Through a system of patient-focused outcomes research which has employed a quality assurance system for tracking client progress in therapy, there has been consistent evidence that utilizing the system to identify those who are not responding to treatment and warning their therapist about the client’s risk significantly improves client outcomes in psychotherapy. Although outcomes have been improved, significant proportions of clients have treatment failures or see no improvement in therapy. Moreover, feedback to therapists appears to be most effective in improving outcomes for the minority of clients who are already at risk of treatment failure.

Attempts to augment the feedback effect with clinical support tools and by providing feedback to clients as well as therapists have yielded inconsistent results. The first goal of the current study was to determine whether providing feedback to participants as well as to therapists would result in better outcomes for university counseling center clients, over and above the effect of feedback to therapists alone. Results indicated that feedback to both participants and therapists resulted in significant reductions in distress, as compared to participants in the therapist-only feedback condition and that the benefit of double feedback extended to participants who were already making expected progress in treatment as well as those at risk of a treatment failure. Secondly, the reason why therapist feedback improves outcomes has remained largely unknown, but one hypothesis has been that feedback to therapists strengthens the relationship between therapists and clients, thus improving outcomes. Thus, the second aim of the study was to test whether the therapeutic alliance mediates the relationship between feedback and outcomes in psychotherapy. Surprisingly, therapeutic alliance was found to be unrelated to any of the outcome measures.

LLU Discipline

Clinical Psychology


Clinical Psychology


Graduate Studies

First Advisor

David A. Vermeersch

Second Advisor

Adam L. Aréchiga

Third Advisor

Kendal C. Boyd

Fourth Advisor

Louis E. Jenkins

Fifth Advisor

T. Lorraine Young

Degree Name

Doctor of Philosophy (PhD)

Degree Level


Year Degree Awarded


Date (Title Page)




Library of Congress/MESH Subject Headings

Psychotherapist and patient; Therapeutic alliance; Feedback (Psychology); Professional-Patient Relations; Feedback, Psychological; Psychotherapy -- methods; Outcome Assessment (Health Care); Analysis of Variance.



Page Count

xiii; 89

Digital Format


Digital Publisher

Loma Linda University Libraries

Usage Rights

This title appears here courtesy of the author, who has granted Loma Linda University a limited, non-exclusive right to make this publication available to the public. The author retains all other copyrights.


Loma Linda University Electronic Theses and Dissertations

Collection Website



Loma Linda University. Del E. Webb Memorial Library. University Archives