Which therapist perceptions best predict client outcomes? A naturalistic examination

Examining associations between therapists' perceptions of therapy sessions and client-reported outcomes in naturalistic settings (real-life therapy settings) can provide valuable guidance for the assessment, treatment, and monitoring of clients. This study included data of 1334 sessions from 127 clients (86 individual and 41 couple cases) and 15 therapists, collected at a therapy training center. Clients reported their personal functioning and individual symptoms before each session. Therapists rated clients' participation, receptivity, session progress, goal progress, and therapeutic alliance at the end of each therapy session. Multilevel Structural Equation Modeling analyses revealed that therapist-rated client participation and goal progress predicted better personal functioning, beyond clients' previous personal functioning scores. In contrast, none of therapist-rated session variables predicted clients' individual symptoms, beyond previous symptom scores. Power analyses suggested sufficient statistical power to detect small effect sizes. Findings of the current study have clinical implications for treatment planning and progress monitoring.     

Therapist Differentiation and Couple Clients' Perceptions of Therapeutic Alliance

Therapeutic alliance has been acknowledged as one of the catalysts for change within a therapeutic relationship. The contributions of therapists' characteristics to alliance are not often studied. From a Bowen System's Theory perspective, the therapist's level of differentiation would be highly relevant to the development of a therapeutic alliance. The hypothesis for this study was that therapists who are able to take a more differentiated stance in therapy will build a stronger therapeutic alliance. To test this hypothesis, multilevel modeling procedures were performed, using data from nine therapists and 93 couple cases collected at a large, Midwestern university. Therapist differentiation of self was found to be weakly associated with the clients' perception of therapeutic alliance across the early sessions of therapy, but not in the expected direction. Although the results were unexpected, this study provides an example of the potential of examining therapist characteristics from within one model of therapy, that can be applied across various clients and various models of therapy.     

“Basically it's the Usual Whole Teen Girl Thing”: Stage‐of‐Life Categories on a Children and Young People's Helpline

This article explores the practices of membership categorization in the interactions of clients and counselors on a national Australian helpline (Kids Helpline [KHL]) for children and young persons. Our focus is on membership categories drawn from three membership category devices (MCDs): stage‐of‐life (SOL), age, and family. Analysis draws on data across different contact modalities—email and web‐counseling sessions—to examine how category‐generated features are relevantly occasioned, attended to, and managed by the parties in the course of interaction. This shows clients' use of MCDs in presenting their trouble and building a relevant case for their grievance. By examining counselors' subsequent receipts of the clients' complaints, we are able to trace some of the cultural knowledge that the clients' categorizations make relevant to the counselors. Moreover, the analysis demonstrates how the inherent flexibility of MCDs allows counselors to exploit these same categorial resources and to re‐specify the clients' trouble in a more positive fashion to accomplish counseling work. In explicating how taken‐for‐granted notions of the lifespan as well as of family relations are mobilized by participants in KHL's sessions, the findings contribute to previous studies of social interaction in counseling, and to research on social identity and categorization more broadly.     

Validation of a Multivariate Career and Educational Counseling Intervention Model Using Long‐Term Follow‐Up

In this study, the author sought to validate the effectiveness of a multivariate career and educational counseling intervention model through long‐term follow‐up of clients seen in private practice. Effectiveness was measured by clients' commitment to and enjoyment of their chosen career paths and the relationship of these factors to adherence to program recommendations. Findings indicated that 65% of clients adhered to program recommendations. Those who adhered to program recommendations were significantly more committed to their careers; however, no significant difference was found in clients' enjoyment of their careers. Additionally, 85% of clients reported that the program met their needs, and 95% would recommend the program.     

The Relationship Between Counselor Verbal Response Modes and the Working Alliance in Career Counseling

The authors examined the use of counselor response modes in career counseling, including the overall proportion of each response mode and the relationship of each response mode to the working alliance. Participants were 19 counselors‐in‐training and 26 clients in 78 sessions, making this the largest reported study of career counselor response modes. Seventy‐nine percent of the counselor responses were information, paraphrase, or close‐ended questions. None of the categorized counselor responses was significantly and positively related to the working alliance, although counselor self‐disclosure had a significant negative correlation with the alliance. The type of self‐disclosure used was largely irrelevant or self‐deprecating.     

When Does Premature Treatment Termination Occur? Examining Session-by-Session Dropout Among Clients with Gambling Disorder

Premature termination challenges the successful outcomes of psychological treatments for gambling disorder. To date, research has primarily identified clients who are at particular risk for dropping out of treatment. A smaller but growing body of literature has investigated when dropout occurs. Typically, those studies have not considered improvement in psychological distress within their operationalizations of dropout and therefore may have misrepresented when dropout occurs. The current study examined when dropout occurs using an operationalization based on the criteria of attaining reliable change in a naturalistic sample of clients with gambling disorder, and the classification rates yielded from that operationalization were compared to the rates from a more common operationalization. Participants (n = 334) were clients meeting diagnostic criteria for gambling disorder at an outpatient private practice who completed a measure of psychological distress at baseline and prior to each subsequent treatment session. A survival analysis was conducted to determine temporal patterns of treatment dropout (i.e., clients who discontinued treatment before realizing reliable changes in psychological distress) and completion (i.e., clients who discontinued treatment after realizing reliable changes in distress) at each treatment session. Forty-nine percent of clients were classified as dropouts, and the majority of those clients did so in the first few sessions. The more common operationalization of dropout classified clients as dropouts when they had improved in their distress and clients as completers when they had not improved in their distress. Discussion centers on the implications of dropout occurring at various stages of treatment and future directions.     

Child welfare clients and school satisfaction

Despite long-standing knowledge about child welfare clients' poor educational outcomes, we know less about these vulnerable young people's situation in school. This article addresses school satisfaction among upper secondary students who have been in contact with the child welfare services. These child welfare clients' school satisfaction is compared with their peers' satisfaction. The results from a survey indicated that the majority of child welfare clients were satisfied with school but that they were less satisfied with school than were their peers. The results showed that the association between school satisfaction and positive school experiences explains a large part of this difference. Among students who reported they were doing well in school, had supportive teachers and friends at school, the difference in school satisfaction between child welfare clients and others was small. Among students who did not report similar positive experiences in school, difference in school satisfaction between child welfare clients and their peers was more substantial. These results show that school can be a good place for child welfare clients, but that facilitating support from teachers, increasing opportunities for making friends at school, and working to develop the child welfare clients' academic performances are important as efforts to improve school satisfaction.     

Systemic alliance in individual therapy: factor analysis of the ITAS-SF and the relationship with therapy outcomes and termination status

Clients providing systematic feedback to therapists via self-report measures of psychological distress and working alliance have been shown to increase therapy outcomes. However, there are few systemic-based measures that are feasible for therapists to use. Recently, Pinsof et al. (Family Process, 2008, 47, 281) developed a brief systemic alliance measure (ITAS-SF) for individual therapy. The current study tested the factor structure of this measure and examined whether the subscales related to clients' therapy outcomes and termination status (N = 570). The results demonstrated supported a 3-factor model for the ITAS-SF (as compared to the seven factors proposed by Pinsof et al.). In the first factor, content combined the goals for therapy, the tasks or methods to reach those goals and bond between the client and therapist. The second factor reflected how clients perceive the relationship with the therapist (i.e., interpersonal dimension-self/therapist), and the third factor reflected how clients perceive the alliance between their social network and the therapist (i.e., interpersonal dimension others/therapist). The two interpersonal factors were related to therapy outcome and termination status.     

Engaging Fathers in Family Therapy with Violent Adolescents

Violent behavior in adolescents can often signal profound distress or pain arising from family conflicts, hostile marital separations, sudden losses and other family turmoil. By circumventing blame the therapist engages the family in a constructive process that allows adolescents to change and grow and parents to share pain and sorrow about their own issues and responsibilities for their children. This re‐establishes healthy generational boundaries, produces a clearer co‐parenting alliance (e.g. after divorce) and creates sibling support. This paper describes an experiential approach, for working with violent adolescents in family therapy influenced by the pioneer work of Satir and Whitaker. It integrates systemic and developmental theories linking the presenting problem to relevant family events. The therapist: (1) explores adolescent development in the family and social context; (2) establishes a therapeutic alliance through understanding the interpersonal context for violent behavior, and (3) re‐directs negative actions into positive connections with family members. Segments of family therapy sessions with two adolescent boys and their families from different cultural backgrounds illustrate the impact of paternal absence for adolescent well‐being and the need to actively engage fathers in family therapy. Mario, the father's ‘tumor’, and Juan with his despairing violence are two problematic adolescents brought to therapy because of their aggressive behavior at home and/or in the school. The paper describes how to give them a different voice and build a therapeutic alliance with the family.     

AN EXPLORATION OF THE THERAPEUTIC RELATIONSHIP AND COUNSELLING OUTCOMES IN A PROBLEM GAMBLING COUNSELLING SERVICE

This study examined the relationship between a number of counselling process variables thought to influence counselling outcomes in a sample of 150 clients undertaking short‐term counselling in the state‐wide government funded Gambler's Help problem gambling counselling services in Victoria, Australia. Factors measured included psychosocial well‐being of clients prior to and after counselling, client readiness to change, self‐reported gambling activity levels before and after counselling, self‐assessment of current gambling behaviour, strength of therapeutic alliance, self‐reported counselling outcomes achieved in the area of symptoms, life matters, and related problems and a measure of client satisfaction with the service. The therapeutic alliance was found to have the strongest predictive power with respect to the level of problem resolution achieved by clients across all but one of the problem areas. The implications of these findings for clinical social work practice and education of practitioners are noted.     

Clients' Attributions of the Presenting Problem and the Therapeutic Alliance in Couple Therapy: Systemic Versus Intrapersonal Perspectives

The therapeutic alliance is central to couples' therapy success. The current study examined associations between couples' initial agreement and causal attributions of the presenting problem and changes in the therapeutic alliance. To test study hypotheses, 85 couples were recruited from a university training clinic focused on couple and family therapy. Couples completed an intake questionnaire concerning their attribution of the presenting problem, either as systemic or individual, and therapeutic alliance was assessed at the end of sessions 2–8. A dyadic multilevel model revealed that a disagreement in the couple's attributions of the problem (with one viewing it as systemic, the other as individual) was associated with a larger initial discrepancy in the couple's therapeutic alliance, as well as a decline in the discrepancy over time. Findings were discussed in the context of systemic family theory, with implications for improving assessment, treatment, and psychoeducation aimed toward couples in distress.     

Therapeutic Alliance and Retention in Brief Strategic Family Therapy: A Mixed‐Methods Study

We explored how the therapeutic alliance contributed to retention in Brief Strategic Family Therapy by analyzing videotapes of eight‐first sessions in which four therapists worked with one family that stayed in treatment and one family that dropped out. Although behavioral exchange patterns between clients and therapists did not differ by retention status, positive therapist alliance‐related behavior followed negative client alliance behavior somewhat more frequently in the retained cases. In the qualitative aspect of the study, four family therapy experts each viewed two randomly assigned sessions and commented on their quality without knowing the families’ retention status. A qualitative analysis of the audiotaped commentaries revealed 18 alliance‐related themes that were more characteristic of either the retained or the nonretained cases.     

Evaluation of Family Therapy: A Comparison of Therapists' and Clients' Views**

In this evaluation of therapy experience for 82 families by brief therapy at Bouverie Clinic to 1976–1977, therapists' and clients' rating of outcome were obtained. After termination of therapy both therapists and clients reported high improvement rates in the presenting problem(s) as well as in the quality of family relationships and in the family's ability to deal with further problems. High agreement was found between therapist’ and clients' ratings of outcomes. Therapists were more favorable than clients in their ratings of change in the presenting problem and in their ratings of change in the quality of family relationships, but not in assessing the change in family's further problem solving ability. At follow-up clients were predominantly satisfied with their therapy experience. In addition, therapists' ability to predict outcome accurately, after the second of therapy, was strongly supported by our finding.     

Shame and the Psychosocial Costs of Contemporary Work: Implications for Career Intervention

This article explores the concept of shame and integrates it into career development and career counseling. The article begins with an overview of shame from a diverse conceptual framework, describing shame as a self-conscious emotion that occurs in response to interactions or events that evoke embarrassment, humiliation, self-doubt, and psychological distress. We discuss the prevalence of shame in work-based interactions and contexts, which is referred to as work shame. Building on this integrative review of shame within the working context, we describe the counseling implications and provide a case study to illustrate the ways in which shame emerges in clients' lives and potential strategies to resist and transcend shame.     

A Preliminary Comparison Study of Online and Face-to-Face Counseling: Client Perceptions of Three Factors

This preliminary study examined the similarities and differences between online and face-to-face counseling with regard to general mental health, working alliance, and social presence. Participants included 50 current counseling clients (37 face-to-face, 13 online) who all were recruited through online mediums. Results indicated that online counseling clients perceived a significantly stronger working alliance on the total Working Alliance Inventory-Short Form as well as the Goal subscale than did those who received face-to-face only counseling. No significant differences existed between the groups on general mental health or social presence. These results suggest that a more controlled study with a larger sample might find that a strong working alliance can be developed through online counseling.     

Needs-led child and youth care: Main characteristics and evidence on outcomes

Needs-led child and youth care has three main characteristics: a continuous focus on clients' needs, client participation in the care process (including decision making), and practitioners' displays of needs-led attitudes and skills. The primary aim of this review was to establish whether there is evidence for using a needs-led approach when working with children and families in need. We performed a literature search to find reviews and outcome studies of child and youth care for school-aged children and their families which included the core characteristics of needs-led care, and related them to outcome measures. Only a few studies attributed positive outcomes of care to the attention given to clients' needs and goals. Most studies referred to participation in terms of clients' involvement or engagement. Higher levels of participation were associated with positive changes in child behaviors and parenting stress, client satisfaction, higher completion rates, safety for children, feelings of well-being and empowerment, and better service coordination. Significant professional attitudes and skills included listening to clients and working in active partnership with them. There is some proof for the relevance of core characteristics of needs-led child and youth care, although that evidence is limited by the lack of rigorous studies. This study indicates that needs-led child and youth care can make a difference. Future research should pay attention to the intertwinement of the characteristics of the needs-led approach in care.     

Mental Health Professionals' Exposure to Clients with Problematic Internet Experiences

ABSTRACT

This paper examines clients' exposure to problematic Internet experiences among a national sample of 2,098 social workers, psychologists, marriage and family therapists, and other mental health professionals. This analysis finds that mental health professionals are working with clients experiencing a range of problems related to Internet use. However, these professionals have generally not been exposed to training or information in the professional literature on the topic of working with clients with problematic Internet experiences. We identify several areas in which additional training is needed and review practical implications for mental health professionals.     

The Impact of Blamer‐softening on Romantic Attachment in Emotionally Focused Couples Therapy

Emotionally Focused Couples Therapy (EFT; Johnson, 2004 ) treats relationship distress by targeting couples' relationship‐specific attachment insecurity. In this study, we used hierarchical linear modeling (Singer & Willett, 2003 ) to examine intercept and slope discontinuities in softened couples' trajectories of change in relationship satisfaction and relationship‐specific attachment over the course of therapy from a total sample of 32 couples. Softened couples (n = 16) reported a significant increase in relationship satisfaction and a significant decrease in attachment avoidance at the softening session. Although softened couples displayed an initial increase in relationship‐specific attachment anxiety at the softening session, their scores significantly decreased across post‐softening sessions. Results demonstrated the importance of the blamer‐softening change event in facilitating change in EFT.     

Sexual behavior of clients with street prostitutes in Camden,NJ

This paper describes the sexual behaviors of 101 male clients with female street prostitutes. An earlier study (Freund, Leonard, & Lee, 1989) was limited to sexual behaviors of street prostitutes themselves. Interviews were given by 62% of the clients approached. The clients were mature men (mean = 39.8 years), long‐term residents of Camden, NJ (mean = 19.2 years), and currently or previously married (78/101). Racial composition was similar to the general population of the area, 65% white, 33% black, 2% Asian. Clients reported a mean of 5.3 years of using prostitution, with 81% having been clients of Camden prostitutes for more than a year. Most were regular (or repeat) clients; 93% monthly or more frequently, and 63% weekly or more frequently. About one‐half (55%) reported sex with the same prostitute or same small group of prostitutes. The primary meeting place was the street (78/101) and 43% of the sexual encounters took place in the clients' cars. Ejaculation into the vagina was most frequently reported (43/101), followed by ejaculation into the mouth (39/101) Reports of condom use were substantial; 72% for vaginal and 33% for oral intercourse (mean = 58% of encounters).