Publications by authors named "Clara E Hill"

67 Publications

Feeling offended by clients: The experiences of doctoral student therapists.

J Couns Psychol 2021 Mar 5;68(2):125-138. Epub 2020 Nov 5.

Department of Psychology.

Ten doctoral student therapists (8 White, 5 female) in 1 counseling psychology doctoral program located in the Mid-Atlantic United States were interviewed for approximately 1 hour each about their experiences of feeling offended by a client during an individual psychotherapy session. Interview data were analyzed with consensual qualitative research (CQR). Trainee therapists typically felt offended related to their sociocultural identities (e.g., being a woman, LGBTQ+, racial-ethnic minority), felt frozen after the events and uncertain about how to respond, wished they had handled the events differently, and struggled when clients expressed opinions or beliefs that ran counter to their own values. Trainees had difficulty maintaining an empathic, nonjudgmental therapeutic stance where they could both value the client and maintain their own sense of integrity and beliefs about social justice and multiculturalism. Implications for training, practice, and research are provided. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000511DOI Listing
March 2021

Do therapists improve in their ability to assess clients' satisfaction? A truth and bias model.

J Couns Psychol 2020 Jul 16. Epub 2020 Jul 16.

Department of Psychology, University of Maryland, College Park.

We used the truth and bias model to examine changes in tracking accuracy and under/overestimation (directional bias) on therapists' judgments about clients' satisfaction. We examined 3 factors of clinical experience that could moderate accuracy: (a) overall level of acquaintanceship with a client, operationalized as treatment length (i.e., less or more time seeing a client), (b) time point in therapy with a specific client, operationalized as session number (i.e., earlier or later in treatment with a client), and (c) order (1st client seen, 2nd client seen . . . last client seen across two years of training in a psychology clinic) in which clients were seen. We conducted a three-level hierarchical linear modeling using data on 6054 sessions, nested in 284 adult clients, nested in 41 doctoral student therapists providing open-ended psychodynamic individual psychotherapy. We found that therapists were able to accurately track client-rated session evaluations with less underestimation (i.e., lower tendency to estimate that clients were less satisfied than they actually were) as they gained experience (both treatment length and client order). Furthermore, therapists exhibited greater tracking accuracy gains over the span of shorter treatments and when working with clients earlier in their clinical training. In longer treatments and with clients seen later in training, tracking accuracy was stable and consistent. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000525DOI Listing
July 2020

"Where is the relationship" revisited: Using actor-partner interdependence modeling and common fate model in examining dyadic working alliance and session quality.

J Couns Psychol 2021 Mar 2;68(2):194-207. Epub 2020 Jul 2.

Department of Psychology, University of Maryland.

Building on previous studies (e.g., Kivlighan, 2007), we explored the application of actor-partner interdependence modeling (APIM) and the common fate model (CFM) in a multilevel framework to examine the dyadic multilevel associations between therapists' and clients' perceptions of working alliance and session quality. Forty-four therapists and their 284 adult community clients completed measures of working alliance and session quality after every session (a total of 8,188 sessions included in this study). We used APIM to unravel the mutual interdependence between therapist and client perceptions and used CFM to model both the shared and individual perceptions of the therapists and clients. APIM analyses showed that, at the between-session level, therapist and client perception of the session quality each was significantly predicted by the other's perception of the working alliance. At the between-client level, only therapist perception of the session quality was significantly predicted by the client's perception of the working alliance. There were no significant partner effects at the between-therapist level. CFM analyses showed that therapist-client shared perceptions of working alliance significantly predicted their shared perception of session quality at all three levels. In contrast, individual perceptions of working alliance correlated with individual perceptions of session quality for therapists only at the between-therapist and between-session levels, and for clients only at the between-client and between-session levels. Theoretical, methodological, and practical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000515DOI Listing
March 2021

A follow-up of undergraduate students five years after helping skills training.

J Couns Psychol 2020 Nov 26;67(6):697-705. Epub 2020 Mar 26.

Department of Psychology.

In a 5-year follow-up assessment, 33 students who had taken an undergraduate helping skills course indicated that they had continued to use the helping skills in both their professional lives and personal relationships. On average, there were no significant changes from pretraining to follow-up on empathy, natural helping ability, or facilitative interpersonal skills. Furthermore, although students had increased in self-efficacy for using the skills during training, on average they maintained their self-efficacy levels at the follow-up. The 15 participants who had further mental health education, however, scored higher at follow-up on empathy, natural helping ability, self-efficacy for using the skills, and facilitative interpersonal skills compared with the 18 participants who had no further mental health education (controlling for pretraining levels), suggesting that continued exposure to and practice using the skills helped them continue to improve their helping abilities. Qualitative data indicated that participants typically had positive experiences in the helping skills course. Implications for training and research are provided. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000428DOI Listing
November 2020

Can a computer detect interpersonal skills? Using machine learning to scale up the Facilitative Interpersonal Skills task.

Psychother Res 2021 Mar 16;31(3):281-288. Epub 2020 Mar 16.

Department of Psychology, Ohio University, Athens, OH, USA.

Therapist interpersonal skills are foundational to psychotherapy. However, assessment is labor intensive and infrequent. This study evaluated if machine learning (ML) tools can automatically assess therapist interpersonal skills. Data were drawn from a previous study in which 164 undergraduate students (i.e., not clinical trainees) completed the Facilitative Interpersonal Skills (FIS) task. This task involves responding to video vignettes depicting interpersonally challenging moments in psychotherapy. Trained raters scored the responses. We used an elastic net model on top of a term frequency-inverse document frequency representation to predict FIS scores. Models predicted FIS total and item-level scores above chance (s = .27-.53, s < .001), achieving 31-60% of human reliability. Models explained 13-24% of the variance in FIS total and item-level scores on a held out set of data (), with the exception of the two items most reliant on vocal cues (verbal fluency, emotional expression), for which models explained ≤1% of variance. ML may be a promising approach for automating assessment of constructs like interpersonal skill previously coded by humans. ML may perform best when the standardized stimuli limit the "space" of potential responses (vs. naturalistic psychotherapy) and when models have access to the same data available to raters (i.e., transcripts).
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http://dx.doi.org/10.1080/10503307.2020.1741047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492408PMC
March 2021

Parallel process in psychodynamic supervision: The supervisor's perspective.

Psychotherapy (Chic) 2020 06 16;57(2):252-262. Epub 2020 Jan 16.

Independent Practice.

Nine postdoctoral-level experienced psychodynamic supervisors were interviewed about working with a supervisee on a case involving parallel process (PP) that started in therapy and was enacted in supervision. Consensual qualitative research was used to analyze transcripts of the interviews. The general pattern that emerged from the analysis of the supervisors' reports was that clients behaved unusually in session, therapists "got hooked" by this change, therapists enacted the client's behavior in supervision, supervisors "got hooked," supervisors reflected on their reactions and intervened in a different way; reported outcomes were mostly positive (e.g., enhanced growth or understanding for the therapist). Results of this qualitative investigation provide evidence of PP and clues as to how experienced supervisors observe, describe, and respond to PP in ways that promote growth, insight, and understanding for their supervisees. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000274DOI Listing
June 2020

Follow you or follow me? Examining therapist responsiveness to client and responsiveness to self, using differential equations model and multilevel data disaggregation from an interpersonal theory framework.

J Couns Psychol 2020 Oct 19;67(5):608-621. Epub 2019 Dec 19.

Department of Psychology.

This study examined the effects of therapist interpersonal responsiveness on client-rated working alliance in their first psychotherapy session using the ordinary differential equations (ODE) model and multilevel data disaggregation. Responsiveness was operationally defined in this study as therapists adjusting their subsequent level of control/affiliation based on their clients' and their own current level of control/affiliation. Every 2-min segment of 111 first psychotherapy sessions for 111 clients nested within 38 therapists was rated by 11 trained raters on therapist and client levels of control and affiliation. An ODE model produced dynamic coefficients capturing therapists' responsiveness to clients and to themselves in that session, which were then disaggregated into between-therapist and within-therapist components. Hierarchical linear modeling revealed that for the control dimension, at the between-therapist level, therapist responsiveness to the client significantly predicted client-rated working alliance: Client-rated working alliance was (a) highest for therapists who generally increased their level of dominance/submission when their client was more dominant/submissive in the previous turn, and (b) lowest for therapists who generally increased their level of dominance/submission when their client was more submissive/dominant in the previous turn. None of the other associations were significant. Theoretical, methodological, and practical implications are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000406DOI Listing
October 2020

Productive silence is golden: Predicting changes in client collaboration from process during silence and client attachment style in psychodynamic psychotherapy.

Psychotherapy (Chic) 2019 12;56(4):568-576

Department of Counseling, Higher Education, and Special Education in the College of Education, University of Maryland.

We investigated the process and outcome of the first silence event for each of 86 clients and 26 doctoral student therapists in individual psychodynamic psychotherapy. Antecedent client collaboration and client attachments styles did not predict type of client or therapist behavior during silence events. Client collaboration increased from before to after silence events if therapists were productive (mostly invitational) and if clients were productive (mostly emotional and expressive) during silence events. Furthermore, subsequent client collaboration was higher when productive therapist silence occurred with clients who were lower rather than higher in attachment anxiety. In contrast, subsequent client collaboration was higher when productive client silence occurred with clients who were higher rather than lower in attachment anxiety. These results suggest that type of silence and client attachment styles are important factors in the immediate outcomes of silence events. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000260DOI Listing
December 2019

The effectiveness of helping skills training for undergraduate students: Changes in ethnocultural empathy.

J Couns Psychol 2020 Jan 7;67(1):14-24. Epub 2019 Nov 7.

Department of Counseling, Higher Education, and Special Education.

Using the Scale of Ethnocultural Empathy, we examined pre-post changes in empathy directed toward people from different racial/ethnic cultural groups than one's own for 189 undergraduate students from 20 sections of helping skills classes. We hypothesized that racial minority students and women would score higher than their respective counterparts in ethnocultural empathy at the beginning of the semester. We also expected that White students would grow more than racial minority students in ethnocultural empathy by the end of the semester. Using latent growth modeling, we found that racial minority women tended to report significantly higher initial levels than racial minority men and White students on all dimensions of ethnocultural empathy. In addition, race predicted ethnocultural empathy changes by the end of the semester, such that White women and men on average showed (a) more growth on the Empathic Feeling and Expression subscale than did racial minority women and men and (b) more growth on the Empathic Perspective Taking subscale than did racial minority women. Findings suggest that helping skills training may be particularly effective for helping White students gain empathic understanding and expression for individuals from different racial/ethnic backgrounds. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000404DOI Listing
January 2020

Therapist skills associated with client emotional expression in psychodynamic psychotherapy.

Psychother Res 2020 09 22;30(7):900-911. Epub 2019 Oct 22.

Department of Counseling, Higher Education, and Special Education in the College of Education, University of Maryland, College Park, MD, USA.

We wanted to determine whether four therapist skills were differentially associated with emotional expression. We compared paraphrases (restatements and reflections of feelings) and open questions (focused on thoughts or feelings) in relation to antecedent and subsequent client emotional expression and client attachment style for 36 clients and 22 therapists in psychodynamic psychotherapy. Therapists gave more paraphrases when clients were expressing more emotions, but more open questions when clients were expressing fewer emotions. Regardless of attachment style, subsequent emotional expression was highest when therapists used open questions for feelings, and intermediate when therapists used reflections of feelings or open questions for thoughts. Subsequent client emotional expression was lowest when therapists used restatements with clients who were low in attachment avoidance, and at about the same level as other skills for clients who were high in attachment avoidance. Therapists differentially used the skills based on how much emotion clients were expressing. Clients expressed emotions differentially depending on antecedent client emotional expression, therapist skills used, and client avoidant attachment style.
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http://dx.doi.org/10.1080/10503307.2019.1680901DOI Listing
September 2020

Therapist-client agreement on helpful and wished-for experiences in psychotherapy: Associations with outcome.

J Couns Psychol 2020 Apr 14;67(3):349-360. Epub 2019 Oct 14.

Department of Psychology, University of Maryland, College Park.

Therapists and clients often have different perspectives about what is helpful and what they wish for in therapy, but it is unclear how their perspectives differ and whether their agreement have implications for therapy outcome. In a mixed-method study, 18 therapists and clients were interviewed separately after termination about their experiences and what they wished had been different about their psychotherapy. Transcripts were analyzed using consensual qualitative research. Therapists and clients agreed moderately that exploration of the therapeutic relationship, therapists' use of challenges, and therapist validation and support were helpful. In contrast, there was low agreement on wishes. Whereas clients wished that therapists had provided more structure and direction, therapists did not mention any typical wishes. Using multilevel modeling, a high level of agreement on what was helpful was associated with reductions in psychological symptoms and interpersonal problems, although no relationship was found between agreement on wishes and outcome. The findings underscore the importance of therapist-client agreement about helpful aspects of therapy for successful therapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000393DOI Listing
April 2020

Deliberate practice for the skill of immediacy: A multiple case study of doctoral student therapists and clients.

Psychotherapy (Chic) 2020 12 26;57(4):587-597. Epub 2019 Aug 26.

Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park.

We examined the effects of deliberate practice training focused on immediacy (Im) for 7 doctoral student trainees. Training included an 8-hr workshop, 4 individual 50-min sessions, and 4 individual 30-min homework sessions. Qualitative results indicated that trainees found the deliberate practice training to be effective, especially in helping them become aware of and manage emotions and countertransference, which had inhibited them from using Im. In addition, there was a moderate and significant effect of training on the trainee's self-efficacy for using Im, a small and significant effect on therapist-rated working alliance, and no significant effect for client-rated working alliance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000247DOI Listing
December 2020

Facilitating client collaboration and insight through interpretations and probes for insight in psychodynamic psychotherapy: A case study of one client with three successive therapists.

Psychotherapy (Chic) 2020 06 18;57(2):263-272. Epub 2019 Jul 18.

School of Psychology.

We investigated therapist interpretations (Ints) and probes for insight (PIs) in relation to changes in client collaboration and insight for 1 male client paired with 3 successive doctoral student therapists in psychodynamic psychotherapy for 192 sessions over 5 years. Judges coded client collaboration and insight in the antecedent and subsequent 3 min for all Ints and PIs in each of 6 middle sessions for each treatment. Qualitative analyses showed that PIs were more helpful than Ints for this defended client. More gains in collaboration were found when antecedent client collaboration was high, antecedent client insight was low, and therapists gave PIs instead of Ints, but no differences were found among therapists. More gains in insight were found when antecedent insight in a given session was higher than in other sessions with the same therapist, with Therapist 3 facilitating more insight than Therapist 1; no differences were found between Ints and PIs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000242DOI Listing
June 2020

Silence is golden: A mixed methods investigation of silence in one case of psychodynamic psychotherapy.

Psychotherapy (Chic) 2019 12 26;56(4):577-587. Epub 2018 Nov 26.

Department of Counseling, Higher Education, and Special Education.

We investigated the antecedents, occurrences, and consequences of 183 silence events in the first 5 and last 5 sessions of a 73-session case of successful psychodynamic psychotherapy. Silences generally occurred within client speaking turns, such that the client often paused to reflect while speaking. In the last 5 sessions, as compared with the first 5 sessions, the client was more collaborative before and after silences, silences were shorter, the therapist was more connectional during silences (e.g., shared emotion and meaning with client), and the client was more emotional after silences. Antecedent client collaboration, duration of the silence, therapist behavior during silence events, client behavior during silence events, and who broke the silence all related to change in collaboration from before to after the silence events. We concluded that silence was helpful in this case because of client factors (the client naturally paused a lot during discussion, the client was quite reflective and insightful), therapist factors (the therapist was comfortable with and believed in silence), and relationship factors (there was a strong therapeutic relationship). (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000196DOI Listing
December 2019

Therapist self-disclosure and immediacy: A qualitative meta-analysis.

Psychotherapy (Chic) 2018 12;55(4):445-460

Department of Psychology, University of Maryland.

We review definitions and provide case examples of therapist self-disclosure (TSD) and immediacy (Im). We then present a qualitative meta-analysis of 21 studies that examined the subsequent process following TSD and Im in psychotherapy (excluding analogue and correlational studies). Across the 21 studies, the most frequent subsequent processes were enhanced therapy relationship, improved client mental health functioning, gains in insight, and overall helpfulness, suggesting that most often TSD and Im were followed by positive and beneficial therapeutic processes. In additional analyses, TSD was associated more often with improved mental health functioning, overall helpfulness, and enhanced therapy relationships, whereas Im was associated more often with clients opening up and being immediate. We also consider possible moderating variables, including client contributions and diversity issues. The article concludes with research-informed recommendations for judiciously using TSD and Im in practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/pst0000182DOI Listing
December 2018

Secrets in psychotherapy: For better or worse?

J Couns Psychol 2019 Jan 8;66(1):70-82. Epub 2018 Oct 8.

Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park.

We investigated how concealment and disclosure of secrets, two related but distinct processes, unfolded over the course of open-ended therapy for 39 clients and 9 therapists, using hierarchical linear modeling to identify longitudinal patterns and investigate relationships with working alliance and session quality. Results indicated that over the course of therapy, 85% of clients disclosed at least one secret and 41% concealed at least one secret, with 18% of sessions including a disclosure and 4% of sessions including concealment. Over time, clients were less likely to disclose secrets, and the secrets they chose to conceal were rated as less significant. Clients rated the working alliance lower after sessions when they disclosed secrets versus when they did not disclose, although the working alliance was not rated as poorly when the disclosed secrets were viewed as significant. Clients rated session quality higher after sessions when they disclosed secrets versus when they did not disclose, particularly when they disclosed preoccupying secrets. Clients tended to feel neutral or positive about their disclosures. Implications for practice and research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000311DOI Listing
January 2019

Therapist-client agreement about their working alliance: Associations with attachment styles.

J Couns Psychol 2019 Jan 9;66(1):83-93. Epub 2018 Aug 9.

Department of Psychology.

Recent research on attachment in therapy indicates that therapist attachment style is related to therapists' agreement with their clients on the quality of their working alliance (WA; Kivlighan & Marmarosh, 2016). This study builds on these findings by examining how both the therapist's and the client's attachment style may be related to their agreement on the WA. The authors expected that less anxious and less avoidant clients working with less anxious and less avoidant therapists would have higher WA agreement. Using hierarchical linear modeling, they analyzed archival session data from 158 clients and 27 therapists at a community clinic. In terms of overall level agreement (averaged across sessions), therapists and clients significantly disagreed on their WA ratings, with therapists rating the WA lower than did their clients; but there was more therapist-client level-agreement when therapists had relatively less attachment avoidance. In terms of (linear) WA agreement from session to session, the authors found no main effects for either therapist or client attachment style alone, but several significant interactions between therapist and client attachment styles. Session-to-session agreement on the WA was higher when clients and therapist had "matching" (both higher or both lower in attachment anxiety or attachment avoidance) or "complementary" (one higher in attachment avoidance, the other lower in attachment anxiety, or one higher in attachment anxiety, the other lower in attachment avoidance) attachment styles than when styles were noncomplementary. The authors discuss these findings in terms of the attachment-related communication, signaling, and behavior that may be occurring in therapy dyads. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000303DOI Listing
January 2019

Group- and individual-level self-stigma reductions in promoting psychological help-seeking attitudes among college students in helping skills courses.

J Couns Psychol 2018 Oct 23;65(5):661-668. Epub 2018 Jul 23.

Department of Counseling, Higher Education, and Special Education.

To promote psychological help-seeking, researchers have studied interventions to reduce self-stigma, a personally held belief that seeking psychological help would make one undesirable and socially unacceptable. We examined the differential impact of individual- and group-level changes in self-stigma on psychological help-seeking attitudes using data from 189 college students nested within 20 sections of a semester-long helping skills lab groups. We applied multi-level polynomial regression and response surface analysis to determine whether discrepancy between pre- and posttest self-stigma scores (i.e., reduction in self-stigma) predicted change in attitudes at the individual- and section-levels. Individual reduction in self-stigma did not predict psychological help-seeking attitudes but students who maintained consistently low to moderate levels of self-stigma throughout the course developed significantly more positive attitude toward psychological help-seeking. On the other hand, we found that greater section level reductions in self-stigma significantly predicted more positive psychological help-seeking attitudes, suggesting potential importance of group norm changes and effects in modifications of individual attitudes. Implications for research and stigma reduction strategies are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/cou0000283DOI Listing
October 2018

Client laughter in psychodynamic psychotherapy: Not a laughing matter.

J Couns Psychol 2018 Jul;65(4):463-473

Department of Counseling, Higher Education, and Special Education.

We studied 814 client laughter events nested within 330 sessions nested within 33 clients nested within 16 therapists at one community clinic in which doctoral student therapists provided psychodynamic psychotherapy to adult community clients. Each laughter event in Sessions 1 to 5 and 16 to 20 was rated for cheerfulness, politeness, reflectiveness, contemptuousness, and nervousness. Across all clients, there was an average of about one laughter even per session. The average laughter event lasted 3.5 seconds, and was characterized primarily by politeness and reflectiveness. Overall amount of client laughter and the characteristics of client laughter did not change across sessions. Most of the variance in the laughter characteristics was at the session level, with less variance attributable to clients and therapists. When client attachment avoidance was high, laughter was less cheerful and more contemptuous. When client attachment anxiety was high, laughter was more nervous. Sessions with more reflective laughter were evaluated more positively by clients, and therapists whose clients had more reflective laughter had more positive client session evaluations. Furthermore, within a therapist's caseload, clients with the most nervous and contemptuous laughter evaluated sessions most positively. Implications are discussed. (PsycINFO Database Record
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http://dx.doi.org/10.1037/cou0000272DOI Listing
July 2018

When in doubt, sit quietly: A qualitative investigation of experienced therapists' perceptions of self-disclosure.

J Couns Psychol 2018 Jul;65(4):440-452

Independent Practice.

Using consensual qualitative research (CQR), we analyzed 13 interviews of experienced psychotherapists about general intentions for therapist self-disclosure (TSD), experiences with successful TSDs, experiences with unsuccessful TSDs, and instances of unmanifested urges to disclose. For TSD generally (i.e., not about a specific instance), typical intentions were to facilitate exploration and build and maintain the therapeutic relationship. Therapists typically reported becoming more comfortable using TSD over time. In successful TSDs, the typical content was accurate, relevant similarities between therapist and client; typical consequences were positive. In unsuccessful TSDs, the typical antecedent was countertransference reactions; the typical intention was to provide support; typical content involved therapists mistakenly perceiving similarities with clients; and the general consequences were negative. In instances when therapists repressed the urge to disclose, the typical antecedent was countertransference and the content typically seemed relevant to the client's issues. We conclude that effective use of TSD requires general attunement to the client's dynamics, attunement to the client's readiness in the moment, ability to manage countertransference, and ability to use a specific TSD appropriately. Implications for practice, training, and research are discussed. (PsycINFO Database Record
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http://dx.doi.org/10.1037/cou0000288DOI Listing
July 2018

Ruptures in psychotherapy: Experiences of therapist trainees.

Psychother Res 2019 11 30;29(8):1086-1098. Epub 2018 Jun 30.

Department of Psychology, University of Maryland , College Park , MD , USA.

We used consensual qualitative research (CQR) to investigate the experiences of therapist trainees who had a rupture with a client. Of 21 trainees who were tracked weekly, 14 experienced a rupture and were interviewed 1 week after the rupture and again 2 weeks later about antecedents, repair attempts, and consequences. Trainees typically reported experiencing tension at the beginning of the rupture session and difficult emotions during the rupture (e.g., anger, depleted self-efficacy). Trainees typically tried to repair the rupture by using immediacy or facilitating exploration about the conflict. Trainees typically reported both negative (e.g., strained therapeutic relationship) and positive consequences (e.g., therapeutic work became more productive). Trainees seemed to be less aware of withdrawal than confrontational ruptures. Implications are that trainees could benefit from learning more about ruptures including how to regulate negative emotions toward clients and acquiring more rupture-repair tools, as well as realizing that ruptures can have some positive as well as negative aspects.
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http://dx.doi.org/10.1080/10503307.2018.1492164DOI Listing
November 2019

Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship.

Psychotherapy (Chic) 2018 03;55(1):9-19

Department of Psychology, University of Maryland, College Park.

Using data from 3,263 sessions nested within 144 clients, nested within 19 therapists, we examined client- and therapist-rated working alliance (WA) and real relationship (RR) at Session 3 and growth in WA and RR across the course of open-ended psychodynamic psychotherapy for clients who identified as racial/ethnic minority (REM) or as White. To be included in the analyses, therapists had to work with at least 2 REM and 2 White clients. There were no significant therapist effects for the interaction between client- or therapist-rated WA and client REM status at Session 3, or for client- or therapist-rated RR and client REM status at Session 3. There were, however, significant therapist effects due to client REM status on the interaction between client-rated linear growth in WA and RR, showing that some therapists had stronger WA and RR growth with REM than that with White clients, whereas other therapists had stronger alliance growth with White than that with REM clients. There were significant therapist effects on therapist-rated linear growth in both WA and RR, which indicated that some therapists reported stronger WA and RR growth with all of their clients, whereas other therapists reported weaker WA and RR growth for all of their clients, although this differential WA and RR growth was not related to clients' REM status. Implications for practice and research are discussed in this paper. (PsycINFO Database Record
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http://dx.doi.org/10.1037/pst0000135DOI Listing
March 2018

Testing a mediation model of psychotherapy process and outcome in psychodynamic psychotherapy: Previous client distress, psychodynamic techniques, dyadic working alliance, and current client distress.

Psychother Res 2019 07 5;29(5):581-593. Epub 2018 Jan 5.

b Department of Psychology , University of Maryland, College Park , College Park , MD , USA.

To test a sequential model of psychotherapy process and outcome, we included previous client distress, therapist psychodynamic techniques, dyadic working alliance, and current client distress. For 114 sets of eight-session segments in 40 cases of psychodynamic psychotherapy, clients completed the Outcome Questionnaire-45 and Inventory of Interpersonal Problems-32 after the first and final session, judges reliably coded one middle sessions on the Psychodynamic subscale of the Multitheoretical List of Therapeutic Interventions, and clients and therapists completed the Working Alliance Inventory after every session. Results indicated that higher use of psychodynamic techniques was associated with higher levels of the working alliance, which in turn was associated decreased client distress; and working alliance was higher later in psychotherapy. There was a significant indirect effect of psychodynamic techniques on decreases in distress mediated by the working alliance. Implications for theory, practice, and research are provided. Conducted a longitudinal, latent variable examination of the relationships of psychodynamic techniques and working alliance on client distress. Psychodynamic techniques have an indirect effect on decreases in client distress through the dyadic working alliance.
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http://dx.doi.org/10.1080/10503307.2017.1420923DOI Listing
July 2019

Using helping skills with Korean clients: The perspectives of Korean counselors.

Psychother Res 2019 08 9;29(6):812-823. Epub 2017 Nov 9.

b Department of Psychology , University of Maryland , College Park , MD , USA.

The purpose of this study was to investigate how Korean counselors modify the helping skills they learned during training in their work with Korean clients. Thirteen practicing Korean therapists who had taken two master's level courses in the Hill helping skills model were interviewed about their experiences in applying the model in their work with clients. Data were analyzed using consensual qualitative research (CQR). Several characteristics were noted of Korean clients that might influence the appropriateness of the helping skills model (e.g., clients regard counseling as authorities and wise experts). Participants had a number of reactions to the overall helping skills model (e.g., noting that Korean counselors deliver empathy and genuineness more through non-verbal rather than verbal channels). Participants also noted needed modifications to specific stages or skills in the model (e.g., using the insight stage less than the exploration stage). Based on these findings, six guidelines are offered for modifying the Hill helping skills approach to fit the needs of Korean clients: Provide a pre-exploration stage to educate clients about approach, utilize indirect and non-verbal communication more than verbal communication, validate client's experiences, work cautiously with emotions, be cautious about using insight skills, and respond to clients' implicit communication when they ask for action.
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http://dx.doi.org/10.1080/10503307.2017.1397795DOI Listing
August 2019

Crying in psychotherapy: The perspective of therapists and clients.

Psychotherapy (Chic) 2017 Sep;54(3):292-306

Department of Counselor Education and Counseling Psychology, Marquette University.

Eighteen U.S.-based doctoral students in counseling or clinical psychology were interviewed by phone regarding experiences of crying in therapy. Specifically, they described crying as therapists with their clients, as clients with their therapists, and experiences when their therapists cried in the participants' therapy. Data were analyzed using consensual qualitative research. When crying with their clients, therapists expressed concern about the appropriateness/impact of crying, cried only briefly and because they felt an empathic connection with their clients, thought that the crying strengthened the relationship, discussed the event with their supervisor, and wished they had discussed the event more fully with clients. Crying as clients was triggered by discussing distressing personal events, was accompanied by a mixture of emotions regarding the tears, consisted of substantial crying to express pain or sadness, and led to multiple benefits (enhanced therapy relationship, deeper therapy, and insight). When their therapists cried, the crying was brief, was triggered by discussions of termination, arose from therapists' empathic connection with participants, and strengthened the therapy relationship. Implications for research, training, and practice are presented. (PsycINFO Database Record
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http://dx.doi.org/10.1037/pst0000123DOI Listing
September 2017

Congruence and discrepancy between working alliance and real relationship: Variance decomposition and response surface analyses.

J Couns Psychol 2017 Jul 6;64(4):394-409. Epub 2017 Apr 6.

Department of Psychology, University of Maryland, College Park.

We examined how congruence and discrepancy in clients' and therapists' ratings of the working alliance (WA) and real relationship (RR) were related to client-rated session quality (SES; Session Evaluation Scale). Ratings for 2517 sessions of 144 clients and 23 therapists were partitioned into therapist-level, client-level, and session-level components and then analyzed using multilevel, polynomial regression and response surface analysis. For both clients and therapists, at all levels of analysis (except the therapist level for therapist ratings), SES was highest when combined WA and RR ratings were high, and lowest when combined ratings were low. For client ratings, discrepancy between WA and RR, at the client and session levels, was associated with greater session quality. Some clients perceived greater session quality when, across all sessions, WA was stronger than RR and other clients perceived greater session quality when RR was stronger than WA. Within clients, session quality was highest when some sessions had a stronger WA than RR whereas other sessions had a stronger RR than WA. These findings are compatible with a responsiveness framework, therapists varied the balance of WA and RR to suit situational demands or needs of different clients. When therapists rated WA and RR the opposite pattern of results emerged; clients perceived greater session quality when therapists' WA and RR ratings, for a session were high and consistent (i.e., no discrepancy between WA and RR). In addition, across all sessions, clients perceived greater session quality when WA and RR ratings were high and consistent. (PsycINFO Database Record
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http://dx.doi.org/10.1037/cou0000216DOI Listing
July 2017

Are you in the mood? Therapist affect and psychotherapy process.

J Couns Psychol 2016 Jul 12;63(4):405-418. Epub 2016 May 12.

Department of Psychology, University of Maryland.

Studies on therapist factors have mostly focused on therapist traits rather than states such as affect. Research related to therapist affect has often looked at therapist baseline well-being or therapist reactions, but not both. Fifteen therapists and 51 clients rated pre- and postsession affect, as well as postsession working alliance and session quality, for 1,172 sessions of individual psychotherapy at a community clinic. Therapists' affect became more positive when clients were initially positive and when clients became more positive over the session, and became more negative when clients were initially negative and when clients became more negative over the session. Furthermore, when therapists were initially positive in affect and when therapists became more positive over the session, clients rated the session quality to be high. Conversely, when therapists were initially negative in affect and when therapists became more negative over the session, clients rated the session quality and working alliance low. On open-ended questions, therapists reported mood shifts in 67% of sessions (63% positive, 50% negative). Positive affect change was attributed to collaborating with the client, perceiving the client to be engaged, or being a good therapist. Negative affect change was attributed to having a difficult client, perceiving the client to be in distress, or being a poor therapist. Thus, therapist state affect at presession and change in affect across a session may independently contribute to the process and outcome of therapy sessions. The examination of within-therapist variables over the course of therapy may further our understanding of therapist factors. (PsycINFO Database Record
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http://dx.doi.org/10.1037/cou0000155DOI Listing
July 2016

Therapist immediacy: The association with working alliance, real relationship, session quality, and time in psychotherapy.

Psychother Res 2017 11 19;27(6):737-748. Epub 2016 Apr 19.

a Department of Psychology , University of Maryland , College Park , MD , USA.

Objective: This longitudinal analysis examined the relationship between amount of therapist immediacy in sessions and client post-session ratings of working alliance (WAI), real relationship (RRI), and session quality (SES).

Method: Using hierarchal linear modeling (HLM), we disaggregated the variables into within-client (differences between sessions in immediacy) and between-clients (differences between clients in immediacy) components, in order to test associations over time in treatment. Three hundred and sixty four sessions were nested within 16 clients and 9 therapists.

Results: When therapists used more immediacy in a session, clients gave higher SES ratings for that session, compared to their sessions with less immediacy (within-client effect). For WAI, it appeared to matter when immediacy was used in treatment. The interaction effect between time in treatment and within-client immediacy revealed that early in treatment, more immediacy in a session was related to lower WAI for that session, whereas later in treatment, more immediacy in a session was related to higher WAI for that session. Another interaction effect was found between time in treatment and between-clients immediacy. Clients with less immediacy in treatment, gave higher SES scores for early sessions, than clients with more immediacy in treatment.

Conclusions: Immediacy has an overall positive effect on session quality, but the time in which it is used in treatment and client characteristics should be taken into account both in practice and research.
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http://dx.doi.org/10.1080/10503307.2016.1158884DOI Listing
November 2017

Working alliance, real relationship, session quality, and client improvement in psychodynamic psychotherapy: A longitudinal actor partner interdependence model.

J Couns Psychol 2016 Mar 21;63(2):149-61. Epub 2015 Dec 21.

Department of Psychology, University of Maryland.

We used the Actor Partner Interdependence Model (APIM; Kashy & Kenny, 2000) to examine the dyadic associations of 74 clients and 23 therapists in their evaluations of working alliance, real relationship, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy. There were significant actor effects for both therapists and clients, with the participant's own ratings of working alliance and real relationship independently predicting their own evaluations of session quality. There were significant client partner effects, with clients' working alliance and real relationship independently predicting their therapists' evaluations of session quality. The client partner real relationship effect was stronger in later sessions than in earlier sessions. Therapists' real relationship ratings (partner effect) were a stronger predictor of clients' session quality ratings in later sessions than in earlier sessions. Therapists' working alliance ratings (partner effect) were a stronger predictor of clients' session quality ratings when clients made greater improvement than when clients made lesser improvement. For clients' session outcome ratings, there were complex three-way interactions, such that both Client real relationship and working alliance interacted with client improvement and time in treatment to predict clients' session quality. These findings strongly suggest both individual and partner effects when clients and therapists evaluate psychotherapy process and outcome. Implications for research and practice are discussed.
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http://dx.doi.org/10.1037/cou0000134DOI Listing
March 2016

Corrective relational experiences in psychodynamic-interpersonal psychotherapy: Antecedents, types, and consequences.

J Couns Psychol 2016 Mar 14;63(2):183-97. Epub 2015 Dec 14.

Department of Psychology, University of Maryland.

In posttherapy interviews with 31 clients who had recently terminated from individual open-ended psychodynamic-interpersonal psychotherapy, 18 reported having had at least 1 corrective relational experience (CRE) during psychotherapy, whereas 13 did not report any CREs. CREs typically occurred in the context of therapeutic relationships that were primarily positive but also had minor difficulties. Therapists typically facilitated CREs by identifying or questioning client behavior patterns and conveying trustworthiness. Corrective shifts for clients typically involved a new understanding of the therapy experience and variantly involved gaining a new understanding of behavior patterns. Consequences generally included improvements in the therapy relationship and intrapersonal well-being. Qualitatively, the 13 non-CRE clients more frequently reported wishing the therapist's theoretical orientation was a better match than did the 18 CRE clients. Quantitatively, the CRE clients rated themselves as having more interpersonal problems at intake on the Inventory of Interpersonal Problems-32 (Barkham, Hardy, & Startup, 1996), had marginally significant improvements in interpersonal functioning over time, rated their therapy alliances higher on the Working Alliance Inventory-Short Revised (Hatcher & Gillaspy, 2006) midtherapy, and rated their therapy alliances higher over time compared with the non-CRE clients. Implications for practice and research are discussed.
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http://dx.doi.org/10.1037/cou0000132DOI Listing
March 2016