Working alliance, therapist expressive skills, and client outcome in psychodynamic therapy.

Abstract

Bordin's (1979) theory suggests that therapist techniques that call for client introspection and self-observation will be more effective when the working alliance (WA) is stronger. Psychodynamic therapists use expressive techniques to elicit this introspection and self-observation. We examined whether therapists' use of expressive skills (e.g., encouraging expression of thoughts and feelings; helping clients understand the reasons behind their thoughts, feelings, and behaviors) when the WA is high, versus low, was related to client outcome in open-ended, psychodynamic treatment. Ten therapists rated the WA with their 47 clients, who rated their perceptions of helping skills, after 2,284 counseling sessions. Clients also completed the Outcome Rating Scale (ORS) in reference to the week following each session. We examined time-ordered relationships by creating lagged variables for WA (T-2) and therapist expressive skills (TES; T-1) and used these scores to predict ORS ratings (T) in a three-level Hierarchical Linear Modeling (HLM) analysis (sessions nested within clients, nested within therapists). Lagged WA (T-2) and expressive skills (T-1) were decomposed into between-therapist, withintherapist, and within-clients components. We found a 3-way interaction for within-therapist working alliance, within-client WA at T-2, and expressive skills at T-1 predicting ORS at T. When clients who had a weaker WA with their therapist than the therapists' other clients, had a session with a stronger WA than the client's usual WA, then more expressive skills in the next session was related to better psychological well-being in the subsequent session. Implications and future directions are discussed. Public Significance StatementThis study suggests that therapists should use expressive skills when clients who usually do not have a strong working alliance (WA) have a stronger than usual WA in the preceding session. The study highlights the importance of monitoring the strength of the WA and with less engaged clients, only using expressive techniques when the alliance is stronger than usual for the client.

Deliberate practice for immediacy: Skill use and client outcome.

“…The ORS is correlated with Outcome Questionnaire-45.2 subscales. In Ahn and Kivlighan (2022), the reliability at the session level was .94 for the ORS. In this study, reliability for the ORS was .92.…”

Therapist and client perceptions of the working alliance: Codevelopment, linear growth, variability, and client functioning.

“…The theoretical and research literature points to several ways to reduce session-to-session variability in the working alliance (e.g., Stevens et al, 2007). For example, therapists should avoid ruptures by not challenging or offering interpretation when the working relationship is not strong (Ahn & Kivlighan, 2022). When a rupture happens, it is important to recognize and address it in the session in which it occurs, using empathy and immediacy skills.…”

The power (and limits) of the therapeutic relationship: Working alliance, psychiatric distress, and the role of trait emotional intelligence

“…Furthermore, the value placed on the therapeutic relationship makes psychodynamic psychotherapy a treatment perspective through which to explore working alliance and how it may function differently depending on individuallevel factors (Ahn & Kivlighan, 2022;Kivlighan et al, 2016).…”

“…Psychodynamic therapy, with its emphasis on insight‐oriented work and attention to developing awareness of emotional states, is a compelling treatment for increasing EI (Lingiardi et al, 2018; Rudenstine & Espinosa, 2018). Furthermore, the value placed on the therapeutic relationship makes psychodynamic psychotherapy a treatment perspective through which to explore working alliance and how it may function differently depending on individual‐level factors (Ahn & Kivlighan, 2022; Kivlighan et al, 2016).…”