Journal of Counseling Psychology © 2012 American Psychological Association

2012, Vol. 59, No. 1, 18 –26 0022-0167/12/$12.00 DOI: 10.1037/a0023648

Valuing Clients’ Perspective and the Effects on the Therapeutic Alliance:

A Randomized Controlled Study of an Adjunctive Instruction

Christoph Flückiger AC Del Re and Bruce E. Wampold

University of Bern and University of Wisconsin—Madison University of Wisconsin—Madison

Hansjörg Znoj, Franz Caspar, and Urs Jörg

University of Bern

The patterns of growth and development of the therapeutic alliance over the course of therapy have been
of continued interest to psychotherapy researchers. The purpose of this study was to investigate whether
a simple institutional metacommunication intervention with clients had an effect on the development of
the alliance. This adjunctive instruction involved inviting therapy clients to take a proactive role in their
treatment by encouraging feedback to their therapist about various aspects of the therapy process. In this
randomized controlled study (N ⫽ 94), clients were assigned to 1 of 2 conditions: (a) an institutional
adjunctive instruction condition in which patients were contacted by clinic personnel at the beginning of
the remediation phase (Session 5) and encouraged to take a proactive role in their treatment and (b) a
control condition that contained no institutional adjunctive instruction. Between-condition differences in
the alliance were tested, controlling for baseline influences and the early therapeutic alliance. Clients’
postsession reports from Sessions 1 to 24 indicated that the adjunctive instruction increased the alliance
over the course of therapy vis-à-vis the control condition. The adjunctive instruction appeared to have
fostered clients’ evaluation of their therapists’ interest in their welfare. The results indicate that
interventions, even brief or subtle, can produce lasting benefits in the alliance when targeted at specific
psychological processes. Systematic metacommunication from the institutional level appeared to rein-
force clients’ therapeutic alliance with their therapists in individual treatment.

Keywords: therapeutic alliance, randomized controlled study, feedback intervention theory

Even brief or subtle, psychological interventions can produce
lasting benefit when targeted at important psychological processes
(Cohen, Garcia, Purdie-Vaughns, Apfel, & Brzustoski, 2010). For
example, lasting effects of subtle psychological interventions have
been demonstrated with 15-min self-affirmation writings for ethnic
minority students (Cohen et al., 2010), short team coordination in
aviation flights (Stout, Salas, & Fowlkes, 1997), and responsibility
reminders in emergency rooms (Tschan et al., 2006). An advantage
of single-event studies is that specific research questions can be
tested within naturalistic settings (Cohen et al., 2010). However, in
comparison to other fields of psychology, designing single-event
studies in psychotherapy process research is rarely considered.
This article was published Online First May 23, 2011.
Christoph Flückiger, Department of Clinical Psychology and Psycho-
therapy, University of Bern, Bern, Switzerland and Department of Psy-
chology, University of Wisconsin—Madison; AC Del Re and Bruce E.
Wampold, Department of Psychology, University of Wisconsin—
Madison; Hansjörg Znoj, Franz Caspar, and Urs Jörg, Department of
Clinical Psychology and Psychotherapy, University of Bern.
This research was supported by Swiss Science National Foundation
Grant PA00P1_124102 awarded to Christoph Flückiger.
Correspondence concerning this article should be addressed to Christoph
Flückiger, Department of Clinical Psychology and Psychotherapy, Univer-
sity of Bern, Gesellschaftsstrasse 49, CH-3012 Bern, Switzerland. E-mail:
christoph.flueckiger@psy.unibe.ch
The importance of the therapeutic alliance as a vital aspect of
the therapist– client interaction has been recognized by psycholo-
gists of different theoretical orientations (Barber & Muran, 2010;
Bordin, 1979; Orlinsky, Rønnestad, & Willutzki, 2004). The alli-
ance, typically defined as the client and therapist agreement on the
goals and tasks of therapy and the development of a therapeutic
bond, is consistently found to be a robust predictor of therapy
success. This was supported across different raters of alliance and
outcome (i.e., client, therapist, observer ratings) and measurements
(Horvath, Del Re, Flückiger, & Symonds, 2011; Martin, Garske, &
Davis, 2000). In addition, the alliance– outcome relationship is
supported as independent of design and treatment characteristics
like randomized controlled study design, disorder-specific manual
usage, specificity of primary and secondary outcomes, and cogni-
tive behavioral therapy (Flückiger, Del Re, Wampold, Symonds, &
Horvath, 2011). Furthermore, these alliance– outcome correlations
seem to compare favorably in terms of prediction of outcome with
other studied therapy variables, such as the competence of the
therapists (r ⫽ .07) or adherence to the protocol (r ⫽ .01; Webb,
DeRubeis, & Barber, 2010). Although these findings are robust in
the presence of several potential confounds, there is less known
about how therapists’ characteristics influence the alliance (Ack-
erman & Hilsenroth, 2001, 2003). There is a small, but emerging
literature on this topic that deserves continued research (Caston-
guay et al., 2004; Constantino et al., 2008; Crits-Christoph et al.,
2006; Hilsenroth, Ackerman, Clemence, Strassle, & Handler,

18
 VALUING CLIENTS’ PERSPECTIVE
2002; Muran, Safran, Samstag, & Winston, 2005; Raue, Goldfried,
& Barkham, 1997; Safran, Muran, Samstag, & Winston, 2005).
Although the alliance is generally assessed cross-sectionally
(therefore, data are limited to one assessment point), recent re-
search has examined its trajectory longitudinally over time. How-
ever, although the alliance tends to increase over time (generally),
it has been shown to fluctuate during different phases of treatment
(Stiles & Goldsmith, 2010). Especially in a remediation phase of
therapy during which therapy is focused on actively changing
clients’ problems/disorders, challenges to the alliance are common
(Gelso & Carter, 1994; Stiles et al., 2004). Therapists often focus
on deeper issues that are painful and/or threatening to the client,
and maintenance of a collaborative therapeutic relationship and
prevention of a lasting breakdown is crucial for therapeutic work.
This has been demonstrated in cognitive and interpersonal thera-
pies (e.g., Stiles et al., 2004), psychodynamic-oriented therapies
(e.g., Kramer, de Roten, Beretta, Michel, & Despland, 2008), as
well as in cognitive behavioral therapies (e.g., Strauss et al., 2006).
To date, within a manageable number of primary studies in the
literature, there is no consistent research support for a systematic
alliance trajectory (i.e., longitudinal slope coefficients) that is
connected with outcome, although the alliance– outcome correla-
tions generally increase over the course of therapy (for an over-
view, see Horvath et al., 2011; Stiles & Goldsmith, 2010). How-
ever, keeping the alliance in a productive balance between
enabling security and fostering change may be a central aspect of
therapists’ responsiveness over various therapeutic traditions (e.g.,
Caspar, 2007; Linehan, 1997; Stiles, Honos-Webb, & Surko, 2006;
Strau␤, 2006).
One salient route to foster the therapeutic alliance involves
encouraging clients’ active participation in the therapist– client
interaction (Bordin, 1979). Fostering proactive behaviors and com-
munication is considered an important element of many psycho-
therapy orientations (Bohart & Tallman, 1996; Duncan, Miller,
Wampold, & Hubble, 2010; Flückiger & Grosse Holtforth, 2008;
Seligman, 1995). Clients’ openness and receptivity is proposed to
be a crucial component for therapeutic work (Kelly & Yuhan,
2009; Newman & Strauss, 2003; Orlinsky et al., 2004). However,
recent publications in the fields of medicine and psychotherapy are
finding that encouraging customers/clients to be active participants
can be challenging (Akerkar & Bichile, 2004; Chiaramonte, 2008).
For example, a therapist’s unwillingness to receive difficult feed-
back can, at times, lead to undesirable consequences for the
alliance (Henry & Strupp, 1994). An anxious therapist reaction
from a critical client’s statements may influence in-session per-
ceptions of help. That is, the clients may perceive their therapists’
subsequent intervention(s) as less helpful than if the therapists had
not reacted anxiously to their clients’ criticism (Hill, Thompson, &
Corbett, 1992; Russell & Snyder, 1963; Thompson & Hill, 1991).
Furthermore, the alliance may be compromised if the therapists
become involved in a power struggle with their clients (Caston-
guay, Goldfried, Wiser, & Raue, 1996; Piper et al., 1991).
One possible route to encourage active clients’ participation
while reducing therapists’ in-session reactivity (e.g., anxious re-
action) is in the use of indirect client feedback systems. In the last
several years, various standardized psychotherapy feedback sys-
tems have been developed and empirically tested (for an overview,
see Knaup, Koesters, Schoefer, Becker, & Puschner, 2009). Some
of these feedback systems are especially focused on feedback of
19
the therapeutic processes (e.g., Anker, Duncan, & Sparks, 2009;
Reese, Norsworthy, & Rowlands, 2009; Pinsof et al., 2009). These
systems facilitate client feedback at the end of each session within
a formalized framework (Lambert & Shimokawa, 2011). However,
these systems do not explicitly focus on (a) communication to the
clients that their perspective is valued and the encouragement of
their active engagement in treatment, (b) what is acceptable to
disclose, or (c) an institutional metacommunication of value and
respect for the clients’ perspectives.
Feedback is crucial not only in psychotherapeutic settings but
also in other working environments. A well-elaborated theory
connecting feedback with task and goal agreement is feedback
intervention theory (FIT), which is based on a meta-analytical
review of feedback in organizational psychology (DeNisi &
Kluger, 2000; Kluger & DeNisi, 1996). FIT postulates that it is not
employer feedback itself that is most important for the success of
feedback, it is really about triggering employee’s central self-
valued goals, expectations, and proactive actions as a coproduct of
the feedback itself. Activation of employee’s personally valued
goals and tasks and its consequences are the critical components
that mediate success of feedback. Relating these findings to psy-
chotherapy, it seems reasonable that valuing clients’ perspectives
and encouraging proactive engagement at an institutional level
(e.g., clinic, hospital) would have a positive impact on the patients’
perception of the therapeutic alliance with their therapists.
In the past several years, leaders in psychotherapy research have
encouraged development of research designs that are focused on
understanding principles of change (e.g., Grawe, 1997; Norcross,
Beutler, & Levant, 2006). The present study introduces an adjunc-
tive instruction to test whether a single/short therapeutic interven-
tion influences well-defined process evaluations in psychotherapy
(minimal intervention paradigm). Such designs especially address
the critique of conventional randomized controlled studies that
multiple interventions make the interpretation of group differences
on specific mechanisms of change difficult and complex (Hof-
mann, Sawyer, & Fang, 2010; Wampold, 2007).
Using a randomized controlled study design, we investigated in
the present study the degree to which a brief metacommunication
of welcoming clients’ active participation (adjunctive instruction)
from the administrators of the outpatient clinic reinforced or chal-
lenged the clients’ perception of the therapeutic alliance at the
beginning of the remediation phase of therapy.
Method
Participants
Clients. The study was conducted between 2008 and 2010 at
a Swiss university outpatient clinic. From the total of 108 people
who contacted the outpatient clinic and completed an intake and a
structured diagnostic interview for Diagnostic and Statistical Man-
ual of Mental Disorders, fourth edition (DSM–IV; Wittchen, Wun-
derlich, Gruschwitz, & Zaudig, 1997), 101 clients fulfilled the
criteria for treatment: (a) adults (age ⬎ 16) and (b) absence of
acute suicidal tendency, psychosis, mania, organic dementia, or
substance abuse disorder. From these 101 clients, 94 completed up
to Session 5. At the beginning of the remediation phase at Session
5, half of the therapies (client–therapist dyads) were then randomly
allocated to an additional adjunctive instruction or to the control
20 FLÜCKIGER ET AL.

condition (47 clients in each condition). The baseline sample Thirty-three of the therapists treated one client, 13 therapists
characteristics of the two treatment conditions are reported in treated two clients, two therapists each treated three and four
Table 1. The clients in the two conditions did not differ with clients, and one therapist participated with six clients. The above-
respect to the DSM–IV main diagnoses, Global Assessment of mentioned randomization procedure allowed for random client-by-
Functioning (GAF; Wittchen et al., 1997), gender, age, Global client allocation of the therapists to the treatment conditions. The
Severity Index (GSI; Franke, 1995), and interpersonal problems study was approved by the local ethics commission for medical
(Inventory of Interpersonal Problems [IIP-64]; Horowitz, Straub, research, and participants gave a general verbal and written con-
& Kordy, 2000). In both conditions, all clients finished at least sent before participating.
eight sessions, and 32 clients terminated therapy before Session
24. From these, 11 clients prematurely terminated therapy (adjunc- Treatments
tive instruction: six dropouts; control group: five dropouts), and 21
Individual therapy sessions typically lasted 50 mins. The ther-
clients regularly completed their course of therapy before Session
apists offered an integrative, time-unlimited form of cognitive
24. For the completer sample, including booster sessions, the mean
behavioral therapy following a case formulation that was com-
therapy length was 26.4 sessions (adjunctive instruction: 26.0
pleted within the first month of treatment (Grawe, 2004). The
[SD ⫽ 13.1]; control group: 26.9 [SD ⫽ 13.8]). These groups did
therapies were monitored by a quality management (Grawe &
not differ significantly on these variables, F(1, 92) ⬍ 0.1, p ⬎ .75.
Baltensperger, 1998; Grawe & Braun, 1994) that included bi-
Therapists. The 94 clients in the research sample were
weekly supervision and a completion of clients’ postsession re-
treated by 54 therapists (48 female and six male therapists; mean
ports after every session. These reports are used for graphical
age: 34.9 years [SD ⫽ 6.4]). The total number of cases completed
feedback of clients’ in-session experiences every fifth session.
by therapists at the outpatient clinic range from first supervised
Furthermore, every 10th session included a battery of status ques-
therapy to therapy number 47 (mean therapies at the outpatient
tionnaires. For several reasons, the recirculation of these question-
clinic: 7.4 therapies [SD ⫽ 9.0]). The total number was strongly
naires was lower than 60% of what might underlie the naturalistic
associated with the level of postgraduate training and therapist
quality of the present study (for precise description of the therapy
experience (Flückiger, Frischknecht, Wüsten, & Lutz, 2008).
guidelines, quality management, and clinical examples, see Grawe,
Forty-eight therapists had a minimum of 2 years of postgraduate
2004, p. 532).
training (mean therapies at the outpatient clinic: 5.2 [SD ⫽ 5.0]).
In addition, six of the therapists were experienced therapists (mean
Adjunctive Instruction: Valuing Client’s Perspective
therapies at the outpatient clinic: 25.1 [SD ⫽ 13.8]) who were also
involved with the supervision of the 48 less experienced therapists. The clients within the adjunctive instruction condition were
These 48 therapists were supervised biweekly in small groups. exposed to two interventions, a letter and a phone call, each

Table 1
Sample Characteristics at Baseline

Treatment group

Characteristic Adjunctive instruction Control group Statistic

Patients
N 47 47
No. of female (%) 28 (60) 33 (70)
No. of male (%) 19 (40) 14 (30) ␹2(1) ⫽ 1.2
Mean age in years (SD) 36.1 (11.6) 35.9 (11.8) F(1, 93) ⫽ 0.007
No. (%) of clients with current Axis I disorder
Depression 15 11
Adjustment disorder 3 6
Panic with/without agoraphobia 5 6
Social phobia 4 4
Other anxiety disorder 7 5
Eating disorder 3 1
Other diagnoses 4 4
No Axis I diagnosis 6 10 ␹2(7) ⫽ 5.5
Axis I comorbidity 16 19 ␹2(1) ⫽ 0.41
No. (%) of clients are married 9 (19) 9 (19) —
No. (%) of foreign European clients 3 (6) 4 (9) ␹2(1) ⫽ 0.15
GAF (SD) 69 (13.5) 68 (10.9) F(1, 93) ⫽ 0.2
GSI (SD) 1.08 (0.69) 1.14 (0.74) F(1, 93) ⫽ 0.02
IIP-64 (SD) 1.57 (0.53) 1.46 (0.51) F(1, 93) ⫽ 1.2

Note. GAF observed range from 45 to 95. GSI observed range from .09 to 2.9. IIP-64 observed range from
.11 to 2.7. GAF ⫽ Global Assessment of Functioning; GSI ⫽ Global Severity Index; IIP-64 ⫽ Inventory of
Interpersonal Problems. Dash indicates that numbers are equal; therefore, no test can be run.
p ⬎ .28.
 VALUING CLIENTS’ PERSPECTIVE
administered by two advanced graduate students in the department
of Psychology at the end of the fifth session. Session 5 was
selected to support the alliance before the beginning of the reme-
diation phase (Gelso & Carter, 1994; Stiles et al., 2004). The letter
invited clients to provide direct verbal feedback to the therapist,
with respect to their perception of the therapeutic relationship and
with regard to their agreement with their therapist on the thera-
peutic goals and tasks. The letter was structured as follows:
(a) Head: Logo of the university, city, date
(b) Form of address: Dear Madam/Sir:
(c) Text: You are currently being treated at our outpatient psycho-
therapy clinic. Therapies are found to be especially efficacious if the
therapists have precise knowledge about what is helpful for you
during and outside of the therapy session. Therefore, the post-session
reports and feedback in general are useful for therapy progress.
[break] Feel free to give positive and, when appropriate, negative
feedback to your therapists during the sessions. Your feedback may
contain what you deem as:
. . . useful and helpful goals during the session.
. . . useful tasks and instruments for goal attainment.
. . . useful behaviors of the therapist, that are helpful for your therapy.
. . . if you are confident in the therapeutic relationship.
. . . what aspects of the therapy you hold in high regard.
. . . what you are possibly missing.
Mr. JX, who is responsible for data administration, will call you in the
next days to see if you have further questions.
(d) Leave-taking: Best regards, [break] BSc. Robert JX [break] Data
administration.
Approximately 1 week after sending the letter, a phone call was
made to the clients. This involved a semistructured 5- to 10-min
interview. In this interview, clients were asked whether (a) they
understood the letter, (b) they would like to give direct feedback to
their therapist, and (c) if so, then how they would like this feed-
back to be presented to the therapist. To have background infor-
mation for the phone call, the administrators had access to the
initial assessment at intake and the short treatment protocols used
by the therapists. In the last selected 20 cases of the feedback
condition, there was an additional phone call to ask whether the
clients gave direct feedback to their therapist. From these 20
clients, 17 clients reported that they gave short positive feedback,
one client gave negative feedback, and three participants were not
interested in giving feedback. The administrators were trained
(initial 4-hr training) and supervised (monthly sessions) by the first
author. The clients in the control condition received no adjunctive
instructions (no letter or phone calls). One hundred percent of the
clients within the adjunctive instruction condition received the
letter and the first phone call.
The therapists were informed via e-mail about the general study
topics, but they were blind to condition (i.e., they were not explic-
itly informed as to which condition their clients were allocated).
Four of the 54 therapists requested to know into which condition
their client was allocated (and were subsequently informed about
the condition but not about the topics of the phone calls).
21
Assessments
The following assessments were used in the present study.
Structured Clinical Interview for DSM–IV disorders (SCID;
Wittchen et al., 1997). Screenings for mental disorders accord-
ing to DSM–IV in the German language included the research
version of the Structured Diagnostic Interviews for Mental Disor-
ders on Axis I evaluated by clinicians. The GAF is a numeric scale
of subjectively rated social, occupational, and psychological func-
tioning (range between 0 and 100; ICC ⫽ .81; Söderberg, Tung-
stöm, & Armelius, 2005). The assessments of GAF at baseline
were used to control for possible unbalanced allocations to the
study conditions.
The GSI. The GSI is the full scale score (overall mean) of the
German version of the revised Symptom Checklist 90 by Derogatis
(Franke 1995), which is a self-report measure of subjective phys-
ical and psychological distress within the past 7 days (Cronbach’s
␣ ⫽ .89). The assessments at baseline were used to control for
possible unbalanced allocations to the study conditions.
Inventory of Interpersonal Problems (IIP-64; Horowitz et
al., 2000). The overall mean of the German version of the IIP is
a self-report measure of the degree to which one experiences
problematic interpersonal interaction (Cronbach’s ␣ ⫽ .90). The
assessments at baseline were used to control for possible unbal-
anced allocations to the study conditions.
Bern Post-Session Reports for Patients and Therapists, short
form 2000 (BPSR-P; Flückiger, Regli, Zwahlen, Hostettler, &
Caspar, 2010). The report is based on general curative factors
proposed by Grawe (1998/2004), which were factor analyzed with
data collected using previous versions of the measure (Grawe &
Braun, 1994; Grawe, Ohlendorf, Retzmann, & Schröder, 1978).
The paper-and-pencil versions of the reports were delivered im-
mediately after the therapy sessions and reposited by the next
session. The BPSR-P shows satisfactory factor structure, ␹2(428,
N ⫽ 429) ⫽ 576, comparative fit index (CFI) ⫽ .94, root-mean-
square error of approximation (RMSEA) ⫽ .057, standardized
root-mean-square residual (SRMR) ⫽ .052. The “global alliance”
scale (Flückiger et al., 2010) represents the factor of how clients
evaluate the quality of client–therapist collaboration. This scale
includes three items (“The relationship with my therapist felt
comfortable today”; “My therapist and I understand each other”; “I
think my therapist is genuinely concerned about my welfare”;
Cronbach’s ␣ ⫽ .83) answered on a 7-point Likert scale ranging
from ⫺3 (not at all) to 3 (yes, exactly).
Statistical Analyses
To test whether the early global alliance was independent from
intake characteristics, Pearson product–moment correlations be-
tween GSI, IIP-64, GAF, and the numbers of therapies were
computed. The analyses reported are based on the available post-
session reports from Session 1 up to Session 24. Baseline repre-
sents the first four sessions (i.e., the time before the adjunctive
instruction started). Because some clients completed the postses-
sion report at home, Session 5 was definite as a first report with
adjunctive instruction. Time was coded as session-by-session nu-
meration from baseline (first four sessions coded as 0) up to
Session 24 (see Bryk & Raudenbush, 1992).
Data analyses are based on a sample of 54 therapists (Level 3)
who treated 94 clients (Level 2). At Level 1, clients documented
22 FLÜCKIGER ET AL.
1,785 postsession reports (mean of 20.0 reports by each client,
SD ⫽ 5.8). The estimated group differences at baseline and the
linear and quadratic course of the global alliance were analyzed
using mixed models in which a nested design consisted of ses-
sions/time at Level 1 and clients at Level 2. Two time ranges were
analyzed: (a) short-term linear effects from baseline up to Session
12 using the global alliance scale and its items (Model 1: YIJ ⫽
␤0[intrcpt] ⫹ ␤01[adinst] ⫹ ␤10[time] ⫹ ␤11 [Time ⫻ Adinst] ⫹
u0 ⫹ e) and (b) long-term linear and quadratic effects from
baseline up to Session 24 using the global alliance scale (Model 2:
YIJ ⫽ ␤0[intrcpt] ⫹ ␤01[adinst] ⫹ ␤10[time] ⫹ ␤11 [Time ⫻
Adinst] ⫹ ␤20[Time ⫻ Time] ⫹ ␤21[Time ⫻ Time ⫻ Adinst] ⫹
u0 ⫹ e). Whereas ␤01[intrcpt] indicates the initial overall means at
baseline (intercept ␲0 is centered to baseline), ␤01[adinst] indicates
whether the two treatment groups differed at baseline prior to the
intervention starting. ␤10 [time] indicates the linear time effect,
and ␤11[Time ⫻ Adinst] indicates the linear slope differences of
both treatment conditions, which is comparable to the Treatment ⫻
Time interaction within a traditional analysis of variance
(ANOVA) procedure. Furthermore, ␤20[Time ⫻ Time] indicates
the quadratic time effect, and ␤21[Time ⫻ Time ⫻ Adinst] indi-
cates the quadratic curve differences of both treatment conditions
(Bryk & Raudenbush, 1992).
Within Model 1, the global alliance scale was examined on the
basis of a two-level model (Model 1a), were integrated as a Level
3 factor into a three-level model (Model 1b) to control for the fact
that 22 of the 54 therapists treated more than one client (clients
nested within therapists; even the above-mentioned randomization
procedure should control for such effects). Model 2 examines the
linear and quadratic effects from baseline up to Session 24 on the
basis of a two-level model to test how stable the effects are over
the trajectories of the therapies. As in Model 1, Model 2 was also
analyzed on the basis of a three-level model and showed the
comparable results as the two-level models; therefore, only the
results of the two-level models are reported. The benefit of mixed
models in contrast to a traditional ANOVA with repeated measures
lies in the hierarchical parameterization of the process variables
(sessions nested within clients, clients nested within therapists;
Bryk & Raudenbush, 1992). To test which Level 1 change model
was generally most adequate (linear, loglinear, or quadratic curve
models), unconditional models were run, which indicated a linear
fit was most appropriate (smallest error variance) for the first 12
sessions, and a quadratic curvilinear model was most appropriate over
the course of 24 sessions (Gallop & Tasca, 2009).
Furthermore, effect sizes for alliance were computed on the
basis of Becker’s Del (⌬), which is a mean differences estimate
that takes into account both baseline values and differences be-
tween each treatment condition (Del Re, 2010).
Results
To determine whether the global alliance was independent from
intake characteristics, we calculated Pearson product–moment cor-
relations. The correlations between the global alliance at baseline
and GAF (r ⫽ .00, p ⬎ .99), GSI (r ⫽ ⫺.09, p ⬎ .37), and IIP-64
(r ⫽ ⫺.14, p ⬎ .18) at baseline indicated early alliance was
independent of symptom severity-related characteristics at intake.
The number of cases completed by therapists were also not related
to alliance (r ⫽ .05, p ⬎ .60).
Global Alliance Scale From Baseline up to Session 12
(Models 1a, 1b)
To test differences between clients in the adjunctive instruction
condition and those in the control condition, a longitudinal multi-
level model was fitted and computed with repeated sessions at
Level 1 and clients at Level 2 (Model 1a). We also included
therapists at Level 3 to control for possible therapist effects (Model
1b). A summary of the short-term effects of the global alliance
scale is presented in Table 2. At baseline, the two treatment
conditions did not differ (␤01[adinst]), which indicates that the
randomization procedure created comparable preconditions on the
global alliance for both conditions. From baseline up to Session
12, there was no general increase or decrease of the global alliance
observed (␤10[time]). The differences in the slopes indicated
(␤11[Time ⫻ Adinst]) that the clients in the adjunctive instruction
condition generally showed an increase over time, whereas those
in the control group remained stable. To determine whether the
adjunctive instruction had an influence on the individual stability
of the alliance scores, we calculated intraclass correlations (ICCs),
which indicated that the adjunctive instruction showed slightly less
stability in the alliance scores from baseline up to Session 12 in
comparison to the control group (adjunctive instruction: ICC ⫽
.58, 95% CIs [.44, .74]; control group: ICC ⫽ .64, 95% CIs [.51,
.78]). Note that at baseline, there was generally an adequate quality
of the therapeutic alliance for both conditions (all ␤00 [intrcpt]
around 2, out of a possible range from ⫺3 to 3).1
Global Alliance From Baseline up to Session 24
(Model 2)
The long-term effect based on a two-level model of the adjunc-
tive instruction on the global alliance scale is illustrated in Figure
1. At baseline, as also demonstrated with the short-term effects, the
global alliance between the treatment conditions did not differ
(␤01[adinst] ⫽ ⫺.008 (SE ⫽ .05), t(92) ⫽ ⫺0.015, p ⬎ .88. There
was no general linear or quadratic time effect (for linear time
effect: ␤10[time] ⫽ .006 [SE ⫽ .007]), t(1779) ⫽ 0.88, p ⬎ .38;
(for quadratic time effect: ␤20[Time ⫻ Time] ⫽ .0002 [SE ⫽
.0004]), t(1779) ⫽ 0.84, p ⬎ .40. The linear slope differences
persisted up to Session 24 (␤11 [Time ⫻ Adinst] ⫽ .016 [SE ⫽
.007]), t(1779) ⫽ 2.3, p ⬍ .024, which indicated that clients with
the adjunctive instruction showed a higher linear increase in the
global alliance in contrast to the control group. The quadratic curve
1
If GSI (at Level 2), IIP-64 (at Level 2), GAF (at Level 2), and therapist
experience (at Level 3) were integrated into a multipredictor three-level
model, the slope differences between the two conditions remained signif-
icant (␤11[Time ⫻ Adinst] for global alliance: .013 [.006]), t(83) ⫽ 2.2,
p ⬍ .05, and the other predictors did not touch significance (␤12-14/21 ⬍
.002 [.001], t ⬍ 1.1, p ⬎ .27). The analyses of the single items confirmed
the significant slope differences between the two treatment conditions. The
group difference of the global alliance was apparently independent of one
or two phone -calls (Urwyler, 2009). An exploratory analysis from Ses-
sions 5 to 12 showed that in the control group, patients with high scores on
the IIP-64 subscale “vindictive” showed lower alliance scores (for inter-
cept: ␤ [intcpt] ⫽ ⫺.057 [.019]), t(86) ⫽ ⫺3.0, p ⬍ .001, and these effects
disappeared in the group with adjunctive instruction, and the algebraic sign
changed (for intercept: ␤ ⫽ ⫹.023 [.020]), t(85) ⫽ 1.1.
 VALUING CLIENTS’ PERSPECTIVE 23

Table 2
Short-Term Effects From Session 1 to Session 12 on the Global Alliance Scale (Model 1a, 1b)

Two-level model (Model 1a) Three-level model (Model 1b)a

Coefficient SE t(93) Coefficient SE t(93) ⌬Sess1–12

For intercept ␲0
␤00[intrcpt] 1.99 .054 37.1ⴱⴱⴱ 1.99 .056 35.5ⴱⴱⴱ
␤01[adinst] ⫺.003 .054 ⬍⫺.1 ⫺.001 .044 ⬍⫺.1
For slope ␲1
␤10[Time] .003 .006 .5 .002 .005 .7
␤11[Time ⫻ Adinst] .016 .006 2.7ⴱⴱ .016 .006 2.6ⴱⴱ .39
a
⫺1 ⫽ control group, ⫹1 ⫽ treatment group.
ⴱⴱ
p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

differences confirm findings from a prior sample (at the same outpa-
tient clinic), in which the control group needed up to 14 sessions to
obtain an increase of the global alliance, represented in the trend of
quadratic growth up to Session 24 (␤21 [Time ⫻ Time ⫻ Adinst] ⫽
⫺.0006 [SD ⫽ .0004]), t(1779) ⫽ ⫺1.8, p ⬍ .073.
Discussion
In this randomized controlled process study, an adjunctive in-
struction was designed to reinforce a model of psychotherapy in
which clients were encouraged to be a proactive participant in their
treatment. The results indicated that the introduction of a brief
metacommunication intervention at an institutional level (valuing
client’s perspective) reinforced clients’ global alliance with their
therapists over the course of therapy. These results persisted even
after controlling for self- and observer-reported symptom severity
at baseline, participants’ self-reported interpersonal problems, and
therapists’ numbers of therapies as an indicator of their profes-
sional experience.
This adjunctive instruction was in addition to a formalized
quality management system that was used in both treatment con-
ditions (Grawe & Baltensperger, 1998). The adjunctive instruction,
implemented by two master’s-level students, contained a (a) short
letter and (b) a 5- to 10-min semistructured phone call to encour-
age clients’ active participation regarding task and goal agreement
and general aspects of the therapeutic relationship. The main
advantages of using a randomized controlled AB design lies in the
fact that the (a) conditions had equivalent baseline and early
process characteristics (e.g., alliance) and (b) design in principle
allowed for causal interpretations of the adjunctive instruction.
From an overview of the literature, Horvath et al. (2011) stated
that a lasting break in the alliance might be negatively associated
with outcome (see also Stiles & Goldsmith, 2010). All other

Figure 1. Long-term change of the global alliance caused by the adjunctive instruction (Model 2). HLM ⫽
hierarchical linear modeling.
24 FLÜCKIGER ET AL.
patterns (such V-, U-, curve shapes) might represent subtypes of
those without a lasting break. Despite these findings, the present
study cannot make any conclusions about the association between
differing alliance levels and trajectories with therapy outcomes.
However, it does add knowledge to the relationship between
institutional metacommunication and the trajectories of the client’s
evaluated alliance (e.g., Stiles et al., 2004; Stiles & Goldsmith,
2010; Strauss et al., 2006).
Within the Organizational Psychology literature, FIT (Kluger &
DeNisi, 1996) proposes three different factors that influence the
success of employers’ feedback within an institutional network. If
the goals are (a) realistic, (b) relevant, and (c) manageable for the
participant, feedback may increase working satisfaction by acti-
vating self-relevant goals and enhance motivation and perfor-
mance for the focal tasks. Although the roles of employers and
employees in some organizational contexts are defined precisely,
in other working contexts these roles are less systematic (Sluss,
van Dick, & Thompson, 2011). In relation to psychotherapy, the
function of the organization (e.g., psychotherapy clinic) may be
more complex than in a “classical” industrial work setting. How-
ever, this circumstance does not have to touch one of the main
theses of the FIT: that success of feedback is mediated by personal
goal and task activation (Kluger & DeNisi, 1996). Although the
institutional adjunctive instruction was designed as a minimal
intervention paradigm, there are potential side effects that were
considered. One potential side effect is that the client may have felt
obligated to respond to the adjunctive instruction, which could
have interfered with the therapeutic process. Another potential side
effect is that without careful preparation of a phone call from a
third party (who was not directly involved in the therapy), clients’
privacy could have been compromised. Although these concerns
are justified, the adjunctive instruction fostered clients’ trust in
perceptions of their therapists’ engagement (i.e., “I think my
therapist is genuinely concerned about my welfare.”), which qual-
ifies the potential of the above-mentioned negative side effects.
These results are in accord with the FIT model, in which the
participants’ information processing about self-related goals me-
diated success of feedback (DeNisi & Kluger, 2000; Kluger &
DeNisi, 1996). From this perspective, the adjunctive instruction
did not necessarily change the tasks of therapy (encouraging direct
feedback) but may have changed the clients’ expectations (valuing
client’s perspective), and therefore altering the therapeutic focus
(e.g., “my opinion and my goals are important in this therapy”;
Van Dijk & Kluger, 2004). In line with this interpretation, the
protocols of the second phone calls indicated that the clients gave
very short feedback (i.e., “This session was very helpful for me”;
“I feel that I can trust you”; “I think we have a very good
relationship, and there is nothing to change”).
There were various limitations of this study. First, the results of
the present study should be replicated. Even though the sample
size in the present study is adequate, this study represents an initial
investigation of a potential promising area in psychotherapy re-
search. Second, perhaps the adjunctive instruction prompted cli-
ents’ responses that were based on social desirability. This is of
concern, but even the group differences of the responses up to 24
sessions as well as “vindictive” clients (on IIP-64) who benefitted
from the adjunctive instruction counter this interpretation. If rep-
licated, future studies should examine whether the present findings
can be explained by client and/or therapist process characteristics.
Third, future research should examine the impact of the adjunctive
instruction on the trajectory of the therapeutic alliance in a thera-
peutic context other than a university outpatient clinic, where a
detailed quality management (i.e., precise case formulations, bi-
weekly supervision, or the use of postsession reports) is available.
Fourth, the present study does not include an active control group.
Alternative adjunctive instructions (i.e., an unstructured phone call
as attention control group) should be examined to determine
whether there are comparable effects as found in this study. How-
ever, if a contrastive control group is designed, potential negative
side effects should be considered. Fifth, from a methodological
point of view, the analysis of a three-item scale may be adequate
with respect to repeated session-by-session measurements using
hierarchical linear models (Bryk & Raudenbush, 1992). However,
the therapeutic alliance could be measured more comprehensively
than a repeated three-item session-by-session scale and could
include perspectives other than the clients. Sixth, further research
should examine the role of adjunctive instruction in predicting
outcome. Seventh, clinical significance of the present findings
should be elaborated more precisely. From a clinical perspective,
BPSR scores under 2 (2 ⫽ yes, 1 ⫽ mostly yes) represent an
indication to take a more precise look at the case formulation with
two questions: (a) Can the answer can be explained according to
the client’s plans/schemata (Caspar, 2007)? and (b) should the
therapy/therapist be more responsive on neglected aspects of the
case formulation?
Although there are several limitations, the present study adds
knowledge regarding the influence of a brief institutional adjunc-
tive instruction on the trajectory of the client’s alliance over time
(Kramer et al., 2008; Stiles et al., 2004; Strauss et al., 2006). It
highlights the significance of an institutional metacommunication,
which is a somewhat unusual perspective considered in psycho-
therapy process research (Orlinsky et al., 2004). The implementa-
tion of this short adjunctive instruction was not time-consuming or
expensive in comparison to other interventions that involves train-
ing therapist. If the results of this study are replicated, its impli-
cations are promising, particularly for psychotherapy that is deliv-
ered in institutions such as in- and outpatient clinics or Veterans
Affairs medical centers.
Although designing standardized adjunctive instructions (mini-
mal intervention paradigm) is not common in psychotherapy re-
search, it appears that it has the potential to facilitate the devel-
opment of the alliance, with the likely result that the effectiveness
of treatment is improved. Systematic interventions on an institu-
tional level may set and reinforce functional characteristics of
therapist– client dyads in individual treatments.
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