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Client and Therapist Therapeutic Alliance, Session Evaluation, and Client

Reliable Change: A Moderated Actor-Partner Interdependence Model

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DOI: 10.1037/a0034939 · Source: PubMed

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 Journal of Counseling Psychology © 2013 American Psychological Association
2014, Vol. 61, No. 1, 15–23 0022-0167/14/$12.00 DOI: 10.1037/a0034939

Client and Therapist Therapeutic Alliance, Session Evaluation, and Client

Reliable Change: A Moderated Actor–Partner Interdependence Model

Dennis M. Kivlighan Jr. Cheri L. Marmarosh

University of Maryland The George Washington University

Mark J. Hilsenroth
Adelphi University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Actor–partner interdependence modeling (APIM; Kashy & Kenny, 2000) was used to study the early
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therapeutic alliance in 74 clients being treated by 29 therapists to explore the relationship between the alliance
and treatment progress, while prioritizing the dyadic nature of the alliance. The APIM examines collaboration/
influence by modeling the impact of one dyad member’s alliance ratings on the other member’s session impact
rating (partner effects). In terms of the alliance, the results revealed significant client–actor effects for client
ratings of session depth and positivity as well as significant therapist–actor effects for therapist ratings of
session smoothness and positivity. For client-rated alliance, there were also significant client–partner effects
for therapist ratings of session depth. For clients who made a reliable change in treatment, an increase in
client-reported alliance was related to therapist reporting more arousal in the 3rd session. For clients who did
not make a reliable change in treatment, client-reported alliance was not related to therapist arousal.
Limitations of the study and implications of the findings are discussed.

Keywords: therapeutic alliance, session evaluation, actor–partner interdependence model

The therapeutic alliance is one of the most examined aspects of
the therapeutic relationship. In meta-analyzing the results of over
30 years of research, Horvath, Del Re, Flückiger, and Symonds
(2011) found that the therapeutic alliance was a significant pre-
dictor of therapy outcome, accounting for approximately 8% of the
variance in treatment outcomes. Theoretically, the therapeutic al-
liance should be differentially related to types of outcomes. In
differentiating the therapeutic alliance and the real relationship,
Gelso (2011) stated that the therapeutic alliance captured the
working aspects of the therapist and client relationship, whereas
the real relationship reflected the personal, nonworking aspect of
this relationship. Therefore, the therapeutic alliance should show a
stronger relationship to outcomes that reflect the work of therapy
and a weaker relationship to outcomes that reflect the personal
aspects of therapy. Researchers have not used this work versus
personal distinction in their studies examining the relationship
between the therapeutic alliance and outcome. Although one of the
moderator analyses results in the Horvath et al. (2011) meta-
analysis hints at this distinction. These authors found that the effect
sizes for the relationship between therapeutic alliance and change
This article was published Online First November 4, 2013.
Dennis M. Kivlighan Jr., Department of Counseling and Personnel
Services, University of Maryland; Cheri L. Marmarosh, Department of
Psychology, The George Washington University; Mark J. Hilsenroth, The
Derner Institute of Advanced Psychological Studies, Adelphi University.
Correspondence concerning this article should be addressed to Dennis
M. Kivlighan Jr., Department of Counseling and Personnel Services, 3214
Benjamin Building, University of Maryland, College Park, MD 20742.
E-mail: dennisk@umd.edu
15
in depression and symptoms were .42 and .47, respectively,
whereas the effect size for the relationship between therapeutic
alliance and dropout was .18. However, only the depression effect
size was significantly different from the dropout effect size.
Changes in depression and symptoms may reflect the working
aspect of treatment, whereas dropout may reflect the personal
relationship between the client and therapist. For example, Tryon
and Kane (1995) found that therapist’s ratings of how well clients
related at intake were related to the client terminating unilaterally.
Therefore, there may be an important theoretical and empirical
distinction between outcomes that reflect the work of therapy and
outcomes that reflect the personal relationship in therapy.
As noted above, however, there are few differential relation-
ships between the therapeutic alliance and type of outcome prob-
ably because outcome is usually measured at termination, which
may be too distal to capture the subtleties of the therapeutic
alliance– outcome relationship (e.g., Hill & Lambert, 2004). Bo-
swell, Castonguay, and Wasserman (2010) argued that looking at
session outcome allows for a closer look at what comes between
process (the therapeutic alliance in a session) and long-term out-
come (the effects of a series of sessions or of a whole treatment).
In line with this observation, Owen, Quirk, Hilsenroth, and
Rodolfa (2012) examined how the therapeutic alliance related to
session-level ratings of client intersession experience. They found
that the alliance was significantly related to therapeutic work
(“applying therapy”) between sessions but was unrelated to the
personal therapy relationship (imagining dialogues with the ther-
apist) between sessions. In the present study, we build on the
Owen et al. (2012) study by examining the relationship between
the therapeutic alliance and session outcome.
 16 KIVLIGHAN, MARMAROSH, AND HILSENROTH
One of the most widely used measures of session outcome is the
Session Evaluation Questionnaire (SEQ; Stiles & Snow, 1984),
which measures session outcome on the dimensions of Depth,
Smoothness, Positivity, and Arousal. Several studies have exam-
ined the relationship between the Depth and/or Smoothness di-
mensions of session evaluation and the therapeutic alliance. Kiv-
lighan (2007) found that counselors’ and clients’ ratings of the
alliance were related to their own ratings of session depth and
smoothness. Kim, Ng, and Ann (2009) only measured session
depth and found a strong relationship between therapeutic alliance
and session depth for Asian American clients. However, Gelso et
al. (2005) found no relationship between client-rated therapeutic
alliance and client-rated session depth and smoothness.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Only one study (Mallinckrodt, 1993) examined the relationship
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between therapeutic alliance and all four dimensions of session
outcome operationalized in the SEQ. In this complex study, alli-
ance and session outcome were rated by both counselors and
clients at different points in treatment. The one consistent finding
in this study was that early client ratings of the therapeutic alliance
were significantly and positively related to client-rated session
depth at early, mid, and late treatment. No other consistent rela-
tionships between therapeutic alliance (either client- or therapist-
rated) and session outcome (either client- or therapist-rated)
emerged. There is some evidence, however, that specific SEQ
scales may capture either the work or personal aspect of session
outcome. In a large study examining the relationship between
session evaluations and session impacts, Stiles et al. (1994) found
that Depth and Arousal were more strongly related to work-
oriented impacts (Understanding and Problem Solving) and that
Smoothness and Positivity were more strongly related to the rela-
tionship oriented impact (Relationship). Given these relationships
we hypothesized that:
Hypthothesis 1: Client and therapist ratings of the therapeutic
alliance will be significantly and positively related to their
ratings of session Depth and Arousal.
The Therapeutic Alliance: Collaboration
and Mutual Influence
There appears to be a consensus across theoreticians and re-
searchers that collaboration, working together, and reciprocity are
the core features of the therapeutic alliance (Hatcher & Barends,
2006; Horvath et al., 2011; Horvath & Symonds, 1991). Research-
ers can measure perceptions of collaboration and reciprocity or
model collaboration and reciprocity statistically. This perception
versus statistical distinction is similar to the objective versus
subjective distinction made by researchers examining similarity in
groups (e.g., Dunlop & Beauchamp, 2011). Most research on the
therapeutic alliance involves perceptions of collaboration and rec-
iprocity, relying on the wording of the therapeutic alliance inven-
tory to get at the client’s and therapist’s perceptions of collabora-
tion and reciprocity. Some items on therapeutic alliance
inventories do assess perceptions of collaboration (e.g., “My ther-
apist and I are working towards mutually agreed-upon goals”);
however, other items assess individual perceptions (e.g., “I believe
my therapist likes me”). Alternatively, collaboration and reciproc-
ity can be assessed using the actor–partner interdependence model
(APIM; Ledermann & Kenny, 2012).
The APIM has two types of effects: actor effects and partner
effects. Actor effects describe the relationship between a partici-
pant’s own predictor and her or his outcome (e.g., the therapist’s
therapeutic alliance and the therapist’s session evaluation). Partner
effects describe the relationship between a participant’s own pre-
dictor and her or his partner’s outcome (e.g., the therapist’s ther-
apeutic alliance and the client’s session evaluation). The APIM
also specifies two correlations: one describes the dependency
between clients’ and therapists’ therapeutic alliance ratings and the
other describes the dependency between clients’ and therapists’
session evaluation ratings. In the APIM, interpersonal influence is
defined as a significant partner effect, whereas mutual influence is
defined as both partner effects being significant.
Kivlighan (2007) argued that therapeutic alliance studies rarely
statistically examine collaboration or mutual influence because the
combined contributions of both therapists’ and clients’ therapeutic
alliance ratings are not assessed in the same study. In the Horvath
et al. (2011) meta-analysis, there were 112 independent effects for
client-rated therapeutic alliance, but only 23 independent effects
for therapist-rated therapeutic alliance. Horvath et al. did not
report how many of the outcomes examined involved the cli-
ents’ or the therapists’ perspective. It is likely, however, that
most of the studies involved only client ratings of outcome.
Therefore, the therapeutic alliance– outcome literature appears
to involve mostly an examination of the clients’ perceptions of
both the therapeutic alliance and treatment outcome (client–
actor effects).
Only two published studies used the APIM to examine the
therapeutic relationship in individual counseling. Gelso et al.
(2012) found that clients’ ratings of the real relationship were
related to their own rating of outcome (a client–actor effect) and to
their therapist’s ratings of outcome (a client–partner effect). In the
study that is the most relevant for the present research, Kivlighan
(2007) used the APIM to examine the relationship between clients’
and therapists’ ratings of the working alliance and their ratings of
session Depth, a session’s perceived power or value, and Smooth-
ness, a session’s comfort or pleasantness (Stiles & Snow 1984). He
found that clients’ and therapists’ ratings of the therapeutic alli-
ance were significantly related to their own ratings of session
Depth and Smoothness (significant client– and therapist–actor
effects). He also found that therapists’ ratings of the therapeutic
alliance were significantly related to clients’ ratings of session
Depth (a therapist–partner effect).
One purpose of the present study was to replicate and extend
Kivlighan’s (2007) study in several important ways. We replicate
the earlier study by using the APIM to once again examine the
relationship between clients’ and therapists’ ratings of the working
alliance and their ratings of session Depth and Smoothness. As
noted above, the SEQ, however, includes two additional subscales:
Arousal, the experience of excitement or vitality after a session,
and Positivity, the experence of positive emotions after a session,
but these subscales were not examined in Kivlighan (2007). There-
fore, we extend the Kivlighan (2007) study by examining the
Positivity and Arousal dimensions of session evaluation as rated
by both clients and therapists.
As noted above, the vast majority of alliance research has
involved an examination of client–actor effects (i.e., the client’s
rating of alliance and the client’s rating of either treatment or
session outcome), yet very few of these studies have controlled for
 CLIENT AND THERAPIST ALLIANCE
partner effects. Despite the lack of controlling for partner effects,
we believe that the alliance studies and alliance theory support the
existence of actor effects. On the basis of our analysis of work-
oriented versus personal-oriented outcomes, we made the follow-
ing hypotheses:
Hypothesis 2a: Clients’ ratings of alliance will be significantly
related to clients’ ratings of session Depth and Arousal, when
controlling for therapists’ partner effects.
Hypothesis 2b: Therapists’ ratings of alliance will be signifi-
cantly related to therapists’ ratings of session Depth and
Arousal, when controlling for clients’ partner effects.
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Eugster and Wampold (1996) found that clients and therapists
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take different factors into account when making judgments about
session outcome because of their differing role perspectives. Sul-
livan (1954) also described differences in the therapist’s and
client’s roles in terms of the therapist’s role as a participant
observer. As a participant observer, the therapist observers the
client’s behavior and participates as a significant other in the
counseling relationship. This participant observer role can be seen
in Lent et al.’s (2006) suggestion that therapists’ session evalua-
tions are related to their own experiences of the counseling rela-
tionship and their inferences about their client’s experiences of the
counseling relationships. Therefore, as a participant observer,
counselors’ session evaluations should be related to their own and
their client’s perceptions of the alliance. The client’s role, how-
ever, in counseling is to be a full participant in the counseling
relationship. Therefore, clients tend to be more self-focused, using
their perceptions of the alliance as evidence for deciding their
evaluations of sessions. The Kivlighan (2007) study did not sup-
port this theoretical model, because he found partner effects only
for the therapists. However, the Gelso et al. (2012) study did reveal
significant client–partner effects. Despite these contradictory find-
ings, we base our hypotheses concerning differences between
clients and counselors in terms of the participant and observer
roles, and we specifically hypothesized that:
Hypothesis 3: Clients’ ratings of alliance (client–partner ef-
fects) will be significantly related to therapists’ session eval-
uations (greater Depth and Arousal), when controlling for
clients’ actor effects.
Therapeutic Alliance, Session Evaluations,
and Outcome
It is clear that therapeutic process differs when clients experi-
ence a more or less successful outcome (e.g., Gelso, Kivlighan,
Wine, Jones, & Friedman, 1997). Therefore, it is important to
examine how the actor–partner relationships described above vary
as a function of the client’s outcome status. We predict that the
client–partner effect described in Hypothesis 3 will be stronger
when the client has a better outcome. Specifically, we expected
that client symptom change would moderate the relationship be-
tween clients’ alliance ratings and therapists’ session evaluations.
This is because theory and research suggest that those therapists
who are better at monitoring the state of their clients’ alliances (as
evidenced by a significant partner effect for client alliance ratings)
will be more successful (Richards, 2011). Therefore, we made the
final hypothesis:
17
Hypothesis 4: There will be significant client–partner effects
of therapeutic alliance on session depth and arousal when
clients report a reliable change and nonsignificant client–
partner effects when there is no reliable change.
The APIM, depicted in Figure 1, contains two actor effects: (a)
client alliance and session evaluation and (b) therapist alliance and
session evaluation; two partner effects: (a) client alliance and
therapist session evaluation and (b) therapist alliance and client
session evaluation; and the effect for the reliable change index
(RCI). The model also contains four interaction effects: (a) client–
actor by RCI, (b) therapist–actor by RCI, (c) client–partner by
RCI, and (d) therapist–partner by RCI. The APIM accounts for the
nesting of clients and therapists within dyads by specifying a
correlation between clients’ and therapists’ session evaluations.
Method
Participants
Clients. This study is an extension of Pesale, Hilsenroth, and
Owen (2012). There were 74 clients receiving individual psycho-
therapy in the Psychodynamic Psychotherapy Treatment Team at a
community outpatient psychological clinic and provided written
informed consent for this research. For a complete description of
the clients, see Pesale et al. (2012).
Therapists. Twenty-nine (14 male, 15 female) third- or
fourth-year doctoral students enrolled in an American Psycholog-
ical Association-approved Clinical Psychology Ph.D. program
conducted the psychological assessment and psychotherapy. One
of these therapists was a racial/ethnic minority, and the rest were
Caucasian. Five therapists saw one patient, eight therapists saw
two patients, 11 therapists saw three clients, two therapists saw
four clients, and one therapist saw five clients. See Pesale et al.
(2012) for a description of these therapists.
Treatment. Clients first received a psychological evaluation
from a therapeutic model of assessment (see Hilsenroth, 2007, for
Figure 1. Actor–partner interdependence model for client and therapist
alliance and client and therapist session evaluation and client reliable
change. Reliable change index (RCI) is calculated from the Global Severity
Index of the Brief Symptom Inventory. The intercorrelations among the
five predictor variables are not depicted in the figure.
 18 KIVLIGHAN, MARMAROSH, AND HILSENROTH

details). The clinician who carried out the psychological assess-
ment also conducted the psychotherapy sessions. Psychotherapy
consisted of once- or twice-weekly sessions of short-term psy-
chodynamic psychotherapy (see Hilsenroth, 2007) and was open-
ended. Blagys and Hilsenroth (2000) describe the key features of
this treatment model.
Measures
The SEQ (Stiles et al., 1994; Stiles & Snow, 1984). The SEQ
is a measure of in-session psychotherapy process that consists of
24 bipolar adjective scales rated from 1 (e.g., weak) to 7 (e.g.,
powerful). It is separated into two sections, each consisting of 12
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0.30 (SD ⫽ 0.31), and test–retest reliability using an outpatient
sample was .90. The mean pretreatment GSI for the present sample
was 1.06 (SD ⫽ 0.59).
Reliable change (RC) was calculated using formulas described
in Jacobsen and Truax (1991) and Jacobson, Roberts, Berns, and
McGlinchy (1999). A client was classified as having made an RC
if her or his RCI was greater than 1.96 (coded as 1) and as not
having made an RC if her or his RCI was less than or equal to 1.96
(coded as 0).
Procedure
Clients filled out the BSI prior to starting treatment. Client and

bipolar scales. Factor analysis revealed two evaluation indices— therapist SEQ and therapeutic alliance ratings were collected from
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Depth and Smoothness—and two postsession mood indices— either the third or fourth treatment session. Clients were informed,
Positivity and Arousal (Stiles et al., 1994; Stiles & Snow, 1984). both verbally and in writing, that their therapists would not have
Previous research has revealed alphas ranging from .74 to .91 for access to their responses on these session measures. The mean
these four SEQ subscales using a subset of the current participants number of sessions in this sample was 31 (SD ⫽ 22), and the
(Ackerman, Hilsenroth, Baity, & Blagys, 2000). The validity of the post-BSI was given at termination. Further details of the measures,
SEQ has been demonstrated by significant correlations between methodology, and procedures used are described more fully else-
SEQ scales and measures of therapist quality, session impact, and where (Hilsenroth, 2007).
global session evaluations (Stiles et al., 1994).
Combined Alliance Short Form–Patient Version (CASF-P; Data Analysis
Hatcher & Barends, 1996). The CASF-P is a client-rated alli-
We used path analysis within a structural equation modeling
ance measure consisting of 20 items rated on a 7-point scale where
framework to analyze the APIM (Kenny, Mannetti, Pierro, Livi, &
1 ⫽ never, 2 ⫽ rarely, 3 ⫽ occasionally, 4 ⫽ sometimes, 5 ⫽
Kashy, 2002). All variables were mean-centered before creating
often, 6 ⫽ very often, and 7 ⫽ always. Hatcher and colleagues
interaction terms.
(Hatcher & Barends, 1996; Hatcher, Barends, Hansell, & Gut-
freund, 1995) reported evidence on both the construct and incre-
mental validity of this scale with regard to outcome. In addition, Results
both Ackerman et al. (2000) and Clemence, Hilsenroth, Ackerman, The means and standard deviations for therapists’ and clients’
Strassle, and Handler (2005) reported convergent validity data ratings of alliance, session Depth, session Smoothness, Positivity,
with related measures of psychotherapy process as well as criterion and Arousal are displayed in Table 1. Clients’ mean GSI posttreat-
validity with regard to the prediction of treatment outcome using a ment scores (0.67, SD ⫽ .62) were significantly smaller than their
sample of clients at the same university-based clinic as the clients pretreatment scores (1.01, SD ⫽ .58), t(73) ⫽ ⫺5.45, p ⬍ .0001.
in the present study, as well as a coefficient alpha of .91. Of the 74 clients, 47 (63.51%) did not make a reliable change
Working Alliance Inventory–Therapist Version (WAI-T; (RCI ⬍ 1.96), and 27 (36.48%) did make a reliable change (RCI ⬎
Horvath & Greenberg, 1989). The WAI-T is a therapist-rated 1.96). Because there was a good deal of variability in the number
alliance measure. The Total scale score for the WAI-T used in this of treatment sessions, we examined the relationship between num-
study was derived from a recent psychometric adaptation (Hatcher, ber of sessions completed and client reliable change. The point
1999) using responses from two samples. The first was a national biserial correlation for number of treatment sessions and reliable
sample consisting of practicing therapists’ ratings on one patient change was .06 (p ⫽ .61). Therefore, reliable change was not
from their current practice (N ⫽ 251). The second was a clinical confounded with sessions completed.
sample consisting of 63 therapists who completed ratings on 259 Because therapists saw more than one client, we initially used a
different patients. Previous research has revealed alphas ranging two-level hierarchical linear modeling (Raudenbush, Bryk,
from .75 to .86 (Hatcher, 1999), and examining a subset of the Cheong, & Congdon, 2005) analysis to test for therapist effects for
current participants, coefficient alphas range from .74 to .91
(Clemence et al., 2005). Ratings on the WAI-T are reported on the
same 7-point scale as described for the CASF-P, ranging from 1 Table 1
(never) to 7 (always). Means and Standard Deviations for Therapists’ and Clients’
Brief Symptom Inventory (BSI; Derogatis, 1993). The BSI Alliance Ratings and Session Evaluations Early in Treatment
is a 53-item self-report inventory that assesses symptom distress in
Clients Therapists
a number of different domains/problem areas using a Likert scale
ranging from 0 (not at all) to 4 (extremely) and was collected at Variable M SD M SD
pre- and posttreatment. The psychometric properties, reliability, Alliance 6.15 0.63 5.75 0.44
and validity of this measure, as well as a description of specific Depth 5.51 0.87 5.02 0.911
symptom subscale scores and a summary score, the Global Sever- Session Smoothness 4.86 1.12 4.65 1.00
ity Index (GSI), are provided in the manual (Derogatis, 1993). The Positivity 4.92 1.08 5.23 0.92
Arousal 3.97 1.08 4.48 1.13
mean GSI for a normal population (N ⫽ 719, nonpatients) was
 CLIENT AND THERAPIST ALLIANCE 19

the session evaluation variables. Therapists who only saw one 14

client were excluded in these tests of therapist effects on client and
12
therapist SEQ ratings. We conducted eight empty models to de-
termine the variance in SEQ ratings accounted for by therapists. 10

Therapist Arousal
The variance estimates from these eight models were used to
8 No
calculate intraclass correlation coefficients (ICCs). The ICCs for Reliable
client session evaluation ratings were Depth (.06; p ⫽ .10), 6 Change
Reliable
Smoothness (.10; p ⫽ .08), Positivity (.17; p ⫽ .02), and Arousal Change
4
(.002; p ⫽ .42). The ICCs for therapist session evaluation ratings
were Depth (.07; p ⫽ .09), Smoothness (.01; p ⫽ .21), Positivity 2
(.06; p ⫽ .10), and Arousal (.05; p ⫽ .12). Because the therapist
0
variance for only one of the SEQ ratings was significant, we did
Low Client Therapeutic Alliance High Client Therapeutic Alliance
not model therapists in our main analyses.
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Data were analyzed using full information maximum likelihood Figure 2. Interaction of client alliance and client reliable change in
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estimation in EQS. Model fit statistics are not reported because the
APIM model is saturated. Table 2 displays the results of the APIM
analyses for alliance and session evaluation. There were significant
client–actor effects for session Depth (b ⫽ .59, p ⬍ .05) and for
Positivity (b ⫽ .47, p ⬍ .05). When clients had higher alliance
ratings, they also had higher session depth and positivity ratings.
The therapist–actor effects for session Smoothness (b ⫽ .76, p ⬍
.05) and session Positivity (b ⫽ .75, p ⬍ .05) were significant.
When therapists had higher alliance ratings, they also had higher
session Smoothness and Positivity ratings. None of the therapist–
partner effects were significant. The client–partner effect for ses-
sion Depth (b ⫽ .46, p ⬍ .05) was significant. When clients had
higher alliance ratings, their therapists rated the sessions as deeper.
There was a significant relationship between clients’ early treat-
ment Arousal ratings and client end-of-treatment reliable change
(b ⫽ ⫺.64, p ⬍ .05). When clients had higher arousal ratings early
in treatment, they were less likely to subsequently show a reliable
change. Clients’ early treatment alliance ratings and client reliable
change interacted to predict therapist early treatment arousal (b ⫽
1.10, p ⬍ .05). The form of this interaction is displayed in Figure
2. The simple slope for clients who made a reliable change was
0.90 (p ⬍ .05). The simple slope for clients who did not make a
reliable change was ⫺0.04 (p ⬎ .05). As seen in the figure, when
therapists had clients who did not make a reliable change at the end
of treatment, there was no relationship between client alliance
ratings and therapist arousal early in psychotherapy. When clients
predicting therapist arousal.
made a reliable change at the end of treatment, clients’ alliance
ratings and therapists’ arousal ratings early in treatment also in-
creased.
The APIM variables accounted for 17% (p ⬍ .05) of the
variance in clients’ ratings of session Depth and 14% (p ⬍ .05) of
the variance in therapists’ ratings of session Depth. Clients’ and
therapists’ ratings of session Depth were not significantly corre-
lated (r ⫽ .14, p ⬎ .05). The APIM variables accounted for 10%
(p ⬍ .05) of the variance in clients’ ratings of session Smoothness
and 15% (p ⬍ .05) of the variance in therapists’ ratings of session
Smoothness. Clients’ and therapists’ ratings of session Smooth-
ness were not significantly correlated (r ⫽ ⫺.04, p ⬎ .05). The
APIM variables accounted for 13% (p ⬍ .05) of the variance in
clients’ ratings of Positivity and 26% (p ⬍ .05) of the variance in
therapists’ ratings of Positivity. Clients’ and therapists’ ratings of
Positivity were not significantly correlated (r ⫽ ⫺.01, p ⬎ .05).
The APIM variables accounted for 16% (p ⬎ .05) of the variance
in clients’ ratings of Arousal and 12% (p ⬍ .05) of the variance in
therapists’ ratings of Arousal. Clients’ and therapists’ ratings of
Arousal were not significantly correlated (r ⫽ ⫺.04, p ⬎ .05). In
all four APIM analyses, clients’ and therapists’ ratings of the
alliance were not significantly correlated (r ⫽ ⫺.10, p ⬎ .05).

Table 2
Regression Coefficients, Standard Errors, and t Statistics for the Actor–Partner Interdependence Model for Client and Therapist
Alliance and Client and Therapist Session Evaluation With Partner-Moderated Actor and Partner Effects

Therapist Reliable change

Client alliance alliance index (RCI) Client ⫻ RCI Therapist ⫻ RCI
Variable b t b t b t b t b t
ⴱ
Client Depth .59 3.18 .12 .43 .02 .12 ⫺.13 ⫺.42 .09 .21
Therapist Depth .46 2.31ⴱ .33 1.11 .04 .17 ⴚ.37 ⴚ1.09 .37 1.00
Client Smoothness .34 1.35 .59 1.61 .28 1.09 .09 .22 ⴚ.93 ⴚ1.61
Therapist Smoothness .19 .87 .76 2.43ⴱ .35 1.53 ⴚ.64 ⴚ1.76 ⫺.27 ⫺.53
Client Positivity .47 1.97ⴱ .11 .30 .33 1.33 .16 .40 .08 .14
Therapist Positivity .22 1.19 .75 2.70ⴱ .23 1.18 ⴚ.32 ⴚ1.02 .53 1.22
Client Arousal ⫺.08 ⫺.32 .31 .90 ⫺.64 ⫺2.65ⴱ .37 .94 .73 1.34
Therapist Arousal ⴚ.04 ⴚ.17 .16 .43 .20 .76 1.01 2.41ⴱ ⫺.08 ⫺.14
Note. RCI ⫽ Global Severity Index of the Brief Symptom Inventory–reliable change index coded 0 for no reliable change attained and 1 for reliable
change attained. Bold type ⫽ partner effects; regular type ⫽ actor effects.
ⴱ
p ⬍ .05.
 20 KIVLIGHAN, MARMAROSH, AND HILSENROTH
Discussion
Actor Effects
As hypothesized, clients’ alliance ratings were related to their
ratings of session Depth but unexpectedly also to their ratings of
Positivity. Also contrary to our expectations, therapists’ alliance
ratings were related to their ratings of session Smoothness and
Positivity. The findings for client Depth and for therapist Smooth-
ness replicate results of Kivlighan (2007). However, he also found
that therapists’ alliance ratings were significantly related to their
ratings of Depth and that the clients’ alliance ratings were related
to their ratings of Smoothness. Across the two studies, clients
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appear to consistently associate the therapeutic alliance with the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
work-oriented outcome of session Depth. However, their therapist
consistently associated the therapeutic alliance with the personal-
oriented outcome of session smoothness. These results confirm
Eugster and Wampold’s (1996) findings that clients and therapists
take somewhat different factors into account when making judg-
ments about the session.
As far as we can tell, this was the first study to examine actor
effects for alliance and session Positivity and Arousal. Contrary to
our hypothesis for both therapists and clients, their own ratings of
alliance were related to their own ratings of Positivity but not to
their own ratings of Arousal. It seems that both therapists and
clients associate a strong therapeutic alliance with the experience
of positive emotions after a session. However, neither party asso-
ciates the therapeutic alliance with the experience of excitement or
vitality after a session. There were, however, important moderated
therapist–partner effects that are discussed below. It is important to
note that all of these significant actor effects were found when
controlling for partner effects. Therefore, it appears that a partic-
ipant’s alliance rating is related in important ways to her or his
evaluation of the session. The evaluations of sessions for clients
and therapists have important convergences (therapeutic alliance
and positivity) and divergences (client alliance with depth and
therapist alliance with smoothness).
Partner Effects
Our partner hypotheses were based on therapist and client role
differences. As noted above, Sullivan (1954) described the thera-
pist’s role as that of a participant observer. As a participant
observer, the therapist observers the client’s behavior and partic-
ipates as a significant other in the counseling relationship. There-
fore, therapists’ session evaluations should be affected by their
own and their clients’ ratings of the alliance. The client’s role in
counseling, especially in early sessions, is, to the extent possible,
to be a full participant in the counseling relationship. As partici-
pants, clients are typically attuned to only their own view of the
alliance. Therefore, we hypothesized that there would be signifi-
cant client–partner effects but not significant therapist–partner
effects when examining work-oriented session outcomes (Depth
and Arousal).
We found one significant client–partner effect: Therapists’ ses-
sion Depth ratings were related to their clients’ therapeutic alliance
ratings. This is in contrast to Kivlighan (2007), who found that
therapists’ alliance ratings were related to their clients’ ratings of
session Depth. Our results are similar to Gelso et al. (2012), who
also found significant client–partner effects. In their study, thera-
pists’ evaluations of treatment outcome were related to their cli-
ents’ ratings of the real relationship. It is hard to see why the
Kivlighan (2007) study did not reveal significant client–partner
effects for the alliance. All three studies used similar measures and
similar client and therapist populations. It will be important for
future research to examine the hypothesis concerning the effects of
the therapist’s role as a participant observer. Given the results of
this study and of Gelso et al. (2012), it seems that therapists’ are
affected by their clients’ view of the early therapy relationship
(either the alliance or the real relationship).
It is also interesting to note that there were no client–partner
effects for session Smoothness, Arousal, and Positivity. Therefore,
the client’s perception of the alliance did not relate to her or his
therapist’s perceptions of the session’s comfort or his or her
positive emotions or experience of excitement or vitality after a
session. We expect that for therapists, Depth may be related to the
working aspect of psychodynamic treatment (i.e., exploratory and
expressive), whereas Arousal, Positivity, and Smoothness may be
related to comfort in treatment. If this is the case, then it seems that
therapists pay attention to the client’s alliance to gauge the work
that can be or is being accomplished.
Moderation Effects
We hypothesized that those therapists who were better at mon-
itoring the state of their clients’ alliances would be more successful
(Richards, 2011); therefore, client–partner effects would be stron-
ger when clients made a reliable change than when the clients did
not make a reliable change. We found support for this hypothesis,
but only in the case of Arousal. When clients did not make a
reliable change in treatment, there was no significant relationship
between the client’s therapeutic alliance and the therapist’s rating
of Arousal early in treatment. The significant relationship between
a client’s therapeutic alliance and her or his therapist’s Arousal
only occurs when clients’ make a reliable change across treatment.
In examining the significant interaction, it is important to keep
in mind that the therapeutic alliance and session evaluation ratings
come from early treatment, whereas the reliable change can only
be calculated after the client terminates treatment, on average
27–28 weeks after the alliance and session evaluation ratings. For
clients who will eventually make a reliable change, when the client
rates the early session therapeutic alliance as stronger, the therapist
ends that session feeling more arousal. For clients who will even-
tually not make a reliable change, their ratings of the therapeutic
alliance are unrelated to their therapist’s arousal. Therefore, it is a
good prognostic indicator if in an early session, the therapist
responds with invigoration or excitement to clients experiencing
higher levels of the therapeutic alliance. And, as per the procedures
of this study, clients were informed, both verbally and in writing,
that their therapists would not have access to their responses on
these session measures. So neither party had access to each other’s
scores on these process measures, and such sentiments were only
discernable from the dyadic interactions during the session.
Why would therapists’ excitement in relationship to higher
alliance ratings very early in treatment be related to clients’ even-
tual improvement in treatment? Stiles et al. (1994) wondered
whether the “energizing impact of psychotherapy” (p. 184) could
be related to novice clinicians being able to apply what they had
 CLIENT AND THERAPIST ALLIANCE
learned with clients. It is certainly possible that when novice
therapists perceived a stronger alliance, they became excited be-
cause they felt able to implement the techniques that they had
learned. Pesale and Hilsenroth (2009) found that therapists’ use of
psychodynamic techniques was significantly related to clients’
perceptions of Depth ratings early in the therapy process. In prior
studies, therapists also rated more Depth when they used more
psychodynamic or interpersonal techniques compared with when
they used more cognitive-behavioral techniques (Stiles, Shapiro, &
Firth-Cozen, 1988). In addition, dynamically oriented therapists
may be more aroused by therapies that emphasize emotional
engagement, exploration of underlying thoughts and needs, and the
linkage of those internal experiences to the therapy relationship.
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Therefore, a series of events may be happening in early sessions
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for clients who make a reliable change. First, when their dynam-
ically oriented therapists perceive that the client has a stronger
therapeutic alliance, the therapist becomes aroused and excited
because she or he sees this strengthened alliance as an opportunity
to use dynamic and interpersonal techniques. Or, conversely, the
therapist used these interventions with apparently good response
on the part of the client, thus leading to an increase in therapist felt
efficacy. The stronger alliance coupled with the presumed use of
these techniques leads to the therapist seeing the session as deeper.
Future research could test whether this sequence of events does
happen in more successful treatments.
Another possible explanation for the positive relationship between
client therapeutic alliance and therapist Arousal in cases in which the
client makes a reliable change is that therapists may be aroused by the
emotional experience of being with clients who are doing the work of
counseling. Therapists consider that their clients are working at a deep
level when clients express unacceptable feelings (Greenberg & Sa-
fran, 1987). They would argue that it is the experiential learning, of
being cared for and valued by the therapist during these moments of
vulnerability that facilitates change. In essence, change in symptoms
occurs when clients are being more emotionally vulnerable in the
therapy. Relatedly, Fosha (2000) described the experience of “alive-
ness” and “realness” that is experienced when people are able to
express these vulnerable affects in therapy. Fosha argued that thera-
pists can rely on their own internal experience to determine whether
their clients are doing the work in the treatment. She says when clients
are less defensive and genuinely experiencing core emotions (i.e.,
exhibiting a strong alliance), the therapist feels as though therapy is
moving or is alive (i.e., aroused), whereas defensiveness and lack of
authenticity in the client engender boredom or the experience of going
nowhere.
The present study suggests that we need more research to tease
apart what is happening in these early sessions of treatments and
how these differences may impact therapists’ and clients’ percep-
tions of the alliance and Arousal. This is an important area of
research because therapists come from a different vantage point
and may feel invigorated by the therapy process, whereas clients
may feel more somber, saddened, or unsettled after sessions.
Clients may feel more introspective versus feelings as if they are
“moving” or “energetic.” Watson and Greenberg (1996) even
found that some “change producing interventions are experienced
as disorganizing and dissatisfying” (p. 272) by clients and that the
initial reaction is often the result of confronting problems that can
make one feel worse before feeling better. In this regard, however,
it is important to note that reliable change was associated with
21
decreased client arousal. Clients who experienced a reliable
change reported feeling less aroused after these early sessions.
This fits with the notion of clients feeling more introspective.
Limitations
There are several limitations to consider when drawing conclu-
sions about the results. One of the most significant limitations is
the reliance on a correlational design that inhibits us from making
causal inferences about the direction of influence in the relation-
ship between working alliance and session evaluations. We are not
sure whether the alliance influences the session experiences or
whether session experiences influence the alliance. In the future,
collecting repeated measures of the alliance, session experience,
and symptom change during the course of treatment would allow
us to explore how these factors influence one another over time. In
addition to the correlational design, we only focused on a relatively
small sample of clients in psychodynamic treatment. Although the
sample is sufficient for the statistical analysis used, we are not
certain that our findings would generalize to another population
of clients being treated with a different form of psychotherapy.
None of the clients were randomly selected, and the majority of
the clients were Caucasian females. The therapists were all
graduate trainees, and we are not certain whether the results
would replicate with a more seasoned group of clinicians.
We tested for therapist nesting and found significant nesting for
only clients’ ratings of positivity. It is important to note, however,
that the test for nesting was conducted on a fairly small sample,
which may not have been large enough to detect what Kenny,
Kashy, and Bolger (1998) called “consequential nonindepen-
dence.” In other words, there may have been nesting effects in our
data, but our tests were not powerful enough to detect it. Therefore,
the results of the APIM should be viewed cautiously and hopefully
replicated in larger samples. Finally, we presumed that therapists
would be able to assess their clients’ view of the alliance. How-
ever, we do not know how well our therapist could detect their
client’s perceptions of the therapeutic alliance.
Another limitation is that alliance and session evaluation were
measured only in an early session. It will be important for future
research to examine how actor and partner effects may change across
counseling sessions. For example, theory suggests that the client’s
observing capacity increases across treatment. This suggests that later
in treatment, clients’ session evaluations would be related to both their
own and their therapists’ alliance perceptions. Despite these limita-
tions, the findings offer interesting directions for future research.
Conclusion
The publication of five different meta-analyses is proof that
researchers are interested in how the therapy alliance relates to
treatment progress and outcome (Flückiger, Del Re, Wampold,
Symonds, & Horvath, 2012; Horvath & Bedi, 2002; Horvath et al.,
2011; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000).
Unfortunately, the majority of our knowledge of the alliance
comes from studies that focus only on the client’s perspective. This
is one of only a handful of studies that have used the APIM in a
therapeutic context, and it is the first study to examine how
treatment outcome would moderate these actor–partner relation-
ships. When using APIM, we found that client’s ratings of the
 22 KIVLIGHAN, MARMAROSH, AND HILSENROTH
therapeutic alliance are related to their therapist’s ratings of ses-
sion Depth. We also found that there are significant positive
relationships between the alliance and Arousal when clients make
a reliable change in treatment. Our results encourage us to continue
to study the alliance and to apply innovative methods, such as
APIM, to understand and appreciate the complexity and interactive
nature of the psychotherapy relationship.
In addition, this was the first study to examine the hypothesis that
the therapeutic alliance would be differentially related to aspects of
session outcome. As noted above, we found two significant partner
effects (client alliance and therapist depth, client alliance–RCI inter-
action and therapist arousal), which both involved working aspects of
session outcome. As argued above, these partner effects are especially
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
important because they are a statistical way of identifying collabora-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tion and influence. Therefore, these partner effects provide some
evidence to support differential outcome effects.
The concepts of work-related and relationship-related outcomes
comes from Gelso’s (2011) distinction that the working alliance is
related to the work of counseling, whereas the real relationship is
related to the personal relationship aspect of counseling. Future re-
searchers could explore this conceptualization in more depth by
simultaneously measuring the therapeutic alliance and the real rela-
tionship and relating them both to the different aspects of session
outcome. In addition, future research may want to examine other
aspects of session outcome like session impact, which more explicitly
operationalizes work and relationship impacts (Stiles et al., 1994).
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Received February 15, 2013
Revision received September 26, 2013
Accepted September 26, 2013 䡲