Development and validation of an 8-item version of the Real Relationship Inventory–Client form

Figures & data

Table 1. Demographics, clinical, and treatment characteristics of participating patients.

	Sample A (N = 700)	Sample B (N = 434)
Demographics	% (n)	% (n)
Age (years)
18–22	9% (66)	7% (29)
23–29	20% (142)	23% (101)
30–39	28% (193)	32% (137)
40–49	16% (109)	16% (69)
50–59	14% (99)	12% (52)
≥60	13% (91)	11% (46)
Gender
Woman	73% (512)	77% (332)
Man	19% (132)	15% (64)
Other	7% (47)	8% (35)
I prefer not to say	1% (9)	1% (3)
Education
Less than high school	0% (2)	0% (1)
High school graduate	3% (24)	4% (19)
Some college	19% (136)	17% (75)
2-year degree	9% (64)	9% (37)
4-year degree	33% (231)	33% (145)
Professional degree	28% (195)	30% (128)
Doctorate	7% (48)	7% (29)
Ethnicity
White	81% (566)	80% (349)
Black or African American	10% (68)	9% (40)
Asian	4% (29)	5% (21)
Native Hawaiian or Pacific Islander	1% (4)	1% (2)
American Indian or Alaska Native	1% (5)	1% (4)
Other	4% (28)	4% (18)
Clinical characteristics^a
Any psychiatric disorder	84% (590)	90% (391)
Any anxiety disorder	66% (464)	76% (328)
Any (unipolar) depressive disorder	56% (391)	63% (273)
Any trauma- and stressor-related disorders	35% (244)	39% (167)
Any neurodevelopmental disorder	24% (165)	29% (124)
Any bipolar or related disorder	13% (88)	15% (65)
Any eating disorder	10% (71)	11% (46)
Any disruptive behavior and dissocial disorder	2% (15)	1% (4)
Schizophrenia or any other psychotic disorders	1% (9)	2% (8)
Any cluster A personality disorder	0% (3)	1% (6)
Any cluster B personality disorder	6% (43)	9% (41)
Any cluster C personality disorder	6% (41)	6% (27)
Treatment characteristics
In psychotherapy from
0–3 months	14% (99)	17% (74)
4–6 months	14% (96)	10% (45)
7–12 months	11% (79)	12% (52)
13–24 months	13% (94)	13% (55)
>24 months	47% (332)	48% (208)
Session frequency
1 or less per month	19% (130)	0% (0)
2–3 per month	39% (276)	49% (213)
1 per week	38% (267)	45% (196)
2 or more per week	4% (27)	6% (25)
Session attendance
Video call	53% (369)	55% (240)
In person face to face	36% (251)	34% (146)
Telephone call	8% (59)	7% (30)
In person on the couch	3% (21)	4% (18)
Therapy location
Private practice	70% (493)	75% (324)
Private health institution	11% (76)	10% (43)
Public health institution	10% (67)	10% (42)
University counseling center	4% (26)	3% (14)
Other	5% (38)	3% (11)
Therapist biological sex (Female)	81% (565)	77% (335)

Note: ^aN sums to more than 700 for sample A and 434 for sample B because cases could have more than one diagnosis.

Table 2. Measurement tools.

Domains and measures	Sample A	Sample B
Demographic and therapy domain
Sociodemographic, clinical, and treatment data form	✓	✓
Personality domain
Big Five Inventory–2-Extra-Short form	✓
The Level of Personality Functioning Scale–Brief Form 2.0	✓
Mental health state domain
International Positive and Negative Affect Schedule-Short Form	✓
Patient Health Questionnaire–9	✓	✓
Generalized Anxiety Disorder–7	✓	✓
Single-item global measures of symptom severity, psychosocial functioning, and quality of life	✓
Therapeutic relationship domain
24-item Real Relationship Inventory–Client form	✓
8-item Real Relationship Inventory–Client form		✓
Working Alliance Inventory–Short Revised	✓	✓
Patient Session Questionnaire	✓
in-Session Patient Affective Reactions Questionnaire	✓	✓
Rift In-Session Questionnaire	✓	✓
Session outcome domain
Session Evaluation Scale	✓	✓

Table 3. Item option characteristics for the Genuineness and Realism factors based on IRT models.

Scale	n.	Item content	α	β1	β2	β3	β4
Genuineness	1.	I was able to be myself with my therapist.	2.81	−1.84	−1.43	−0.10	−0.00
	4.	I appreciated being able to express my feelings in therapy.	3.39	−1.97	−1.53	−1.07	−0.08
	7.	I was open and honest with my therapist.	3.92	−1.92	−1.36	−0.93	0.22
	11.	I was able to communicate my moment-to-moment inner experience to my therapist.	2.37	−2.45	−1.29	−0.59	0.69
Realism	5.	My therapist liked the real me.	3.05	−2.15	−1.63	−0.50	0.60
	9.	The relationship between my therapist and me was strengthened by our understanding of one another.	2.97	−2.10	−1.47	−0.48	0.71
	13.	I appreciated my therapist’s limitations and strengths.	2.81	−2.49	−1.63	−0.65	0.68
	20.	I had a realistic understanding of my therapist as a person.	2.17	−2.27	−1.39	−0.62	1.02

Table 4. Descriptive statistics, precision, and inter-scale correlations.

	Total scale	Genuineness	Realism
Descriptive statistics^a	8 items	4 items	4 items
Potential Range	8–40	4–20	4–20
Observed Range	8–40	4–20	4–20
Mean, SD	32.46 (6.20)	16.68 (3.40)	15.78 (3.24)
POMP, SD	76.40 (19.40)	79.20 (21.30)	73.60 (20.30)
Skew	−1.18	−1.40	−.78
Kurtosis	1.66	2.05	.63
Standard Error of Measurement (SEm)	1.75	1.27	1.17
Standard Error of Difference (SEd)	2.48	1.80	1.65
Clinical change benchmarks^a
90% Critical Change	2.88	2.09	1.92
95% Critical Change	3.44	2.49	2.29
Minimal Important Difference (MID)	3.10	1.70	1.62
Minimum Change for a Reliable Change	4.86	3.53	3.24
Scale correlations^b
RRI-C-SF total score	1	–	–
RRI-C-SF Genuineness score	.94***	1	–
RRI-C-SF Realism score	.93***	.75***	1
RRI-C full form total score	.96***	.90***	.90***
RRI-C full form Genuineness score	.95***	.93***	.85***
RRI-C full form Realism score	.94***	.84***	.93***

Note: ^aData based on pooled samples. ^bData based on sample A. POMP = percentage of maximum possible. MID was operationally defined as d = .5. ****p < .0005, two-tailed.

Figure 1. Bland-Altman Plots comparing accuracy of short and full-length version of Real Relationship Inventory–Client form. Note. Data based on sample A. The difference of measures is computed by subtracting the scaled-up score of the shortened scale from the score of the full-length scale, where a positive difference indicates that the full-length scale has a higher score, and a negative difference suggests the opposite.

Table 5. Criterion-related and construct validity correlations.

	Total scale	Genuineness	Realism
Demographics
Age	.04	.08	.08
Gender	−.06	−.07*	−.07*
Education	.09*	.09*	.09*
Ethnicity	−.02	−.02	−.02
Average absolute correlation across subset	.05	.07	.07
Clinical characteristics
Any psychiatric disorder	.06	.05	.05
Any anxiety disorder	.01	−.01	−.01
Any (unipolar) depressive disorder	.04	.04	.04
Any trauma- and stressor-related disorders	.04	.02	.02
Any neurodevelopmental disorder	.04	.02	.02
Any bipolar or related disorder	.03	.02	.02
Any eating disorder	−.00	−.03	−.03
Any disruptive behavior and dissocial disorder	−.03	−.03	−.03
Schizophrenia or any other psychotic disorders	−.05	−.07	−.07
Any cluster A personality disorder	.03	.02	.02
Any cluster B personality disorder	−.00	−.02	−.02
Any cluster C personality disorder	.05	.05	.05
Average absolute correlation across subset^a	.03	.03	.03
Treatment characteristics
Therapy length (months, ordinal; see prior table)	.18***	.12***	.12***
Session frequency (ordinal, see prior table)	.15***	.13***	.13***
Session attendance	.02	.04	.04
Therapy location	−.08*	−.08*	−.08*
Therapist’s sex	.02	−.00	−.00
Average absolute correlation across subset	.09	.07	.07
Mental health state domain
GAD-7	−.12***	−.13***	−.09***
PHQ-9	−.18***	−.19***	−.13***
Average absolute correlation across subset	.15	.16	.10
Therapeutic relationship domain
SPARQ positive affect	.58***	.49***	.59***
SPARQ negative affect	−.42***	−.42***	−.37***
RISQ	−.25***	−.24***	−.23***
WAI-SR total score	.59***	.5***	.60***
WAI-SR goal	.51***	.44***	.52***
WAI-SR task	.52***	.46***	.52***
WAI-SR bond	.56***	.46***	.60***
Average absolute correlation across subset^b	.47	.42	.46
Session outcome domain
SES	.54***	.49***	.51***

Note: Data based on sample A. Coefficients are point-biserial correlations for dichotomized variables, point-biserial correlations for dummy-coded categorical variables, Spearman correlations for ordinal variables, and Pearson correlations for continuous variables.

^a “Any psychiatric disorder” excluded from the matrix.

^b WAI-SR subscales score excluded from the matrix due to redundancy with WAI-SR total score.

*p < .05, **p < .01, ***p < .001.

Table

		Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	I was able to be myself with my therapist.	1	2	3	4	5
2	I appreciated my therapist’s limitations and strengths.	1	2	3	4	5
3	The relationship between my therapist and me was strengthened by our understanding of one another.	1	2	3	4	5
4	My therapist liked the real me.	1	2	3	4	5
5	I was open and honest with my therapist.	1	2	3	4	5
6	I had a realistic understanding of my therapist as a person.	1	2	3	4	5
7	I was able to communicate my moment-to-moment inner experience to my therapist.	1	2	3	4	5
8	I appreciated being able to express my feelings in therapy.	1	2	3	4	5