This document summarizes a study that analyzed written responses from clients who had completed couple therapy. The study explored how clients experienced therapy through their responses to open-ended questions about therapy at a 6-month follow-up. The responses were analyzed thematically and compared between clients whose therapists did or did not use systematic feedback. Most clients found personable, active therapists who maintained neutrality to be helpful. Some expressed dissatisfaction with lack of structure or challenge from therapists. Lack of flexibility in scheduling was also problematic. Clients who used feedback generally found it very helpful.
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
THIS CHAPTER DISCUSSES
•
Systematic feedback and the Partners for Change Outcome Management System (PCOMS)
•
PCOMS as a way to truly privilege clients, include them as full partners in decision-making and operationalize social justice and a pluralistic approach
This document summarizes a study on implementing a systematic client feedback protocol into a marriage and family therapy training program to improve trainee competence and accountability. The study describes how the program integrated continuous client feedback into coursework, clinical training, and supervision using an Outcome Management system. Research shows that incorporating client feedback improves client outcomes and therapist effectiveness. The program believes this approach will train therapists to be more accountable to clients and enhance services provided at their family therapy clinic.
The Partners for Change Outcome Management System: Duncan & Reese, 2015Barry Duncan
Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers one solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only two have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration’s National Registry of Evidence based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of the Partners for Change Outcome Management System, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large scale data collection, to re-prioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.
The first quasiexperiemental study of the ORS/SRS in a telephonic EAP company. Doubled outcomes and improved retension. Set the stage for the RCTs that followed
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
This study examined the psychometric properties of Dutch translations of the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Data was collected from 126 clients who completed a total of 1005 ORS and SRS assessments over multiple therapy sessions. Results found the Dutch translations had good internal consistency and test-retest reliability, similar to previous American studies. Scores on the ORS and SRS also converged with therapist satisfaction ratings. Additionally, SRS scores predicted later ORS scores, supporting the validity of both measures. Overall, the study provides preliminary support for using the Dutch ORS and SRS in cross-cultural settings.
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
Duncan & Sparks Ch 5 of Cooper & DrydenBarry Duncan
THIS CHAPTER DISCUSSES
•
Systematic feedback and the Partners for Change Outcome Management System (PCOMS)
•
PCOMS as a way to truly privilege clients, include them as full partners in decision-making and operationalize social justice and a pluralistic approach
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
This study investigated whether providing client feedback data to supervisors for use in supervision would influence supervision and counselor self-efficacy. Trainees were assigned to either a continuous feedback condition, where feedback was provided to supervisors, or a no-feedback condition. Results showed that trainees in both conditions improved client outcomes over the year, but those in the feedback condition improved more. However, ratings of supervisory alliance and satisfaction did not differ between conditions. The relationship between counselor self-efficacy and outcomes was stronger for those in the feedback condition, suggesting feedback may facilitate a more accurate assessment of skills.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
Most therapists want to improve their skills and help more clients. However, research shows that factors like personal therapy, specific treatment approaches, training, or experience do not necessarily correlate with better outcomes. After studying thousands of therapists over 15 years, one key factor was identified - "Healing Involvement", where therapists are fully engaged with clients through empathy, skills, efficacy, and handling difficulties constructively. This state can be achieved through career development improving skills over time, self-care reducing burnout, and connection to purpose and values in their work.
The original validation of the CORS for kids and the ORS for adolescents. Allowed the benefits of client based outcome feedback to expand to youth and family and paved the way to the current RCT with kids in the schools.
Article by Dr Mary Haynes about her agency's journey to a recovery orientation via CDOI and PCOMS published in the SAMHSA Recovery to Practice Newsletter.
PCOMS: A Viable Quality Improvement Strategy for Public Behavioral HealthBarry Duncan
This is the latest from the research team of the Heart and Soul of Change Project, published in the Journal of Consulting and Clinical Psychology. This study demonstrated that PCOMS is not only a viable quality improvement strategy but also that services to the poor and disenfranchised provided in a public behavioral setting, contrary to earlier research, can be as effective as those delivered in randomized clinical trials.
Slone, N. C., Reese, R. J., Mathews-Duvall, S., & Kodet, J. (2015). Evaluating the Efficacy of client feedback in group psychotherapy. Group Dynamics: Theory, Research, and Practice, 19, 122-136. doi:10.1037/gdn0000026
The Norway Couple Project: Lessons LearnedBarry Duncan
The document discusses lessons learned from studies on using client feedback to improve outcomes in couple therapy. A large randomized clinical trial in Norway found that routinely collecting and discussing client feedback on progress and the therapeutic alliance using brief measures led to better outcomes compared to treatment as usual. Specifically, couples receiving feedback showed greater improvement in their relationships and were less likely to deteriorate over time. The findings suggest incorporating systematic client feedback into routine practice can help therapists improve outcomes for couples across different therapy approaches.
Feedback condition achieved nearly four times the amount of clients reaching reliable or clinically significant change. Nearly a 50% less separation/divorce at rate at follow up.
PCOMS works with kids too!
Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). School-based counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488.
PCOMS as an Alternative to Psychiatric Diagnosis (Duncan, Sparks, & Timimi, 2...Barry Duncan
Part of an incredible series about diagnostic alternatives by the Journal of Humanistic Psychology edited by Sarah Kamens, Brent Dean Robbins, & Elizabeth Flanagan
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
This article discusses applying research on psychotherapy outcomes, which has shown that common factors like the therapeutic relationship are more influential than theoretical approach or techniques. The article proposes intentionally using the client's frame of reference to enhance common factors and collaboration. It suggests emphasizing the client's perceptions of their relationship with the therapist and understanding of their issues over theoretical perspectives. A client-directed process is outlined that de-emphasizes theory and maximizes common factors and the client's involvement.
This 2 page article, which appeared in The Iowa Psychologist, provides an ultra brief summary of what makes therapy effective (the common factors) and how we can get better at what do: namely, add PCOMS, harvest client existing resources, and rely on that neglected old friend, the therapeutic alliance.
The article discusses the development and research supporting the Partners for Change Outcome Management System (PCOMS). PCOMS uses two brief measures - the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) - to collect feedback from clients at each session on their progress and the therapeutic alliance. The ORS and SRS were developed to be brief and feasible for routine use. Research shows providing therapists feedback based on these measures improves client outcomes compared to treatment as usual. The article outlines how PCOMS was developed and refined, presents supporting research on the measures' psychometrics and clinical usefulness, and discusses examples of implementing PCOMS in behavioral health settings.
This is the validation study of the Group Session Rating Scale (GSRS). In a nutshell, this study found more than acceptable reliability and validity with not only an alliance measure but also with group climate and cohesiveness scales. The GSRS was also predictive of last session outcomes. An RCT comparing PCOMS to TAU in group therapy has been submitted.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
This study investigated whether providing client feedback data to supervisors for use in supervision would influence supervision and counselor self-efficacy. Trainees were assigned to either a continuous feedback condition, where feedback was provided to supervisors, or a no-feedback condition. Results showed that trainees in both conditions improved client outcomes over the year, but those in the feedback condition improved more. However, ratings of supervisory alliance and satisfaction did not differ between conditions. The relationship between counselor self-efficacy and outcomes was stronger for those in the feedback condition, suggesting feedback may facilitate a more accurate assessment of skills.
This article, "Casting a Wider Net in Behavioral Health Screening in Primary Care" found that the ORS identified more clients for behavioral healthcare consultation than the PHQ-9. A first step toward the upcoming RCT with PCOMS in an integrated setting.
Overview of PCOMS and couple and family therapy.
Duncan, B., & Sparks, J. (2017). The Partners for Change Outcome Management System. In J. L. Lebow, A. L. Chambers, & D. C. Breunlin (Eds.), Encyclopedia of Couple and Family Therapy (pp. 1-10). New York: Springer.
Most therapists want to improve their skills and help more clients. However, research shows that factors like personal therapy, specific treatment approaches, training, or experience do not necessarily correlate with better outcomes. After studying thousands of therapists over 15 years, one key factor was identified - "Healing Involvement", where therapists are fully engaged with clients through empathy, skills, efficacy, and handling difficulties constructively. This state can be achieved through career development improving skills over time, self-care reducing burnout, and connection to purpose and values in their work.
This document summarizes a conversation with Saul Rosenzweig, the founder of the common factors approach in psychotherapy. It discusses how Rosenzweig published the first paper on common factors in 1936 but received little attention until later theorists like Carl Rogers, Paul Hoch, Sol Garfield, and Jerome Frank promoted similar ideas in the 1940s-1960s without referencing Rosenzweig. The document reviews how these early common factors theorists were influenced by Rosenzweig's work and compares their perspectives to his original formulations. It then presents an interview with the 93-year-old Rosenzweig, who reflects on the evolution of his thinking and career spanning over 80 years.
Chapter from the book, Duped by Kottler and Carlson. Clients who taught Barry the value of believing clients and even the therapeutic impact of a big fat lie.
Here is a recent chapter I did making the case for a relational perspective in therapeutic services (Duncan, B. (2014). The person of the therapist: One therapist’s journey to relationship. In K. J. Schneider, J. F. Pierson, & J. F.T. Bugental (Eds.). The Handbook of Humanistic Psychology: Leading Edges in Theory, Practice, and Research (2nd ed.) (pp. 457-472). New York: Sage Publications.
This study further supports both the feasibility and the importance of the feedback (PCOMS) intervention. The alliance significantly predicted outcome over and above early change, demonstrating that the alliance is not merely an artifact of client improvement but rather a force for change in and of itself. The study also found that those couples whose alliance scores ascended attained significantly better outcomes than those whose alliances scores did not improve. Together these findings suggest that therapists should not leave the alliance to chance but rather routinely assess it and discuss it with clients in each session
Individual expertise versus domain expertise (2014)Scott Miller
This document discusses the effectiveness of evidence-based practices (EBPs) for veterans with mental illness. It states that EBPs have led to unprecedented improvements for some veterans, not achieved in decades of prior treatment. However, more work needs to be done to refine EBPs and promote their wider use in clinical settings. Veterans and others with mental illness deserve the most effective care available now and in the future.
Running head: THERAPEUTIC ALLIANCE 1
The Therapeutic Alliance
Student’s Name
Institution
The Therapeutic Alliance
Abstract
The therapeutic alliance is a subject m, which has constantly been discussed for several decades. Conferring to several sources and tests, the client-therapist association is an essential secondary and primary factor in the therapy. Research that is conducted by Charles J. Geslo from the University of Maryland. From the experiment, Charles established that the connection among the therapist, along with the client, is linked to the outcome of the medication therapy. What is more, the therapy is the acuity of the client, which adds to the quality of the effect of the medication. In order to have a good and operational liaison between the therapist and client, there are components, which must be available. The conclusions in this paper are to back up the point that the client-therapist affiliation is critical in a session of the therapy.
The therapeutic relationship has always been a debated subject for several decades; few people consider that the relationship does have an impact on the medication results while other people do not approve of this. The therapeutic relationship performs a vital action in the aftermath of the therapy session. The therapeutic relationship comprises of three fundamentals: they include, therapeutic alliance, a dynamic process, as well as a real and personal relationship. Besides, for a long time, there has been extra consideration on the transference along with the therapeutic alliance than in the actual bond amid the clinician and the client. Mr. Charles J. Geslo, who worked at Department of Psychology at the University of Maryland, directed an investigation to discover how the client-clinician relationship influenced the result of the medication. To attain this, Mr Charles Geslo worked with an illustration of 43 patrons in the experiment.
At the start of the medication, he assessed the connection between both the clients and therapists in the early medication sitting. After finalizing the four therapy meetings, Mr. Charles Geslo established that the connection amid the client and the therapists is precisely associated to the results of the medication of the meetings of therapy. Rendering to Geslo, the clients who professed their liaison with the clients positively had good results compared to the clients who negatively perceived the relationship. Through re.
Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescent...HMO Research Network
This document summarizes a study examining the cost-effectiveness of preventing depression in at-risk adolescents. The study involved 316 youth aged 13-17 at high risk for depression due to parental depression or their own subthreshold depressive symptoms. Participants were randomly assigned to receive either a cognitive-behavioral prevention program consisting of group therapy sessions or usual care. Outcome measures included depression-free days and quality-adjusted life years over 9 months. The study also collected cost data on the interventions, usual care services, and parents' time to assess the cost-effectiveness of the prevention program compared to usual care.
Behavioral couples therapy (BCT) is a 12-session substance abuse treatment program for married, engaged, or cohabitating couples experiencing substance abuse issues. BCT was developed in 1976 and focuses on supporting recovery, enhancing the relationship, improving communication skills, and maintaining sobriety. Research shows BCT is effective for couples with one or dual substance-using partners, including women partners. BCT yields better outcomes than individual therapy alone and has shown effectiveness with same-sex couples.
Exploring Adventure Therapy as an Early Intervention for Struggling AdolescentsWill Dobud
This paper presents an account of a research project that explored the experiences of adolescents struggling with behavioural and emotional issues, who participated in a 14-day adventure therapy program in Australia referred to by the pseudonym, ”Onward Adventures.” All participants of this program over the age of 16 who completed within the last two years were asked to complete a survey. Additionally, the parents of these participants were invited to complete a similar survey. The qualitative surveys were designed to question participants’ and parents’ perceptions of the program (pre- and post-), the relationships (therapeutic alliance) built with program therapists, follow-up support, and outcomes of the program. Both participants and parents reported strong relationships with program leaders, stressed the importance of effective follow-up services, and perceived positive outcomes when it came to self-esteem and social skills, seeing comparable improvement in self-concept, overall behaviour, and coping skills.
Benchmarking the Effectiveness of Psychotherapy Treatment for .docxikirkton
Benchmarking the Effectiveness of Psychotherapy Treatment for Adult
Depression in a Managed Care Environment: A Preliminary Study
Takuya Minami
University of Utah
Bruce E. Wampold and Ronald C. Serlin
University of Wisconsin–Madison
Eric G. Hamilton
PacifiCare Behavioral Health
George S. (Jeb) Brown
Center for Clinical Informatics
John C. Kircher
University of Utah
This preliminary study evaluated the effectiveness of psychotherapy treatment for adult clinical depres-
sion provided in a natural setting by benchmarking the clinical outcomes in a managed care environment
against effect size estimates observed in published clinical trials. Overall results suggest that effect size
estimates of effectiveness in a managed care context were comparable to effect size estimates of efficacy
observed in clinical trials. Relative to the 1-tailed 95th-percentile critical effect size estimates, effec-
tiveness of treatment provided in this setting was observed to be between 80% (patients with comorbidity
and without antidepressants) and 112% (patients without comorbidity concurrently on antidepressants) as
compared to the benchmarks. Because the nature of the treatments delivered in the managed care
environment were unknown, it was not possible to make conclusions about treatments. However, while
replications are warranted, concerns that psychotherapy delivered in a naturalistic setting is inferior to
treatments delivered in clinical trials appear unjustified.
Keywords: benchmarking, effectiveness, managed care, clinical trials, depression
More than a decade has passed since estimating the effect of
psychotherapy as it is delivered in natural settings was identified as
a critical issue in psychotherapy research (e.g., Barlow, 1981;
Cohen, 1965; Luborsky, 1972; Seligman, 1995; Strupp, 1989;
Weisz, Donenberg, Han, & Weiss, 1995). Although the benefits of
psychotherapy have been investigated in laboratory environments
with randomized clinical trials (RCTs) and found to be substantial
as early as the late 1970s (Smith & Glass, 1977; also Smith, Glass,
& Miller, 1980), surprisingly little is known about the effects of
psychotherapy in natural settings. The dichotomy of laboratory and
natural settings was emphasized by Seligman (1995), who discrim-
inated between efficacy, which is now used to denote the effects of
psychotherapy in RCTs, and effectiveness, which is used to denote
the effects of psychotherapy in clinical practice.
The few studies that have investigated effectiveness over the
years have provided mixed results, attributed in part to a variety of
methodologies used to investigate effectiveness because of diffi-
culty in using a randomized control group design in natural set-
tings. Notably, three methods have been used to estimate the
effects of psychotherapy in natural settings: clinical representa-
tiveness, direct comparison, and benchmarking. Clinical represen-
tativeness studies, including some of the analyses conducted by
Smith et al ...
This document summarizes and analyzes research on family presence during CPR and invasive medical procedures. It discusses a study by Jensen and Kosowan that surveyed 169 medical professionals on their attitudes towards family presence. The study found that while acceptance of family presence was under 50%, most supported developing policies around it. Other research presented had mixed findings. The document concludes by discussing how nurses can advocate for developing family presence policies based on the evolving research.
This study represents an effectiveness study and service evaluation of a cognitive behavioral, couple-based treatment for depression (BCT-D) provided in London services that are
part of the “Improving Access to Psychological Therapies” (IAPT) program in England.
Biglan et al the critical role of nurturing environments for promoting human ...Dennis Embry
The recent Institute of Medicine report on prevention (National Research Council & Institute of Medicine, 2009) noted the substantial interrelationship among mental, emotional, and behavioral disorders and pointed out that, to a great extent, these problems stem from a set of common conditions. However, despite the evidence, current research and practice continue to deal with the prevention of mental, emotional, and behavioral disorders as if they are unrelated and each stems from different conditions. This article proposes a framework that could accelerate progress in preventing these problems. Environments that foster successful development and prevent the development of psychological and behavioral problems are usefully characterized as nurturing environments. First, these environments minimize biologically and psychologically toxic events. Second, they teach, promote, and richly reinforce prosocial behavior, including self-regulatory behaviors and all of the skills needed to become productive adult members of society. Third, they monitor and limit opportunities for problem behavior. Fourth, they foster psychological flexibility—the ability to be mindful of one's thoughts and feelings and to act in the service of one's values even when one's thoughts and feelings discourage taking valued action. We review evidence to support this synthesis and describe the kind of public health movement that could increase the prevalence of nurturing environments and thereby contribute to the prevention of most mental, emotional, and behavioral disorders. This article is one of three in a special section (see also Muñoz Beardslee, & Leykin, 2012; Yoshikawa, Aber, & Beardslee, 2012) representing an elaboration on a theme for prevention science developed by the 2009 report of the National Research Council and Institute of Medicine. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
International Journal of Humanities and Social Science Invention (IJHSSI)inventionjournals
International Journal of Humanities and Social Science Invention (IJHSSI) is an international journal intended for professionals and researchers in all fields of Humanities and Social Science. IJHSSI publishes research articles and reviews within the whole field Humanities and Social Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
This document summarizes and critiques research on psychoneuroimmunology (PNI) and claims that psychological factors can influence cancer outcomes. It finds that PNI research often relies on weak study designs, ignores negative findings, and overstates small or insignificant positive results. Better designed studies find little evidence that stress influences cancer or that psychosocial interventions impact survival time. The document cautions against overinterpreting immune system changes without considering the system's complexity.
Volume 39 n um ber 2a pril 2017pages i l6 l3 ld o iio .iojas18
This article provides an introduction to narrative family therapy techniques. It discusses the theoretical foundations of systems theory and social constructionism that influence this approach. The article then illustrates various NFT techniques through a case study, such as eliciting family stories, externalizing problems, and reauthoring narratives. It concludes by recommending further development of competence in NFT.
This article examines the preliminary psychometrics of a newly developed measure of the group therapy alliance called the Group Session Rating Scale (GSRS). The study tested 105 clients in substance abuse group therapy. Results provided support for the reliability and validity of the GSRS, showing it measured a single factor related to other measures of group process and predicted early change over the first four therapy sessions. The findings suggest the GSRS may be a useful ultra-brief tool for therapists to assess the group therapy alliance and identify clients at risk for poor outcomes.
To Chart a Course: How to Improve Our Adventure Therapy Practice Will Dobud
Presented at the 8th International International Adventure Therapy Conference in Sydney 2018.
In the most comprehensive adventure therapy study published to date, Bowen and Neill (2013) argued that “a small percentage of adventure therapy programs undergo empirical program evaluation” (p. 41), that being less than 1%. With about three decades of research supporting the efficacy of adventure therapy, though we still have questions about dose-effect and for who adventure therapy is most effective (Gass, Gillis, & Russell, 2012; Gillis & Speelman, 2008; Norton et al., 2014) and adventure therapy performing on par with other therapeutic modalities (Dobud & Harper, 2018), there is little question that adventure therapy stands as a bonafide option as a therapeutic treatment. That is the good news.
With the publication of the first meta-analysis of psychotherapy outcomes, Smith and Glass (1977) found that participants engaging in some type of therapy were bever off than 70-80% of those that received no therapy at all. These encouraging effect sizes were on par with or outperformed many common medical treatments, such as taking an ibuprofen for a headache (Miller, Hubble, Chow, & Seidel, 2013). The psychotherapy clinical trials were conducted with research participants randomly receiving either some type of therapeutic interventions or no treatment at all (Smith & Glass, 1977). The researchers further acknowledged that when participants were randomly selected to receive one of
two different therapies, such as Cogni`ve-Behavioural or Psychodynamic Therapy, no difference in outcomes could be
found despite the theoretical differences of the two. Despite the limited publications and dissertations where adventure therapy was compared to a therapeutic intervention containing no adventurous components, we have a similar issue that adventure therapy tends to perform on par, no greater and no worse, than its counterparts (Dobud & Harper, 2018; Harper, 2010). The specific differences that suggest certain therapies are unique hold little to no variance in outcomes (Ahn & Wampold, 2001). Since Smith and Glass' (1977) pinnacle study, outcomes across psychotherapy have flatlined. Despite a ballooning of new diagnostic criteria and mushrooming of empirically supported treatments, there has been no improvement in outcomes (Asay & Lambert, 1999; Miller et al., 2013; Wampold, 2001). This presentation will attempt to untangle some of the factors put forward by researchers over the last two decades to illustrate those factors most likely to lead to improved therapeutic outcomes, such as establishing goal consensus with clients, improving the therapeutic relationship, and monitoring outcomes (Lambert, 2010; Wampold, 2001). Though this workshop will present some of these important findings, the presentation will stage my experiential journey in reaching out to coaches, researchers, and supervisors in trying to improve my outcomes as a therapist, one client at a time.
The document summarizes seminars from the SUNLOWS 2013 seminar series on research studies related to mental health. It describes 6 studies presented at various seminars, including studies on caregiving for those with psychosis, interventions to assist caregivers of people with anorexia nervosa, service users' experiences of recovery programs, and a study comparing family therapy approaches for at-risk youth. The studies covered topics like developing models of caregiver relationships, how caregiver traits impact patient functioning, reducing caregiver distress and improving coping skills, and investigating treatment approaches for conditions like anorexia nervosa and antisocial behavior in youth.
The document discusses research on whether using a continuous feedback system called the Partners for Change Outcome Management System (PCOMS) can improve psychotherapy outcomes. PCOMS involves clients completing brief measures after each session to assess treatment progress and the therapeutic relationship. Studies found that clients who used PCOMS with their therapists demonstrated statistically significant treatment gains compared to those receiving usual treatment and were more likely to experience reliable change in fewer sessions.
·Response GuidelinesReply to the posts of two peers in thi.docxlanagore871
·
Response Guidelines
Reply to the posts of two peers in this discussion. Share any professional or personal insights you may have that are related to your peer's research problem. Comment on how it might benefit you as a counselor if research on your peer's research problem were conducted.
First Peer’s Post
Since, Trauma Focused- Cognitive Behavioral Therapy or TF-CBT has been found to be very successful with children and adolescents why hasn't there been much if any research done to see if it would be effective for adults as well? TF-CBT is an evidence based program that addresses childhood symptoms of PTSD
(
Sigel
, Benton, Lynch, & Kramer, 2013)
. Research has shown that TF-CBT it has as "well-established" efficacy and in a recent study it was the only treatment to be given the highest rating in all reviews
(Sigel, Benton, Lynch, & Kramer, 2013)
. Having used the treatment method myself with a client during my internship I've seen the effectiveness first hand on how it can impact a client in a positive manner. While the treatment was made with children in mind, it brings up the question of why it hasn't been tweaked in a way that it might benefit an adult as well.
What's great about TF-CBT is it's almost like a bunch of different treatments all wrapped up into one. Each treatment is essentially put into a unit or section that the counselor and client will work on. Some of the sections include psycho education, stress management, cognitive coping, etc.. Stress management, in my opinion, is probably one of the most important sections to go over with the client. If the client doesn't know how to deal with their stress than the rest of the treatment will be for naught because the client won't be able to control their stress. The stress management section focuses on teaching the cl controlled breathing, thought stopping and relaxation techniques.
A mind-body skills program was made in Gaza to essentially determine how effective these things were for people's overall quality of life in people with PTSD, depression, and anxiety
(Gordon, Staples, He, & Atti, 2016)
. They did a 10 session mind-body skills group that included meditation, guided imagery, breathing techniques, autogenic training, biofeedback, genograms, and self-expression through words, drawings, and movement
(Gordon, Staples, He, & Atti, 2016)
.
At the end of the program they found a significant improvement in overall quality of life in the clients that participated in the program, and at a 10 month follow-up the improvements were fully maintained
(Gordon, Staples, He, & Atti, 2016)
. This shows that one of the major parts of treatment in TF-CBT can be effective and makes me wonder even more if more research was done could an adult-version of TF-CBT be made and implemented while still be as effective and successful as the child/adolescent version
Resources:
Gordon, J. S., Staples, J. K., He, D. Y., & Atti, J. A. (2016). Mind–body skills groups for posttr.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
Andreas Schleicher, Director of Education and Skills at the OECD presents at the launch of PISA 2022 Volume III - Creative Minds, Creative Schools on 18 June 2024.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
2. Footprints of Couple Therapy 23
Couple therapy has a proven record of efficacy over no treatment, with
an effect size (ES) ranging from of 0.59 (Shadish & Baldwin, 2005) to 0.84
(Shadish & Baldwin, 2002). However, couple treatment in routine care often
falls short of controlled trials outcomes (Christensen & Heavey, 1999). For
example, Hahlweg and Klan (1997) reported an ES of 0.28 for practicing
couple clinicians in Germany. Anker, Duncan, and Sparks (2009) found that
only 10.8% of couples receiving usual care in a naturalistic setting achieved
clinically significant change (Jacobson & Truax, 1991) compared to 40.8%
of couples in the experimental feedback condition. Findings regarding the
durability of couple treatment are similarly mixed. Several reviews have
concluded that as many as 30% to 50% of couples relapse 1 to 4 years post-
treatment (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; Christiansen &
Heavey, 1999; S. Johnson & Lebow, 2000). In contrast, gains at 2-year follow-
up after brief couple clinic treatment in Sweden were largely maintained
(Lundblad & Hansson, 2006). In a study of long-term follow-up of 130 cou-
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ples, 69% of couples receiving integrative behavioral therapy were improved
at follow-up compared to 60% of those receiving traditional behavioral ther-
apy (Christensen, Atkins, Yi, Baucom, & George, 2006). Both groups initially
dipped in marital satisfaction immediately post termination but rebounded
and remained significantly improved throughout the remainder of the 2-year
follow-up period.
Despite variations in rates of success and durability of effects, cou-
ples receiving treatment do better, on average, than those untreated. One
variable consistently associated with outcome in couple work is the thera-
peutic alliance (e.g., Bourgeois, Sabourin, & Wright, 1990; Brown & O’Leary,
2000; Raytek, McCrady, Epstein, & Hirsch, 1999). In one study, the alliance
explained as much as 22% of the variance in outcome (Johnson & Talitman,
1997), with the bulk attributable to the task subscale of the alliance
measure—couples who felt that the therapist’s method was relevant to their
presenting concern did the best, accounting for 27% of posttreatment vari-
ance in outcome and 36% at follow-up. Knobloch-Fedders, Pinsof, and Mann
(2007) found that the therapeutic alliance is a strong predictor of marital dis-
tress posttreatment, explaining 5% of the variance in marital distress for men
and 17% for women. Analyzing alliances of couples treated in a naturalistic
setting, Anker, Owen, Duncan, and Sparks (2010) reported that the alliance
predicted outcome over and above early change suggesting that the alliance
is not simply a by-product of successful treatment. Moreover, couples with
ascending alliances reported significantly better couple outcomes, suggesting
that ongoing alliance assessment is warranted.
Client perceptions of fit appear to play a role in alliance formation, as
clients tend to experience therapy idiosyncratically. Bischoff and McBride
(1996) found that clients held definite views regarding the helpfulness of
techniques, but these views varied from one client to another. One study
3. 24 M. G. Anker et al.
of therapists’ and clients’ perceptions of critical change incidents in couple
therapy reported little resemblance between the two perspectives (Wark,
1994). Bedi, Davis, and Williams (2005), analyzing client perceptions of
critical incidents, found a discrepancy between clients’, therapists’, and
investigators’ views of the alliance. Similarly, Helmeke and Sprenkle (2000)
reported that spouses concurred very little with one another and with the
therapist in identifying pivotal moments in their therapy. In another study,
clients appreciated therapists who encouraged them to determine the session
focus without having to adopt a particular world view and who ensured that
discussions were relevant to presenting concerns (Quinn, 1996). Similarly,
Kuehl, Newfield, and Joanning (1990) found that clients welcomed therapists
generating directions when these fit with clients’ unique views of change.
Finally, although general domains of change were identified in an anal-
ysis of interviews with 13 heterosexual couples, the specific pathways to
change were variable and multiple (Christensen, Russell, Miller, & Peterson,
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1998).
Gender weighs in as an important consideration in couple therapy
alliances although findings vary. Bourgeois et al. (1990) found that men’s
alliance ratings at the third session more strongly predicted outcome than
women’s. Knobloch-Fedders et al. (2007) reported that when men scored the
alliance higher than their partners at mid-treatment, couples showed greater
improvement. Similarly, the correlation between alliance and outcome was
greater when males rated the alliance higher than females in one study
(Symonds & Horvath, 2004), and men’s alliance scores were stronger predic-
tors of therapy outcomes at post and follow-up as compared to their partners
in another (Anker et al., 2010). In contrast, Knobloch-Fedders et al. found
that women’s ratings of the couple’s alliance at mid-treatment uniquely pre-
dicted improvement beyond that accounted for by early alliance ratings.
In addition, Pinsof, Zinbarg, and Knobloch-Fedders (2008) reported that
women’s first session alliance scores predicted eighth session individual and
couple outcomes. Finally, Knobloch-Fedders et al. found that both men’s and
women’s early and mid-treatment alliance scores predicted improvement. In
sum, how gender influences couple alliance formation and outcome needs
more investigation.
Although there are few studies in the couple therapy literature regard-
ing therapist variability (Blow, Sprenkle, & Davis, 2007; Sparks & Duncan,
2010), data suggest that the therapist’s ability to forge a working alliance
with both members of a couple impacts how well couples do in treatment.
Owen, Anker, Duncan, and Sparks (2010) found that therapists accounted
for 6% of the variance in outcome in their study of 118 couples, with alliance
scores at the third session explaining 33% of that variability. Therapists work-
ing with couples must form simultaneous, nonconflicting working alliances
in an often emotionally charged atmosphere. Qualitative analyses of client
4. Footprints of Couple Therapy 25
perceptions indicate that therapists who are accepting, caring, and empathic
and who also are capable of providing structure may be the most adept in
negotiating these types of complex relational tasks with couples (Bischoff
& McBride, 1996; Bowman & Fine, 2000; Green & Herget, 1991; Kuehl
et al., 1990; McCollum & Trepper, 1995). One ethnographic study found that
clients want therapists to provide safety and meaningful input (Sells, Smith,
& Moon, 1996). Clients expressed dissatisfaction when goals were unclear
and therapy lacked direction. Safety and therapist qualities of being non-
judgmental, validating, and supportive while showing genuine interest were
mentioned as helpful in interviews with five heterosexual couples (Bowman
& Fine, 2000). Holtzworth-Munroe, Jacobson, DeKlyen, and Whisman (1989)
concluded that client involvement in the tasks of therapy, considered a prod-
uct of the therapeutic alliance, predicted the success of 32 couples in their
study. They suggested that the proportional contributions of the client and
therapist in this process needed further examination.
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The impact of using client feedback to inform treatment decisions (see
Howard, Moras, Brill, Martinovich, & Lutz, 1996) was recently tested in a
large (N = 205 couples) randomized trial in a naturalistic setting in Norway
(Anker et al., 2009). Investigators found that couples whose therapists con-
tinuously incorporated alliance and outcome feedback throughout treatment
achieved nearly four times the rate of clinically significant change com-
pared to their nonfeedback counterparts (40.8% and 10.8%, respectively).
Moreover, couples in the no-feedback condition were more likely to be
divorced or separated (34.2%) than those in the experimental feedback con-
dition (18.4%) 6-months posttreatment. These findings are consistent with
those from individual feedback trials. For example, Lambert (2010) summa-
rized the findings of five randomized clinical trials and found that at-risk
cases where therapists and clients had routine access to client feedback
were over twice as likely to reach reliable and clinically significant change
(Jacobson & Truax, 1991) compared to treatment as usual at-risk cases.
Although Anker et al. (2009) admit that the “how and why” of feedback
needs more study, they suspect that greater attention to the alliance may
prevent deterioration and dropout (p. 702).
Understanding how clients experience therapy contributes to knowl-
edge of therapeutic process with implications for predicting outcome and
improved effectiveness (Elliott, 2008). The current study hopes to expand
the emerging picture of couple therapy through an analysis of couples’
reflections posttreatment. It examines the written client responses to three
open-ended questions about client experiences in couple therapy as part
of a 6-month follow-up at two community counseling agencies in Norway.
Answers from clients who had completed a randomized trial comparing
outcomes for continuous feedback and nonfeedback couples (Anker et al.,
2009) allowed a comparison of qualitative responses between these groups.
5. 26 M. G. Anker et al.
A subset of clients were asked to rate their experience of the use of feedback
instruments during their treatment; an analysis of these ratings is included.
The following questions guided the current study:
1. What aspects of couple therapy do couples identify as most salient?
2. How do aspects identified by couples as meaningful expand under-
standing of the alliance, the role of the therapist, and gender in couple
treatment?
3. What different experiences, if any, emerge for couples whose therapists
used systematic feedback compared with those who did not?
4. How did couples experience their use of feedback protocols during
therapy?
The study utilized thematic analysis (Braun & Clarke, 2006) to generate
categories, domains, and evaluations of responses and quantitative methods
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to compare responses based on gender and study condition (i.e., feedback
vs. nonfeedback).
METHOD
Sample
Couple clients were invited to participate in a research study about improv-
ing the benefits of therapy. At 6-month follow-up, 519 of 918 clients (56.54%)
responded to the questionnaire. Couples were white, Euro-Scandinavian,
and heterosexual from two outpatient counseling offices in Norway provid-
ing free government subsidized services in southern Norway. Participants
were recruited from October 2005 to December 2007. Respondents’ ages
ranged from 20 to 72; mean age was 38.2 years (SD = 8.71). Mean years as
a couple was 10.87 (SD = 7.89). Couples had between 1 and 16 sessions;
mean number of sessions, 4.03 (SD = 2.73); 66 clients (12.7%) had 1 ses-
sion; modal number of sessions was 2 (121 clients; 23.3%). Three hundred
and sixty-three (69.9%) participants were employed full time and 58 (11.2%)
were employed part time, whereas 98 (18.9%) were unemployed or did not
work outside the home.
Regarding education levels, 125 (24.1%) had completed lower sec-
ondary school, 193 (37.2%) had completed upper secondary school, and
195 (37.6%) had completed university or college. Six individuals left this
question blank. Couples self-referred to the agencies with a broad range
of typical relationship problems, including communication difficulties, loss
of feeling for partner, jealousy/infidelity, conflict, and coping with partner’s
physical or psychological problem. Couples were excluded at phone intake
6. Footprints of Couple Therapy 27
when one member refused to attend, one or both members of the cou-
ple expressed the desire to end the relationship, or one or both refused
informed consent.
Before the first session, study participants were asked to identify their
goals on a standard intake form. Three hundred seventy-nine (73.03%)
participants marked the goal of achieving a better relationship, whereas
118 (22.74%) sought clarification regarding whether the relationship should
continue. Fourteen individuals (2.7%) indicated a goal of terminating the
relationship in the best possible way and another 8 (1.54%) marked “other”
without elaboration. Three hundred sixteen (60.89%) individuals were in a
relationship where both marked the goal of achieving a better relationship,
while 203 (39.11%) were in a relationship where both had not marked the
goal achieving a better relationship. The mean intake score of the 519 par-
ticipants on the Outcome Rating Scale (ORS; Miller, Duncan, Brown, Sparks,
& Claud, 2003) was 18.96 (SD = 7.54), indicative of a clinical popula-
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tion and similar to distress levels of other clinical sites (Miller & Duncan,
2004). Similarly, the mean marital satisfaction score on the Locke-Wallace
Marital Adjustment Test (Locke & Wallace, 1959) was 73.88 (SD = 25.93),
indicative of a dissatisfied relationship and well under the traditional cutoff
score of 100.
Of those responding to the questionnaire, 382 (73.6%) answered the
two open-ended questions about their experiences in therapy. These respon-
dents (225 women and 157 men) constituted our qualitative subsample.
In this sample, women had contacted the family counseling office 61% of
the time. A portion of these 382 respondents (n = 197) had participated
in a large, randomized clinical trial comparing feedback and nonfeedback
conditions in routine practice (Anker et al., 2009). These individuals com-
prised the randomized clinical trial (RCT) subsample. Also of the 519 clients
responding to the questionnaire, 377 marked the check-off survey questions
regarding their experience of their use of feedback instruments in therapy.
These respondents made up the feedback survey subsample.
Clients from the RCT and feedback survey subsamples had been given
the ORS1 at the beginning of each session. Results from this measure were
scored by the therapist and discussed with couples at each session (see
Duncan, Miller, & Sparks, 2004). The ORS asked clients to rate their view of
distress along individual, interpersonal, social, and overall domains. In addi-
tion, the Session Rating Scale (SRS; Duncan et al., 2003) was administered at
the end of each session. This instrument asked clients to score their view of
the strength of the therapeutic alliance based on dimensions of the alliance
described by Bordin (1979). These included clients’ felt connection to the
therapist as well as agreement on goals and tasks.
1
The ORS is free for individual clinician use and can be downloaded at www.heartandsoulofchange.com
7. 28 M. G. Anker et al.
Questionnaire
Each member of the couple received their own questionnaire. Respondents
formulated their answers in writing in their own home without a researcher
present. The questionnaire asked clients to respond to a series of questions
regarding outcome and satisfaction. These questions inquired about the cur-
rent status of the couple (e.g., together, separated, or divorced), the problem
presented in the prior therapy (e.g., better, worse), and the quality of the
couples’ communication since the end of therapy (Anker et al., 2009). Those
clients who had utilized feedback instruments throughout treatment were
asked to check the box that best matched how they had experienced the
feedback process (e.g., helpful, not important). The questionnaire concluded
with three questions, inviting clients to express their views further in writing
(see Appendix 1):
How did you experience the contact with the family counseling office and
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the therapist?
Was there something missing?
Was there something you were satisfied with?
Client answers to these three questions and the checked boxes regarding
experiences using feedback provided the data for the current study.
Therapists
Couples were seen by 20 therapists (13 women and 7 men). Therapists
worked at two family counseling agencies in Norway, 10 therapists from
each agency. Ten were licensed psychologists, nine were licensed social
workers, and one was a licensed psychiatric nurse. All therapists professed
an eclectic orientation using a variety of approaches—solution-focused,
narrative, cognitive-behavioral, humanistic, and systemic—similar to those
typically practicing in Norway family counseling agencies. The average age
of the therapists was 44 years (SD = 12.6 years), age ranged from 26 to
61 years. The mean years of experience with couple therapy was 6.7 years
(SD = 6.98 years) experience ranged from 0 to 19 years.
Analysis
Two researchers independently read all client responses to 6-month follow-
up, open-ended questions several times, dividing clients’ written replies into
statements. Statements consisted of clients’ descriptions, generally a phrase
or brief sentence, of a dimension of their therapy. Next, statements were
coded thematically. Themes emerged from the data (Glaser & Strauss, 1967;
Kvale, 1996). Similar themes were collected into a category, which was
8. Footprints of Couple Therapy 29
then given a cue word or words (Thagaard, 1998). Clients’ statements were
also categorized into subcategories of evaluation (satisfied/problematic).
To maintain an open mind and to view client statements from a fresh
perspective, the couple therapy research literature was reviewed after
categorization.
After independent coding, we compared our separate analyses.
Categories derived independently from multiple readings produced a satu-
ration of content (Strauss & Corbin, 1998), suggesting that relevant meaning
units were reached from the existing data. Fifteen final categories (numbered
0–14) surfaced in this step. Finally, we examined this list for connections
between categories to create an additional level of general domains.
The following illustrates the method described previously, using the
following client’s statement:
Was very satisfied to have a neutral conversation partner who had a struc-
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ture for the conversation, provided competence with different strategies
we could use, gave feedback on the good things we did that contributed
so that we found and can find solutions ourselves.
This response was coded in the following way:
Neutral conversation partner = satisfied (neutrality)
Who had a structure for the conversation = satisfied (therapist’s
structure/guiding the session)
Competence with different strategies we could use = satisfied (instrumental)
Gave feedback on the good things we did that contributed = satisfied
(acknowledging positive actions)
Descriptive statistics were used to illustrate the number of responses
by category and by evaluation (satisfied/problematic). Analysis by feed-
back condition utilized chi-square analyses to determine significance of
differences in responses based on feedback and nonfeedback conditions.
RESULTS
In the qualitative subsample, 225 woman and 157 men answered the open-
ended questions with 742 statements about their experience with the family
counseling office and the therapist. The mean number of statements was 1.94
(SD = .93) and the median was 2 (range 1–7). Ninety-eight clients provided
statements from the feedback condition in the RCT subsample and 99 non-
feedback clients responded. Respondents from the RCT subsample made
385 statements (approximately 52% of the total statements). There were
9. 30 M. G. Anker et al.
191 statements made by feedback clients compared to 194 by nonfeedback
clients. The mean numbers of statements in the feedback and nonfeedback
groups were 1.95 (SD = 1.11) and 1.96 (SD = .87), respectively, with a
median of two statements in each, representing a nondifferential distribution
of numbers of statements among responders in each group, t(195) = –0.08,
p > .05. In response to the feedback survey, 377 persons responded to
check-off questions indicating their experience of use of the measures.
Categories
The following 15 categories (with exemplars) emerged from analyses of the
742 statements:
0. Unspecified: “Satisfied with the therapy.” “Was very satisfied with the
work you did.”
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1. Therapeutic setting: “To have an arena to raise the problems.” “Easy and
calm atmosphere.” “Good to talk to a third party.”
2. Therapists’ characteristics: “Humor, the therapist was very sympathetic,
so it was easy for both of us to talk.” “The therapist showed insight and
was skilled.”
3. Relationship with the therapist: “Established a good trusting relationship
with the therapist.” “The therapist also revealed some information from
his personal life experience. That makes it easier for others to open up.”
4. Therapist’s structure/guiding the session: “Having an objective chair-
man.” “The possibility to speak without interruption.” “Having a more
explicit guiding from the therapists of the sessions.”
5. Neutrality: “We only had one session, but it was nice that my husband
also felt appreciated.” “I felt the therapist was objective and neutral.”
“That the therapist understood both sides of the case.”
6. Individual sessions: “Missed time alone with the therapist.” “Could
have had more sessions separately.” “Satisfied with the separate
conversations”
7. Acknowledging positive actions: “In the first session we got a homework
assignment to search for positive signs that was a very good start.” “A
positive acknowledging to both.” “. . .focus on the positive”
8. Instrumental: “I missed that we could end the sessions with a plan so we
could continue the work at home.” “We got good suggestions about what
we could do, and it helped.” “Missed a bit more concrete homework.
For example to do something concrete, not only reflect on what has
been said or what we ought to do.”
9. New angle: “Felt that we were helped to put things in perspective.”
“I missed greater input to new ways of thinking.” “We were helped to
frame the problems in a very different way than what we could have
done ourselves.”
10. Footprints of Couple Therapy 31
10. Challenge/straightforward: “I missed some critical comments from the
therapist to both him and myself.” “More direct questions because I
omitted to tell everything.” “Demanded answers and opinions—pushed
us a little.”
11. Central/depth/causal connections: “Go more in depth in what I/we
thought was important.” “Missed dealing with the essential aspects of
the problems.” “He helped me go further into my self than I ever had
done before.”
12. Communication in session: “The way we talked all three of us.” “We
managed to say a lot more to each other, than we would have man-
aged at our own.” “It was easy to talk about the problems without us
screaming at each other.”
13. Service delivery: “We had too few sessions.” “The second session was
cancelled due to illness at the family counseling office. It was especially
at that point we needed the session.” “Missed the possibility to have
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sessions outside my work schedule.” “The therapist should have insisted
on scheduling more sessions.” “The therapist was nice but forgot to
schedule another session.” “The therapist was especially conscientious
with regards to phoning us to make a new appointment or when I had
some questions.” “That we could have follow-ups at regular intervals.”
14. Relapse: “After three sessions the problems did not appear so huge, but
in a short time we were back to quarrelling, irritated about the same
issues, and continued in the same pattern.” “During the period we were
in therapy things were better, but now things fell back into their old
groove.”
Figure 1 illustrates the distribution of evaluations (satisfied/problematic)
for each category for the qualitative subsample. Of a total of 742 state-
ments, 527 were determined “satisfied” compared with 215 statements,
“problematic.”
Domains
Two groups of general domains emerged when exploring connections
between categories—relationship and tasks. Domains included the following
categories:
Relationship: therapeutic setting, therapists’ characteristics, relationship
with the therapist, and neutrality
Tasks: therapists’ structure/guiding the session, individual sessions,
instrumental, new angle, challenge/straightforward, making central/
depth/causal connections, communication in session, and service
delivery
11. 32 M. G. Anker et al.
120
Satisfied
Problematic
100
Number of Statements
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Categories
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0. Unspecified: good/satisfied-not satisfied.
1. Therapeutic setting.
2. Therapists´ characteristics.
3. Relationship to the therapist.
4. Therapist’s structure/guiding the session.
5. Neutrality.
6. Individual sessions.
7. Acknowledging positive actions.
8. Instrumental.
9. New angle.
10. Challenge/straightforward.
11. Central/depth/causal connections.
12. Communication in session.
13. Service delivery.
14. Relapse.
FIGURE 1 Profile of Client Evaluations of Categories (742 Statements) From Qualitative
Subsample (n = 382 Clients)
The role of the therapist, and qualities valued, or disliked, related to the ther-
apist, were embedded within these two domains. For example, in addition
to the straightforward therapist’s characteristics, respondents expressed their
views about what helped them feel comfortable and safe with their thera-
pist, what they liked about what the therapist did, and what they wish the
therapist had done differently. Acknowledging positive actions encompassed
elements of the relationship and tasks. Relapse was not grouped under either
domain, appearing to represent general feelings of disappointment in lack
of overall progress.
Of all statements, 38.7% (287 statements) expressed relationship cate-
gories (1, 2, 3, and 5). As Figure 1 depicts, clients felt satisfied with these
elements of their therapy by an overwhelming margin. Following are exam-
ples of client statements in categories 2, 3, and 5, those with the most
responses in the relationship domain.
12. Footprints of Couple Therapy 33
Therapists’ characteristics (2):
Had a good sense of humor.
Humor, therapist was very sympathetic/pleasant, in a way that it was easy
for both of us to talk.
She had good motivating skills.
Our therapist was very professional and nice.
Satisfied with her humanity.
The therapist appeared insightful and competent.
Very nice therapist and helpful and clever.
Very positive that it was a man, thinking in relationship to my husband.
He was calm and warm.
A good listener.
A comfortable therapist. Got me to relax. Had a bit of humor.
Experience the therapist as open, competent, flexible.
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The therapist had the skill to get the conversation started
Relationship to the therapist (3):
Good connection.
Felt that we got a very good connection with the therapist
Established fast a good and trusting relationship to the therapist.
Therapist did even reveal some personal matter. This makes it easier for
others to open up.
The chemistry with the therapist.
Neutrality (5):
He was good at meeting both of us.
Satisfied with her neutrality.
Competent therapist that managed to see both parties.
That both parties were listened to and valued equally.
Skillful in illuminating both sides.
That the therapist was neutral to both of us.
The tasks domain encompassed eight categories (4, 6, 8, 9, 10, 11,
12, and 13), including the therapist’s activities of structuring the session,
being instrumental, providing a new angle, challenging, making central or
causal connections, and providing an effective service delivery framework
for sessions and therapy in general. Statements (261) in these categories
cover 35.2% of all statements. Clients experienced more problems in this
domain than in the relationship domain (see Fig. 1). The category service
13. 34 M. G. Anker et al.
delivery contained 56 statements, the most for any category in the tasks
domain. These statements were particularly negative:
We had too few sessions.
More sessions and the possibility to meet in the evening.
The sessions ended because the therapist had excuse on account of
illness.
Therapist should be more firm to schedule more sessions.
We had to change the session and the session we changed to, did not fit
the therapist. And we heard nothing from him. The follow up was bad.
Many clients in this study expressed the desire for the therapist to follow
them more closely and take the initiative for a new session, regardless of
whose fault it was for missed sessions. Couples frequently stated that they
wanted the therapist to provide more and flexible meetings. Some clients
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stated that they wished to have individual sessions or the opportunity to
have more individual sessions than they were granted.
Clients requested more instrumental action and challenge from their
therapist. The following are examples of these sentiments:
Missed some concrete matters that we could work on. The conversations
often do not lead to or end in something tangible that we could
work further on.
It was too much focus on how things were before. That was not positive
for us. Missed ideas on how we could get a better life now!
I missed more structure. Constructive advice—not so much talk about
feelings (“What do you feel when he says that?”).
Everything was too uncertain and vague; we were in need of advice and
guiding with different specific problems.
In this category, negative statements referred exclusively to a desire for
greater instrumentality; there were no statements expressing dissatisfaction
with too much therapist instrumental activity.
Although therapist’s structuring/guiding the session had more satisfied
than problematic comments, this category garnered the fourth most negative
statements in the tasks domain. The following client’s response illustrates the
importance of this therapist activity:
I missed that the therapist structured the dialogue onto a constructive
track. Our sessions degenerated in a way that my partner exclusively
monopolized the time and continually lied and raged against me. I expe-
rienced this as very insulting and definitively not constructive. In my
opinion it was the therapist’s responsibility to stop/subdue this, which
14. Footprints of Couple Therapy 35
the therapist did not do. It was a painful and a degrading experience to
have to go through this.
The category communication in session encompassed couples views of
whether they found new ways of talking or repeated negative communica-
tion in the therapy sessions. In general, respondents expressed satisfaction
that therapy was a place where a different kind of communication could
occur between partners.
Gender
The 382 informants in our qualitative subsample consisted of 225 women
and 157 men. Of a total of 742 statements, 478 were made by women
and 264 by men. Women had 335 satisfied and 143 problematic state-
ments compared with 192 satisfied and 72 problematic for men. Based on
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these numbers, women had 2.34 times as many positive to negative state-
ments, whereas men had 2.67 times as many positive than negative. We
conducted a 2 (Statement) × 2 (Gender) repeated measures analysis of vari-
ance (ANOVA). The main effects for Statement was statistically significant,
F(1, 380) = 144.03, p < .001, but the Statement by Gender interaction was
not statistically significant, F(1, 380) = 0.44, p > .05. There was a signifi-
cant effect for Gender, F(1, 380) = 22.20, p < .001, as women listed more
statements (M = 2.13, SD = .97) as compared to men (M = 1.68, SD =
.78). Collectively, these results suggest that although women listed more
statements than men, both men and women reported more satisfied than
problematic statements.
Women’s and men’s interest in categories largely mirrored one another.
In fact, only two categories revealed gender differences. Figure 2 shows the
distribution of clients with satisfied and problematic statements by gender.
As seen in Figure 2, women had more satisfied responses in the category
relationship to the therapist χ 2 (1, N = 382) = 11.44, p < .05. Approximately
29% of women and 14.6% of men listed a comment reflective of this cate-
gory. For example, one woman commented: “We felt that we had very good
contact with the therapist.”
Although the base rates for satisfied with service delivery were low,
women (6.7% of all women) listed more satisfied comments than men (1.9%
of all men) for this category, χ 2 (1, N = 382) = 4.66, p < .05. There were
no other significant differences between men and women for the other
categories (ps > .05).
Feedback and Nonfeedback Conditions
Figure 3 depicts the total distribution of clients who reported satisfied and
problematic statements for feedback and nonfeedback conditions derived
15. 36 M. G. Anker et al.
70
Men satisfied
60 Men problematic
Women satisfied
50 Women problematic
Number of Clients
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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Categories
FIGURE 2 Profile of Problematic/Satisfied Categories for Men and Women From the
Qualitative Subsample (n = 382 Clients)
from our RCT subsample. As indicated, most statements fell within cate-
gories 2, 3, 8, and 13 (excluding unspecified). The clients and feedback
condition did not differ in their satisfied or problematic statements for cat-
egories 2, 3, and 8 (ps > .05). However, nonfeedback clients made more
negative statements related to category 13, service delivery, χ 2 (1, N = 197)
= 6.49, p < .01. More nonfeedback clients were unhappy with the thera-
pist’s attempts to follow up with them or take the initiative for a new session,
even if the client had dropped out or misunderstood when a session was
scheduled.
Fit
This study found evidence that, even when clients had the same therapist,
experiences tended to be unique to the therapy dyad. This phenomenon
is vividly illustrated with the following examples from two different clients
with the same therapist.
Client A:
Was very satisfied to have a neutral conversation partner who had
a structure for the conversation, provided us with competence with
different strategies we could use, gave feedback on the good things
we did that contributed so that we found and can find solutions
ourselves.
16. Footprints of Couple Therapy 37
35
Feedback satisfied
TAU satisfied
30
Feedback problematic
TAU problematic
25
Number of Clients
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Categories
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FIGURE 3 Profile of Satisfied/Problematic Categories for Feedback and Nonfeedback
Conditions From the Randomized Clinical Trial (RCT) Subsample (n = 197 Clients)
Client B:
I missed more structure. Constructive advice—not so much talk about
feelings (“What do you feel when he says that?”). Everything was too
uncertain and vague, we were in need of advice and guidance on
different specific problems.
Even when the therapist was the same person, clients differed in their views
of that therapist’s effectiveness. Interestingly, in the previous example, client
B was in the nonfeedback condition in which the therapist was not provided
alliance feedback. Comments from other clients in the feedback condition
illustrated the value of attending to unique client meanings and preferences
for how the treatment should proceed:
Felt that the therapist came up with several bad ideas in the beginning
of the therapy, but I think the ideas got better and better every time
(from session to session) Yes, and the therapist’s skills in improving their
techniques and ideas, I think this is the key to solving many conflicts in
relationships.
Experience of Feedback
Clients from the feedback survey subsample (n = 377) rated their experience
of using feedback instruments routinely during treatment. The fixed alterna-
tives they could mark were “disturbing,” “not important,” “useful/helpful,”
17. 38 M. G. Anker et al.
90
80
70
60
50
%
40
30
20
10
0
Disturbing Not important Useful/helpful Useful/helpful. Do not
Individual goal remember
better rel.
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FIGURE 4 Distribution of Clients’ Responses of Their Experience of Use of Feedback From
the Feedback Survey Subsample (n = 377 Clients)
and “do not remember” (see Appendix 1). Of these clients, 60.7% marked
“helpful/useful,” rising to 83.7% when their own goal was achieving a better
relationship, compared to 6.6% who marked “disturbing.” Figure 4 indicates
the distribution of clients’ responses of their experience of use of feedback.
DISCUSSION
This study analyzed 742 written client responses from 382 individuals in
our qualitative subsample to three questions as part of a 6-month follow-
up of couple therapy in a routine clinical setting in Norway. Because of the
number of respondents and statements, the categories generated were partic-
ularly robust, and the emergent themes more likely reflect attitudes couples
might hold about what is helpful and unhelpful in couple counseling. By
responding without a therapist or researcher present, at their own pace,
and 6 months after the conclusion of therapy, clients may have provided
particularly thoughtful reflections unencumbered by concerns for the ther-
apy relationship. Additionally, responses from the RCT subsample provided
data to compare the experiences of clients who utilized routine feedback
measures throughout their treatment with those who did not. Finally, check-
off questions answered by our feedback survey subsample added to the
picture of how clients experienced the use of a feedback protocol in their
therapy.
18. Footprints of Couple Therapy 39
Our analysis of client responses to open-ended questions about their
therapy experiences connected categories under two broad domains: rela-
tionship and tasks. These domains correspond with similar groupings in
couple therapy literature (Bishcoff & McBride, 1996; Green & Herget, 1991;
Sells et al., 1996). Moreover, they mirror Bordin’s (1979) definition of the
alliance. In total numbers, more comments referred to relationship cate-
gories, and these comments more often expressed satisfaction than those
in the tasks domain. Statements regarding therapist warmth and friendliness
along with the therapist’s ability to listen well and remain neutral were well
represented, as they are in the literature. Respondents frequently commented
on therapist neutrality and these comments were largely positive. Neutrality
perhaps represents a unique quality of couple therapy. Many individuals in
this study did not appear to want the therapist solely on his or her side.
Instead, respondents often expressed an appreciation for therapists’ forming
balanced relationships during their therapy. That respondents commented
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frequently in these areas may reflect the value clients place on feeling at
ease with their therapist and trusting that the therapist has the couples’, not
just the individuals’, best interest at heart.
The greatest number of negative comments occurred in the tasks
domain. Specifically, respondents often wrote that they wished their ther-
apist had given more tangible and usable advice. These findings support
conclusions from Helmeke and Sprenkle (2000) and Denton, Burleson,
Clark, Rodriguez, and Hobbs (2000) that stressed the importance clients
place on practical suggestions relevant to their lives. Similarly, Sells et al.
(1996) concluded that many clients value having clear directions from ses-
sion to session. Studies further indicate that couples want their therapist to
provide structure and a safe space for frank and often highly charged con-
versation (Bowman & Fines, 2000; Christensen et al., 1998). The number
of negative expressions in instrumental and challenge/straightforward cate-
gories suggests that these are areas that could benefit from greater attention
by practicing clinicians.
That more problematic statements emerged in tasks categories overall
suggests that therapists may be less practiced in, or deem less valuable,
behaviors clients want, specifically a willingness and ability to challenge,
push clients in new directions, and offer new input into the therapy process.
Many respondents also stated that they wanted therapists to more actively
engage them and be flexible with session scheduling. In fact, the most prob-
lematic statements in our study fell in the service delivery category, with
both women and men surprisingly vocal and dissatisfied. To our knowledge
this aspect of therapy is not well researched (see Orlinsky, Ronnestad, &
Willutzki, 2004), perhaps because it is seen as not integral to actual ther-
apy. In our sample, how therapists handled appointments, maintained an
active outreach to clients in scheduling, and provided enough and flexible
meetings mattered a great deal. We speculate that this disregarded aspect
19. 40 M. G. Anker et al.
of therapy has implications for the therapeutic alliance. Although Bordin
(1979) described the working alliance primarily in terms of in-session thera-
peutic process, he also included other structural aspects of therapy such as
the payment of the therapist and frequency of meetings, stating that “col-
laboration between patient and therapist involves an agreed-upon contract,
which takes into account some very concrete exchanges” (p. 254). Therapist
accommodation to client preferences regarding these elements may impact
the maintenance of viable partnerships.
The striking agreement between women and men preferences in our
sample was surprising. In addition, expressed views were not stereotypically
gender-based, with women desiring an active, challenging therapist and men
valuing connection with a personable therapist. Quinn, Dotson, and Jordan
(1997) found that when wives scored higher on the Task subscale of the
Couple Therapy Alliance Scale (CTAS; Pinsoff & Catherall, 1986) than their
husbands’, outcomes were better. In heterosexual couples, women’s views
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of the therapist’s approach may warrant particular attention. The greater
frequency of satisfied comments by women in the relationship to therapist
categories suggests that an empathic relationship with men may need to be
cultivated more systematically in couple treatment.
An analysis of feedback and nonfeedback study conditions indicated
no significant differences in satisfied and problematic statements with the
exception of one category. Clients in the nonfeedback group were signif-
icantly more likely to complain about the therapy service delivery than
feedback clients. This finding raises intriguing questions. Were therapists
who regularly received feedback more responsive to clients’ wishes regard-
ing the scheduling of sessions? Did asking for and following client feedback
prompt therapists to take greater responsibility for this aspect of the work?
That only this one area emerged as different between the two groups did
not conform to our initial expectations. It may be that participants felt more
comfortable expressing negativity about the impersonal service delivery of
therapy, even if their dissatisfaction had more to do with relationship or
in-session process. Alternatively, the “nuts and bolts” of therapy simply may
have greater import for the alliance and client engagement than commonly
thought.
Therapist skill and attributes emerged as central points in respon-
dents’ feedback. However, when matched to therapists, statements indicated
that one person’s “good therapist” was another’s “not so good.” In other
words, different clients described their experience with the same therapist
differently. This suggests that simply learning to be more instrumental or
straightforward may miss the mark. What may matter more is how to ensure
the fit of one’s approach with each particular client. In sum, our findings
suggest that both relationship and task activities of therapists as well as ther-
apists’ personal attributes have implications for client satisfaction and are
likely components of the alliance.