What Contributes to the Working Alliance and Psychotherapy Outcome: Exploration of Therapist Responsiveness, Therapist-client Similarity and Complementarity from the Therapist Perspective

Abstract

Psychotherapy primarily refers to interpersonal treatment based on psychological principles. The treatment involves a trained therapist and a client with mental disorder, problem, or complaint. The effective mechanism of psychotherapy is controversial. The quality of relationship between clients and therapists plays a critical role in psychotherapy effectiveness. However, to the best of our knowledge, a commonly agreed plausible explanation of the mechanisms of how the relationship between therapists and clients develops and contribute to outcomes has been lacking. Several key interpersonal factors are noteworthy, such as therapist responsiveness, which is crucial in developing the therapeutic relationship and fostering positive therapeutic outcomes. Yet, relevant study of therapist responsiveness is sacred. Apart from the therapist factor, the client–therapist match is a concern of psychotherapy research. However, subjective perception of matching has not been investigated. In addition, cultural values, such as interpersonal harmony, are supposed to influence psychotherapy relationship. Thus, the effect of interpersonal harmony in psychotherapy process must be examined.

The principle of interpersonal complementarity from interpersonal theory predicts that reciprocity in the control dimension and correspondence in the affiliation dimension contribute to the quality of the working alliance and outcomes. The present study proposes a theoretical framework based on interpersonal theory to understand the process and outcomes in psychotherapy. Generally, the theoretical framework argues that certain factors facilitate the development of strong therapeutic relationships and further influence psychotherapeutic outcomes. These factors include societal interpersonal harmony, therapist and client attachment and interpersonal styles, therapist responsiveness, therapist–client match on interpersonal styles (interpersonal complementarity), attachment and other demographic characteristics, perception of general complementarity and similarity between client and therapist, therapist empathy of client, and therapist perceived client self-acceptance. Consequently, several research questions and hypotheses arise.

A mixed method approach applies to examine the research questions and test the hypotheses from the therapist perspective. In Study 1, a qualitative approach was adapted to interviews with nine therapists about their experiences in conducting psychotherapy, with an aim to consolidate the theoretical framework and conceptualize responsiveness. The analysis followed the grounded theory method. In Study 2, self-report data was gathered from 239 therapists. Based on their work with a client, therapists completed measures for their responsiveness, interpersonal complementarity with clients, working alliance quality, psychotherapeutic outcomes, and others. The hypotheses were then tested based on the theoretical framework.

Study 1 revealed fitting and steering as the two core psychotherapy processes. Important process factors, such as the active and passive fitting between therapists and clients, therapist empathetic understanding, working alliance, client trust, and the working mechanisms of these process factors were revealed. For therapist responsiveness, accurate assessment and allegiance to the treatment goal emerged as key categories. Study 2 indicated that interpersonal complementarity was observed, but the effect of complementarity on control was not as strong as the effect of affiliative complementarity on working alliance. Moreover, attachment styles and therapist responsiveness were antecedents of interpersonal complementarity. Similarity in attachment styles and therapist-perceived similarity and complementarity contributed to working alliance quality and treatment outcomes. Therapist responsiveness played a positive role in the psychotherapeutic process. Moreover, societal interpersonal harmony moderated primarily on the relationship between attachment style and psychotherapy process, indicating the cultural variability of the application of attachment theory.

Theoretically, the studies enrich interpersonal theory by testing and expanding it, contribute to understanding the whole effective psychotherapy process by generating the fitting–steering model, clarify the concept of therapist responsiveness, and indicate how societal interpersonal harmony influences the psychotherapy process. Practically, the thesis contributes to improving therapy and therapist quality, enhancing cultural adaptation of Western theories, and fostering the matching of clients with appropriate therapists.

Date of Award	24 Aug 2020
Original language	English
Awarding Institution	City University of Hong Kong
Supervisor	Chau Kiu Jacky CHEUNG (Supervisor) & Oi Wah Esther CHOW (Supervisor)