Psychological Reports, 1990, 66, 883-897.
O Psychological Reports
CHANGES DURING THE COURSE O F THE PSYCHOTHERAPEUTIC RELATIONSHIP ',* STEPHEN W. LEVINE AND WILLIAM G. HERRON St. Iohn's Uniuersity Summary.-Changes in the therapeutic relationship over time were explored using the Therapy Session Report for 30 patients and six therapists at an out-patient clinic. 11 patients dropped out after the third session, while the continuing group consisted ant on both of 19 patients for whom sessions ranged from 5 to 33 S ~ g n ~ f ~ cdifferences patient and therapist evaluations were found between the dropout and continuing groups, there being high agreement from inception to termination. Results emphasized the importance of early establishment of a collaborative relationship in short-term psychotherapy.
Recent decades have witnessed an extensive increase in research relating to the question of how psychotherapy actually works. A wide variety of potential variables have been studied, including treatment techniques, patient- and therapist-related variables, optimal conditions for effective psychotherapy, and the nature of the therapeutic relationship (Saltzman, Leutgart, Roth, Creaser, & Howard, 1976). In spite of the impressive amount of research which currently exists, Frank (1979) asserts that clearly established, clinically relevant knowledge about therapy process and outcome is largely lacking. The state of uncertainty reflects what Orlinsky and Howard (1978) referred to as the "preparadigmatic" level of current research and theory on psychotherapy. The variability and diversity in research approaches are emblematic of the variety of theoretical models of therapy and behavior change, from analytic to behavioral, that now exists in clinical practice. With this preparadigmatic state of the field in mind, Orlinsky and Howard (1778) distinguish four aspects of psychotherapeutic process which can be studied. The one which is focused upon in the present study is termed concurrent experience. This refers to the participants' perceptions of what is occurring in the therapeutic treatment. It can include perceptions of the self, the other participant, and the therapeutic relationship. This aspect of therapy is studied from within the relationship rather than using the more traditional nonparticipant-observer format in which rater(s) view therapy sessions and evaluate them on one or more variables (Orlinsky & Howard, 1978). The subjective therapeutic experience of participants has been described 'This stud is based upon a doctoral dissertation completed by the first author under the $kction o r t h e second author at St. John's Univeniry, Jamaica, New York 11439. Requests for reprints should be sent to Stephen Levine, 370 East Central Avenue, Pearl River, New York 10965.
S. W. LEVINE & W. G. HERRON
often in case reports, diaries, and narratives written by patients and therapists (Orlinsky & Howard, 1975). These sources do not provide systematic knowledge about how the therapy sessions are perceived by both participants, which would be a viable way to study the therapeutic relationship. There has been some inquiry in this area, slowly increasing in the early 1970s to the most prolific point in the latter part of the decade, then gradually decreasing to the present time. The study to be presented below assessed the conjoint experience and perceptions of therapy participants over the course of their treatment, investigating the nature of the therapeutic relationship over time, along with evaluations of the best, poorest, and typical session experiences. There is a need to study potential changes in the therapeutic relationship over time, as each session has an "outcome" of its own, possibly reflecting changes in the perceptions of the participants from one juncture of therapy to the next. The research which has been conducted is restricted in the duration of therapy sessions sampled or does not investigate the therapeutic relationship per se. From these studies, two conflicting views have emerged. Research conducted by Bernard, Schwartz, Oclatis, and Stiner (1980), Graff and Luborsky (1977), Snyder (1961), and Stiles and Snow (1984) has suggested that changes can occur from session to session in many aspects of the therapeutic relationship, making therapy a very "up and down" experience for the participants. Opposedly, O'Mdey, Suh, and Strupp (1983) and Saltzman, et af. (1976) have asserted that the relationship is formed in the first few therapy sessions and is relatively unchangeable after that. At present no study has tested these seemingly conflicting positions and neither group of researchers appears to hypothesize a third possibility suggested by MarzialLi (1984). Specifically, it is conceivable that, while some fluctuations in affect, satisfaction, and other process variables occur over time in therapy, they do so within the context of a relationship formed early in treatment. This relationship, based upon the feelings, attitudes, and behaviors of each participant toward themselves and each other, proscribes a limited range within which these process variables fluctuate. W e n observed, the fluctuations may not reflect real changes in the therapeutic relationship from one point in time to another. The present study attempted to resolve the apparent conflict in the literature by discovering those variables important in the formation and ongoing status of the therapeutic relationship, assessing these variables and possible changes in them at several junctures of therapy. The variables included goals of patient and therapist, expectations, session evaluations, feelings and thoughts about themselves, each other, and their relationship. These were assessed by having patients and therapists fill out the Therapy Session Report (Orlinsky & Howard, 1966) after each therapy session.
CHANGES IN THERAPEUTIC RELATIONSHIP
Hypotheses The research proceeded with the hypotheses that the nature of the therapeutic relationship, defined as the affective process, dialogue, behavioral relationship, and attitudes of and between the participants with regard to themselves and the other, w d fluctuate within a limited range circumscribed by the experiences in the early (first three) sessions. Thus, Therapy Session Reports may show a few changes in ratings on some of the therapeutic relationship variables from one juncture of therapy to the next. It was thought that these ratings, however, w d remain withn the parameters set early in treatment. I t was also thought that the reports of patients who drop out of therapy early (before Session 5) would significantly differ from the same Therapy Session Reports of therapeutic dyads with patients who remain in therapy longer. Finally, it was hypothesized that for those patients who continue in therapy, greater agreement would be seen between patients and therapists as sessions proceeded.
Subjects Thirty adult patients (18 yr. or older) and 6 therapists worlung at satellite offices of an out-patient clinic which served Union County, New Jersey participated in the study. Patients were 50% women and 50% men, ranging in age from 18 to 49 yr., with a mean age of 30.7. They fell into many of the diagnostic categories of the DSM-111, with most being diagnosed as either dysthymic (3O%), personality (3O%), or adjustment (27%) dsorders. Patients were 80% Caucasian and 20% black; 63% had been involved in some type of therapy prior to the current work. The therapists (2 men, 4 women) ranged in age from 29 to 45 yr. Five of the therapists were Caucasian and one was black. They averaged 7.2 yr. of experience, with three holding degrees in psychology (one Ph.D., two Master's) and three in social work. The out-patient clinic utilized in the study is a state- and county-funded mental health agency which serves urban and suburban residents of various racial, economic, and educational backgrounds. Instruments The major assessment tool in the present study was the Therapy Session Report constructed by Orlinsky and Howard (1966). The patient form (TSR-P) contains 167 items and the therapist form (TSR-T) 166, each one taking about 10 min. to complete after some practice (Orlinsky & Howard, 1975). The report assesses the immediately preceding therapy session. I t is constructed to investigate five separate aspects of therapy aiming to inquire into as much information about the session and current therapeutic relation-
S. W. LEVINE
ship as possible. The five aspects of therapy sessions assessed are: (1) session dialogue or content, (2) affective involvement (what participants felt and their perception of the others' feelings), (3) behavioral relationship (how they related to each other), (4) nonverbal exchange (patient's hopes, goals, and expectations as seen by both participants), ( 5 ) session development items which assess such variables as patient's and therapist's motivation and anticipation of the session, how freely the patient was able to speak, how well the therapist understood the patient, in-session rapport, how helpful the therapist was, how much progress was made, and how well the patient is faring psychologically at the time of the session. There is also an item which asks participants to make an over-all evaluation of the preceding session on a 6-point scale. The Therapy Session Reports of patients and therapists are constructed with a view of therapy as a special type of social relationship, giving participants equal status as interpreters of what occurred in the session. The report has been used extensively in the field and is seen as a viable measure of subjective experience in a therapy session (Mintz, Auerbach, Luborsky, & Johnson, 1973). Therapists also filled out the Therapist Orientation Questionnaire (TOQ) constructed by Sundland (1972). This was done prior to the onset of data collection. The questionnaire has 104 items which attempt to measure the theoretical and practical approach therapists use in conducting therapy. The revised version has been shown to yield 11 factors reflecting various attitudes toward psychotherapy. These 11 factors are grouped into three clusters which roughly describe three schools of therapy: experiential, analytic, and cognitive/behavioral. The Therapist Orientation Questionnaire has been used previously in research on therapists' attitudes and qualities and is viewed as a useful and meaningful measure of a therapist's clinical approach to treatment. Therapists were also asked to fill out personal data sheets from which demographic data were obtained. Patients who sought treatment at the clinic were routinely asked to fill out an application questionnaire and their demographic data were taken from this form.
Procedure Participating therapists were asked to discuss the research with their patients during the initial intake session. Criteria for inclusion of patients was that they be over age 18, that they be voluntary referrals, that they not be overtly psychotic, and that their language and verbal abilities be at a level at which they would be able to read and understand the forms. Also, therapists did not introduce rhe study if they believed a patient to be overly distraught or distracted in the initial session. Therapists were given an instruction sheet which they were either to
CHANGES IN THERAPEUTIC RELATIONSHIP
read from or use as a guide in describing the research to the patient. The study was explained as part of the clinic's attempt to assess the quality of service patients receive. Patients were assured of the confidentiality of their responses. If the patient agreed to participate, he was asked to read and sign an informed consent sheet, which the therapist also filled out. After obtaining the patient's consent to participate, both participants filled out their respective forms in separate rooms after the next session. The data from each patient-therapist pair represents consecutive sessions until termination with no data missing. At the conclusion of the data-collection period, participants were asked to rate whether the measuring process used in the study altered what they considered to be the "traditional" therapy experience. A second question focused on the nature of this change, if it existed, and asked for a general reaction to the research process.
Statistical Analysis Data from the reports were organized and analyzed on several levels, each focusing upon a different research question. Essentially, each section of the report was analyzed via t tests, analysis of variance, or a calculation of the frequency of responses, depending upon the particular variable and the question being assessed. The session development variables, for example, are pure rating scale items which lend themselves to analysis and comparison of means and variances. Statistical procedures applied to these data were analyses of variance and t tests. Analysis of the report data focused on three major questions of interest, with other analyses subsumed under these primary issues. These were (1) early session differences between patients who dropped out of treatment and patients who continued, (2) assessment and comparison of the participants' perceptions of their typical, best, and poorest session, (3) assessment of possible changes in the therapeutic relationship at various junctures during the course of the treatment sessions sampled. In analyzing potential early session differences between dropout and continuing patient-therapist pairs, each section of the report was assessed on a session-to-session basis with the dropout group's first-session ratings compared via t tests with the continuing group's first session ratings. Second and third session ratings were compared in the same manner. Several types of analyses were applied to the assessment of typical, best, and poorest therapy sessions. These session types were then first described through the calculation of means or response frequency. They were then compared using t tests where possible or a simple contrasting of response frequency between the session types. To discover what participants saw as the best and poorest sessions, the over-all session evaluation item on the report was used as a criterion. All the data from those sessions which patients and/or therapists rated as "one of
S. W. LEVINE
W. G . HERRON
the best sessions we have had" were used in compiling a picture of the best session experience. The poorest sessions were ascertained in the same manner, except that the report data came from sessions rated by either patient or therapist as poor or really poor. The third and most important question in the present study was that addressing potential changes in the therapeutic relationship over time in treatment. For this purpose, the report data were organized to assess the relationship at different junctures of the treatment process. The session development and behavioral relationship variables of the report were used in this analysis as it was thought that these most closely assess the nature of the therapeutic relationship. As the continuing group patients were seen in treatment for a range of 5 to 33 sessions, the relationship was assessed throughout this range, at Sessions 1, 6, 11, 16, 21, and 26, in a repeated-measures analysis of variance. Analysis of the second type of change over time used the same report data but compared participants' responses on the pardel items from the session development and behavioral relationship variables. Means were calculated and a set of difference scores obtained between the means of pardel items from reports of patients and therapists, attempting to get a picture of the agreement between the participants.
Eleven of the 3 0 participating patients dropped out after the third session and were placed in the dropout group. The other 19 patients, making up the continuing group, were seen in treatment for a range of 5 to 33 sessions covering a time period of 6 wk. to 9 mo. The mean number of sessions was 9.3 which is consistent with the estimates of out-patient treatment cited in the literature (Phillips, 1985; Saltzman, et al., 1976). The report data are based upon a total of 284 psychotherapy sessions. Each therapist had either four or six patients participating in the study, with at least two in the continuing group. Termination of patients in the continuing group was by mutual patient-therapist agreement in 14 of the 19 cases. Prior to discussing the report results a brief description of the questionnaire findings is presented. Three of the therapists scored highest on Cluster 1, allying themselves most closely with an experiential approach. Two therapists scored highest on Cluster 2, emblematic of a cognitive emphasis, while one therapist espoused an analytic treatment style most highly. Each therapist certainly had a single highest score, but three of the therapists did not espouse a major orientation to the same extent as the others, suggesting that these three therapists may be more eclectic. The working model for the majority of the therapists favored short-term psychotherapy, but theoretical orientation was less distinct.
CHANGES IN THERAPEUTIC RELATIONSHIP
Differences Between Dropout and Continuing Groups Patients' and therapists' ratings on the over-all session evaluation variable were significantly higher for the second and third sessions of the continuing group than the dropout group. First sessions were rated similarly. Continuing patients also rated anticipation of the session, therapists' understanding, therapists' helpfulness, and session progress higher than the dropout group in the second session, thud session, or both. Continuing group therapists rated their own session motivation, patient motivation, session rapport, therapist understanding, therapist helpfulness, and session progress higher than dropout group therapists in the second session, third session or both (for t ratios, p< .05). In terms of behavioral relationship, continuing group patients saw themselves as working together with their therapists, while dropout group patients felt that they were waiting for direction. Continuing patients felt deeply stirred in their early sessions (2 and 3 ) , with dropout patients reporting a more businesslike tone. Continuing group therapists felt themselves to be working together with continuing group patients, while being responsive to dropout patients. They also saw themselves as acting in mutually influencing ways with the group who continued in treatment, while tending to go along with the patients who dropped out. Participants tended to view each other in consistent ways over the three sessions. Other initial session group differences included the continuing group of participants talking more about spousal or romantic relationships than dropout pairs. Therapists also indicated that the patients who dropped out spoke more often about domestic and financial concerns. These patients felt that they more often wanted to get the session over with, show their therapist that they knew what was going on, and get advice than the continuing group. Continuing patients wanted to get a better understanding of their thoughts and feeling significantly more often than the dropout group (for all t ratios, p < .05). With regard to affective process, analysis of the groups' initial sessions showed that, although a wide variety of positive, negative, and somatic feelings were endorsed, no differential patterns emerged between continuing and dropout patient-therapist pairs. -
Analysis of Typical Session Experience The first step at this level of analysis was to describe, through calculation of means or response frequencies, the participants' views of their typical session experience. Patients typically wanted to get a better understanding of their feelings and behavior, ventilate, and get relief from bad feelings. They most often spoke about feelings toward themselves, social activities, and current family relationships. Patients reported feeling typically anxious, frus-
S. W. LEVINE & W. G. HERRON
trated, optimistic, and interested. They related by initiating- topics, mutually influencing and sharing with their therapist, being friendly, and feeling deeply moved and stirred. They saw their therapists as feeling calm, involved, and alert, while indicating that they related by working together, mutually influencing, being friendly and supportive, and were deeply stirred and moved. Therapists reported their typical feelings to be calm, interested, involved, and sympathetic. They felt that they related by worlung together, facilitating a mutually influencing atmosphere, being friendly and supportive, and acting in a businesslike manner or feeling deeply stirred. They saw their patients as typically wanting to gain insight, get relief, work through a conflict, and ventilate. For therapists, patients usually talked about feelings toward self, social activities, and current family relations, while typically feeling anxious, tense, and frustrated. Patients were seen to relate by working together, mutually influencing, being friendly and warm in attitude, and feeling deeply or taking a more businesslike stance. In terms of the session-development variables, both patients' and therapists' views of the typical session reflect relatively high motivation, rapport, therapists' understanding and helpfulness, session progress, and over-d session evaluation. There was very little difference in the Therapy Session reports of patients and therapists for items in this section. Given the sirnilarity here and in other sections of the report, there was a good deal of congruence in the participants' views of their typical session experience. -
Analysis of Best and Poorest Session Experience Therapists rated only eight of the 284 sessions as "one of the best sessions we have had," while patients rated 27 sessions at that level. Eleven percent of these ratings overlapped, meaning that in only four cases participants agreed that the session they had just experienced was one of their best. Ninety-seven percent of these "best" sessions occurred in continuing group sessions. Therapists rated 15 sessions as pretty poor or really poor while patients saw nine sessions in this way. Of these, only two were rated identically by the participants. One-quarter of these sessions occurred in the dropout group. Patients indicated that in their best sessions they felt optimistic, interested, alert, effective, and anxious. They spoke about current family relations, social activities, their relationship with spouse or lover, and feelings toward self. They most often wanted to get a better understanding of their feelings and behavior, work together with the therapist, ventilate feelings, and get advice. They related to their therapists by initiating topics, mutually influencing, being friendly, and feeling deeply stirred. They saw their thera-
CHANGES IN THERAPEUTIC RELATIONSHIP
pists as working together, mutually influencing, being friendly, and feeling deeply stirred. Therapists indicated that in the best sessions they felt calm, interested, involved, alert, and sympathetic. They thought that the patients most often spoke about current family relations, feelings toward self, plans and hopes, social activities, and relationship with spouse or lover. According to therapists, the patients wanted to gain insight and work through a problem. They were seen as working together, mutually influencing, friendly or ambivalent, and feeling deeply stirred. Therapists saw themselves as relating to their patients in this same way. The poorest sessions lacked many of the positive qualities observed in the best sessions. Usual feelings of patients included frustration, discouragement, tension, and helplessness. Therapists felt interested, frustrated, and discouraged. Session content in these poorest sessions were generally s i d a r to that of the best sessions, with the small increase in factual, everyday topics like work and school. I n the worst sessions patients wanted to ventilate, get help in talking, and get the session over with. Therapists indicated that poor sessions were marked by patients being defensive, wanting to get advice, and get the session over with. The participants were neutral in attitude toward each other, businesslike in emotional tone, and distanced, not worlung together. Analysis of the session development variables in these two session types indicates that on almost all items of the Therapy Session Reports by patients and therapists ratings of the best sessions were significantly higher or better by both participants. These are shown in Table 1, with the only exceptions being the patients' report variable assessing how well the patient knew what to say in the session and the therapists' report variables assessing therapists' motivation (for d significant t ratios, p < .01).
Analysis of Possible Changes in Therapeutic Relationship The next level of report data analysis involved two methods of assessing possible changes in the therapeutic relationship. The report variables thought to get most closely at the nature of the ongoing relationship were analyzed, including the session development and behavioral relationship items. A repeated-measures analysis of variance was conducted for each of these variables, assessing patients' and therapists' ratings at Sessions 1, 6 , 11, 16, 21, and 26. Results showed that on only one of the 35 variables tested was there any significant change from one of these sessions to another. This occurred on the therapists' report variable which assessed how the patient structured the session. At Session 16 therapists felt their patients to be working together with them, while by Session 2 1 this had changed to the patients following the therapists' lead. These ratings corresponded to significantly different numerical values ( p < .05).
S. W. LEVINE & W. G. HERRON TABLE 1
BESTAND POOREST SESSION MF.AN AND STANDARD DEVIATION VALLIESONSESSION VARIABLESOF THERAPY SESSION REPORT-PATIENTS AND THERAPISTS DEVELOPMENT Therapy Session Report: Measures
Patients Patient Motivation Motivation, Next Session Patient Knew What To Say Therapist Understand Speak Freely Therapist Helpful Session Progress Patient Getting Along Therapist Patient Motivation Therapist Motivation Patients Speak Freely Sense of Rapport True Feelings Emerge Therapist Understand Therapist Helpful Session Progress Patient Getting Along "All listed t values significant at p < .01.
Another method of assessing change over time in this study was used to ask the question regarding patients' and therapists' agreement on parallel variables of the patients' and therapists' reports over sessions. To present a picture of the pattern of the report means over time, a difference score was calculated between the reports for therapists and patients on each variable for each session. I n that way, the difference (or agreement) between participants at each juncture of treatment could be assessed. Table 2 presents these difference scores as absolute values. As can be seen, none of the 14 report variables showed any clear pattern of greater agreement as sessions ensued. A slight tendency in this direction may be seen in the behavioral relationship variable assessing the therapists' emotional responsiveness. I n the first four sessions sampled, the differences between participants' ratings were .66, .59, S O , and .85. The last two sessions, however, showed identical ratings (no difference), suggesting that agreement certainly increased in these later sessions. I t is interesting to note that, while in most cases there is no indication of greater agreement of time in therapy, it may be due to the fact that participants show relatively high agreement on these variables at each juncture in therapy assessed. There may not be growing agreement as much as it is a situation in which patients and therapists seemed relatively close to agreement throughout.
CHANGES IN THERAPEUTIC RELATIONSHIP
A question regarding whether the measurement process changed the nature of what the participants expected to be the "typical" therapeutic experience was answered with relative clarity. All six therapists and 14 of the 19 continuing group patients felt that the research process did not alter the treatment in any way. Both sets of participants indicated that they tended to think more about the session than they would have typically. Further, there were several therapists and patients who indicated that the report became a burden after awhile, its length forcing the participants to take more time than they would have liked. TABLE 2
Therapy Session Report Patient's Ability to Speak Freely Therapist's Understanding Therapist's Helpfulness Session Progress Patient's Getting Along Session Evaluation Patient's Structuring Patient's Influencing Patient's Attitude Patient's Emotional Response Therapist's Structuring Therapist's Influencing Therapist's Attitude Therapist's Emotional Response
DISCUSSION The findings answered the question regarding the stability of the therapeutic relationship with some clarity. For the patients and therapists who participated in the present study, their relationship was seen as a stable and consistent aspect of the treatment. As a group, the therapy participants saw relatively few fluctuations in the session behavior, attitudes, and emotional response toward each other over the course of their treatment. The session-to-session variability observed in some of the literature was not evident in the present data. While there were a few fluctuations on some of the variables from one session to the next, participants' experience of their therapeutic relationship proceeded at levels consistently close to where they began the treatment. For these patients and therapists, the initial sessions appeared to set the tone for the therapy. Given these findings, it is important to look at what aspects of the ther-
S. W. LEVINE & W. G. HERRON
apeutic relationship were tied to the issue of who stays in treatment and who drops out early. The first finding is that there were no initial session differences between the dropout and continuing groups, suggesting that the participants were getting acclimated to the therapeutic situation, "feeling each other out." In Sessions 2 and 3, however, this tentative stage began to change, with many group differences emerging. In general, the tone of the continuing groups' sessions were more cooperative and compromising, what Orlinsky and Howard (1975) refer to as a mutuaUy influencing relationship. The participants saw themselves and each other as more often working together and collaborative. The results of this kind of collaborative effort were seen in the continuing groups' higher ratings of those variables assessing the participants' view of the therapeutic relationship. In contrast to patients who continue in treatment, pairs in the dropout group characterized their experience as somewhat more businesslike and stilted in content and tone, lacking a sense of collaboration and mutuality. In Sessions 2 and 3, the therapeutic relationship had not evolved to the level observed for the continuing group. Pairs in the dropout group did not appear to be able to move past the initial feeling-out process. If this situation remained static for much longer than one or two sessions, the therapeutic relationship, lacking a sense of mutuality and collaboration, seemed to collapse before a strong foundation could be built. As this occurred, the patient dropped out of therapy, whch highlights the importance of these sessions. The various changes over time appeared consistent with the results of other studies of therapy experience such as those of O'Malley, et al. (1983) and Saltzman, et a/. (1976). Both showed early sessions to be paramount in setting the parameters of the therapeutic relationshp, which was hypothesized to be stable over the course of ensuing sessions. Although the methodology of these and the present study were different, the therapeutic relationship variables studied were similar. In all three cases, the variables studied reflect the participants' behavioral, attitudinal, and emotional relationship with each other and their sense of how the therapy is progressing. Studies which have posited a very fluctuating, changeable therapeutic relationship (Bernard, et al., 1980; Graff & Luborsky, 1977; Snyder, 1961; Stiles & Snow, 1984) have assessed variables like in- and postsession affect, over-d patients' satisfaction, session evaluation, transference, resistance, reported dreams, and interpretations. These variables appear to be of a different nature than those investigated in the other studies, less directly associated with the therapeutic relationship. The differences in the variables assessed may be the primary explanation for the discrepancy between the present findings and those of Bernard, et al. (1980), Graff and Luborsky (1977), Snyder (1961), and Stiles and Snow (1984). What appears to be true is that those aspects of the therapeu-
CHANGES IN THERAPEUTIC RELATIONSHIP
tic relationship which reflect ways the participants work together, respond to and influence each other, their sense of motivation, rapport, understanding, and progress are relatively enduring, stable, and not subject to very much fluctuation past the crucial early sessions. The more specific and individualized variables like patients' and therapists' affect, satisfaction, and resistance may be more subject to session-to-session or even intrasession changes. These changes occur, however, within the context of a relationship which is formed early in treatment and whose broader parameters are more consistent. An early sense of collaboration and mutuahty, then, may be the conduit through which the therapeutic relationship is built. I t seems not to be based solely upon the Truax and Rogers (1967) notion of necessary "therapist-offered conditions," but as Saltzman, et a/. (1976) state, a "function of interaction and mutual influence" (p. 553). I n looking at the over-all experience of the psychotherapy participants, the typical session was viewed as a generally positive encounter. Patients and therapists felt themselves to be involved in a collaborative effort seeking change Both reported to be typically moved and stirred in the sessions, experlenclng a wide variety of positive and negative emotions. The participants tended to agree on what comprised a typical session, suggesting that they were using similar criteria to gauge their usual experience of a therapy session. The patients' and therapists' views of the best or ideal sessions appeared to be a somewhat heightened or glowing version of the typical experience. This is a finding similar to that reported by Orlinsky and Howard (1975). The major differences observed between these types of therapy experiences occur on the variables of session development, how the participants assessed motivation, performance, and outcome of the session. In this section of the Therapy Session Report there were meaningful and significant differences on variables such as level of therapists' helpfulness and understanding, along with patients' progress on both forms of the report. I t seems that what most clearly distinguishes best and typical experiences are those variables which assessed the in-session nature of the therapeutic relationship (rapport, understanding, helpfulness, ability to speak freely, etc.) as it exists at the moment. I n those sessions seen as ideal, these feelings about patient and therapist are heightened and more positive, resulting in a more helpful and meaningful experience. I t is as if there is "something extra" going on in these sessions between the participants that was not necessarily tapped by variables which investigated session content, goals, and behavioral relationship. The poorest sessions lacked most of the positive qualities of the best and typical experiences. While session content was roughly similar, all other report sections for both participants showed differences between the session
S. W. LEVINE
W. G. HERRON
types. The poor experience had a constricted quality about it. The majority of affect was negative and the behavioral relationship between participants could be described as one in which they were turning away from each other. Patients were distant and remote, with therapists at first trying to join the patient, then growing frustrated. They were clearly experiencing what Orlinsky and Howard (1975) referred to as a conflictual pattern of interaction, with the sessions characterized by frustration and withdrawal. The session experience data are largely consonant with other research on therapy participants' reactions to their treatment. Hoyt (1980), Orlinsky and Howard (1975, 1977), Mintz, Auerbach, Luborsky, and Johnson (1973), and Stiles (1980) have all looked into typical, best or poorest session experience. In general, typical sessions were positive experiences for participants, who usually felt that they were working together, with the patient benefitting from the experience. Best sessions were often characterized as high on therapists' understanding, helpfulness, and as a relationship made up of positive emotional responses between participants. Patients felt comfortable and at ease, working together with their therapists in a safe environment. Poor sessions lacked a feeling of safety with the material covered not seen as deep and valuable. Again, we can see that the sense of working together in a collaborative, open relationship is a critical and distinguishing variable in discerning- a good therapy experience from a poor one. . It is interesting to note that therapists were more critical of the sessions than patients. This raises the possibility that therapists may underestimate the value of therapy for the patients. This may be a function of an ongoing introspective attitude by therapists which is more likely to turn u p "flaws" in the therapy process and which could be tempered by giving positive factors a higher profile. The results stress the importance of a collaborative relationship, the crucial nature of early sessions, and the probability of successful short-term therapy with continuing patients in a typical out-patient setting. Limitations concerned the specificity of the sample and variables measured, the lack of generali~abilit~ to longer term therapy, and the relative diffuse quahty of the therapists' theoretical orientations. REFERENCES
BERNARD, H . S., SCHWARTZ,A. J., O c ~ ~ nK. s ,A,, & STINER,A. (1980) Relationship between patients' in- rocess evaluations of therapy and psychotherapy outcome. JournaI of y , 310-316. Clinical ~ s y c ~ o f o g47, FRANK,J. D. (1979) The present status of outcome studies. Journal of Consulting and Clinical Psychology, 47, 310-316. GARFIELD,S . L. (1981) Psychotherapy: a 40-year appraisal. American Prychofogirt, 36, 174-183. GRAFT,H., & LUBORSKY, L. (1977) Longterm trends in transference and resistance: a report on a quantitative-analytic method applied to four psychoanalyses. lournal of the American Prychoonalytic Association, 25, 471-498.
CHANGES I N THERAPEUTIC RELATIONSHIP
HOYT,M. F. (1980) Therapist and patient actions in "good" psychotherapy sessions. Archives of General Psychiatry, 37, 159-161. MARZIALU, E . (1984) Three viewpoints on the therapeutic alliance. The Journal of Neruous and Mental Disease, 172, 417-423. MLNTZ,J., AUERBACH, A. H., LLIBORSKY, L., &JOHNSON, M. (1973) Patients', therapists', and observers' views of psychotherapy: a 'Rashomon' experience or a reasonable consensus. British Journal of Medical Psychology, 46, 83-89 O'MALLEY, S. S., SUH, C. S., & STRUPP,H. H . (1983) The Vanderbilt Psychotherapy Process Scale: a report on the scale development and a process-outcome study. Journal of Consulting and Clinical Psychology, 51, 5S1-586. ORLINSKY,D. E., & HOWARD,K. I. (1966) Therapy Session Report, Forms P and ?: Chicago, IL: Institute for Juvenile Research. ORUNSKY,D. E., & HOWARD,K. I. (1967) The good therapy hour. Archives of General Psychiatry, 16, 621-632. ORUNSKY,D. E., & HOWARD,K. I. (1975) Varieties of psychotherapeutic experience. New York: Teachers College Press. ORLINSKY,D. E., & HOWARD,K. I. (1977) The therapist's experience of psychothera y In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: a handbook orresearch. Oxford, Eng.: Pergamon. Pp. 566-589. ORLINSKY,D. E., & HOWARD,K. I. (1978) The relation of rocess to outcome in psychotheraIn S. L. Garfield & A. E. Bergin (Eds.), ~ a n d & o o kof psychotherapy and behavior %inge. (2nd ed.) New York: WJey Pp. 284-329. ORUNSKY,D. E., & HOWARD,K. I. (1986) Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds 1, Handbook of psychotherapy and behavior change. (3rd ed.) New York: Wiley. Pp. 311-381. PH U IPS, E. L. (1985) Psychotherapy revised: new frontiers in research and practice. Hillsdale, NJ: Erlbaum. SALTZMAN, C., LEUTGART, M. J., ROTH,C. H . , CREASER,J., & HOWARD,L. (1976) Formation of a therapeutic relationship: experiences during the initial phase of psychotherapy as of treatment duration and outcome. Journal of Consulting and Clinical Psychology, 44, 546-555. SNYDEX,W. U. (1961) The psychotherapy relationship. New York: Macmillan. STILES, W. B. (1980) Measurement of the impact of psychotherapy sessions. Journal of Consulting and Clinical Psychology, 48, 176-185. STILES,W. B., & SNOW,J. S. (1984) Counseling session impact as viewed by novice counselors and their clients. Journal of Counseling Psychology, 31, 3-12. SWNDLAND, D. M. (1972) Theoretical orientations of psychotherapists. In A. S. Gurman & A. M. Razin (Eds.), Effective psychotherapy: a handbook of research. Oxford, Eng.: Pergamon. Pp. 189-219. SUNDLAND, D. M. (1977) Theoretical orientation: a multi-professional, American sample. Paper presented at the June meeting of the Society for Psychotherapy Research, Madison, Wisconsin. TRUAX,C. B., & ROGERS,C. R. (1967) The therapeutic conditions antecedent to change: a theoretical view. In C. R. Ro ers (Ed.), The therapeutic relationship and its impact: a study of psychotherapy with sctfizophrenics. Madison, WI: Univer. of Wisconsin Press. Pp. 97-108.
Accepted April 2, 1990