Client self-image, therapist acting, and the establishment of the therapeutic alliance in a training context

ABSTRACT

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.

ABSTRAKT

Diese Studie erforrscht das Selbstbild und die Wahrnnehmung des Verhaltens von dem Therapeuten welches mit der therapeutischen Verknuepfung, sowie um herauszufidnen in wiefern diese Variablen sich verandern in dem psychotherapeutischen Prozess, spezielle die Auszubildende Psychotherapy.Ein hundernt und sechzig Teilnehmer (M= 28.9 Jahre) die zwei Semestern der Psychology Klinik Clinic of Umeå University mitgemacht und beendet haben. Diese haben auch die sogennate „working Alliance Inventory“ ausgefuellt im ihre Wahrnehmung der Verknuepfung mit den Therapeuten zu beurteilen. Die Teilnehmer haben ebenfalls zwei Umfragen ausgefuellt die auf ein Model der strukturierte Analyse des Sozialverhaltens basieren um einen Einblick ueber das Selbstbild und die vernetzten Strukturen zu verschaffen und letztendlich um die Wahrnehmungen der Therapeuten zu analysieren

Die Ergebnisse zeigen ein positives Selbstbild und eine positive Wahrnehmung der Verhaltenweisen des Therapeuten sind bedeutend uber den Kurs der Therape angestiegen, mit einem dazugehoerigen Rueckgang in negativen Strukturen. Die Verknuepfungsergebnisse zeigen dass die therapeutische Verknuepfung sich erheblich mit der Zeit erhoet und dass diese beinflusst is von den Wahrnehmung des Verhaltens der Therapeuten, mehr als durch das Selbstbild. Das Selbstbild wird wichtiger nach der Haelfte der Therapie, und somit wird die Rolle des Therapeuten hervorgehoben welche die therapeutische Beziehung mitgestaltet. Die Konsequenzen dieser Ergebnisse werden erwogen, sowie die Richtungen der zukuenftigen Forschung in anderen ausbildungsgebunden Umgebungen und Stichproben.

Este estudio examina cómo la imagen del ‘’sí mismo” en los clientes y su percepción de la conducta del terapeuta, se relacionan con la alianza terapéutica, así como también explora como dichas variables cambian durante el proceso terapéutico en terapias conducidas por estudiantes. Se entrevistaron ciento sesenta y cuatro participantes (Media de edad: 28,9 años) los cuales asistieron durante dos semenstres de tratamiento a la Clínica Psicológica de la Universidad de Umea, completaron el Inventario de la Alianza de Trabajo (IAT) para evaluar la percepción de su alianza con el terapeuta, y además completaron dos cuestionarios basados en el modelo de Análisis Estructural de Conducta Social (AECS), para proporcionar la comprensión de la manera de percibirse a si mismos y para analizar su percepción de la conducta de los terapeutas. Los resultados mostraron que un concepto positivo del ‘’sí mismo” y percepciones positivas de la conducta de los terapeutas aumentaban significativamente durante el curso de la terapia con una correspondiente disminución en pautas negativas. Las marcas acerca de la alianza terapéutica muestran que ésta gana importancia en el tiempo y que está más bajo la influencia de la percepción de la conducta del terapeuta que de la percepción del ‘’sí mismo”; ésta última es más relevante después de la primera mitad del período de terapia, subrayando el papel del terapeuta en co-crear la relación dentro del tratamiento. Se discuten las implicaciones de estos resutados y se dan direcciones para investigaciones futuras en otros escenarios y ejemplos con estudiantes.

ABSTRACT

Questo studio ha esaminato come l’immagine di sé dei pazienti e la percezione del comportamento del terapeuta siano correlati all’alleanza terapeutica, nonché come queste variabili cambino nel processo terapeutico condotto da un tirocinante. Centosessantaquattro partecipanti (M = 28,9 anni) che hanno frequentato due semestri di trattamento presso la Clinica di Psicologia dell’Università di Umeå hanno completato il Working Alliance Inventory (WAI) per valutare la loro percezione dell’alleanza terapeutica. Hanno anche completato due questionari basati sul modello SASB (Structural Analysis of Social Behaviour) al fine di evidenziare i loro modelli di immagine di sé, nonchè per analizzare le loro percezioni circa il comportamento del terapeuta. I risultati mostrano che un’immagine positiva di sé e la percezione positiva delle azioni del terapeuta aumentano significativamente nel corso della terapia, con una corrispettiva diminuzione dei pattern negativi. Anche i punteggi relativi all’alleanza terapeutica mostrano come essa acquisti importanza nel tempo e come sia influenzata più dalla percezione del comportamento del terapeuta che dall’immagine di sé. L’immagine di sé diventa più rilevante nella secoda parte della terapia, sottolineando il ruolo del terapeuta nella co-creazione della relazione terapeutica. Vengono discusse le implicazioni di questi risultati e le direzioni future per la ricerca in altri contesti e con differenti campioni.

Cette étude examine les liens entre l’image de soi des clients et la perception des comportements du thérapeute, ainsi que la façon dont ces variables changent au cours d’une thérapie menée par un thérapeute en formation. Cent soixante-quatre participants (M=28.9 ans) qui ont été en traitement à la clinique de psychologie de l’université de Umeå pendant deux semestres ont rempli la WAI (Inventaire de l’Alliance de Travail) afin d’évaluer leur perception de l’alliance avec leur thérapeute.

Ils ont également rempli deux questionnaires basés sur le modèle SASB (Analyse Structurelle du Comportement Social) qui ont servi à renseigner sur les structures de leur image de soi et à analyser leurs perceptions des comportements des thérapeutes. Les résultats montrent qu’une image de soi positive et des perceptions positives des actions du thérapeutes augmentent de façon significative au cours de la thérapie avec une baisse correspondante des schémas négatifs. Les scores concernant l’alliance montrent que l’alliance thérapeutique prend davantage d’importance au fil du temps et qu’elle est davantage influencée par la perception du comportement du thérapeute que par l’image de soi. L’image de soi devient pertinente après le milieu de la thérapie, soulignant ainsi le rôle du thérapeute dans la cocréation de la relation thérapeutique. Les implications de ces résultats sont discutées tout comme le sont les directions pour de futures recherches sur d’autres contextes où le thérapeute est en formation et sur d’autres échantillons.

Περίληψη

Η παρούσα έρευνα εξέτασε πώς σχετίζονται η αυτοεικόνα των πελατών και η αντίληψη της συμπεριφοράς του πελάτη με τη θεραπευτική συμμαχία, καθώς και το πώς αυτές οι μεταβλητές αλλάζουν κατά τη θεραπευτική διαδικασία με εκπαιδευόμενους ψυχοθεραπευτές. Εκατόν εξήντα τέσσερις συμμετέχοντες (M = 28.9 έτη) που βρίσκονταν σε θεραπεία για δύο εξάμηνα στην Ψυχολογική Κλινική του Πανεπιστημίου Umeå συμπλήρωσαν το Ερωτηματολόγιο Θεραπευτικής Συμμαχίας (Working Alliance Inventory) για να εκτιμήσουν την αντίληψη τους γύρω από τη συμμαχία τους με τον θεραπευτή. Επίσης, συμπλήρωσαν δύο ερωτηματολόγια βασιζόμενα στο Μοντέλο της Δομικής Ανάλυσης της Κοινωνικής Συμπεριφοράς (Structural Analysis of Social Behavior) για να δώσουν μια εικόνα γύρω από τα μοτίβα της αυτοεικόνας τους και να περιγράψουν τις αντιλήψεις τους γύρω από τη συμπεριφορά του θεραπευτή. Τα αποτελέσματα έδειξαν ότι η θετική αυτοεικόνα και οι θετικές αντιλήψεις των πράξεων του θεραπευτή αυξάνονταν σημαντικά κατά τη διάρκεια της θεραπείας, ενώ παρατηρήθηκε μια αντίστοιχη μείωση στα αρνητικά μοτίβα. Τα σκορ της συμμαχίας δείχνουν ότι η θεραπευτική συμμαχία βελτιώνεται σημαντικά στο πέρασμα του χρόνου και ότι επηρεάζεται περισσότερο από την αντίληψη για τη συμπεριφορά του θεραπευτή παρά από την αυτοεικόνα. Η αυτοεικόνα σχετίζεται σημαντικά μετά το μέσο μέρος της θεραπείας, υπογραμμίζοντας τον ρόλο του θεραπευτή στη συνδημιουργία της θεραπευτικής σχέσης. Συζητούνται οι επιπτώσεις των ευρημάτων, όπως και οι κατευθύνσεις για μελλοντικές έρευνες σε άλλα εκπαιδευτικά πλαίσια και δείγματα.

KEYWORDS:

• Self-image
• therapeutic alliance
• perception of therapist behavior
• SASB
• WAI
• psychotherapy

HAUPTWORTER:

• Selbstbild
• therapeutische Verknuepfung
• Wahrnehmung des Verhaltens desTherapeuten
• SASB
• WAI
• psychotherapie

PALABRAS CLAVE:

• concepto del ‘’sí mismo“
• alianza terapéutica
• percepció de la conducta del terapeuta
• IAT
• AECS
• psicoterapia

PAROLE CHIAVE:

• immagine di sé
• alleanza terapeutica
• percezione del comportamneto del terapeuta
• SASB
• WAI
• psicoterapia

MOTS-CLÉS:

• image de soi
• alliance thérapeutique
• perception du comportement du thérapeute
• SASB
• WAI
• psychothérapie

Λέξεις-κλειδιά:

• αυτοεικόνα
• θεραπευτική συμμαχία
• αντίληψη της συμπεριφοράς του θεραπευτή
• ΔΑΚΣ
• ΕΘΣ
• ψυχοθεραπεία

The client self-image has come to be regarded as one of the factors contributing to the working alliance (McWilliams, 2012), and to the psychotherapy outcome (e.g. Arnold, Farber, & Geller, 2000; Critchfield, Henry, Castonguay, & Borkovec, 2007; Dennhag, Östgård-Ybrandt & Armelius, 2011; Halvorsen & Monsen, 2007; Ryum, Vogel, Walderhaug, & Stiles, 2015). Important issues, therefore, are how variations in the client’s self-image are related to the establishment of the working alliance, and the role of both the client-perceived therapist behavior and the client characteristics in building the alliance to promote efficacious psychotherapy.

One of the models that have been found to be useful in the study of the client’s self-image and the client’s perceived behavior of the therapist is the Structural Analysis of Social Behavior (SASB; Benjamin, 1974) model (Constantino, 2000). The model is based on interpersonal theory (Sullivan, 1954) and allows the study of various aspects of intrapsychic processes and interpersonal communication by analyzing underlying components’ interactive profiles (Henry, 1996). In recent decades, the SASB model has been applied in different schools of psychotherapy and in supervision (e.g. Greenberg & Malcomb, 2002; Lindfors, Kneckt, Heinonen, Virtala, 2014; Lorentzen, Fjeldstad, Ruud, Marble, Klungsøyr, Ulberg & Høglend, 2015; Marble, Høglend, & Ulberg, 2011; Quintana & Meara, 1990; Wiser & Goldfried, 1998; Ybrandt & Armelius, 2009), and in the study of different aspects of psychopathology (Henry, 1996). For example in the study of dissociative disorders (e.g. Alpher, 1996), psychotic and borderline disorders (e.g. Armelius & Granberg, 2000; Benjamin & Wonderlich, 1994), depression disorders (e.g. Knobloch-Fedders et al., 2014), and eating disorders (e.g. Wonderlich & Swift, 1990).

The SASB is a three surface circumplex model that integrates interpersonal and intrapsychic behavior along two basic orthogonal dimensions—affiliation, ranging from positive to negative and interdependence, ranging from differentiated to enmeshed. The SASB has three foci, a focus on the other or on actions, a focus on the self or on reactions, and a focus on the self-image (Figure 1). Excluded in this study are the reactions to the actions of another person’s perceived initiations. Each of the three foci is divided into eight clusters of behavior each representing combined degrees of affiliation and control. The ‘baseline’ positions for both the perceived actions and the individual’s actions toward the self should include love and friendliness accompanied by pleasant affects and flexible, open, well-focused cognitive styles (for more details see Benjamin, 1996).

Figure 1. The structural analysis of social behavior: The eight cluster version. The focus are presented in order TRANSITIVE (action toward other), INTRANSITIVE (reaction to other), and INTROJECT (self-concept).

The study of the self-image with the SASB has focused on the self-image change in psychotherapy, showing primary changes on the affiliation dimension of the SASB, demonstrated in several studies (e.g. Bedics, Atkins, Comtois, & Lineham, 2012; Dennhag, Östgård-Ybrandt & Armelius, 2011; Junkert-Tress, Schnierda, Hartkamp, Smitz & Tress, 2001; Lorentzen, Fjeldstad, Ruud, Marble, Klungsøyr, Ulberg & Høglend, 2015). Halvorsen and Monsen (2007) found in their study of the self-image change in a sample of 233 Norwegian outpatients, an overall change toward less negative self-image profiles. Patients with elevated pretreatments levels of self-control also changed along the interdependence dimension. At post-treatment 40 % of the clients presented a self-loving self-image. In a study by Ryum et al. (2015) the results demonstrated that five out of six of the studied clusters changed with a medium effect size. The clients’ affiliation clusters self-love and self-affirm increased significantly through the psychotherapy process, together with a decrease in self-control, self-blame, self-attack and self-ignore, resulting in reduced self-criticism and enhanced self-compassion. The SASB were rated pre- and post-treatment in a sample of 170 clients with depression and anxiety symptoms in a university clinic.

A small number of studies have addressed the question of which specific client personality features that are associated with a good or poor therapeutic relationship, none of them have used the SASB self-image concepts (which are expressed as affiliation or control actions against the self). Wong and Pos (2014) found client disclosing to predict the client-therapist bond, explaining unique 14% of the variance in session—one alliance. Coleman (2006) found significant moderate positive correlations between the personality traits agreeableness, extraversion and conscientiousness and clients’ global working alliance in a cross-sectional study with 103 mental health patients with diverse problems. Hirsh, Quilty, Bagby, and McMain (2012) also reported a positive relationship between agreeableness and alliance in a sample of 87 borderline patients. In a recent study of Dennhag, Sundström, and Ybrandt (2017) 10% of the variance in alliance was explained by change (pre- and post-assessment) in hedonism and negative affectivity in a sample of 143 clients with moderate symptoms at a training clinic. Studies utilizing the specific self-image features that are associated with a good or poor therapeutic relationship point to the importance of a client-therapist personality congruence. Personality similarity between the client and therapist is associated with the client perceiving a bond with the therapist in the early stages of the therapy (Taber, Leibert, & Agaskar, 2011).

The focus on the other or on actions in the SASB circumplex model of communication identifies the presence of reciprocating friendly—to unfriendly and dominant—to submissive behavior, in the psychotherapy context, the client perceived therapist´s affirmative and dominant communication behavior. Bedics et al. (2012) concluded that the client-perceived therapeutic relationship involves complex elements of both affirmation and control that vary as a function of time in treatment. They studied the psychotherapy process in Dialectical Behavior Therapy (DBT) and found that the therapist behavior was overall perceived as affiliative and accepting through the psychotherapy process, somewhat less controlling toward the end of the treatment.

The main aims of this study were to explore, by using the SASB questionnaires, how clients’ self-image and their perceptions of the therapist’s behavior may change and be related to the therapeutic alliance at five different sessions (1, 8, 16, 24, and 32 session) in short-term trainee-led psychotherapy. Over time the client´s self-image is expected to change toward reduced self-criticism and enhanced self-compassion according to results from earlier studies.

Method

Participants in this longitudinal study were drawn from the project Effects of Trainee Therapies that was undertaken during 2008–2013 at the Psychology Clinic, Umeå University, Sweden. The aim of the project was to study client, therapist, and supervisor effects on psychotherapy outcome. The study was reviewed and approved by the Regional Ethical Board at Umeå University.

Clients

A total of 164 clients who had been accepted for treatment at the Umeå University Psychology Clinic participated in this study. The mean age of the clients was 28.4 years (SD = 8.32, range 19–63 years). Most of them were women (82%). In terms of their family situation, 28% of the clients were currently living with a partner and 9% were married. In terms of employment, 42% were students, 38% were engaged in paid work, 2% were on sick leave, 5% were unemployed, and 13% were ‘other’. In terms of educational level, 76% of the clients had higher education, 12% had completed secondary school, 1% primary school, and 11% had other educational skills. Moreover, 9% of the clients had an ethnic background other than Swedish. The psychological problems that the clients wanted help with were the following (clients could have mentioned more than one problem): anxiety (45%), relationship problems (28%), depression (14%), identity/self-image problems (8%), stress-related problems (6%), and phobia (3%).

Trainees

The trainees were enrolled in a 5-year professional psychology program. Altogether 67% of the trainees (n = 164) were female, average age was 29 years (SD = 5.8, range 23–51 years), 40% were single, 8% were married, and all were native Swedes. The trainees started their training in the fourth year of the MSc and they had no previous experience of working as a psychotherapist. Half of the participants (49%) received training in CBT and the remainder were trained in PDT. The trainees in the two methods saw individual clients one hour per week (for at least 32 sessions) and they were given two hours of group supervision (three students) per week, in all 60 h. The students received 400 hr of theoretical instruction in both CBT and PDT before starting to practice under supervision.

Supervisors

The therapy was supervised by highly experienced, registered psychologists and psychotherapists who had completed a two-year training program in psychotherapy supervision. The average supervisor had more than 15 years of experience as a psychotherapy supervisor. Supervisors supervised in their own PDT or CBT specialization. The primary role of the supervisor was to help trainees develop basic clinical skills and an emerging professional identity, and to assure the quality of their psychotherapeutic work. About half of the supervisors (55%) were male and 45% were female. Their mean age was 58.8 years (range 44 to 76 years).

Instruments

Participants filled out the three questionnaires described below at the end of five of the sessions of the treatment process (numbers 2, 8, 16, 24, and 32).

Structural Analysis of Social Behavior (SASB). This study used the Swedish long-form version of the SASB (Armelius, Lindelöf, & Mårtensson, 1983) to measure clients’ perceived self-image. The SASB measures self-image with 36 items around the two dimensions in the SASB model: affiliation (positive and negative) and interdependence (autonomous and controlled). The 36 items are grouped into eight clusters: self-emancipate (1), self-affirming (2), self-love (3), self-protection (4), self-control (5), self-neglecting (6), self-attacking (7), and self-blame (8). Attachment theory has been incorporated into the SASB model. According to Florsheim, Henry, and Benjamin (1996), the two fundamental and normative developmental processes, attachment seeking (in SASB terms ‘positive enmeshment’) and exploration (in SASB terms ‘friendly differentiation’), are described by a balance of behaviors in the clusters to the right of the SASB circle. These clusters, namely two, three and four, are together referred to as the attachment group (AG) of clusters. The clusters to the left, namely six, seven, and eight, describe behavior that is characterized by criticizing, rejecting, and ignorance and represent negative attachment. These clusters are together labeled as the disruptive attachment group (DAG) of clusters (Benjamin, 1996; Florsheim et al., 1996). A balance between self-emancipate (cluster 1) and self-control (cluster 5) is also desirable in the development of the self-image. The 36 items (five items each for cluster one and five) are rated on a scale between ‘do not agree’ (scale point 0) to ‘perfect agreement’ (scale point 100). Internal consistency was satisfactory for the two groups in the present study. The Chronbach’s alpha reliability was r = 0.82 for AG, and r = 0.84 for DAG. The test–retest reliability is r = 0.87 for both the American version (Benjamin, 1987) and the Swedish version (Armelius, 2001). Factor analyses showed that the Swedish translation is consistent with the model (Armelius & Öhman, 1990).

The clients’ perception of therapist behavior was evaluated using the short form of the SASB questionnaire which consists of eight items, each one representing one of the eight clusters of the model. The short form has the same rating scale as the long version.

Working Alliance Inventory. The 36-item Swedish version of the Working Alliance Inventory (WAI) (Horvath & Greenberg, 1989) was used to assess the client-perceived working alliance. The client rated the quality of alliance on a 7-point Likert scale (1 = never, 2 = rarely, 3 = occasionally, 4 = sometimes, 5 = often, 6 = very often, and 7 = always). A total score of the 36 items was used as the alliance index in the present study, based on Tracey and Kokotovic (1989) and Stiles et al. (2004). The reliability of the different WAI versions has a modal estimate of .92 (Hanson, Curry, & Bandalos, 2002). In the present study, internal consistency was .91 (Cronbach’s α) for the total scale. There is support for its validity correlation with outcome indices (e.g., Horvath, Del Re, Flückiger, & Symonds, 2011).

Procedure and treatment

The clients themselves applied for treatment, using the internet. Before clients were placed on the waiting list for psychotherapy, they were interviewed (manualized interview) by a clinical psychologist to determine whether their problems were too severe for novice trainees. Clients with severe levels of eating problems, severe depression and anxiety problems, chronic psychological problems, severe comorbidity problems, and/or suicidal ideation behavior were excluded. To get treatment the client had to fill out a written consent and agree to participate in the regular evaluation of the psychotherapy process at the clinic. The client also had to agree to stay in therapy for one year to fulfill the students need for length of treatment experience. Clients where asked which method (PDT or CBT) they wanted and those who had requests got what they preferred and the other clients were randomized to the student groups for the supervisor to distribute.

The treatments given at the Psychology Clinic were non-manualized traditional psychodynamic therapy (PDT) and cognitive behavioral therapy (CBT). The main therapeutic techniques used in PDT were therapist interventions such as clarifications and interpretations of resistance and transference to enhance the clients’ understanding of patterns in their actions, thoughts, feelings, experiences, and relationships. In CBT, the interventions used by the therapist focused on the client’s present dysfunctional thinking with regard to emotions, behavior, and future functioning.

Statistical analysis

One-way ANOVAs with repeated measures were used to assess change of the different aspects of the self-image: positive self (AG), negative self (DAG), autonomous self (C1), and controlled self (C5) and to assess the therapeutic alliance (WAI total score) and perceptions of the therapist’s behavior: positive (AG-T), negative (DAG-T), supporting autonomy (C1-T), and controlling (C5-T). Pearson correlations were used to assess the relationship between the different aspects of the self-image, and the perceptions of therapist’s behavior and the therapeutic alliance for each assessment point. Finally, five step-wise regression analyses were computed; one for each assessment point with therapeutic alliance as the dependent variable and the four aspects of the self-image (AG, DAG, C1, C5) and the four aspects of the perception of therapist behavior (AG-T, DAG-T, C1-T, C5-T) as the independent variables. Variance inflation factor did not indicate multicollinearity problems in the model (Field, 2009; Tabachnick & Fidell, 2013).

Results

The results show that the self-image becomes significantly more positive and less negative over time, F(4, 44) = 32.37, p < .001, η² = .67 for AG and F(4, 44) = 15.29, p < .001, η² = .49 for DAG. Slight variations appear over time for self-autonomy and self-control. For both there was an increase from the first to the last assessment, F(4, 44) = 7.16, p < .00, η² = .39 and F(4, 44) = 3.10, p < .02, η² = .17 respectively.

Similar tendencies emerged for perception of therapist behavior. Ratings over time of the therapist’s positive behavior increased significantly F(4, 51) = 7.5, p < .001, η² = .20. Ratings of negative behavior were low at all assessment points and were unchanged. Therapist supporting autonomy (C1-T) and controlling behavior from the therapist (C5-T) did not show any systematic change over time.

The total score of the WAI became more positive over time, F(4, 137) = 8.5, p < .00, η² = .45. Mean values and standard deviations for all measures are shown in Table 1.

Table 1. Mean scores and standard deviations for all SASB measures (AG, DAG, C1, and C5) and (AG-T, DAG-T, C1-T, C5-T) and for WAI for 2–32 sessions.

	2 session		8 session		16 session		24 session		32 session
Measure	M	SD	M	SD	M	SD	M	SD	M	SD
AG	49.61	16.03	53.29	14.49	55.47	1.75	60.34	15.83	66.16	14.79
DAG	31.91	17.09	28.48	16.56	26.98	17.44	23.65	16.15	18.13	13.93
CL 1	35.06	13.12	34.52	14.79	36.09	14.7	39.26	14.19	41.29	15.67
CL 5	35.06	13.12	58.91	16.48	56.34	17.22	55.93	14.51	53.39	15.41
AGT	73.24	19.24	81.89	15.07	80.6	16.51	83.50	15.71	85.63	16.29
DAGT	3.00	7.03	3.46	8.89	4.03	8.28	3.53	7.82	1.86	4.36
CL 1 T	46.31	35.42	52.94	36.47	46.85	36.35	47.97	37.45	43.63	36.43
CL 5 T	38.46	34.01	29.08	32.56	36.62	32.72	32.29	34.97	26.82	32.13
WAI	5.59	0.86	5.68	0.75	5.78	0.70	5.69	0.85	6.05	0.65

The results from the regression analyses assessing the relative influence of the SASB ratings of the self-image and perception of therapist behavior on the alliance are shown in the Table 2.

Table 2. Results of step-wise regression analyses predicting alliance from therapist positive (AG-T) and negative behavior (DAG-T) and client positive (AG) and negative self-image (DAG) (n = 164). Only significant results are presented.

Dependent variable and variables entered	R^2	β	p
WAI 2
AG-T	0.19	0.44	0.00
DAG-T	0.29	−0.31	0.01
WAI 8
AG-T	0.28	0.53	0.00
DAG-T	0.31	−0.19	0.03
WAI 16
AG-T	0.35	0.59	0.00
DAG-T	0.45	−0.35	0.00
AG	0.47	0.15	0.04
WAI 24
DAG-T	0.24	−0.49	0.00
AG-T	0.36	0.36	0.01
WAI 32
AG-T	0.34	0.58	0.00
DAG-T	0.42	−0.30	0.00
DAG	0.47	−0.22	0.01

Notes: WAI 2/8/16/24/32 = WAI score from session 2, 8, 16, 24, 32

As can be seen in Table 2, the client perceived positive (AG-T) and negative behaviors (DAG-T) of the therapist are related to the alliance at all assessment points, and the importance of these behaviors increases over time. Positive behavior explains 19% of the variance in alliance at the second session and 35% at the sixteenth session, while negative behavior accounts for 45% of the variance in the alliance at the sixteenth session. At the sixteenth session the client’s positive self-image (AG) also emerges as an important factor for the alliance. At the 32 session a negative self-image (DAG) has a negative effect on the alliance.

Discussion

The main aims of this research were to explore the change of and relationship between the therapeutic alliance, the client’s self-image, and perceptions of the therapist’s behavior over the course of brief therapy in a training context.

First, a significant increase in the client´s positive self-image occurred together with a gradual decrease in the client´s negative self-image from the second assessment. This result is in line with earlier research of for example Lorentzen et al. (2015). Furthermore, the clients indicated a positive perception of the therapist’s actions and behavior already at the beginning of the psychotherapy process, a tendency which continue to gain significance until the last assessment. The results in this study are consistent with earlier findings from Bedics et al. (2012) stressing the client´s overall perception of a supportive and encouraging therapist in the therapeutic setting. The fact that the therapeutic alliance experiences a relevant enhancement over time suggests that it may be fostered by the development of a more positive self-image and by the perception of the therapist’s behavior as a supporting figure.

The client’s self-image does not seem to influence the therapeutic alliance at the start of treatment. What appears to be more relevant over the course of the therapy is the perception of the therapist’s behavior from the client’s point of view. The self-image becomes relevant at the three last assessment points where the structure of the self-image starts to orient the inner exploration and the development of the alliance in both a positive and negative way. The dual increase in the attachment and disruptive attachment scores may be interpreted either as a consequence of the symptoms the clients suffer from or as a reflection of the diverse expectations and trust the clients have in their own self. The rise of a more negative self-image over the course of therapy could be explained as reflecting growing uncertainty about their own abilities in light of the coming end of their relationship with the therapist and the loss of his or her support. Alternatively, a more positive self-image may be seen as a result of the work on the symptoms and as a good outcome of the psychotherapy.

The control–autonomy dimension of the SASB model has negligible significance in explaining the therapeutic alliance at the different assessment points in the psychotherapy process; in fact, spontaneous and controlled behavior patterns become relevant only at the last assessment.

It is interesting that self-image appears relevant only at the third and fifth assessment, whereas the therapist’s attitudes influence the alliance at all assessment points of the treatment. The lack of significance of the self-image in the first assessments may reflect a focus on the interpersonal patterns and intersubjective negotiation that lay the base for the establishment of the therapeutic alliance. The building of a constructive relational experience may, indeed, represent the first step toward the creation of a supportive setting in which clients can work on their own self (Muran & Safran, 2002).

The consistent significance of the therapist’s contributions over the course of therapy confirms why the therapeutic relationship is considered a two-person system, in which two people are involved and equally responsible for the process of negotiation (Safran & Muran, 2000). In particular, the results show that the client’s interpretations of the therapist’s attitudes may influence the client’s self-image. The relationship between both members of the dyad is indeed, not only built by the negotiation of tasks and goals, but is primarily influenced by the client’s interpretations of the therapist’s behavior.

Some researchers (Beutler, Cargo, & Arizmendi, 1986; Hill & Knox, 2009) stress the role of the therapist in influencing the quality of the relationship and in promoting the development of the therapeutic alliance. This study has shown that perceptions and interpretations of the therapist’s behavior play a greater role in influencing those factors than the client’s self-image.

The shortcomings of this study present a starting point for an in-depth examination of the relation between the therapeutic alliance, clients’ self-image, and their perception of therapist’s behavior. The first important shortcoming relates to the sample size and the total number of analyses at the five time points. The second refers to the context in which this research was conducted. Further research in other trainee-led settings and in psychiatric settings would facilitate comparison of different types of treatment realities for example between CBT and PDT in manualized therapy with more experienced therapists. Determining whether the therapeutic alliance and the self-image are also influenced by other factors would supply more information about how the therapeutic alliance can be established in a specific treatment frame. Third, the group of clients studied in this project was homogeneous and the clients had minor problems and a positive self-image. Including clients with different kinds of diagnoses or with a more negative self-image would highlight differences in the way the therapeutic alliance develops and, in particular, the role that the client’s self-image and the therapist’s behavior may have in its evolution.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

C. E. Pasquali

Caterina E. Pasquali is a doctoral student within the Clinical Psychology program with emphasis in forensic psychology at the California School of Professional Psychology (C.S.P.P.), in San Diego. She received her Bachelor’s degree and Master’s degree with major in Psychology from University of Padua, Italy, in 2011 and 2013 respectively. She participated in an exchange program with Umeå Universitet, Sweden, where she completed he Master’s thesis. Her research interests include risk assessment, sexual offending, personality assessment, and clinical applications of the Rorschach.

H. Ybrandt

Helene Ybrandt is an associate professor in the Dept. of Psychology at Umeå University, Sweden. She is also a licensed specialist psychologist and licensed psychotherapist. She is teaching and supervising students at the Dept. of Psychology, Umeå University, Sweden. Her clinical experience is from work with families, children and youth. Her main research areas are the training of psychotherapists and outcome of psychotherapy.

K. Armelius

Kerstin Armelius is a professor in the Dept. of Psychology at Umeå University, Sweden. Her main research areas are interpersonal psychology and outcome of psychotherapy. At present she is working in a research project at the department of social work at the university with evaluation of interventions for clients with drug abuse.