help people solve problems, change, or l e a r n about themselves. The information that 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. There are many d i f f e r e n t kinds of e f f e c t i v e h e l p i n g r e l a t i o n s h i p s . We would l i k e to know some of your ideas, opinions, and f e e l i n g s about your r e l a t i o n -ship with your helper. Your cooperation with the research p r o j e c t i s important and we would l i k e to have the b e n e f i t of your experience. Your responses to the questionnaires are completely c o n f i d e n t i a l . The researchers w i l l not know who you are, neither w i l l your t h e r a p i s t see your questionnaire. Your part i n the research involves the f i l l i n g out of some questionnaires. The f i r s t questionnaire w i l l take about ^ hour to complete. A few weeks from now you w i l l be asked to respond to an even shorter instrument (5 minutes). Thank you for your cooperation. 2 2 4 Consent Form I hereby voluntarily consent to participate i n the helping relationship research study. The nature of this research has been explained to me and I understand that I w i l l be required to complete some questionnaires. I have been informed that the responses on the questionnaires w i l l be treated anonymously and confidentially and the researchers w i l l not know my name nor w i l l they have any identifying information about me. > • If I do not wish to participate in this study, I understand thay my decision w i l l in no way affect the standard or the a v a i l a b i l i t y of the service I w i l l receive. I understand that I am free to withdraw from this study at any time, and that my withdrawal w i l l in no way affect-the standard of service I w i l l receive. Signed Date W i t n e s s ( T h e r a p i s t ) PSYCHOTHERAPY RELATIONSHIP RESEARCH PROJECT TO THE PARTICIPANT: PLEASE COMPLETE THE ATTACHED QUESTIONNAIRES IN THE  ORDER GIVEN AND SEAL THE COMPLETED FORMS IN THE ENVELOPE PROVIDED, YOUR THERAPIST (COUNSELLOR) WILL RETURN THESE ALONG WITH HER/HIS QUESTIONNAIRE TO THE RESEARCHERS, PLEASE MAKE SURE YOU RESPOND TO EVERY ITEM. THANK YOU. W o r k i n g A l l i a n c e I n v e n t o r y I n s t r u c t i o n s B e l o w a r e some s e n t e n c e s t h a t d e s c r i b e some o f t h e d i f f e r e n t ways a p e r s o n m i g h t t h i n k o r f e e l a b o u t h i s o r h e r t h e r a p i s t ( c o u n s e l l o r ) . As y o u r e a d t h e s e n t e n c e s m e n t a l l y i n s e r t t h e name o f y o u r t h e r a p i s t ( c o u n s e l l o r ) i n t h e p l a c e o f t h e i n t h e t e x t . B e l ow e a c h s e n t e n c e t h e r e i s a f i v e p o i n t s c a l e : 1 2 3 4 5 N e v e r S o m e t i m e s A l w a y s I f t h e s e n t e n c e d e s c r i b e s t h e way t h a t y o u a l w a y s f e e l ( o r t h i n k ) c i r c l e no. 5; i f i t n e v e r a p p l i e s t o y o u c i r c l e t h e number 1. Use t h e p o i n t s i n b e t w e e n t o d e s c r i b e t h e v a r i a t i o n s b e t w e e n t h e s e e x t r e m e s . T h i s q u e s t i o n n a i r e i s c o n f i d e n t i a l ; NEITHER YOUR THERAPIST OR THE AGENCY  WILL SEE YOUR ANSWERS. P l e a s e work f a s t , y o u r f i r s t i m p r e s s i o n s a r e t h e o n e s we w o u l d l i k e t o g e t . ( P l e a s e d o n ' t f o r g e t t o r e s p o n d t o e v e r y i t e m . ) T h ank y o u f o r y o u r c o o p e r a t i o n . 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s I f e e l u n c o m f o r t a b l e w i t h . 1 2 3 4 5 a n d I a g r e e a b o u t t h e s t e p s t o be t a k e n t o i m p r o v e my s i t u a t i o n . 1 2 3 4 5 I w o r r y a b o u t t h e c h a n g e s t h a t m i g h t r e s u l t a s t h e o u t c o m e o f t h e s e s e s s i o n s . 1 2 3 4 5 I f e e l we a r e a p p r o a c h i n g my p r o b l e m s t h e r i g h t w a y . 1 2 3 4 5 I f e e l r e a l l y u n d e r s t o o d . 1 2 3 4 5 p e r c e i v e s a c c u r a t e l y w h a t my g o a l s a r e . 1 2 3 4 5 I f i n d w h a t we do i n t h e r a p y c o n f u s i n g . 1 2 3 4 5 My t i m e w i t h i s i m p o r t a n t f o r m e . 1 2 3 4 5 I w i s h w o u l d c l a r i f y t h e p u r p o s e o f o u r s e s s i o n s . 1 2 3 4 5 I d i s a g r e e w . i t h a b o u t my g o a l s . 1 2 3 4 5 I b e l i e v e t h a t t h e t i m e we a r e s p e n d i n g t o g e t h e r i s n o t s p e n t e f f i c i e n t l y . 1 2 3 4 5 228 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 12. I d o n ' t know what we a r e t r y i n g t o a c c o m p l i s h i n t h e r a p y . 1 2 3 4 5 13. I am c l e a r on what my r e s p o n s i b i l i t i e s a r e i n t h e r a p y . 1 2 3 4 5 14. The g o a l s o f t h e s e s e s s i o n s a r e m e a n i n g f u l t o me. 1 2 3 4 5 15. I f i n d w h at a n d I a r e d o i n g f a r r e m o v e d f r o m my c o n c e r n s . 1 2 3 4 5 16. I f e e l t h a t w h a t I do h e r e w i l l h e l p me t o a c c o m p l i s h t h e c h a n g e s t h a t I want. 1 2 3 4 5 17. I b e l i e v e i s g e n u i n e l y c o n c e r n e d f o r my w e l f a r e . 1 2 3 4 5 18. I am c l e a r a s t o w h a t w a n t s me t o do i n t h e s e s e s s i o n s . 1 2 3 4 5 19. I r e s p e c t as a h i g h l y c a p a b l e a n d s k i l l f u l i n d i v i d u a l . 1 2 3 4 5 20. I f e e l t h a t i s n o t t o t a l l y h o n e s t a b o u t h i s / h e r f e e l i n g s t o w a r d me. 1 2 3 4 5 21. I am c o n f i d e n t i n 's a b i l i t y t o h e l p me t h r o u g h my p r e s e n t d i f f i c u l t i e s . 1 2 3 4 5 22. We work t o w a r d s m u t u a l l y a g r e e d upon g o a l s . 1 2 3 4 5 1 2 3 4 5 2 2 9 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s . 23. I f e e l t h a t a p p r e c i a t e s me. 1 2 3 4 5 24. We a g r e e on what i s i m p o r t a n t f o r me t o work o n . 1 2 3 4 5 25. As a r e s u l t o f t h e s e s e s s i o n s I am c l e a r e r as t o what I n e e d t o c h a n g e . 1 2 3 4 5 26. I t r u s t . 1 2 3 4. 5 27. a n d I ha v e d i f f e r e n t i d e a s on what I s h o u l d be a i m i n g f o r . 1 2 3 4 5 28. My r e l a t i o n s h i p w i t h i s v e r y i m p o r t a n t t o me. 1 2 3 4 5 29. I h a v e t h e f e e l i n g t h a t i f I s a y o r do t h e wr o n g t h i n g s , w i l l s t o p w o r k i n g w i t h me. 30. We a g r e e on t h e t h i n g s I s h o u l d g e t o u t o f my t h e r a p y . 1 2 3 4 5 31. w a n t s me t o c h a n g e t o o f a s t . 1 2 3 4 5 32. We h a v e e s t a b l i s h e d a good u n d e r s t a n d i n g f o r t h e d i r e c t i o n o f c h a n g e s t h a t w o u l d be g o o d f o r me. 33. The t h i n g s t h a t I am d o i n g h e r e d o n ' t make much s e n s e t o me 1 2 3 4 1 2 3 4 5 N e v e r S e l d o m Sometimes O f t e n A l w a y s 2 3 0 34. I d o n ' t know what t o e x p e c t a s t h e r e s u l t o f my t h e r a p y . 1 2 3 4 5 35. I b e l i e v e t h a t t h e way we a r e w o r k i n g w i t h my p r o b l e m i s c o r r e c t . 1 2 3 4 5 36. I f e e l r e s p e c t s me e v e n when I do t h i n g s t h a t h e / s h e d o e s n o t a p p r o v e o f . 1 2 3 4 ^ 231 (Revised Form) COUNSELOR RATING FORM L i s t e d below are seve r a l scales which contain word p a i r s at e i t h e r end of the scale and seven spaces between the p a i r s . Please rate the counselor you just saw on each of the s c a l e s . I f you f e e l that the counselor very c l o s e l y resembles the word at one end of the s c a l e , place a check mark as follows: f a i r : : : : : : X u n f a i r . OR f a i r y : : : : : : u n f a i r I f you think that one end of the scale quite c l o s e l y describes the counselor then make your check mark as follo w s : rough : X : : : : : smooth OR rough : : : : : X : smooth I f you f e e l that one end of the scale only s l i g h t l y describes the counselor, then check the s c a l e as follo w s : a c t i v e : : X : : : : passive OR a c t i v e : : : : X : : passive If both sides c f the scale seem equally associated with your impression of the counselor or i f the scale i s i r r e l e v a n t , then place a check mark i n the middle space: hard : : : X : : : s o f t Your f i r s t impression i s the best answer. PLEASE NOTE: PLACE CHECK MARKS IN THE MIDDLE-CF THE SPACES C o p y r i g h t © , M. B. LaCrosse, and A. Barak, '1974, 1975 . Not to b« reproduced without permission. agreeable unalert ' analytic unappreciative a t t r a c t i v e casual cheerful unclear distant compatible unsure suspicious undependable in d i f f e r e n t inexperienced inexpert unf r i e n d l y honest disageeable a l e r t d i f f u s e appreiative unat t r a c t i v e formal depressed clear close Incompatible conf ident be 1i evab1e dependable enthusiastic experienced expert fr i e n d l y dishones t informed i n s i g h t f u l stupid unlikeable l o g i c a l open prepared unreliable d i s r e s p e c t f u l irresponsible s e l f l e s s sincere s k i l l f u l sociable d e c e i t f u l ignorant i n s i g h t l e s s i n t e l l i g e n t likeable i l l o g i c a l closed unprepared r e l i a b l e respectful responsible trus twor thy genuine s e l f i s h insincere u n s k i l l f u l unsoc iable straightforward untrustworthy phony warm cold 234 C o d e : D a t e : (BARRETT-LENNARD) RELATIONSHIP INVENTORY—FORM OS—64* B e l o w a r e l i s t e d a v a r i e t y o f ways t h a t one p e r s o n may f e e l o r behave In r e l a t i o n t o a n o t h e r p e r s o n . P l e a s e c o n s i d e r e a c h numbered s t a t e m e n t w i t h r e f e r e n c e t o y o u r p r e s e n t r e l a t i o n s h i p w i t h your c o u n s e l l o r , m e n t a l l y a d d i n g h i s o r h e r name i n t h e s p a c e p r o v i d e d . F o r e x a m p l e , i f t h e o t h e r p e r s o n ' s name was J o h n , y ou w o u l d r e a d s t a t e m e n t if], a s ' J o h n r e s p e c t s me a s a p e r s o n ' . Mark e a c h s t a t e m e n t i n t h e an swe r co l umn on t h e r i g h t , a c c o r d i n g t o how s t r o n g l y you f e e l t h a t i t i s t r u e , o r no t t r u e , i n t h i s r e l a t i o n s h i p . PI e a s e  be s u r e t o mark e v e r y one . W r i t e i n +3, +2, +1, o r -1, -2, -3, t o s t a n d f o r t h e f o l l o w i n g a n s w e r s : +3: Yes, I strongly feel that it is -1: No, I feel that it is probably true. untrue, or more untrue titan true. +2: Yes, I feel it is true. -2: No, I feel it is not true. +1: Yes, I feel that it is probably -3: No, I strongly feel that it is true, or more true than untrue. not true. ANSWER 8 9 10 11 r e s p e c t s me as a p e r s o n . . . wan t s t o u n d e r s t a n d how I s ee t h i n g s ' s i n t e r e s t i n me depend s on t h e t h i n g s I s a y o r do i s c o m f o r t a b l e and a t e a s e i n o u r r e l a t i o n s h i p f e e l s a t r u e 1 i k i n g f o r me may u n d e r s t a n d my w o r d s b u t h e / s h e doe s n o t s ee t h e way I f e e l Whethe r I am f e e l i n g happy o r unhappy w i t h m y s e l f makes no r e a l d i f f e r e n c e t o t h e way f e e l s abou t me I f e e l t h a t p u t s on a r o l e o r f r o n t w i t h me i s i m p a t i e n t w i t h me n e a r l y a l w a y s knows e x a c t l y what I mean . . . . Depend i n g on my b e h a v i o u r , has a b e t t e r o p i n i o n o f me s omet imes t h a n he/ she has a t o t h e r t i m e s * Combines Forms OS-M-64 and 0S-F-64 235 2 . ANSWE 12. I f e e l t h a t i s r e a l and genu ine, w i t h w-.o 13. I f e e l a p p r e c i a t e d by )k. l o o k s a t what I do f r o m h i s / h e r own p o i n t o f v i e w . 15. 1 s f e e l i n g t o w a r d me d o e s n ' t deoend on how I f e e l t o w a r d h i m / h e r 16. I t makes unea s y when I a s k o r t a l k a b o u t c e r t a i n t h i n g s 17. i s i n d i f f e r e n t t o me 18. u s u a l l y s e n s e s o r r e a l i s e s what i am f e e l i n g . . . . 19. w a n t s me t o be a p a r t i c u l a r k i n d o f p e r s o n 20. I f e e l t h a t what s a y s u s u a l l y e x p r e s s e s e x a c t l y what h e / s h e i s f e e l i n g and t h i n k i n g a t t h a t moment 2 1 . f i n d s me r a t h e r d u l l and u n i n t e r e s t i n g 22. " s own a t t i t u d e s t o w a r d some o f t he t h i n g s I do o r s ay p r e v e n t h i m / h e r f r o m u n d e r s t a n d i n g me 23. I c a n ( o r c o u l d ) be o p e n l y c r i t i c a l or_ a p p r e c i a t i ve o f w i t h o u t r e a l l y m a k i n g h i m / h e r f e e l any d i f f e r e n t l y a b o u t me ' 2*1. wan t s me t o t h i nk , t h a t he/ she l i k e s me o r u n d e r s t a n d s me more t h a n he/ she r e a l l y does 25. _ _ _ _ _ c a r e s f o r me 26 . Somet imes t h i n k s t h a t j _ f e e l a c e r t a i n way , b e c a u s e t h a t ' s t h e way he/ she f e e l s 27. l i k e s c e r t a i n t h i n g s a b o u t ms, and t h e r e a r e o t h e r t h i n g s he/ she does n o t l i k e _ _ _ _ _ 28. d oe s n o t a v o i d a n y t h i n g t h a t i s i m p o r t a n t f o r o u r r e l a t i o n s h i p .; 29. I f e e l t h a t d i s a p p r o v e s o f me 30. r e a l i s e s what I mean e ven when I have d i f f i c u l t y i n s a y i n g i t . 31. ' s a t t i t u d e t o w a r d me s t a y s t he s a n e : he/ she i s n o t p l e a s e d v/ i th me s omet ime s and c r i t i c a l o r d i s a p p o i n t e d a t o t h e r t i m e s 32. Somet imes i s no t a t a l l c o m f o r t a b l e but we go o n , o u t w a r d l y i g n o r i n g i t • 33. j u s t t o l e r a t e s me 3*1. u s u a l l y u n d e r s t a n d s t h e w h o l e o f what I mean . . . . . : 3 6 3. 35. I f I show t h a t I am a n g r y w i t h he/she becomes h u r t o r a n g r y w i t h me, t o o 36. e x p r e s s e s h i s / h e r t r u e i m p r e s s i o n s and f e e l i n g s w i t h me 37- i s f r i e n d l y and warm w i t h me 38. j u s t t a k e s no n o t i c e o f some t h i n g s t h a t I t h i n k o r f e e l 39. How much 1 i k e s o r d i s i i k e s me i s not a l t e r e d by a n y t h i n g t h a t I t e l l him/her about m y s e l f 40. At t i m e s I s e n s e t h a t i s n o t aware o f what he/she i s r e a l l y f e e l i n g w i t h me 1*1. I f e e l t h a t r e a l l y v a l u e s me 42. ^3. 48. a p p r e c i a t e s e x a c t l y how t h e t h i n g s I e x p e r i e n c e f e e l t o me _ a p p r o v e s o f some t h i n g s I d o , and p l a i n l y d i s a p p r o v e s o f o t h e r s . . . . 44. i s w i l l i n g t o e x p r e s s w h a t e v e r i s a c t u a l l y i n h i s / h e r mind w i t h me, i n c l u d i n g p e r s o n a l f e e l i n g s a b o u t e i t h e r o f us 45. d o e s n ' t l i k e me f o r m y s e l f 46. A t t i m e s t h i n k s t h a t I f e e l a l o t more s t r o n g l y about a. p a r t i c u l a r t h i n g t h a n I r e a l l y do 47. Whether I happen t o be i n good s p i r i t s o r f e e l i n g u p s e t does not make f e e ! any more o r l e s s a p p r e c i a t i v e o f me . i s o p e n l y h i m s e ! f / h e r s e l f i n o u r r e l a t i o n s h i p . 49. I seem t o i r r i t a t e and b o t h e r 50. does not r e a l i s e how s e n s i t i v e I am a b o u t some o f t h e t h i n g s we d i s c u s s •. 51. Whether t h e i d e a s and f e e l i n g s I' e x p r e s s , a r e "good" o r " b a d " seems t o make no d i f f e r e n c e t o 's f e e l i n g t o w a r d me 52. T h e r e a r e t i m e s when I f e e l t h a t 's o u t w a r d r e s p o n s e t o me i s q u i t e d i f f e r e n t f r o m t h e way he/she f e e l s u n d e r -n e a t h . 53. f e e l s contempt f o r me . 54. u n d e r s t a n d s me 55- Sometimes I am more w o r t h w h i l e i n 's eyes t h a n I am a t o t h e r t i m e s '. . - . ANSWER 237 ANSWER 56. d o e s n ' t h i d e a n y t h i n g f r o m h i m s e l f / h e r s e l f t h a t he/ she f e e l s w i t h me 57* i s t r u l y i n t e r e s t e d i n me 58. ' s r e s p o n s e t o me i s u s u a l l y so f i x e d and a u t o m a t i c t h a t I d o n ' t r e a l l y g e t t h r o u g h t o h i m / h e r 59. ' I d o n ' t t h i n k t h a t a n y t h i n g I say o r do r e a l l y change s t h e way f e e l s t o w a r d me 6 0 . What s a y s t o me o f t e n g i v e s a w rong i m p r e s s i o n o f h i s / h e r t o t a l t h o u g h t o r f e e l i n g a t t h e t i m e 6 1 . f e e l s deep a f f e c t i o n f o r me 62. When I am h u r t o r u p s e t c a n r e c o g n i s e my f e e l i n g s . e x a c t l y , w i t h o u t becom ing u p s e t t o o 63. What o t h e r p e o p l e t h i n k o f me does ( o r w o u l d , i f he/ she knew) a f f e c t t h e way f e e l s t o w a r d me 6*». I b e l i e v e t h a t has f e e l i n g s he/ she does no t t e l l me a b o u t t h a t a r e c a u s i n g d i f f i c u l t y i n o u r r e l a t i o n s h i p . C l i e n t Form *Posttherapy Questionnaire This survey i s part of a research project to study how c l i e n t s f e e l about t h e i r therapy experiences. Please t r y to answer a l l questions as completely and accurately as you can. Return your completed questionnaire i n the envelope provided. Your cooperation i n t h i s research i s very much appreciated. •Adopted from the questionnaire developed by Dr. H. Strupp et a l . 1. Age: / J y 2. Sex ( c i r c l e one): M F 3. M a r i t a l status: Single Married Divorced Widowed 4. Education (check highest l e v e l and complete question): Elementary school (indicate number of years: ) High school ( i n d i c a t e number of years: ) High school graduate College ( i n d i c a t e number of years: ) College graduate Graduate study or pr o f e s s i o n a l t r a i n i n g (kind, degree, etc.) 5. How much i n need of further therapy/counselling do you f e e l now? No need at a l l ' S l i g h t need Could use more Considerable need Very great need 6. I f t h i s i s your l a s t session, what led to the termination of your therapy/ counselling? My decision My therapist's decision Mutual agreement External f actors 7. How much have you benefitted from your therapy/counselling? A great deal A f a i r amount To some extent _ Very l i t t l e , Not at a l l Everything considered, how s a t i s f i e d are you with the r e s u l t s of you* therapy/counselling experience? Extremely d i s s a t i s f i e d Moderately d i s s a t i s f i e d F a i r l y d i s s a t i s f i e d F a i r l y s a t i s f i e d Moderately s a t i s f i e d Highly s a t i s f i e d Extremely s a t i s f i e d Was your therapist of the same sex? Yes No What impression d i d you have of his/her l e v e l of experience as a t h e r a p i s t / counsellor? Extremely inexperienced Rather inexperienced Somewhat experienced F a i r l y experienced Highly experienced Exceptionally experienced At the beginning of your therapy how w e l l did you f e e l you were get t i n g along? Very w e l l F a i r l y w e l l Neither well nor poorly F a i r l y poorly Very poorly Extremely poorly How long before entering therapy did you f e e l i n need of p r o f e s s i o n a l help? l e s s than 1 year 1 - 2 years 3 - 4 years 5 - 1 0 years 1 1 - 1 5 years 16 - 20 years years (specify) Extremely Very much Moderately Somewhat Very s l i g h t l y disturbed disturbed disturbed disturbed disturbed How much anxiety did you f e e l at the time you sta r t e d therapy/counselling? A tremendous A great A f a i r Very None at amount deal amount l i t t l e a l l How great was the i n t e r n a l "pressure" to do something about these problems when you entered therapy/counselling? Extremely great Very great F a i r l y great R e l a t i v e l y small Very small Extremely small How much do you f e e l you have changed as a r e s u l t of therapy/counselling? A great deal A f a i r amount Somewhat Very l i t t l e _ Not at a l l How much of th i s change do you f e e l has been apparent to others? (a) People clo s e s t to you (husband, wife, etc.) A great A f a i r Somewhat Very Not at deal , amount l i t t l e a l l (b) Close friends A great A f a i r Somewhat Very Not at deal amount l i t t l e a l l (c) Co-workers, acquaintances, etc. A great A f a i r Somewhat Very Not at deal amount l i t t l e a l l On the whole how w e l l do you f e e l you are getting along now? Extremely well Very well F a i r l y w e l l Neither well nor poorly F a i r l y poorly Very poorly Extremely poorly How adequately do you f e e l you are dealing with any present probl Very adequately F a i r l y adequately Neither adequately nor inadequately Somewhat inadequately Very inadequately To what extent have your complaints or symptoms that brought you to therapy/counselling changed as a r e s u l t of treatment? Completely disappeared Very greatly improved Considerable Improved Somewhat improved Not at a l l improved Got worse How soon a f t e r entering therapy did you f e e l any marked change? hours of therapy (approximately) How strongly would you recommend therapy/counselling to a close f r i e n d with emotional problems? Would strongly recommend i t Would m i l d l y recommend i t Would recommend i t but with some reservations Would not recomment i t Would advise against i t Please i n d i c a t e the adequacy of t h i s questionnaire i n describing your therapy experience. Give any a d d i t i o n a l data which you f e e l are relevant to an understanding of your experience. THANK YOU FOR YOUR COOPERATION 244 T h e r a p i s t Consent Form I h e r e b y v o l u n t a r i l y c o n s e n t t o p a r t i c i a p t e i n t h e 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 s t u d y . The n a t u r e o f 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 u n d e r s t a n d t h a t I w i l l be r e q u i r e d t o c o m p l e t e some q u e s t i o n n a i r e s . I have been i n f o r m e d t h a t the r e s p o n s e s on t h e 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 t h e y have any i d e n t i f y i n g i n f o r m a t i o n about me. I have e x p l a i n e d the n a t u r e of the r e s e a r c h t o my c l i e n t ( s ) and I am aware t h a t I am f r e e t o w i t h d r a w f r o m t h i s s t u d y a t any t i m e . S i g n e d Date DEMOGRAPHIC DATA SHEET Professional a f f i l i a t i o n : Psychologist __ S o c i a l Worker _ Counsellor P s y c h i a t r i s t _ Other (please specify) Highest degree completed: B.A. M.D. M.A. Ph.D. Ed.D. M.Ed. B.S.W. M.S.W. Other (please specify) Number of years of experience as a therapist/counsellor: None 1 - 5 6 - 1 0 11 - 15 More The o r e t i c a l o r i e n t a t i o n you have employed while working with this p a r t i c u l a r c l i e n t : (check only one) a n a l y t i c behavior modification g e s t a l t c l i e n t centered Adlerian e x i s t e n t i a l other (please specify) 246 W o r k i n g A l l i a n c e I n v e n t o r y I n s t r u c t i o n s B e l o w a r e some s e n t e n c e s t h a t d e s c r i b e some o f t h e d i f f e r e n t ways p e o p l e i n t h e r a p y ( c o u n s e l l i n g ) may f e e l o r t h i n k a b o u t e a c h o t h e r . As y o u r e a d t h e s e n t e n c e s m e n t a l l y i n s e r t t h e name o f y o u r c l i e n t i n t h e p l a c e o f t h e i n t h e t e x t . B e l o w e a c h s e n t e n c e t h e r e i s a f i v e p o i n t s c a l e : 1 2 3 4 5 N e v e r S o m e t i m e s A l w a y s I f t h e s e n t e n c e d e s c r i b e s t h e way t h a t y o u a l w a y s f e e l ( o r t h i n k ) c i r c l e No. 5; i f i t n e v e r a p p l i e s t o y o u c i r c l e t h e number 1. U s e t h e p o i n t s i n b e t w e e n t o d e s c r i b e t h e v a r i a t i o n s b e t w e e n t h e s e e x t r e m e s . T h i s q u e s t i o n n a i r e i s c o n f i d e n t i a l ; N E I T H E R YOUR C L I E N T OR T H E A G E N C Y WILL SEE YOUR A N S W E R S . P l e a s e work f a s t , y o u r f i r s t i m p r e s s i o n s a r e t h e o n e s we w o u l d l i k e t o g e t . ( P l e a s e . d o n 1 t f o r g e t t o r e s p o n d t o e v e r y i t e m . ) T h a n k y o u f o r y o u r c o o p e r a t i o n . 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 247 1. I o f t e n f e e l u n c o m f o r t a b l e w i t h . 1 2 3 4 5 2. a n d I a g r e e a b o u t t h e s t e p s t o be t a k e n t o i m p r o v e h i s / h e r s i t u a t i o n . 1 2 3 4 5 3. I w o r r y a b o u t t h e o u t c o m e o f t h e s e s e s s i o n s . -1 2 3 4 5 4. I f e e l we a r e a p p r o a c h i n g h i s / h e r p r o b l e m s t h e r i g h t way. 1 2 3 4 5 5. I f e e l I r e a l l y u n d e r s t a n d . 1 2 3 4 5 6. I f i n d what we do i n t h e r a p y c o n f u s i n g . 1 2 3 4 5 7. I h a v e a n a c c u r a t e p e r c e p t i o n o f 1 s g o a l s . 1 2 3 4 5 o The t i m e _ s p e n d s w i t h me i s i m p o r t a n t f o r h i m / h e r . 1 2 3 4 5 9. I n e e d t o c l a r i f y f o r t h e p u r p o s e o f o u r s e s s i o n s . 1 2 3 4 5 10. I o f t e n d i s a g r e e w i t h a b o u t o u r g o a l s , i 1 2 3 4 5 11. I b e l i e v e t h a t t h e t i m e a n d I a r e s p e n d i n g t o g e t h e r i s n o t s p e n t e f f i c i e n t l y . 1 2 3 4 5 I 248 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 12. I don''t know what we a r e t r y i n g t o a c c o m p l i s h i n t h e r a p y . 1 2 3 4 5 13. I am c l e a r on what 's r e s p o n s i b i l i t i e s a r e i n t h e r a p y . 1 2 3 4 5 14. The g o a l s o f t h e s e s e s s i o n s a r e m e a n i n g f u l t o . 1 2 .3 4 5 15. I f i n d what and I a r e d o i n g f a r removed f r o m 's c o n c e r n s . 1 2 3 4 5 16. I f e e l t h a t what we do h e r e w i l l h e l p t o a c c o m p l i s h t h e c h a n g e s t h a t h e / s h e w a n t s . 1 2 3 4 5 17. I am g e n u i n e l y c o n c e r n e d f o r 's w e l f a r e . 1 2 3 4 5 18. I am c l e a r as t o what s h o u l d do i n t h e s e s e s s i o n s . 1 2 3 4 . 5 19. r e s p e c t s me as a h i g h l y c a p a b l e i n d i v i d u a l . 1 2 3 4 5 20. I f e e l t h a t I am n o t t o t a l l y h o n e s t a b o u t my f e e l i n g s t o w a r d . 1 2 3 4 5 21. I am c o n f i d e n t i n my a b i l i t y t o h e l p t h r o u g h h i s / h e r p r e s e n t d i f f i c u l t i e s . 1 2 3 4 5 22. We work t o w a r d s m u t u a l l y a g r e e d upon g o a l s . 1 2 3 4 5 1 2 ' 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 249 23. I a p p r e c i a t e . . 1 2 3 4 5 24. We a g r e e on what i s i m p o r t a n t f o r t o work o n . 1 2 3 4 5 25. As a r e s u l t o f t h e s e s e s s i o n s i s c l e a r e r as t o what h e / s h e n e e d s t o c h a n g e . 1 2 3 4 5 26. I f e e l t h a t t r u s t s me. 1 2 3 4 5 27. a nd I h a v e d i f f e r e n t i d e a s on what h e / s h e s h o u l d be a i m i n g f o r . 1 2 3 4 5 28. My r e l a t i o n s h i p w i t h i s v e r y i m p o r t a n t t o h i m / h e r . 1 2 3 4 5 29. has t h e f e e l i n g t h a t i f h e / s h e s a y s o r d o e s t h e wr o n g t h i n q s , I w i l l s t o p w o r k i n g w i t h h i m / h e r 1 2 30. We a g r e e on t h e t h i n g s s h o u l d g e t o u t o f t h e r a p y . 1 2 3 4 5 31. f e e l s t h a t I want h e r / h i m t o make c h a n g e s t o o f a s t . 1 2 3 4 5 32. We ha v e e s t a b l i s h e d a good u n d e r s t a n d i n g f o r t h e d i r e c t i o n o f c h a n g e s t h a t w o u l d be good f o r 33. The t h i n g s t h a t we a r e d o i n g h e r e d o n ' t make much s e n s e t o 1 2 3 4 5 250 1 2 3 4 5 N e v e r S e l d o m S o m e t i m e s O f t e n A l w a y s 34. d o e s n ' t know what t o e x p e c t a s t h e r e s u l t o f t h e r a p y . I' 2 3 4 5 35. b e l i e v e s t h a t t h e way we a r e w o r k i n g w i t h h i s / h e r p r o b l e m i s c o r r e c t . 1 2 3 4 5 36. I r e s p e c t e v e n when s h e / h e d o e s t h i n g s t h a t I do n o t a p p r o v e o f . 1 2 3 4 5 Leaves 251-254 not filmed. Permission not filmed. Relationship Inventory in G.T. Barrett-Lennard Relationship Inventory Form D-0 64. Personal communication, 1979. 250b Leaves 255-259 not filmed. Permission not obtained. Client's Posttherapy Questionnaire in H.H. Strupp, Patients view their •psychotherapy. (Baltimore, Md., John Hopkins Press* 1969) RELATIONSHIP INVENTORY —FORK MO- - 6 A * Below are l i s t e d a variety of ways that one person may f e e l or behave in r e l a t i o n to another person. Please consider each statement with reference to your present r e l a t i o n -ship with , mentally adding his or her name in the space provided. If, for example, the other person's name was John, you would read statement #1 as 'I respect John as a person'. Mark each statement in the l e f t margin, according to how strongly you f e e l that i t i s true, or not true, in this relationship. Please mark every  one. Write i n +3, +2, +1, or -1, -2, -3, to stand for the following answers: +3: Yes, I s t r o n g l y f e e l t h a t -1: No, I f e e l t h a t i t i s i t i s t r u e . p r o b a b l y u n t r u e , or more +2: Yes, I f e e l i t i s t r u e . u n t rue than t r u e •2: No, I f e e l i t i s not t r u e . +1: Yes, I f e e l t h a t i t i s p r o b a b l y t r u e , or more -3: No, I s t r o n g l y f e e l that t r u e than u n t r u e . I t i s not t r u e . 1. I respect as a person. 2. I want to understand how sees things. 3. The interest I f e e l i n depends on the things he/she says or does. 4. I f e e l at ease with • 5. I r e a l l y l i k e • 6. I understand 's words but do not know how he/she actually f e e l s . 7. Whether . i s feeling pleased or unhappy with himself/herself does not change my feeling toward him/her. 8. I am inclined to put on a role or front with . 9. I do f e e l impatient with . 10. I nearly always know exactly what means. 11. Depending on 's actions, I have a better opinion of him/her sometimes than I do at other times. *Combines Forms MO-M-64 and MO-F-64 c G.T. Barrett-Lennard 252 12. I f e e l that I am genuinely myself with • 13. I appreciate . as a person. 14. I look at what does from my own point of view. 15. The way I f e e l about doesn't depend on his/her feelings toward me. 16. I t bothers me when t r i e s to ask or talk about certain things. 17. I f e e l indifferent to . 18. I do usually sense or r e a l i s e how i s f e e l i n g . 19. I would l i k e to be a particular kind of person. 20. When I speak to I nearly always can say freely just what I'm thinking or feeling at that moment. 21. I find rather d u l l and uninteresting. 22. What says or does arouses feelings i n me that prevent me from understanding him/her. 23. Whether ' c r i t i c i s e s me or shows appreciation of me does not (or would not) change my inner feeling toward him/her. 24. I would r e a l l y prefer to think that I l i k e or understand him/her even when I don't. 25. I care for . 26. Sometimes I think that feels a certain way, because that's the way I f e e l myself. 27. I l i k e in some ways, while there are other things about him/her that I do not l i k e . 28. I don't feel that I have been ignoring or putting off anything that i s important for our relationship." 29. I do f e e l disapproval of . 30. I can t e l l what • means, even when he/she has d i f f i c u l t y i n saying i t . 31. My feeling toward stays about the same; I am not i n sympathy with him/her one time and out of patience another time. 32. Sometimes I am not at a l l comfortable with but we go on, outwardly ignoring i t . 253 _ 3 -33. I put up with . 3A. I usually catch and understand the whole of 's meaning. 35. If gets impatient or mad at me I become angry or upset too. 36. I am able to be sincere and direct in whatever I express with 37. I f e e l friendly and warm toward . 38. I ignore some of 's feelings. 39. My l i k i n g or d i s l i k i n g of i s not altered by anything that he/she says about himself/herself. 40. At times I just don't know, or don't r e a l i s e u n t i l l a t e r , what my feelings are with . 41. I value pur relationship. 42. I appreciate just how 's experiences f e e l to him/her. 43. I f e e l quite pleased with sometimes, and then he/she disappoints me at other times. 44. I f e e l comfortable to express whatever i s i n my mind with , including any feelings about myself or about him/her. 45. I r e a l l y don't l i k e as a person. 46. At times I think that feels strongly about something and then i t turns out that he/she doesn't. 47. Whether appears i n good s p i r i t s , or i s bothered and upset, does not make me f e e l any more or any less appreciation of him/her. 48. I can be quite openly myself i n our relationship. 49. Somehow r e a l l y i r r i t a t e s me (gets 'under my skin'). 50. At the time, I don't r e a l i s e how touchy or sensitive i s about some of the things we discuss. 51. Whether 's expressing "good" thoughts and feelings, or "bad" ones, does not affect the way I f e e l toward him/her. 52. There are times when my outward response to i s quite different from the way I f e e l underneath. 5.3. In fact, I f e e l contempt toward . 254 - 4 -54. I understand . 55. Sometimes seems to me a more worthwhile person than he/she does at other times. 56. I don't sense any feelings i n r e l a t i o n to that are hard for me to face and admit to myself. 57. I truly am interested in . 58. I often respond to - rather automatically, without taking i n what he/she i s experiencing. 59. I don't think that anything says or does r e a l l y alters the way I f e e l toward him/her. 60. What I say to often would give a wrong impression of my f u l l thought or feeling at the time. 61. I f e e l deep affection for . 62. When i s hurt or upset I can recognise just how he/she feels, without getting upset myself. 63. What other people think and f e e l about does help to make me f e e l as I do toward him/her. 64. I f e e l there are things we don't talk about that are causing d i f f i c u l t y i n our relationship. Therapist Form 255 *Posttherapy Questionnaire This survey i s part of a research project to study how therapists assess therapy experiences. Please t r y to answer a l l questions as accurately as you can. Return your completed questionnaire i n the envelope provided. Your cooperation i n t h i s research i s very much appreciated. •Adopted form the questionnaire developed by Dr. H. S trupp et a l . 1. How m u c h m o r e t h e r a p y do y o u f e e l ' y o u r c l i e n t n e e d s now? No n e e d a t a l l S l i g h t n e e d C o u l d u s e m o r e C o n s i d e r a b l e n e e d V e r y g r e a t n e e d 2. I f y o u a r e t e r m i n a t i n g w i t h t h i s c l i e n t n o w , w h a t d e t e r m i n e d t h i s c h o i c e ? C l i e n t ' s d e c i s i o n T h e r a p i s t ' s d e c i s i o n M u t u a l a g r e e m e n t E x t e r n a l f a c t o r s 3. How m u c h h a s y o u r c l i e n t b e n e f i t t e d f r o m t h e r a p y ? A g r e a t d e a l A f a i r a m o u n t To some e x t e n t V e r y l i t t l e N o t a t a l l 4 . E v e r y t h i n g c o n s i d e r e d , how s a t i s f i e d a r e y o u w i t h t h e r e s u l t s o f h i s / h e r p s y c h o t h e r a p y e x p e r i e n c e ? E x t r e m e l y d i s s a t i s f i e d M o d e r a t e l y d i s s a t i s f i e d • F a i r l y d i s s a t i s f i e d F a i r l y s a t i s f i e d M o d e r a t e l y s a t i s f i e d H i g h l y s a t i s f i e d E x t r e m e l y s a t i s f i e d 257 As a therapist (counsellor) how would you describe yourself? Extremely inexperienced Rather inexperienced Somewhat experienced F a i r l y experienced Highly experienced Exceptionally experienced At the beginning of therapy how w e l l d i d you f e e l your c l i e n t was getting along? Very well F a i r l y well Neither well nor poorly F a i r l y poorly Very poorly Extremely poorly How severely disturbed was your c l i e n t at the beginning of therapy? Extremely Very much Moderately Somewhat Very s l i g h t l y disturbed disturbed disturbed disturbed disturbed How much anxiety did your c l i e n t experience at the beginning of therapy? A tremendous A great A f a i r Very None at amount deal amount l i t t l e a l l How much i n t e r n a l "pressure" did your c l i e n t experience, about these problems when he/she entered psychotherapy? Extremely great 0 Very great F a i r l y great • R e l a t i v e l y small Very small Extremely small ' 10. How much do you f e e l he/she has changed as a r e s u l t of therapy? A great deal A f a i r amount Somewhat Very l i t t l e Not at a l l 11. How much of t h i s change do you f e e l has been apparent to others (a) People c l o s e s t to him/her (husband, w i f e , etc.) A great deal A f a i r amount Somewhat Very l i t t l e (b) Close f r i e n d s . A great deal A f a i r amount Somewhat Very l i t t l e (c) Co-workers, acquaintances, etc Not at a l l Not at a l l 12, A great deal A f a i r amount Somewhat Very l i t t l e Not at a l l On the^whole how w e l l do you f e e l he/she i s g e t t i n g along now? Extremely w e l l • Very w e l l F a i r l y w e l l N either w e l l nor poor l y F a i r l y p o o r l y Very p o o r l y Extremely poorly 25? How adequately do you feel he/she is dealing with any present problems? Very adequately Fairly adequately Neither adequately nor inadequately Somewhat inadequately Very inadequately To what extent has his/her complaints or symptoms that brought him/her to therapy changed as a result of treatment? Completely disappeared Very greatly improved Considerably improved Somewhat improved • Not at a l l improved Got worse How soon after entering therapy did you feel that marked changes had taken place in him/her? hours of therapy (approximately) THANK YOU FOR YOUR PARTICIPATION IN THIS PROJECT .260 Scoring key for the WAIt ( f i n a l version) TASK scale: 2, 4, 6, 11, 13, 15, 16, 18, 24, 31, 33, 35, BOND scale: 1, 5, 8, 17, 19, 20, 21, 23, 26, 28, 29, 36, GOAL scale: 3, 7, 9, 10, 12, 14, 21, 25, 27, 30, 32, 34, -261 Scoring key for the WAIc ( f i n a l version) TASK scale: 2, 4, 7, 11, 13, 15, 16, 18, 24, 31, 33, 35. BOND scale: 1, 5, 8, 17, 19, 20, 21, 23, 26, 28, 29, 36, GOAL scale: 3, 6, 9, 10, 12, 14, 21, 25, 27, 30, 32, 34, 

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