..,.-. , “3.19:;- ‘ NV W» mm lllllllliltlllllllllllllilllllllltlll lllvllilliiililyllli 3 1293 10592 7820, \ we "'E‘ 55 In an: - «2 en ea «3 .‘u - s‘q ' “A \\\\ MM my. 1 1 1 This is to certify that the dissertation entitled THE EFFECT OF CLIENT AND THERAPIST GENDER ON THE OUTCOME AND PROCESS OF PSYCHOTHERAPY presented by ATbert Benjamin Lichtenstein has been accepted towards fulfillment ofthe requirements for Ph.D. degreein Psychology . Major professor » Dr. Nerman.Abeles 7/31/84 Date MSUis an Affirmative Action/Equal Oppormniry Institution 012771 83 in“ i M M‘ «Q‘ in I.‘ i w) to»? as? mg Mt.“ Oh «a as an 8%. we SQ i i i l N f? w i J msm‘ MSU LIBRARIES RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. § {‘2‘ 6 .9 1% :iN 3 5”,,“ ‘ mr’t WVt‘r—v ’ *' 7*w ”an I I 1 l rt THE EFFECT OF CLIENT AND THERAPIST GENDER ON THE OUTCOME AND PROCESS OF PSYCHOTHERAPY By Albert Benjamin Lichtenstein A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1984 ABSTRACT THE EFFECT OF CLIENT AND THERAPIST GENDER ON THE OUTCOME AND PROCESS OF PSYCHOTHERAPY By Albert Benjamin Lichtenstein Previous research had indicated that both female therapists and female clients were judged to attain more positive outcome in psychotherapy than their male counterparts. Aspects of the female gender role theorized to account for these findings included an emphasis on nurturance and openness to feelings which better prepared both female therapists and clients for their respective roles in psychotherapy. It was hypothesized that the female gender role would facilitate the formation and maintenance of a therapeutic alliance, emotional intensity in the relationship and therapist warmth and empathy in dyads with a female therapist, client, or both. As a result, these dyads would achieve better outcome. In a more preliminary fashion, therapist and client exploration and therapist directiveness were investigated in their relationship to the major hypotheses. Outcome measures included symptom change measures and subjective rating of benefit, satisfaction, and overall change obtained from 65 clients at a university, psychological clinic. Therapist ratings of symptomatic improvement and overall change were also obtained. Ratings of audiotapes on the Vanderbilt Psychotherapy Process Scale and post therapy ratings on the Post Therapy Client and Therapist Questionnaires provided measures of the process variables. With regard to therapists, no conclusive evidence was found to indicate a gender advantage in psychotherapy outcome for clients of male or female therapists. A trend for clients of female therapists to fare better on one of the symptom change indices was found, while clients of male therapists reported more satisfaction with therapy. 0f the process variables, only change in directiveness, distinguished between male and female therapists. Male therapists tended to change toward being more directive later in therapy more so than female therapists. Female clients achieved more positive outcome in both symptom change measures than did male clients. Process variables did not prove to differentiate between groups of male and female clients. However, three variables observed post hoc; self exploration, client hostility, and therapist directiveness did differentiate between male and female clients in later therapy sessions. These results were posited as showing a more intense working relationship between female clients and their therapists later in treatment. This dissertation is dedicated to my parents, Bernard and Yetta Lichtenstein ii ACKNOWLEDGEMENTS There are several people whose help and support were instrumental in accomplishing what once seemed like the unobtainable goal of a finished dissertation. My doctoral committee members, Drs. Thornton, Karon, and Levine provided much needed guidance, time, and support. I am especially indebted to the chair of the committee, Dr. Norman Abeles, for his suggestions and criticism about the work itself, and for his guidance in times of need. The role of the chair of the dissertation committee seems to me to be like that of a psychotherapist in that he/she must allow the student the freedom to put facts and ideas together to reach his/her own conclusions. Otherwise, growth as a researcher would not occur. Dr. Abeles was adept at providing both freedom and structure; an excellent combination. Finally, I'd like to express my extreme gratitude to my wife, Diane, for her continuous love and support under less than ideal circumstances. Having shared the process with her, sharing the outcome is that much more sweet. TABLE OF CONTENTS LIST OF TABLES ....................... INTRODUCTION ........................ Therapist Gender .................... Outcome Studies ................... Gender Differences Prior to Training in Psychotherapy ................... Effects of Therapist Gender Differences on the Therapeutic Relationship ................ Empathic Skills ................... Authority ...................... Client Gender ...................... Outcome Studies ................... Client Gender Differences in Psychotherapy Process. . Gender Combinations ................... Outcome Studies ................... Gender Combination Differences in Psychotherapy Process ...................... Summary ....................... HYPOTHESES ......................... Exploratory Hypotheses ................ METHOD ........................... Subjects ....................... Instrument ....................... Outcome Measures ................... Process Measures ................... Procedure ...................... Statistical Analysis ................. RESULTS .......................... Reliability of Ratings of the Vanderbilt Psychotherapy Process Scale (VPPS) .......... Tests of the Hypotheses ............... Some Methodological Issues .............. Additional Findings ................. Accounting for Overall Positive Change in Psychotherapy .................... iv Page vi 52 52 7O 71 72 DISCUSSION ............................ Bl Outcome .......................... 81 Process Measures Accounting for Differential Gender Outcome ...................... 84 Gender Composition and Process Measures .......... 87 Variables Accounting for Positive Outcome ......... 89 Suggestions for Future Research .............. 92 APPENDICES APPENDIX A ............................ 94 APPENDIX B ............................ 96 APPENDIX C ............................ ll8 BIBLIOGRAPHY ........................... 129 LIST OF TABLES Table Page l. Abbreviations ..................... 57 2. Relationships found Between Therapeutic Alliance and Outcome ..................... 59 3. Summary of Results from Hypothesis III, Subhypothesis C: Same Sex Dyads Have a More Positive Therapeutic Alliance Than Opposite Sex Dyads ........... 62 4. Multiple Regression for the PCQ + PTQ Outcome Cluster Using All Independent Variables ........ 75 5. Multiple Regression for the PTO + PCQ Outcome Cluster Using PCQTA and Emotional Intensity ...... 77 6. Multiple Regression for the SCL90 Symptom Change Cluster Using All the Independent Variables ...... 78 7. Multiple Regression for the SCL90 Symptom Change Cluster for Client Sex, Therapist Experience, and Client Negative Experience ............ 80 vi INTRODUCTION When one begins to address the particular elements of the psychotherapeutic interaction one of the most obvious and voluminously expounded upon areas is the gender of the participants. This is clearly an important area in that it is one of the basic questions one faces in matching client and therapist to facilitate the most productive outcome. Yet this is by no means a clearly researched area for at least two reasons. The first is the emotional charge which this area has taken on. There are charges of sex bias on the part of male therapists (Chesler, in Murray, 1983) as well as rebuttals to those allegations. In addition arguments that women are inherently better suited to the role of therapist due to the preparation given by social roles (Carter, 1971) may be difficult to evaluate, particularly by male therapists. The second, and perhaps more crucial, reason for the lack of clarity in gender related psychotherapy research is its methodological shortcomings. A good number of the studies in this area have been analogue rather than naturalistic (Jones and Zoppel,1982). There is little evidence that the laboratory situation adequately approximates what goes on in the therapist's office (Smith, 1980). Studies have differed in client and therapist characteristics and types of therapy. Outcome measures are, at times, utilized from the client's perspective, and often these measures are done posthoc, occasionally as long as a year after therapy. In addition outcome measures are rarely uniform. Global ratings of functioning, specific symptom change, ratings of satisfaction, and ratings of degree of comfort are all used. It is the rare study that attempts to relate these diverse viewpoints and methods in a clear fashion. Despite the emotional charge of the area, its methodological flaws, and the diversity of data it has produced, there are some clear trends which deserve to be examined and nurtured. The remainder of the introduction of this study will outline these trends and the research questions to be addressed. Therapist Gender Outcome Studies Starting at a global level a reasonable point of departure for relevant studies is a with therapist's gender as a main effect. Does therapist gender have a differential effect on the outcome of psychotherapy? There have been surprisingly few studies bearing directly on this issue. Meltzoff and Kornreich (1970) in their review of the pre 1970 literature found four studies all of which reported no differential effects of gender on psychotherapy outcome. Their conclusion was that there "is no clear basis for preferential assignment of a patient of either sex to a therapist of either sex." Luborsky, Auerbach, Chandler, Cohen, and Bachrach (1971) report only one study in this area in their "exhaustive survey...of quantitative studies of factors influencing the outcome of psychotherapy." That study also reports no differences between the genders. By 1978 Kirshner, Genack, and Hauser correctly concluded that "systematic differences in the process or outcome of psychotherapy as a consequence of the gender...of the therapist have not been demonstrated in empirical studies." Following up on this conclusion Kirshner et a1. short term psychotherapy; specifically investigating, among other things, the hypothesis that clients are more satisfied and feel more improved when seeing a female therapist. Three hundred and ninety five Clients of a university health center who had been in therapy for at least three sessions were sent two questionnaires including background information, seven ten point scales covering a range of possible areas of improvement, and a nine point satisfaction with treatment scale. One hundred and eighty nine clients, split evenly between males and females responded.w As hypothesized clients of both sexes reported 1 greater improvement, greater satisfaction, and more congruence with 1.’ their therapist's ratings when they were seen by female therapists. 1 Specifically, clients rated themselves as significantly more improved! in self acceptance, and in their main problem, although this trend didwnot reach statistical significance. One difficulty with the methodology of this study was the lack of independence of measurements. The 189 client respondents were seen by 22 psychotherapists, only five of whom were female. It is not clear how homogeneous or representative these subsamples were. For instance‘ one extraordinary female therapist, either good or bad, would carry much more weight than therapists in the male sample and skew the the results. In addition, Orlinsky and Howard (1970) have shown, at least with female clients, that age and marital status of client and therapist had a major effect on clients' ratings of satisfaction. The chances of having a representative subsample of female therapists in Kirshner et al.'s study is called into question with so few therapists. Finally it is not at all clear that the 189 respondents (of the 395 clients who were sent rating forms) are representative of the total client population. ' An interesting aspect of the results of this study is that when there were disagreements between female therapists and their clients . in ratings of improvement or satisfaction they were almost uniformly i in the direction of the client ratings being more positive than the therapists. Positive difference scores were significantly higher for clients who saw female therapists than for those who saw male therapists. This result is a difficult one to interpret but seems to suggest a process which, if one takes therapists' ratings as a baseline, indicates a tendency to inflate the outcome ratings by clients seen by female therapists. One could speculate that this is a confounding factor which influences the overall rating. Another study which presents evidence for the greater psychotherapeutic effectiveness of female therapists is that of Jones and Zoppel (1982). One hundred and sixty individual outpatients were selected from case records of several West Coast clinics. Clients were between 18 and 50 years old, diagnosed as neurotic, as having personality disorders or adjustment reactions. Half were male; the other half were female. Therapy ranged from 8 to 150 sessions with a mean of 34.6 hours. One hundred and forty dynamically oriented therapists, with a mean of 4.4 years of experience were involved in the study. Therapist gender was evenly divided. Therapists rated clients on the Rating Scales for Therapy Outcome (5 scales of 11 items each tapping symptoms and problems, productiveness, sexual adjustment, interpersonal relationships, and ability to handle stress), Strupp, Wallach, and Hogan's Therapist Questionnaire (which provides information about the therapist's reaction to the client as a person, the extent to which they enjoyed working with the individual, and the overall success of treatment) and Gough's Adjective Checklist. All 11 of the Rating Scales for Therapy Outcome showed statistical significance and positive relationships indicating that therapists of both sexes believed treatment to be effective. However, female 1 therapists rated their clients as displaying significantly more i I improvement of five of the rating scales; symptoms, happiness, ability to enjoy life, ability to get along with spouse and children, and ability to handle personal problems. In addition female therapists rated clients on the Therapist Questionnaire as having greater overall success in therapy, having undergone a greater degree of change in basic personality structure, and experiencing greater satisfaction with treatment. Another finding of this study which may impinge on the results listed above is the following. On the Gough Adjective Checklist male therapists tended to describe their clients in more disparaging terms '- while female therapists endorsed more socially desirable adjectives. This finding is congruent with that of Markel and Roblin (1965) as well as Osgood, Suci, Tannenbaum (1957) that female judges had the tendency to rate subjects more positively on adjectives falling on the evaluative dimension of the semantic differential. Both sets of authors hypothesized that female judges resolve the anxiety of the evaluative process by giving favorable responses. Be that as it may the question exists whether the female therapists in the Jones and ZDppel (1982) study rated clients more positively due to response set or real change. Obviously the opposite question could be asked of the male therapists since there is no evidence to suggest that either male or female therapists are any more accurate in their clinical judgments. In fact Camicia (1977) found no differences between male and female post graduate clinicians in the accuracy of their diagnostic judgment when accuracy was defined as agreement with a panel of four psychologists with diplomates from the Board of Professional Psychologist. Findings of the second part of the Jones and Zoppel (1982) study speak in part to the questions asked above. In this part of the study 99 clients, roughly half male and half female, were asked to fill out the Rating Scale for Therapy Outcome and participated in an interview derived from Strupp's Client Post Therapy Questionnaire (rating global outcome and subject experience of therapy). Forty of these clients overlapped with those in the first part of the study. Clients seen by female therapists did report significantly more energy to do things than did clients of male therapists, whereas, clients did not rate themselves as more improved on any dimension when seen by male as opposed to female therapists. The results of the client ratings agree to some extent with the therapist ratings previously cited. Thus they provide some evidence that the more positive ratings by female as opposed to male therapists were not just an artifact due to response set. On the other hand the scale on which clients of female therapists rated themselves as more improved than clients of male therapists was not the same as the ones which these clients were rated more improved by the female therapists. In addition correlations for specific outcome scales between client and therapist ratings were generally small correlations with a mean of .26, with only 3 of 11 reaching significance. Therefore, although the results of this study presents some evidence for more positive outcome for female therapists, the reasons for these results are not as clear cut as they could be. Additionally methodological difficulties with both parts of the study complicate the picture even further. Pre and post therapy therapist ratings were obtained six to eight weeks post therapy. If response set is indeed a mitigating factor then this type of retrospective rating system increases the chances of subjective influence. Client ratings were obtained in the same retrospective manner although the authors do not report how long post therapy the rating procedure took place. While there is not a wealth of evidence compelling one to conclude that one gender or the other makes better therapists irregardless of interacting variables two recent studies do suggest that female therapists are more successful on some dimensions of psychotherapy outcome. There are no studies in which male therapists are rated as more sucCessful. Gender Differences Prior to Training in Psychotherapy Thereis limited literature on the specific factors which lead to differential success in psychotherapy by gender. The majority of the literature which does exist relates to female therapists. Carter (1971) asserts that role expectations differentially prepare the genders for the psychotherapists' role. Girls are expected to experience a wide range of feelings, and are given more freedom to express them. Throughout life they are rewarded for understanding, nurturance, and responsiveness. Boys on the other hand, are ”rewarded instead for strength which is synonymous with emotional control, and for caping with things rather than people and relationships." Therefore, Carter asserts, much of the graduate training of a male therapist to be is spent unlearning emotional distance and restraint whereas women are "already accomplished therapists when they begin graduate training." It follows then, according to Carter, that female therapists are more emotionally responsive, able to allow "the patients'experience to have an impact on them in a feeling way and skilled at verbalizing how they have been affected." In reviews of the sex difference literature by both Tyler (1965) and Hillerman (1976) females were found to be more socially and interpersonally oriented than males, who are more individually and aggressively oriented. Bakan's description of these personality differences and subsequent confirming research, cited by Nillerman, provides a very good example. Bakan uses the concepts of agency and communion. Agency encompasses such characteristics as self assertiveness, separateness, instrumentality, mastery, and libidinal sexuality; communion is represented by interpersonal concerns and interests, connectedness and union, and cooperation. According to Bakan themes of agency, predominate for males whereas themes of communion predominate for females. Several studies using adjective checklists and ideal self descriptions provide evidence for this line of thinking. However, conclusions from reviews of the sex difference literature are by no means uniform. Maccoby and Jacklin (1974) in their review found no clear cut differences in regard to social and interpersonal orientation. Theyconclude that both sexes are equally interested in social stimuli and respond equally to social reinforcement. Maccoby and Jacklin found both genders to be roughly equivalent in the understanding of emotional reactions of others (empathy) and in their willingness to be helpful (altruism). The reviewers did find a preponderance of studies suggesting that males were more aggressive than females. They also report that in ratings of self confidence "girls rate themselves higher in the area of social competence; boys often see themselves as strong, powerful, dominant and potent" (p. 350). In essence a clear consensus that evidence exists which demonstrates sex differences suggesting that one gender or the other comes to the role of therapist inherently more prepared, as Carter theorizes, is lacking. However the general trend of this literature does support Carter's contentions. In a study that more directly investigates people entering the helping profession using an adjective checklist measuring self concept and the California Psychological Inventory, Cartwright (1972) found that female medical students tended to display more sensitivity to relationship values, more general acceptance of feelings, and greater alertness to moral and ethical issues than male medical students. They also valued independence and individuality to a greater degree than their male colleagues. As Kirshner, Genack, and Hauser (1978) interpreted these results "female medical students were more likely 10 to combine tough analytic with nurturant sensitive traits than men, who tend to be cast in the role of more rigid authoritarian personalities" (p. 159). The Cartwright study provides some supporting evidence for Carter's (1971) contentions with a group of subjects (medical and social work students) that might be assumed to be more similar to students entering clinical psychology than were the subjects in the studies reviewed by Maccoby and Jacklin (1974). The majority of the subjects in the studies Maccoby and Jacklin reviewed were under 12 years of age. Theories about components of male therapists' behavior that describe special strengths of males which lead to successful outcome are scarce. Carter (1971) asserts that male therapists tend to work from a cognitive framework. "They are quick to grasp the concrete difficulties of the patient's dilemma and almost immediately begin to formulate coping alternatives." Although Carter continues that a male may use a cognitive, reality based approach at the expense of understanding the client's underlying feeling state, she does relate the former as a strength of male therapists. Carter's assertions are quite congruent with sex difference research cited by Tyler (1965) in her review of cognitive styles. In research on problem solving males were much more adept than females on problems requiring restructuring: That is in situations in which the person needed to discard their first system of organizing the facts he had been given and trying new approaches. Male superiority in this realm was evident in groups that had been equated for general intelligence,verbal ability, mathematical ability, "relevant" knowledge and various background factors. Tyler relates these results to ll findings by Nitkin and others that females show more field dependence than males. Males, being more field independent, are able to be less influenced by the structure of a situation and provide new solutions. These abilities would allow males to be less influenced by the therapeutic relationship and the client's current coping or defensive strategies and help formulate more effective strategies while interacting in more appropriate ways within the relationship. It is important to note that recently the notion that males have superior "set breaking" or restructuring skills has been called into question (Maccoby and Jacklin, 1974). The criticism of the conclusion comes from the fact that many of the studies which provide evidence used only visual spatial tasks on which males are superior rather than verbal ones on which females are often superior. Effects of Therapist Gender Differences on the Therapeutic Relationship Empathic Skills From the foregoing discussion it is reasonable to hypothesize that it is a strong possibility that a more sensitive, affective interpersonal orientation is brought into the therapeutic relationship be female therapists. If so it will enhance the psychotherapeutic enterprise in several ways. First, it has been fairly well documented that accurate empathy, warmth, and genuineness play an important part in successful psychotherapy (Luborsky, Auerbach, Chandler, Cohen, and Bachrach, 1971). Since women tend towards more openness to feelings and interpersonal warmth one would also expect them to exhibit these traits in the therapeutic relationship. Two studies found female 12 therapists to have greater empathic skills than their male counterparts. Both are analogue studies, which may reduce the generalizability of the results. Abramowitz, Roback, Schwartz, Yasuna, Abramowitz, and Games (1976) asked experienced group therapists for clinical reactions to case material of a fictional outpatient. Therapists were given a list of 19 possible reactions they might use in the therapy incident involving the fictional patient. These alternatives ranged from supportive and reassuring to confrontative and interpretative. The therapists were asked to rank order three choices. Female therapists made significantly more empathic remarks, while male therapists used more clarification and confrontation. Interestingly, female therapists also asked more group dynamic questions, encouraged more discussion about behavior change, gave more psychodynamic interpretaion, and tended to give more subtle guidance. In addition to more empathy, as Zeldow (1978) states "such findings, even in an analogue study, raise the question whether female therapists are more active and in possession of broader therapeutic resources than are males." These results are also consonant with the description of female medical students as combining tough analytic and nurturant sensitive traits. Abramowitz, Abramowitz, and Heitz (1976) studied graduate students in clinical and counseling psychology who had equivalent amounts of hours of supervision and were similar in age. The graduate students viewed videotapes of student volunteers playing client parts. Each tape was a half minute long portraying a man or woman whose verbal or nonverbal communications indicated distress. Immediately after the presentation the graduate students were asked to write down the 13 most helpful reaction. The same procedure was followed before and after one semester of practicum. Abramowitz et al. found that regardless of the time of testing the female graduate students were rated as more empathetic than their male counterparts. Although both genders of graduate students increased their empathic skills through training, at least after one semester the females maintained their edge. Although the two studies presented do not exactly constitute an incontrovertible avalanche of evidence favoring higher empathy skills in female therapists they do present some evidence of a trend and are in line with the theoretical base presented earlier. In addition there are no studies which show males to possess relatively superior empathic skills. However, what is clearly missing in the literature is evidence that greater empathy skills on the part of female therapists in themselves lead to more successful psychotherapy outcome. Therapeutic Alliance Another possible benefit in psychotherapy of the proposed interpersonal sensitivity and emotional openness of female therapists is a more easily and highly developed therapeutic alliance. Marziali, Marmar, and Krupnick (1981) in their review of the theoretical literature comment that "consistent in these writings is the belief that the work of therapy cannot proceed in the absence of a constructive therapeutic alliance." Luborsky (1976) in constructing a set of signs used to characterize the helping alliance defined the alliance as being composed of two parts: "Type 1: A therapeutic alliance based on the patients experiencing the therapist as supportive and helpful 14 with himself as recipient. Type 2: A therapeutic alliance based on a sense of working together in a joint struggle against what is impeding the patient" (p. 94). In much the same way, Holberg (1977) describes the therapist's part of the therapeutic alliance as involving "gaining the patients confidence, arousing expectations of help, motivating the conviction that the therapist wishes to work with the patient and is able to do so, motivating the patient to accept the conditions of therapy, and clarifying misconceptions" (p. 44). The hypothesis certainly presents itself that the combination of sensitive nurturant and tough analytic traits and high empathic skills proposed to be present in the female therapist would be especially useful in facilitating the relationship described above. However, the only data relating directly to gender differences in the therapeutic alliance comes from the study previously described by Jones and Zoppel (1982). They factor analyzed a 38 item interview based on Strupp's Post Client Questionnaire given to 99 clients. Five factors were derived: Therapeutic Alliance, Formality/Detachment, Emotional Intensity, Therapist Neutrality, and Negative Experience. Therapeutic Alliance accounted for 68% of the variance. Over six times as much as the next highest factor. According to Jones and Zoppel "this factor appeared to tap aspects of the therapist's personal stance or attitude toward the client as well as elements of intervention technique. It gauges therapist interest in, acceptance of, and respect for the client, as well as the extent to which his or her manner was warm and attentive. Clients who received higher scores on this factor were less likely to feel uncertain about their therapist's feelings toward them, and less frequently felt they were just another 15 patient. Also included in this factor were items reflecting the degree of client trust in the therapist, the therapist's selection of relevant material for discussion and his or her activity level and under- standability" (p. 267). Jones and ZDppel found that female therapists and their clients scored significantly higher on this factor than the male therapists and their clients. In addition the therapeutic alliance factor significantly correlated with several measures of successful outcome. Unfortunately, this measure of therapeutic alliance was taken post therapy (the authors do not state how much time elapsed before rating) and only from the client's point of view. The outcome ratings with which this factor was correlated were also client self report. Therefore a good deal of subjectivity may have entered into the process and a halo effect may be in evidence. One bit of supporting evidence for the results of therapeutic alliance from the client's point of view is that female therapists reported having better working relationships with their clients on the Post Therapy Therapist's Questionnaire. Two other studies relate to the foregoing discussion. Marziali, Marmar, and Krupnick (1981) and Morgan, Luborsky, Crits-Cristoph, Curtis, and Solomon (1982) related therapeutic alliance to psychotherapy outcome with essentially the same results. Both studies used therapy process scales rated by outside observers which broke down the therapeutic alliance measures into the therapist and patient components. In the Morgan et al. study, the therapist is rated for such characteristics as warmth, supportiveness, hopefulness, wanting the patient to achieve their goals, and conveying a sense of 16 rapport and feeling of acceptance. They are also rated for a sense of working together with the patient and the patient's being increasingly able to deal with his problems. The patient is rated for his experiencing of these dimensions. The Marziali et a1. research essentially rated the same dimensions as well as negative therapist behavior such as harsh criticism, and negative patient behavior such as attacking hostility. In both studies the measures of the patients perception of the therapeutic alliance significantly discriminated between more and less improved patients. In the Morgan et al. study it proved to be as good if not better than the best predictors of successful outcome of the 57 pretreatment variables used. This gives added support for the results obtained by Jones and Zoppel from their client rated results. However, results based on actual therapist behavior was much more equivocal. In the Marziali et al. study therapist behavior on the therapeutic alliance scale did not discriminate the unsuccessful from successful outcome groups. In addition there was only a nonsignificant .27 correlation between therapist behavior and the patient's experience of a therapeutic alliance. Therapist behavior in the Morgan et a1. study tended to show differences between the more versus less improved cases that were in the same direction as the helping alliance scores derived from patient behavior but did not reach statistical significance. Therapist behavior, however, was correlated significantly with one of two composite scores used as a outcome measure. In addition therapist behaviors and patient behaviors on the helping alliance scale were highly correlated (r's ranged from .50 to .85 for different parts of the scales). 17 These data do not present a clear picture of the relationship between therapist behaviors that facilitate a therapeutic alliance, the client's perception of the alliance and therapy outcome. From the Morgan et a1. research one possible conclusion is that therapist behaviors have an effect on how the client perceives or experiences the therapeutic alliance but the most important aspect in terms of therapy outcome is ultimately the client's perception of his experience. This may depend on the therapist or it may depend on the client's abilities to interact with the therapist in a way that would allow the therapist's behaviors to have an impact. According to the Marziali et a1. study the latter would be the most important. Authority There are few if any studies which investigate the relationship between aspects of helping behavior which are possible strengths for male therapists and the therapeutic relationship. Abramowitz, Abramowitz, and Heitz (1976) suggest that although the female may have an advantage in empathy the male in our culture has a greater degree of authority which serves to cancel out any differential efficacy in therapy outcome. There is one study that bears on this suggestion. Goldberg (1978) in dissertation research showed mock therapy seSsions to 244 graduate and undergraduate students. There were two independent variables with two levels each: Responsiveness (responsive and unresponsive), and gender of the therapists. After reviewing the sessions students rated the therapists on a semantic differential and a questionnaire. Male therapists regardless of the therapy version were seen as more of an authority figure than were female therapists. 18 In summary, although there was no evidence of differential effects on therapy outcome due to gender in the pre 1970 literature, two later studies found female therapists to achieve more successful outcome. This trend does lead to the hypothesis that female therapists may be more successful than their male counterparts. Theoretical and empirical evidence was presented supporting the reason female therapists may be more successful in that they combine sensitive, nurturant traits with tough-analytic ones and may be more empathic and thus generate a stronger therapeutic alliance. However, the data related were from an analogue study and one which did not directly tap therapy process but instead relied on post therapy client reports. Although no data is available in the literature, theory suggests that male traits of field independence and skills in restructing data to come up with new solutions facilitate a style of therapy whose main strength is a reality, coping orientation. It is also suggested that our culture invests males with more authority than females. The current study proposes to examine the therapist patient relationship through direct observation of therapy process to determine the effects of these gender traits on therapy outcome. Client Gender Outcome Studies The next major question to be addressed is whether there are differences in therapy outcome and process for client gender irrespective of interactive effects (i.e., as a main effect). As with therapist gender there is not a great deal of literature bearing on the subject. In terms of outcome in reviews of the l9 pre 1970 literature Meltzoff and Kornreich (1970) reported 11 studies in which no differences were found, three studies in which female clients were more successful, and three studies in the behavior therapy literature (reported as incidental findings) in which male clients were more successful. Meltzoff and Kornreich concluded that females did slightly better in therapy, except in behavior therapy. Luborsky et al. (1971) reported five studies in which male and female clients were about equal, no studies in which male clients were more successful, and two in which female clients were more successful. In one of the two studies in which female clients were more successful (Mintz, Luborsky, and Auerbach, 1971) client gender correlated much more highly with treatment outcome and client satisfaction r = .50 (as measured by global therapist ratings) than three of the four factors (Optimal Empathic Relationship, Directive Mode, Patient Health versus Distress, and Interpretive Mode with Receptive Patient) derived from 26 demographic and process variables. In the multiple correlation of these factors with success and satisfaction the overall increment due to the four factors over gender alone was not significant. Thus, there appeared to be, as Meltzoff and Kornreich suggested, a slight trend toward more success for female clients in psychotherapy in the research prior to 1972. There is some indication of a continuation of this trend in the 1980 review of the literature by Smith, Glass, and Miller using meta-analysis. They found a -.13 correlation between the percentage of males in the client sample and positive therapeutic outcome. This was second only to reactivity of measurement in the strength of the correlation out of 17 variables analyzed including client IQ and age, 20 therapist experience, internal validity of the study, and duration of therapy among others. Although the correltation is statistically significant considering the number of observations (1,425), the clinical significance of such a small amount of variance accounted for is somewhat questionable. In addition Smith et a1. point out that this correlation may have been inflated by predominantly female groups of high social and educational levels treated for anxiety and assessed with highly reactive instruments. Nonetheless, these results are consistent with previous reviews. The two studies listed in the previous section which found greater success for female therapists (Kirshner et al., 1978, and Jones and Zoppel, 1982) also report differential effects for client gender. Kirshner et al. report significantly higher self rated improvement by female clients in attitude towards career. Nonsignificant trends were found in the same direction for academic motivation, academic performance, and family relations. Male clients did not report greater improvement then females in any area. Although therapists rated their clients on the same scales, there is no report of similar ratings from the therapists' point of view. Therapists did tend to report more satisfaction with female clients, which may in some way be related to more successful outcome. In the Jones and Zoppel study, female clients rated themselves as improving more than men in their ability to enjoy life, to handle personal problems, and in overall happiness. Again male clients did not rate themselves as more improved than the female clients on any of the scales. As reported earlier, however, correlations between therapist and client point of view tended to be small and 21 nonsignificant on the particular scales (correlations for the three scales reported above were .29, .20, and .15, respectively). Moreover as a main effect male and female clients were rated equally as having benefited from treatment. One other study was found which investigated the relationship of client gender in therapy outcome as a main effect. Barresi (1979) in dissertation research hypothesized that female clients would be more successful in psychotherapy. Ratings were obtained from clients, therapists, and supervisors of global outcome and specific target problems on 18 male and 21 female clients of 15 graduate level therapists. Barresi controlled for client age, personality, nature of therapy I concerns, diagnosis, previous therapy, pre therapy expectations, preference of therapist gender, and in therapy behavior. Therapist experience, orientation, preferences for client gender, and in therapy behavior were also controlled. Barresi found no significant differences in outcome for the genders. So as with therapist gender there is not an all out assault on ones sensibilities by the empirical evidence to suggest that one gender is always more successful than another in psychotherapy irregardless of interacting variables. However, again, the evidence that does exist suggests that female clients sometimes are more successful with the exception of strict behavior therapy. Client Gender Differences in Psychotherapy Process Can the elements that account for the trend outlined above be identified? In many ways much the same arguments could be made for female clients as were suggested for female therapists in the previous section. Role expectations dictate that girls will 22 experience a wider range of feelings and will be given more freedom to express them than boys, who are rewarded for emotional control (Carter, 1971). Indeed, Cartwright (1972) found that even professionally oriented women, who might be considered to have broken from traditional role expectations, and who valued independence and individuality, tended to display more sensitivity and acceptance of feelings than their male counterparts. Openness to affective experience, expression, and exploration is almost universally valued in psychotherapy and has been related to positive outcome (e.g., Luborsky, 1971). This openness to affective experience, and expression can be related to findings in three areas of the literature: direct measurement of in-session affect, self disclosure, and self exploration. Since, in each area increased affective awareness and expression could be expected to facilitate progress in therapy. Goldenholz's (1976) dissertation is relevant to all three areas of research. In obtaining 494 male and female clients of two community mental health centers pre-therapy expectations it was found that female clients, regardless of therapist gender, expected to discover and understand feelings and behavior more than the male clients. They also expected to talk more about their problems than male clients. Although there was no measure of whether they actually did so, female clients expected to express feelings, to self explore, and to self disclose more than the male clients. Actually, the amount of experimental research in these areas is scant. Fuller (1963), in a study with eight female and eight male clients at a university counselling center, found that regardless of 23 therapist gender female clients were found to have expressed more feelings both in intake and first counselling sessions. Fuller points out, however, that the amount of feeling statements were rated from case notes rather than directly from tapes. Although Fuller compared the case notes with a few of the tapes and found them to be fairly similar, the affective quality of the voice cannot be transmitted, a factor which may limit this procedure. In addition, males may be slower to express affect but do so later. Fuller measured only the first session. Contrary to Fuller's results, Hill (1975), in her university counselling center based study, did not find any main effects for gender in expression of feelings when measured by counting affective self referents directly from tapes. Again, however, Hill 'tapped only the second session, leaving open to question what happens in the rest of therapy. In terms of self exploration Hill did find that female clients were judged by raters to have explored feelings in greater depth than males, using Carkhuff's scale for depth of exploration. Since these ratings were also from the second session the same criticism as mentioned above is appropriate. There are no other studies on the subject. Brooks (1974), in a brief review of the literature of the effects of client gender on self disclosure, reported mixed results. One study found females u)be more self disclosing, another found the opposite, and a third reported mixed results. Brooks in her own study found no main effect for client gender in regard to self disclosure. All these studies, including Brooks', were analogue in nature which makes their validity questionable to begin with. 24 It is apparent that the body of process literature just reviewed does not provide much explanation for the ways in which female role expectations influence the therapy process. The experimental evidence provides only a slight suggestion that female clients may explore themselves in more depth than males. Other than that the evidence is contradictory and inconclusive. One other possibility is that female clients are more successful at forming and maintaining a therapeutic alliance. The theoretical literature in the previous section certainly suggests that woman are more interpersonally oriented and sensitive, whereas men are more individually oriented. In addition women are more field dependent and depend more one environmental cues for decision making. It was suggested that these qualities facilitate the forming of a therapeutic alliance on the part of the therapist. It follows that the same should hold true for female clients in the sense that female clients are able to work with the therapist in a trusting, affectively connected environment and make use of interpersonal support. In fact Goldenholz (1976) found that female clients, regardless of their therapist's gender, expected to build more meaningful relationships with their therapists than did male clients. There are no studies that experimentally examine this issue, with the exception of Jones and Zoppel (1982). They do not report any client gender differences in therapeutic alliance as measured by post therapy client self report. In summary, research indicates that female clients tend to be somewhat more successful in psychotherapy, perhaps with the exception of behavior therapy. From theoretical considerations one might expect more affective expression, self disclosure, and self exploration 25 from female clients to help account for the difference. The evidence is contradictory, with the exception of more self exploration by female clients, which was supported by one study. Theoretical consideration also suggest that female clients would be more adept at forming and maintaining a therapeutic alliance. The only study bearing on this issue did not confirm this expectation. Gender Combinations Outcome Studies The next logical area to be examined after the separate effects of therapist and client gender on psychotherapy process and outcome is the effects of gender combinations. As with the preceding sections there is a dearth of literature on the subject. In terms of outcome what little literature there is, that reports differences, with few exceptions favors same gender combinations. Male and female therapists in Geer's (1973) dissertation research treated 44 under- graduates with scores on the 80th percentile or above on the Suinn Test Anxiety Behavior Scale (STABS) with accelerated mass desensitization for three sessions. They were then tested again on the STABS. Ahtough a treatment effect was found in all groups, Geer reports that male therapists were significantly more effective than female therapists with male clients. Conversely, female therapists were more effective than their male counterparts with female clients, although this did not reach statistical significance. Blase (1979), also in dissertation research, asked 40 clients of 19 therapists from two outpatient clinics to fill out Client Perception Questionnaires among other measures. Results from the study indicate 26 that clients in same gender dyads were more satisfied with their treatment then clients in opposite gender dyads. Unfortunately, results from the MMPIs given in the study were too contaminated by methodological flaws to be interpretable. Barresi (1979) in the previously cited study at a university counseling center hypothesized that like gender dyads would be most successful. Barresi found some results in this direction. Clients rated therapy relationships significantly more favorably in like gender matches. Also, nonsignificant trends from client, therapist and supervisor ratings of global outcome and specific target problems indicated more favorable outcome for like gender matches. In a post hoc analysis Barresi separated clients into adjustment reactions and neurotic samples. Interestingly, it was found that like gender dyads were more successful in treating clients with adjustment reactions, but no differences were found for the neurotic sample. In other studies presented earlier (Goldenholz, 1976; Kirshner, Genack, and Hauser, 1978; Jones and Zoppel, 1982) there were very few outcome measures which showed differences among the various gender combinations. Goldenholz (1976) found no significant gender combination differences in outcome at the two community mental health centers studies. Kirshner et a1. (1978) found the interaction of therapist and client gender to be significant only when therapist experience was taken into account. Out of the possible gender interactions on each of 10 scales two significant results and one trend were noted. Female clients who saw senior (10-25 years of post training experience) male therapists reported significantly more main problem improvement than male clients of senior male therapists. 27 This is the only result found in the literature providing evidence for superiority of outcome for cross gender matches. Kirshner et al. also found that female clients who saw senior female therapists reported significantly more improvement in friendship with others than female clients who saw male therapists. Finally there was a trend of greater improvement in self acceptance in female clients who saw senior female therapists. The few findings due to gender combinations reported by Jones and Zoppel (1982) are congruent with two of the three results from Kirshner et a1. listed above in that like gender pairs with female participants account for the outcome differences. Jones and Zoppel found that female therapists rated their female clients as significantly more improved in symptoms, ability to enjoy life, relationships with spouse and children, and relationships with others than did male therapists. Unfortunately, client ratings did not parallel these differences. Hhat scant outcome literature is available suggests that like gender pairings achieve somewhat more successful results. Moreover a few studies suggest that female therapist/client dyads tend to achieve the best outcome when differences are found. The next important step is to review studies which have investigated process variables which might account for these trends. Most of the literature in this regard has to do with the differential effects of therapist gender with female clients. 28 Gender Combination Differences in Psychotherapy Process Howard, Orlinsky, and Hill (1969) had 28 female clients and therapists fill out the Therapy Session Report which tapped feeling processes, and the therapeutic relationship among other things from both viewpoints. The clients were between 20 and 40 years old, highly educated, 85% of whom suffered from neurotic or personality disorders. Therapists were psychiatrists, psychologists, and psychiatric social workers at a community mental health center, with a mean of six years experience. The authors found that male therapists reported a relatively greater frequency of unpleasant and personal feelings as opposed to professional feelings (e.g., intimate, attracted, playful, inadequate, preoccupied, detached, withdrawn, bored, angry, dull, etc.) They factor analyzed the feeling items for the therapist sample into nine factors: Feeling Good, Uneasy Intimacy, Disturbing Sexual Arrousal, Withdrawn versus Involved, Intent versus Calm, Sense of Failure, Suffering, Resigned, and Nurturant Warmth. There was a significant different on three of the factors between male and female therapists. Male therapists felt more Uneasy Intimacy, more Withdrawn, and more Resigned than their female counterparts. Howard et al. drew several interesting conclusions when they analyzed the therapists responses in interaction with factor analyzed dimensions of client experiences. There was a tendency for female therapists to respond to more of the client experience dimensions than did male therapists indicating a "more sensitive and responsive (attitude) to the emotional expressive components of the relationship." In contrast, Howard et a1. hypothesized that male therapists became professional rather than giving emotional 29 support since male therapists experienced little Nurturant Warmth or Intimacy when female clients were going through Painful Self Exploration. Howard et al. also suggested that there was more evidence for identification between all female dyads than when a male therapist was involved, since female therapists responded with relatively more Involvement when female clients were showing CDllaborative Involvement. Howard at al. buttressed this observation with the fact that female therapists reacted more positively to Positive Transference thus "positive feelings of female therapists match their clients." Perhaps as much as identification these observations point to a strong therapeutic alliance. Orlinsky and Howard (1976) reanalyzed the Therapy Session Report data described above collected from 118 women in outpatient psychotherapy in 1964. Clients' ages in this study ranged from 18 to 60 years old, 47% were married, and 78% were employed. Forty six dimensions were identified using factor analysis. Each client was scored for each dimension for at least eight sessions and a mean was derived. Fifteen significant differences were found for clients of male and female therapists. Clients of male therapists felt more eroticized affection, anger, inhibition, and depression. They saw their therapists as being more demanding, more detached, and less expansive. Clients of male therapists saw themselves in treatment as being less self possessed, less open, more self critical, and getting less encouragement. However, there were no significant differences in reported levels of catharsis, mastery, insight, or overall experienced benefit. Orlinsky and Howard concluded that although female clients found 30 their therapeutic experience to be less supportive with a male therapist, they did not report it to be less beneficial. Orlinsky and Howard divided their sample by age and marital status. Interestingly, they found that the group that reported the greatest differences in experiences due to therapist gender were "Young Single Women" (18 to 22 years old), and "Single Women" (23 to 28 years old). Both groups experienced the lack of support and emotional openness of male therapists and their reaction to it listed above. Single Women were the only group that reported clear differences in their experience of benefit and increased mastery and insight; experiencing more with a female therapist. Orlinsky and Howard conclude that men have the most emotional significance for unmarried women in the 23 to 28 year old age group in that society fully expects women in this group to be married. The fact that the data of the last two studies are 20 years old and that there are no direct observations to corroborate the self report aside, there as some strengths in the data. Therapist and client reports tend to buttress one another. In dyads with a male therapist both parties report feeling less comfort in the relationship. Male therapists report feeling more detached, withdrawn, and bored. Their female clients experience this. Clients may very well be reacting by drawing the negative conclusions about themselves that they report in the second study. These trends in the data as well as the interaction between involvement dimensions of female therapists and clients in the first study provides some evidence to indicate that there may be a stronger therapeutic alliance between dyads with all females than in dyads with a male therapist. It is significant to note however that 31 with the exception of women in the 23 to 28 year old age group there is no evidence that the differences noted in the relationship produce a difference in experienced benefits. In line with the last two studies cited Barresi (1979) in the dissertation research previously related found that female clients with female therapists rated themselves as most comfortable in therapy while individuals in the female client/male therapist group were on the other end of the continuum. Notably there were no differences in outcome between the dyads as a function of the differences in comfort level. From the theoretical and empirical literature noted in the first two sections that women are more emotionally open and sensitive to feelings in others (Cartwright, 1972; Carter, 1971) one might expect these qualities to be present most in female client/female therapist dyads and to some extent in dyads with one female. There is a kernel of evidence to support this. In the Jones and Zoppel (1982) study one of the factors isolated in the factor analysis of the Post Client Questionnaire was Emotional Intensity. Examples of items correlating highest with this factor were: My therapy was a very emotional experience, My therapy was often a very painful experience, On the whole I experienced very little feeling in therapy (negatively correlated), and An important topic in treatment was my childhood experiences. 'This factor seems to tap emotional, sometimes painful self exploration possibly of childhood experience. Although not significant, there was a strong trend for clients in the female client/female therapist dyads to score higher on this set of items. Congruent with the rest of the results presented in this section Fuller (1963) in her counseling center study rating therapist notes 32 found that client/therapist pairs including a female expressed more feelings in the first counseling session. And Brooks (1974) reported in an analogue study using the Revealingness Scale (measuring internal and self involvement versus external and distant content) that psuedoclients in dyads containing a female self disclosed more than all male dyads. Finally, Hill (1975) in her study directly tapping therapy process through audiotapes of the second session of counselling found that both experienced and inexperienced counselors were most empathetic and focused most on feelings with like gender clients. However, where inexperienced therapists were most active with like gender clients, experienced therapists were most active with opposite gender clients. The findings of Hill are inconsistent with those of Fuller (1963) who found cross gender pairings to express more feelings than all male dyads. In summary, sparse outcome studies of gender combinations that show differential findings tend to point to an advantage for like gender pairs and all female pairs in particular. Process research in this area is slightly imbalanced because two of the more enlightening studies (Howard, Orlinsky, & Hill, 1969; Orlinsky & Howard, 1976) used only female clients. However from the available studies it appears that all female dyads engender a more comfortable, open, involved relationship, especially in the 18 to 28 year old age group. Although no data exists on the subject this would suggest a stronger, more intense therapeutic relationship. Only one study (Jones and Zoppel, 1982) has related this to more positive outcome. 33 Summary Trends exist in the literature on gender effects in psychotherapy which suggest that female therapists tend to be slightly more successful, that female clients tend to be slightly more successful, and that like gender pairs, especially all female dyads, tend to have the most success. Although there is theoretical rational that would tend to predict these results, empirically they rest on a few studies that have some methodological difficulties. The purpose of the present research is to investigate these trends from both therapist and client viewpoints, integrating a variety of outcome measures. Process research and theoretical considerations indicate that the trends described above may be explained on the basis of the strength of the therapeutic alliance, emotional sensitivity and openness in the interaction, and depth of self exploration. These process variables will be investigated using client and therapist viewpoints, as well as observers ratings of the therapy process. HYPOTHESES As discussed in the review of the literature, evidence to date (Meltzoff & Kornreich, 1970; Smith & Glass, 1980; Luborsky, Auerbach, Chandler, Cohen, & Bachrach, 1971) suggests that gender composition of the dyad is related to psychotherapy outcome. Clients of female therapists have been shown to have more positive therapeutic outcome than clients of male therapists. Female clients in general have been shown to have more positive outcome than male clients regardless of the sex of the therapist. In addition the literature also suggests (e.g. Kirshner, Genack, & Hauser, 1978; Geer, 1973; Blase, 1979) that same sex dyads have more positive psychotherapy outcome and that the female therapist-female clients combination fares the best. This evidence leads to the following hypotheses. Hypothesis 1: Ho: There is no relationship between the gender of the therapist/client dyad and outcome in psychotherapy. Ha: There is a relationship between the gender of the therapist/client dyad and outcome in psychotherapy. Subhypothesis Ia: Ho: There is no difference in the outcome of psychotherapy between clients of male therapists and female therapists. ~ Hazl Clients of female therapists show more positive \.w psychotherapy outcome than do clients of male therapists. 34 35 Subhypothesis Ib: Ho: There are no differences in psychotherapy outcome _ between male and female clients. (:Hag Female clients have more positive psychotherapy outcome than male clients. Subhypothesis Ic: Ho: There are no differences in psychotherapy outcome between same sex and opposite sex dyads. 'Hai) Same sex dyads have more positive outcome than opposite sex dyads. Subhypothesis Id: Ho: There are no differences in psychotherapy outcome between female client/female therapist dyads and male client/male therapist dyads. 3 Ha:‘ Female client/female therapist dyads have more positive outcome than male client/male therapist dyads. Since both Marzialli et a1. (1981) and Morgan et al. (1982) found a positive therapeutic alliance associated with positive psychotherapy outcome, a basis for the following hypothesis is provided: Hypothesis 11: Ho: There is no relationship between the therapeutic alliance and psychotherapy outcome. Ha: There is a positive relationship between therapeutic alliance and psychotherapy outcome. 36 The literature also suggests a positive relationship between therapist warmth and empathy and positive psychotherapy outcome (e.g., See Luborsky, 1971) suggesting the following hypothesis. Hypothesis III: Ho: There is no relationship between therapist warmth and empathy and psychotherapy outcome. Ha: There is a positive relationship between therapist warmth and empathy and positive psychotherapy outcome. The next series of hypotheses concerns the gender composition of the dyad and therapy process. The review of the theoretical and empirical literature in the introduction points to the conclusion that the same pattern of results that holds for the different gender dyads in terms of psychtherapy outcome holds for the process variables of therapeutic alliance and therapist warmth and empathy Hypothesis IV: Ho: There is no relationship between gender composition of the therapy dyads and the level of therapeutic alliance. Ha: There is a relationship between gender composition of the therapy dyad and the level of therapeutic alliance. Subhypothesis IVa: Ho: There is no difference in the therapeutic alliance for dyads in which there is a male therapist and dyads in which there is a female therapist. Ha: 37 There is a greater therapeutic alliance in dyads with a female therapist than in dyads with a male therapist. Subhypothesis Ivy: Ho: Ha: There is no difference in the therapeutic alliance for dyads in which there is a male client and dyads in which there is a female client. There is a greater therapeutic alliance in dyads with a female client than in dyads with a male client. Subhypothesis IVc: Ho: Ha: There is no difference in therapeutic alliance between same sex and opposite sex dyads. Same sex dyads have a more positive therapeutic alliance than opposite sex dyads. Subhypothesis IVd: Ho: Ha: There is no difference in therapeutic alliance between female client/female therapist dyads and male client/ male therapist dyads. Female client/female therapist dyads have a more positive therapeutic alliance than male client/male therapist dyads. Hypothesis V: Ho: There is no relationships between gender composition of the therapy dyad and the level of therapist warmth and empathy. 38 Ha: There is a relationship between gender composition of the therapy dyad and the level of therapist warmth and empathy. Subhypothesis Va: Ho: There is no difference in therapist warmth and empathy for male and female therapists. Ha: Female therapists show more warmth and empathy than male therapists. Subhypothesis Vb: Ho: There is no difference in therapist warmth and empathy for same sex and opposite sex dyads. Ha: Therapists in same sex dyads show more warmth and empathy than therapists in opposite sex dyads. Subhypothesis Vc: Ho: There is no difference in therapist warmth and empathy in same sex dyads with a female therapist and same sex dyads with a male therapist. Ha: Female therapists in same sex dyads show more warmth and empathy than male therapist in same sex dyads. Jones and Zoppel (1982) found in their study that clients from female client/female therapist dyads reported more emotional intensity in the therapeutic relationship than did male clients in same gender dyads. They also found a positive relationship between emotional intensity of the dyad and positive psychotherapy outcome. This study will attempt to replicate these findings. 39 Hypothesis VI: Ho: There is no relationship between gender pairings and emotional intensity of the dyad. Hal: Female client/female therapist dyads show more emotional intensity than the other gender pairings. Ha2: Same sex dyads show more emotional intensity than opposite sex dyads. Hypothesis VII: Ho: There is no relationship between the emotional intensity of the dyad and psychotherapy outcome. Ha: There is a positive relationship between the emotional intensity of the dyads and positive psychotherapy outcome. Exploratory Hypotheses In addition to testing the hypotheses outlined above, another purpose of this study is to investigate in an exploratory fashion therapist behaviors that lead to a positive therapeutic alliance and positive outcome. As reported in the introduction Morgan et a1. (1982) found a positive correlation between therapist facilitory behaviors and therapeutic alliance. In addition they also found a near statistically significant relationship between these behaviors and positive outcome. As will be reported in the Methods section, one of the measures of the therapeutic alliance to be used in this study is the Vanderbilt Psychotherapy Process Scale (VPPS). The VPPS not only provides a measure of therapeutic alliance but also provides scales of Therapist Exploration, Therapist Directiveness, Therapist Warmth 40 and Friendliness, and Negative Therapist Attitude. Two of these scales, Therapist Exploration and Therapist Warmth and Friendliness, correspond quite closely to the therapist facilitative behaviors measured by Morgan et a1. Therefore one would expect these scales to be positively correlated with therapeutic alliance and positive psychotherapy outcome, suggesting the following exploratory hypotheses. Hypothesis VIII: Ho: Ha: There is no relationship between therapist exploration and therapeutic alliance. There is a positive relationship between therapist exploration and therapeutic alliance. Hypothesis IX: Ho: Ha: There is no relationship between therapist exploration and positive psychotherapy outcome. There is a positive relationship between therapist exploration and positive psychotherapy outcome. Hypothesis X: Ho: Ha: There is no relationship between the gender of the therapist and therapist exploration. There is a relationship between the gender of the therapist and therapist exploration. Hypothesis XI: Ho: Ha: There is no relationship between therapist warmth and empathy and therapeutic alliance. There is a positive relationship between therapist warmth and empathy and therapeutic alliance. 41 There is no data on the relationship between therapist directiveness, and therapist gender, therapeutic alliance, or psychotherapy outcome. However, one might hypothesize in a tentative way from Carter's (1971) arguments about the cognitive, problem solving orientation of male therapists combined with his role as an authority figure (Abramowitz, Abramowitz, & Weitz, 1976) that male therapists would be more directive than female therapists within similar orientations. Hypothesis XII: Ho: There is no relationship between therapist gender and therapist directiveness. Ha: Male therapists are more directive than female therapists. Hypothesis XIII: Ho: There is no relationship between therapist directiveness and therapeutic alliance. Ha: There is a relationship between therapist directiveness and therapeutic alliance. Hypothesis XIV: Ho: There is no relationship between therapist directiveness and psychotherapy outcome. Ha: There is a relationship between therapist directiveness and psychotherapy outcome. METHOD Subjects The subjects of this study were 65 clients of the Michigan State University Psychological Clinic who volunteered to participate in the ongoing collection of research data at the clinic. Provision of service at the clinic was in no way affected by a client's decision to participate in the research. The Michigan State University Psychological Clinic is an outpatient clinic serving a small metropolitan community and several outlying rural areas. The majority of the clients served by the clinic could be classified as neurotic (the clinic does not require a DSMIII diagnosis) although there is a fairly wide variation in symptomology including borderline and characterological difficulties, as well as a few ambulatory psychotic individuals. Any adult client (over 18 years old) was included as a subject for this study who had completed the pre and post therapy research mateials, for whom there were the necessary audiotapes available, and who had completed at least four therapy sessions. Of the 65 clients in this study, 22 (33.8%) were male and 43 (66.2%) were female. Forty two percent of the sample had never been married, approximately 22 percent were separated or divorced, and 35 percent were married, remarried, or living with someone. All but three clients had a high school education while 50 percent of 42 43 the sample had at least a bachelors degree. In terms of occupation the majority of the sample described themselves as working in sales or clerical-technical jobs. Twenty percent of the sample described themselves as managers, proprietors of medium size businesses or minor professionals. Eight percent stated they were executives, proprietors of a large concern or major professionals. Administrative personnel of a large concern, owners of small business and semiprofessionals comprised six percent of the sample. Skilled workers comprised five percent of the sample, semiskilled 11 percent and unskilled three percent. Fourteen percent of the sample were students and nine percent were homemakers. The age range of the sample was 30 to 57 with a mean of 29.4 and the standard deviation of 7.64. However, two clients in their 50's increased the mean slightly. The median age is 27.4 while clients modal age is 24. Seventy percent of the clients were under 30 years old while just 10 percent were over 40 years old. All but two clients were white. Clients participated in a mean number of 25 sessions with a standard deviation of 13.8. The range for number of sessions was between 4 and 81 sessions. Ninety percent of the clients participated in 10 or more sessions, 50 percent of the clients had 23 or more sessions, and 30 percent of the clients had 30 or more sessions. The 47 therapists in the study (30 male, 17 female) were students in the doctoral clinical psychology program at Michigan State University. Experience level ranged from beginning practicum students to students with two years of practicum and 2000 hours of internship. 44 There was one postdoctpral psychologist included in the study. Although no exact data on age was available, most if not all of the therapists were under 35 years old; all but two were white. The predominant orientation of the graduate program, and therefore the graduate students, was psychodynamic, although the client-centered and cognitive-behavioral orientations were represented. Clients and therapists were placed into one of four groups Male client-male therapist (MC-MT), male client-female therapist (MC-FT), female client-male therapist (FC-MT), female client-female therapist (FC-FT) according to gender. The n of each group was as follows: MC-MT had 14 clients and 14 therapists, MC-FT had 8 clients and 6 therapists, FC-MT has 25 clients and 16 therapists and the FC-FT group has 18 clients and 11 therapists. Since the clients were placed in groups purely on the basis of gender rather than randomly or in a matched fashion the possibility existed that the groups might differ significantly on any one of their demographic characteristics. Therefore, the groups were examined for differences in demographic characteristics using analysis of variance for the ordinal or ratio level variables (age, number of sessions, education) and chi square for the nominal level variables (marital status, occupation). There were no statistically significant differences (p < .05) between the four groups on any of the demographic variables. 45 Instruments Outcome Measures Three outcome measures were used in this study in order to examine outcome from multiple viewpoints: the Symptom Checklist 90R (SCL-90), the Post Therapy Client Questionnaire, and the Post Therapy Therapist Questionnaire. The SCL-90 (Derogatis, 1977) is a 90 item self report questionnaire which asks the client to rate themselves on a five point scale for 90 different symptoms. The 90 items have been factor analyzed resulting in nine symptom dimensions and three global indices. See Appendix A for the definitions of the symptom dimensions. Alpha coefficients range from .77 to .95 for the symptom dimensions multest retest reliability has been reported to vary from .78 to .90. In addition, good convergent validity and clinical sensitivity have been reported (Hankin, 1979). Since the SOL-90 was given pre and post therapy, this measure provided a good view of symptom change during therapy. Outcome data from the SCL-90 was used in two ways. First, the change in the Global Severity Index (GSI), which combines information on the number of symptoms and intensity of perceived distress was used as a measure of global symptom change. Second,change on the symptom dimension on which the client originally reported the most distress was evaluated as a measure of change in the main symptom area. Hopefully this dimension reflected more specifically the main problem area for which the client entered therapy. Both the Post Therapy Therapist and Client Questionnaires (Strupp, Lessler, & Fox, 1969) were developed as subjective self report measures designed to tap both the process and outcome of psychotherapy. The Client questionnaire was cluster analyzed into 10 dimensions, one 46 of which, labeled Amount of Change, is an outcome dimension. This dimension was used in this study as the measure of the client's subjective experience of therapy outcome. Items comprising this factor rated by the client are: benefit from therapy, satisfaction with therapy, amount of change as a result of therapy, symptom relief as a result of therapy. Intercorrelations of these items range from .58 to .91. Therapist subjective ratings of therapy outcome were measured using questions related to outcome from the Therapist Post Therapy Questionnaire. While no formal outcome scales parallel to the one developed from the Client Questionnaire had been developed, two items appeared to relate directly to outcome from a face validity standpoint; degree of symptomatic improvement and overall success of therapy. These items were to be intercorrelated. 0n the basis of the correlation, the items were to be summed or not summed based on the results. If the correlation was sufficiently high with a small confidence band the item scores were to be summed. If not they were to be used as separate measures of outcome from the therapist's point of view. Finally, the various outcome measures, the SCL-90 and the Therapist and Client Post Therapy Questionnaires,were to be intercorrelated. If the intercorrelations were sufficiently high, the outcome measures were to be summed into a composite index in order to maximize reliability. Process Measures Two process measures with multiple dimensions were used. The first is the Vanderbilt Psychotherapy Process Scale (VPPS) which is a "general purpose instrument for assessing significant aspects of two-person interaction in counselling or psychotherapy" (Strupp et al., 47 1983). It is reported to be neutral with respect to any particular theory of psychotherapy. This measure is from the viewpoint of an outside observer in that therapists and client behavior is rated from tapes of therapy sessions. Interrater reliabilities are reported as .79 for client items and .75 for therapist items. This 80 item measure has been factor analyzed into seven process scales: Patient Exploration, Therapist Exploration, Patient Participation, Patient Hostility, Therapist Warmth and Friendliness, Negative Therapist Attitude, and Therapist Directiveness. Two of these scales, Patient Participation c//” and Patient Hostility (inverted), have been combined by Gomes=Schwartz (1978) as a measure of Patient Involvement and used by Moras and Strupp (1982) as a measure qf:patient therapeutic alliance) Morasfiand Strupp describe Patient Involvement as an index of a patient's active participation, openness, trust in the therapist, and lack of hostility and negativism in the therapeutic interaction. See Appendix B for I the composition of the subscales. Thus, this measure 0f therapeutic alliance encompasses both a sense of rapport and trust, as well as a sense of working as a team to achieve the desired outcome; both of the dimensions tapped by Morgan et al's. (1982) Penn Helping Alliance Scale and Luborsky's original Helping Alliance Scale (Luborsky, 1976). It also gives the added advantage of measuring more specific behaviors than the Penn scale. Therefore the Moras and Strupp (1982) measure of therapeutic alliance was one of the measures used to tap that dimension in the study. The scale Therapist Warmth and Friendliness from the VPPS encompasses a variety of areas: warmth and friendliness, support of client's self esteem, level of empathy, level of therapist activity, level of involvement, optimism, and self disclosure. This 48 scale was used in this study as a rough measure of therapist warmth and empathy measured from an outside observer's point of view. The additional scales in the VPPS tapping therapist behavior (Therapist Exploration, Therapist Directiveness, Negative Therapist Attitude) were related to the outcome measures as well as the measures of therapeutic alliance in an exploratory fashion to examine whether those behaviors measured by the scales promote therapeutic alliance and positive outcome. The second multidimensional process measure that was used in the study is the Client Post Therapy Questionnaire (Strupp, Fox, & Lessler, 1969). As reported in the introduction, the process questions of this instrument were factor analyzed by Jones and Zoppel (1982) into five factors: Therapeutic Alliance, Formality/Detachment, Emotional Intensity, Therapist Neutrality, and Negative Experience. The Therapeutic Alliance factor was used in the present study as a second measure of this dimension - in this case, from the client's subjective point of view. The Emotional Intensity factor was also analyzed in order to test the hypotheses concerned with differing levels of emotional openness due to dyad composition. Finally, the question "How would you characterize your working relationship with this patient?" from the Post Therapy Therapist Questionnaire was used as a measure of the therapist's experience of the therapeutic relationship. Procedure _ Clients at the Michigan State University Psychological Clinic were requested, as a matter of routine, to participate in the ongoing collection of research data at the clinic by the intake worker. 49 Participation was purely voluntary and did not have any effect on service delivery. If the client agreed to participate he/she was asked to fill out a packet of materials, including the instruments used in this study, prior to therapy, at the 18th session - if therapy required at least that number of sessions, and again approximately one week post therapy. Audiotapes of therapy Sessions were obtained for the first, third, and eighth and every subsequent fifth session until termination. As per the suggestion in the VPPS manual, 10 minute segments of the audiotapes were rated (Strupp, 1983). While Games-Schwartz found no differences in ratings of the VPPS as a function of the portion of the session rated, it is apparent from the work of Karl and Abeles (1969) that variables tapped by the VPPS would probably be most meaningfully measured in the middle 40 minutes of the therapy hour. Therefore, 10 minute segments were randomly chosen from the middle 40 minutes of the therapy hour for each client. In order to investiagte possible changes in therapeutic alliance as well as other pertinent process variables across sessions, the third therapy session was rated as well as the session closest to the two thirds point in therapy. In other words if therapy lasted 30 sessions, the third session and the session closest to the 20th session were rated. If there are no statisically significant differences between the intersession ratings they summed. Raters were four advanced clinical psychology graduate students. three of whom have completed at least 1000 hours of internship in addition to extensive practicum experience. The fourth rater was in advanced practicum. Reliabilities were obtained by pairing the 50 raters and establishing reliability for each pair. Each pair rated five of the same segments to establish initial reliability. Then after five sessions of individual rating each pair rated two of the same segments. This pattern continued until each pair had rated 65 segments in order to prevent slippage in interrater reliability. Statistical Analysis There are three types of variables that were used in the statistical analysis in this study; demographic, process, and outcome. The demographic variables are client and therapist gender. The outcome variables were from three sources. The first was the Symptom Checklist 90 which provided a measure of change of the major presenting symptom dimension and a measure of change of the global distress level of the client. The second source, the Post Therapy Client Questionnaire, provided a subjective measure of change from the clients point of view. The third source, The Post Therapy Therapist's Questionnaire, provided a subjective measure of change in the client from the therapist's point of view. The process variables that were used in the study were from two sources. The Vanderbilt Psychotherapy Process Scale (VPPS) was used as an objective, observer rated instrument, to measure therapeutic alliance and the therapist behaviors directiveness, exploration, warmth and empathy, and negative attitude. Since the VPPS was rated at two points across sessions the VPPS provided two measures of these variables across time as well as change score. Finally, the second group of process measures that were used in the study were the factors of Therapeutic Alliance and Emotional Intensity isolated from the Post Therapy Client Questionnaire by 51 Jones and Zoppel (1982). These factors provided measures of therapeutic alliance and emotional intensity as rated from the subjective viewpoint of the client. The statistical analysis was comprised of two main parts. The first was a correlation matrix consisting of all the variables listed above which provided a measure of the interrelationship between a variable and each of the others. In the second main part of the analysis there was an attempt to form separate clusters of the outcome and process measures in order to increase reliability. The clusters were formed by inspecting the correlation matrix for variables that have unique high intercorrelations within a given set. Them multiple regression was used to predict the outcome clusters from the process clusters and dyad gender. When no statistically and theoretically meaningful clusters were found variables were used separately in the regression equations. RESULTS Reliability of Ratings of the Vanderbilt Psychotherapy Process Scale (VPPS) As stated in the method section, the four raters were combined into groups of two for purposes of calculating reliabilities. Pair A had a mean reliability of .82. Fourteen reliability estimates were taken with the range being from .62 to 1.00. Pair 8 was more consistent over the rating period with a mean of .82 and a range between .69 and .86. Tests of the Hypotheses Hypothesis I: There is a relationship between the gender of the therapist/client dyad and outcome in psychotherapy. Types of outcome measures (see Table 1). There are three types of outcome measures. The first are objective measures of symptom change from the SCL90 (Derogatis, 1977). Clients filled out the SCL90 pre and post therapy. The change measures were derived by subtracting the post SCL90 from the pre SCL90. Two change measures were calCulated from the SCL90. One was the measure of change from the symptom dimension on which the client initially reported the most distress. The second was change for the distress level on all 90 symptoms tapped by the SCL. The second measure of outcome was the therapist subjective report of client change taken from the Post 52 53 Therapy Therapist Questionnaire (Strupp, Lessler, & Fox, 1969). This measure (PTQ) consisted of two questions, the first one tapping symptom change and the second tapping overall success. Since the correlation between these two questions was highly significant (r = .73, p < .001) they were combined into one global score. The third measure of outcome was from the client's subjective point of view and was measured by the Client Post Therapy Questionnaire (Strupp, Lessler, & Fox, 1969). The Post Therapy Client Questionnaire (PCQ) measure of change is comprised of four questions tapping client overall benefit, satisfaction, total amount of change, and symptom relief. Correlations between these items ranged from .41 to .73. Since all intercorrelations were significant at the .001 level, these questions were also combined into a total composite index. Subhypothesis A: Clients of female therapists show more positive psychotherapy outcome than do clients of male therapist. Measures of symptom change (SCL90). The following findings suggested trends toward more positive outcome for clients of female therapists. On the change measure for the symptom dimension showing the most initial distress (SYM) clients of female therapists showed a trend towards more positive change (r = .20, p < .066). However C the same relationship did not hold up for the global change measure, GSIa(ru= .07, p < .30). Since the initial level of SYM and 651 were both highly correlated with their respective change scores (SYM r = .54, p < .001 and 651 r = .65, p < .001), partial correlations between dependent variables and change scores were calculated. The 54 relationship between therapist sex and SYM was lowered slightly when the initial level of SYM was partialled out (r = .18, p < .083) with the same trend for clients of female therapists to fare slightly better. Since male therapists tended to have more sessions with their clients than female therapists (r = .23, p < .066, mean for male therapists 26.35, mean for female therapists 20.84), number of sessions was partialled out along with initial symptom level. The partial correlation between therapist sex and SYM, indicating an advantage for clients of female therapists, was raised slightly (r = .20, p < .066). On a five unit scale which went from O, denoting none of a particular symptom, to 5, denoting an extreme amount of that symptom, mean change in SYM for clients of female therapists was 1.19. The mean change in SYM for clients of male therapists was .87. Therapist subjective measure of outcome (PTQ). Correlations between PTQ and therapist sex did not reach the .05 level of significance. (For correlations not reaching the .05 level of significance not mentioned in the text see Appendic C.) Client subjective measure of outcome (PCQ). Only one of the four questions from the PCQ differentiated between therapist genders. Opposite from predictions, clients reported more satisfaction when seeing a male therapist then when seeing a female therapist (r = .21, p < .049). However, when number of sessions was taken into account the correlation was reduced to .16 (p < .11). Subhypothesis B: Female clients have more positive outcome than male clients. 55 SCLQQ, As predicted female clients showed more positive symptom change on both measures (SYM r = .27, p < .02 and 651 r = .32, p < .006). When initial levels of SYM and 651 were partialled out the correlations were lowered slightly (SYM r = .20, p < .065 and 651 r = .28, p < .015). The mean change in SYM for female clients was 1.28 while the mean change for males was .78. The mean Change in 651 for females was .72 and for males was .31. £19, Correlations between PTQ and client sex did not reach the .05 level of significance. PCQ, Correlations between PCQ and client sex did not reach the .05 level of significance. Subhypothesis C: Same sex dyads have more positive outcome than opposite sex dyads. sgtgg, Results from the SCL90 were in the opposite direction from predictions for clients of male therapists on 651. Female clients of male therapists fared better than did their male clients (r = .35, p < .035 and 651 with initial level partialled out r = .34, p < .017). The mean for female clients was .70. The mean for male clients was .27. Correlations of SYM with same versus Opposite sex dyads did not reach the .05 level of significance. £19, Correlations between PTQ and same versus opposite sex dyads did not reach the .05 level of significance. PCQ. Correlations between PCQ and same.versus opposite sex dyads did not reach the .05 level of significance. 56 Subhypothesis 0: Female client/female therapist dyads have ‘more positive outcome than male client/male I i therapist dyads. Sngg, All female dyads did show more positive change on both symptom change measures (SYM r = .45, p < .006 and GSI r = .38, p < .017). These correlations were not appreciably altered when initial level of symptom and number of sessions were partialled out (SYM r = .41, p < .016 and GSI r = .36, p < .028). However, this finding loses some meaning in context of the results that in general female clients showed more positive symptom change. P19, Contrary to the symptom change measures from the SCL90, female therapists reported on the PTO that their male clients showed more symptom change than did their female clients (r = .44, p < .02). No other correlations between the PTQ and sex of same sex dyads reached the .05 level of significance. PCQ, None of the correlations between PCQ and sex of same sex dyads reached the .05 level of significance. Hypothesis II: There is a positive relationship between therapeutic alliance and psychotherapy outcome. Measures of therapeutic alliance (see Table 1). There are three measures of therapeutic alliance in this study. The first, as described in the method section, was derived through factor analysis of the PCQ I by Jones and Zoppel (1982). The second was derived from the VPPS (Moras & Strupp, 1982). Ratings of therapeutic alliance taken with the VPPS were rated at the third session, and two thirds of the way Table 1 57 Abbreviations SCL90 SYM GSI PCQ PCQTA PTQ VPPS VPPSTA HORKREL Symptom checklist tapping 90 different symptoms, organized into 9 different symptom dimensions Symptom dimension of the SCL90 on which the client reported the most initial distress Index of severity of all 90 symptoms tapped by the SCL90 Client's subjective report of psychotherapy outcome from the Post Therapy Client Questionnaire. Consists of four questions: benefit from therapy, satisfaction with therapy, change as a result of therapy, and symptomatic improvement Measure of therapeutic alliance derived from the Post Therapy Client Questionnaire Therapist subjective report of psychotherapy outcome from the Post Therapy Therapist Questionnaire. Consists of two questions: degree of symptomatic improvement and over success in therapy Vanderbilt Psychotherapy Process Scale. Eighty item scale factor analyzed into seven process dimensions Therapeutic alliance measure derived from the VPPS Therapist's rating of the working relationship taken from the Post Therapy Therapist Questionnaire 58 through therapy. In addition a change measure for this variable was calculated by subtracting the third sessions scores from the scores of the session two thirds of the way through therapy. The third measure is a question taken from the PTQ which asks the therapist to rate the working relationship with the client. Results (see Table 2). 1. Therapeutic alliance measure from the PCQ (PCQTA) a. With the SCL90. Correlations between PCQTA and the “’ symptom change measures from the SCL90 did not reach significance at the .05 level. With the PTQ. The correlation between PCQTA and the combined index from the PTQ was .42 (p < .001), providing support for the hypothesis. With the PCQ. The correlation between PCQTA and the combined index form the PCQ was .48 (p < .001), also providing support for the hypothesis. 2. Therapists rating of the working relationship (WORKREL) a. With the SCL90. The correlation between the therapist's rating of the working relationship and 051 was .32 (p < .008), also providing support for this hypothesis. However, the correlation between the therapist's rating and SYM was not significant at the .05 level. With the PTQ. The correlation between the therapist's rating of the working relationship and the combined index from the PTO was .74 (p < .001), indicating in the least that therapists were consistent in their ratings of process and outcome. 59 Table 2 Relationships Found Between Therapeutic Alliance and Outcome A. PCQTA 1. With PTQ r = .42 p < .001 2. With PCQ r = .48 p < .001 B. WORKREL 1. With GSI r = .32 p < .008 2. With PTQ r = .74 p < .001 3. With PCQ r = .54 p < .001 C. VPPSTA l. VPPSTA rated two thirds of the way through therapy a. With SYM r .26 p < .04 .18 p < .09 b. With GSI r 2. VPPSTA change from the third session to the session two thirds of the way through therapy a. With SYM r .26 p < .04 b. With GSI r .22 p < .047 60 c. With the PCQ. The correlation between the therapist's rating of the working relationship and the combined index from the PCQ was .52 (p < .001). 3. Therapeutic alliance measure from the VPPS (VPPSTA) a. With the SCL90. Although correlations between the SCL90 and the VPPS rated in the third session did not reach the .05 level of significance, VPPSTA rated two thirds of the way through therapy did correlate with SYM at the .05 level (r = .26, p < .04) and showed a trend in it's correlation with GSI (r = .18, p < .079). In addition, positive change in VPPSTA from the third session to the session two thirds of the way through therapy had correlations whose significance did reach the .05 level (SYM r = .26, p < .04 and GSI r = 22, p < .047). b. With the PTQ. None of the correlations between the VPPSTA and the PTO reached the .05 level of significance. C. With the PCQ. None of the correlations between the VPPSTA and the PCQ reached the .05 level of significance. Hypothesis III: There is a positive relationship between therapist warmth and empathy and positive psychotherapy outcome. Measures of therapist warmth and empathy. Therapist warmth and empathy were measured on the VPPS. Ratings were taken from the third session, two thirds of the way through therapy, and a change score was calculated by subtracting the former from the later. 61 Results. Correlations between therapist warmth and empathy and all the outcome measures did not reach the .05 level of significance. Hypothesis IV: There is a relationship between gender combination of the therapy dyad and the level of therapeutic alliance. Subhypothesis A: Therapeutic alliance is greater in dyads with female therapists than in dyads with male therapists. Correlations between therapist gender and all measures of therapeutic alliance did not reach the .05 level of significance. Subhypothesis B: Therapeutic alliance is greater in dyads with a female client than in dyads with a male client. As with therapist gender as a main effect, correlations between client gender and all measures of therapeutic alliance did not reach the .05 level of significance. Subhypothesis C: Same sex dyads have a more positive therapeutic alliance than opposite sex dyads (see Table 3). PCQTA, There was a trend for same sex dyads to have a more positive therapeutic alliance than opposite sex dyads (r = .19, p < .079). In particular female clients reported a greater therapeutic alliance with their female therapists than did male clients (r = .39, p < .03). A somewhat unexpected finding was that male therapists showed a strong tendency to have a more positive therapeutic alliance 62 Table 3 Summary of Results from Hypothesis III, Subhypothesis C: Same Sex Dyads Have A More Positive Therapeutic Allianpg_Than Opposite Sex Dyads l. PCQTA a. Same sex dyads has a more positive therapeutic alliance than opposite sex dyadsr = .19, p < .079. b. Female clients reported greater therapeutic alliance with female therapists than did male clients r = .39, p < .03. c. Male therapist had a greater therapeutic alliance with male clients than did female therapsts r = .41, p < .03. 2. WORKREL There were no statistically significant differences between same sex and opposite sex dyads for WORKREL. 3. VPPSTA a. Female client/female therapist dyads had a more positive therapeutic alliance than male client/female therapist dyads two thirds of the way through therapy r = .53, p < .004. 63 with their male clients than did female therapists (r = .41, p < .038). Whereas the tendency for female therapists to have a greater positive therapeutic alliance with their female clients than male therapists . was much less strong (r = .19, p, .114). Therapist rating of the working relationship (WORKREL). Correlations between this therapist rating and same versus opposite sex dyads did not reach the .05 level of significance. VPPSTA, Although the correlation between same versus opposite sex dyads and VPPSTA rated in the third session did not reach the .05 level of significance, VPPSTA ratings two thirds of the way through therapy showed same sex dyads to have a more positive therapeutic relationship than opposite sex dyads. As with PCQTA this finding appeared to be carried by the therapeutic alliance that female therapists had with their male and female clients. VPPSTA rated two thirds of the way through therapy was greater for female client/female therapist dyads than for male client/female therapist dyads (r = .53, p < .004). Change in_the VPPSTA was also greater for female client/ female therapist dyads than for male client/female therapist dyads (r = .36, p < .044). In addition there was a tendency for male therapists to be rated two thirds of the way through therapy as having a greater therapeutic alliance with their opposite sex clients than were female therapists. Subhypothesis 0: Female client/female therapist dyads have a more positive therapeutic alliance than male client/ male therapist dyads. 64 None of the correlations between sex of same sex dyads and therapeutic alliance reached the .05 level of significance. Hypothesis V: There is a relationship between gender composition of the therapy dyad and the level of therapist warmth and empathy. Subhypothesis A: Female therapists show more warmth and empathy than male therapists. The correlations between therapist gender and therapist warmth and empathy did not reach the .05 level of significance. Subhypothesis B: Therapists in same sex dyads show more warmth and empathy than therapists in opposite sex dyads. The correlations between therapist warmth and empathy and same versus opposite sex dyads did not reach the .05 level of significance. Subhypothesis C: Female therapists in same sex dyads show more warmth and empathy than male therapists in same sex dyads. As with the other subhypotheses in this section, correlations between gender of the therapist in same sex dyads and therapist warmth and empathy did not reach the .05 level of significance. Hypothesis VI: There is a relationship between gender ' .composition of the therapy dyad and the emotional intensity of the dyad. 65 The measure of emotional intensity. Emotional intensity was measured with a scale derived from the PCQ in a factor analysis by Jones and Zoppel (1982). Subhypothesis A: Same sex dyads show more emotional intensity than opposite sex dyads. Results indicate that, contrary to the prediction, clients of opposite sex dyads report more emotional intensity than clients of same sex dyads. Subhypothesis B: Female client/female therapist dyads show more emotional intensity than male client/male therapist dyads. Again, contrary to predictions, the all female dyads did not rate themselves as showing more emotional intensity than any of the other dyads. In fact, that dyad rated itself lowest, although not statistically significantly so at the .05 level. Hypothesis VII: There is a positive relationship between the emotional intensity of the dyad and positive psychotherapy outcome. §§Lgp, Correlations between emotional intensity of the dyad and the symptom change measures from the SCL90 did not reach the .05 level of significance. £19, The correlation between the PTO combined index and emotional intensity of the dyad was .46, p < .001. 66 £99. The correlation between the PCQ combined index and emotional intensity of the dyad was .34, p < .004. Tests of Exploratory Hypotheses Hypothesis VIII: There is a positive relationship between therapist exploration and therapeutic alliance. The measure of therapist exploration. Therapist exploration was measured using one of the scales of the VPPS. As with all the VPPS variables in the study, therapist exploration was rated in the third session, two thirds of the way through therapy, and a change score was calculated. PCQTA, The correlation between therapist exploration rated in the third session and PCQTA was negative (r = -.31, p < .011), while the correlation between PCQTA and the change in therapist exploration from the third session to the session two thirds of the way through therapy was positive (r = .24, p < .04). Therapist's ratingof the working relationship. Correlations between the therapist's rating of the working relationship and therapist exploration show essentially the same pattern as reported with PCQTA. The correlation for the third session although not statistically significant was negative (r = -.l4, p < .157). The correlation with the change in therapist exploration from the third session to the session two thirds of the way through therapy was positive (r = .28, p <.018). In general, it appears that an increase in therapist exploration from the third session to the session two thirds of the way through therapy was associated with positive subjective ratings of therapeutic alliance by both the client and the therapist. 67 Hypothesis IX: There is a positive relationship between therapist exploration and positive psychotherapy outcome. SQLQQ, Correlations between the symptom change measures of the SCL90 and therapist exploration did not reach the .05 level of significance. £19, The correlation between therapist subjective rating of symptom change and therapist exploration did not reach the .05 level of significance. However, the correlation between change in therapist exploration and the therapist rating of overall success was .29 (p < .016). This finding essentially parallels the finding of a positive correlation between change in therapist exploration and the therapist's and client's experience of a positive therapeutic relationship. £99, The correlation between the client's rating of benefit from therapy and therapist exploration in the session two thirds of the way through therapy was .25, (p < .024). The correlation between the clients rating of overall change from therapy and change in therapist exploration was .20 (p < .062). Again these findings parallel those reported above. Hypothesis X: There is a relationship between gender of the therapist and therapist exploration. Correlations between therapist gender and therapist exploration did not reach the .05 level of significance. Hypothesis XI: There is a positive relationship between therapist warmth and empathy and therapeutic alliance. 68 Correlations between therapist warmth and empathy and all measures of therapeutic alliance did not reach the .05 level of significance. Hypothesis XII: Male therapists are more directive than female therapists. The measure of therapist directiveness. Therapist directiveness was measured using one of the scales from the VPPS. Therapist directiveness was measured in the third session, two thirds of the way through therapy, and a change score was calculated. Results. Correlations between therapist directiveness and therapist gender did not reach the .05 level of significance for both the third session and the session two thirds of the way through therapy. However, male therapists tended to change toward being more directive more than female therapists (r = .23, p < .036). That is change scores on directiveness were higher for male therapists than for female therapists. Interestingly, female therapists became less directive with their male clients (mean change in directiveness = -3.0) but changed only slightly with their female clients to be more directive (mean change in directiveness = .44). Male therapists became more directive for their female clients (mean change in (directiveness = 2.65) with little change with male clients (mean change in directiveness = .29). The mean directiveness rating overall was 9.9 with a standard deviation of 2.9. Hypothesis XIII: There is a relationship between therapist directiveness and therapeutic alliance. ./ 69 PC TA. Correlations between therapist directiveness and the PCQTA did not reach the .05 level of significance. Therapist ratingof the working relationship. The correlation between the therapist's rating of the working relationship and directiveness in the third session was .28 (p < .019). The correlation with therapist directiveness rated two thirds of the way through therapy was not significant at the .05 level, while the correlation with change in directiveness was -.25 (p < .032). Thus, it appears that therapists rated the working relationship as positive when directiveness was positive early in therapy but an increase in directiveness was associated with a decrease in the positive rating of the working relationship. VPP§IA, In a somewhat contradictory fashion VPPSTA was negatively correlated with directiveness both in the third session (r = -.22, p < .022) and two thirds of the way through therapy (r = -.30, p < .01). Hypothesis XIV: There is a relationship between therapist directiveness and psychotherapy outcome. §gpgp, Correlations between the SCL90 and therapist directiveness did not reach the .05 level of significance. PTQ, Therapist directiveness in the third session was positively correlated with the combined index from the PTO (r = .32, p < .007). However, positive change in therapist directiveness was negatively correlated with the same index (r = -.25, p < .032). Thus, it appears that from the therapist's point of view clients fare better when they have been directive early in therapy, but do not increase in direCtiveness over the course of therapy. 70 Egg. Correlations between the PCQ and therapist directiveness did not reach the .05 level of significance. Some Methdolpgical Issues Correlations between outcome measures. The correlation between client subjective rating of outcome (PCQ) and the therapist subjective rating of outcome (PTQ) was .65 (p < .001). However, the correlation of both measures with the symptom change measures from the SCL90 were much lower (Composite PCQ index with SYM r = .18, p < .083 and with GSI r = .23, p < .042. Composite PTQ index with SYM r = .12, p < .20 and with GSI r = .28, p < .022). In fact, in only one instance did the correlations between the specific questions on both the PCQ and PTQ asking for subjective ratings of symptom change and SYM or GSI reach the .05 level of significance (PTQ and SYM r = .14, p < .14, PTQ and GSI r .26, p < .03; and PCQ and SYM r = .12, p < .183, PCQ and GSI r .17, p < .091). The correlation between the specific questions regarding symptom change on the PCQ and PTQ with each other was somewhat higher (r = .38, p < .002). The correlation between the two symptom change measures from the I SCL90 was .87 (p < .001). This correlation is probably slightly i inflated in that the symptom index and the total measure may share anywhere from 6 to 12 items out of the total 90. So in general there appears to be two clusters of outcome measures; the subjective ratings of the client and therapist, and the symptom change measures of the SCL90. Correlations between measures of therapeutic alliance. The correlation between the therapist's rating of the working relationship and the client's report of the therapeutic alliance derived from the 71 PCQ by Jones and Zoppel (1982) was .39 (p < .003). However, the correlation between these measures and the therapeutic alliance measure from the VPPS did not reach the .05 level of significance. Thus, as with the outcome measures therapist and client subjective reports tended to agree with each other, but not with the more objective measure. Additional Findings Number of sessions. The correlation between number of sessions and PTQ was .28 (p < .05). The correlation between number of session and PCQ was .32 (p < .006). In addition, therapists tended to rate the working relationship as better when there were more sessions (r = .32, p < .007). Thus, subjective rating of outcome by the client, and process and outcome by the therapist, was related to length of therapy. Age of client. Interestingly, although age of the client did not show any relationship to any of the outcome measures, there was some relationship to two of the therapeutic alliance measures. According to the VPPSTA therapeutic alliance was negatively correlated with the client's age in the third session (r = -.22, p < .044). Whereas in the session two thirds of the way through therapy the reverse was true (r = .27, p < .016). There was also a trend for clients to rate the therapeutic alliance positively post therapy with increasing age on the PCQTA (r = .19, p < .077). It is as if, with increasing age, the therapeutic alliance started out more negatively but developed more. Therapist experience. There was a mixed bag of contradictory results in terms of therapist experience. On the VPPS more experienced 72 therapists were rated as showing more warmth and empathy (r = .29, p < .011), as being more directive (r = .33, p < .005), and as showing a more negative attitude (being intimidating, acting annoyed, confronting in a negative manner r = .23, p < .039). In addition, both symptom change measures from the SCL90 showed small, but statistically significant, negative correlations with therapist experience (SYM r = -.23, p < .038, and GSI r = -.21, p < .051); indicating that less experienced therapists helped produce more symptomIChange in their c1i6ht57 Male therapists in the study were somewhat more experienced than were female therapists. However, when the effect of therapist experience was partialled out the correlations between therapist gender and the outcome and process variables did not change appreciably. Accounting for Overall Positive Change in Psychotherapy Ratings of overall change §§£99. In general, all the outcome measures indicated that psychotherapy was a positive endeavor. On the symptom change measures from the SCL90 the change in SYM was significant at the .003 level (r = .38). The mean level for SYM pre therapy was 2.29 (5.0. = .85), which resides between quite a bit (3) and a moderate amount (2) of the particular symptom dimension. The mean post therapy level for SYM was 1.25 (5.0. = .85), residing between a moderate amount (2) and a little bit (1) of the symptom dimension; approximately one unit of change. For GSI change from pre to post level was significant at the .037 level (r = .26). The mean pre therapy level was 1.47 (5.0. = 1.02) and the mean post therapy level was .77 (5.0. = .52), with a rating of (0) indicating none of the particular symptom. Thus, I although the symptom dimension on which the client showed the most 73 initial distress showed more change than all 90 symptoms, overall both did show positive change. Since it was not possible to include a control group in the study, it isn't possible to definitely attribute this change to the psychotherapy process. Yet, since both the therapist and client subjective measures to be reported next indicate positive changes from the psychotherapy process, this does give some convergent validity to the notion that the psychotherapy process may have been at least partially responsible for the symptom change. 319, On a nine point scale which runs (1) very little, (3) some, (5) moderate, (7) fairly great, (9) very great, the mean therapist rating for symptom change was 5.13 (5.0. = 2.0) and 5.11 for overall success of therapy (8.0. = 1.96). .399, Client ratings from the PCQ were as follows. The mean client rated benefit from therapy was 7.6 (S.D. = 2.13). Scale values were (1) not at all, (3) very little, (5) to some extent, (7) a fair amount, and (9) a great deal. The mean rating of satisfaction was 5.6 (S.D. = 1.2): Scale values: (1) fairly dissatisfied, (2) moderately dissatisfied, (3) fairly dissatisfied, (4) fairly satisfied, (5) moderately satisfied, (6) highly satisfied, and (7) extremely satisfied. The mean rating of change due to therapy was 3.8 (5.0. = 1.09): Scale values: (1) not at all, (2) very little, (3) somewhat, (4) a fair amount, and (5) a great deal. The mean rating of symptom change was 4.05 (5.0. = 1.02): Scale values: (1) got worse, (2) not at all improved, (3) somewhat improved, (4) considerably improved, (5) very greatly improved, (6) completely disappeared. 74 Methodology In general all the outcome measures showed moderate client improvement. In order to determine what process and demographic variables accounted for the moderately positive outcome two multiple regression analyses were performed entering all independent variables simultaneously in each. The reason that two separate analyses were performed was that there appeared to be two separate, highly intercorrelated clusters of outcome variables. As related earlier, one cluster was made up of the PCQ and PTQ while the other cluster was composed of the symptom change scores from the SCL90. For both analyses all variables were entered in the equation as dependent variables that were correlated with the criterion outcome cluster at the .05 level of significance. Process and demographic variables accounting for variance in the outcome clusters PCannd PTQ. For this outcome cluster eight variables were entered into the equation as dependent variables; the client's subjective negative experience of therapy (a scale derived from the PCQ by Jones and Zoppel, 1982), the change in therapist exploration over the course of therapy, the emotional intensity of the dyad, patient hostility during the later part of therapy (rated on the VPPS), PCQTA, number of sessions, therapist exploration during the later part of therapy, and the therapist rating of the working relationship. Together these variables achieved a multiple R of .72, accounting for approximately 52% of the variance in PCQ + PTQ, with an F significant at the .001 level (see Table 4). However, only one of the variables, PCQTA, reached the .05 level of signifiance (F = 6.69, p < .014) as 75 nosmcowuopoc ocwxcoz mooom. moomo. cospm. moopn. oop. oom-.~ omume umwgmgmgp aooemsp a? bump munwm. Feooo. oonoo. Pmooo. omm. Pmooo. cowumgopoxo unvoecmsp opomm. msmoo. moose. mepoo. Now. ommmo. mcovmmmm mo Lmasoz macaw. omemp. mmmee. aeamm. w 4mmn1. mmmme.m «Page zomgogu ow comp moosp.- mompo. noomm. oomom. moo. «mooo. apwp_umo; acoVFo pmnmo. noeop. ooomm. mmmum. mmmo.H oooom.m auwmcoucp pwcompoEm cowumgopaxo poo—m. oemoo. popop. ohpoo. Nmo. momeo. umwomcmgp cw oocmno mocmwgmaxo ooo. ooemo.e mm~o~.- Noooo. Noooo. mmmom. mom. onoo~.P o>pumoo= «compo wocmoww a a «mango omgmaom m mocmo o>o5mm omgoucm upoowm ppmeo>o opoewm mcmaom a mpawupoz -mopcowm so gmuom mpnmwem> m ow... . mapaaoee> “caeeoaoeeo Pposom omgmpcu uwcowm Fpmcm>o mpasvm memoom m mpovupoz -vcovm Lo gmueu wpnmwgm> ~— . -> o» L Rs Vi . i xuwmcmuom PooowuoEw too cw mocmgo xuvppumo; acmwpu cw mocmzo mocowgooxm m>wumomc ucmmpo mucmwgmoxm ammomeozh xamgmgp cw mum. xmm pcmwpo opawupsz omcmpcm mpnmwga> mopomwcm> ucmocumooco on» pp< meow: emumopo umcmgo Eouoazw oooom on» Low copmmmemom opavapoz e apaee 79 little short of reaching significance at the .05 level (F = 3.83, p < .057). Therapist experience and client negative experience were negatively correlated with the SCL90 change scores (see Table 7). For client sex, as stated earlier female clients tended to have higher positive change scores. 80 oucowcmaxm Neop4.- Nmmmo. meom. maomm. «no. mompm.¢ a>aoama= oemwpu om_mm.- mpmmo. m~m_~. Poems. “mo. _mm~m.m aoeooemaxm omaaecaep moo. maoem.m Newem. ompmp. ompmp. Namem. «No. opmop.m xam ocmwpu mocmowm a m omoazo mgmocm m mucmowm m>osmm omcmucm -wcomm ppmcw>o opoewm menoom m mpamppoz -Fcopm so gwwcw mpomvcm> mocmwgmoxu m>vummmz ucovpo oceiaoucowgooxu umwmmcmzhlwxmm pcmmpo so» coumopo mocmgo souoszm oooom mop Low covmmogoom mpowapoz u wpooh DISCUSSION Outcome There was no major evidence to indicate a superiority for one gender or the other in achieving positive therapeutic outcome. There was a trend for clients of female therapists to show more symptom ; change, though the trend was quite small .( Contrary to the [' ;<..i hypotheses in this study, and the findings of Kirshner, Genack, and Hauser (1978), clients reported more satisfaction with therapy when they were seen by a male therapist. However, the strength of this relationship was reduced, in the current study, when the effects of number of sessions was partialled out. Kirshner et al. do not report whether number of sessions was controlled for in the design of their study or in the statistical analysis. This might very well be an important consideration because in the current study subjective ratings of outcome by the client were significantly correlated with the length of therapy. However, since it is not clear whether clients stayed in therapy because they were more satisfied with therapy or for other reasons, it is not clear whether the raw correlation or the partial correlation most accurately represents the relationship between satisfaction and gender.7) Clients of female therapists did not rate themselves as more improved on any index when seeing a female versus a male therapist. as they did in the Kirshner e al. study or as they did in the study 81 1 1 I 1 82 by Jones and ZDppel (1982). In addition the finding from Jones and Zoppel that female therapists rated their clients higher in terms oflig€pfi overall success was not replicatedr/fThere-are two possible A I explanations that might account for the differences between the findings of Kirshner et a1. and the Jones and Zoppel study, and the results of the present study. The first is methodological. Gender differences in outcome between therapists were found in subjective ratings of particular outcome areas.(/For instance, in the Kirshner et al. study the major difference in outcome between therapist genders was that clients of female therapists improved more in self-acceptance. Jones and Zoppel found that clients of female therapists report more energy to do things. They also found that women therapists rated their clients as displaying more improvement on symptoms, happiness, ability to enjoy life, ability to get along with spouse and children, and ability to handle personal problems. Of all these areas, only C symptomatic improvement was directly explored in this study. As various authors have pointed out (e.g., Gurman & Kniskern, 1981) outcome is not a unitary entity. There are several ways to measure outcome, from several different viewpoints, which do not always agree with one another. Perhaps given the chance for a more detailed rating /8\ of outcome in the present study the differences in outcome between ‘ therapist genders reported elsewhere may have appeared. \) The second possibility is that the results of this study represent f _ some real differences in the therapeutic relationship attributable to . some variable or variables in the populations of the studies. For instance a midwestern quasi-rural-population may be fundamentally different from the urban client population on either coast (Jones and 83 Zoppel was done in a major west coast city, Kirshner et al. was done in a major east coast city). The value system of rural midwestern clients may very well be more traditional. Therefore, clients may have expected a male therapist and have responded more positively to male therapists as authority figures (as suggested by Abramowitz, Abramowitz, & Weitz, 1976). The increase in directiveness by male therapists, especially with female clients, found in this study lends some support to the notion of male therapists as authority figures. It may be that with more traditionally oriented clients the traditional male role has an equalizing effect, in terms of differential / therapeutic efficacy, with strengths assumed to accrue from the feminine role for female therapists. ‘ Although client and therapist subjective reports of outcome did not show differential effects for gender of client, the symptom change measures from the SCL90 did show differences. Female clients reported more 1 positive changes, both for the symptom dimension on which the client indicated the most initial distress and on a global measure of symptom ‘ 1’? 5 change. This finding is compatible with reviews of the outcome literature by Meltzoff and Kornreich (1970) and Smith, Glass and Miller (1980), both of which suggested a trend for female clients to be more successful in psychotherapy. The findings of this study did not indicate that like gender pairings fared any better than opposite gender ones, as did some of (L/ 5;? the literature (Blase, 1979; Geer, 1973; Barresi, 1979; Jones & / Zoppel, 1982). In fact, female clients showed more symptom change than did male clients with their male therapists. This finding emphasizes the advantage in positive symptom change for female clients as a main effect. 84 Unlike Kirshner, Genack, and Hauser (1978), therapist experience when taken into account, did not produce any change in the relationship between gender and outcome. This may have been because the range of experience was much more truncated in this study (one to six years pregraduate training with the exception of one post- doctoral therapist, as opposed to three years pregraduate training to 25 years postgraduate training). In comparison to the Kirshner et a1. study the difference between inexperienced and experienced therapists in years of experience was small. In addition, there may be some qualitative differences between therapists in training and those in practice for several years which was tapped by Kirshner et al. but was not accessible in the present study due to the truncated range. Process Measures Accountipg_for Differential Gender Outcome .«/—~ In essence none of the main process variables hypothesized to account for client gender differences in outcome did so for the difference found in symptom change. There were no differences between male and female clients on therapeutic alliance, the amount of emotional intensity in the dyad, or the amount of warmth and empathy shown by the therapist. When anticipated relationships are not found, it is difficult to tease out whether the relationships do not exist or whether there is something about the measurement of the concepts that are at fault. There were low correlations between the VPPSTA and the other two measures of therapeutic alliance. This may indicate that, at least for therapeutic alliance, a unitary concept was not being tapped. However, there was a modest correlation between therapist and client subjective ratings of the therapeutic alliance and these measures failed to distinguish between male and female clients. This -\ . 85 1 result suggests that neither member of the therapeutic dyad experienced : the therapeutic relationship as more positive when there was a female I client involved solely on the basis of gender. W /¢ir There were a few small, statistically significant, correlations for client gender with process variables tapped by the VPPS which were not covered by the hypotheses in the study. These were observed on a post hoc basis. Female clients tended to show more self-exploration in the later part of therapy than did male clients (R = .23, p < .036). This finding is congruent with Hill (1975) although she only measured self exploration in the second session. There was also a tendency for female clients to be less hostile and more trusting than male clients later in therapy (r = .21, p < .052). In addition, as reported earlier, there was a tendency especially for male therapists, to be more directive with female clients in the later part of therapy. These variables taken together could be conceptualized as loosely denoting a heightened working relationship for female clients. In Luborsky's conceptualization of therapeutic alliance there are two major components (Morgan, Luborsky, Crits-Cristoph, Curtis, & Solomon, 1982). The first component is the client's experience of receiving help or a helpful attitude from the therapist. The second component is the client's experience of being involved in a team effort working toward his/her goal. Morgan et al. found an increase in the second component for more improved clients, although this result was not statistically significant. Higher self-exploration on the part of female clients and higher directiveness on the part of their therapists may reflect more of Luborsky's second component of the therapeutic alliance. One further avenue of research would be to correlate these process 86 variables with Luborsky's Helping Alliance Scale and related these measures to symptom change on the SCL90 to see whether they would account for differential symptom change between genders. Another reason for the lack of success in isolating process variables that account for differences in symptom change between client genders may be that a more detailed approach needs to be taken. This approach would need to take into account personalityfivarjgbles as well as variables measuring the nature of the clients difficulties. Different process variables may be important in differentiating among gender combinations depending on client and therapist personality and on the nature of the clients difficulties. For instance, from a psychoanalytic perspective Mogul (1982) reviewed the differences in transference phenomena depending on the gender of client and therapist. As an example she cited a paper by Freud on female sexuality in which he noted that preoedipal attachment between female clients and their mothers seemed to emerge only hazily in analysis with him but much more clearly with female analysts. Mogul also cited several authors who pointed out that issues around early parental loss or difficulties- in early relationships with parents need to be considered in gender matching. Depending on the intensity of the conflict a therapist of the same gender may be more helpful in providing an identification figure, or if the conflict is too intense treatment may be paralyzed. Thus, empirically it has been noted that the nature of conflicts which bring a client into therapy can make a difference in the nature of the therapeutic relationship. This in turn may effect the process variables responsible for positive therapeutic outcome. h-w—r —~ ......-.....—~-—...-- 87 Gender Composition and Process Measures There was an unexpected finding in regard to the relationship between therapeutic alliance as measured by the VPPSTA and PCQTA and gender composition. Male therapists showed a stronger tendency to have a more positive therapeutic alliance with their male clients than did female therapists. Yet the reverse was less strong in that the therapeutic alliance between male and female therapists and female clients did not differ. In addition, scores on the VPPSTA and the PCQTA were in agreement in showing female therapists to have a more positive therapeutic alliance with their female clients than with their male clients. These results taken together indicate that the gender combination that\formed the least positive therapeutic alliance was the female gifieht/male theHagist one. This is somewhat different .5, than would have been expected from the literature which indicated that most often it is the male therapist/female client dyad that expresses the most dissatisfaction with their relationship (Barresi, 1979, and to some extent Howard, Orlinsky, & Hill, 1969, 1970). This difference cannot be accounted for by the initial level of either symptom index from the scores on the SCL90, both of which did not differ significantly for any of the gender combination groups. In this study the female therapist/male client group had the smallest n with eight subjects and six therapists. Ratings of the VPPSTA two thirds of the way through therapy were particularly low for two of the female therapists with their clients accounting for three of the eight clients. These therapists achieved much better ratings with their female clients in the female client/female therapist pairings. Thus, the finding in this study that female therapists have a 88 particularly poor therapeutic alliance with their male clients might in part be due to the overly influential effect of two therapists because of a small n. This is not to minimize the fact that from an outside observers point of view at least a portion of the sample of female therapists had difficulty in maintaining a therapeutic alliance with their male clients in the later part of therapy. Scores on the PCQTA also shows the same finding and the PCQTA scores did not correspond to the ones from the VPPSTA. In other words the therapists who were rated as having a relatively poor therapeutic alliance by the outside raters on the VPPSTA were not the same ones which received poor ratings on the PCQTA by their clients. It remains unclear whether, in this study, a few female therapists accounted for the finding of a relatively lower level therapeutic alliance with male clients or whether this finding is more widespread in the sample and perhaps in the population. Therefore it would make sense to continue to investigate this phenomenon from multiple viewpoints. For instance, as suggested previously, particular presenting problems and/or personality variables of the client and therapist may be important in accounting for the lower level therapeutic alliance found between some of the female therapists and their male clients. Particularly with male clients that exhibit severe pathology there may be extreme role conflicts with the opposite gender which inhibits the development of a strong therapeutic relationship. Another possibility is that in a population with traditional values a female therapist/male client match might engender the most resentment and resistance on the part of the client. 89 In either case the results of this study suggest that in order to maximize therapeutic alliance male clients should be matched with male therapists. Variables Accounting for Positive Outcome Two outcome clusters were generated by this study, one comprised of the client's and therapist's subjective post therapy ratings (PCQ + PTQ), and the other comprised of symptom change measures from the SCL90. For the PCQ + PTQ two variables, the client's subjective rating of the therapeutic alliance and the client's subjective rating of the emotional intensity of the relationship aecounted for 42% of the variance. Adding six other variables correlated with the cluster accounted for only an additional 10% of the variance. At least for subjectively rated outcome, rated post therapy, the client's positive experience of the therapeuitc relationship is the best predictor of positive outcome. This finding fits very well with the results from both Marzialli, Marmar, and Krupnick (1981) and Morgan, Luborsky, Crits-Cristoph, Curtis, and Solomon (1982) that the client perception of the therapeutic alliance is the best discriminator of positive outcome. In fact, the client's perceptions may not correlate with therapist behavior rated by other sources. In the present study the only therapist behavior tapped which correlated with therapeutic alliance was therapist exploration, which had small correlations with PCQTA scores and the PCQ + PTQ outcome cluster variables. However, therapist exploration did not add appreciably to the variance accounted for in PCQ + PTQ when included in the regression equation. 90 It is not clear from the previous research (e.g., Marzialli et al. or Morgan et a1.) and from this study as to how the client constructs and maintains his/her view of the therapeutic alliance. To date therapist behaviors, which are assumed to be responsible for building the relationship, have not been clearly related to the therapeutic relationship. Yet from a theoretical and experiential base therapists attest to the importance of their behavior in building the therapeutic relationship. Perhaps what is needed is to monitor the therapeutic alliance while treatment is in process, as suggested by Marzialli et a1. (1981), in order to test out interventions that might help build and maintain the alliance. Or it may be helpful to rate clients and therapists on a session by session basis since different therapeutic behaviors may be called for by the therapist at different times during different sessions. For instance a therapist may need to be supportive and especially empathic during one portion of a session and more directive in another portion. Or a therapist may actively encourage self exploration at some time and discourage it at a different time depending on the issues or timing involved. Our sampling techniques would tend to miss or confound these fluctuating, yet important, behaviors. One very important conclusion that should not be overlooked is that the therapist needs to be aware not only of the theoretical correctness of their behavior but also most be acutely aware of the client's experience of it. In essence this is an issue not only in accurate communication but in accurate reception. For the second outcome cluster, the symptom change measures from the SCL90, three variables accounted for 30% of the variance. 91 These were client gender, client negative experience of therapy, and years of therapist experience. As reported earlier, female clients showed more positive symptom change than did male clients. As might be expected negative client experience of therapy was negatively associated with reported symptom change. Somewhat contrary to expectations, years of therapist experience was negatively correlated i with symptom change. Clients of therapists who were in practicum fared better than clients of therapists who had completed internships. One possible explanation for this finding is that it is the policy of the Psychological Clinic for more experienced therapists to be matched with clients who are judged to have more severe problems. One of the criteria may be that client symptoms are more severe and less amenable to change. This selection procedure certainly confounds the interpretation of this particular result. However, if one were going to predict which clients show the most symptom change on the SCL90 the best group to pick according to this study would be female clients who do not find therapy to be a negative experience. I The results of this study indicate the importance of having more than one type of outcome measure since different process and demographic variables were related to different types of outcome. So in order to maximize the type of outcome considered to be most important one needs to capitalize on the appropriate process and demographic variables. It appears in this study that for a subjective rating of at least moderately successful therapy by both clients and therapists symptom change is not the most important factor. Therapists and clients felt the experience to be positive if the client experienced the therapeutic alliance as a strong one. This may have been the case because the 92 majority of the therapists where interpersonal/dynamic in orientation. Symptom change may have been seen as less important than other types of changes that were reflected in the client's view of the therapeutic relationship. Therefore, given this orientation an investigation of how to maximize the clients experience of a positive therapeutic relationship would be most important. ' However, if one were concerned more with objective measures of symptom change results from this study would indicate that a different track would be most fruitful. One would need to continue to investigate the role played by client gender in enabling female clients to achieve more symptom change than male clients. Suggestions for Future Research Essentially, this study raises many more questions than it answers. In trying to account for the lack of differences in outcome for male and female therapists it will be important to investigate whether more specific measures of particular typs of outcome would reveal differences between the genders. It would also be important to get measures of traditional beliefs and expectations from clients to see whether a quasi-rural midwestern population might be more apt to respond to a more traditional figure (i.e., a male) in the role of therapist. In terms of continuing to investigate possible differential therapeutic efficacy of the various gender combinations it appears that designations of treatment groups according to gender alone is not sufficient. A more detailed approach in terms of specifying particular presenting problems (e.g., particular behaviors, nature of the conflicts, particular defenses, developmental level) might provide fruitful results, if results are to be found. At least by 93 taking a more specific approach one might be able to conclude that the gender combination of the dyad does not account for much variance in treatment outcome. Two findings in this study appear to be especially worth following up. The first is that female therapists had relatively lower levels of therapeutic alliance with male clients. Since the n of this particular subgroup was low, the finding needs replication in order to verify its validity. If the finding is valid then it is important to investigate the variables that would account for it in this population (since other studies have not found this result). Knowing what variables account for the finding would provide information as to when male clients should be seen by a male or female therapist to maximize the therapeutic alliance. The second area that would be especially interesting to follow up is in pinning down the variables that account for greater positive symptom change in female clients. The variables found on a post hoc basis to be related to gender later in therapy, self exploration, trust, and therapeutic directiveness, point to a greater therapeutic alliance for female clients, especially as they relate to Luborsky's definition of the helping alliance (Morgan et al.,1982). One could use these variables and the Helping Alliance Scale as another way of getting at whether therapeutic alliance, and what aspects of the alliance in particular, account for the differential symptom change. APPENDICES APPENDIX A 94 APPENDIX A DEFINITION OF THE SCL90 SYMPTOM DIMENSIONS SOMATIZATION: Distress arising from perceptions of bodily dysfunctions. Focus on cardiovascular, gastrointestinal, respiratory, and other systems with strong autonomic mediation. Includes headaches, pain and discomfort of the gross musculature and additional somatic equivalents of anxiety. OBSESSIVE-COMPULSIVE: Thoughts, impulses, and actions that are experienced as unremitting and irresistible but are ego-alien or unwanted. INTERPERSONAL SENSITIVITY: Feelings of personal inadequacy and inferiority. Self-deprecation, feelings of uneasiness, acute self-consciousness and negative expectancies concerning the communications and interpersonal behaviors with others. DEPRESSION: Symptoms of dysphoric mood and affect are represented as are signs of withdrawal of life interest, lack of motivation, and loss of vital energy. Feelings of hopelessness, thoughts of suicide, and other cognitive and somatic correlates of depression are included. ANXIETY: Nervousness, tension and trembling, panic attacks, feelings of terror. Feelings of apprehension and dread, and some of the somatic correlates of anxiety. HOSTILITY: Thoughts, feelings or actions that are characteristic of the negative affect state of anger. Aggression, irritability, rage, resentment. PHOBIC ANXIETY: Persistent fear response to a specific person, place, 8 object, or situation which is characterized as being irrational and disproportionate to the stimulus, which leads to avoidance or escape behavior. PARANOID IDEATION: Paranoid behavior is represented by a disordered mode of thinking. The cardinal characterististics of projective thought, hostility, suspiciousness, gardiosity, centrality, fear of loss of autonomy, delusions. PSYCHOTICISM: Items indicative of a withdrawn, isolated, schizoid life style are included, as are first-rank symptoms of schizophrenia, such as hallucinations and thought-broadcasting. The scale provides a graduated continuum from mild interpersonal alienation to dramatic evidence of psychosis. 95 ADDITIONAL ITEMS: Seven items that did not fit under any primary symptom dimension. These include poor appetite, overeating, trouble falling asleep, awakening early in the morning, sleep that is restless or disturbed, thoughts of death or dying, feelings of guilt. These items contribute to the global scores on the SCL90 but are not scored collectively. GLOBAL INDICES OF DISTRESS: GLOBAL SEVERITY INDEX (GSI): The best single indicator of the current level of depth of psychopathology. It combines information on numbers of symptoms and intensity of perceived distress. POSITIVE SYMPTOM DISTRESS INDEX (PSDI): A pure intensity measure "corrected"£br numbers of symptoms. POSITIVE SYMPTOM TOTAL (PST): A count of the number of symptoms the patient reports as positive. Adapted from SCL90 (r) Manual-l by Leonard R. Derogatis APPENDIX B 96 APPENDIX B VPPS ITEM DEFINITIONS 1. What is your global impression of this session? Rate evidence of reciprocity and collaboration between the therapist and patient. To what extent did the patient and therapist seem to be "meshing" suCcessfully? 2. How productive was this hour? Rate your impression of the extent to which beneficial therapy-related work was accomplished during the hour. For example, the patient seemed to have made progress toward achieving his/her goals in therapy, or toward resolving troublesome issues. 3. How well does the patient seem to be getting along at this time? Make a global rating of your impression of the patient's current overall functioning. I. Characterize the Patient's Behavior During the Hour: 4. Actively participated in the interaction. Active participation involves level of verbalization and willingness to break silences. A high rating is merited if: (a) the patient's level of verbalization at least matched the therapist's participation, and (b) the patient elaborated on topics that were brought up. 5. look the initiative in bringing up the subjects that were talked about. The patient supplied topics either in response to the therapist's probes or spontaneously. The topics were 97 pursued by the patient rather than merely mentioned. Initiative would also be indicated if the patient returned to topics s/he wanted to pursue despite therapist's questions which led elsewhere. 6. Seemed to be motivated for therapy. The patient seemed to want therapy and was willing to work on his/her problems. There was evidence that the patient was willing to try to get better. Evidence may have included direct verbal references (e.g., "I really think this will help me") or behavior (e.g., relating a painful episode). A low rating would be based on evidence that the patient did not see therapy as a source of help for his/her problems or refused to undertake tasks assigned or suggested by the therapist. 7. Asked for advice on how to deal more effectively with self and others. For this item, rate whether the patient specifically asked for advice. 8. Concern with how to deal more effectively with self or others. Broadly, this item refers to patient communications which relate to concerns about realizing his/her human potential or enjoying rewarding interpersonal relationships. Specific evidence would include the patient's describing the nature of his/her personal conflicts as relating to attitudes toward significant others; what s/he perceives other's attitudes are toward him/her; or how his/her present or past behavior, perceptions, or relationships have contributed to his/her current distress. 98 9. Tried to elicit approval, sympathy, or reassurance from the therapist. This item taps relatively overt nurturance-seeking on the patient's part. A patient question such as "How am I doing (e.g., in therapy)?" would be one example. Another form of eVidence could be the patient's response to a reassuring, sympathetic, or approving response from the therapist: that is, did the patient seem pleased by a nurturant remark from the therapist? Also, it can be inferred that a patient who presents herself/himself as victimized is seeking sympathy from the therapist. 10. Relied upon the therapist to solve his/her problems. The patient seemed to seek therapist-offered solutions for problems rather than trying to work with the therapist toward a solution. For example, did the patient ask the therapist what to do in some situation? Other evidence could be unrealistic expectations of therapy and of the therapist. ll. Reacted negatively to the therapist's comments. A high rating is merited by unqualified rejection of a therapists' comments such as "that doesn't make sense". However, evidence of disagreeing with a therapist's remarks or interpretations does not necessarily qualify for a high rating on this item. For example, a patient might say "I don't think it's exactly like that because..." with 'the intention of clarifying the therapist's understanding. The patient's attitude and tone when s/he disagrees with a 99 therapist's statement is important to consider in rating this item. "Reacting negatively" can also connote becoming angry or refusing to answer therapist's questions. 12. Tried to learn more about what to do in therapy and what to expect from it. In general, this item refers to patient's attempts to clarify the nature of his/her role in therapy; to formulate notions about the therapeutic process, the therapist-patient relationship; or to determine the possibility of his/her benefitting from therapy. For example, the patient may discuss his/her feelings and reactions to therapy or the treatment relationship in order to elicit the therapist's views, i.e., "Isn't it natural to feel this way in therapy?" 13. Discussed his/her feelings and perceptions about the therapist. The patient talked about his/her attitudes towards or feelings about the therapist. This should be an active and obvious reference, where the patient relates his/her thoughts or feelings to the therapist. Inferences that the patient is trying to express his/her feelings about the therapist when talking about some other person or situation are not what this item is attempting to capture. 14. Focused on a particular problem. The patient spent a substantial portion of the segment concentrating on various aspects of a single problematic (psychologically meaningful or therapy related) situation or on a specific, shared theme across many situations. A high score requires evidence that the patient was at least partially responsible for maintaining the focus. 100 15. Was logical and organized in expressing thoughts and feelings. The patient expressed himself/herself in a manner which was easily understandble to the observer. A low score would be indicative of rambling, frequent disgression, and the observer's inability to follow the connections between topics the patient discussed. A 16. Tried to understand the reasons behind problematic feelings or behavior. This item taps evidence that the patient was interested in identifying motives, needs, need-frustrations, etc. that lead to behaviors or feelings that s/he finds troublesome. That is, the patient was trying to understand internal rather than external forces that prompted problematic feelings or behaviors. 17. Explored feelings and experiences. In this item, the emphasis is on explored in the sense that the patient considered experiences and related feelings from variousyperspectives or related particular experiences and feelings to other situations in his/her past or present life. Exploration of feelings and experiences suggests consideration of the complexity of an experience or feeling rather than reporting them as simple facts. 18. Was struggling to achieve better control over feelings or impulses. Rate evidence that the patient was bothered by problematic feelings or habits that s/he wanted to control. 101 19. Seemed to trust the therapist. "3" is a typical rating for this item. Evidence that the patient felt free to divulge information of a personal or embarrassing nature merits a higher score. A low rating requires direct evidence that the patient did not trust the therapist, e.g., the patient indicated that s/he was not willing to discuss an issue. 20. Discussed his/her feelings as a patient and his/her progress in therapy. The patient made specific comments about his/her feelings as a patient or his/her progress in therapy. Only explicit statements about some aspect of being a patient are to be rated. 21. Talked about his/her feelings. This item refers to whether the individual discussed his/her feelings. In contrast to #20, this item does not solely relate to the patient's feelings about therapy or the therapist. Rather, any feelings about a person outside of therapy or about some situation are considered pertinent evidence for rating this item. 22. Portrayed himself/herself as overwhelmed by his/her problem. Evidence that the patient questioned whether s/he had the resources to cope with his/her difficulties applies to this item. Patient statements of the "I don't know where to turn" variety apply here as do statement implying that s/he felt that the therapist's--or someone's--aid was essential to his/her continued welfare. 102 II. Describe the Patient's Demeanor During this Hour: 23. Withdrawn The patient seemed to be keeping within himself/herself rather than relating to the therapist. 24. Guilty Patient blamed himself/herself for some negative aspects of his/her life. 25. Optimistic The patient had a hopeful, positive outlook. For example, s/he felt that help could be found in therapy, that s/he could succeed at a task, or that s/he or his/her situation had improved. 26. Self-critical The patient depreciated his/her own self-worth, potential, or behavior. Specific examples may include the acceptance of blame for a situation, belittling oneself, or apologizing for one's actions. 27. Mistrust The patient seemed to lack trust or confidence in the therapist. This may be evidenced by the patient doubting the validity or effectiveness of the therapist's suggestions or if s/he was suspicious of the therapist in any way. For example, the patient may question the therapist's motives or integrity. 28. Depressed 8 Rate this item if patient appeared sad, morose, let down, or disheartened. Evidence may consist of a low energy level, 103 a dejected tone of voice or statements describing or implying depression. 29. Hostile Rate evidence that the patient behaved in an unfriendly, critical or belligerent manner during the session. This item should receive the highest rating if the patient's general attitude toward the therapist seems antagonistic, and this demeanor is explicitly conveyed by the nature of his/her responses. 30. Frustrated This item refers to frustration in response to a therapist who seemed not to understand what the patient was trying to convey or in same way was pursuring a topic that the patient felt was irrelevant to his/her present concerns. This item reflects dissatisfaction with the way therapy is progressing: difficulty in working something through or frustration with attempts to reach goals outside of therapy is ppt_tapped by this item. 31. Tense The patient seemed to be ill at ease. For example, tension may be reflected in a driven quality to the patient's speech. 32. Impatient The patient appeared restless, dissatisfied or irritated with the pace and/or manner in which his/her therapy was progressing. 104 33. Intellectualizing The patient used an abstract or intellectual style to avoid acknowledging emotions or objectional impulses. 34. Defeated Rate evidence that the patient perceived that s/he applied his/her energy or resources to a certain goal and failed to attain it. More generally, this item taps a patient's sense of hopelessness, despair and failure regarding his/ her likelihood of attaining certain goals (e.g., a satisfying relationship, a sense of self-worth, recognition on the job). 35. Dependent This quality implies an overt reliance on the therapist or the therapeutic situation for protection or support. Specific evidence would include the patient's desiring the therapist to take the lead in solving his/her problems or in making decisions. This item may encompass, but is gpt_limited to patients who adopt a passive and docile demeanor in their interactions. 36. Controlling The patient exercised restraining or directing influence over the session. For example, the patient dominated the inter- action with compulsive talking. A high score would be given if the patient interrupted the therapist frequently and dominated the conversation. 37. 3B. 39. 40. 41. 105 Deferential The patient readily submitted or yielded to the therapist's wishes or Opinions. S/he seemed eager to please the therapist even if it meant suppressing or altering his/her own viewpoint or feelings. Evidence may include overly enthusiastic or non-critical agreement with the therapist or tempering his/her own position to more closely match the therapist's. Defensive Evidence of defensive behavior on the patient's part may include: (a) offering justifications of his/her behavior to the therapist. (b) offering a rationalization or counter-evidence to a suggestion by the therapist that the patient may have behaved differently in a situation. (c) actively avoiding discussion of personal issues or seeming to withhold information. Inhibited The patient's conversation was not free-flowing. S/he seemed restrainted or tentative. Spontaneous There was an unrehearsed, unself—conscious quality to the patient's participation. Passive The patient was influenced or acted upon by the therapist but did not extert influence or act in return. 106 III. Characterize the Therapist's Behavior During This Hour: 44. Communicated approval of some aspects of the patient's behavior. The therapist commented favorably on the patient's behavior or attitudes either in therapy or outside of therapy. 45. Tried to help the patient evaluate his/her reactions and feelings. The therapist attempted to work with the patient to determine the significance of the patient's feelings about or reactions to himself/herself, an event, a person, or the therapist. This evaluation may include deciding whether a reaction was appropriate, or whether it will have a beneficial or deleterious effect upon the patient. This item is not meant to tap efforts to understand why a feeling or reaction occurred, but concentrates on the importance and possible consequences of the feeling or reaction. 46. Placed the patient's report in a new perspective or reorganized the patient's experience. Rate the extent to which the therapist offered the patient a new way of understanding himself/herself or his/her situation. One example would be the therapist restating material presented by the patient with a new emphasis or focus. 7 47. Showed warmth and friendliness towards the patient. Rate the extent to which the therapist seemed to care about and be interested in the patient. Friendliness involves an amicable attitude lacking in hostility; 107 consequently, a rating of 1 would require a hostile attitude on the part of the therapist. A 3 is the standard rating on this item. Evidence for this item might be most salient in the beginning and end of the session when the patient and therapist meet and take leave of each other. 48. Helped the patient feel accepted in the relationship. The therapist conveyed sympathetic understanding of the reasons gby_a patient was behaving in a certain way, while at the same time acknowledging that the patient may not necessarily have been handling life events in the most adaptive fashion. The therapist fostered a sense of mutuality in the interaction. An example may be the use of "we" or "us" to impart a feeling of alliance with the patient. 49. Supported the patient's self-esteem, confidence, and building hope. Rate the extent to which the therapist conveyed the sense that s/he was in the patient's "corner." If the therapist confronted the patient, s/he was supportive and offered encouragement at the same time. This support may have been evidenced by the therapist's emphasis of the patient's particular strengths or by agreement with the patient's positive self-statements. In certain instances, the therapist may make comments to bolster the individual's confidence, or hope, i.e., "You did this in the past, you can do it again." 108 50. Responded empathically to the patient. This item taps the capacity of the therapist to perceive the patient's feelings and moods. Ratings should not be made on the basis of pat phrases meant to convey empathy (i.e., "I hear you saying..."). Rather, a high rating is merited only if the therapist seemed to convey that s/he truly understood what the patient felt, and that s/he could view the patient's experiences as the patient did. Evidence of empathic behavior could be the therapist's re-phrasing the patient's report such that the patient responds, "Yes, that's just how I felt." 51. Explicity encouraged the patient to express feelings and concerns. Rate the extent to which the therapist explicitly directed the patient toward the discussuon of his/her feelings and troublesome issues. For example, a therapist may try to make a reticent patient verbalize his/her feelings and thoughts more freely. General statements by the therapist regarding the patient's role in therapy may also apply to this item, i.e., the therapist may state that the expression of feelings and fears would facilitate therapeutic progress. ‘52. Tried to get a better understanding of the patient, of what was really going on. The therapist asked questions in order to clarify an issue or to gain more information about the circumstances surrounding the patient's experiences, feelings, or reactions to a situation. The therapist may also have sought 109 confirmation of his/her understanding of the patient's communication, i.e., “Is this what you mean...?" 53. Tried to help the patient recognize his/her feelings. The therapist made statements or interpretations which helped the patient identify or become aware of unacknowledged feelings associated with some issue s/he discussed. 54. Tried to help the patient understand the reasons behind his/her reactions. This item relates to discussion in which the therapist attempted to elicit from the patient explanations for why s/he reacted the way s/he did. Motives, plans, goals, and needs are all possible reasons the patient might give for her/his behavior. Therapist's interpretations are also pertinent to this item if they attempt to direct the patient's attention toward examining the causes of his behavior. £55. Encouraged depth rather than shallowness. This item reflects the level of discourse of the session. A high score may indicate that emotionally charged, conflictual issues were dealt with or that the therapist explicitly made an effort to encourage a more meaningful level of communication. A low score indicates that the therapist allowed the patient to communicate on a superficial, shallow level and to maintain emotional distance. 110 56. Dealt with the interpersonal dynamics between himself/herself and the patient. The therapist discussed the way s/he and the patient interact. This can include directly discussing their interaction within the therapy situation or pointing out how their interaction parallels the patient's way of relating to others. 57. Actively participating in the interaction. The therapist was interacting with the patient. S/he was willing to talk, break silences, respond to the patient, and generally convey the idea that s/he was trying to work with the patient. 58. Encouraged the patient to take a more active role in therapy. Rate this item if (a) the therapist explicitly asked the patient to be more active or (b) if the therapist did so implicitly by explaining the patient role and the therapeutic task. For instance, the therapist may explain that in order to make progress in therapy, the patient needs to bring up troublesome issues. £59. Identified themes in the patient's experience or behavior. The therapist pointed out recurrent patterns in the patient's reported experience or behavior. (50. Encouraged the patient to accept responsibility for his/her problems. Therapist interventions such as "Let's look at what you may have done to elicit that response (from another person)" is clear evidence for this item. Any evidence that the 111 therapist attempted to convey to the patient that s/he must take some action or change somehow if his/her difficulties were to improve applies to this item. 61. Maintained focus on therapy-related topics. This item requires evidence that the therapist's statement and questions consistently pertained to psychological issues, such as emotional states, self-perception, or interpersonal conflicts. A high score is appropriate if the therapist explicitly encouraged a focus on therapy related issues or if such issues were focused on without much guidance from the therapist. A "1" would be rated if he fostered disgression from therapy-related topics. 62. Modeled behavior or set an example for the patient. It is recognized that thetherapist continually "models behaviors" or "sets an example for the patient." Examples are the therapist's calmness and acceptance of the patient's failure, shortcomings, mistakes, shameful experiences, etc. To rate this item, consider evidence that the therapist was less critical of the patient's behavior than the patient was, thereby mitigating the patient's self-criticism, self-derogation, and other negative attitudes. Average amounts merit a rating of "3"; however, in order to achieve a high score on this scale the therapist must have given specific evidence--over and beyond a general attitude--of "modeling" or "setting an example." High ratings may include, but are not restricted to, statements 112 of what the therapist would do in a particular situation; they may also include other specific instances by which the therapist sought to induce greater self-acceptance in the patient. An example of a low score would be a therapist who failed to be accepting or who was so inactive that there was no opportunity to model. 63. Tried to help the patient achieve better control over his/her feelings and impulses. Rate evidence that the therapist discussed with the patient ways to restrain or mitigate feelings or impulses that are troublesome to the patient. This discussion might include talking about methods of achieving more control or suggestions as to how this might be accomplished. 64. Encouraged the patient to try new ways of dealing with self and others. Rate evidence that the therapist (a) explicitly suggested that the patient experiment with a new approach in some situation, or (b) invoked the therapeutic "principle" that in order to alleviate a problem or to enhance his/her satisfaction, the patient must change his/her behavior in some way.. (55. Explicitly tried to impose his/her own set of values on the patient. Rate if the therapist verbalizes his/her personal viewpoint or values on an issue and expects or asks the patient to adopt them as his/her own. For example, ther therapist states how s/he thinks the patient should act, think or feel. 113 66. Offered specific suggestions for things that the patient could do. The therapist outlined specific coping strategies or ways of approaching a problem that the patient could adopt. 67. Conveyed expertise. Evidence that the therapist gave information, stated a knowledgeable Opinion and answered direct questions while speaking as an authority or drawing on experience may be used to rate this item. Such statements conveyed that the therapist was confident, knowledgeable and self- assured regarding therapy-related issues. 68. Disclosed his own feelings, attitudes, values, or experiences. The therapist explicitly revealed things about himself/ herself. 69. Confronted the patient. This item refers to therapist interventions which call attention to something the patient could be talking about but is not. For example, the therapist may observe that the patient has described an incident without mentioning any of his feelings about it. A high rating would be merited if the therapist challenges the patient's beliefs, perceptions, or behavior. '70. Confronted the patient in a negative manner. In contrast to #69, rate this item if the therapist's confrontation was in the form of a hostile interpretation, or resulted in an aggressive assault on the patient's defenses. IV. 71. 72. 73. ‘74. 75. 114 Describe the Therapist's Demeanor During This Session: Annoyed The therapist seemed aggravated, irritated, or displeased by some aspect of the patient's behavior or statements. Evidence may be verbal or nonverbal, e.g., curtness, sighing. Involved This item related to the extent to which the therapist seemed to be engaged in the patient's experience. A low score would be merited if there was evidence that the therapist was detached from the patient's emotional experience or was inattentive to his/her concerns. Relaxed This item taps the extent to which the therapist appeared to be comfortable and at ease during therapy. Evidence for this may include voice quality or how the therapist handles particularly embarrassing or personal issues. A "39 is generally an appropriate score for this item. Low ratings would be merited if the therapist seemed tense or anxious while indications that the therapist was particularly comfortable would merit a high score. Intimidating . The therapist adopted a stance or interacted in a manner that appeared to make the patient feel put-down or subdued.v Authoritarian . The therapist presented his/her view as the only possible approach. Interpretations or explanations were stated dogmatically as facts, not as hypotheses. 115 76. Optimistic The therapist explicitly communicated a hopeful, positive outlook for the patient. For example, the therapist may have indicated that there are solutions to the patient's problems or that the patient could succeed at a task. A low score does not necessarily indicate a pessimistic outlook but rather the absence of overt optimism. 77. Lecturing There may have been a monologue or moralizing quality to some of the therapist's communications. The impression that the therapist was trying to impose his/her viewpoint on a submissive listener would merit a high rating. 78. Defensive The therapist acts to protect himself/herself. S/he may be unwilling to talk about certain issues or s/he may offer rationalizations and excuses for his/her behavior. 79 . Judgmental The therapist conveyed his/her own views (or those of society) as to the appropriateness of the patient's beliefs, attitudes or behavior. Implicit in this item is the therapist's expression of an internal or external standard to the patient. The tone of the therapist's questions or statements may merit a moderate rating; however, high ratings should be reserved for explicit judgmental statements. BO. 116 Respectful In general, one expects that therapists will be respectful of patients. A "3" is therefore seen as the typical rating for this item. A lower rating would be required if the tone or content of any of the therapist's interventions seemed to depreciate the patient in some way. A high rating would be appropriate if the therapist's manner conveyed a noteworthy degree of respect for the patient. 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