Therapist Rating Scale (Williams, 1989)

Treatment Process

Varying Definitions

Processes of change through which clients improve

Any and all events that may be observed and experienced during therapy sessions, including:

Actions

Perceptions

Intentions

Thoughts

Feelings

Of patient or therapist, or both

The therapeutic relationship

Varying Perspectives

Client
Therapist
Objective observer

Varying Levels

Micro vs. macro analysis - from seconds to years

Relationship of Process to Outcome

Varying Levels

Session Outcome

Treatment Outcome

Some Examples of Topics

Frequency and number of sessions (e.g., short vs. long term therapy)

Client preparation for therapy

Goal consensus between client and therapist

Cost of treatment

Therapist competence

Therapist level of training, education, or experience

Client's problem focus

Therapist's interventions (e.g., interpretation, clarification)

Therapist's credibility

Therapeutic relationship

Client Variables in Psychotherapy

Who refuses referral for therapy?

Who drops out of therapy?

Who does well in therapy?

The Case of The Therapeutic Relationships: Multiple Perspectives

Method I: Client Ratings Therapist Rating Scale (Williams, 1989) (A Measure for Behavior Therapy) Humanistic Therapy Dimensions

Dimensions: Empathic, Warm, Interested, Encouraging, Etc. (a.k.a. The Nice Therapist)

Sample Items: "My therapist tries to see things through my eyes."

"My therapist almost always seems very concerned about me."

Dimensions: Unconditionally Accepting

Sample Item: "My therapist likes me better when I behave in some ways than he/she does when I behave in other ways." (Reverse scored)

Dimensions: Willing To Be Known

Sample Item: "My therapist will freely tell me his/her own thoughts and feelings, when I want to know them."

Dimensions Developed for Behavior Therapy

Dimension: Assertive & Confident

Sample Items: "My therapist seems frightened and unsure of himself/herself." (Reverse scored)

"My therapist seems to feel comfortable with himself/herself."

Dimension: Challenging

Sample Item: "My therapist often presents me with new challenges intended to further my progress."

Dimension: Explicit

Sample Item: "I wish my therapist would make himself/herself clearer in communicating with me." (Reverse scored)

Relationship to Treatment Outcome on Behavioral Avoidance (Williams & Chambless, 1990)

Dimension	r with improvement	P
Nice Therapist	.30	.05
Unconditionally Accepting	.05	ns
Willing to be known	-.02	ns
Assertive & Confident	.39	.02
Challenging	.17	ns
Explicit	.22	ns ??

Method 2: Therapists' Ratings Therapist and Client Agreement on Relationship: Who's Right?

Client
	Therapist

	Regard	Emp	Congr.		Uncon.	Willing TBK

Regard	.23

Empathy		.09

Congru-ence			.27

Uncondi-tionality				.33*

Willing to be Known						.32*

* p < .05 Method 3: Observer Ratings The California Psychotherapy Alliance Scale - Rater Version (Gaston & Marmer)

24 items rated on 7-point scales by 3 expert judges

4 factors:

Inter-Rater Reliability

Patient Working Capacity Scale r = .52

The patient's ability to work actively and purposefully in treatment, to form a working alliance with the therapist.

Patient Commitment Scale r = .60

The patient's attitude toward the therapist and the therapy; commitment to persist despite momentary obstacles.

Working Strategy Consensus Scale r = .53

Agreement between patient and therapist as to how to proceed in therapy.

Therapist Understanding and Involvement r = .36

Therapist's empathy and active participation in therapy on patient's behalf.

Notice that even trained experts disagree.

Relationship of Expert Alliance Ratings to Treatment Outcome in Behavioral, Cognitive, or Psychodynamic Therapy for Depression (Gaston et al., 1998)

Variable r with BDI change r with Ham-D
change

Patient Working Capacity .26* ns

Patient Commitment .42* .35*

Working Strategy Consensus ns ns

Therapist Understanding and Involvement ns ns

Resources

Stumped for ideas about what you'd like to focus on for your paper? You can (a) come talk to me about areas of possible interest or (b) read some good review papers to get an idea of topics in which you might be interested. These will give you more information about the areas I've mentioned in the above outline in addition to others. Of course, you can always do a PsychInfo search on psychotherapy process, but you might get overwhelmed by the results.

Bergin, A. E., & Garfield, S. L. (1994). Handbook of psychotherapy and behavior change (4^th ed.). New York: Wiley. In Davis Library, RC 480.286 1994.

See chapters by Garfield, Beutler et al., and Orlinsky et al.

Variable	r with BDI change	r with Ham-D change

Patient Working Capacity	.26*	ns

Patient Commitment	.42*	.35*

Working Strategy Consensus	ns	ns

Therapist Understanding and Involvement	ns	ns