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151

The
British
Psychological
Psychology and Psychotherapy: Theory, Research and Practice (2007), 80, 151–163
q 2007 The British Psychological Society
Society

www.bpsjournals.co.uk

Getting clients to hear: Applying principles and

techniques of Kiesler’s Interpersonal
Communication Therapy to assessment feedback

Rema Lillie*
University of Victoria, Canada

Limited attention has been paid to the process of providing assessment feedback and
few concrete recommendations exist for the practicing clinician. The author proposes
that principles and techniques of Kiesler’s (1979, 1982, 1988, 1996) Interpersonal
Communication Therapy (ICT) can be applied to guide the provision of assessment
feedback. Using such an approach has the potential to increase the likelihood that
information is heard, accepted, integrated, and acted upon. A review of current
research on the provision of assessment results is supplied along with a description of
basic ICT principles and techniques. Practical suggestions for applying elements of ICT
in this context are given along with a discussion of the rationale for integrating such a
model into the assessment process.

A key element in psychological assessment, and one that has received limited attention,
is the provision of assessment feedback to clients. As compared with the wealth of
information available regarding psychometric properties of assessment tools, selection
of appropriate tests and interpretation of results, there is little guidance on how
clinicians share test results with clients. This finding runs in parallel to observations of
psychotherapeutic techniques made by Wachtel (1993) that a substantial gap exists
both in the literature and in many training programmes in moving from an
understanding of the patient towards putting that understanding into words.
I propose that Kiesler’s (1979, 1982, 1988, 1996) Interpersonal Communication
Therapy (ICT) offers a useful guide to the clinician in providing feedback on assessment
results. ICTwas developed and applied primarily in individual and group psychotherapy as
well as supervision and has more recently been applied to patient–physician interactions.
To date, ICT has not been discussed in the context of psychological assessment. I begin
with an overview of current literature on the provision of assessment feedback.
A discussion of relational aspects of communication between assessor and client provides
an introduction to ways in which ICT could inform practice in the provision of assessment
results. A review of basic principles of ICT includes a description of how such techniques

* Correspondence should be addressed to Rema Lillie, Department of Psychology, University of Victoria, PO Box 3050 STN
CSC, Victoria BC V8W3P5, Canada (e-mail: rlillie@uvic.ca).

DOI:10.1348/147608306X115198
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152 Rema Lillie

have been used to track physician–patient interactions, a relationship arguably similar to

that of assessor–client. I conclude with practical suggestions for how theories and
techniques of ICT could be applied in the provision of assessment feedback. Using such a
theoretical framework to guide the provision of assessment results allows the clinician to
flexibly respond to diverse clients and maximizes the likelihood of having assessment
results heard, accepted, integrated and acted upon.

Provision of assessment feedback

As we witness an increase in popularity of treatment models utilizing assessment (Dunn,
Deroo, & Rivara, 2001), the issue of integrating assessment results into the therapeutic
process becomes more pressing. Recent research on the role of feedback suggests that
the discussion of test results can lead to decreased symptomatic distress and increased
self-esteem (Finn & Tonsager, 1992). These positive effects appear to be related
specifically to receiving feedback and not to completing assessment measures in general
or receiving examiner attention (Newman & Greenway, 1997). In addition, they do not
appear to be confounded by differing perceptions of examiner credibility when
feedback is provided (Allen, Montgomery, Tubman, Frazier, & Escovar, 2003).
Further studies have attempted to identify key components underlying the
therapeutic value of providing assessment results. Finn and Tonsager (1992, 1997)
present a model of ‘therapeutic assessment’ recommending that clinicians focus on the
following objectives within the assessment process: (1) develop and maintain empathic
connections, (2) work collaboratively to define assessment goals, (3) share and explore
assessment results. This last point relates directly to the provision of feedback and
importantly recognizes the collaborative process (e.g. ‘share and explore’) between
assessor and assessee. Patient motives that have been suggested to impact the
therapeutic utility of assessment (Finn & Tonsager, 1997) and serve as a means of
guiding the provision of feedback include a desire to have one’s self-concept and reality
affirmed (self-verification), a desire to be loved, cherished and think well of oneself
(self-enhancement), and a desire for creativity, knowledge, personal growth and
mastery over one’s environment (self-efficacy/self-discovery). The clinician must
consider each of these motivators when providing assessment feedback.
Other researchers have tried to identify processes that probably underlie the impact
of assessment feedback on therapeutic outcomes. Allen et al. (2003) identified two
processes that influence outcome: early rapport-building in the therapist–client
relationship and intervention that enhances self-understanding, positive self-regard and
self-awareness. By solidifying the therapist–client bond early in the relationship,
feedback can lead to increased likelihood of treatment initiation (Ackerman, Hilsenroth,
Baity, & Blagys, 2000). Similarly, Allen et al. hypothesized that assessment feedback can
impact therapeutic outcomes through self-enhancement, such as accelerating self-
awareness and increasing self-efficacy and self-esteem.
Although there is general agreement on the importance of providing feedback to
clients and some factors probably impacting the utility of feedback have been identified,
there are few concrete recommendations available to guide the clinician in this process.
As Wachtel (1993) observed in the area of psychotherapeutic communication, there is
an implicit or explicit assumption that ‘if one really understands, what to say will
become clear rather readily’ (p. 1). This is a striking assumption that warrants
consideration. Is it reasonable to expect that understanding a client will lead directly to
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Getting clients to hear 153

clear feedback on test results? As Dana (1985) observed, ‘ownership of assessment

findings is imperative if there is to be constructive use of these findings by the client’
(p. 601). Attending to how feedback is provided, then, becomes an important factor in
shaping how assessment results will be ‘owned’ by the client.
In terms of practical suggestions for providing feedback, at least one author provides
guidelines for integrating test results on commonly used instruments. Finn (1996)
presents a framework for addressing discrepancies in test results, specifically for the
Minnesota Multiphasic Personality Inventory (MMPI-2) and the Rorschach inkblot test.
He presents a model identifying each possible pattern of results (e.g. agreement
between each test vs. high disturbance on one with low disturbance on the other) and
identifies common scenarios and clinical profiles that would lead to these patterns.
Importantly, he then goes on to discuss ways clinicians can share these insights with
clients. For instance, he provides a case example of a 56-year-old man whose test results
showed little to no elevation on scales of the MMPI-2 with a great deal of distress and
disturbance evidenced on the Rorschach. Finn provides a description of the feedback
session that includes sequential enumeration of the client’s strengths and ways to
discuss areas of discrepancy (e.g. ‘I then told Harry that I thought more was going on in
him than met the eye and I talked about the underlying difficulties revealed on the
Rorschach’ p. 553). Following the general principles described above, Finn recognizes
and responds to motivating factors of self-verification (i.e. affirmed internal distress
detected on the Rorschach) and self-enhancement (i.e. ambivalence towards getting
close to others), while recognizing the need for self-efficacy/self-discovery (i.e.
understanding the choices facing him). One can see how such feedback lends itself to
therapeutic change and sets the stage for the next step in the intervention process.
Notably, respecting clients’ motivating factors does not imply shying away from or
avoiding negative feedback (Ackerman et al., 2000). Instead, the clinician should begin
the feedback process with information congruous to the client’s sense of self (Ackerman
et al., 2000). While not always positive, such initial feedback allows the client to feel
heard and understood while setting the stage for further collaborative exploration.
Research to date has expanded our understanding of the role of feedback in assessment
and has identified factors linked to its therapeutic utility. By continuing to explore
conceptual models for approaching this process, we provide the practicing clinician with
general guidelines allowing for flexible responses to a variety of clients and client needs. In
addition, pursuing a conceptual model provides a context for conducting research on
relevant aspects of the process as a whole. One such model is discussed below.

Setting the stage: Relational aspects of communication

Assessment feedback occurs within the context of a relationship and involves
communication between two people. Higgins, Hartley, and Skelton (2001) argue that
the very nature of ‘assessor’ and ‘assessee’ makes for a problematic form of
communication marked by issues of power, identity, emotion, discourse and
subjectivity. Although these authors focused on the student–evaluator relationship,
parallels can be drawn to the context of the clinician–client. When the clinician takes on
the role of assessor, there is a shift in the balance of power as compared with
relationships with peers in everyday life. Clients often feel powerless in the face of
psychological assessment, especially since the focus of assessment is on personal
elements of the self. While this sense of powerlessness can be curtailed by creating an
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154 Rema Lillie

environment of collaboration, recognizing the potential impact of the power differential

in approaching clients with feedback can increase sensitivity to aspects of the clinician–
client relationship. In terms of issues of identity, emotion and subjectivity, one could
argue that such relational/communicative features are even more salient in the
clinician–client interaction since the client has a profound investment in test results as
they inform and relate to his or her self-concept and emotional well-being. As in the
student–evaluator relationship, clear communication can often be problematic in the
assessment setting as technical jargon can be potentially confusing, anxiety provoking
and overwhelming for clients. Similar to the student–evaluator relationship, there is a
need for the clinician to consider such issues as how to construct feedback, how the
client understands the feedback (e.g. makes sense of it) and how the client makes sense
of assessment in general (Higgins et al., 2001). By examining the context of relational
communication we can address these issues.

Kiesler’s Interpersonal Communications Therapy (ICT)

Kiesler’s (e.g. 1996) circumplex model of interpersonal transactions provides a
theoretical framework for understanding communication within relationships. As
Kiesler and Auerbach (2003) point out, the interpersonal circumplex has served as a
theoretical model for understanding personality, psychopathology and psychotherapy
for over 50 years. Kiesler’s circumplex (see Kiesler, 1983 for a description) includes two
primary dimensions of human interaction: a dimension of affiliation, ranging from
friendly to hostile, and a dimension of control, ranging from dominant to submissive.
The circumplex itself can be thought of as a circle formed by the axes of affiliation and
control that summarizes the domain of interpersonal behaviour (Van Denburg & Kiesler,
2002).
The interpersonal circumplex captures a broad range of interpersonal styles or ways
of relating. If we think of different levels of behaviour, we can conceptualize how some
ways of relating to others (e.g. in a friendly-dominant manner) may be effective at low
levels (e.g. assured, confident and self-reliant), but may become more troubling at the
extremes (e.g. arrogant, rigidly autonomous). We can also conceptualize how having a
broad range of approaches to interacting with others will probably be most effective.
Many clients run into difficulty in interpersonal relationships as they have rigid means of
relating to others or a limited arsenal of interpersonal styles (Kiesler, 1996). For
example, owing to past experiences, an individual may have a propensity to expect
hostility from others and, hence, will respond to others in a hostile, and perhaps
dominant, manner. While at times being hostile and dominant may be an effective means
of interacting with others (e.g. in competitive situations), one could imagine how
consistently interacting with others in a hostile-dominant way could cause problems in
relationships (e.g. romantic relationships, work relationships).
A central concept in this model is the idea that interpersonal actions are designed
to pull, draw, entice or evoke reactions from persons with whom we interact (Kiesler,
1983). The principle of complementarity suggests that our behaviours are likely to pull
for a corresponding response on the affiliation dimension (i.e. friendliness pulls for
friendliness, hostility pulls for hostility) while at the same time pulling for a reciprocal
response on the control dimension (i.e. dominance pulls for submission, submission
pulls for dominance). In the example previously provided of an individual who
approaches others in a hostile-dominant manner, he or she will probably elicit a
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Getting clients to hear 155

response from others that is hostile and submissive (e.g. self-doubting, dependent).
One can easily see how a self-perpetuating maladaptive pattern of relating to others
could occur: the individual is consistently expecting hostility from others so
approaches them in a hostile-dominant manner, thus eliciting a hostile-submissive
response, thus validating the underlying expectation (hostility) and reinforcing the
response pattern.
In working with clients, clinicians in this framework are encouraged to identify the
types of behaviours that clients pull for or draw out of the clinician. This requires a
high level of insight and self-awareness as the clinician must separate his or her own
pulls from those of the client. Through self-monitoring, the clinician can identify
patterns of behaviour over time by responding to the client in a genuine manner and
identifying one’s own feelings, actions and tendencies. Allowing oneself to be ‘hooked’
to the client’s pull, the therapist may recognize that the client has a tendency to pull
for support or reassurance. Conversely, the therapist may recognize a tendency to pull
for competition. The therapist would then have to become ‘unhooked’ or disengaged
from the interaction to avoid providing the complementary response to a client’s
maladaptive interpersonal behaviour, thus perpetuating the common transactional
cycle.
Continuing with our example of the individual who interacts with others in a
hostile-dominant manner, the clinician may recognize reluctance in providing
information or may feel somewhat unassured. In order to break the typical maladaptive
pattern the client has of relating to others, the therapist would want to provide a
corrective experience through interventions that empathetically confront and
challenge the client’s interpersonal pattern. Techniques to accomplish this goal
include providing an asocial position (withholding the customary, preferred or
expected complementary response), an acomplementary response (reactions that
correspond on affiliation or are reciprocal on control but are not complementary to
both) or an anticomplementary response (reactions do not correspond on affiliation
nor are they reciprocal on control). In this specific example, if we recognize that the
client needs to act less critical and controlling while acting more docile and respectful,
the therapist would want to act less submissive and flattering. Possible responses would
include providing feedback on how the clinician feels criticized by something the client
said (asocial), acting competitive, dominant, docile or respectful (acomplementary), or
acting sociable and assured (anti-complementary). This type of therapeutic approach
thus provides a means of disrupting the maladaptive interpersonal pattern by providing
a new learning experience for interpersonal behaviour in the context of a protective
relationship.
As conceptualized by Kiesler (1996), communication includes both verbal and non-
verbal elements. He describes individuals as constantly communicating since ‘regardless
what they do or don’t do, they continuously send messages to each other’. (p. 204).
These messages evoke cognitive or affective responses in others either through words
and sentences (verbal channel) or through tempo, volume and pitch of speech, gaze,
facial expressions, posture, interpersonal distance or touch (non-verbal channel). At
times, it may be effective for clinicians to address directly the type of communication
transpiring between themselves and clients. This form of meta-communication
(communicating about communication) can serve as an additional means of addressing
various elements of clients’ maladaptive ways of interacting with others. Discussing
these processes directly can lead to conjoint, collaborative exploration, validation and
understanding of clients’ patterns of interpersonal behaviour.
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156 Rema Lillie

Physician–patient interactions
While Kiesler’s ICT, to the best of my knowledge, has not been studied in assessor–
assessee relationships, concepts of Kiesler’s ICT have been applied in research on
physician–patient interactions. A brief review of this literature may help inform our
understanding of communication between assessor and client.
In the physician–patient interaction literature, constructs of affiliation and control
have been identified for some time as important aspects of communication (for a review
see Kiesler & Auerbach, 2003). Early studies, that tended to focus solely on the
physician, consistently showed that highly affiliative (e.g. friendly) physician
communications were related to increased patient satisfaction and adherence to
medical regimens (Kiesler & Auerbach, 2003). However, studies of physician control
(e.g. dominance) showed mixed results. While some studies suggested that increased
compliance was related to more controlling and authoritarian physician communi-
cations, others suggested that increased compliance was related to less controlling
physician communications (Kiesler & Auerbach, 2003). As Kiesler and Auerbach
suggest, these contradictory findings may be due in part to a lack of complementarity
between physician and patient interpersonal behaviours.
The application of ICT concepts in this research has introduced a transactional
element of communication that was previously ignored. Recent studies have informed
our understanding of physician–patient interactions suggesting that it is the
transactional fit between members of the dyad (e.g. physician and patient) that
predicts better outcomes. Poorer patient outcomes have been found to occur when the
degree of ‘fit’ or complementarity between physicians and their patients is low
(Auerbach et al., 2002). Similarly, both patient and physician appraisals have been found
to impact patient outcomes independently (Auerbach, Penberthy, & Kiesler, 2004),
suggesting that each member of the dyad has the potential to impact outcome.
In the limited studies of non-verbal communication patterns, a critical concept in
ICT, results suggest that greater patient satisfaction is associated with higher levels of
physician non-verbal affiliation, mutually satisfactory levels of practitioner and patient
affiliation, and less physician control (Kiesler & Auerbach, 2003). Yet again these studies
were limited by a unidirectional view of communication. Other studies on non-verbal
physician–patient communication suggest that high non-verbal affiliation by the
physician (e.g. decreased interpersonal distance, frequent head nodding and smiling)
improves understanding and recall of information by the patient, but does not impact
compliance to medical regimens. Conversely, high non-verbal dominance in physician
communications (e.g. asymmetrical posture, uninterrupted pauses within speech turns)
is related to improved compliance (Kiesler & Auerbach, 2003). Unfortunately, these
studies have only addressed one or two forms of non-verbal communication and have
confused similar constructs of communication (e.g. non-verbal affiliation, involvement,
rapport and empathy).
Some may argue that the therapist–client relationship bears little resemblance to the
physician–patient interaction so that these findings have limited relevance to our
current discussion of providing feedback to clients. However, when the clinician takes
on the role of assessor, the nature of their interaction changes and may more closely
mirror what is anticipated or expected in the physician–patient relationship. For one,
the client will have certain expectations as to how feedback on test results is commonly
administered. For many individuals, interactions in the medical setting will be one of the
few life-experiences where a professional provides intensely personal and influential
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Getting clients to hear 157

feedback. It seems natural that expectations may carry over from that environment.
Additionally, there are times when a psychologist or psychotherapist may be called on to
do an assessment as a third party and will not be involved in treatment. In these
instances, the nature of the relationship, and hence of the environment for feedback,
will be one solely of assessor–assessee. Obviously, there are some limitations to these
comparisons. For one, the medical setting often requires individuals to hand over care to
a physician (i.e. in the case of an invasive medical procedure, such as surgery) in a way
that is distinct from a psychotherapeutic interaction. Similarly, in psychological
assessment the decision-making process on the type of care is much more likely to be
collaborative in nature. One could argue, then, that owing to the collaboration required
for successful psychological intervention, connecting with clients during the
assessment process in a way that facilitates their ability to attend to the information
provided may become all the more relevant.
Based on these observations, research on physician–patient interactions can inform
our understanding of assessor–assessee interactions. By looking at research on
physician–patient interactions, and aspects of these interactions that are often ignored
(e.g. the role of patient communication), we can develop enhanced sensitivity to key
issues. Paralleling previous reports in the psychological literature that feedback can have
therapeutic value, research findings in this area suggest that physician–patient
interactions can impact adherence to treatment regimens and even physical outcomes.
The direct relationship between physician–patient communication and outcome
highlights the importance of providing feedback in a manner that is sensitive to the
individual. This research also shows the benefit that concepts of ICT can bring to
interpreting communication between service provider and client. Methods of ICT
provide a means of acknowledging and studying the transactional nature of
communication between two people and can be easily applied in the service provider
context. While recent efforts in studying the physician–patient interaction have focused
more on understanding these constructs and less on the translation of these findings
into practice, one could imagine future clinical applications of such results, including a
potential impact on physician training.

Integrating ICT concepts into the provision of assessment feedback

ICT provides a conceptual framework for understanding interpersonal interactions.
Since the provision of assessment feedback occurs within an interpersonal context, it
may be helpful to use ICT techniques to guide that interaction.1 Looking at assessment
as a process, clinicians often have time during the course of the intake interview, and
perhaps during the administration of test instruments, to observe and attend to clients’
salient interpersonal behaviours. As would occur in early stages of psychotherapy,
clinicians can allow themselves to get ‘hooked’ to the complementary response being
pulled for by the client. By then ‘unhooking’ prior to the feedback session and using the
framework of the interpersonal circumplex, clinicians can anticipate the types of
behaviours that will most probably be pulled for during feedback and identify any
potentially maladaptive behaviours that may impact the acceptance of feedback.

1
For the interested reader, the specific ICT principles described in this section are ‘interpersonal complementarity principles of
intervention’ as described by Kiesler (1996) in Propositions 10-1 to 10-6 (pp. 242–252). These principles are distinct from the
‘impact disclosure principles of metacommunication’ detailed in Propositions 11-5 to 11-15 (1996, pp. 291–302), many of
which would be less applicable to the assessment situation.
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158 Rema Lillie

With some clients, providing assessment feedback in a complementary manner may

increase the likelihood it will be heard by the client. With others, to do so would be highly
problematic. Regardless, considering the issue should aid the clinician in thinking about
the process of providing feedback and not simply the content. For example, clinicians
may want to consider questions such as the following: What would be a complementary
style to this person? What would be the impact (pro and con) of responding in a
complementary manner? Is this someone who has a tendency to take a submissive stance
and not ask questions? If I put myself in a position of dominance, is this someone who will
take me at my word and not question anything I say? Does this person’s dominant stance
make it difficult for me to get my point across? Is this person’s hostility going to interfere
with his/her ability to accept test results? Formulating a conceptualization of clients’ most
common interpersonal styles prior to the feedback session allows clinicians to anticipate
in advance potential problem situations. Furthermore, once adept at the model, the
clinician will be better able to respond to interpersonal shifts within the feedback session.
Using a framework such as the interpersonal circumplex can provide the clinician with
guidance concerning the best way to present information so that the client attends to and
accepts it throughout the feedback process.
The interpersonal circumplex also helps the clinician to consider his or her own role
in the communication. Useful questions to ask oneself include, ‘How is my behaviour
impacting the client’s?’ and ‘What is my reaction to this client?’ For example, perhaps
the clinician is providing information in an overly friendly and dominant manner that is
pulling for the client to be more submissive and less collaborative. Conversely, perhaps
the clinician, in an attempt to be respectful, is behaving in a flattering manner leading
the client to present as more assured and outgoing and less likely to question results or
speak up when test results do not fit with his or her own experience.
Clinicians should attend to both verbal and non-verbal communication patterns. In
terms of non-verbal behaviours, the clinician may want to consider the placement of
chairs in the room. Sitting behind a desk may introduce an added dimension of
dominance and could be perceived by some as hostile and interpersonally isolating.
Direct body orientation, forward lean, mutual gaze and softer tone of voice have all been
noted to be non-verbally affiliative (Kiesler & Auerbach, 2003). Conversely, non-
reciprocal gaze, asymmetrical posture and quick and loud vocal tones have been
characterized as non-verbally dominant (Kiesler & Auerbach, 2003). Considering how
one’s own body positioning, tone and voice may contribute to the impact of feedback
can be valuable. Similarly, monitoring a client’s non-verbal behaviour during the
feedback process can give the clinician clues as to whether the intended message is
being received. If a client responds to assessment results with clenched fists, folded
arms and increasing interpersonal space from the clinician, he or she may be exhibiting
signs of an inability fully to process and accept feedback at that moment. Directly
exploring non-verbal behaviours detected by the assessor may be crucial to assuring the
client’s ability to take in information. From the context of ICT, non-verbal behaviours
can be conceptualized in a similar manner as verbal behaviours (e.g. common patterns
of relating to others) and similar strategies can be used to address each.
ICT provides a variety of techniques for addressing ineffective interpersonal
behaviours. As the assessor typically has had only limited contact with the client (as
compared with the context of a psychotherapeutic relationship), the types of
techniques applicable to the feedback session will be somewhat reduced, primarily due
to a weaker therapeutic alliance. Additionally, as clients are unlikely to have consented
to therapy as part of the assessment process, the clinician would want to be wary of
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Getting clients to hear 159

extending feedback into a therapeutic intervention. However, approaches such as meta-

communication can be used effectively within a feedback setting to maximize the
therapeutic nature of sharing assessment results within the boundaries of the assessor–
assessee relationship. Meta-communication may include: discussing the clinician’s own
feelings to help clients become aware of their impact on others; communicating about
changes in the interaction as a means of probing for clients’ internal experiences; or,
directly identifying and pointing out clients’ interpersonal markers (Safran & Segal,
1990). Each of these forms of meta-communicating may be used constructively within a
feedback session. For example, the clinician may share with the client, ‘I’m feeling
distanced from you right now. Is that similar to what you are experiencing?’ or ‘I noticed
that you have grown quiet since I gave you the diagnosis. How are you feeling?’ or
‘I notice that when I try to discuss the test results, you interrupt me to tell a story’. As in
the therapeutic relationship, these tools can be used to explore issues in the here-and-
now. Unique to the assessment experience, use of meta-communication may impact the
client’s ability to take in information provided on assessment results.
Although meta-communicating with clients can be a useful tool, the clinician would
also want to be careful in its use. If the clinician’s feelings are intense, for example, it is
best to withhold feedback until one can clarify this experience and gain some degree of
non-attachment (Kiesler, 1988). As with many psychotherapeutic techniques, meta-
communicating can also lose its impact when overused. A client may feel overwhelmed or
condescended to if the clinician comments on every silence or change in body stance.
Employed at key moments in the transaction, meta-communicating can be a useful means
of probing a deeper level of communication. When considering a response, the clinician
should keep in mind that any attempt at meta-communicating should be provisional,
empathetic, descriptive, problem centred, equalizing, and if possible, spontaneous rather
than strategic (Kiesler, 1996). As described by Kiesler (1996; Propositions 11-5 to 11-7,
pp. 291–292), the success of meta-communication is impacted by the therapist’s attitude
and intent. With a goal of facilitating change, the clinician must be able to provide
feedback in a manner that is confrontative as well as supportive. As with most therapeutic
interventions, a positive therapeutic alliance is critical. In addition, the success of meta-
communication from an ICT framework requires willingness by the clinician to examine
openly one’s own contributions to the transactional cycle. With many factors to consider
simultaneously within a session, contemplating these elements in advance of providing a
response can maximize the therapeutic impact of a meta-communication.
Another ICT technique that may be used sparingly in the feedback setting is
acomplementary responses. To reiterate, acomplementary responses are interpersonal
behaviours that either correspond on affiliation (e.g. friendly-friendly) or are reciprocal
on control (e.g. dominance-submissiveness) but are not complementary on both
dimensions simultaneously. Acomplementary responses may be appropriate to the
feedback setting, especially when a client’s submissiveness towards the clinician, or
alternatively dominance over the interaction, interferes with the ability to attend to
provided information. Similarly, extreme friendliness or hostility may be responded to in
an acomplementary manner (although meta-communication may also be appropriate in
these instances). When responding with an acomplementary behaviour, it is important
clinicians recognize that a certain degree of anxiety may result in the client. Since the
feedback setting is not a therapy session, one would not want to push for extreme
anxiety that may interfere with the goals of feedback.
It is less likely that an assessor would respond to a client with an anticomplementary
behaviour. Anticomplementary responses do not correspond on the affiliation dimension
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160 Rema Lillie

(e.g. friendly-hostile or friendly-neutral) nor are they reciprocal on the control dimension
(e.g. dominant-dominant). As these types of responses often require a high level of trust
on the part of the client and take place within the context of a strong therapeutic alliance,
they may be counterproductive in the feedback environment. As Kiesler (1996) notes:
‘[b]ecause the anticomplementary response represents total rejection of the patient’s self-
presentation, its use early in therapy would likely result in the patient’s rejection of
treatment : : : These patient reactions would represent very sensible responses to a
threatening and aversive situation’ (p. 249)

Since the feedback setting occurs early in the treatment process, it is unlikely that a
sufficiently strong working therapeutic alliance exists to warrant use of an
anticomplementary response.
Despite these caveats, there may be certain instances where an anticomplementary
response during the feedback process would be appropriate. These include situations
where the assessee presents as uninterested in assessment results. Examples would
include highly hostile–dominant clients who see limited value in the discussion of
assessment findings. In these instances, the clinician may find it necessary to respond in
an anticomplementary manner (e.g. friendly-dominant) to accomplish the goal of
providing feedback. Acknowledging that these actions place the alliance at risk and
increasing other complementary behaviours as a means of rebuilding the alliance may
be useful in these situations. On a related note, when providing acomplementary or
anticomplementary responses, the clinician should be careful to avoid being pulled to
enact responses that are antagonistic and harmful to the patient (e.g. hostile).
How the clinician chooses to respond to behaviours within the feedback setting will
vary based on an array of factors including the context of the assessment (e.g. pre-therapy
assessment, third party assessment), the clinician’s conceptualization of the client’s
problem areas, and the strength of the therapeutic alliance. In the case of a third party
assessment, the feedback session may be the last contact the clinician has with the client.
In this instance, the clinician may be more hesitant to apply challenging techniques. In
addition, in this setting, research on the physician–patient interaction may be more
applicable as both forms of communication occur within a time-limited context. This
research suggest that patients’ adherence to treatment recommendations is best in the
context of complementary interpersonal responses and high affiliation (e.g. friendliness).
When the assessment occurs prior to therapy, the clinician may take more liberty at
subtly attempting different therapeutic techniques to judge the client’s response to
specific interventions. As Strupp and Binder (1984) have observed, there are several key
elements of the assessment process that can be beneficial to monitor and can inform
treatment recommendations. These include observations of emotional discomfort with
feelings and/or behaviours, basic trust, willingness to consider conflicts in interpersonal
terms, willingness to examine feelings, capacity for mature relationships and motivation
for treatment offered. Each of these factors can predict responsiveness to intervention
and can be monitored using an ICT framework. Similarly, it has been suggested that
clinicians try out various therapeutic approaches within the assessment process to
determine what fits best with a client’s interpersonal style and self-conception. ICT
provides a means of directly assessing the potential impact of various psychotherapeutic
interventions. The clinician may provide an asocial meta-communication, for example,
to determine whether the client responds well to such observations or freezes up.
By conceptualizing a client’s interpersonal behaviour within a framework of ICT,
the clinician is given the opportunity to provide a corrective experience by not
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Getting clients to hear 161

engaging with the client in a complementary manner. Although the assessor may
choose not to add anxiety to the feedback situation by responding in an
acomplementary or anticomplementary manner, considering one’s options and
coming to a conscious decision as to how to respond to a client leads the clinician to
make a more informed choice. When the clinician feels cut off in the feedback process
or not heard, the context of ICT also provides means of conceptualizing why this may
be occurring and provides ways to address it. One of the key components of feedback
is that the client comes away with a better understanding of the self. Approaching
feedback from the conceptual framework of ICT gives the clinician a means of tailoring
the interaction to the needs of the individual client and provides a way of tracking the
process of feedback, not just the content.
Lastly, using a framework of ICT can inform research practices on feedback. The
context of ICT provides operational definitions of key elements of interpersonal
communications and a model for conceptualizing the interaction between clinician and
client. Circumplex inventories are available for studying long-standing personality traits,
interpersonal adjustment problems, interpersonal behaviours in specific situations and
emotional impacts experienced by interactants (see Kiesler & Auerbach, 2003 for brief
descriptions). These instruments lend themselves to both self-report and observational
studies and can lead to replication in various settings. Importantly, they capture the
often ignored bidirectional nature of communication. Inventories on interpersonal
transactions can also assist the practicing clinician in quality assurance studies. By
completing and having clients complete such inventories following assessment,
clinicians can monitor whether they are responding effectively to their clients in a
manner that will increase the likelihood of assessment results being incorporated into
the concept of self and recommendations followed.

ICT and the feedback literature

As Finn and Tonsager (1997) have suggested, crucial factors to consider in providing
feedback include client motivations of self-verification, self-enhancement and self-
efficacy/self-discovery. By considering the context of the feedback session itself and
acknowledging the role of both client and clinician behaviours, ICT sets the stage for
responding effectively to each of these client-motivating factors. For example,
approaches such as attending to the interpersonal circumplex and responding with
meta-communication provide a means of validating the client’s experience and
supporting self-verification. Understanding how interpersonal markers can impact
reactions from others can lead the client to feel mastery over the environment and
enhance self-efficacy. Coming to a better understanding of oneself with the aide of
assessment results can lead to improved self-esteem and self-enhancement. Following
recommendations of Finn and Tonsager (1992, 1997), the use of ICT provides a
framework for developing and maintaining empathic connections, working collabora-
tively and sharing and exploring results. Other processes that have been identified as
underlying the impact of assessment feedback on therapeutic outcomes include early
rapport-building and intervention that enhances self-understanding, positive self-regard
and self-awareness (Allen et al., 2003). Each of these underlying processes can be
positively impacted by an ICT approach to the administration of feedback, thus
enhancing the likelihood of a ‘therapeutic assessment’ (Finn & Tonsager, 1992, 1997).
ICT is by no means the only theoretical model that could lend insight to the process of
providing assessment feedback. For example, one approach that shares a common goal of
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162 Rema Lillie

attending to clients’ needs as a means of getting clients to hear is motivational

interviewing, used for over a decade in fields such as addiction treatment, medical care,
health promotion, social work and corrections (see Miller & Rollnick, 2002 for an up-to-
date review). Similarities between motivational interviewing and ICT include the use of
specific psychotherapeutic methods to diminish resistance and resolve ambivalence.
A key difference between ICT and motivational interviewing, though, is that motivational
interviewing focuses on promoting behaviour change. ICT in an assessment context
focuses on the broader goal of helping clients take in assessment feedback without
underlying assumptions of moving a client towards change. While change is often an
element of the assessment process, it is not a necessity. The application of ICT to the
assessment setting is intended to provide the clinician with a flexible approach for
monitoring and reacting to the interpersonal context within the assessment setting. This
goal would seem to be somewhat different from the change-oriented focus of
motivational interviewing techniques. Further exploration of the similarities and
differences between ICT as applied to the provision of assessment feedback and other
theoretical models is warranted.
While there will always be an ‘art’ in providing feedback to clients, ICT may provide
a solid conceptual framework for both new therapists and skilled clinicians in
conceptualizing cases and the process of providing feedback to individual clients. In
doing so, the ICT framework moves towards what Wachtel (1993) would describe as a
translation of our understanding of clients into ways to share that understanding.
Importantly, it fills a gap in the literature by providing concrete recommendations for
sharing assessment results with clients.

Conclusions
Recent research has shown a surge in the integration of assessment procedures into
clinical practice and has highlighted the potential therapeutic value of providing
feedback on test results to clients. Feedback has been shown to relate to symptom
reduction and increased self-esteem (e.g. Finn & Tonsager, 1992), and physician and
patient interaction has been shown to impact adherence to treatment outcomes and
even physical, medical outcomes (e.g. Kiesler & Auerbach, 2003). Due to the potential
therapeutic benefit of feedback, and I would argue the potential detriment of poorly
delivered feedback, increasing our focus on ways to provide feedback is warranted.
By focusing on models that may inform feedback processes we can (1) improve client
contact and (2) provide a framework for research endeavours. ICT is well-suited to these
purposes as it acknowledges the transactional nature of the feedback communication and
provides a context for understanding and approaching a variety of clients.

Acknowledgements
I am grateful to Drs Lara Robinson, James Hill and Donald Kiesler as well as anonymous reviewers
for their thoughtful comments on previous drafts of the current manuscript.

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Received 14 July 2005; revised version received 14 March 2006