Clients' Perspectives of the Working Alliance Inventory
Watson-Gaze, James Eliot
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The working alliance is one of the most widely studied constructs in the psychotherapy research literature, and ratings of the working alliance are widely used in clinical research and practice to measure the relationships between clients and their therapists and courses of treatments. Nonetheless, relatively little is known about how clients understand and engage with the scales from which such ratings are derived. To address this gap in the literature, clients in ongoing psychotherapy were interviewed after completing a version of the most widely used alliance rating scale, the Working Alliance Inventory (WAI). This study was comprised of two primary phases. In the first phase, 12 clients took part in semi-structured interviews focused on understanding what they were aware of when completing a version of the WAI, the WAI Short Revised (WAI-SR). Then, transcripts from this phase were analyzed using Grounded Theory methods. Analyses yielded a core category of Rolling on the Right Track, which encapsulated participant reflections of the scale as a means to communicate the degree to which clients and therapists are moving together towards shared therapeutic goals. In the second phase, 10 clients took part in cognitive interviews that targeted specific information about whether clients identified any difficulties with understanding elements of the WAI-SR. Transcripts were analyzed using the Classification Coding Scheme and findings indicated that participants noted difficulties with several parts of the scale. Item comprehension challenges were the most frequently raised areas of concern. Results were triangulated across both primary phases and key findings discussed in the context of ongoing debates in the research literature. This study exemplifies and underscores the dynamic nature of clients rating processes when completing a version of the WAI, as well as the ways they use the measure as a means to assess and communicate the degree to which they are working effectively in treatment. This study also raises concerns about the intelligibility of the WAI-SR for clients who complete it and calls into question the confidence with which researchers and clinicians can maintain their faith in the accuracy of clients ratings.