Psychotherapy Research The relationship between

This article was downloaded by: [Owen, Jesse J.] On: 16 August 2010 Access details: Access Details: [subscription number 925832115] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 3741 Mortimer Street, London W1T 3JH, UK

Psychotherapy Research

Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713663589

The relationship between therapist and client hope with therapy outcomes Timothy E. Coppocka; Jesse J. Owenb; Elena Zagarskasa; Melissa Schmidta a Department of Psychology and Counseling, Gannon University, Erie, Pennsylvania b Department of Education and Counseling Psychology, University of Louisville, Louisville, KY, USA First published on: 16 August 2010

To cite this Article Coppock, Timothy E. , Owen, Jesse J. , Zagarskas, Elena and Schmidt, Melissa(2010) 'The relationship

between therapist and client hope with therapy outcomes', Psychotherapy Research,, First published on: 16 August 2010 (iFirst) To link to this Article: DOI: 10.1080/10503307.2010.497508 URL: http://dx.doi.org/10.1080/10503307.2010.497508

PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

Psychotherapy Research 2010, 18, iFirst article

The relationship between therapist and client hope with therapy outcomes

TIMOTHY E. COPPOCK1, JESSE J. OWEN2, ELENA ZAGARSKAS1 & MELISSA SCHMIDT1 1

Department of Psychology and Counseling, Gannon University, Erie, Pennsylvania & 2Department of Education and Counseling Psychology, University of Louisville, Louisville, KY, USA

Downloaded By: [Owen, Jesse J.] At: 16:10 16 August 2010

(Received 22 February 2010; Revision received 27 April 2010; Accepted 25 May 2010)

Abstract The current study examined whether clients’ perceptions of hope and therapists’ hope in their clients were associated with therapy outcomes. The authors conducted a naturalistic study of brief therapy with 10 therapists and 43 adult clients. Client-rated hope significantly increased after one session of therapy. However, no significant relationship was found between pretherapy client-rated hope and first-session symptom change. Further, client-rated hope at any point in therapy was not significantly related to therapy outcomes. Therapists’ hope in their clients after the first and last sessions was significantly related to client outcomes. Implications for therapy practice and research are offered.

Keywords: hope; therapy outcome; therapist effects; expectations; outcome research; alliance

Over the past 50 years, researchers have examined the facets that make psychotherapeutic change possible. In a large quantitative review, Wampold (2001) found that at least 70% of the effects of therapy were due to common factors (e.g., alliance, hope, empathy), 8% of the variance was due to specific ingredients (i.e., techniques), and the remaining 22% was unexplained. Of particular interest, many scholars have espoused that clients’ hope in their lives and therapists’ ability to instill hope are foundational common factors that contribute to promoting change (e.g., Frank & Frank, 1991; Hanna, 2002; Imel & Wampold, 2008; Seligman, Rashid, & Parks, 2006; Snyder, 2000; Wampold, 2007). Building from the common factors literature, Hanna (2002) identified seven client-specific change characteristics or precursors to change: (1) a sense of necessity or urgency for change to occur; (2) a willingness or readiness to experience anxiety or difficulty; (3) awareness of the existence of the problem and its symptoms; (4) confronting and addressing the problem; (5) effort or will toward change; (6) hope for change, identified as the client’s ability to see the possibility for change and the pathway to change; and (7) social support for change. In particular,

Hanna referred to hope as a catalyst for the other precursors because it can attenuate anxiety, decrease apathy, and increase confidence to confront the problem. Theorists have also inferred the importance of the instillation of hope based on investigations of hopelessness. Notably, Frank and Frank (1991) observed that clients often experience demoralization resulting from their symptoms, and postulated that this state of hopelessness was a common characteristic among those seeking therapy. They concluded that therapy achieves its effects by directly treating demoralization while overt pathological symptoms are treated indirectly. Several researchers have found links between hopelessness and suicidal rumination, suicidal ideation, and depression (i.e., Beck, Brown, & Steer, 1989; Connor, Duberstein, Conwell, Seidlitz, & Caine, 2001; Lester & Walker, 2007; Miranda, Fontes, & Marroquin, 2008; Smith, Alloy, & Abramson, 2006). Moreover, hopelessness has been identified as a mediating variable between cognitive vulnerability and depression (Abramson et al., 2002; Haeffel, Abramson, Brazy, & Shah, 2008). The role of hope in clients’ lives is arguably paramount to their well-being and ability to work effectively in therapy.

Correspondence concerning this article should be addressed to Timothy E. Coppock, Department of Psychology and Counseling, Gannon University, 109 University Square, Erie, PA 16541, United States. E-mail: [email protected] ISSN 1050-3307 print/ISSN 1468-4381 online # 2010 Society for Psychotherapy Research DOI: 10.1080/10503307.2010.497508

2

T. E. Coppock et al.


Hope Theory and its Application to Therapy Snyder, Irving, and Anderson (1991) defined hope as ‘‘a positive motivational state that is based on an interactively derived sense of successful (a) agency (goal directed energy), and (b) pathways (planning to meet goals)’’ (p. 287). As implied, goals function as the foundation of Snyder’s (1994) theory of hope and must be sufficiently imperative so as to motivate individuals. Specifically, Snyder (1994, 2002) referred to goals as the central targets of cognitive action sequences. A second link between goals and hope involves circumstances in which goals are perceived as constrained (Snyder, 2002). For instance, a client may want to have a healthy relationship but feels that he or she does not have the skills to establish one. Lazarus (1999) contended that hope involves a condition or assumption that one’s present life circumstance is unsatisfactory, presumably because of constraints surrounding one’s goals, which may ultimately lead to uncertainty of the future. Snyder (2002) regarded this underlying uncertainty as a necessary feature of hope goals, possibly reflective of the underlying assumptions of Frank’s (1974) earlier concept of demoralization. Before goals can be attained, there must be the perception that various pathways can be produced to reach the goals. Hence, pathways are one’s ability to develop possible routes to the perceived goals (Snyder, 2000). Additionally, Snyder asserted that agency is the mental motivation component that drives the individual to complete the pathway to the envisioned goal. The combination of developing multiple pathways and having the agency or willpower to reach the envisioned goal is essential in the face of barriers or challenges. For instance, clients must believe that therapy can provide the necessary environment to reduce their psychological distress. Snyder, Illardi and colleagues (2000) asserted that clients with greater hope may experience various psychotherapeutic advantages. For instance, individuals with higher levels of hope also report better psychological adjustment, ability to cope with health-related problems, academic achievement, grief recovery, and the attainment of life goals (i.e., Kwon, 2002; Snyder, 2002; Snyder et al., 1996; Snyder, Harris, et al., 1991; Snyder, Feldman, Taylor, Schroeder, & Adams, 2000; Snyder, Michael, & Cheavens, 1999). Snyder et al. (1996) found that individuals who reported more hope also have more positive thoughts and higher self-esteem, describe themselves as more energetic and confident, and are more goal directed than those who report less hope. In addition, individuals with a lower level of hope have a propensity toward negative thoughts with regard to pursuing their goals in counseling.

Snyder, Feldman, and colleagues (2000) posited that the early symptom relief in the first few sessions can be attributed to an increase in agency thinking, which leads to an increase in pathways thinking, implicated by the initial decision to seek therapy for the purpose of pursuing the goal of self-improvement (Magyar-Moe, 2003; Snyder et al., 1999). As therapy continues, clients’ sense of hope has been related to better therapy outcomes in group therapy (e.g., Cheavens, Feldman, Gum, Michael, & Snyder, 2006), marital therapy (e.g., Worthington, Riply, Hook, & Miller, 2007), and individual therapy (e.g., Cooper, 2009). However, clients’ and therapists’ levels of hope have not been invariantly related to better outcomes. For instance, in a study of 77 individual-therapy clients, Cieslak (2009) found that both clients’ and therapists’ levels of hope were not related to better therapy outcomes or working alliance. Therapist’s Hope in their Clients Therapists’ hope in their clients has been conceived as a ‘‘positive expectancy of goal attainment’’ (Menninger, 1959) and more specifically in the Snyder model as ‘‘motivation and planning . . . necessary to attain goals’’ (Cheavens, Feldman, Woodward, & Snyder, 2006). Accordingly, therapists’ hope in their clients may have a central role in the ways they implement treatment. As is commonly discussed, therapists aim to instill hope in their clients: For instance, Greenberg, Constantino, and Bruce (2006) noted in a review of expectations in therapy that ‘‘reshaping of patient expectations (or assumptions) appears to be at the foundation of virtually every major model of psychotherapy’’ (p. 670). Clinically, therapists work with their clients to understand their sense of agency and goaldirected thinking and to promote the belief that change is possible through a shared sense of hope for a positive outcome. Therapists’ hope in their clients may be influenced by a number of elements, such as client factors (e.g., readiness for change, resources, symptom severity) and therapy process factors (e.g., remoralization, therapeutic alliance; Frank & Frank, 1991; Prochaska & DiClemente, 1992; Safron & Greenberg, 1993). Moreover, therapists’ hope that their clients can change also may be related to positive therapy outcomes. Conceptually, therapists’ hope in their clients may affect their clients in direct (e.g., interventions to instill hope) or indirect (e.g., positive countertransference or reactions) ways. For instance, therapists’ sense of hope in their clients may empower their clients to access their internal and external resources to promote change (see Duncan

Relationship between hope and outcomes & Miller, 2000). Several related studies have shown that therapists’ level of motivation can increase their clients’ level of motivation (Magyar-Moe, 2003). Consistently, Snyder, Illardi, Michael, and Cheavens (2000) noted that higher agency in therapists correlated with higher agency in clients (also see Crouch, 1989). Hanna (2002) also raised the notion that hope can be viewed as a ‘‘contagion’’ or positive influence on client change in therapy. The concept of hope as a contagion expands on Farran, Herth, and Popovich’s (1995) commentary on how both hope and hopelessness are ‘‘contagious’’ and the important role that medical health practitioners and families assume in facilitating hope in individuals with critical medical illnesses. However, little is known of the role of therapists’ hope in their clients and its possible influence on psychotherapeutic change.


The Current Study The purpose of this study was to expand the investigation of the role of hope as a predictor of therapy outcomes. Toward this end, we tested four hypotheses. First, clients’ level of hope would increase from pretherapy to after the first session and from after the first session to the end of therapy, and therapists’ hope in their clients would increase from the first to the last session. Second, clients’ pretherapy hope would be related to first-session symptom change. Third, clients’ hope and therapists’ hope in their clients after the first session would be positively related to therapy outcomes. Fourth, clients’ hope and therapists’ hope in their clients after the last session would be positively related to therapy outcomes. Method Participants Clients. Forty-three clients were solicited by their therapists to participate in the current study. Clients’ specific diagnoses were not formally assessed by all therapists; however, clients typically presented with a variety of mental and emotional problems, ranging from mild mood disorders and relational issues to more severe disorders such as major depressive disorder, eating disorders, and personality disorders. Informally, therapists recorded the primary presenting problems as described by their clients. The majority of clients reported one to two primary presenting problems (77.2%). The most often cited problems included ‘‘feeling stressed/anxious’’ (59.1%) and ‘‘feeling sad/depressed’’ (43.2%), followed by relationship problems (27.3%), eating/weight issues (16%), ‘‘other’’ problems (11.3%), alcohol/substance

3

abuse (6.8%), and adjustment issues (6.8%). Based on the Outcome Questionnaire-45 (OQ-45; Lambert et al., 2004) clinical cutoff (i.e., score 64), 31 of the 43 clients were in the clinically distressed range. Exclusionary criteria for included active psychosis at initial intake session and age younger than 18 years. We also excluded clients who only attended one session. The duration of therapy was typically brief in this sample (60.5% of clients attended three sessions, 18.6% of clients attended four to five sessions, and 21% attended six sessions). Demographic information for one client was not obtained, and the following data thus reflect a sample size of 42. Participants ranged in age from 18 to 57 years (M 24.6, SD 9.51). The majority were women (70.5%) and had 13 to 16 years of education (61.9%). The remaining distribution for years of education is as follows: 0 to 8 years, 0%; 9 to 12 years, 14.3%; 16 years or more, 23.8%. Most of the clients were voluntarily seeking therapy (88.6%) versus nonvoluntary (9.1%) and had not previously sought therapy with the current therapist (95.5%). However, approximately half of the sample had previously sought counseling (54%) in general. Therapists. Ten therapists from a variety of practices located in two metropolitan cities in the Great Lakes region were selected to solicit patients. Eight therapists were licensed as professional counselors and two were licensed as psychologists. Nine therapists had master’s degrees and one had a doctoral degree. Three of the therapists were engaged in private practice, six practiced in university counseling centers, and one practiced in an eating disorder clinic. Participating therapists were selected by the principal researcher based on their expressed interest in the research, availability of office manager/ receptionist for distributing information packets and receiving completed client participant forms, and approval of the agency in which the therapist practiced, if required. Procedure Clients were invited to participate before their initial session. Upon checking in at the therapist’s office, the receptionist offered each prospective client an assessment packet containing the State Hope Scale (Snyder et al., 1996) and OQ-45. Those who chose to participate completed the measures in the waiting room both before and after their first session and following each session thereafter. For each participating client, therapists completed the State Hope Scale after every session. Participation in the study was voluntary, and clients were able to refuse further participation at any point by simply returning the

4


noncompleted assessment packet to the receptionist. No record was kept of clients refusing the packet. Both therapists and clients provided informed written consent before taking part in the research. A preexperimental, one-group pretestposttest design was implemented. This study was approved by a university institutional review board.


Measures State Hope Scale (Snyder et al., 1996). This sixitem self-report inventory was used to measure clients’ perceptions of hope and current level of goal-directed thinking and therapists’ hopefulness about the psychotherapeutic outcome for their clients. Using an 8-point rating system, the State Hope Scale assesses agency and pathways development, which reflect the general hope theory (Snyder et al., 1996). Clients were asked to respond to the items based on their current presenting problem. According to its developers, this scale is designed to measure individuals’ ‘‘temporal state’’ of hope related to ongoing events in their lives. Respondents are encouraged to adopt a here-and-now mind-set in their rating of items (Lopez, Ciarlelli, Coffman, Stone, & Wyatt, 2000), allowing it to be used for a variety of purposes and in a range of settings. Previous studies have supported the reliability of the measure, with internal consistency estimates ranging from .79 to .95 and testretest correlations ranging from .48 to .93 (Lopez et al., 2000). Further, the State Hope Scale has been correlated (r .79) with the Dispositional Hope Scale (Snyder, Harris, et al., 1991), supporting its concurrent validity (Lopez et al., 2000). For the current study, Cronbach’s alpha was .83. OQ-45 (Lambert et al., 2004). Used as the outcome measure in the current study, the OQ-45 is a 45-item inventory commonly relied on in therapy studies to assess clients’ psychological distress. Items are rated on a 5-point Likert scale ranging from

0 (almost always) to 4 (never). Individual ratings are summed for a total score ranging from 0 to 180; higher scores indicate greater psychological distress. Lambert et al. reported on the reliable change index and clinically significant change based on data from clinical clients and community nonclients. They noted that a change, positive or negative, of 14 points indicates reliable change (i.e., beyond what could be expected from measurement error). Further, a score of 64 was the clinical cutoff used to statistically differentiate distressed from nondistressed clients. Thus, clients whose scores improve by 14 points or more and whose posttherapy scores are below 64 have met the criteria for clinically significant change. Previous research has supported the internal consistency of the measure, with testretest reliability estimates ranging from .82 over a 2-week period to .66 over a 10-week period and internal consistency reliability ranging from .70 to .93 (Lambert et al., 2004). Internal consistency reliability for the present study was .92. Concurrent validity was reported as being moderately high with a variety of measures intended to measure similar variables. Lambert et al. (2004) found the OQ-45 total score and Symptom Distress subscale score to be strongly correlated with depression: .79 with the Beck Depression Inventory, .87 with the Zung Self-Rating Depression Scale, and .80 with the Zung Self-Rating Anxiety Scale. Results We first tested whether clients’ hope and therapists’ hope in their clients would change during the course of therapy. As seen in Table I, our first hypothesis was only partially supported. Clients’ report of hope increased after one session of therapy, t(42) 3.05, p B.01, d0.31; however, level of hope stayed relatively stable from the first to the last session, t(42)1.52, p .14, d0.11. As hypothesized, therapists’ report of hope in their clients also increased from the first to the last session, t(42)3.61, pB.001,

Table I. Descriptive Information and Pretherapy, First-Session, and Posttherapy Differences for State Hope Scale and OQ-45 Measure State Hope Scale Client Therapist OQ-45

Pretherapya

31.70 (7.83) 74.42 (19.47)

Post first sessiona

Last sessiona

Significance/effect size

34.09 (7.99)

34.95 (8.41)

33.77 (7.19)

35.67 (7.82)

PF: t 3.05**, d0.31 FL: t 1.52***, d0.11 FL: t 3.61***, d0.26

64.19 (17.90)

PL: t 4.12***, d0.53

Note. For all comparisons, df42. Effect sizes are classified as follows: 0.2, small; 0.5, medium; 0.8, large. Effects sizes were calculated based on prefirst or last session score/SD pre. OQ-45, Outcome Questionnaire-45; PF, pretherapyafter first session; FL, first session last session; PL, pretheraphy-last session. a Values represent M9SD. **p B.01. ***p B.001.


Relationship between hope and outcomes d 0.26. The amount of change in psychological distress from pre- to posttherapy was a medium effect size, t(42)4.12, p B.001, d0.53 (see Table I). Next, we tested whether clients’ pretherapy State Hope Scale scores would be related to first-session symptom change. We calculated first-session symptom change by subtracting clients’ pretherapy OQ45 scores from their second-session OQ-45 scores (M 67.79, SD 18.11, difference score 6.63 or d 0.35). Again, our second hypothesis was only partially validated. Clients’ initial level of hope was not significantly associated with their initial gains in therapy, based on a bivariate correlation that was not statistically significant (r .25, p .11). However, therapists’ hope in their clients after the first session was significantly related to first-session symptom change (r .31, p B.05). Accordingly, we retained first-session symptom change in the next analysis to control for this shared variance. The correlations between the variables are listed in Table II. To test our third hypothesis*that both clients’ hope and therapists’ hope in their clients after the first session would predict therapy outcomes*we conducted hierarchical linear modeling (HLM) to predict clients’ OQ-45 score at posttreatment (i.e., therapy outcomes), entering clients’ OQ-45 pretherapy scores and clients’ State Hope Scale scores in Step 1 and then therapists’ State Hope Scale scores in Step 2. The results for the full model were statistically significant, F(4, 39)8.20, pB.001, Step 1 R2 .406, Step 2 DR2 .064 (see Table III, Model 1). Examination of the predictor variables revealed that therapists’ first-session report of hope in their clients was a significant predictor of therapy outcomes, after controlling for the variance in the other variables. However, clients’ reports of hope were not related to therapy outcomes in either step of the model, thus again only partially supporting our hypothesis. Finally, we tested whether clients’ sense of hope and therapists’ hope in their clients at the last session would be associated with therapy outcomes, after controlling for pretherapy functioning and first-session symptom change. As in the prior analysis, using

5

HLM, we entered client variables in Step 1 and therapists’ last-session State Hope Scale score in Step 2. The results of the full model were statistically significant, F(4, 39)9.35, p B.001, Step 1 R2 .436, Step 2 DR2 .067. Similar to the previous analysis, therapists’ last-session report of hope in their clients was significantly associated with therapy outcomes, after controlling for the variance in the other variables (Table III, Model 2), but clients’ report of hope was not. Collectively, our results suggest that, in general, clients’ perceptions of hope were unrelated to therapy outcomes, but therapists’ perceptions of hope in their clients were positively related. Finally, we classified clients based on the degree to which they reached (1) clinically significant change (n 8), (2) reliable change (n 5), (3) no reliable change (n 17), (4) no reliable change but ended therapy in the nondistressed range (n 11), and (5) reliable change but in a negative direction (i.e., symptoms worsened; n 2). Although only 30.2% of the sample demonstrated reliable or clinically significant change, this was due, in part, to the mild severity (based on OQ-45 scores) of their symptoms. Table IV shows the mean scores for clients’ hope and therapists’ hope in their clients based on these classifications. Given the small sample size per group, we did not conduct statistical tests. Further, it did not make statistical or conceptual sense to collapse groups (e.g., reliable change group with clinically significant change group) because clients who reached reliable change had notably lower selfrated State Hope Scale scores at the last session than those who reached clinically significant change, for instance. Discussion The purpose of this study was to expand the investigation of the role of clients’ perception of hope and therapists’ hope in their clients during shortterm, naturally occurring therapy. First, clients who reported greater initial symptom severity, as

Table II. Correlations between State Hope Scale and OQ-45 Scores Variable 1. 2. 3. 4. 5. 6. 7.

C Hope pretherapy C Hope first session C Hope last session T Hope first session T Hope last session OQ-45 pretherapy OQ-45 posttherapy

1

2

3

4

5

6

7

.79*** .70*** .35** .35** .42*** .32**

.90*** .46*** .36** .59*** .33**

.50*** .46*** .56*** .49***

.76*** .36** .42***

.24 .43***

.62***

Note. C, client; T, therapist; OQ-45, Outcome Questionnaire-45; Hope, State Hope Scale. **p B.01. ***p B.001.

6


Table III. Summary of Regression Models Predicting Therapy Outcomes Model 1: OQ-45 Variable

Model 2: OQ-45 b

B (SE)

b

B (SE)

Step 1 OQ-45 pretherapy OQ-45 change C Hope first session C Hope last session

0.64*** (0.15) 0.54 (0.34) 0.38 (0.36)

.70 .21 .17

0.51*** (0.14) 0.44 (.32) 0.21 (0.33)

.56 .17 .10

Step 2 T Hope first session T Hope last session

0.71* (0.34)

.28

0.67* (0.30)

.28


Note. C, client; T, therapist; OQ, Outcome Questionnaire-45; Hope, State Hope Scale. *p B.05. ***pB.001.

measured by the OQ-45, were also less hopeful throughout therapy, suggesting that in brief therapy clients’ initial distress may have a persistent effect on their sense of agency and goal-directed thinking. Yet the degree to which therapy can affect clients’ sense of hope was supported, because their level of hope increased after one session of therapy (a small effect size). This finding suggests that clients may experience some instillation of hope in the first session of therapy (Greenberg et al., 2006; Illardi & Craighead, 1994). Although it is a positive finding that clients’ hope was bolstered after a brief encounter with their therapist, their level of hope measured at any time during therapy was not related to therapy outcomes. Further and in contrast to Snyder, Feldman, et al.’s (2000) prediction, clients’ initial level of hope was not related to symptom change after one session. In perspective, the amount of symptom change after one session (i.e., small effect size) and over the course of therapy (i.e., medium effect size) was not large, which is due, in part, to a mildly distressed sample. Nonetheless, these findings are inconsistent with the majority of research associated with Snyder’s hope theory (e.g., Cheavens et al., 2006) and Hanna’s (2002) notion that hope is a necessary condition or precursor for change. Yet these findings are consistent with Cieslak (2009), who also found no relationship between clients’ hope and therapy outcomes.

Our findings suggest that clients, regardless of their level of hope, are able to benefit from therapy. That is, clients with lower levels of hope were able to benefit from therapy similarly to those with higher levels. As such, therapists should not feel discouraged with clients who express lower levels of hope. However, it is unknown whether these results would replicate in a sample of clients with greater distress. Potentially, clients in the current study may have felt that their sense of agency or goal-directed thinking was not directly related to the process of therapy. In addition, there could have been other mediating processes between hope and therapy outcomes that were not examined. For instance, clients’ hope may have promoted their readiness to change and subsequently impacted therapy outcomes. Future research is needed to explore these relationships. In contrast to these findings, therapists’ hope in their clients at the first and last sessions was related to their clients’ therapy outcomes. Therapists’ hope in their clients may affect their clients directly. For instance, therapists’ initial hope may reflect the potential they observe in their clients’ sense of agency and pathways to solve their problems. As such, they may work with their clients to explore their goal-related thinking and focus on new ways to confront their problems. Alternatively, therapists’ level of hope in their clients may indirectly affect their clients. For instance, they may project their

Table IV. Mean State Hope Scale Scores (and Standard Deviations) Classified by Change on the Outcome Questionnaire-45 CS (n 8)

Variable C C C T T

Hope Hope Hope Hope Hope

pretherapy first session last session first session last session

33.13 33.75 38.25 37.88 42.50

(8.87) (8.26) (7.50) (3.80) (4.87)

RC (n 5) 28.60 29.80 29.00 30.00 35.60

(9.56) (10.26) (12.94) (8.40) (4.28)

NRC (n 17)

NRT (n 11)

DET (n 2)

30.35 32.94 33.82 30.00 31.88

35.00 38.45 38.36 34.82 37.91

34.00 40.00 36.00 36.00 34.00

(4.92) (7.98) (8.22) (8.04) (8.26)

(4.92) (3.80) (3.44) (4.90) (6.52)

(9.90) (5.66) (8.49) (1.41) (1.41)

Note. CS, clinically significant change; RC, reliable change; NRC, no reliable change; NRT, no reliable change but ended therapy below the clinical cutoff, indicating nondistress (eight of the 11 clients also started therapy in the nondistressed range); DET, reliable change but more symptomatic at the end of therapy.


Relationship between hope and outcomes sense of hope to their clients, which may unconsciously assist their clients (e.g., if the hope is internalized). At the end of therapy, the relationship between therapists’ level of hope and therapy outcomes may relate to their view of clients’ potential to carry forward the positive gains made as therapy ends. Ultimately, therapists should be mindful about how their perceived hope in their clients may impact their clients’ therapy outcomes. Future research is needed to understand how therapists’ hope directly or indirectly affects the process and outcome of therapy. For instance, therapists’ hope in their clients may foster feelings of greater therapist alliance among clients, which may lead to better outcomes. Several limitations are worthy of note with regard to our study. First, this was a naturalistic, descriptive field study without a randomized sample or manipulated variables. Therapists were self-selected by the principal researcher, and the client sample was regulated according to the various practices of the therapists. Although descriptive field studies generally yield a higher level of external validity, there is less confidence regarding causality and in this case less internal validity with regard to therapeutic outcomes. In addition, other therapist behaviors may have contributed to the changes identified. Second, on the basis of their OQ-45 scores, the current sample was only mildly distressed; further research is needed to ascertain whether these results would replicate in more distressed clinical samples. Third, the type of treatment used by the therapists in the study varied based on their preference. Although it can be assumed that a variety of types of treatment contribute to more generalization, it is not known how treatment type may have impacted or interacted with levels of therapist hope. Fourth, the number of therapy sessions was limited (e.g., maximum of six sessions, which is considered to be consistent with brief models of therapy). As a result, we examined first-session change, compared with early change, which is typically defined as change within the first three sessions. Further, it is uncertain whether the effects observed in the first six sessions of therapy would be consistently maintained in longer term therapy. Fifth, there might have been differences among therapists’ caseloads in terms of initial severity. A cursory examination of therapists’ caseloads demonstrated a notable range in clients’ pretherapy OQ-45 scores (61105). The study sample did not include enough clients per therapist or enough therapists to determine whether clients who were treated by the same therapist reported similar levels of hope or had similar therapy outcomes (i.e., multilevel modeling). Thus, replication in a larger sample of clients and therapists is warranted to detect the potential influence of therapist effects.

7

On the basis of results of the current study, in concert with other common factors research, we encourage therapists to balance their focus on specific techniques with a consideration of common factors, such as hope, that are more relational. Indeed, Owen, Wong, and Rodolfa (2010) found that a sizable proportion of clients identified relational factors (e.g., support, hope, empathy) as curative. Thus, although specific therapy techniques are useful in helping clients to achieve their goals, therapists’ relational and attitudinal factors (i.e., hope) are also important to consider. Incorporating an awareness of these factors into treatment strategies can significantly enhance the examination of clients’ strengths, the exploration of multiple pathways to promote change, and the instillation of a positivistic therapy perspective. In contrast to the diagnostic and medical model approach to treatment and training, use of positive psychology concepts may encourage therapists to broaden the ways they can explore the development of increased agency and pathways. References Abramson, L. Y., Alloy, L. B., Hogan, M. E., Whitehouse, W. G., Donovan, P., Rose, D. T., et al. (2002). Cognitive vulnerability to depression: Theory and evidence. In R. L. Leahy & E. T. Dowd (Eds.), Clinical advances in cognitive psychotherapy: Theory and application (pp. 7592). New York: Springer. Beck, A. T., Brown, G., & Steer, R. A. (1989). Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology, 57, 309310. Cheavens, J. S., Feldman, D. B., Gum, A., Micheal, S.T., & Snyder, C. (2006). Hope theraphy in a community sample: A pilot investigation. Social Indicators Research, 77(1), 6178 Cheavens, J. S., Feldman, D. B., Woodward, J. T., & Snyder, C. R. (2006). Hope in cognitive psychotherapies: On working with client strengths. Journal of Cognitive Psychotherapy, 20, 135145. Cieslak, E. N. (2009). Hope in psychotherapy process and outcome. Dissertation Abstracts International: Section B. Sciences and Engineering, 69(9), 5770. Connor, K. R., Duberstein, P. R., Conwell, Y., Seidlitz, L., & Caine, E. D. (2001). Psychological vulnerability to completed suicide: A review of empirical studies. Suicide and LifeThreatening Behavior, 31, 367385. Cooper, S. L. (2009). A content analysis of client hope in psychotherapy sessions. Dissertation Abstracts International: Section B. Sciences and Engineering, 69(11), 7132. Crouch, J. A. (1989). The Hope Scale and head injury rehabilitation: Staff ratings as a function of client characteristics. Dissertation Abstracts International: Section B. Sciences and Engineering, 51(4), 2056. Duncan, B. L., & Miller, S. D. (2000). The client’s theory of change: Consulting the client in the integrative process. Journal of Psychotherapy Integration, 10, 169187. Farran, C. J., Herth, K. A., & Popovich, J. M. (1995). Hope and hopelessness: Critical, clinical constructs. Thousand Oaks, CA: Sage. Frank, J. D. (1974). Therapeutic components of psychotherapy: A 25-year progress report of research. Journal of Nervous and Mental Disease, 159, 325342.


8


Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press. Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are patient expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 26, 657678. Haeffel, G. J., Abramson, L. Y., Brazy, P. C., & Shah, J. Y. (2008). Hopelessness theory and the approach system: Cognitive vulnerability predicts decreases in goal-directed behavior. Cognitive Therapy and Research, 32, 281290. Hanna, F. (2002). Therapy with difficult clients: Using the precursors model to awaken change. Washington, DC: American Psychological Association. Illardi, S. S., & Craighead, W. E. (1994). The role of non-specific factors in cognitive-behavioral therapy for depression. Clinical Psychology: Science and Practice, 1, 138156. Imel, Z. E., & Wampold, B. E. (2008). The importance of treatment and the science of common factors in psychotherapy. In S. Brown & R. W. Lent (Eds.), The handbook of counseling psychology (4th ed., pp. 249266). New York: Wiley. Kwon, P. (2002). Hope, defense mechanisms, and adjustment: Implications for false hope and defensive hopelessness. Journal of Personality, 70, 207231. Lambert, M. J., Morton, J. J., Hatfield, D. R., Harmon, C., Hamilton, S., Shimokawa, K., et al. (2004). Administration and scoring manual for the OQ-45.2 (Outcome Questionnaire). Wilmington, DE: American Professional Credentialing Services. Lazarus, R. (1999). Hope: An emotion and a vital coping resource against despair. Social Research, 66, 665669. Lester, D., & Walker, R. L. (2007). Hopelessness, helplessness, and haplessness as predictors of suicidal ideation. Omega: Journal of Death and Dying, 55, 321324. Lopez, S., Ciarlelli, R., Coffman, L., Stone, M., & Wyatt, L. (2000). Diagnosing for strengths: On measuring hope building blocks. In C. Snyder (Ed.), Handbook of hope (pp. 5788). New York: Academic Press. Magyar-Moe, J. L. (2003). Predictors of therapy outcome: An attempt to explain more of the variance. Dissertation Abstracts International: Section B. Sciences and Engineering, 64(9), 4624. Menninger, K. (1959). The academic lecture on hope. American Journal of Psychiatry, 109, 481491. Miranda, R., Fontes, M., & Marroquin, B. (2008). Cognitive content-specificity in future expectancies: Role of hopelessness and intolerance of uncertainty in depression and GAD symptoms. Behaviour Research and Therapy, 46, 11511159. Owen, J. J., Wong, J. Y., & Rodolfa, E. R. (2010). The relationship between clients’ conformity to masculine norms and their perceptions of helpful therapist actions. Journal of Counseling Psychology, 57, 6878.

Prochaska, J. O., & DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. Progress in Behavior Modification, 28, 183218. Safron, J. D., & Greenburg, L. S. (1993). The therapeutic alliance rupture as a transtheoretical phenomenon: Definitional and conceptual issues. Journal of Psychotherapy Integration, 3, 3349. Seligman, M., Rashid, T., & Parks, A. C. (2006). Positive psychotherapy. American Psychologist, 61, 774788. Smith, J. M., Alloy, L. B., & Abramson, L. Y. (2006). Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: Multiple pathways to self-injurious thinking. Suicide and Life-Threatening Behavior, 36, 443454. Snyder, C. R. (1994). The psychology of hope: You can get there from here. New York: Free Press. Snyder, C. R. (2000). Handbook of hope: Theory, measures, and applications. San Diego, CA: Academic Press. Snyder, C. R. (2002). Hope theory: Rainbows in the mind. Psychological Inquiry, 13, 249275. Snyder, C. R., Feldman, D. B., Taylor, J. D., Schroeder, L. L., & Adams, V. III. (2000). The roles of hopeful thinking in preventing problems and enhancing strengths. Applied and Preventive Psychology, 15, 262295. Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al. (1991). The will and the ways: Development of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570595. Snyder, C. R., Illardi, S., Michael, S. T., & Cheavens, J. (2000). Hope theory: Updating a common process for psychological change. In C. R. Snyder & R. E. Ingram (Eds.), Handbook of psychological change: Psychotherapy processes and practices for the 21st century (pp. 128153). New York: Wiley. Snyder, C. R., Irving, L. M., & Anderson, J. R. (1991). Hope and health. In C. R. Snyder & D. R. Forsyth (Eds.), Handbook of social and clinical psychology: The health perspective (pp. 285 305). Elmsford, NY: Pergamon. Snyder, C. R., Michael, S. T., & Cheavens, J. S. (1999). Hope as a psychotherapeutic foundation of common factors, placebos, and expectancies. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 170200). Washington, DC: American Psychological Association. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum. Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 857873. Worthington, E. L., Ripley, J. S., Hook, J. N., & Miller, A. J. (2007). The hope-focused approach to couple therapy and enrichment. Journal of Psychology and Christianity, 26(2), 132 139.