Trainee Therapist Characteristics in the Prediction of Client Rated Alliance
Author’s Note: We would like to thank the Society for the Advancement of Psychotherapy (2013 Charles Gelso Grant), the Society for Psychotherapy Research (Small Grant Program) and Augusta University (multiple small grants) for support of this work. Correspondence regarding this article should be addressed to Jenelle Slavin-Mulford, Department of Psychological Sciences, Augusta University, 2500 Walton Way, Augusta GA 30909. Email: firstname.lastname@example.org.
Clinical Impact Statement: This article presents pilot data showing that a multi-method assessment of clinical trainees at the beginning of graduate school robustly predicted future client rated alliance. Importantly, attachment and interpersonal measures uniquely contributed to the regression model whereas GRE and undergraduate GPA did not. Implications for the graduate admissions process are discussed.
Ample research suggests that therapists differ in their level of effectiveness (Blow et. al., 2007; Wampold, 2001). Even more striking is that therapist effects appear to be larger than treatment effects (e.g., Lindgren et al., 2010). These findings suggest that “who” the therapist is may be more important than the type of treatment used. Moreover, therapist training, experience, and theoretical orientation do not appear to explain the majority of therapist effects (e.g., Okiishi et al., 2003; Stirman & Crits-Cristoph, 2011). Thus, it has been hypothesized that therapists’ personal characteristics impact treatment (e.g., Black et al., 2005; Heinonen et al., 2012).
Hypotheses regarding which therapist characteristics are important have centered around constructs such as: intelligence (e.g., Shedler, 2006), empathic ability (e.g., Hill et al., 2008), and interpersonal and attachment styles (e.g., Marmarosh et al., 2013). Unfortunately, the empirical literature has largely ignored some of these factors and produced inconclusive or limited results for others. For example, GRE scores and GPA are often thought to be markers of intelligence and work ethic. However, there has been limited research on how these scores relate to therapeutic abilities and the work that has been done does not suggest a positive association (Smaby et al., 2005; Hill et al., 2008). Given that GPA and GRE scores are the two most heavily weighted “objective” variables in the graduate admissions process (Norcross, 1997), the need for further research is clear.
A therapist’s empathic ability is also theorized to be important (e.g., Rogers, 1957) and research suggests that a significant portion of outcome variance is related to therapists’ level of empathic responding in session (e.g. Elliot et al., 2011). However, research on the amount that pre-screening measures of empathy can predict later therapeutic effectiveness is mixed (e.g., Hill et al., 2008; Moyers & Miller, 2013). Given the strong relationship of empathy to outcome, further investigation of empathy as an innate therapist characteristic is needed.
A therapist’s interpersonal and attachment style are also thought to be important. These constructs have been found to relate to the alliance (Diener & Monroe, 2011; Hilsenroth et al., 2012), the effectiveness of individual sessions (Mohr et al., 2005) as well as to problems in therapy (Black et al., 2005). However, the majority of these studies examine therapists’ interpersonal and attachment styles and therapeutic process/outcome concurrently. Thus, future work is needed to determine whether interpersonal and attachment styles measured prior to a therapist’s training can predict later therapeutic abilities.
In sum, while there is considerable evidence that therapist characteristics impact the process and outcome of therapy, more work is needed. Developing a greater understanding of which therapist factors are most important and the degree to which these factors are innate versus developed through training will have important implications for graduate school admissions criteria. To add to this knowledge base, we examined whether a multi-method evaluation of trainees at the beginning of graduate school could predict which trainees would demonstrate the greatest therapeutic skill during their first clinical encounters. Given that the therapeutic alliance is one of the most reliable predictors of psychotherapy outcome (e.g., Horvath et al., 2011), we used client rated alliance as the first measure of therapeutic ability.
Presently, data have been collected from 5 cohorts of clinical graduate trainees (N=44) attending a southeastern university. The participant group is currently 75% female with a mean age of 24 years (SD = 5.24). The racial composition of the sample is 68% European American, 16% African American, 9% Hispanic, 2% Asian American, and 5% other. In addition, participants’ academic records indicated a mean undergraduate GPA of 3.56 (SD = .28), quantitative GRE score of 147.73 (SD = 5.44) and verbal GRE score of 152.05 (SD = 4.82).
Volunteer undergraduate students from the same university served as therapy patients. These students were enrolled in a class focused on personal growth and they received course credit for participating in the sessions and writing a reflection essay. None of these undergraduates knew the researchers in this project, and their professor was not provided any information about the therapy sessions except that the students participated. The patient group (N = 44) is 75% female, 46% European American, 36% African American, 9% Asian American, 5% Hispanic, and 4% other. The mean age of the group is 20 years (SD = 2.13).
At the beginning of their graduate training (2nd day of class of the 1st semester), all clinical graduate students completed a multi-method personality assessment as part of their course work. A research assistant unaffiliated with the program administered, de-identified, and scored the assessments. All student responses are confidential and are not shared with anyone in the program.
In their second semester, all clinical students took an introductory therapy course with curriculum based on Hill’s three-stage model as presented in Helping Skills: Facilitating Exploration, Insight, and Action (2009). As part of this course, each trainee was assigned an undergraduate student volunteer with whom they had four non-manualized therapy sessions. The first session was a 1.5-hour intake and the remaining three sessions were 45 minutes. Patients were told that they could use the sessions to work on whatever felt most important to them. However, they were instructed not to share concerns related to suicidal or homicidal ideation or child or elder abuse. Common presenting problems included relational difficulties, anxiety associated with school, and concerns regarding choosing a career path.
All sessions were videotaped. Trainees received supervision from the course instructor who is a licensed clinical psychologist. Following sessions one, two, and four, trainees received 1.5 hours of group supervision (2-3 trainees per group). In addition, students received 1.5 hours of individual supervision following session 3. Supervision focused heavily on the review of video-recorded case material with emphasis on case conceptualization and clinical interventions. For all students, this was their first training case.
Evaluation of therapist characteristics: During the initial assessment, trainees complete a number of self-report questionnaires. These include: The Experiences in Close Relationships-Revised (ECR-R; Fraley et al., 2000) to assess anxious and avoidant attachment styles, The Inventory of Interpersonal Problems-Short Circumplex (IIP-SC; Soldz et al., 1995), and The Perspective Taking Scale of the Interpersonal Reactivity Index (IRI; Davis, 1980, 1983). In addition, seven Thematic Apperception Test (TAT; Murray, 1943) cards are administered and scored by two expert raters using the Social Cognition and Object Relations Scale Global Rating Method (SCORS-G; Stein & Slavin-Mulford, 2018; Westen, 1995). GRE and undergraduate GPA were also obtained from participants’ applications.
Evaluation of alliance: The Working Alliance Inventory Client Form (Horvath & Greenberg, 1989) was rated by the clients following the 3rd session.
Results and Discussion
Multiple regression was used to explore whether we could predict client rated alliance (WAI-C total score) based on clinical trainees’ scores from the initial assessment. The independent variables included: Verbal and Quantitative GRE scores, undergraduate GPA, IIP-SC total score, IRI Perspective Taking score, SCORS-G total score, and ECR-R Avoidant and Anxious Attachment Scores.
The overall regression model significantly and robustly predicted (p < .05, R =.58) client rated alliance. In line with a recent meta-analysis suggesting that therapist interpersonal functioning is the therapist factor most strongly linked to treatment outcome (Lingiardi et al., 2017), we found that trainees’ self-reported interpersonal problems (p = .05, β = -.42, sr2 = .08) and attachment related avoidance (p = .05, β = .34, sr 2= .08) both made unique contributions to our model with moderate effects. Although none of the other variables made a unique contribution, it is important to note that undergraduate GPA was uncorrelated (r = .03), and quantitative (p < .05, r = -.38) and verbal (p < .05, r = -.35) GRE scores significantly and negatively correlated with client ratings of alliance. Given that GRE and GPA are used to screen most clinical and counselling applicants (e.g., Sampson & Boyer, 2001), these findings are particularly noteworthy. They are also in line with the limited previous work in this area. Specifically, they mirror Smaby and colleagues’ (2005) findings that verbal GRE scores negatively related to the Skilled Counseling Scale and Hill and colleagues’ (2008) finding that once outliers were accounted for, GPA was unable to predict therapeutic effectiveness.
Conclusions and Future Directions
Our findings raise concerns about common clinical and counselling program admissions processes which focus more heavily on grades and test scores than on relational qualities (Anderson et al., 2015). Our results suggest that assessing applicants’ interpersonal functioning is likely to be important in selecting effective therapists. Unfortunately, there is a lack of research regarding the validity of the admissions process in evaluating these characteristics (e.g., Kuncel et al., 2014). Specifically, while letters of recommendation and personal statements are almost ubiquitously used for this purpose in the initial review of applicants, they have been largely unstudied in terms of whether they can predict therapeutic ability (GlenMaye & Oakes, 2002). Thus, future research needs to examine the admissions process to clinically oriented programs and work to find valid methods for assessing candidates interpersonal functioning.
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