ABSTRACT
The aim of this study was to assess whether a modified version of the Emotional Availability
Scales (EAS), created to assess interaction quality between parents and children, could be
applied to psychotherapy sessions and whether emotional availability (EA), as assessed by
the modified EAS-T, was associated with client- and therapist-rated working alliance. EAS-T
was used to assess 42 sessions from 16 therapies. The therapies came from the LURIPP
project, comparing IPT with BRT for depressed clients. The results showed that sessions
could be reliably rated with EAS-T. Most rating scales had acceptable variance. The client’s
perception of task alliance was associated with several of the EA subscales (sensitivity,
nonhostility, responsiveness) assessed over therapies, whereas the perception of bond was
associated with Structure on EAS.
INTRODUCTION
Aspects of the therapeutic relationship are key elements in the change process in
psychotherapy. Different perspectives have been brought forward in order to better
understand the nature of this relationship. One of them is attachment theory. According to
Bowlby (1988), a therapist and a parent have similar roles. Like the parent, the therapist
serves as a secure base from which explorations in the mental and physical world become
possible and as a safe haven to retreat to in times of perceived danger. A therapist who is
attentive, empathic, and reliable can encourage the client to explore his or her mental and
emotional world, and one who is sensitive to safety needs and understands these can promote
autonomy. The therapist’s encouragement of the client’s autonomy should be based on an
understanding of the client’s need for attachment and emotional security.
Several authors have argued that the therapeutic relationship could be seen as an
attachment relationship, with similar positions between therapist and client as between parent
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and child (Farber & Metzger, 2009; Mallinckrodt, 2010). Other authors, however, have
contested this idea (see, e.g., Daniel, 2011). Power issues, the length of the relationship, and
the fact that the therapeutic relationship has a limited importance in the participants’ lives
may reduce the applicability of attachment theory on psychotherapy. Most studies using
attachment theory in psychotherapy have analyzed the significance of the client’s prior
attachment pattern on the therapeutic process (Ackerman et al., 2001; Meyer & Pilkonis,
2001, 2002; Mikulincer & Shaver, 2007; Smith, Msefti, & Golding, 2010). The most
common finding is that relational trust is necessary for productive therapeutic work
(Greenberg & Watson, 2006; Samoilov & Goldfried, 2000). Fewer studies have attempted to
rate attachment-related aspects of the interaction directly on filmed therapy sessions. The
present study is an attempt to do this.
An important task for the therapist is to identify the client’s capacity to create a viable
therapeutic alliance conducive to the collaborative therapeutic work. Several studies have
explored the relations between alliance in psychotherapy and self-rated attachment style
(Diener & Monroe, 2011). Results seem to indicate that secure attachment predicts better
alliance (Eames & Roth, 2000; Reis & Grenyer, 2004; Satterfield & Lyddon, 1998; Smith,
Msefti, & Golding, 2010), whereas research results about the relation between attachment
avoidance (implying a reduced need of close relationships) or attachment anxiety (implying a
fear of being emotionally abandoned) and alliance are less conclusive (Smith et al., 2010;
Diener et al., 2011).
Although doubts may be raised about the proposed parallel between attachment as an
aspect of the relationship between child and caregiver, and as a process in psychotherapy,
some elements of the attachment interaction may be useful to apply to the therapeutic
interaction. One such concept is the Emotional Availability (EA). This concept has received a
specific denotation in studies of the interaction between parent and child by the creation of
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the Emotional Availability Scales (EAS; Biringen, Robinson, & Emde, 1998), which are a
method for rating the quality of the interaction between parent and child. EAS are based on a
combination of attachment theory and concepts of emotional availability (Biringen et al.,
1998). Emotional availability (EA) in the parent can be seen as a fundamental principle for
the child’s healthy socio-emotional development and can be described as an individual’s
emotional susceptibility and attunement to someone else’s needs and goals (Easterbrooks &
Biringen, 2000; Easterbrooks & Biringen, 2009). According to Easterbrooks and Biringen
(2009), it can be seen as the “connective tissue” in relationships, highlighting the role of
affective exchanges in attachment relationships.
The construct of EA in EAS can be seen as an integration of the perspectives of EA in its
original sense (Mahler, Pine & Bergman, 1975) with attachment theory (Bowlby, 1969).
According to Mahler and colleagues (1975), EA is an aspect of the mother’s supportiveness
and ability to encourage the child during his or her explorations. As she provides a secure
base for the child, the emotionally available mother allows for the child’s autonomous
functions to develop in an optimal way. Emde and Easterbrooks (1985) later used the term
when they described EA as “the degree to which each partner expresses emotions and is
responsive to the emotions of the other” (p. 80). They described maternal sensitivity as the
mother’s ability to read the infant’s actions and signals and to respond to them. Combining
the two perspectives of EA and maternal sensitivity, Biringen and Robinson (1991)
conceptualized the EA construct and created the observation rating scale EAS. A number of
studies have indicated that EAS captures aspects of attachment security (Bornstein et al.,
2010; 2008; Ziv, Aviezer, Gini, Sagi & Koren-Karie, 2000). Ziv and colleagues (2000)
studied several hundred mother-child dyads and found that mothers of securely attached
infants were more sensitive and more structuring than mothers of insecure infants, and secure
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infants were more involving and more responsive toward their mothers than insecure
children.
Although ratings on the EAS in parent-child interaction has been found to correlate
with ratings of attachment, measured both in parents with the Adult Attachment Interview
and in children in the Strange Situation Procedure (Biringen, 2000), the concepts of
Emotional Availability and attachment patterns differ in certain ways. In attachment theory,
the main focus is on how the child reacts in stressful situations and how the parent with
sensitivity takes care of the child in need of consolation and protection (Easterbrook &
Biringen, 2000; Edelstein, Alexander, Shaver, Schaaf et al., 2004). The concept of emotional
availability focuses on the parent’s ability to create an emotionally safe haven also in neutral
or even pleasant situations. In attachment ratings, it is basically the child’s behavior that is
rated, whereas in EA the parent’s contribution to the interaction is also taken into account.
The interaction is highlighted in the sense that the caregiver’s behavior is assessed based on
how well the child responds to it.
Biringen (2010) argues that emotional availability is a fundamental aspect in all
relationships, and not only for that between parent and child. The importance of emotional
availability in the therapeutic relationship has been discussed by Zeddies (1999). He argued
that the therapist’s emotional availability is essential in order to offer the client an optimal
emotional climate. Zeddies defined the term emotional availability as the therapist’s
willingness to develop a profound and continuous emotional contact with the client. An
emotionally available therapist can use his or her own emotional experience in order to
understand something within the client that he or she cannot verbally express. Zeddies argued
that the therapist’s emotional availability is a key factor in creating a fruitful therapeutic
alliance.
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The alliance is the most researched aspect of the relationship between therapist and
client. It has a significant impact on treatment outcome (Falkenström, Granström &
Holmqvist, 2013; Horvath, Del Re, Fluckiger, & Symonds, 2011). Alliance is a conscious
and goal-oriented process. Bordin (1979), like Summers and Barber (2003), claimed that
alliance is the key to therapeutic change, regardless of method and technique. Bordin
distinguished between three parts in the alliance: the goal in therapy, the different tasks used
to achieve the goals, and the emotional bond that develops between therapist and client.
Horvath (2001) defined the concept as both containing an emotional aspect (mutual trust, a
respectful attitude, and a concern for the other partner) and a more instrumental aspect (a
consistent picture of how to work in therapy, what goals the client has, and the resources
available to achieve these goals).
Several measures have been developed to rate the therapist’s and client’s emotional
interplay. One of them is the Experiencing Scale (Klein, Mathieu-Coughlan, & Kiesler,
1986), which measures the depth of emotional experiencing on one single scale focused on
the degree and extent of emotional experiencing. Another is the Achievement of Therapeutic
Objectives Scale (ATOS; McCullough et al., 2003) measuring a number of process aspects.
In addition, the Structural Analysis of Social Behavior (SASB; Benjamin, 1974) in its
observer version measures aspects of the emotional process, conceptualized as affiliation and
control. More to the point in this context is the Client Emotional Arousal Scale (CEAS;
Carryer & Greenberg, 2010; Greenberg, Auszra, & Herrmann, 2007), which measures the
kind and intensity of affective display in short segments of therapy sessions. CEAS is usually
rated on quite short segments of the therapy session, whereas EAS is measured during longer
periods. CEAS focuses specifically on affects, whereas EAS assesses the more overarching
emotional aspects of the relationship. Our intention in trying to asses emotional availability
on longer segments of filmed therapy sessions was complement existing rating instruments
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with a method that specifically measures the behavior of therapist and client with regard to
the creation of an emotionally satisfying cooperative climate.
Based on previous findings about associations between secure attachment style and
alliance, we wanted to find out whether higher ratings on the EAS were associated with
higher alliance ratings. Thus, the aim of this study was to evaluate the usefulness of EAS as a
method to assess EA in the therapist-client relationship and to analyze if ratings on EAS
correlate with the therapist’s and the client’s ratings of the working alliance. Potential
correlations between EAS and working alliance ratings were presumed to inform about the
validity of the instrument in a psychotherapeutic context.
Method
Participants
The study was based on filmed therapy sessions from the ongoing LURIPP project
(Linköping University Relational and Interpersonal Psychotherapy Project), where Brief
Relational Therapy (BRT; Safran & Muran, 2000) and Interpersonal Psychotherapy (IPT;
Weissman, Markowitz, & Klerman, 2000) are compared as effective treatments for depressed
clients. All therapies were 16 sessions. The clients were recruited at the participating
therapists’ workplaces such as psychiatric clinics and psychotherapeutic agencies. Inclusion
criteria for clients was that they were between 17 and 65 years old and that they met the
criteria for Major Depression according to DSM-IV and are rated at more than 18 on the
Hamilton Depression Rating Scale (Hamilton, 1960). Clients with psychosis, organic brain
damage, or ongoing substance abuse were excluded.
In this sample, the mean age of the clients was 41 years (SD = 12.6). All but one of the
clients were women. All had the diagnosis of Major Depression Disorder. Their average pre-
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treatment Hamilton score was 25.2 (SD = 12.6). About half of the clients also had an Axis II
disorder.
The six therapists whose therapies were analyzed were psychologists or social workers.
All of them had basic psychotherapy training, worked at psychiatric or primary care units,
and had extensive experience of therapy. They had received specific training in BRT and IPT
for two years at Linköping University. In addition to theoretical training, participation as a
study therapist demanded two approved supervised therapies in each therapy method.
LURIPP uses a crossed therapist design (Falkenström, Markowitz et al., 2012), that is, the
same therapists perform both IPT and BRT. They received continuous supervision in the two
therapy modalities when participating in the study. In the present study, the analyses used 42
sessions from 16 therapies delivered by six therapists. Out of these, 19 sessions came from
BRT therapies and 23 from IPT therapies.
Treatments
The clients received either IPT or BRT. IPT is a structured and manualized therapy,
based on theories of attachment, communication, and the importance of social networks
(Weissman et al., 2000; Stuart & Robertson, 2003). Early in treatment a focus area is
established that connects the depressive symptoms to a specific interpersonal issue (e.g., a
loss, a conflict, a role transition) in the client’s life, and this focus is maintained throughout
therapy. BRT is a relatively new psychodynamic therapy method, based on relational
psychoanalytic theory and research on ruptures in the therapeutic alliance (Safran, Muran,
Samstag & Winston, 2005). BRT has a low degree of structure concerning content. The focus
is on the relationship between the client and the therapist in the here and now, especially on
the quality of the therapeutic alliance (Safran & Muran, 2000). Thus, compared to IPT, the
focus in BRT is more on the relationship between client and therapist, rather than on
interpersonal issues in the client’s life. BRT has not been created, in the tradition of
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psychodynamically based therapies, as a therapy for a specific group of clients. In LURIPP,
where BRT is used as a treatment for depression, a modified version of the therapy is used.
BRT is a therapy open to changes of focus during the therapy (Safran, 2002) but it has in this
study been complemented by a clear recommendation to the therapist to pay particular
attention to the depression and consequences of this state, particularly in the therapeutic
relationship (Holmqvist, 2010). A detailed manual (in Swedish) for the use of BRT with
depressed clients has been created and taught to the therapists, with a clear rationale for
attention to the depression.
Material
Six different therapists and 16 different therapist-client dyads are represented in the
study material. Eight therapies were IPT, eight were BRT. There were five therapies (three
BRT and two IPT) from one therapist, four therapies (two BRT and two IPT) from one
therapist, threes therapies (two BRT and one IPT) from one therapist, two therapies (two IPT)
from one therapist, and one therapy from two therapists (one BRT and one IPT). In order to
include sessions from different phases of therapy, sessions 3, 8 and 15 were selected for
assessment. In two of the 16 therapies, only session 3 was available for assessment, and in
two therapies session 15 was not available. Thus, a total of 42 episodes from different
sessions were assessed. In one therapy, session 4 was available instead of session 3, and in
another therapy; session 7 instead of session 8 was available. The middle parts of the
sessions, starting at about 15 minutes into the session and ending at about 30 minutes, were
chosen because it was assumed that in this part of the session the emotional content of the
therapeutic process would most likely to be at their peak. Thirty-six of the 42 EAS-assessed
episodes had alliance assessments from the clients and 38 from the therapists.
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Rating methods
Emotional Availability Scales – Therapy (EAS-T) is a modification of the Emotional
Availability Scales (Biringen et al., 1998; Biringen et al., 2000) developed specifically for
therapy sessions. Numerous studies have used the EAS, and there is ample evidence of its
reliability and validity (Oppenheim, 2012). The EAS-T contains four scales for the therapist’s
behavior (sensitivity, structuring, nonintrusiveness, and nonhostility), and two scales for the
client’s behavior (responsiveness and involvement).
Below is a brief description of the EAS-T dimensions. For a longer description, see the
appendix.
Therapist scales

Sensitivity. This dimension refers to the central aspect of the therapist's
emotional availability to the client. The therapist should be accepting, warm,
and above all genuine. Both verbal and nonverbal communication should be
congruent to display a sensitive impression.

Structuring. This describes how the therapist structures the therapy and the
interaction with the client. An optimally structuring therapist provides a
framework for the therapy, makes suggestions, presents just enough
information, sets appropriate limits, makes reasonable demands, and can assist
the client when stuck.

Nonintrusiveness: On this dimension, the therapist’s ability to respect the
client’s integrity and autonomy is assessed.

Nonhostility. This dimension refers to displays of hostile behavior in the
interaction, both covert and overt, and primarily from the therapist. Client
hostility, however, does also contribute to a lower rating.
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Client scales

Responsiveness. The responsiveness dimension is the client’s equivalent of
therapeutic sensitivity and refers to how emotionally available the client is to
the therapist.

Involvement: This dimension captures to what degree the client involves the
therapist in the interaction.
In this study, the original EAS manual for caregiver and child was modified to rate the
relationship between therapist and client. Biringen (2010) argues that the principles of
emotional availability can be applied to different kinds of relationships. Despite this view,
several aspects of the interaction were rated differently in this modified version of EAS.
Thus, in a parent-child interaction, several activities may be going on, whereas in a
therapeutic situation there is only one activity, namely, therapy. The description of a parent
who switches between tasks and activities has been modified to a description of how a
therapist may shift themes in the session. To illustrate: when rating the dimension
structuring, it is the therapy session that is the subject of structuring. Example behaviors were
specified for each dimension. Some aspects of the original manual, which apply to only
parent-child relationships and cannot be adapted to the therapist-client relationship, have been
eliminated from the EAS-T coding manual.
Assessments with EAS are holistic in nature and require the observer to be clinically
sensitive (Biringen et al., 2000). EAS scorings should not be based on counts of discrete
behaviors but instead on general behavior patterns and emotional signals present in the
interactions. Even if parent and child behaviors are scored on separate dimensions, they both
contribute to the rating of all dimensions. It is the relationship that is being rated. To receive
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high scores, it is not enough for either parent or child to merely “act correctly” if the other
partner does not respond well.
EA should not be considered an individual “trait.” It may be different in various
relationships and contexts (Biringen et al., 2000). Thus it is important for the observer to
make judgments based on what the behavior in the current situation is and not based on
assumptions of what the parent or child is “really” like. Observations of at least 20 minutes
are recommended for assessment with EAS (Biringen, 2005). However, there are examples in
the literature of shorter observations of 3–10 minutes that have led to meaningful results
(Easterbrooks, Lyons-Ruth, Biesecker & Carpenter, 2000; Kogan & Carter, 1996).
The clients rated the alliance using the Working Alliance Inventory–Short Revised (WAI-SR;
Tracey & Kokotovics, 1989; Hatcher & Gillaspy, 2006). The WAI-SR is based on the WAI36 (Horvath, 1981, 1982), which was developed from Bordin’s concept of the alliance as
consisting of goal, task, and bond. WAI-SR gives an overall measure of the alliance as a
whole but also scores on the sub-scales (goal, task, and bond) that contribute to the alliance.
The Working Alliance Inventory–Short (WAI-S; Tracey & Kokotovic, 1989, Swedish
translation Holmqvist & Skjulsvik) was used to measure the therapists’ perception of the
alliance.
For simplicity, we will call the WAI measures WAI-T and WAI-C in the text.
Several studies have shown acceptable reliability and validity in the WAI forms
(Horvath & Greenberg, 1989; Samstag, Muran, Wachtel, Slade, et al., 2008).
Procedure
The first two authors, who were psychology students, did the ratings. They had
completed a distance course in EAS by watching nine recorded VHS tapes and calibrated
their ratings with a certified EAS assessor. In addition, the raters watched five 15-minute
episodes from three sessions of a recorded Interpersonal Psychotherapy (IPT) with an
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experienced therapist and two 15-minute episodes from each of six Brief Relational Therapy
(BRT) sessions with Jeremy Safran. In total, the raters separately assessed 17 episodes from
different therapy sessions, and the Intraclass Correlation Coefficient reliability was calculated
to .81.
In the first phase of the rating of the researched therapy sessions, the raters assessed
separately ten 15-minute episodes from LURIPP sessions. The overall interrater reliability
(ICC, average measures) of these ratings was .84 (sensitivity = 1.00, structure = .88, nonintrusiveness = .90, non-hostility = .84, responsiveness = .73, and involvement = .67). After
this, the raters distributed the remaining episodes randomly and assessed them separately.
Three of these separately assessed episodes were rated jointly because questions arose
regarding how they should be assessed.
Data analysis
The EAS ratings for each session were correlated with the WAI ratings that were completed
by client and therapist after each session. There was dependency in the data because sessions
were nested within therapies, and these in turn nested within therapists. This dependency
would best be handled using multilevel modeling (e.g., Raudenbusch & Bryk, 2002), but this
method utilizes Maximum Likelihood estimation which is an asymptotic method meaning
that estimates approach population values as the sample size approaches infinity. In practice,
this means that results are reasonably unbiased given a large enough sample size. For
multilevel models, simulation studies have shown that when the highest level N is below 30,
results (especially standard errors) may be biased (Maas & Hox, 2005). Because we had an N
of 16 at the therapy level and only 6 at the therapist level, we chose to aggregate WAI and
EAS ratings across all sessions for each therapy (although separately for client and therapist).
In this way dependency at the repeated measures level was eliminated, although dependency
due to the fact that several clients were seeing the same therapist was still present.
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Because the number of therapies was small even for ordinary least squares methods (which
are also based on asymptotic assumptions), the statistical program XPro (Weerahandi, 19942008; 2003), which handles exact statistics, was used. Exact statistics is a branch of statistics
that focuses on computing p-values and confidence intervals that are not based on asymptotic
theory. We used linear regression in Xpro to test relationships between therapy-level
aggregate WAI and EAS scales.
As a post hoc sensitivity analysis, we retested all significant results using multilevel modeling
by specifying a client-level random intercept model for the WAI, with client-average EAS
score used as a level 2 predictor and client-mean centered scores as a level 1 predictor. If
results were still significant, a therapist-level random effect was added in order to test if
results were affected by therapist-level dependency. Results were very similar in these
analyses, and because exact statistics are more appropriate for small samples than Maximum
Likelihood–based procedures such as MLM, we report only results of exact tests.
Ethical considerations
The therapists and clients who participated in this study gave informed consent to
participation in LURIPP, as well as to therapy sessions being filmed and recorded material
being used within the project boundaries. The complete LURIPP project has been approved
by the Regional Ethical Review Board in Linköping.
Results
Descriptive statistics are presented in Table 1 for EAS-T (n = 42), WAI-client (n = 36)
and WAI-therapist (n = 38).
Please insert Table 1 about here
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As seen in Table 1, several mean values on EAS are close to the top assessment
(especially nonhostility and nonintrusiveness), implying a ceiling effect. On these
dimensions, the standard deviations were low and the range was narrow. However, the range
is considerably wider on the other EAS-T dimensions. Table 1 also shows that the clients’
mean ratings on WAI were virtually similar to the therapists’ WAI ratings on goal and bond,
but higher on WAI task.
Table 2 shows the correlations between the EAS-T dimensions (n = 42). Correlations
were calculated using Spearman’s rho.
Please insert Table 2 about here
As shown in Table 2, the correlation between responsiveness and involvement was the
strongest (.89). Strong correlations were also found between sensitivity and structuring (.80),
sensitivity and responsiveness (.76) as well as between structuring and responsiveness (.73).
The correlations between structuring and nonhostility and between nonintrusiveness and
nonhostility were not significant.
Table 3 shows the correlations between the WAI subscales for client (n = 36) and
therapist (n = 38) and EAS-T. Correlations were calculated using Spearman’s rho.
Please insert table 3 about here
As shown in Table 3, moderate and significant correlations were found between WAI
goal and EAS nonhostility, responsiveness, and involvement, and between WAI task and EAS
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nonhostility, responsiveness, and involvement. No significant correlations were found for the
alliance variable bond. No significant correlations were found between the EAS-T
dimensions and the therapists’ WAI assessments.
Within and between therapies
Because there was dependence in the data because sessions were nested within
therapies, and these in turn nested within therapists, analyses were made of within-therapies’
and between-therapies’ correlations. Analyses of between-therapists’ correlations could not
be made because of the small number of therapists. The analyses of correlations within
therapies, that is, because of variation between sessions, using deviations from the mean for
each therapy (so-called person-mean centering), showed no significant correlations between
EAS dimensions and WAI scores, for either client or therapist. Results from these analyses
can be obtained from the authors.
The between-therapies correlations indicated, however, several substantial correlations. Table
4 shows the results.
Please insert Table 4 about here
As the results in Table 4 show, there were several significant correlations between the
mean ratings of the WAI scores and the mean ratings of the EAS scales. The mean WAI task
score correlated with several EAS scales (sensitivity, nonhostility, responsiveness), and the
bond ratings correlated with EAS structure.
Discussion
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The aim of this study was to evaluate the usefulness of a modified version of the Emotional
Availability Scales on psychotherapy sessions and to analyze whether EAS-T assessments
correlate with therapist- and client-rated working alliance. The analyses showed that it was
possible to rate EAS-T reliably. Acceptable variation was found for most EAS-T dimensions.
Correlations between EAS ratings and alliance were assessed on both the session level using
all observations and on the therapy level. There were some salient differences between these
analyses which could be interpreted but which may also be due to limited power.
For two of the EAS-T dimensions, sensitivity and structure, the assessment range was
relatively wide. For two other, nonintrusiveness and nonhostility, it was narrower. This is not
surprising considering that therapists are a professional group where one would expect to find
neither intrusive nor hostile behavior. Another reason for the high scores and low variance on
these dimensions could be that neither of the therapy methods that were used belong among
the most confrontative therapies. The nonhostility dimension had high overall ratings, and the
hostile behaviors found were merely covert and in no cases overt. This being said, the
observers detected not severe but still clear signs of hostility in some therapies.
Because the number of observations was small, the interpretations of results that follow
must be seen as highly tentative and in need of corroboration in larger samples. Several
important topics, such as the significance of personality disorder syndromes in some of the
clients, cannot be analyzed due to the small sample size.
In the analysis of association between session ratings and alliance reports, both
responsiveness and involvement, the client dimensions in EAS-T, were associated with the
client’s task and goal ratings. Responsiveness refers to the client’s reaction to the therapist’s
behavior, and the responsiveness dimension might be considered closely related to the
client’s experience of the therapist’s invitation to therapeutic work and to the clinet’s
experience of mutual understanding about tasks and goals. This association between
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responsiveness and instrumental aspects of the relationship was also found when sessions
were aggregated over therapies. This may indicate that the working climate established in the
therapy may be consistent over sessions, both as observed and as experienced by the patient.
Similarly involvement correlated with the client’s experience of task alliance and goal
alliance. Involvement concerns the client’s behavior to make the therapist interested and
stimulated in the client’s problems and perspectives. It is in a way the counterpart of
responsiveness, although strongly correlated, as it focuses on the client’s initiative. It is of
interest to note that involvement correlated with the client’s own perception of task and goal,
but not with the therapist’s. The client seems to experience a better relationship after trying to
communicate his or her view to the therapist, but in this analysis we did not find a reciprocal
increase in the therapist’s perception of the alliance. It is also worth noting that there was no
effect over time for this association. Thus, the idea that a working climate is created as
illustrated by the tie between alliance and responsiveness is not valid for the client’s
involvement attempts.
No association with alliance was found for structure on session level. A strong
association was, however, found on therapy level. In the individual session, the therapist’s
structure-giving does not influence the alliance. But over time, better structure was associated
with the client’s bond rating. A stable pattern seems to build over sessions, where a therapist
who can structure the sessions throughout the therapy is perceived in a more positive way.
Ackerman and Hilsenroth (2003) argued that the alliance is enhanced when the
therapist is genuine, open, flexible, empathetic, respectful, trustworthy, and interested. Such
behavior might be expected to result in high scores on the EAS-T dimension sensitivity.
Sensitivity was not related to alliance in the session-wise ratings. There was, however, a
rather strong correlation with WAI Task when ratings for therapies were analyzed. This could
be interpreted as showing that in similarity with Structure, the therapist’s comportment in the
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individual session does not influence the client’s perception of the alliance in that session, but
seen over the whole therapy, the therapist’s sensitivity influences the client’s view of the
alliance substantially.
No correlations were found between EAS-T and the therapists’ WAI ratings although
most of the EAS ratings are made on therapist behavior. Apparently, the relations between
the observable behavior and the clients’ ratings of the alliance are stronger than therapists’
alliance ratings, even when assessed in relation to their own behavior.
One interpretation of this finding could be that therapists sometimes misjudge the
client’s experience of the relationship, and perhaps even their own behavior, and thus
therapists’ alliance assessments may be less reliable than assessments made by clients or
outside observers (Safran and Muran, 2000). From another perspective, therapists may assess
other aspects of the relationship than the clients do. It is probable that therapists who score
low on alliance are not content with this, but try to ameliorate the relationship. Thus,
therapists’ alliance ratings are often used as information for themselves and they may be
integrated in their future therapeutic work.
Summing up the findings for individual dimensions on EAS-T and the clients’ alliance
ratings, we found that for some dimensions on EAS, correlation were found only on the
individual session level, for other dimensions only on the aggregated therapy level and for
some on both. The therapist’s nonhostility and the client’s responsiveness were on both levels
associated with the client’s perception of the task in the alliance, suggesting that less hostility
and more responsiveness in sessions and over the therapy consolidate the client’s perception
of mutual understanding of what should be done in the therapy. The therapist’s sensitivity
and structure were associated to alliance over therapies, but not in individual sessions,
suggesting that such behavior lay the ground for stable alliance over the therapy. The clients’
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behavior seems to a larger degree to be associated with perceptions of the alliance in the
individual sessions.
In this attempt to use EAS for rating psychotherapy process, a number of problems and
limitations should be noted. The aim was to stay as close to the original instrument as
possible. Even though many of the interaction issues are similar in a parent-child relationship
and in a therapist-client relationship, there are also clear differences. A caregiver and a child
have formed a bond with each other continuously over a long time and can therefore be
expected to relate to each other in a different way than a therapist and a client who have
recently met. A caregiver is expected to know his or her child and to be able to adjust more
easily to his or her emotional level, whereas the relationship between a therapist and a client
is of a more exploring, and sometimes challenging, kind. This raises the question of whether
it is reasonable to evaluate a good therapist by assessing his or her emotional behavior toward
the client depending on the client’s response to it. In EAS, a behavior is judged based on the
response from the other partner; because the client already has developed an emotional
repertoire through her previous relationships and attachment patterns, it may be difficult, or
even unsuitable, for the therapist to be fully responsive in a therapeutic relationship, even
though he or she may display highly sensitive behaviors.
An interesting finding by Zimmerman and McDonald (1995) might mitigate somewhat
this difficulty. They found that children with different caregivers changed in emotional
availability behavior depending on the other part in the relationship and were not dependent
on their mother’s EA. This suggests that a therapist might create an emotionally available
dyad with the client to some degree independent from the client’s and the therapist’s own
previous relationships.
19
The interrater reliability for EAS-T between the two observers was acceptable but has
not been tested and approved against a standardized rating norm. According to Biringen and
colleagues (1998), observers’ ratings of EAS for parents and children are affected by their
attachment patterns. It is of course likely that the two observers in this study were affected by
theirs. A person with an avoidant attachment style, for instance, is according to Biringen and
colleagues, more likely to have difficulties observing a lack of intimacy and can experience
intimate behaviors as threatening. This aspect of EAS complicates the ratings, and Biringen
and colleagues (1998) point out that the observer should stay sensitive to his or her own
emotional experience when studying an interaction.
The EA ratings were based on 15 minutes of observations in the middle of the session,
and it is fair to discuss whether this is enough to make an adequate EA rating representative
for the whole session. This is especially so in this study as the therapists’ and clients’ WAI
ratings were based on the session as a whole. Biringen (2005) recommends longer
observations for more valid assessments. It may also be that the experience of alliance is
colored by the fact that it is rated at the end of the session. This could suggest that the
emotional availability assessment, when compared with the WAI ratings, should be retrieved
from the last part of the session, if not the complete session. There is a risk of missing
important findings when the observation is limited in time. In longer segments, on the other
hand, the participants may change their way of behaving, thus making the rating somewhat of
a compromise. Most process studies on parts of therapy sessions use quite short segments
(Pascual-Leone & Greenberg, 2007). We tried to strike a balance between these two methods,
and found 15 minutes to be a useful period. The decision to rate 15 minutes from the middle
phase of the sessions was thus a compromise between two conflicting needs: to get rich
material for better reliability and to rate parts of sessions that were reasonably homogeneous.
20
Another weakness in the study is the limited sample of therapists and therapist-client
dyads, which decreases the possibility of valid results. Because the therapy episodes were not
independent, multilevel analyses would have been appropriate. A simplified version was used
because data did not allow tests that are more thorough. However, Biringen and colleagues
(1998) argue that EA could vary in different situations, even in the same relationship. In
addition, the results indeed showed variation in assessments for the same therapist and with
the same therapist-client dyads.
More studies of EAS-T regarding its validity and reliability have to be made.
Standardization of the EAS-T would be a natural next step in the process of making the
instrument reliable for assessing the therapeutic relationship. The standardized manual should
focus on giving a clear description of each dimension scale and what criteria are needed to
fulfill to receive a certain score. The range for each dimension should be reviewed and
perhaps modified in order to get a larger variance when rating. In particular, the dimension
nonhostility could use a broader range or other wording. It should also be noted that the
intercorrelations between several of the EA dimensions are rather strong, implying that it may
be difficult to discriminate between the associations between these dimensions and the WAI
ratings.
On conceptual grounds, it could be debated why EA should be associated with the
alliance. A number of other measures of the emotional interaction in psychotherapy have
been created and, in some cases, widely used. The Experiencing Scale (Klein, MathieuCoughlan, & Kiesler, 1986), for instance, focuses on the quality of emotional experiencing,
and the Structural Analysis of Social Behavior (Benjamin, 1974), on affiliation and control in
interaction. Ratings on client SASB have been found to correlate with the alliance (Hersoug,
Høglend, Havik, von der Lippe et al., 2009). The potential advantage with EAS-T is that it is
easy to rate and that it catches important aspects of the interplay in the therapy session. In
21
future studies, it would seem important to compare ratings on EAS-T with, for instance,
ratings on the Experiencing Scale, on the CEAS, and with ratings of mentalization in the
therapeutic process.
A clinical conclusion to be drawn from the present study is that the therapist’s
emotional availability may increase the client’s perception of a meaningful alliance. It is
probable that different therapists have different abilities in this regard, and that this ability
might be a focus for therapist training.
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27
Table 1.
Means and standard deviations for EAS-T (n = 42), WAI-C (n = 36) and WAI-T (n = 38).
Mean Standard deviation
Range
Sensitivity
6.19
1.55
2-9
Structuring
4.21
0.73
2.5-5
Nonintrusiveness
4.76
0.50
3-5
Nonhostility
4.86
0.34
4-5
Responsiveness
5.13
1.20
2-7
Involvement
4.94
1.18
2-7
Goal-C
5.01
1.60
1.00-7.00
Task-C
5.05
1.51
1.67-7.00
Bond-C
5.81
0.95
3.25-7.00
Goal-T
5.02
0.95
3.25-6.75
Task-T
4.64
1.10
2.75-7.00
Bond-T
4.83
0.89
3.50-6.75
WAI-Client
WAI-Therapist
28
Table 2.
Pearson correlations between the EAS scales(n = 42).
Sensitivity
Structuring
Nonintrusiveness
29
Nonhostility
Responsiveness
Involvement
Sensitivity
Structuring
Nonintrusiveness
1.0
.80**
.46**
.42**
.76**
.64**
1.0
.46**
.23
.73**
.60**
1.0
.25
.37*
.32*
1.0
.50**
.41**
1.0
.89**
Nonhostility
Responsiveness
Involvement
1.0
* ρ ≤ .05.
** ρ ≤ .01.
30
Table 3.
Correlations (Pearson) between WAI-Client (n = 36) and WAI-Therapist (n = 38) subscales and the EAS
scales.
Sensitivity
Structuring
Nonintrusiveness
Nonhostility
Responsiveness
WAI-C
Involvement
.
Goal
.26
.11
.27
.34*
.41*
40*
Task
.31
.12
.13
.36*
.34*
.34*
Bond
.22
.04
.16
.20
.26
.17
Goal
-.03
-.02
.25
.13
.01
.05
Task
-.02
-.01
.26
.10
.08
.11
Bond
-.13
-.13
.07
.08
-.09
.00
WAI-T
* ρ ≤ .05.
31
Table 4.
Linear regression of working alliance scores on EAS scales using exact tests for therapy mean scores
(n = 15).
Sensitivity
Structuring
Nonintrusiveness
Nonhostility
Responsiveness
WAI-C
Involvement
.
Goal
.49
.31
.49
.30
.44
.32
Task
.62*
.51
.48
.58*
.67**
.51
Bond
.51
.60*
.27
.16
.33
.11
a
Values represent standardized regression coefficients
* p < .05, ** p < .01
32
Appendix
Emotional Availability Scales - Therapy
Therapist
Sensitivity. This dimension refers to a general aspect of the therapist’s emotional availability
to the client. Positive affect is central, and for high ratings the therapist is accepting, warm
and above all genuine. Both verbal and nonverbal communication is assessed, and these
should be congruent to display a sensitive impression. The therapist is not necessarily
positive about everything the client does, because this may be perceived as fake, but has a
generally positive attitude. A sensitive therapist detects and is responsive to a client’s various
types of emotional signals, and also the absence of such. The therapist is flexible and able to
adjust his or her behavior to the client, and tries different strategies to lead the client without
compromising autonomy. A sensitive therapist has a sense of timing and can switch themes
without being abrupt. Although sensitive therapists may experience conflicts with the client,
they can resolve them in a way that makes the client feel safe and respected. A therapist may
have different styles of interaction, both quiet and lively, but still be sensitive.
Examples of sensitive behaviors: Detects subtle signals, makes correct interpretations of
present emotions, listens carefully, keeps eye contact, smiles genuinely, displays an inviting
body language.
Nonsensitive behaviors: Lets emotional signals pass, makes abrupt switches between themes,
is unenthusiastic, displays bland affects.
Structuring. Describes how the therapist structures the therapy and the interaction with the
client. An optimally structuring therapist provides framework for the therapy, makes
suggestions, presents just enough information, sets appropriate limits, makes reasonable
33
demands, and can assist the client when stuck. While the therapist leads the client, he or she
also encourages the client’s own commitment and exploration, and does not compromise his
or her autonomy. Whether the therapist’s structuring style is considered successful depends
on whether the client responds well to it or not.
Structuring behaviors: Shifts themes smoothly, makes suggestions, challenges client’s views.
Nonstructuring behaviors: Is passive, backs off and lets client take over, is a friend rather
than a therapist.
Nonintrusiveness. Assessed on this dimension is the therapist’s ability to respect the client’s
integrity and autonomy. An intrusive therapist leaves little space to the client, is overly
directive or overprotective and shows weak confidence in the client's own ability. The
intrusive therapist can be rigid and behaves more like an educating teacher than a sensitive
therapist. An intrusive therapist gives the impression that his or her own needs control the
therapy. A therapist who does not display these intrusive behaviors receives high scores. A
therapist who structures well usually scores high on this dimension as well.
Intrusive behaviors: Interrupts, talks constantly, gives orders.
Nonintrusive behaviors: Absence of the above.
Nonhostility. This dimension refers to display of hostile behavior in the interaction, both
covert and overt. Covert hostility can be indications of the therapist being bored, impatient, or
indifferent. Overt signs of hostility are clear indications of anger or resentment in the
communication. Hostility does not have to be aimed directly toward the client in order for the
therapist to be judged as hostile.
Hostile behaviors: Yawns, gives cold stares, displays uninterested facial expressions, raises
voice, rolls eyes, threatens, teases, ridicules, bangs the table.
34
Nonhostile behaviors: Absence of the above.
Client
Responsiveness. The responsiveness dimension is the client’s equivalent of therapeutic
sensitivity and refers to how emotionally available the client is to the therapist. The observer
assesses the client’s willingness, satisfaction, and commitment in the relationship. A client
who responds well answers the therapist’s bids with enthusiasm, eagerness, and above all
positive affect. Because autonomy is an important component, the client does not receive
high scores if responses are too eager or tend to be compulsive. Thus, the client can disagree
with and talk back to the therapist and still receive high scores. Giggles and smiles are
considered to be signs of responsiveness but only if these are perceived as genuine and are
part of the interaction and not directed toward other things.
Responsive behaviors: Faces therapist, keeps eye contact, nods, answers with enthusiasm,
giggles, smiles genuinely.
Non-responsive behaviors: Looks away, gives evasive answers, is passive, is indifferent,
ignores therapist, complains, whines, and expresses anger toward therapist.
Involvement. Assessed on this dimension is to what degree the client involves the therapist in
the interaction. An involving client keeps eye contact, can ask for suggestions, asks
questions, and invites the therapist in a relaxed and non-forced manner. Positive affect is not
accentuated as much as on the responsiveness dimension but is still an important aspect.
Balance between autonomy and involvement is important, and a client who signals that he or
she cannot manage on his or her own receives lower scores. A lower score can tell something
important about the therapist, for example, that he or she is intrusive and does not leave
35
enough space for the client to be involved. The assessment should not be based on the guess
that the client would involve the therapist if she or he had not been hindered to do this.
Involving behaviors: Faces therapist, leans towards therapist, keeps eye contact, looks at
therapist and pauses after speaking, asks questions.
Noninvolving behaviors: Looks away, talks constantly, holds the face away from therapist.
EA is not considered a “trait” but is determined by the therapist’s actual interaction with the
client. A therapist does not receive high scores for doing “the right things” if the client does
not respond well to these behaviors. EA, as assessed with EAS-T, is context dependent and
may be different in different relationships. Thus, a therapist can be perceived as sensitive in a
therapy with one client but nonsensitive in a therapy with another client. The observer should
make assessments based on what he or she sees in the current situation and not based on
assumptions about what therapists or clients are “actually” like.
36