Association between helping skills variability and subsequent client functioning: Mediated by working alliance and...

We examined the associations among helping skills flexibility (HSF), defined as how much therapists use a range of helping skills in sessions with clients, working alliance (WA), session evaluation (SE), and client functioning, as well as the indirect effect of HSF on client improvement as mediated by WA and SE. Adult clients (n = 121) receiving open-ended individual psychodynamic therapy, provided by 19 therapy trainees in a university clinic, rated their functioning at the beginning of each session and rated their perceptions of the WA, SE, and therapist use of helping skills at the end of each session. We found that HSF in one session was positively and plausibly associated with the clients' ratings of the WA and SE in the subsequent session. There was also a positive and plausible indirect effect for therapist HSF on subsequent client functioning through the WA but not through SE. This mediation effect was not moderated by treatment length, nor were there quadratic associations for therapist HSF or reverse causality. The results suggest therapist HSF temporally precedes and plausibly leads to improvements in the WA, which temporally precedes and presumably leads to improvements in client functioning. (PsycInfo Database Record (c) 2025 APA, all rights reserved).