If you think you really know what’s going on in the moment to moment of therapy, you might want to read this and reconsider. This micro-analysis of a single therapy session highlights just how differently we and our clients may experience our interventions.
Conducting Psychotherapy micro-Process Research With Clients and Therapists is not, on the face of it, a title designed to grab your attention. I confess to reading masses of research abstracts and bailing out before I’ve reached their end. Having read a lot of research by one of the authors (Joshua Swift), however, I stuck with it and I’m very glad I did.
To give it its full title, Paying Attention to the Details: Conducting Psychotherapy micro-Process Research With Clients and Therapists, is a recent blog post on the Society for Psychotherapy website. Written by Swift and Kelley A Thompson, [i] it is a case study of a single session in which therapist and client provided moment to moment ratings of the effectiveness of the session. I found it riveting, illuminating, and also mildly disturbing.
It was part of a larger study of 18 client-therapist dyads in which both parties provided moment to moment ratings of the effectiveness of a single session. The overall aims of the study were to:
Examine whether variability in the moment to moment ratings within sessions was present.
Identify therapist and client behaviours associated with higher and lower rated segments of the sessions.
Test whether clients and therapists were congruent in their moment to moment ratings.
This blog post provides a glimpse into the early findings of ongoing analysis of the study data.
The client-therapist dyad, and session and alliance ratings
The client was a 30-year-old American Indian woman seeking help primarily for depression, but also experiencing some anxiety and alcohol use concerns. The therapist was a similarly aged woman on a clinical psychology Master’s programme working from an integrative approach.
The session in question was their fifth therapy session. After this session the client rated the quality of the therapeutic relationship at 47 (of 60) on the Working Alliance Inventory-Short Revised (WAI-SR), [ii] and the effectiveness of the session at 32.5 (of 40) on the Session Rating Scale (SRS). [iii] The therapist rated the therapeutic relationship at 40 (of 60) on the WAI-SR. In other words, lower than the client’s rating.
Coding of moment to moment session segments
The session in question was first watched by the client. Using a dial rating device, she was instructed to rate each moment of the session from beginning to end. The scale ranged from helpful (100, dial pointing to the right) to hindering (0, dial pointing to the left), with 50 being neutral.
After watching and rating the entire session the client was asked to watch their three highest and lowest rated segments and say why those segments were helpful or hindering.
After the client had completed her ratings, the therapist watched the same session and completed the moment to moment ratings in the same way.
She was then shown her highest and lowest rated segments and asked to describe what was happening in each. Last, the therapist was shown the client’s highest and lowest rated segments. Rather than being told, however, she was asked to guess which segments the client had rated as helpful, and which hindering.
Variability of client and therapist ratings
The client rated the overall session neutrally (an average rating of 52.20 on the 0 – 100 scale). Within this were also several segments that were rated very positively, and some more negatively. By contrast, the therapist tended to fluctuate more in her positive and negative ratings, rarely identifying segments of the session as just neutral. As the researchers point out:
“…it is clear an end-of-session global rating would not represent the many highs and occasional lows that occurred during this session. By pinpointing the highs and lows, researchers can more specifically identify the processes leading to change.”
There are also clear discrepancies between client and therapist experiences of what was happening in the segments each rated as being helpful and unhelpful. These are outlined briefly below.
Perceptions of helpful segments
The therapist helped the client to be more accepting of her positive and negative thoughts
The therapist allowed the client to express her own motivation for change, rather than judge her for doing something wrong
The therapist validated her progress
The therapist was able to just listen and provide support while the client engaged in change talk or made her own connections leading to insight.
In general, the therapist characterised all three segments by her feeling like she and the client were on the ‘same page’
Perceptions of hindering segments
The therapist twice asked a question (presumably experienced by the client as unhelpful)
The therapist offered advice that did not seem congruent with the subject of discussion or the session direction
The two occasions where she had tried to provide validation to the client which the client did not accept
An awkward silence where the therapist forgot the point of what she was sharing with the client
For this pair, this session seemed to be more helpful when the therapist was providing support and validation to the client, allowing the client to lead the direction, and helping the client to be more accepting of herself. The hindering segments appeared to be characterised by “the therapist trying to lead the client in a direction the client did not understand or was not ready to go.”
Interestingly, none of the helpful segments were characterised by the use of specific treatment techniques or by the therapist providing any specific education or insight to the client.
Congruence between client and therapist
A significant, but modest, correlation was found between the client and therapist’s moment to moment ratings (helpful to hindering) across the session. Client and therapist both recognised one hindering segment towards the end of the session. There were also segments where they diverged at about one-quarter and five-eights of the way through the session.
A number of further points are noteworthy:
Client and therapist ratings matched for about half of the positively rated segments.
The therapist rated as hindering, several segments that the client felt were neutral or positive.
The therapist missed several of the segments rated as positive by the client.
When asked to guess which of the client’s three positively rated and three negatively rated segments were which, the therapist guessed just four of the six correctly.
What are we to take from this picture?
This session is one of a number of sessions, and the wider study holds 18 client/therapist dyads. Only further analysis will show whether or not the pattern of similarities and discrepancies evident from this session are more widely replicated. Nonetheless, this vignette provides a fascinating insight into what moments in the session client and therapist, respectively, rated as helpful or hindering.
The client’s average rating of the session was 52.20 (on the 0 – 100 scale), which is very similar to the therapist’s rating of 53.07. This similarity, however, disguises some significant differences between client and therapist experience of particular segments. We should also note that the average ratings are only two or three points above the neutral rating of 50.
We know that clients drop out of therapy, often without explanation. We also know that ruptures can occur which place strain on the therapeutic alliance. Those can be repaired, but only if we know about them.
Would the events in this session that led the client to rate certain segments as hindering be significant enough to call into question her commitment to the process? We don’t know, but it would be interesting to find out, for this client in particular and for clients more generally.
Whether we care to acknowledge it or not, clients are marking our work, especially in the early stages of therapy. They can be very forgiving of our occasional clumsiness or insensitivity, but if they are repeated, and we remain unaware of our mistakes, we cannot take it for granted.
We are all going to make mistakes, and sometimes we may not be aware of them. But that shouldn’t stop us actively looking for them.
Here are three ways in which we might go about that.
Drop-out, about which I’ve written elsewhere is a potential indicator of problems in the therapeutic alliance. Look to your drop-out rates, and if you are able to, benchmark them against colleagues or other similar services. In addition, compare your dropout rates over consecutive time periods.
Regularly check-in with your clients about their experience of sessions and go further than a general ‘how was the session for you?’ You can ask specifically if there was anything that they found unhelpful, or anything that jarred. They may too polite to tell you, but unless you ask you’ll almost certainly never find out.
Consider using a measure of the strength of the alliance such as the WAI-RS or the SRS.
Attend to the small moments in sessions and go in search of those that you may have missed, and it may just make the difference between an empty chair and one with a client sitting in it.
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[i] Swift, J. K., & Tompkins, K. A., (2016). Paying attention to the details: Conducting psychotherapy micro-process research with clients and therapists. Psychotherapy Bulletin, 51(2), 11-15.
[ii] Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16(1), 12-25. doi:10.1080/10503300500352500
[iii] Johnson, L. D., Miller, S. D., & Duncan, B. L. (2000). The Session Rating Scale 3.0. Chicago, IL: Author.