ABSTRACT
In order to investigate clients’ role in the mutuality of therapeutic encounter, this pilot study examined data from 49 participants who had undergone at least three sessions of therapy. The participants completed the Working Alliance Inventory and the Kentucky Inventory of Mindfulness Skills. As hypothesised, higher levels of mindfulness were associated with enhanced working alliance. All three dimensions of the working alliance (quality of therapeutic bond, agreement on tasks, and agreement on goals) were found to be associated with mindfulness. These results suggest that it would be worthwhile to develop future longitudinal research on the relationship between client variables and the development of therapeutic encounter.
Key words: Mindfulness, person-centred therapy, therapeutic alliance, mutuality.
Recent theoretical work suggests that person-centred therapy (PCT) consists of a mutual encounter in which the therapeutic relationship leads to more fully-functioning behaviour on the part of the client, which in turn enhances the therapeutic relationship, and so forth, leading to increasing relational depth and mutuality of encounter (Murphy et al., 2012).
Therefore, it is not only the therapist who contributes to the development of the therapeutic relationship, but also the client. Hence, it might be predicted that not only the therapist’s congruence, but also the client’s, that contributes to the quality of the relationship.
Accordingly, the client’s ability to be present in the moment, open to all aspects of their experience, and to the internal responses that arise from being with themselves, may be predicted to be associated with their experience of therapeutic relationship as a mutual encounter. To test this prediction, we report the results of a pilot study aimed at examining the association between the level of mindfulness reported by clients and their working alliance with the therapist.
Participants
The participants were recruited via online groups for therapy clients under the PCT model; the researchers did not know the participants personally. The study was advertised as voluntary, and no incentives were offered. All the participants were in therapy with an accredited counselling psychologist using the PCT model. Forty-nine counselling therapy clients ( 36 women, 13 men; aged 21 to 63, with a mean age of 40.55 years, SD = 12.85) responded and completed the scales described below. All participants were proficient in the English language, to be able to complete the questionnaires.
Procedure
The research was approved by the Institutional Ethics Review Board of the University of East London. The risks faced by the participants in this study were low; however, given the possibility that the questionnaire completion could lead to questions or create confusion related to the participant’s experience of mindfulness or the therapeutic alliance, the participants were provided with the researchers’ contact details, for any questions that might arise. Additionally, the participants were encouraged to share with their therapist any difficulties they encountered regarding the research.
Following their recruitment, the participants received an email invitation letter that described the study and listed its requirements. Initially, the participants had to sign a consent form. They then proceeded to complete the questionnaires, including basic demographics. The estimated time required to complete the questionnaires was approximately 15 minutes. Once they completed the questionnaires, the participants were handed a debrief sheet describing the purpose of the study.
The existing literature indicates that the working alliance is sufficiently established after the third therapy session and can be rated reliably from that point onwards (Duncan et al., 2003). Therefore, the study’s design allowed only the participation of clients who had completed at least three sessions with their therapist; that has been an inclusion criteria.
Measures
The Kentucky Inventory of Mindfulness Skills (KIMS) (Baer et al., 2004) was used in the study. This 39-item questionnaire assesses baseline trait mindfulness levels. It uses four categories of mindfulness to calculate the score: Observing, namely attending to stimuli – internal as well as external; describing, that is one’s ability to put an experience into words without judgment; acting with awareness, the skill of remaining mindful while acting; and accepting, the ability to avoid labelling experiences as “good” or “bad” and accept situations as they are, without trying to force any change.
The KIMS was created to investigate levels of trait mindfulness in the general population. Participants choose levels of agreement with items by using a Likert scale of 1 (never, rarely true) to 5 (very often or always true). Those who score higher in the questionnaire have higher levels of trait mindfulness. The KIMS was shown to be reliable and valid, with alpha coefficients ranging from 0.83 to 0.91 (Baer et al., 2004). The questionnaire was also found to be valid for use in clinical populations (Baum et al., 2010).
The Working Alliance Inventory (WAI) (Horvath and Greenberg, 1989) is a questionnaire that is a very widely used measure of the strength of the patient-therapist alliance. The present study used the short-form (12-items), rather than the original 30-item questionnaire. The short-form version has been demonstrated to reflect scores of the full version (Tracey and Kokotovic, 1989). The questionnaire, based on a tripartite conceptualisation of the working alliance (Bordin, 1979), yields three subscales:
(1) Quality of therapeutic bond – indicating the level of relational bond between the therapist and client
(2) Agreement on tasks – indicating agreement between the client and therapist on the means and methods of the therapy
(3) Agreement on goals – indicating that client and therapist have the same goals.
A Likert scale of 1 (not at all) to 7 (completely) is used by the participants to indicate the level of their agreement with each of the 12 statements. Higher scores indicate a stronger working alliance. The WAI correlates closely with other measures of the working alliance, and predicts the treatment outcome, which proves that it is highly valid (Horvath and Symonds, 1991). High alpha coefficients were found for this questionnaire's internal consistency, ranging from 0.85 to 0.96 (Tichenor and Hill, 1989; Horvath and Greenberg, 1989). Only clients (and not therapists) were asked to complete the WAI.
Correlational analyses were conducted between the three WAI subscales and the KIMS total mindfulness score. A statistically significant positive correlation was found between WAI-Bond and KIMS (r = 0.42, p < 0.05; 1-tailed), WAI-Tasks and KIMS (r = 0.37, p < 0.05; 1-tailed), and WAI-Goals and KIMS (r =0.42, p < 0.05; 1-tailed).
The results show that the participants’ levels of mindfulness and working alliance were indeed positively associated. However, although we tested a prediction derived from contemporary person-centred theory, the measures used were derived from other theoretical perspectives. These were chosen because they seemed to offer operational definitions closely related to the core constructs of congruence and therapeutic relationship, are widely used by psychotherapy researchers, and have been shown to have excellent psychometric properties. However, in interpreting the practice implications of these results, we would return to the person-centred theory.
It might be suggested by researchers from these other traditions that if mindfulness is associated with the client’s experience of therapy, we may consider commencing the therapy session with a practice of mindfulness, or allocating time for it during the session. This is because such a practice may trigger self-acceptance, openness, and presence for the client, and its benefits could enhance the therapeutic experience.
Either way, it would be premature to suggest new practice implications. The main limitation to this study is that there is no way to discern the nature of their causal relationship from the current cross-sectional data. It could be that the client with higher levels of mindfulness is better able to contribute to the alliance, or that it is the quality of the alliance that fosters mindfulness in the client. More likely, it is a mutual relationship in which both of these causal relationships hold across time (Murphy et al., 2012). The results of the present pilot work suggest such research is warranted. Accordingly, there is now a need for future work to adopt longitudinal methods of investigation that can fully explore the relationship between these variables over time.
Another limitation to consider is the number of sessions clients had with their therapist before completing the questionnaires. Logically, a higher number of sessions would be linked to a greater working alliance and greater mindfulness. Future studies in this area could investigate this question while measuring the impact of mindfulness on other measures of therapy clients, such as compassion, self-acceptance and self-awareness.
The authors have not declared any conflict of interests.
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