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THE CLIENT’S AND THERAPIST’S VOCAL QUALITIES
IN CBT AND PE-EFT FOR DEPRESSION
by
Beth Ellen Bernholtz
A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Graduate Department of Applied Psychology and Human Development
Ontario Institute for Studies in Education
University of Toronto
© Copyright by Beth Ellen Bernholtz 2013
ii
THE CLIENT’S AND THERAPIST’S VOCAL QUALITIES
IN CBT AND PE-EFT FOR DEPRESSION
Doctor of Philosophy, 2013 Beth Ellen Bernholtz
Graduate Department of Applied Psychology and Human Development
University of Toronto
Abstract
The psychotherapy client’s vocal quality indicates the quality of and shifts in the client’s
engagement in treatment. In contrast, the therapist’s vocal quality is a treatment intervention,
either facilitating or hindering the client’s progress. The Client Vocal Quality (CVQ) and
Therapist Vocal Quality (TVQ) measures (Rice & Kerr, 1986) were applied to responses in the
middle 20 minutes of low and high change sessions for 61 clients who received either cognitive
behavioural therapy (CBT) or process-experiential emotion focused therapy (PE-EFT) for
depression (Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003). Sessions were selected
using the Client Task Specific Change Measure-Revised (CTSC-R; Watson, Greenberg, Rice, &
Gordon, 1996). Outcome measures included the Beck Depression Inventory, Dysfunctional
Attitude Scale, Global Severity Index of the Symptom Checklist-90-Revised, Inventory of
Interpersonal Problems, Problem-Focused Style of Coping Scale, and Rosenberg Self-Esteem
Scale. The CVQ categories differentiated between treatment types, with PE-EFT clients
expressing a significantly higher proportion of Emotional vocal quality and CBT clients
expressing a significantly higher proportion of Externalizing vocal quality. There was no
difference between the treatment types for Focused or Limited vocal quality. The CVQ
categories predicted outcome. This relationship was particularly evident in the session in which
clients first reported moderate to high change on the CTSC-R. The combination of Emotional
and Focused categories was a stronger predictor than either category alone. In contrast, a higher
iii
proportion of Externalizing vocal quality predicted worse scores. In terms of Therapist Vocal
Style, PE-EFT therapists spoke predominantly in the Softened-Irregular Vocal Style, while CBT
therapists spoke predominantly in the Natural-Definite Vocal Style. Therapists’ use of a
Softened-Irregular Vocal Style, compared with a Natural-Definite Vocal Style, was associated
with the client’s report, at the end of therapy, that he/she felt less easily exploited by others and
had a greater ability to assert interpersonal boundaries without fear of offending others.
Limitations of the study are discussed.
iv
Acknowledgements
I would like to thank my supervisor, Dr. Jeanne Watson. I feel tremendously privileged to have
been your student and I am so grateful to you for supporting me and this research. I would also
like to thank my committee members Dr. Lana Stermac and Dr. Ruth Childs. Thank you so
much Lana for making me feel comfortable in the program since the beginning. And Ruth, thank
you for giving me your time and expert guidance. I always left our meetings feeling like I knew
more about statistics than I had thought! Thank you also to Evelyn McMullen, Jon Danson,
Aline Rodrigues, and Laura Gollino for doing such a wonderful job as raters on this project and
for your insights about vocal quality. And, to Olesya Falenchuk, I can’t imagine how my study
would have looked without your assistance. I greatly enjoyed our time together working on the
statistics for this project. I also want to thank Gillian Kerr and Sharon Rappaport for bringing
my study to life by providing essential training information as well as a wonderful historical
connection. Thank you also to Dr. Steve Hollon and Dr. Les Greenberg for providing audio of
psychotherapy sessions for training purposes. Finally…. my family. To my beloved husband
Jeff, thank you for always understanding everything—I love you. To my kids, I am very proud
of you and think you are very astute observers of vocal quality. To my sister, Adrienne, thank
you for always sending happiness and love my way. To my mother, Marcia Krem, thank you for
loving me so much. You always make me feel that I have a special, unique purpose in this
world. To my father and stepmother, Marvin and Linda Feldman, I want to thank you for
supporting me through such difficult times in my life. I would not be here, in this happy,
successful place, without your love.
v
Table of Contents
Abstract .......................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iv
List of Tables ................................................................................................................................. ix
List of Figures ..................................................................................................................................x
List of Appendices ......................................................................................................................... xi
Glossary ....................................................................................................................................... xiv
Chapter 1: Literature Review .......................................................................................................1
Special Characteristics of Vocal Quality and Audition .............................................................1
Connecting to other people through imitation ...........................................................................4
Rhythm, vocal quality, and synchronizing states of consciousness...........................................5
Rhythm, emotion, and vocal quality ..........................................................................................7
Paralanguage ..............................................................................................................................8
Psychotherapists listen to their clients’ vocal qualities..............................................................9
Personality..........................................................................................................................10
Emotional States ................................................................................................................13
Level of arousal..................................................................................................................15
Psychopathology ................................................................................................................16
Using vocal quality to guide treatment interventions ........................................................18
The therapist’s vocal quality: The therapist’s vocal quality as a
treatment intervention ..............................................................................................................18
Mutual influence of the client’s and therapist’s vocal qualities ..............................................20
Studies of the therapist’s vocal quality ....................................................................................24
Rice (1965).........................................................................................................................25
Duncan, Rice, and Butler (1968) .......................................................................................28
Kerr (1983).........................................................................................................................29
Summary of studies of the therapist’s vocal quality ..........................................................35
The client’s vocal quality: How the client’s use of his or her own vocal
quality can facilitate treatment .................................................................................................35
The physical act of speaking and emotional changes ........................................................36
Paying attention to how one sounds...................................................................................36
Increasing emotional arousal .............................................................................................37
Studies of the client’s vocal quality .........................................................................................37
vi
The client’s vocal quality and treatment outcome-Butler, Rice, and
Wagstaff (1962) .................................................................................................................38
The client’s vocal quality and treatment outcome-Rice and Wagstaff (1967) ..................42
The client’s vocal quality and other treatment orientations-
Sarnat (1976) and Nixon (1980) ........................................................................................43
The client’s vocal quality and in-session-Greenberg (1983) .............................................44
The client’s vocal quality and in-session processes-
Watson and Greenberg (1996) ...........................................................................................47
Summary of the client’s vocal quality, treatment outcome, and
in-session processes ...........................................................................................................48
The therapist’s and client’s vocal qualities together-
Butler, Rice, and Wagstaff (1962) ...............................................................................49
The therapist’s and client’s vocal qualities together-
Wiseman and Rice (1989) ............................................................................................49
Different Treatments, Different Demands ...............................................................................52
Methods of Studying vocal quality in the Psychotherapy Setting ...........................................54
Summary ..................................................................................................................................54
Research questions and hypotheses .........................................................................................55
Research Question 1 ..........................................................................................................55
Research Question 2 ..........................................................................................................56
Research Question 3 ..........................................................................................................56
Chapter 2: Method .......................................................................................................................57
Participants ...............................................................................................................................57
Therapist ..................................................................................................................................57
Treatments................................................................................................................................59
Process Measures .....................................................................................................................60
Client Vocal Quality Scale (CVQ) ....................................................................................60
Therapist Vocal Quality Scale (TVQ) ...............................................................................62
Outcome Measures...................................................................................................................64
Beck Depression Inventory (BDI ) ....................................................................................64
Dysfunctional Attitudes Scale (DAS) ................................................................................64
Problem-Focused Style of Coping (PF-SOC) ...................................................................65
Inventory of Interpersonal Problems (IIP) .........................................................................66
Rosenberg Self-esteem Scale (RSES) ................................................................................67
Symptom Checklist-90-Revised (SCL-90-R) ....................................................................68
vii
Post-Session Outcome Measure ...............................................................................................69
Client Task-Specific Change Measure-Revised (CTSC-R) ...............................................69
Procedure .................................................................................................................................70
Session selection ................................................................................................................70
Preparation of materials .....................................................................................................71
CVQ Training ....................................................................................................................71
Rating the CVQ data set ....................................................................................................74
TVQ Training.....................................................................................................................75
Rating the TVQ data set .....................................................................................................76
Descriptive Statistics for the Outcome Measures ..............................................................77
Alpha level .........................................................................................................................78
TVQ Inter-rater reliability on the data set..........................................................................78
TVQ Descriptives ..............................................................................................................81
CVQ Inter-rater reliability .................................................................................................83
Boxplots of CVQ Data .......................................................................................................87
Chapter 3: Results........................................................................................................................91
Research Question 1-Vocal quality and the client’s report of change .....................................91
Research Question 2-Vocal qualities and the client’s scores on
outcome measures ....................................................................................................................94
Hypothesis 2a-Productive CVQ categories will predict better scores
for clients on the outcome measures at the end of treatment .............................................95
Emotional vocal quality in the first report of moderate to
high change session .....................................................................................................96
Focused vocal quality in the first report of moderate to
high change session .....................................................................................................97
Emotional Plus Focused vocal quality in the first report of
moderate to high change session .................................................................................97
Additional Analyses of Externalizing and Limited vocal qualities
in the first report of moderate to high change session for
Research Question 2a ...................................................................................................99
Externalizing vocal quality in the first report of moderate to
high change session .............................................................................................100
Additional analyses of Limited vocal quality and Externalizing
vocal quality in the session with the lowest change score for
Research Question 2a .................................................................................................101
viii
Additional analyses of Limited vocal quality and Externalizing
vocal quality in the session with the highest change score for
Research Question 2a .................................................................................................102
Hypothesis 2b-Productive TVQ categories will predict better scores
for clients on the outcome measures at the end of treatment ...........................................104
Research Question 3-Differences between therapist and client vocal
qualities and treatment types ..................................................................................................107
Additional tests addressing Research Question 3 and the client’s
vocal quality .....................................................................................................................109
Exploration of Hypothesis 3b-Therapist Vocal Style and treatment types ......................111
Summary of results ................................................................................................................112
Chapter 4: Discussion ................................................................................................................116
CVQ predicts clients’ scores on outcome measures at termination .......................................117
Emotional Plus Focused vocal quality predict more favourable treatment
outcomes in the first report of moderate to high change session ....................................117
Limited vocal quality predicts more favourable treatment outcomes in the
first report of moderate to high change session ..............................................................121
Externalizing vocal quality predicts worse treatment outcomes in the
first report of moderate to high change session ..............................................................124
No difference in CVQ in the sessions with the lowest change score and the
session with highest change score .........................................................................................125
Client and therapist vocal qualities differentiate the treatment types ....................................125
Indirect support for other studies comparing different treatment types ...........................126
CBT clients expressed a higher proportion of Externalizing vocal quality
than PE-EFT clients .........................................................................................................127
There was no difference between the treatment types for Focused
vocal quality .....................................................................................................................129
Natural-Definite and Softened-Irregular Therapist Vocal Style and the
treatment types .................................................................................................................129
Strengths of the current study ................................................................................................132
Limitations of the study .........................................................................................................133
Future Research .....................................................................................................................136
Implications for practice ........................................................................................................142
Conclusion .............................................................................................................................146
References ...................................................................................................................................148
ix
List of Tables
Table 1 Features of the vocal quality Qualities and Manner of Speaking
categories for the Client Classification System ..............................................................40
Table 2 Client Characteristics at Pre-treatment ............................................................................58
Table 3 Preliminary Inter-Rater Reliability Between the CVQ Raters and
Each Rater and the Expert...............................................................................................74
Table 4 Preliminary Inter-Rater Reliability Between the TVQ Raters and
Each Rater and the Expert...............................................................................................76
Table 5 Results of Cluster Analysis for the TVQ Observers (N = 59 Sessions) .........................80
Table 6 Results of Cluster Analysis on the TVQ Data Set (N = 177 Sessions) ...........................81
Table 7 Crosstabulation Tables for Therapist Vocal Style by Treatment Type
in Sessions with the Lowest and Highest Change Scores ...............................................82
Table 8 Crosstabulation Tables for Therapist Vocal Style by Treatment Type
in the First Report of Moderate to High Change Session ...............................................83
Table 9 Intraclass Correlation Coefficients for CVQ Inter-Observer
Agreement (N = 63) ........................................................................................................84
Table 10 Results for Hypothesis 1a and b: Wilcoxon Signed-rank test –
Mean Ranks, Ties, Z statistics, p values for the CVQ categories
in the Highest Change Score Sessions and the Lowest Change
Score Sessions (N = 61) ................................................................................................92
Table 11 A Higher Proportion of CVQ Category Predicts Outcome Scores
at Post Treatment .........................................................................................................104
Table 12 Results for Hypothesis #3a: Mean Ranks, Z statistics, Effect Sizes,
and p values of CVQ Categories in Lowest plus Highest Change Score
sessions by Treatment Type (N = 61 Clients) .............................................................108
Table 13 Results for Hypothesis #3a: Mean Ranks, Z statistics, Effect Sizes,
and p values of CVQ Categories in First Report of Moderate to High
Change Score sessions by Treatment Type (N = 58 Clients) ......................................109
x
List of Figures
Figure 1 Crosstabulation matrix for the Focused vocal quality test with
the main rater and expert ...............................................................................................85
Figure 2 Boxplots of CVQ categories in first report of moderate to high
change sessions (N = 60) ..............................................................................................88
Figure 3 Boxplots of CVQ categories in sessions with the lowest change score
and sessions with the highest change score (N = 63) ....................................................89
xi
List of Appendices
Appendix A Ranges for interpretation of statistics ....................................................................160
Appendix B Spearman’s Rho Correlations Between Outcome Measures .................................170
Appendix C, Figure C1 Boxplots of CVQ Categories in Sessions with
the Lowest Change Score (N = 61) ..............................................................................................171
Appendix C, Figure C2 Boxplots of CVQ categories in Sessions with
the Highest Change Score (N = 61) .............................................................................................172
Appendix C, Figure C3 Boxplots of CVQ categories in First Report
of Moderate to High Change Session (N = 58) ...........................................................................173
Appendix D Means, Standard Deviations, and Medians for CVQ
Categories in the Session with the Lowest Change Score and the
Session with the Highest Change Score .......................................................................................174
Appendix E Means, Standard Deviations, and Medians for Treatment
Groups by CVQ Category in the First Report of Moderate to High
Change Session ............................................................................................................................175
Appendix F, Table F1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Emotional Vocal Quality in the Session with the Highest
Change Score ...............................................................................................................................176
Appendix F, Table F2 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Focused Vocal Quality in the Session with the Highest
Change Score ...............................................................................................................................177
Appendix F, Table F3 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Emotional Plus Focused Vocal Quality in the Session with
the Highest Change Score ............................................................................................................178
Appendix G, Table G1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Emotional Vocal Quality in the Session with the Lowest
Change Score ...............................................................................................................................179
xii
Appendix G, Table G2 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Focused Vocal Quality in the Session with the Lowest
Change Score ...............................................................................................................................180
Appendix G, Table G3 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values Emotional Plus Focused Vocal Quality in the Session with the
Lowest Change Score ...................................................................................................................181
Appendix H, Table H1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values for Emotional Vocal Quality in the Session with the First
Report of Moderate to High Change ...........................................................................................182
Appendix H, Table H2 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Focused Vocal Quality in the Session with the First Report
of Moderate to High Change .......................................................................................................183
Appendix H, Table H3 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Emotional Plus Focused Vocal Quality in the Session with
the First Report of Moderate to High Change .............................................................................184
Appendix I, Table I1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Limited Vocal Quality in the Session with the First Report of
Moderate to High Change ...........................................................................................................185
Appendix I, Table I2 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Externalizing Vocal Quality in the Session with the First Report
of Moderate to High Change .......................................................................................................186
Appendix J, Table J1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Limited Vocal Quality in the Session with the Lowest
Change Score ...............................................................................................................................187
xiii
Appendix J, Table J2 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors,
and p values Externalizing Vocal Quality in Session with the Lowest
Change Score ...............................................................................................................................188
Appendix K, Table K1 Results for Hypothesis 2a: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values Limited vocal quality in the Session with the Highest Change Score............................189
Appendix K, Table K2 Results for Hypothesis 2a: Standard (β) an
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values Externalizing Vocal Quality in the Session with the Highest
Change Score ...............................................................................................................................190
Appendix L, Table L1 Results for Hypothesis #2b: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Post-Treatment Scores for Outcome Measures by Therapist
Vocal Style (Softened-Irregular and Natural-Definite) for Sessions with
the Lowest and Highest Change Scores .......................................................................................191
Appendix L, Table L2 Results for Hypothesis #2b: Standard (β) and
Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Post-Treatment Scores for Outcome Measures by Therapist
Vocal Style (Softened-Irregular and Natural-Definite) in First Report of
Moderate to High Change Scores ................................................................................................193
xiv
Glossary
Some terms in this dissertation are complex. This glossary can be used as a guideline while
reading.
Session with the lowest change score: This is one of the groupings of sessions used in
the analyses. Sessions placed in this group are those with the lowest CTSC-R score.
Session with the highest change score: This is one of the groupings of sessions used in
the analyses. Sessions placed in this group are those with the highest CTSC-R score.
First report of moderate to high change session: This is one of the groupings of sessions
used in the analyses. Sessions placed in this group are those that are the first session
scored as 5 or more on the CTSC-R.
Low change sessions: Sessions with the lowest change score
High change sessions: Either sessions with the highest change score or the first report of
moderate to high change session, depending on the analysis.
Acronyms
CTSC-R: Client Task Specific Change-revised
CBT: Cognitive Behaviour Therapy
PE-EFT: Process-Experiential Emotion-Focused Therapy
1
Chapter 1:
Literature Review
Special Characteristics of Vocal Quality and Audition
Some researchers estimate that 55% of communication is nonverbal, consisting of
behaviours such as physical movements, facial expressions, and vocal quality characteristics
(Tepper & Haas, 1978). Of these behaviours, a person’s vocal quality is considered to be the
most accurate indicator of his or her inner state because it reflects physiological correlates of
emotion (Moses, 1954) and because it is the most difficult of the nonverbal behaviours to control
by choice (e.g., Ekman & Friesen, 1969). Vocal quality is also seen as transmitting more
information about the speaker than his or her words, contradicting, underscoring, undermining,
or calling into question the meaning of spoken content (Egan, 1998).
Despite the potential power to alter the impact of words, the sounds of a person’s vocal
quality are constantly changing and fleeting. For example, even if sound is recorded on
audiotape or video, it still cannot be caught, held still, and examined like a visual or tangible
object (Winkel, 1996, as cited in Ross, 2001). Sound also connects people to the world in ways
that the other senses cannot. For example, people hear sounds caused by objects that are out of
their visual range and people can be alerted to events occurring behind them by hearing them
first, before seeing them (Sabbadini, 1997, as cited in Ross, 2001).
Psychoanalysts have lauded vocal quality and audition for their special properties. One
reason for this is that they consider the sound of a patient’s mother’s vocal quality, even before
birth, to be among the first important experiences for the patient that can be accessed in
psychotherapy (e.g., Wrye, 1997). In addition, in spite of its apparent intangibility,
psychoanalysts have referred to sound as providing a physical “contact” experience (Bady,
2
1985). Sound has been described as having a physical impact on the listener that enables him or
her to hear (e.g., Ackerman, 1990) and as forming a “psychobiological bridge” between a
person’s physical/biological functioning and his or her psychological functioning (Stone, 1961,
p. 86).
Bady (1985) referred to the work of Niederland (1985) when commenting about the
physical aspects of sound that enable people to hear:
Sound waves from a person’s voice or other sources are transmitted through a medium of
air to create tiny, yet definite impressions on the skin and eardrum. A loud noise is thus
felt as well as heard. At lower frequencies, there is a gentle but definite vibration distinct
from and superimposed on the sound. (Bady, 1985, p. 488)
Ackerman (1990) described the links between sound and hearing at an even more fundamental
level, explaining that sound waves cause molecules in the air to vibrate. This vibration causes
molecules next to one another to vibrate as in a chain reaction. Molecules move one another
until they enter the ear, where they vibrate against the:
Three colorfully named bones (the hammer, the anvil, and the stirrup), the tiniest bones in
our body . . . [to] press fluid in the inner ear against membranes, which brush tiny hairs
that trigger nearby nerve cell, which telegraph messages to the brain: we hear.
(Ackerman, 1990, p. 177)
Referring to Stone’s (1961) idea that vocal quality forms a “psychobiological bridge” (p. 86)
with other people, Wrye (1997) wrote that unborn babies literally feel their mother’s vocal
qualities and heartbeats “even before birth, as the infant, rocked and rolled in the quadraphonic
audio chamber of the womb, heard and felt her voice ” (p. 360). The physical sensation of vocal
3
quality continues to dominate the baby’s world even after birth. Stern (1990) wrote about what it
must be like for a 6-week-old baby to hear his parents speak to him:
Step into Joey’s earliest world and . . . imagine that none of the things you see or touch or
hear have names or functions, and few any memories attached to them. Joey experiences
objects and events mainly in terms of the feelings they evoke in him . . . . When his
parents call him “honey”, he doesn’t know that honey is a word and refers to him. He
doesn’t even particularly notice it as a sound distinct from a touch or a light. But he
attends carefully to how the sound flows over him. He feels its glide, smooth and easy,
soothing him; or its friction, turbulent and stirring him up, making him even more alert.
Every experience is like that, having its own special feeling tone. (p. 13)
The “psychobiological bridge” formed by speech enables a child to develop, eventually
separating from his or her mother, while still feeling the safety of connection to her (Stone, 1961,
pp. 85-86). Nass (1971) provided an example of this in explaining that the baby feels connected
to his or her mother just by hearing her vocal quality or the sounds of her activities in another
room. Nass (1971) stated that the mother’s vocal quality allows the child to “maintain the object
at a distance” and that hearing her vocal quality enables the child to hold on to her even though
she is not within physical reach (p. 309).
In addition to sound providing a kind of physical contact that enables the child to
develop, sound is an integral part of the child’s emotional growth. Moses (1954), a laryngologist
who wrote at length about the connections between vocal quality, human development, and
psychopathology, explained that as the child grows, he or she makes constant sensory and
emotional associations with sound. For example, the baby associates the enjoyable vocal sounds
he creates with his vocal quality with the pleasant physical experience involved in making them.
4
Examples of such physical experiences might include the feeling of running his tongue along the
insides of his mouth or feeling the rush of air through his lips, filling up his lungs as he prepares
to make a joyful shriek. In addition to associating his own vocal quality with his physical
sensations, the child also makes associations between physical experience and the sounds of his
environment. For example, the sounds of anger, arguing, and bickering in the home would be
deeply associated with the child’s somatic experience of tension or fear.
Such links between vocal quality and feeling occur early on, before the child even learns
to speak. Moses (1954) wrote that, “family and group relationships have been symbolized by
vocal patterns before verbal thinking was mastered” (p. 27). These vocal pattern-feelings
associations are then linked to vocabulary as the child learns to speak in words. The result is
then heard in the child’s vocal quality as described by Moses (1954): “The voice of the child is
like a complicated engraving etched by experience with multitudinous fine traces which cannot
be easily eradicated” (p. 27). For Moses, the end result of the child’s vocal pattern-feeling
development is that vocal quality is the primary transmitter of the speaker’s personality and state
of mental health.
Connecting to other people through imitation
In addition to the human vocal quality and audition playing necessary roles in a child’s
development, Moses (1954) has asserted that they have been crucial in phylogenesis, or the
development of the human species. Moses explained that primitive humans understood or
acquired new information by imitating the new stimuli in their environment. Referring to
Bernfeld (1928) and his theories of fascination, Moses (1954) wrote, “primitive perception is
close to motor reaction. The primitive ego imitates what it perceives in order to master intense
stimuli” (p. 11). Moses (1954) also quoted Bernfeld (1928) when he wrote that, “perceiving and
5
changing one’s own body according to what is perceived were originally one and the same
thing” (Moses, 1954, pp. 11-12).
According to Moses (1954) people continue to use this primitive identification process,
though most do so unconsciously. For example, Moses wrote that listeners instinctively
reproduce the physical actions that the speaker must be making in order to emit particular sounds
or tones of vocal quality. Moses explained that this phenomenon is the reason so many people
were awed by legendary speakers like Franklin Delano Roosevelt and Adolf Hitler. These
speakers were able to captivate their audiences “with their superior breathing techniques that the
listener tends to duplicate” (Moses, 1954, pp. 38-39). Moses suggested that for early humans,
this duplication process likely began as pantomiming with physical gestures and vocal sounds.
An example might be of hunters using their body movements as well as vocal qualities to tell the
story of the hunt to their clan. They likely imitated other sounds in their environment which,
over time, developed into words and eventually sentences and language.
Rhythm, vocal quality, and synchronizing states of consciousness
Anthropologist Byers (1979) wrote that each person and animal functions according to
underlying biological rhythms. People operate according to individual rhythms and their
interactions with one another create their own unique rhythmic states. In addition, according to
Byers, people can synchronize one another into a similar rhythmic state or state of
consciousness. Byers reported observing this in conversations between warrior Yananamo
leaders whose distinct rhythm of conversation appeared to have a peace-keeping function. Byers
(1979) concluded that “two interactants in a tight synchrony necessarily and biologically are
brought into the same state (of consciousness) by virtue of their mutual entrainment” (p. 416).
6
Synchronizing states of consciousness as a means of healing has also been observed in
primitive healing ceremonies. Byers (1979) referred to the work of Coberly (1972) who studied
healing ceremonies in diverse cultures:
Coberly (1972) has examined the sequences, or processes, involved in shamanistic curing
ceremonies in ten cultures, and has shown that, despite the variety of cultural content, the
process is always the same: the shaman collects a group, synchronizes the group through
dance, movement, song, chanting, etc., and then brings in the state deviant patient who
joins—is entrained by—the group and is brought to their state in synchronous
participation. In eastern religions, and in numerous primitive religions, instrumental
means (chanting, breathing, dancing, singing, etc.) are used to change the state of
consciousness of individuals or to bring a group to the same state of consciousness.
(Byers, 1979, p. 416)
This finding as well as Bernfeld’s (1928, as cited in Moses, 1954) observation that people
instinctively imitate others has also been noted in current psychology as emotional contagion.
Emotional contagion has been defined as “the tendency to automatically mimic and synchronize
movements, expressions, postures, and vocalizations with those of another person, and
consequently, to converge emotionally” (Hatfield, Cacioppo, & Rapson, 1992, pp. 153-154, as
cited in Rosner, Beutler, & Daldrup, 2000, p. 3). In terms of creating effective social
interactions, Giles and Coupland (1991) described a similar concept rooted in communication
accommodation theory, or CAT. In CAT, the convergence of the nonverbal behaviours of
people engaged in dialogue occurs because of, “a speaker’s or group’s need (often nonconscious)
for social integration or identification with another” (Giles & Coupland, 1991, pp. 71-72 as cited
in Gregory, Green, Carrothers, Dagan, & Webster, 2001, p. 38). Giles and Coupland (1991)
7
listed a number of vocal characteristics that can converge during a conversation such as
“linguistic/prosodic/non-vocal features including speech rate, pausal phenomena and utterance
length, phonological variants…and so on” (p. 63 as cited in Gregory et al., 2001, p. 38).
Rhythm, emotion, and vocal quality
Byers (1979) referred to the work of Stetson (1905, 1951) and Lashley (1951) when
explaining the importance of vocal rhythm in conveying emotional information. Stetson (1905)
stated that a person’s vocal quality is the “most important natural rhythm-producing apparatus”
(p. 257). However, the rhythms produced by the human vocal quality are different from the
exact recurring rhythms produced by a machine. Instead, the rhythm of vocal quality is
“inexact” as it mirrors the “rapidly shifting inner affect states” of the speaker (Byers, 1979, p.
402). In addition to vocal quality reflecting an underlying emotional rhythm, Lashley (1951)
explained that people function on different levels of organization and that the rhythm of speech
is located on a different level than the content of speech. Lashley (1951) wrote, “the mechanism
[rhythm] which determines the serial activation of the motor units [speech] is relatively
independent, both of the motor units [speech] and of the thoughts structure” (p. 118). Stetson
(1951) also acknowledged the division between rhythm and words in his example of how hard it
is to learn a foreign language, explaining, “the rhythm is certainly one of the most fundamental
characteristics of the utterance of a language, and is most difficult for a foreigner to acquire” (p.
124).
The early psychoanalysts also commented on this distinction between manner and
content of speech. Gilles (1990) stated that Reich (1928/1950) recognized the division between
“what” a person says and “how” he or she says it (Gillies, 1990, p. 24). Sullivan (1954, as cited
in Gilles, 1990) described this division as “vocal” and “verbal”. The “verbal” category refers to
8
spoken words, while the “vocal” category developed into what is currently called “paralanguage”
(Gillies, 1990, pp. 24-25).
Paralanguage
Otswald (1979) explained that researchers began investigating which human vocal
sounds convey emotion as a result of the development of the telephone. According to Otswald
(1979), as scientists worked to make speech transmitted through the telephone understandable,
they discovered that “spoken language is highly redundant, i.e., that when a person speaks he
produces many more acoustic signals than are necessary for correct speech perception (Shannon
and Weaver, 1949)” (Otswald, 1979, p. 261). Otswald wrote that this finding prompted
researchers to discover which of these sounds carry the emotional tone of what people say as
well as to understand how the acoustic qualities of person’s voice are connected to his or her
psychiatric state.
Regarding the acoustic aspects of speech, Meservy and Burgoon (2008) referred to
Trager (1958) as well as Pittenger, Hockett, and Danehy (1960) as pioneers in the field of
paralanguage, or the study of how communicative behaviours, other than spoken content, convey
meaning. Meservy and Burgoon (2008) defined paralanguage this way:
Paralanguage refers to the nonverbal elements of speech – such as vocal pitch, intonation,
and speaking tempo – that can be used to communicate attitudes, convey emotion, or
modify meaning. In simple terms, paralanguage can be thought of as how something is
said rather than what is said. (no page number)
Scherer and Oshinsky (1977) gave examples of paralinguistic terms used to characterize different
emotions. For example, small variation in pitch and slow tempo are paralinguistic descriptors of
9
boredom. In contrast, wide variation in pitch and fast tempo can be used to describe the sounds
of a person expressing happiness.
These terms describe the physical expressions of physiological changes that accompany
the speaker’s emotional state. As Ozdas, Shiavi, Silverman, Silverman, and Wilkes (2004)
explained, “there is considerable evidence that emotional arousal produces changes in the speech
production scheme by affecting the respiratory, phonatory, and articulatory processes that in turn
are encoded in the acoustic signal” (pp. 1530-1531). These physical changes thus alter the way
the speaker’s vocal quality sounds. Otswald (1979), referring to his earlier work (1960),
suggested that variations in “acoustic patterns are subject not only to the physiological laws
governing respiration and phonation, but to social rules regarding acoustic expression of emotion
as well” (Otswald, 1979, p. 261).
Psychotherapists listen to their clients’ vocal qualities
Otswald (1979) referred to Moses (1954) as one of the clinicians whose interest in vocal
quality as a transmitter of emotional information was motivated by the discoveries coming from
the development of telephone communication. Although Moses was a laryngologist, he asserted
that conditions such as neurosis and schizophrenia were diagnosable from patients’ vocal
qualities alone. Moses urged psychoanalysts to increase their understanding of the human vocal
quality as a tool for diagnosing mental disorders.
Moses (1954) also pointed out that because of the physical arrangement specified at that
time in psychoanalysis, in which the patient lies on the couch facing away from the analyst, the
analyst relies almost entirely on the patient’s vocal quality for information about his or her
psychic state. Referring to the work of clinicians as far back as Freud (1893) and Reich (1949)
Davis and Hadicks (1990) wrote that, “it has long been recognized that evaluation of nonverbal
10
behavior is an integral part of clinicians’ assessment of clients’ psychological states” (p. 340).
Of the nonverbal cues, the client’s vocal quality continues to be valued an important source of
information for the psychotherapist. Vocal quality has been appreciated not only as an indicator
of psychopathology (Moses, 1954), but also as a reflection of the client’s personality (e.g., Rice
& Gaylin, 1979), changing emotional states (e.g., Stetson, 1905), intensity of emotional arousal
(e.g., Warwar & Greenberg, 1999); and as micro-marker of cognitive-affective processing (e.g.,
Elliott, Watson, Goldman, & Greenberg, 2004). Having this information allows the therapist to
gauge the appropriateness, timing, and effect of specific treatment interventions.
Personality.
Moses (1954) asserted that vocal quality, “is the primary expression of the individual” (p.
1). The connection of a person’s vocal quality to his or her personality was understood early on
as is seen in the Latin word for a drama character’s mask: persona. Moses (1954) explained that
persona means “per sona: the sound of the voice passes through” (p. 7), reflecting that vocal
quality conveys the essence of one’s personality. Moses (1954) regretted that persona eventually
evolved into the contemporary word, personality, bypassing its essential connection to vocal
quality.
However, vocal quality continues to be regarded as an indicator of personality. Moses
(1954) referred to his earlier investigations into vocal quality and personality in which he
described an adolescent man’s personality only from having listened to a phonographic recording
of his vocal quality. He remarked that his findings, based on the vocal analysis and described in
acoustic terms, corresponded well to his interpretation of the young man’s Rorschach protocol.
More than 30 years after Moses’ (1954) informal investigation, Rice and Gaylin (1973)
explored whether the client’s vocal quality was related to personality when tested on the
11
Minnesota Multiphasic Personality Inventory (MMPI) and on the Rorschach. The measure of
the client’s vocal quality they used is the Classification System for Client Vocal Quality (Rice &
Wagstaff, 1967), currently known as the Client Vocal Quality Scale (CVQ; Rice & Kerr, 1986).
While this classification system uses paralinguistic terms, the terms are grouped together to
define specific vocal quality categories called Focused, Externalizing, Limited, and Emotional.
The paralinguistic terms used - include energy, stress, pitch, terminal contours, cadence, and
resonance (Rice & Gaylin, 1973).
Rice and Gaylin (1973) explained that, “previous evidence had suggested that vocal
quality reflects the kinds of resources that the client brings to the therapy situation, rather than
being related to particular kinds of psychopathology” (p. 134). Three of the four previously
mentioned categories were analyzed: 1) Focused, 2) Externalizing, and 3) Limited. The excluded
category, Emotional, was not expressed enough in the data set to be interpreted. The three vocal
quality categories were expected to reflect distinct personality styles. For example, clients using
predominantly Focused vocal quality were believed to have personality styles in which they
would pay attention to their psychological experience and use high energy to explore it. This
exploration could be heard in their vocal qualities as “groping and hesitation” associated with
“the pondering quality of one who is actively feeling his way into new territory” (Rice & Gaylin,
1973, p. 134). The person speaking in an Externalizing vocal quality, however, was thought to
be turning his or her attention to the outside and using his or her vocal energy “instrumentally to
accomplish something in the outside world.” The client may appear expressive, but the
expressiveness has a “‘talking at’ quality” (Rice & Gaylin, 1973, p. 134). The Limited category
leaves the impression “of limited involvement, of distance from what is being said. There is a
12
fragile, walking-on eggs quality that suggests a distancing or even passivity” (Rice & Gaylin,
1973, p. 134).
Fifty-two clients who had received client-centered therapy were tested on the MMPI and
the Rorschach. Samples of their therapy sessions were rated on the CVQ. While vocal quality
and MMPI scores were not significantly related, vocal quality categories and Rorschach scores
were. The Rorschach scores used in this study are called Rorschach function scores (Gaylin,
1966), which had been derived from a previous study. The Rorschach function scores reflected
the client’s “immediately available resources for engaging in a creative perceptual process” (Rice
& Gaylin, 1973, p. 134).
The results of the study indicated that clients with a Focused vocal quality had Rorschach
function scores showing high energy and high “internal organizational complexity” (Rice &
Gaylin, 1973, p. 137). Rice and Gaylin (1973) suggested this meant that clients using
predominantly Focused category “were able to bring to the therapy task resources of a high
order, immediately usable energy coupled with the availability of inner input, which could be
explored in complex and creative ways” (p. 137). In contrast, clients using Externalizing vocal
quality had fewer and less complex Rorschach responses. This finding was interpreted as
providing support for the clinical impressions and some research which suggested that people
speaking with Externalizing vocal quality lack awareness of their inner experience and that they
have “a preoccupation with the formal at the expense of the affective” (Rice & Gaylin, 1973, p.
137). However, Rice and Gaylin (1973) explained that the nature of the Rorschach test did not
enable the researchers to determine whether or not the client directed his or her attention outward
in order to have an impact on other people.
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For clients with Limited vocal quality, the low number of Rorschach responses
corresponded to the low energy defining that vocal quality category. But, clients speaking
primarily in Limited vocal quality also responded with a large proportion of nonform
determinants. Rice and Gaylin (1973) explained that this finding suggested that Limited speakers
are quite aware of their emotions, but that they may suffer from “too much affectivity, imagery,
etc., compressed into too meager an output” (p. 138). Lastly, their Rorschach responses showed
the lowest organizational ability, suggesting “a withholding of affect that is potentially available,
possibly in quantities too difficult to handle” (Rice & Gaylin, 1973, p. 138).
Rice and Gaylin (1973) suggested that in order for clients to make use of client-centered
therapy they must be able to make “an intensive, self-directed inner search” which “requires
precisely the kind of functioning that is characteristic of the focused group,” which is “the ability
to interact freely with one’s own affect, imagery, impulses, etc., yet with controlled
concentration rather than free association” (p. 138). Because their findings linked vocal quality
to different personality-related capacities for engaging in psychotherapy, the researchers
suggested future research could focus on determining whether people with particular vocal
styles, as well as other characteristics, were better suited for particular treatments than others.
Emotional States.
Therapists also attend to their clients’ observable nonverbal behaviours for the information
they provide about their internal emotional experience (e.g., Elliott, Watson, Goldman, &
Greenberg, 2004). Greenberg and Johnson (1988) explained that, “nonverbal emotional
expression is clearly a visible and observable signal accompanying an emotional state” (p. 15).
While this is particularly important for therapists trained in emotion-oriented treatments like
gestalt therapy (Rosner, 1996), therapists from other treatment orientations also value nonverbal
14
information. For example, Bady (1985) explained psychoanalyst Karpf’s (1980) position that
vocal qualities are “among the other nonverbal cues are reflecting intrapsychic conflict in the
patient and alerting the therapist to opportune times for intervention” (Bady, 1985, p. 480). Also,
even though cognitive behaviour therapy (CBT) is not known for its focus on the client’s
emotional state, exercises such as thought records include the client’s emotional state before and
after formulating an alternative view of a disturbing experience (see psychologytools.org for a
thought record worksheet). Helping the client identify his or her emotions during this exercise
can come from drawing the client’s attention to his or her expressions of sadness or relief, for
example.
Of the nonverbal behaviours, vocal quality is an especially clear indicator of emotion.
For example, listeners are able to discern some emotional states from the speaker’s vocal quality
alone, without words (e.g., Mohr, Shoham-Salomon, Engle, & Beutler, 1991). Also, listeners are
able to identify emotion from vocal quality samples just as well, and in some cases even more
effectively, than if they are also able to see the speaker’s facial expressions (Kappas, Hess, &
Scherer, 1991). Also by using “content-free” vocal quality samples, Scherer, Banse, and
Wallbott (2001, p. 87) demonstrated that there is significant cross-cultural agreement in
identifying emotions just from vocal cues. Scherer et al. (2001) had 428 participants from nine
countries listen to the “content-free” (p. 87) vocal quality samples of German actors expressing
different emotions. There was significant agreement among listeners about which emotions were
being expressed in the vocal quality samples. This led Scherer et al. (2001) to comment that
there may be “similar inference rules from vocal expression [of emotion] across cultures” (p. 76).
However, there was also enough disagreement that Scherer et al. (2001) “concluded that culture-
and language-specific paralinguistic patterns may influence the decoding process” (p. 76).
15
Level of arousal.
Sounds of the client’s vocal quality such as squeaks, mumbles, droning, and angry shouts
for example signify different emotional intensities. Evaluating the intensity of the client’s
emotional expression is important to clinicians for a number of reasons. The client’s high
intensity expression alerts the CBT therapist to the arousal of “hot” cognitions (e.g., Samoilov &
Goldfried, 2000) and the PE-EFT therapist to activation of important emotion schemes (e.g.,
Greenberg, Rice, & Elliot, 1993). To gauge arousal in research contexts, scales have been
developed such as the Client Emotional Arousal Scale revised (CEAS-r; Machado, 1992) and
Client Expressed Emotional Arousal Scale III—Revised (CEAS; Warwar & Greenberg, 1999).
Both are ordinal scales in which the intensity of the speaker’s vocal quality is used as one of
several indicators of emotional arousal.
Research using the CEAS-r has shown a correspondence between emotional arousal and
problem resolution (Greenberg & Malcolm, 2002) as well as to the client’s report of change after
a session (Goldstein, 2002). Ratings using the CEAS-r have also differentiated between
treatment approaches, as seen in the study conducted by Rosner, Beutler, and Daldrup (2000) of
a cognitive therapy and an emotional expressive therapy.
Carryer and Greenberg (2010) used the CEAS to investigate the most therapeutically
productive amount of emotional intensity. They wrote that using the CEAS to rate the client’s
arousal from videotapes involves evaluating the level of emotion in the client’s vocal quality:
“Emotional vocal quality is indicated by irregular patterns of accentuation, an uneven regularity
of pace, and unexpected terminal contours, suggesting accessibility to feelings” (Carryer &
Greenberg, 2010, p. 193). The authors found that a moderate amount of emotional expression
was more beneficial than either low or high amounts. This tends to fit with the idea that
16
emotional arousal is effective if it is at an intensity that activates the client’s problematic
emotion, but still permits the client to make new cognitive sense of his or her experience in the
session (e.g., Kennedy-Moore & Watson, 1999; Marks, 1991).
Psychopathology.
In addition to promoting the patient’s vocal quality as a diagnostic tool, Moses (1954)
wrote that, “one can go so far as to say that vocal expression is a record of the history of
mankind as well as a record of the individual” (p. 5). Moses (1954) presented the schizophrenic
patients’ vocal quality as evidence of this because it “has a marked archaic character, with
primordial attributes” (p. 5). In contrast, the neurotic patient’s vocal quality reflects his own
delayed development.
Though Moses’ (1954) explanations may not seem plausible today, his premise that the
speaker’s vocal quality reveals his or her psychological state holds true today and continues to be
supported by research linking mental health to paralinguistic cues and emotional arousal. Ozdas
et al. (2004) described the diagnostic value “at a noncontent level” (p. 1530) of the speaker’s
vocal quality from a physiological, emotional arousal perspective. Ozdas et al. (2004) wrote:
There is considerable evidence that emotional arousal produces changes in the speech
production scheme by affecting the respiratory, phonatory, and articulatory processes that
in turn are encoded in the acoustic signal. This is largely due to the fact that vocalization
reflects the activity of many different aspects of the functioning of the neurophysiological
structures. (pp. 1530-1531)
Acoustic parameters measure different qualities of the speaker’s vocal quality. The
parameter used most widely in psychopathology investigations is fundamental frequency (fo)
(e.g., Ozdas et al., 2004). Fundamental frequency is the sound wave that “color[s]” (Scherer and
17
Zei, 1988, p. 179) the speaker’s vocal quality with prosodic and emotional information (e.g.,
Ellgring & Scherer, 1996). The fundamental frequency of a person’s vocal quality is heard by
listeners as baseline pitch or that aspect of a speaker’s vocal quality that is unique and identifying
of him or her.
According to Scherer and Zei (1988), there are several factors that influence the speaker’s
pitch, including emotional arousal. The reason for the latter is that sound waves are created by
air being pushed from the lungs through the speaker’s vocal folds. The vocal folds are muscles
which open and close at different rates depending on their level of tension. Tension in the vocal
folds is related to the “overall muscle tension of the speaker” (Scherer, 1979b; Scherer, 1986, as
cited in Ellgring & Scherer, 1996, p. 87). An example of this is that a relaxed person sounds
calm because “relaxed muscular walls of the vocal resonators… ‘damp’, stop or absorb high
frequencies and produce a mellow tone” (Green, 1964, p. 53, as cited in Laver, 1980, p. 142). In
contrast a person who is tensed up from anxiety or fear for example could have vocal folds with
“taut muscular walls” that would “act as reflectors and produce harsh tone” (Green, 1964, p. 53,
as cited in Laver, 1980, p. 142). This high tension in the vocal folds can make the speaker’s
vocal quality sound high pitched (e.g., Hagenaars & Minnen, 2005).
Scherer and Zei (1988) suggested this relationship between the speaker’s body tension
and vocal fold tension can explain the seemingly contradictory results from research on the vocal
characteristics of depressed patients. Although the link between depression and altered speech
has long been accepted, some studies report high fundamental frequency for depressed
participants while others report low fo. Scherer and Zei explained that while there are other
possible reasons for these conflicting results, it could be that low frequencies characterize the
vocal qualities of patients with retarded depression while high frequencies characterize those
18
with an agitated depression. Scherer and Zei (1988) wrote, “it is important to note that agitated
forms of depressive symptomatology are generally considered to contain significant levels of
anxiety, which leads to an increase in fundamental frequency variation” (p. 1531).
Using vocal quality to guide treatment interventions.
Therapists also listen to their client’s vocal quality to signal the right moment for a
particular treatment intervention as well as to assess the effect of the intervention. For example,
process-experiential researchers pay attention to client behaviours, or markers, which may
indicate that the client is dealing with his or her psychological experience in a potentially
problematic way. Elliott et al. (2004) wrote that, “markers are client statements or behaviors that
alert therapists to various aspects of clients’ functioning that might need attention (p. 55).
In describing his study of the gestalt two chair intervention for “conflict splits”,
Greenberg (1979) explained that the therapist can use nonverbal clues about the client’s
cognitive-affective state to determine if and when to begin this intervention. Greenberg (1979)
wrote:
The client’s voice may suggest a certain urgency, his body an agitation; some increased
intensity of feeling is portrayed by the way in which the person talks about his
experiences. A difference is observed, some aspect of the client comes alive for the
therapist and it is this present cue which prompts the therapist’s intervention. (p. 319)
The therapist’s vocal quality: The therapist’s vocal quality as a treatment intervention
The vocal quality of the therapist has been seen as useful in treatment when it evokes the
client’s memories (Wrye, 1997); provides the patient with a connection to the analyst that is
potentially evocative and soothing, like the connection between a mother and child (Bady, 1985;
19
Stone, 1961); and supports the client in various emotional states (Bady, 1985). The therapist’s
vocal quality has also been linked to helping the client engage more productively in therapy.
Wrye (1997) referred to the work of Welch (1978) and Kahne (1995) when she explained
that psychoanalysts have compared the relationship between them and their patients to the
relationship between mothers and their children. This special psychotherapeutic relationship
evokes “sensual memories” (Wrye, 1997, p. 361) of the patient’s mother which may be
important to analyze in the session. Moreover, Wrye urged analysts to be aware of their client’s
nonverbal signalling for this kind of attention. Wrye (1997) commented that it is easy for
analysts to focus on the content of what their patients say rather than listening with “our third ear
for sounds we may be unaccustomed to hearing and to absorbing our patient’s need at certain
points in the treatment” (p. 365). For example, clients may need “to be rocked simply in the
lullaby of our voices, our enfolding sound envelope, or bathed in a ‘wordbath’” (Wrye, 1997, p.
365).
The parallel between the analyst using his or her vocal quality to sooth the vulnerable
patient is similar to Stone’s (1961) concept of the mother’s vocal quality forming a
“psychobiological bridge” (p. 86) for the child, enabling the child to keep her presence with him
even when she is out of sight. In referring to Stone’s (1961) writings, Bady (1985) commented
that, “speech is a form of human contact that the child learns while achieving actual physical
separation from the mother” (p. 483). In the case of the patient, the psychoanalyst’s vocal
quality is the main form of physical connection the patient can have with him or her. In this
way, the psychoanalyst’s vocal quality forms a “psychobiological bridge” to the patient (Stone,
1961, p. 86), assisting in his or her psychological development (Wrye, 1997).
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In addition, Bady (1985) listed the various ways she uses her vocal quality to help her
clients move through important psychological states. Bady (1985) wrote:
I will intentionally use my voice along with my words. Sometimes I attempt through
vocal tones to sooth an anxious, agitated patient. Other times I use my voice to stimulate
a depressed and hopeless one. On still other occasions I talk to give the patient a human
response and my words are less important than the vocal indication of my presence.
Sometimes I remain silent in order to encourage separation from me. (p. 483)
Elliott et al. (2004) also commented that the empathic and caring therapist “speaks in a
gentle, prizing way, with a quiet, caring voice that respects the client’s fragile feelings as if
speaking to a small, frightened animal” (p. 133). In addition, there is research support for the
therapist’s use of vocal quality in this facilitative manner. For example, Ritchie (1998) cited
Old’s (1983) findings that a client was more likely to talk about personal issues when the
therapist used a mild vocal quality. Ritchie also cited Knowlton’s (1989) findings that the
optimal therapist vocal quality with which to deliver progressive muscle relaxation instructions
to anxious clients is one that gradually slows and softens.
Mutual influence of the client’s and therapist’s vocal qualities
While previously mentioned work concentrated on the idea of nonverbal behaviours of
two or more interactants converging or synchronizing, Lynch’s (1979) experiment showed how
physiological matching or harmony is associated with the therapist’s enhanced focus on the
patient. The study, discussed briefly in Bady (1985), demonstrated how the interaction between
the therapist and client can be so synchronous that even their hearts beat to a similar rhythm.
Lynch conducted experiments involving cardiac patients and their psychotherapists. In some of
these experiments, the heart rates of the psychotherapist and cardiac patient were monitored.
21
Bady (1985) wrote that “all experiments found a close coordination in increase or decrease of
heart rate between the two persons according to the material being discussed” (p. 488).
However, the “cardiac relationship was closest in those sessions where the therapist reported he
felt least distracted by personal concerns or counter transference responses to the patient” (Bady,
1985, pp. 488-489).
Mutual influence has also been a focal interest in the psychotherapy domain. Butler,
Rice, and Wagstaff (1962) were client-centered therapy researchers who discussed the power of
both the client and therapist to draw one another into different states of functioning through their
individual styles of participation. Insights about client-centered theory gained from previous
work about how people self-actualize, or strive to fulfill their potentials (see Butler & Rice,
1960) led Butler et al. (1962) to consider this possibility. Butler et al. (1962) concluded that
people are driven to self-actualize by a primitive, basic drive which they called “stimulus
hunger” (p. 187). “Stimulus hunger”, in theory, makes people want to have new experiences or
stimulation (Butler et al., 1962, p. 187). Stimulation could be in the form of obtaining things or
objects, but it could also be achieved through changing the degree or type of experience.
“Stimulus hunger” was also understood as having both the power to drive people toward
dark and self-destructive stimuli as well as toward positive and healthful experiences (Butler, et
al., 1962, p. 188). For example, the act of working toward having a new psychological
experience, like clients do in psychotherapy, would be considered a positive result of the
“stimulus hunger” drive (Butler, et al., 1962, p. 188). In fact, Butler et al. (1962) suggested that
psychotherapy provides a potentially tremendously satisfying experience for a client’s “stimulus
hunger” drive, despite the emotional pain that is often involved (p. 188).
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Butler et al. (1962) and Rice (1965) suggested that the therapist’s “style of participation”
in the therapy process can either help clients satisfy their “stimulus hunger” drive--through
assisting them to create new psychological experience--or constrict clients’ ability to engage in
the therapy process, thus frustrating the “stimulus hunger” drive (Butler, et al., 1962, p. 188).
Butler et al. (1962) suggested that the therapist’s “style of participation”, including vocal
behaviours, “with the greatest connotative range, with the most far-reaching reverberations
within the organism” would result “in a maximum of satisfying experience” (p. 188).
Also, although Rice and Kerr (1986) did not refer specifically to styles of participation,
they did suggest that the therapist’s effective “style of participation” would provide the client
with a model of how to explore and process cognitive-affective information. For example, when
the client-centered therapist is trying to articulate the essence of the client’s experience, his or
her vocal style can sound fragmented, unpredictably fast or slow, with abrupt halting and
resuming of speech. Rice and Kerr suggested that just hearing this different style of putting
one’s inner thoughts and feelings into words could help the client to do the same. About this
style of speech, sometimes referred to as Expressive or Irregular, Rice and Kerr (1986) wrote
that, “if a therapist can slow a client’s pace to match this voice quality, it may in itself facilitate
exploration by breaking up habitual cognitive patterns and introducing gaps in the client’s rush
of externalizing verbiage” (p. 96). While this theoretical point comes out of the client-centered
tradition, Rice (1965) commented that the goal of all therapists, regardless of theoretical
orientation, is to help the client generate new experience.
Butler et al. (1962) also commented that instead of helping the client, the therapist’s
vocal quality could also be unhelpful or even damaging to the client. For example, a therapist
whose vocal quality conveys harshness, disinterest, detachment, or authoritarian attitude will
23
thwart the client’s efforts to satisfy his or her “stimulus hunger” drive (Butler, et al., 1962, p.
188). The authors also warned that the client’s vocal quality could adversely influence the
therapist. For example, a client’s dull and disengaged vocal “style of participation” could
enervate and dampen the therapist’s own “style of participation” without him or her even being
aware that this is happening (Butler, et al., 1962, p. 189). Butler et al. explained that even if
these client behaviours are the result of his or her emotional problems, they could neutralize or
diminish the therapist’s effective style of participation and, ultimately, undermine the healing
potential of the therapy. The researchers advised that if the therapist can maintain “stylistic
independence” from the client, then he or she can continue to stimulate the client in the direction
of new psychological insights, helping him or her to open up to novel experiences, which they
can explore and make sense of together (Butler, et al., 1962, pp. 189-190).
Butler et al. (1962) researched vocal quality in psychotherapy in order to learn what kinds
of therapist behaviours would “stimulate the client to generate new experience for himself” and
which client behaviours are associated with the client’s engagement in self-actualizing, being
“open to the creation of new experience” and breaking “through the endless repetition of
experience so characteristic of maladjusted persons” (pp. 188-189). To investigate these
behaviours as they occur in the therapy sessions, two scales were developed: One was called the
Client Classification System and the other the Therapist Classification System. To create both
scales, the client’s and therapist’s behaviours were observed as they occurred in the therapy hour.
These observations, coupled with theory, were used to create scales that were more objective, as
opposed to being based on “supposed clinical meaning” (Butler et al., 1962, p. 190).
The Client Classification System was composed of three classes including level of
expression, quality of participation and voice qualities and manner of speaking. Subclasses of
24
the voice qualities and manner of speaking class were defined by the amount of energy in the
vocal quality, the direction of this energy (inward or outward), and the level of control of this
energy (e.g., did the vocal quality convey controlled energy or did the energy sound as if it were
pouring forth without control?). Terms such as hesitations, pace, pitch and stresses in speech
were also used to describe the categories.
The Therapist Classification System was also composed of three classes including
freshness of words and combinations, functional level of response, and voice quality. The
therapist’s vocal quality class consisted of several subclasses, each described in terms of varying
amounts of energy, control, and newness vs. closure. They were also described with
paralinguistic terms such as inflection, pitch, and accentuation.
To study the elements of effective psychotherapy, Butler et al. (1962) planned to “apply
and analyze separately the classification systems for client and therapist, treating the responses of
client and therapist separately, and then to treat each dyad of client-therapist response as a unit”
(p. 194). Studies in the 1960’s and 1980’s addressed each of the goals and led to measures of
client and therapist vocal quality known today as the Client Vocal Quality and Revised Therapist
Vocal Quality systems. Studies related to the therapist’s vocal quality, the client’s vocal quality,
and to their vocal qualities together are presented below.
Studies of the therapist’s vocal quality
The major studies using scales specifically developed to evaluate the therapist’s vocal
quality in psychotherapy sessions include Rice (1965), Duncan, Rice, and Butler (1968), and
Kerr (1983). Rice’s (1965) study investigated the three main classes of the Therapist
Classification System in relation to one another. Duncan et al. (1968) researched sessions
identified as “peak” and “poor” using paralinguistic terms such as intensity and pitch and speech
25
fluency (p. 566). The authors wanted to know “could these significant therapy hours be
differentiated by taking only voice quality into account, quite apart from content?” (Duncan,
Rice, & Butler, 1968, p. 566). Kerr’s (1983) study refined the vocal quality scale to its current
form, known as the Revised Therapist Vocal Quality scale or Revised TVQ and then analyzed
the categories in relation to outcome measure scores for clients.
Rice (1965).
Rice (1965) used the Therapist Classification System to explore the therapist’s behaviour
in client-centered therapy. The study was based on the theoretical position that “one of the
primary functions of the client-centered therapist, or indeed of any therapist, is to help the client
to generate new inner experience” (Rice, 1965, p. 156). Rice (1965) continued:
Even when the content of the therapist’s response is within the client’s internal frame of
reference…there is a range of possible responses, all equally accurate perhaps, but with
different stylistic qualities, having sharply different kinds of stimulus value for the client.
The more expressive the verbal and vocal behavior of the therapist, the more the client is
stimulated to generate new experience. The more constricted the therapist’s behavior, the
more the client tends to be confined within the grooves of his own repetitive thinking
process. (p. 156)
There were three subclasses used to categorize the therapist’s vocal quality: Expressive,
Usual, and Distorted. Each subclass was described in paralinguistic descriptors such as “pace,
hesitations, pitch range, patterns of emphasis, etc.” (Rice, 1965, p. 156). The Expressive
category was described this way:
This voice is characterized by high energy used in a controlled but not constricted way.
Color and range are present in the voice, but not to the extent of emotional overflow. The
26
pitch range is wide, and although there is considerable emphasis, it is irregular and
appropriate to the structure. (Rice, 1965, p. 157)
The second therapist vocal category, Usual, was characterized by a narrow range for pitch, but
sufficient energy. Distorted was the last vocal category which could vary in terms of energy and
pitch. For the Distorted vocal quality, “the most distinguished feature is the regular emphasis,
seemingly for effect rather than for spontaneous meaning. There is a subtly cadenced or sing-
song quality, in which emphasis is shifted from its natural location” (Rice, 1965, p. 157).
The other two categories of the Therapist Classification System were freshness of words
and combinations and functional level. The former category referred to therapist’s language,
with effective language stimulating the client’s own capacity for making more complex
associations and more vivid and rich “inner experience” (Rice, 1965, p. 156). One subcategory
of the freshness of words and combinations was defined by evocative therapist language having
“high imagery, auditory and kinaesthetic as well as visual” (Rice, 1965, p. 156) characteristics.
The other subcategory was called ordinary language because of its mundane quality. The
functional level category is based on the assumption that “the stance the client takes toward his
own experience may be much influenced by the expressive stance that the therapist takes in
response to his message” (Rice, 1965, p. 157). Functional level referred to therapists responding
to the clients’ stances of exploring their inner worlds, observing them, or attending to situations
outside of themselves.
Rice’s (1965) study consisted of 20 client and therapist pairs. There were no reported
diagnoses for the clients who received Rogerian psychotherapy at the University of Chicago
Counseling Center. The number of psychotherapy sessions the clients had received ranged from
six to 68. The therapists also had a wide range for experience. The success of each case was
27
determined by the therapist and the study included nine successful cases, four identified as
moderate to limited success, and seven considered to be poor. The second and the penultimate
sessions were selected for rating. To select the therapist responses that would be rated, Rice
divided each session using time to identify the beginning, middle, and end phases. Ten
responses from each phase were rated on each of the three components of the Therapist
Classification System: Freshness of words and combinations, functional level, and vocal quality.
A factor analysis of the ratings was then conducted which resulted in three factors. Rice
(1965) referred to the Type I factor as the “garden variety” (p. 158) because the therapist’s
language was Usual with an “even and relatively uninflected” vocal quality (p. 158). Most
responses in the Type I factor addressed the observations the client made about “the self as an
object” (Rice, 1965, p. 157), with little attention paid to the client’s inner exploration. Type II
was defined by the therapist’s Distorted vocal quality and involved a limited number of fresh and
connotative responses. Attention was directed mainly to the client’s observations of himself.
Type III was characterized by the therapist’s use of expressive vocal quality, fresh and
connotative language, and attention to the client’s inner exploration.
Rice (1965) then conducted a correlation analysis with these three therapist factors and
several criteria used to evaluate the success or failure of the treatment for the client. The criteria
were based on both the client’s and therapist’s perspectives. Taken together, the results showed
that in both the second and penultimate sessions, Type II, characterized by Distorted vocal
quality, was related to cases which both the therapist and client saw as unsuccessful. The
therapist’s vocal quality in the Type II factor sounded planned as if the therapist were trying to
have an impact on the client as opposed to sounding spontaneous. In contrast, Type III in the
penultimate session was associated with successful treatment according to both the therapist’s
28
and client’s evaluation. The therapist’s vocal quality in the Type III factor was Expressive. An
Expressive vocal quality is full of controlled energy, with a wide pitch range and an irregular
pattern of emphases on the words but not because the speaker is hesitant, but because he or she is
searching for the word that best describes the client’s experience.
In the last test of the study, Rice (1965) grouped therapists according their level of
experience. A Mann-Whitney U test compared the experienced and inexperienced groups on the
three factors. The results showed that “experienced therapists show significantly more Type III
behaviour than do inexperienced ones both early and late in therapy” (Rice, 1965, p. 160). This
meant that experienced therapists tended to use Expressive vocal quality more than the
inexperienced therapists.
Duncan, Rice, and Butler (1968).
Duncan et al. (1968) conducted a factor analysis of paralinguistic patterns and sessions
rated as either exceptionally good or poor sessions. Nine therapists, all from the Counseling and
Psychotherapy Research Center of the University of Chicago, submitted two of their own
sessions. One session was selected because it was evaluated as a “peak” or good session and the
other was considered to be poor session (Duncan et al, 1968, p. 566). These sessions were rated
on the therapists’ vocal patterns that Duncan et al. (1968) described in combinations of
paralinguistic qualities such as intensity, pitch height, vocal cord control (referred to as vocal lip
control), and speech nonfluencies, such as unfilled hesitation pauses, filled hesitation pauses and
repeats (e.g., not completing sentences and false starts).
The analyses produced three factors that distinguished the session types. Duncan et al.
(1968) provided paralinguistic descriptions of each factor as well as audio impressions each
factor was thought to make on the listener. The therapists’ vocal qualities associated with Factor
29
I were described as sounding “dull and flat, rather uninvolved” and at times, it seemed as if the
therapists were “speaking for effect” (Duncan et al., 1968, p. 569). In Factor III, the therapists’
vocal qualities consisted mainly of filled pauses. Filled pauses are utterances such as “uhm” or
“uh”. Both of these Factors were associated with the poor sessions. In contrast, Factor II was
associated with peak sessions and was described as lacking filled pauses, having an “oversoft
intensity with overlow pitch” and giving the “impression of being serious, warm, and relaxed”
(Duncan et al., 1968, p. 569).
Despite the striking contrast between the factors, the authors warned that the results
should be interpreted with caution. The reason for this is that there was only one male in the
peak group and only two women in the poor group. Because of this, the results should be
interpreted in light of the fact that “the peak behaviors were used by the therapists in
communicating primarily with females and the poor behaviors used in communicating primarily
with males” (Duncan et al., 1968, pp. 569-570).
Kerr (1983).
Kerr (1980, 1983) revised the Therapist Classification System for Vocal Quality
described in Rice (1965). Now known as the Revised Therapist Vocal Quality (TVQ), the
system consists of seven nominal categories representing different patterns of vocal quality.
Each of the TVQ categories is described thoroughly in the Method section. However, the TVQ
categories of special importance in this review of Kerr’s (1983) study are explained here also
using paralinguistic terms and the expected impact on the client. The first category was called
Softened because the vocal quality does sound soft, with a lower pitch and slower rate of speech.
Softened vocal quality conveys “intimacy and involvement” (Kerr, 1983, p. 30). The second was
the Irregular category which reflects the therapist’s deep attunement to and involvement in the
30
client’s psychological exploration. The therapist’s vocal quality lacks fluency as a result of
unfilled pauses, emphases in unusual places, and ragged-sounding phrases or sentences.
Irregular vocal quality is closest to the Expressive therapist vocal quality category which was
associated with good treatment outcomes described in Rice (1965). The third category was
called Natural vocal quality. While it sounds similar to a vocal quality used in daily
conversation, it is different in that it is “unstrained and natural”, giving the listener the sense that
the speaker is interested in what the listener has to say (Kerr, 1983, p. 31).
The fourth category, called Definite, was described as moderately energetic, sometimes
taking on a pattern in which sentences end in a downward sloping pitch. This pattern can turn
Definite vocal quality into a “confrontational vocal quality” and make the speaker “sound
somewhat overbearing” (Kerr, 1983, p. 31). This vocal quality category seems closest to Rice’s
(1965) Distorted therapist vocal quality in which “the most distinguished feature is the regular
emphasis, seemingly for effect rather than for spontaneous meaning” with a “sing-song quality,
in which emphasis is shifted from its natural location” (Rice, 1965, p. 157). In Rice’s (1965)
study, this vocal quality was associated with psychotherapy cases which were evaluated as
failures by the therapists.
Finally, the Restricted category does not seem to fit with therapist vocal categorizations
mentioned in previous studies. The Restricted vocal quality in the TVQ however was thought to
adversely affect the client because it conveys tension and even insensitivity. While the speaker’s
vocal quality has enough energy to give over the message or content, the vocal quality also
sounds like the speaker is holding back or keeping him or herself distant. Kerr (1983) wrote,
“the voice can be slightly tremulous, whiny, droning or sounding as though the air is escaping
before the word is formed” (p. 31).
31
In this study, Kerr (1983) used data from an Interpersonal Process Recall (IPR) study
conducted by Elliott (1979). In the IPR study, the therapist and client, separately, reviewed a
video tape of the therapy session soon after it occurred. They evaluated the therapist’s responses
in the session on a questionnaire of items rated on a Likert scale. The results of the IPR
questionnaires (Elliott, 1978, as cited in Kerr, 1983, p. 100) produced four evaluations from the
client’s perspective and four from the therapist’s perspective. One of the client’s evaluations
was called CEmp and referred to the client’s rating of the therapist’s empathy for him or her.
This evaluation was based on the question: “When your therapist said that, did you feel
misunderstood or understood?” A second client evaluation was called CHelp, or the client’s
rating of the therapist’s helpfulness to him or her, and came from the question: “When your
therapist said that, did it hinder or help you?” CAff, or the client’s rating of the therapist’s
affective impact on him or her, was based on the question: “When your therapist said that, did it
make you feel worse or better?” The last evaluation, CCog, referred to the client’s rating of the
therapist’s cognitive impact on the client and is based on this question: “Did what s/he said make
you think more or less?”
The therapist’s evaluations were based on a questionnaire that paralleled the client’s
questionnaire. The abbreviations for the therapist’s evaluations are TEmp, THelp, TAff, and
TCog. These evaluations refer to the therapist’s ratings of his or her own impact on the client in
these four dimensions. Finally, there were evaluations made from the observer’s perspective. In
this study, five undergraduate students rated the therapists’ responses as the observers. Each was
also made on a Likert scale and included ObHelp or a measure of General Helpfulness ranging
from the therapist’s being helpful to hindering the client. ImpExpl, or the Impact on Exploration
evaluation, was based on the question: “Does the response facilitate the Helpseeker in further
32
exploring or in bringing up new material? Or does it block or distract Helpseeker?” (p. 102).
The Collab or measure of collaboration was based on the question: “Does the Helper’s manner
communicate a sense of working together in a collaborative process?” Finally, a measure of the
Therapeutic Alliance was also given for the session overall.
In the IPR data set used for Kerr’s (1983) study, there were 16 client-therapist dyads
having the above post-session ratings. The therapists were psychodynamic in their orientation.
The author divided each session into three phases with the first starting 5 minutes into the
session, the next was 25 and the last was 40 minutes into the session. Responses in each phase
were analyzed according to the revised TVQ. Two hundred and sixteen therapist responses were
then analyzed. Kerr (1983) correlated the “proportions of the TVQ categories across the session
with the averaged evaluative measures for all responses” (p. 52).
Kerr’s (1983) results showed that the therapists’ responses made in Irregular vocal
quality were associated with the clients’ evaluation of feeling their therapists understood them
(CEmp; r = .52), helped them (CHelp; r = .60), made them feel better (CAff; r = .40), and made
them think more (CCog; r = .43). From the therapist’s perspective, responses made in Irregular
vocal quality were associated with the therapists’ evaluation that they were more helpful to the
client (THelp; r = .44) and made the client feel better (TAff; r = .45). Irregular vocal quality
was also associated with the observers’ evaluations that the therapist had succeeded in creating a
strong Therapeutic Alliance (r = .50), that the therapist was helpful to the client (ObHelp; r =
.62); collaborated well with the client (Collab; r = .46), and facilitated the client’s exploration
(ImpExpl; r = .51). For all results, see Kerr (1983, p. 53).
According to Kerr (1983), the results for the therapist’s Restricted vocal quality,
however, were negatively associated with many evaluations. From the client’s perspective,
33
therapist responses made in Restricted vocal quality were associated with the client’s feeling that
the therapist did not understand him or her (CEmp; r = - .51). From the therapists’ perspective,
responses made in a Restricted vocal quality were associated with the therapists’ view that they
hindered the client’s progress (THelp; r = - .50) and made the client feel worse (TAff; r = - .57).
Finally, from the observers’ perspective, Restricted therapist responses were associated with
poorer Therapeutic Alliances (r = - . 42).
In addition to Irregular and Restricted vocal qualities, Kerr (1983) reported that there
were also significant results for Natural and Definite vocal qualities. There were no results for
these categories with the client’s evaluation. However, from the therapist’s perspective, Natural
vocal quality responses were associated with making the client feel misunderstood (THelp; r = -
.53). In contrast, responses made in Definite vocal quality were associated with the therapists’
evaluation that they helped the client (THelp; r = .62) and that they made the client think more
(TCog; r = .53). There were no significant results for the Softened vocal quality.
In her summary, Kerr (1983) suggested that these results point to Irregular and Restricted
vocal qualities as being very important in treatment given their significant correlations with all
three perspectives. Irregular vocal quality was thought to represent “a style that is very
productive in therapy for both therapist and client” (Kerr, 1983, p. 69), while Restricted vocal
quality reflected unproductive processes. Regarding Definite vocal quality, Kerr (1983)
suggested that during the IPR, the therapists who heard themselves speak in this self-assured
vocal quality might have paid “more attention to the remembered feeling of confidence than to
what the client’s experience is” (p. 73). This would explain why the Definite category was
associated with positive therapist ratings, but not with the clients’ or observers’ ratings. In terms
of Natural vocal quality, Kerr (1983) explained that this category was “baseline vocal quality for
34
most therapists” that “makes up almost half of the TVQ freque0ncies” (p. 72). Kerr commented
that while Natural vocal quality seems to be a neutral pattern in terms of its effect on clients and
observers, therapists saw themselves as lacking in empathy when they used this vocal quality.
Kerr (1983) wrote that clinicians may construe Natural vocal quality as “negative because it does
give the effect of not doing anything special in the way of showing either intimacy or
competence” (p. 72).
Finally, there were no significant correlations with Softened vocal quality and the IPR
measures from any perspective. However, in other analyses, Kerr (1983) found that the impact
of Softened responses “varied widely…according to which of the other categories it
accompanied” (p. 75). Responses often exhibited more than one TVQ category. The vocal
pattern most often found together with Softened was Restricted. Kerr (1983) commented that in
these instances, “the effect seemed to be of weakness or phoniness” (p. 75). In contrast, the
presence of Softened with either Irregular or Definite seemed to enhance the effect of each: “In
conjunction with ‘Softened’ they sounded more intimate, and their higher energy seemed to lend
the ‘Softened’ category more impact in a positive way” (Kerr, 1983, p. 75). Kerr (1983)
suggested that patterns of vocal qualities might explain how the Softened vocal quality seemed to
change the impact of the other categories. Referring to Elliott’s (1983) examination of
noteworthy client responses, Kerr (1983) wrote that “the important insight was stated in the
‘Irregular’ pattern but prepared, in the response just previous, by the ‘Softened’ pattern” (p. 76).
Taken together, Kerr (1983) stated, “in fact, importance of many of the TVQ categories may lie
in their patterns of use” (p. 76).
35
Summary of studies of the therapist’s vocal quality.
Rice (1965), Duncan et al. (1968), and Kerr (1983) pioneered the exploration of the
therapist’s vocal quality in the psychotherapy hour. Taken together, the findings suggest that the
particular therapist vocal qualities are differentially associated with other therapist behaviours
(Rice, 1965), different post-session evaluations (Kerr, 1983), and treatment outcome as evaluated
by the therapist alone (Duncan et al., 1968) and by both client and therapist (Rice, 1965).
Specifically, vocal qualities that sound energetic, controlled, searching (Kerr, 1983; Rice, 1965)
and soft with a lower pitch (Duncan et al., 1968) were associated with successful treatment.
As a group, the studies have some limitations. One limitation is the size of the samples,
ranging from 16 to 20 therapists, and the limited number of therapeutic orientations (e.g.,
Rogerian and psychodynamic). Also, there was no way to compare the studies due to a lack of
standardized research protocols. For example, there is no mention of diagnoses and the cases
varied in treatment lengths.
The client’s vocal quality: How the client’s use of his or her own vocal quality can facilitate
treatment
When the client speaks, his vocal quality can also help him heal. This is thought to occur
in several ways. One example is Bady’s (1985) suggestion that the physical act of speaking can
affect the body’s emotional experience. Second, as with other nonverbal behaviours,
experiential therapists might draw the client’s attention to his or her vocal quality to heighten
awareness of underlying emotions (e.g., Greenberg, 1979). They may also ask the client to
exaggerate vocal characteristics that seem to reflect something of importance to the client in
order to increase arousal (e.g., Murray & Segal, 1994). Finally, the client’s vocal quality may
help him or her to engage in therapy in a more productive manner (e.g., Rice & Kerr, 1986).
36
The physical act of speaking and emotional changes.
Bady (1985) has asserted that just by speaking, the client may be helping to heal himself
or herself. This can occur through the physical, sensory act of confining thoughts and emotions
within the boundaries of words. During this process, the speaker can feel the production of
words and sentences. Using singing as an example, Bady (1985) wrote:
If we consider the actual mechanics of vocal quality production, we realize that when we
speak, something really is happening” because articulation involves “the movement of
the diaphragm, the relaxing of jaw and throat, the vibration of airwaves in the chest and
head. (p. 487) [italics in original]
When the speaker’s vocal quality matches the content of speech, the speaker can experience an
even more powerful physical sensation. Bady (1985) suggested that a catharsis leads to relief
because of “the physical action of a strong outpouring of words” (p. 487). The reason for this is
that “it may actually feel to the person as though he is ejecting an angry or sad thought from his
body” (Bady, 1985, pp. 487-488).
Paying attention to how one sounds.
Another use of the client’s vocal quality for healing involves the clients’ becoming aware
of how he or she sounds in the moment. According to Greenberg (1979), “often clients are
engaged in certain behaviours or processes in the present that are fairly obvious but of which
they themselves are not aware” (p. 321). When the therapist believes it is helpful, he or she
draws the client’s attention to the behaviour and asks him or her to stay with the unique feeling
associated with that behaviour. For example, if the client states that a recent loss is not that
important to him, but he says this with a quiet and tremulous vocal quality, the therapist might
share his observation of this vocal quality with the client. Doing this can help the client gain
37
awareness of what the quivering in his vocal quality signifies. Drawing the client’s attention to
discrepant behaviours, as seen in the vocal quality example, is a way of putting clients “more
fully in touch with their present experiencing” (Greenberg, 1979, p. 322).
Increasing emotional arousal.
Murray and Segal (1994) wrote, “there is a good deal of emphasis in the clinical literature
on the capacity of vocal expression to arouse emotion in various forms of psychotherapy” (p.
393). In the case of experiential therapy, a therapist may ask a client to use his or her vocal
quality in order to increase emotional arousal. For example, if an edge of irritation sharpens the
client’s vocal quality when discussing how hard it is to confront his boss, the therapist might
suggest that he speak with even more irritation or even anger. This is done to increase the
client’s level of arousal so that thoughts, feelings, memories, and somatic sensations associated
with the client’s anger in this context come alive, making them more amenable to exploration
and change. In PE-EFT, this is known as activating a person’s emotion schemes. Doing this
enables the client to come into more direct contact with his or her psychological difficulty so that
it can be worked on in the session (Greenberg & Paivio, 1997).
Studies of the client’s vocal quality
The Client Vocal Quality measure, or CVQ, and its precursor, the vocal qualities and
manner of speaking component of the Client Classification System (Butler et al., 1962) have
been used in many studies to evaluate the client’s vocal quality in psychotherapy sessions.
Reviews are found in Rice and Koke (1981) and Rice and Kerr (1986). Studies by Rice and
Wagstaff (1967), Sarnat (1976), and Nixon (1980) are reviewed here because they address the
client’s vocal quality and treatment outcome. Work by Greenberg (1983) and Watson and
Greenberg (1996) have linked the client’s vocal quality to in-session processes. Finally, the
38
Wiseman and Rice (1989) and Butler et al. (1962) studies have investigated the client’s and
therapist’s vocal qualities in relation to one another.
The client’s vocal quality and treatment outcome-Butler, Rice, and Wagstaff (1962).
As part of their plan to study client and therapist behaviours that impact treatment, Butler
et al. (1962) developed the Client Classification System which included three components. The
level of expression component was used to rate “the level at which the client is dealing with and
expressing whatever subject matter is under discussion” (Butler, et al., 1962, p. 190). The
quality of participation component was used to assess whether the client was behaving as an
observer or as a participant in the session. The third classification component was the voice
qualities and manner of speaking which was used to rate the client’s vocal quality.
Ratings for the voice qualities and manner of speaking system were made based on the
amount of energy in the vocal quality, the direction of this energy (inward or outward), and the
level of control of this energy (e.g., did the vocal quality convey controlled energy or did the
energy sound as if it were pouring forth without control?). This system included four vocal
subcategories: Focused, Emotional, Externalizing, and Limited. The essential features of the
Focused category include the client’s use of energy “in a controlled problem-solving way” so
that his vocal quality “gives an impression of pondering or exploration” (Butler et al., 1962, p.
191). The essential feature of Emotional vocal quality is that the client’s energy spills outward
and his or her vocal quality “breaks, trembles, is choked with crying” (Butler et al., 1962, p.
191). The primary characteristic of Externalizing vocal quality is substantial energy, but directed
“toward having some effect on the outside world” (Butler et al., 1962, p. 191). Here the client’s
vocal quality would have a pattern and smooth rhythm, giving a “soapbox quality” (Butler et al.,
1962, p. 191). For the Limited category, the client’s energy is low and it is not clear where the
39
energy is directed, though the client’s vocal quality can come through in a “matter-of-fact, even
incidental tone” (Butler et al., 1962, p. 191). Table 1 summarizes the characteristics of vocal
quality energy, rhythm and pace of the categories.
To study the elements of effective psychotherapy, Butler et al. (1962) planned to study
the therapist’s and client’s behaviors both separately and together, intending to “apply and
analyze separately the classification systems for client and therapist, treating the responses of
client and therapist separately, and then to treat each dyad of client-therapist response as a unit”
(p. 194). This review of the study will focus only on the client’s vocal quality. Butler et al.
(1962) classified 24 cases of clients receiving Rogerian psychotherapy sessions as successful or
unsuccessful. Next, the three components of the Client Classification System (level of
expression, quality of participation, and voice qualities and manner of speaking) were used to
rate the first 10 responses from the beginning, middle, and late phases of each client’s second
and penultimate sessions. Butler et al. (1962) then conducted a factor analysis which revealed
three client factors.
According to Butler et al. (1962), in Factor I, clients expressed their inner experience
directly as opposed to speaking as if they were observers and they also spoke about their
feelings. The vocal qualities found in Factor I were Focused and Emotional. In Factor II, clients
were also engaged in the session as participants and, while they explored and expressed
psychological experience that lay “beneath the surface” (Butler et al., 1962, p. 190), they avoided
discussing their feelings. In addition, “the outstanding characteristic [of Factor II] seems to be
the low energy level of responses” with more than two-thirds of the responses in the group
40
Table 1
Features of the Vocal Qualities and Manner of Speaking categories for the Client Classification System
Emotional Focused Externalizing Limited
Qualit
y of Energ
y
“high energy level,
but the energy tends
to overflow into
discharge rather than
being used in a
controlled way”
High energy used in
a “problem-solving
way”
“fairly high energy” “low energy used in
a matter-of-fact, even
incidental tone”
Direct
ion o
f Energ
y
Energy spills into
speech, not directed
toward influencing
others.
“The energy seems to
be turned inward
rather than being
propelled outward”
Energy is “directed
outward, seemingly
toward having some
effect on the outside
world”
“It is clearly a
communication to the
therapist, but it is not
clearly directional in
the sense of” Focused
or Externalizing.
Rhyt
hm
, pace
etc
.
vocal quality “breaks,
trembles, is choked
with crying…
discharge of acute
tension”
“hesitations and
irregularities of pace”
especially “in stress
of syllables”
The vocal quality has
“cadence or rhythmic
pattern… often
mechanical
inflection”
“the pace is even and
relatively unstressed”
Note. Adapted from Butler, Rice, and Wagstaff (1962, p. 191).
41
having a Limited vocal quality in which the client’s vocal quality sounded “rather matter-of-
factly serious and lacking in search or exploring quality” (Butler et al., 1962, p. 197). In Factor
III, the clients were about evenly split as participants and observers in the session. However, the
vast majority of responses involved “ideas or actions” and not the direct expression of feeling.
The vocal quality associated with Factor III was Externalizing, with clients sounding in most
responses as if they were “dramatizing or making a speech” (Butler et al., 1962, p. 197).
In summary, the factor analysis of the client’s vocal qualities revealed that Factor I was
dominated by the Focused and Emotional categories. Limited was the major vocal quality in
Factor II. Factor III was dominated by the Externalizing category. The researchers explained
that Factor I reflected therapy characteristics that would be most beneficial to the client. They
wrote, “the client’s energy, openness of expression, and ability to directly communicate
experience seem to point toward the likelihood of favourable personal reorganization” (Butler et
al., 1962, p. 198). Factor III behaviours were viewed as representing poor client participation in
therapy and a poor prognosis. Of this Factor, Butler et al. (1962) wrote, “the self-avoidant,
nonparticipating, describing, verbal behaviour with its externalizing quality, seem unlikely to be
associated with favourable outcomes in therapy” (p. 199). The behaviour in Factor II was not as
clear. The researchers wrote, “on the one hand the client communicates relevant material in a
somewhat expressive way, but some of the important ingredients of expressiveness seem to be
missing” (Butler et al., 1962, pp. 198-199).
To test the relationship between the factors and treatment outcome, Butler et al. (1962)
then conducted a correlation analysis of these Factors with other treatment measures, such as the
therapist’s and client’s ratings of whether or not the therapy was successful. The results
indicated that Factor I (defined by Focused and Emotional vocal qualities) was associated with
42
good treatment outcomes as identified by the therapist and with the client’s report of self-change
from before and after therapy. Factor II (defined by Limited vocal quality) was associated with
partially successful outcomes. In contrast, Factor III (defined by Externalizing vocal quality)
was significantly associated with unsuccessful treatment outcomes.
The client’s vocal quality and treatment outcome-Rice and Wagstaff (1967).
Also supporting the CVQ’s relationship to outcome is a study by Rice and Wagstaff
(1967), the results of which were recomputed by Rice and Kerr (1986). In this study,
psychotherapy sessions from 53 clients from the University of Chicago Counseling and
Psychotherapy Research Center were rated. Forty-one had received 20 therapy sessions (two per
week) in the client-centered orientation. Data for the study were obtained from the first, second,
and eleventh sessions. The first and second sessions were selected for 12 early attrition clients.
Rice and Wagstaff (1967) divided each session into consecutive thirds and then rated 10
consecutive responses within each third. A total of 30 responses per session were rated on the
CVQ.
Rice and Kerr (1983) explained the outcome evaluations like this: “(1) unequivocal
success; (2) mixed group TH (high from therapist’s perspective but low from client’s); (3) mixed
group CH (high from client’s perspective but low from therapist’s); (4) unsuccessful group (as
seen from both perspectives); and (5) early attrition” (p. 82). Rice and Kerr’s (1983)
recalculation of the results indicated that clients in the unequivocal success group had
significantly more Focused vocal quality responses than clients in the unsuccessful, early
attrition, and mixed CH outcome categories. A higher number of responses made in
Externalizing voice were made by clients in the early attrition group than clients in the
43
unequivocal success one. Last, clients with unsuccessful outcomes had a significantly higher
number of Limited responses than clients in the mixed and unequivocal success groups.
The client’s vocal quality and outcome in other treatments-Sarnat (1976) and Nixon
(1980).
Because the CVQ developed out of the client-centered tradition, its originators
encouraged researchers to use the measure in different treatment conditions (e.g., Rice & Kerr,
1986). Sarnat (1976) applied the CVQ to a psychodynamic sample of N = 40. She found that
when she controlled for the number of psychotherapy sessions, there was a significant correlation
between Focused vocal quality and treatment outcome as rated by the therapist (r = .43, p < .05)
(in Rice & Kerr, 1986).
Nixon (1980) applied the measure to a wholistic primal therapy sample (N = 29).
Speech samples were drawn from the pre-treatment interview and from the second therapy
session. Nixon predicted that Focused and Emotional vocal qualities would be positively
correlated with measures of client change after treatment was completed, but that the Limited and
Externalizing vocal qualities would be negatively correlated with these outcome measures.
Measures of client change included the clients’, therapists’, and independent observers’
perspectives. Measures were obtained from before treatment began and then again, seven and a
half months after treatment was completed.
In terms of the study’s results, there were no significant findings for the Externalizing or
Focused categories. Nixon (1980) explained that reliability for the Focused category was very
poor due to the very small number of Focused responses and to the poor audibility of the audio
recordings. However, Nixon suggested that it could be that neither the Focused nor
Externalizing categories is linked to change in wholistic primal therapy.
44
In contrast, there were significant findings for the Limited category which was negatively
correlated with measures of client change from the client’s and therapist’s perspectives.
Correlations ranged from .31 to .36. The Emotional category was also significantly correlated
with change, but in the positive direction. Nixon (1980) found positive correlations between the
Emotional category and post-treatment scores on a measure from the client’s perspective called
the Q-sort Self-Ideal Correlation (Butler & Haigh, 1954) (r = .50) and on an observer rated
measure called the Psychiatric Status Schedule (Spitzer, Endicott, Fleiss, & Cohen, 1970) (r =
.54).
Importantly, while Nixon’s (1980) study was underway, raters heard a distinct type of
Emotional vocal quality which sounded as if clients were forcing the emotion out. Nixon
removed responses that sounded forced from the Emotional category and used them to create a
second category called Forced Emotional Voice. Nixon (1980) wrote that “forced emotional was
separated from the emotional category because it was felt that the two types of vocal patterns,
while sharing a common denominator of affective release, differ in terms of the manner in which
the affect is expressed” (p. 77). There were no significant results for the forced emotional vocal
category, though some findings approached significance suggesting that “forced emotional voice
quality may have value as a negative predictor in primal therapy” and that the results “certainly
justify a further exploration” (Nixon, 1980, p. 79).
The client’s vocal quality and in-session processes-Greenberg (1983).
The client’s use of Focused or Emotional vocal quality and progress in a treatment
intervention was demonstrated by Greenberg (1983), who conducted a study of the gestalt two-
chair intervention for conflict splits. Conflict split is the name for a psychological experience in
which a person feels that two parts of the self are in conflict with one another. Indications that
45
the client is experiencing a conflict split can include his or her making a statement along the lines
of wanting to do X, but not feeling entitled or able to do so. It could also be indicated by a shift
in the client’s vocal quality. For example, the client might express hopefulness about resolving a
difficult situation, but do so in a vocal quality that turns wistful at the end, suggesting that, in his
reality, he cannot be hopeful after all.
Greenberg (1983) identified three stages to the model of resolution for the two chair task:
(1) opposition, when the two sides of the self oppose one another; (2) merging, when each side
states his or her position and each is able to see the worth or intent of the other’s position; and (3)
integration, when the two sides come together to form a whole. The sides of the self are
identified like this: The side of the self represented by “the ‘other chair,’ is critical, hostile,
intimidating or threatening toward another part labeled the ‘experiencing chair,’ which is…
passively compliant, helpless or avoiding” (Greenberg, 1983, p. 191).
To study this intervention, Greenberg (1983) used the task analytic method (Gottman &
Markman, 1978; Greenberg, 1975). In the task analytic approach, aspects of the intervention that
are necessary for success are specified and then tested to determine the degree to which these
aspects distinguish groups that succeeded in the task, such as resolving their conflict, from the
groups that are unsuccessful, or that did not resolve their conflict. Greenberg (1983) expected
that the clients would use different vocal quality categories for the “other” and “experiencing”
chairs in different stages of the intervention (p. 191).
To evaluate the vocal qualities in this intervention, Greenberg (1983) used the Client
Vocal Quality (CVQ) categories. Greenberg (1983) grouped Focused and Emotional vocal
qualities into a single category called “good contact” (p. 193), indicating that the speaker is
“predominantly ‘in touch’ with him- or herself, experiencing what is being said or processing
46
new information” (p. 193). Externalizing and Limited vocal qualities were also grouped into
another single category called “poor contact” (Greenberg, 1983, p. 193), indicating that the client
is distant from his experience.
Greenberg (1983) predicted that the group that successfully resolved the conflict would
speak in more “good contact” than the group that did not resolve the conflict (p. 192). He found
that in the opposition phase, there were no significant differences in the type of “contact”
category for either the “experiencing chair” or “other chair” in the resolution and nonresolution
groups (Greenberg, 1983, p. 196). However, in the merging phase, there was a significantly
higher proportion of the “good contact” vocal qualities in both the “other chair” and
“experiencing chair” in the resolution group (Greenberg, 1983, p. 196). In addition, in the
resolution group, there was significantly more “good contact” vocal quality for the “other chair”
in the merging phase than in the opposition phase (Greenberg, 1983, p. 196). Moreover, an
additional test showed that in the resolution group, the “other chair” switched from Externalizing
to Focused at the beginning of the merging stage more often than in the nonresolution group
(Greenberg, 1983, p. 196). This point was especially meaningful to Greenberg (1983) who
explained:
It appears as though the “turning inward” by the other chair, indicated by focused voice,
is a critical aspect of the process of softening. No longer is there a lecturing at quality of
the critic, but rather a true looking inside for what is to be said. This change of voice in
the other chair seems to be an important indicator that something new is happening and
almost always accompanies the affiliative content. (p. 199)
Greenberg (1983) interpreted the study’s findings to support that idea that the client’s
vocal quality can be relied on as a “good cue of ‘true process’” in successful resolution of these
47
conflicts (p. 199). While Greenberg (1983) listed other possible reasons for these results, he
concluded that the most likely explanation is that the resolution arose through the “naturalistic,
transactional occurrence of client performance in a specific task environment” (p. 199).
Limitations of the study include its lack of generalizability beyond the gestalt two-chair task and
the correlational design which precludes inferring causality.
The client’s vocal quality and in-session processes-Watson and Greenberg (1996).
Watson and Greenberg (1996) also the investigated client change processes using the
CVQ. They used Focused and Emotional vocal qualities to demonstrate differences in problem
resolution between clients receiving client-centered therapy and clients receiving PE-EFT for
cognitive-affective difficulties such as conflict splits, unfinished business, and problematic
reactions. In this study, clients receiving client-centered therapy were used as a control group.
This was done because PE-EFT is based on client-centered therapy, but also uses gestalt
interventions for problems such as conflict splits described in Greenberg (1983). Gestalt
techniques are highly emotionally evocative. Their sample consisted of 36 clients who were
diagnosed with depression.
In addition to the CVQ, the experimenters used two other measures. One measure called
experiencing (EXP; Klein, Mathieu-Coughlan, & Kiesler, 1986) reflects the degree to which the
client is engaged in self-exploration. The second measure called Expressive Stance (ES)
indicates “the stance [the clients] adopt toward their own experience during sessions” (Watson &
Greenberg, 1996, p. 266). For example, the ES “Category 1 refers to clients focusing inside and
actively re-experiencing an emotion or feeling in the session as they try to express it in words”
(Watson & Greenberg, 1996, p. 266).
48
Watson and Greenberg (1996) found a difference between treatment groups when clients
were working on a conflict split problem. The PE-EFT clients expressed more statements that
showed the combination of productive expressive stance plus productive vocal quality (either
Focused or Emotional) than client-centered therapy clients (z = .008, p < .01). The PE-EFT
clients’ levels of experiencing were also higher than the client-centered group.
Taken together, these results support the relationship of CVQ to client processes, with
Focused and Emotional vocal qualities being associated with productive processes. Referring to
researchers such as Greenberg (1986), Watson and Greenberg (1996) also suggested there was a
“need for more micro-process analyses of the steps in the pathway to change to more fully
illuminate the active ingredients of various treatment approaches” (p. 273). While the study did
not link the CVQ measure through from the session to outcome stages of treatment, Watson and
Greenberg (1996) added that a larger sample would be needed to adequately test links between
“clients’ in-session process, degree of problem resolution, post-session outcome, and final
outcome” (p. 273).
Summary of the client’s vocal quality, treatment outcome, and in-session processes.
Taken together, studies of the client’s vocal quality have shown that productive vocal
categories (Focused and Emotional) are related to beneficial client processes (Butler et al., 1962)
and to successful treatment outcomes from the client’s and therapist’s perspectives (Rice &
Wagstaff, 1967). In psychodynamic therapy, Focused vocal quality was also related to
successful treatment (Sarnat, 1976) as was Emotional vocal quality in wholistic primal therapy
(Nixon, 1980). In terms of in-session process, Focused and Emotional vocal qualities were
judged to be “true process” signals during the merging phase in gestalt chair work (Greenberg,
1983) and were found to be more evident in the more emotionally evocative PE-EFT therapy
49
than client-centered therapy (Watson & Greenberg, 1996). Some of the limitations of the studies
were the small sample sizes, lack of generalizability, and their correlation design.
The therapist’s and client’s vocal qualities together-Butler, Rice, and Wagstaff (1962).
Although analysis of the relationship between the therapists’ and clients’ responses was
not complete at the time of publication, Butler et al. (1962) presented some findings. To analyze
the therapists’ responses, Butler et al. (1962) correlated the Expressive therapist vocal category
with the Client Classification System Factors previously described. The Expressive therapist
vocal quality category, characterized as “energetic”, “warm and confident” and as having a
“pondering, exploring quality” (p. 192) was found to be strongly and positively correlated with
client Factor I, which was characterized by Focused and Emotional vocal categories, and had
been associated with good treatment outcome. However, the Expressive therapist vocal quality
category was strongly and negatively correlated with client Factor III, which was characterized
by the client’s Externalizing vocal quality, and was associated with poor treatment outcome.
Butler et al. (1962) concluded from this and similar findings with other measures that “the
therapist behavior judged to be optimal tends to be associated with client behavior judged to be
optimal” (p. 202). No association was found between Factor II, characterized by the client’s
Limited vocal category, and the therapist’s vocal quality.
The therapist’s and client’s vocal qualities together-Wiseman and Rice (1989).
Wiseman and Rice (1989) investigated the therapist’s and client’s vocal qualities in a
sequential analysis. They used the Client Vocal Quality scale (CVQ; Rice et al., 1979), which is
described in the Method section and presented in a more general form in Table 1 and the
Therapist Vocal Quality scale (TVQ; Kerr, 1983), which uses the same therapist vocal categories
described in the Kerr (1986) study and is more fully detailed in the Method section.
50
In the sequential analysis, the client and therapist behaviours were analyzed while both
people were engaged in a treatment intervention. The client’s behaviour was recorded at time
“1”, before the therapist’s behaviour, and at time “2”, after the therapist’s behaviour. The
differences between these client behaviours were then analyzed. Wiseman and Rice (1989)
explained that “by using sequential designs in a conceptually based manner, the researcher-
clinician can study therapist-client interactions that are clinically significant and relevant to his
or her particular microtheory of change” (p. 285).
Wiseman and Rice (1989) predicted that the therapist’s vocal quality, as measured by the
TVQ, would impact the client’s cognitive-affective processing as it occurred in a client-centered
therapeutic intervention called systematic evocative unfolding (e.g., Greenberg, Rice, & Elliot,
1993). The therapist uses this intervention when the client makes a statement indicating that he
or she is puzzled or upset by his or her reaction to a specific situation. This statement is known
as a marker and its presence alerts the therapist that the client is experiencing a specific
cognitive-affective processing problem. The systematic evocative unfolding method is a
treatment for this problem and involves the therapist’s helping the client to unfold events
surrounding the perplexing event.
In the Wiseman and Rice (1989) study, two sessions from each of five female clients
receiving psychotherapy at a local university counseling center were selected. The sessions were
selected because they contained instances of the systematic evocative unfolding intervention.
Responses for the therapist and the client were rated on the Vocal Quality measures and
Experiencing scale (EXP) (Klein et al., 1986). The response was the unit of analysis and was
defined as “everything one participant said between two successive productions of the other
participant” (Wiseman & Rice, 1989, p. 283).
51
Wiseman and Rice (1989) hypothesized that the therapist’s use of Irregular vocal quality
would precede a shift in the client’s vocal quality. The hypothesized shift for the client would be
from an unproductive vocal quality, Externalizing, to a productive vocal quality, Focused. The
Focused category has been described as the client’s version of the therapist’s Irregular vocal
quality (e.g., Kerr, 1983). When the client speaks in a Focused vocal quality, he or she is
believed to be searching unexplored psychological territory in such a way as to permit new
meanings to emerge. When the therapist is speaking in Irregular vocal quality, he or she is co-
exploring new ground. During this process it appears for the therapist that “the effort to
symbolize seems to be as much for oneself as for the listener” (Kerr, 1983, p. 69).
The researchers also predicted that Irregular responses would precede a shift toward
improved client engagement in the therapy process as determined by the client Experiencing
scale (EXP) (Klein et al., 1986). Low EXP would reflect limited psychological engagement and
thus, poor processing. High EXP would reflect focused psychological engagement and,
therefore, productive client processing. Also, the peak rating of a response was evaluated on the
EXP measure in this study. The peak rating refers to the highest level of EXP reached in a
response.
The results were significant for the Vocal Quality measures: Irregular TVQ preceded the
client’s shift in vocal quality from Externalizing to Focused. In other words, the therapist’s use
of Irregular vocal quality preceded the client’s shift from speaking in an unproductive vocal
quality to a productive one. Wiseman and Rice (1989) did not test whether or not the client’s
vocal quality impacted the therapist’s vocal quality. While the analysis did not show that
Irregular vocal quality preceded a client shift from Low EXP (peak rating of 1, 2, or 3) to High
52
EXP (peak rating of 5, 6, or 7), it did show that Irregular vocal quality preceded a shift from
Low EXP to intermediate EXP (peak rating = 4).
Although the study violated the assumption of independence, the researchers saw these
results as support for the usefulness of task-focused sequential analysis for understanding how
the therapist impacts the client. They suggested that future studies link client processes at the
session level, such as systematic evocative unfolding, to end-of-treatment outcomes for
successful versus unsuccessful cases.
Different Treatments, Different Demands
Nixon (1980) attributed the lack of significant results for Focused and Externalizing
vocal categories in her study to the possibility that these vocal patterns are not central to change
processes in wholistic primal therapy. Gillies (1990) encountered a similar situation in a study in
which three patients received brief psychodynamic treatment through the Mount Zion
Psychotherapy Project. During the pilot study, Gillies (1990) listened to two audio taped
psychodynamic therapy sessions and found so few Focused examples that she consulted with
two CVQ developers. Gillies (1990) referred to her personal communication with Rice and
Greenberg who “hypothesized the Focused voice may be rather weak in psychodynamic therapy
(as opposed to client-centered or experiential therapy) because different psychological processes
may be at work” (p. 41).
Nixon’s (1980) and Gillies’ (1990) findings highlight the idea that different treatment
approaches can make different demands on the client. Rice and Kerr (1986) urged researchers to
apply the Vocal Quality scales to different treatments and problems in order to understand how
vocal quality is related to change processes in them. Rice and Kerr (1986) suggested that
examining vocal quality in cognitive behavioural therapy (CBT) would be particularly intriguing.
53
One reason this would be interesting is that the CBT client is not required to do the
emotionally-charged, self-searching that is required in experiential therapies like client-centered
and process-experiential therapies. Instead, there is a focus on understanding how one’s
thoughts lead to different emotions and behaviours. The work of CBT is on changing a person’s
thoughts, beliefs, etc., so that more comfortable or healthier psychological experiences can
follow (Beck & Weishaar, 1989 in Burgoon et al., 1993). In addition, although the processing of
emotions is becoming more valued among CBT proponents, the CBT client’s emotions have
generally been used diagnostically, such as hot cognitions which indicate that the client is in
touch with important issues (Samoilov & Goldfried, 2000). As a result, the CBT client may not
display Focused vocal quality in the amounts related to good client engagement and outcome as
seen in the studies cited above where treatments were primarily client-centered or experiential.
Regarding the therapist’s vocal quality, Kerr (1983) wrote that “one of the underlying
assumptions of the function of therapist vocal quality was that therapists will use different vocal
patterns when engaged in different help intended communications or speech acts” (p. 35). Like
the CVQ, the TVQ was also developed within the client-centered tradition. Research using this
measure found that Irregular vocal quality, which corresponds to therapist behaviours that
facilitate the client’s experiential searches (e.g., Kerr, 1983), was related to productive client
behaviours (Wiseman & Rice, 1989). Because the experiential search is not a core value of the
CBT approach, Irregular vocal quality would not be expected to be used as much in this
treatment. However, it makes intuitive sense that the CBT therapist would express warmth and
caring as well as a problem-solving attitude in his or her vocal quality. It seems that Natural
vocal quality would be an effective conveyor for these types of messages.
54
Methods of Studying Vocal Quality in the Psychotherapy Setting
In the psychotherapy setting, vocal quality has also been investigated by using acoustic
parameters such as fundamental frequency. Diamond, Rochman, and Amir (2010) measured a
number of acoustic parameters in their exploration of emotional changes in the client’s vocal
quality while he or she was engaged in a PE-EFT intervention for unfinished business. This
approach, however, has not yet been used to investigate the acoustic properties of the more
complex vocal quality patterns found in the Therapist and Client Vocal Quality scales.
Filtering the content from speech so that only vocal quality remains is another way in
which the psychotherapy client’s vocal quality has been studied. Removing the content from the
speaker’s speech is accomplished by running the audio-taped therapy sessions through a low
pass filter at 300 Hz. Mohr et al. (1991) used this technique to study anger in clients engaged in
an emotionally evocative treatment. While their results were interesting, the content-filtering
procedure has drawbacks. The problem is that low pass filters remove the upper frequencies of
sound. Verbal content is at these frequencies as well as important acoustic characteristics such
as tier and tone (Ochai and Fukumura, 1957 in Gillies, 1990). While some emotions may be
detectable after low pass filtering, more subtle variations and accents needed to judge vocal
categories in the Client and Therapist Vocal Quality scales are not (David Orgel, personal
communication, March, 2007; Rice & Koke, 1981).
Summary
Butler et al. (1962) laid out a plan to investigate the vocal characteristics of the therapist
and client as individuals and in interaction with one another. These goals were achieved over the
course of twenty plus years with several different studies (e.g., Butler et al., 1962; Rice, 1965;
Wiseman & Rice, 1989). There are some similarities in the methods of these studies, such as
55
analyzing data sets of clients treated with Rogerian style therapy and doing correlational designs
for the client’s and therapist’s vocal qualities. However, most sample sizes were small, there
were no discernible standard criteria in terms of diagnoses or treatment duration for the
participants, and different versions of the Vocal Quality scales were used in the more
contemporary studies. Several researchers suggested future investigations should involve larger
samples (e.g., Watson & Greenberg, 1996); different treatment orientations (Rice & Kerr, 1986);
and linking in-session process with treatment outcome (e.g., Wiseman & Rice, 1989).
To date, there are no studies testing the relationship of the therapist’s and client’s Vocal
Quality categories (TVQ and CVQ) in terms of the client’s report of in-session change. The
Kerr (1983) study involved the client’s evaluation of how the therapist impacted him or her, but
did not assess the degree to which the client felt he or she changed or experienced a shift in
insight from a particular session. Also, there are no studies of the relationship of TVQ and CVQ
to end-of-treatment outcome in process-experiential therapy (PE-EFT) for depression or
cognitive-behavioural treatment (CBT) for depression. As a result, the goal of the current study
is to explore the therapist’s and client’s vocal quality categories as they relate to the client’s
report of change in the session and to end-of-treatment outcome in PE-EFT and CBT treatments
for depression.
Research questions and hypotheses
Research Question 1.
The first research question is: Are the therapist’s and client’s vocal quality qualities
related to the client’s report of change? Three hypotheses follow from this.
1a. There will be a higher proportion of productive CVQ categories (Emotional, Focused,
Emotional Plus Focused) in high change than low change sessions.
56
1b. There will be a higher proportion of unproductive CVQ categories (Limited and
Externalizing) in low change than in high change sessions.
1c. There will be a higher proportion of Productive TVQ (Irregular, Softened, and
Natural) in high change than in low change sessions.
Research Question 2.
The second research question is: Are the therapist’s and client’s vocal qualities related to
the client’s scores on the outcome measures at termination? Two hypotheses follow from this:
2a. A higher proportion of the productive CVQ categories (Emotional, Focused,
Emotional Plus Focused) will predict better scores for clients on the outcome measures at the
end of treatment.
2b. A higher proportion of the Productive TVQ (Irregular, Softened, and Natural) will
predict better scores for clients on the outcome measures at the end of treatment.
Research Question 3.
The third research question is: Is there a difference in the TVQ and CVQ categories
primarily expressed in PE-EFT and CBT? Two hypotheses follow from this:
3a. CBT clients will have a lower proportion of Focused vocal quality than PE-EFT
clients.
3b. CBT therapists will have a higher proportion of Natural vocal quality than PE-EFT
therapists.
57
Chapter 2:
Method
Participants
Data for the current study were drawn from the Depression Project conducted at the
Ontario Institute for Studies in Education/University of Toronto (OISE/UT). Sixty-six clients
who were diagnosed with major depression participated in the Depression Project. Table 2
displays the clients’ demographic and pre-treatment characteristics. Clients were diagnosed with
major depression using the Structured Clinical Interview for DSM-IV (SCID-IV; First, Spitzer,
Williams, & Gibbon, 1997) and the Diagnostic and Statistical Manual for Mental Disorders (4th
ed.; DSM-IV; American Psychiatric Association, 1994). None of the participants was diagnosed
with the Axis I disorders of eating, manic depression, psychosis, or substance abuse or with the
Axis II disorders of antisocial, borderline, or schizotypal. None of the participants was at a high
suicide risk, receiving pharmacotherapy, or other psychological treatments during the study. All
clients were able to speak and understand English.
Therapists
There were 15 therapists about evenly divided between the CBT condition (n = 8) and the
PE-EFT condition (n = 7). Two therapists were psychologists and 13 were graduate students at
OISE/UT. Therapists treated more than one client. Therapists ranged in age from 26 to 43 years
(M = 32.73, SD = 6.08) and their experience varied from 1 to 15 years (M = 5.23, SD = 4.74).
There were no significant differences in age, experience, education or gender between therapists
in the treatment conditions.
58
Table 2
Client Characteristics at Pre-treatment
Completers (n = 66)
Variable n (%) M
Gender
Male 22(33)
Female 44(67)
Age in years
41.52a
Marital Status
Married/common law 28(42)
Single 28(42)
Separated/divorced 9(14)
Widowed 1(2)
Education
Secondary 16(24)
Postsecondary/college 37(56)
Graduate school 13(20)
Beck Depression Inventory
Mild-moderate 12(18)
Moderate-severe 38(58)
Extremely severe 16(24)
No. of previous episodes of MDDb
Current episode=1st episode 4(6)
2-4 episodes 17(26)
5 or more 41(62)
Length of current episodec
< 6 months 19(29)
6 months-9 years 34(51)
> 9 years 8(2)
Global assessment of functioninge 58.17 Note. MDD=major depressive disorder. Criteria for excluding a client from the study: taking medication,
engaged in another form of treatment, inability to communicate in English, high risk of suicide, and current
or previous diagnosis of DSM-IV Axis 1 disorders of substance abuse, psychosis, manic-depression, or
eating disorder. aRange – 21-65 years, SD = 10.82. bUnknown for 4 completer clients. cUnknown for 5 completer clients. dDSM-IV axis II disorders that were excluded include borderline, antisocial, or schizotypal. eMean
Structured Clinical Interview for DSM-IV—global assessment of functioning; range = 51-65 for completers.
This table was adapted from Watson, Gordon, Stermac, Kalogerakos, & Steckley (2003, p. 774).
59
Treatments
An expert in CBT trained the CBT therapists and an expert in PE-EFT trained the PE-
EFT therapists. The CBT therapists were trained according to the treatment manual written by
Beck, Rush, Shaw, and Emery (1979). The PE-EFT therapists were trained using the manuals
written by Greenberg, Rice, and Elliot (1993) and Greenberg and Watson (1998). The experts
trained and supervised students as well as personally acting as therapists in the study. This
arrangement controlled for investigator bias in that it eliminated any bias that may have resulted
from having an expert from only one of the treatment orientations conduct the training and
supervision of all the therapists on the study.
In terms of the differences between the treatments, CBT therapists target their clients’
dysfunctional cognitions, attitudes, core beliefs, and behaviours since these are seen as causing
the clients’ psychological distress. PE-EFT therapists focus on their clients’ distressing emotions
because these are seen as root causes of psychological distress. CBT therapists provide
treatment interventions such as behavioural experiments and thought records. PE-EFT therapists
provide interventions such as empathic reflections and gestalt-based chair work.
Clients were randomly assigned to either the PE-EFT or CBT treatment group. They
received 16 sessions of one-on-one therapy, one hour per week. Weekly supervision sessions
were used to check treatment adherence. All of the psychotherapy sessions were recorded on
audio and video after having obtained the clients’ consent.
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Process Measures
Client Vocal Quality Scale (CVQ; Rice, Koke, Greenberg, & Wagstaff, 1979; Rice &
Kerr, 1986).
According to Rice (1980), the “CVQ was designed to assess the vocal style of
participation of the client in any given utterance, without regard to the content of what is being
said” (p. 1). The measure is usually used to rate the response or utterance, defined as everything
one speaker says “between two successive productions of the other participant” (Wiseman &
Rice, 1989, p. 283). The CVQ consists of four nominal categories, each of which is defined by
the “accents, accentuation, regularity of pace, terminal contours, perceived energy, and
disruption of speech” (Rice & Kerr, 1986, p. 79).
Speakers using Externalizing vocal quality speak in an even pace with high energy. They
accent their speech through rising pitch and sometimes by increasing loudness. Although the
person’s vocal quality seems full of energy and expression, there is a rhythm to it that conveys a
quality of “talking at” (Rice & Kerr, 1986, p. 78) or a “well-rehearsed speech or chatting to a
friend” (Kennedy-Moore & Watson, 1999, p. 207). In contrast, the vocal quality of Limited
vocal quality speakers sounds very low in energy and hollow. A vocal quality that sounds
“fragile, thin, or empty” is prototypical of this category (Rice & Kerr, 1986, p. 80). Emotional
vocal quality is present when emotion contorts the regular flow of speech. The speaker may
sound as if he or she is struggling to keep his vocal quality under control. “The vocal quality
may break, tremble, rise to a shriek, and so on” (Rice & Kerr, 1986, p. 80). Laughter, however,
is not considered to be Emotional vocal quality. In the Focused category, the speaker’s vocal
quality is energetic, but also softer than usual. According to Rice and Kerr (1986), words are
emphasized by increasing the loudness or drawling rather than pitch. Focused speech sounds
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choppy with a pace that can slow down, speed up, and halt abruptly. In addition, unfilled pauses
and word accents occur in unpredictable places. Sometimes words sound drawled and the
endings of phrases and sentences can have “ragged” terminal contours (Rice & Kerr, 1986, p.
79).
Regarding the CVQ’s psychometric properties, more recent inter-rater reliabilities range
from .70 to .88 (Greenberg & Malcolm, 2002; Watson & Greenberg, 1996). The measure’s
construct validity is supported by Rice and Gaylin’s (1973) study involving clients in client-
centered therapy and their Rorschach scores. Wexler’s (1974) study of vocal quality and
therapy-relevant processes of differentiation and integration in university students also provides
evidence of construct validity.
Research also supports the measure’s predictive validity, such as the Butler et al. (1962)
study which associated Externalizing vocal quality with poor client processing and with poor
end-of-treatment outcome in client-centered therapy. Limited vocal quality has been associated
with poor client processes and with partially successfully outcomes in client-centered therapy
(Butler et al., 1962; Rice & Wagstaff, 1967) and with poor treatment outcome in wholistic primal
therapy (Nixon, 1980). In contrast, Emotional vocal quality has been associated with productive
client processes in client-centered (Butler et al., 1962; Rice & Kerr, 1986) and process-
experiential therapy (Watson & Greenberg, 1996) and has been shown to be significantly
correlated with outcome in a study of wholistic primal therapy (Nixon, 1980), psychodynamic
therapy (Sarnat, 1976 in Rice & Kerr, 1986), and client-centered therapy (Butler et al., 1962).
Research on Focused vocal quality shows it is positively related to productive psychological
processes in gestalt, client-centered and process-experiential therapy (Greenberg, 1983; Watson
& Greenberg, 1996; Wiseman & Rice, 1989) and to end-of-treatment outcome in client-centered
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and psychodynamic therapies (Butler et al., 1962; Rice & Wagstaff, 1967; Sarnat, 1976, as cited
in Rice & Kerr, 1986).
Therapist Vocal Quality Scale (TVQ; Rice & Kerr, 1986).
The TVQ was designed to identify therapist vocal qualities that impact the client’s ability
to engage in therapeutic work. The TVQ does this by identifying the therapist’s vocal quality in
relation to his or her baseline vocal quality. Shifts from the therapist’s baseline vocal quality can
be tracked and represent shifts in his or her interaction with the client (Rice & Kerr, 1986). The
TVQ is applied to the response or utterance, defined as everything one speaker says “between
two successive productions of the other participant” (Wiseman & Rice, 1989, p. 283).
The TVQ categories are viewed as helpful or unhelpful depending on the effect they are
thought to have on the client in theory. Works by Kerr (1983) and Rice and Kerr (1986) suggest
that Softened, Irregular, and Natural categories are productive because they either convey client-
centered relationship conditions or reflect the kinds of therapeutic assistance the client-centered
therapist would offer the client when exploring not-yet-known emotional experience and
working through newly discovered experience. The effectiveness of the Definite category is
thought to depend on the situation and context. Restricted, Patterned, and Limited vocal quality
qualities are expected to dampen the client’s ability to engage in therapeutic processes and were
regarded as negative regardless of the situation.
Regarding the TVQ’s psychometric properties, for inter-rater reliability, Rice and Kerr
(1986) report significant Cohen’s (1960) kappas “for the seven nominal TVQ categories… .33,
.31, and .31 for the combinations of the three raters” (p. 99). Rice and Kerr (1986) explain that
low inter-rater reliability is inevitable given the number and complexity of the TVQ categories.
They state that if the scale were simplified in order to increase inter-rater reliability, the scale’s
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validity would likely be compromised. Wiseman and Rice (1989) report a Cohen’s kappa of .60
(p < .001) for two raters.
The TVQ categories have been described in acoustic terms. Softened vocal quality
sounds soft and slow. It has been called a “lax voice” that sounds “muffled or fuzzy” (Rice &
Kerr, 1986, p. 95). Wiseman and Rice (1989) regarded the Irregular vocal quality as a parallel
to the client’s Focused vocal quality in that it “is characterized by the therapist groping for the
meaning of the client’s message with a new path quality” (p. 282). The pace of the Irregular
vocal quality speaker is variable with abrupt stops and starts as well as unexpected slowing and
quickening. Accentuation is also uneven and unexpected, with some words spoken with a drawl
or lengthening. Natural vocal quality has “adequate energy, fairly full, standard English
emphasis patterns and tempo, with neither an overly tense nor relaxed voice. The voice is
unstrained and natural” (Rice & Kerr, 1986, p. 95).
Definite vocal quality sounds energetic, full, and confident. Rice and Kerr (1986) write:
Stresses are usually down pitched, though they can rise in pitch if accompanied with high energy
and an irregular pattern. Phrase endings are definite, with “heavy,” strong emphases. This
category includes “confrontational voice;” for example, “Well, what are you going to do?” (p.
95). Restricted vocal quality has enough energy to convey the content, but the speaker’s voice
sounds strained, as if “something is being held back” with a “slightly tremulous, whiny, droning”
quality” (Rice & Kerr, 1986, p. 95). The effect of the Restricted vocal quality on the listener is
thought to be “unsatisfying, distanced, and seems uninvolved” (Rice & Kerr, 1986, p. 95).
Patterned vocal quality is although regarded as negatively impacting the listener as it is:
Patterned for emphasis, especially using pitch. Often a syllable at the end of a phrase, on
which pitch would normally go down, has a rising or level pitch. The tempo is normal or
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fast, and the rhythm of the words is distorted to fit into the pattern. The category as a
whole sounds “sing-song”. (Rice & Kerr, 1986, p. 95)
Limited vocal quality sounds lifeless, flat, and monotone. “This pattern may be just too soft—so
whispery, breathy, or creaky that it fades away—or high-pitched, ending in a kind of squeak”
(Rice & Kerr, 1986, p. 95).
Outcome Measures
Beck Depression Inventory (BDI ).
The BDI (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a well-researched,
commonly used self-report measure of depression. The questionnaire contains 21 items, each of
which reflects a depressive symptom. Each item contains four statements reflecting the severity
of the symptom ranging from the absence of the symptom (0) to very intense (3). Respondents
are instructed to select the one statement that most accurately reflects the way he/she has felt
over the past week. The total of all 21 items is the score used for interpretation. Higher scores
indicate worse depressive symptoms. The BDI’s psychometric properties are well established.
Reported test-retest reliabilities ranged from .69 to .90 (Moreno, Fuhriman, & Selby, 1993).
High internal consistency has also been reported (α = .81) as well as good discriminate
capabilities (Beck, Steer, & Garbin, 1988). Testing with the Hamilton Rating Scale for
Depression shows the BDI has strong convergent validity (r = .84) (HRSD; Hamilton, 1960 in
Moreno et al., 1993).
Dysfunctional Attitudes Scale (DAS).
DAS (Weissman & Beck, 1978) is a self-report questionnaire meant to evaluate attitudes
that may make the respondent vulnerable to depression. The questionnaire contains 40
statements which respondents rate on a 7-point Likert scale ranging from totally disagree to
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totally agree. Instructions on the first page of the questionnaire tell the respondent to answer
based on the way he/she thinks most of the time. An example of a DAS item is: “If I do not do
as well as other people, it means I am an inferior human being” (Cane, Olinger, Gotlib, &
Kuiper, 1986, p. 308). Higher scores indicate more dysfunctional thinking. Two subscales
include Performance Evaluation and Approval by Others. The DAS has solid psychometric
properties. Dobson and Breiter (1983) report high test-retest reliability (r = .84) for a two-month
time frame. Reports of internal consistency include α = .85 for an adult sample (Oliver and
Baumgart, 1985) and = .88 - .90 for university sample (Dobson & Breiter, 1983).
Problem-Focused Style of Coping (PF-SOC).
The PF-SOC (Heppner, Cook, Wright, & Johnson, 1995) measures a person’s preferred
or dispositional manner of coping with problems. Wei, Heppner, and Mallinckrodt (2003)
explain that “in essence, the PF-SOC assesses the extent to which people believe in general that
they are coping well and making progress toward resolving their problems” (p. 440). Items
reflect cognitive, affective, and behavioral coping experiences. Respondents are asked to rate
how typical each item is of the way they respond to problem situations. They indicate their
responses on a 5-point scale ranging from 1 (almost never) to 5 (almost all of the time).
Factor analysis of all the items revealed three distinct coping methods. The Reflective
Style describes a tendency for a person to be systematic in his or her approach by considering
cause and effect and by planning responses. The Reactive Style of coping indicates negative
cognitive-affective reactions that would exhaust and confuse the person and interfere with efforts
to cope productively. A person using the third method, Suppressive Style, would avoid dealing
with the problem or perhaps not even acknowledge that there is a problem. The mean score of all
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items within each coping style is that subscale’s score. Higher scores mean the person is
engaging more in that particular style.
Regarding the measure’s psychometric properties, Heppner et al. (1995) found test-retest
correlations with a three week span between testing to be .71 for Reactive Coping, .67 for
Reflective Coping, and .65 for Suppressive. They also reported internal consistency figures for
each style: Reactive ( = .73), Suppressive ( = .76), and Reflective ( = .77). Concurrent
validity was demonstrated in a study pairing the PF-SOC scales with the Problem-Solving
Inventory (PSI; Heppner, 1988).
Inventory of Interpersonal Problems (IIP).
According to its developers Horowitz, Rosenberg, Baer, Ureno, and Villasenor (1988),
the IIP “describes the types of interpersonal problems that people experience and the level of
distress associated with them before, during, and after psychotherapy” (p. 885). The self-report
questionnaire consists of 127 items representing interpersonal problems in terms of “It is hard for
me to….” or “These things I do too much.” An example of the former is “It is hard for me to
trust other people” and of the latter is “I am too easily persuaded by other people”. For each
item, clients indicate their level of suffering by rating the statement on a scale ranging from 0
(not at all) to 4 (extremely). Higher scores reflect worse interpersonal problems. The mean
score of all IIP items produces the Circumplex Total, which is a global measure of interpersonal
suffering. Also, the 127 items can be classified into eight subscales: Domineering-Controlling,
Vindictive/Self-Centered, Cold-Distant, Socially Inhibited, Nonassertive, Self-Sacrificing,
Overly Accommodating and Intrusive-Needy. Higher scores indicate greater interpersonal
distress.
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Regarding the IIP’s psychometric properties, Horowitz et al. (1988) reported test-retest
correlations for the subscales from .80 to .87, with an IIP total correlation of .98 over a 10-week
interval. Good internal consistency alphas have been reported, ranging from .82 to .94
(Horowitz et al., 1988) and .72 to .85 (Alden, Wiggins, & Pincus, 1990). Comparisons of the IIP
with other measures of interpersonal distress indicate good concurrent validity (Lambert,
Hansen, Umpress, Lunnen, Okiishi, Burlinggame, & Reising, 1996, as cited in Woodward,
Murrell, & Bettler, 2005). Research has also demonstrated the measure’s criterion validity and
sensitivity to clinical change in high versus low stress in university students (Woodward et al.,
2005). In addition, Horowitz et al. (1988) found that the measure could sort treatment
completers from noncompleters.
Rosenberg Self-esteem Scale (RSES).
The RSES (Rosenberg, 1989) is a well-known measure of self-esteem in the social
sciences. The current study used the Bachman and O’Malley (1977) version of the RSES which
consists of 10 self-report items. An example of one item is: “I feel that I am a person of worth,
at least on an equal plane with others”. Respondents are asked to rate their agreement on each
item according to a 5-point scale ranging from never to almost always. The score used for
interpretation is the mean of the items. Higher scores indicate higher self-esteem.
The RSES has good psychometric properties. The measure has good test-retest reliability
(r = .82) for a college sample after one week (Torrey, Mueser, McHugo, & Drake, 2000 referring
to a study conducted by Fleming & Courtney, 1984). Bachman and O’Malley (1977) reported
good internal consistency (α = .81). Studies have also provided evidence of the measure’s
construct validity by demonstrating positive correlations with measures of happiness (r = .54)
and needs for self-development (r = .44) (Bachman & O’Malley, 1977) as well as parental
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warmth (r = .42), optimism (r = .61), and life satisfaction (r = .61) (Greenberger, Chen,
Dmitrieva, & Farruggia, 2003). Discriminant validity was further supported by negative
correlations of the RSES with somatic symptoms (r = −.34) and negative affective states (r =
−.52) (Bachman & O'Malley, 1977) as well as depressive symptoms (r = −.64) (Greenberger et
al., 2003).
Symptom checklist-90-Revised (SCL-90-R).
The SCL-90-R (Derogatis, Rickels, & Rock, 1976) is a 90-item self-report questionnaire
used to evaluate clients’ psychological suffering in both therapy and research contexts (Schmitz,
Hartkamp, & Franke, 2000). Peveler and Fairburn (1990) wrote that “each item describes the
experience of having a psychiatric symptom” (p. 874). Respondents are instructed to refer to
their experience from the past week when rating each item on a 5-point scale increasing in
intensity of distress from 0 (not at all) to 4 (extremely). Raw scores are converted to T-scores.
Higher scores indicate more distress.
In addition to a Grand Total score, the SCL-90-R scores produce three indices of distress:
The Global Symptom Index, the Positive Symptom Total, and the Positive Symptom Distress
Index. The Global Symptom Index score reflects the total number of symptoms the respondent
reports plus the reported severity. According to Derogatis (1983), the Global Symptom Index is
“the best single indicator of the current level or depth of the disorder, and should be utilized in
most instances where a single summary measure is required” (Derogatis, 1983, p. 11 as cited in
Tingey, 1989, p. 24).
The measure has strong psychometric properties. High test-retest reliability has been
reported (r = .84) for the SCL-90-R total and for the subscales (r = .68 - .83) (Horowitz et al.,
1988, p. 887). Tennen, Affleck, and Herzberger (1985) to report the measure’s impressive
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“internal consistency and test-retest reliability correlations; both ranged almost exclusively in the
eighties and nineties” (cited in Tingey, 1989, p. 23). Woodward, Murrel, and Bettler (2005)
reported high concurrent validity for the Global Symptom Index. Regarding clinical sensitivity,
Tennen et al. (1985) to support his conclusion that, “the scores…are sensitive to treatment effects
(p. 586)” (cited in Tingey, 1989, p. 23).
Post-Session Outcome Measure
Client Task-Specific Change Measure-Revised (CTSC-R; Watson, Greenberg, Rice,
& Gordon, 1996).
The CTSC-R is a post-session self-report questionnaire intended to gauge the degree to
which clients felt they changed in the session. The CTSC-R was used as a measure of the
client’s report of change from the session. The items refer to experiences the client might have
had given the specific treatment orientation. For example, 12 items refer to PET treatment
effects such as “I understood a puzzling reaction of my own after I discovered what a particular
situation meant to me or how I was interpreting it”. Four items refer to CBT interventions such
as “I feel that I was able to successfully challenge my negative/automatic thoughts”. The clients
indicate how much they agree with the statements on a 7-point scale where number 1 is “not at
all” and number 7 is “very much”. The client’s indication of agreement for each question is
averaged over all questions, providing a single index of post-session change. Higher scores
indicate the client’s report of higher change. Mean scores of five indicate that the client is
reporting moderate to high change in that session. Watson, Goldman, and Greenberg (2007)
explain that a CTSC-R mean of five or more signifies a shift in the clients’ “understanding of
their problems, how they are treating themselves, and how they are feeling about themselves and
others” (p. 19).
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Regarding the measure’s psychometric properties, Watson, Schein, and McMullen (2010)
reported that factor analysis revealed two distinct constructs underlying the questions: 1.
Behaviour Change and 2. Understanding and Awareness. Also, the measure has been found to
have high internal consistency, with Cronbach alphas ranging from .94 to .98. Most item-total
correlations reported are as high as .90 to .96, with most exceeding .70. The construct validity of
the measure was established through its relationship to the Beck Depression Inventory (BDI,
Beck et al., 1961). CTSC-R (Watson et al., 1996) scores predicted BDI scores regardless of the
treatment type or of the two factors (Behaviour Change and Understanding and Awareness).
Procedure
Session selection.
Sessions were selected from all but the final session (#16). Sessions were selected based
on the CTSC-R mean score. For each client, the session with the lowest CTSC-R score and the
session with the highest CTSC-R score were chosen. The session with the lowest CTSC-R score
is referred to as the session with the lowest change score. The session with the highest CTSC-R
score is referred to as the session with the highest change score.
Another session representing the client’s first report of moderate to high change was
selected. The first session having a CTSC-R score of 5 or more was included in this group. This
session is referred to as the first report of moderate to high change session. If the client’s
highest CTSC-R scored session was a 5, it was included in this group. If the client did not have a
CTSC-R scored session of 5, then that client’s highest change score session was used. There
were 12 clients for whom the same session was the session with the highest change score and the
first report of moderate to high change session. Both of these sessions are referred to as “high
change sessions”, but analyses of them are run separately because of this overlap. If the client’s
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session with the highest change score and the first report of moderate to high change session had
the same CTSC-R score, the earlier session was used in the first report of moderate to high
change group and the later session was used in the highest change score group. Lastly, some
clients did not have any sessions with a CTSC-R mean score of 5 or more. In order to be
included in the first report of moderate to high change session, it was decided that the score for
this session must be at least 3.5. There were three clients who did not meet this criterion and
they were excluded from analyses involving the first report of moderate to high change session.
Preparation of materials.
The audio for each session was converted to MP3 format. Audio for each rater was
loaded onto an Apple iPod Nano assigned to that rater. Raters listened to the sessions with their
iPods mounted onto Bose sounDock® Portable Digital Music systems. De-identifying numbers
were used for the transcripts and MP3 files.
The middle 20 minutes of each session were transcribed and formatted into a rating sheet,
with a column for raters to indicate their vocal quality rating for each response. For the CVQ
responses, the primary investigator made slash marks to indicate shifts in intonation. The raters
were instructed to rate each shift. When the session was complete, the primary investigator
tallied the ratings for each intonation shift for an overall rating for the response. This was done
in accordance with rules provided in the Manual for Client Vocal Quality (Rice et al., 1979).
CVQ Training.
The CVQ raters trained for more than 100 hours for more than 1 year using the Manual
for Client Vocal Quality (Rice et al., 1979) with an expert rater. Additional audio from
psychotherapy sessions that were not part of the data set were also used. Raters trained to an
acceptable level of agreement with each other and the expert before proceeding to code the data.
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The preliminary inter-rater reliability was established through a test of non-data audio which was
assembled by the current study’s primary investigator.
When the tests were completed, the primary investigator entered the data and conducted
the analysis. During data entry, there were instances in which the raters gave a borderline rating
for a response. For example, for the same response, one rater may have indicated Focused vocal
quality, but the other rater may have written that the response was not clearly classifiable in
Focused vocal quality or Externalizing vocal quality—that it could be either category. Rice and
Kerr (1986) reported the same situation for TVQ raters, reporting that “since there were
‘borderline’ areas between each TVQ category in which either of two different ratings may have
been equally appropriate, each rater would vary slightly no matter how well trained” (p. 99).
Based on this, it was decided in the current study that raters were in agreement for a response
when the rating for one rater was the same as one of the two borderline categories indicated by a
second rater.
Preliminary reliability was calculated between the raters and the expert. Three measures
of rater agreement were used: Cohen’s kappa (κ), Brennan and Prediger’s kappa (κn) and raw
agreement (râ). Cohen’s kappa was used because it is the inter-rater reliability statistic used in
the majority of studies using the CVQ measure. Brennan and Prediger’s kappa and raw
agreement were added to address the non-uniform marginal totals found in the CVQ
crosstabulation matrices, as per von Eye and Mun’s (2005) recommendation. The non-
uniformity in the CVQ reliability data was due to the high number of observations of one
category (Externalizing vocal quality) in contrast to a very small number of observations for
another category (Emotional vocal quality). This large disparity in observations per category can
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distort Cohen’s kappa (Cohen, 1960) so that it does not accurately represent the raters’ level of
agreement.
Von Eye and Mun (2005) explain that Brennan and Prediger’s kappa, referred to as a
“‘free’ marginals” kappa (Brennan & Prediger, 1981, p. 690), is interpreted the same way as
Cohen’s kappa, while its formula, seen in Table 3, incorporates both the number of categories in
the scale as well as raw agreement (râ). By providing all three measures, agreement between two
raters can be understood as fitting within a range that spans from the overly stringent Cohen’s
kappa, to the more balanced Brennan and Prediger’s kappa and, finally, to the overly lax raw
agreement statistic.
The reliability statistics for the preliminary CVQ tests are located in Table 3. Significant
Cohen’s kappas were obtained for each pair of raters. Agreement for the Cohen’s and Brennan
and Prediger’s kappas range from moderate to substantial (Landis & Koch, 1977 in von Eye &
Mun, 2005). Raw agreement statistics range from necessary to adequate (House, House, &
Campbell, 1981). Ranges for interpretation of the statistics are found in Appendix A.
Also, regarding the Cohen’s kappas, the statistics reported here are in line with the
significant Cohen’s kappas reported for rater reliability in early published CVQ research, which
ranged from κ = .40 (Wiseman & Rice, 1989) to κ = .49 (Rice & Kerr, 1986). More recent
studies report significant kappas for rater reliability ranging from κ = .36 (Safran & Muran,
1996) to κ = .72 (Watson & Greenberg, 1996). In sum, the results of the preliminary inter-rater
reliability tests were sufficient to proceed with the CVQ rating of the data set.
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Table 3
Preliminary Inter-Rater Reliability Between the CVQ Raters and Each Rater and the Expert
N Responses Κ ΚNa RȂ
Rater #1 + Rater #2 147 .75 .79 .84
Rater #1 + Expert 128 .63 .57 .68
Rater #2 + Expert 128 .72 .69 .77
Note. Κ = Cohen’s kappa, ΚN = Brennan & Prediger’s kappa, and RȂ = raw agreement.
a ΚN = raw agreement – (1/# of categories) from von Eye & Mun, 2005.
1 – (1/#categories)
Rating the CVQ data set.
One rater rated all of the sessions, called the main rater, and the second rater rated one
session for each client (N = 63) so that inter-rater reliability for the data set could be calculated.
The sessions were randomized so that there was an equal number of sessions with the lowest
change score, sessions with the highest change score, and first report of moderate to high
change sessions. The main rater did not know which sessions were to be used for reliability
calculations.
The CVQ raters were instructed to ground themselves in the training audio and the CVQ
category descriptions before each rating session. They worked in separate rooms, they did not
consult with one another, and they did not have access to one another’s coded transcripts.
Three consistency checks were conducted during the rating process. In the first two
checks, there was a limited review of training audio, discussion of a few responses from the data
set, and some discussion of new non-data audio to address some variation in agreement. The
CVQ raters were also told they could provide an alternate rating for especially difficult
responses. This decision was based on Rice and Kerr’s (1986) experiences with TVQ raters who
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made alternate ratings when “there were ‘borderline’ areas between one TVQ category in which
either of two different ratings may have been equally appropriate” (p. 99). Vognsen (1969) also
noted that CVQ raters would spontaneously include additional comments to clarify their final
ratings when they heard a response as a borderline or mixture of categories that prevented them
from settling on only one rating.
TVQ Training.
TVQ raters were not the same people who had rated the responses on the CVQ. The
TVQ raters were trained for more than 100 hours over more than one year using the Therapist
Vocal Quality manual (Rice & Kerr, 1986) with an expert rater. Additional audio from
psychotherapy sessions that were not part of the data set was also used.
During training, it was decided to combine the Restricted and Limited vocal quality
categories into one category called Restricted-Limited vocal quality. The reason for this is that it
was difficult to differentiate the categories from the Manual’s training audio. Because both are
considered to be unproductive TVQ categories and because the differences between the
categories were almost imperceptible from the audio, it was decided to combine them.
Raters trained to an acceptable level of agreement with each other and the expert before
proceeding to rate the data. Preliminary inter-rater reliability was established through a test of
non-data audio which was assembled by the study’s primary investigator. The marginal totals
for the crosstabulation matrices for each pair of raters were non-uniform due to the large number
of observations for Irregular vocal quality and very small number for Patterned vocal quality.
As a result, von Eye and Mun’s (2005) recommendation of reporting Cohen’s kappa, Brennan
and Prediger’s kappa (κn), and raw agreement (râ) were followed and are displayed in Table 4.
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The raw agreement statistics were acceptable (House et al., 1981) and the Cohen’s kappa
and the Brennan and Prediger’s kappa ranged from moderate to substantial (Landis & Koch,
1977 in von Eye & Mun, 2005). Ranges for interpretation of the statistics are found in Appendix
A. These values also exceed those reported by Rice and Kerr (1986) for three pairs of raters (κ =
.31 to .33) and those reported by Wiseman and Rice (1989) (κ = .60) for three raters using the
Spearman Brown formula. The results of the preliminary inter-rater reliability tests were
sufficient to proceed with rating the TVQ data set.
Table 4
Preliminary Inter-Rater Reliability Between the TVQ Raters and Each Rater and the Expert
N Responses Κa ΚNb RȂ
Rater #1 + Rater #2 43 .61 .66 .72
Rater #1 + Expert 43 .70 .75 .79
Rater #2 + Expert 43 .71 .75 .79
Note. Κ = Cohen’s kappa, ΚN = Brennan & Prediger’s kappa, and RȂ = raw agreement.
a The Online Vassar Kappa Calculator was used to calculate Cohen’s kappa when analyses included rater
#2. The reason for this is that SPSS does not calculate Cohen’s kappa unless both raters have at least one
observation for each category. Rater #2 had made observations for five of the six categories, whereas
rater #1made at least one observation for all six categories. bSee Table 3 for the formula.
Rating the TVQ data set.
Both TVQ raters rated one session for each client (N = 63) to calculate the inter-rater
reliability on the data set. The sessions were randomized so that there were an equal number of
sessions with the lowest change score, sessions with the highest change score, and the first
report of moderate to high change sessions. In addition, rater #1 rated a second session for each
client and rater #2 rated a third session for each client. The raters did not know which sessions
were to be used for reliability calculations.
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The TVQ raters were instructed to ground themselves in the training audio and the TVQ
category descriptions before each rating session. They worked in separate rooms, they did not
consult with one another, and they did not have access to one another’s rated transcripts. They
were also asked to rate in two hour blocks, as recommended by Kerr (1980). In addition, the
raters were asked to rate one group of eight pre-selected sessions at a time. The groups were
composed of sessions from different therapists. This was done to prevent the raters from being
influenced by hearing the same therapist’s vocal quality in relation to two different clients.
Three consistency checks were conducted during the rating process. In the first two
checks, there was a limited review of training audio, discussion of a few responses from the data
set, and some discussion of new non-data audio to address some variation in agreement. The
TVQ raters were also told they could provide an alternate rating for especially difficult
responses. This decision was based on Rice and Kerr’s (1986) experiences with TVQ raters who
made alternate ratings when, “there were ‘borderline’ areas between one TVQ category in which
either of two different ratings may have been equally appropriate” (p. 99).
Descriptive Statistics for the Outcome Measures.
The Spearman Rho correlation was used to detect high correlations in the same direction
of two different measures or subscales. Measures that are highly correlated in the same direction
may be measuring the same construct. To reduce redundancy in the subsequent analyses, only
one measure was selected in these cases. The results are presented in Appendix B. The scales
that were not highly correlated with one another and were therefore included in the subsequent
analyses, include the BDI, DAS Total, RSE, the SCL-90-R (GSI only), the IIP and all its
subscales, and all levels of the PF-SOC.
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Alpha level.
The alpha level for the current study is p < .05, as is conventionally used in psychology
research (e.g., Perneger, 1998). While there were many planned analyses, the Bonferroni
correction was not used to determine significance. Perneger (1998) explains that while the
Bonferroni adjustment decreases the probability of a Type I error (rejecting the null hypothesis
when it is true) for multiple tests, it also increases the probability of making a Type II error
(accepting the null hypothesis when it is not true). Perneger (1998) writes, “Type II errors are no
less false than type I errors” (p. 1236). In a medical context, this could mean that “an effective
treatment may be deemed no better than placebo” (p. 1236). In the current study, using the
Bonferroni correction could obscure the relationship between vocal quality and psychological
change. Given the exploratory nature of the current study and the reasons above, the risk of
making a Type I error was considered acceptable.
TVQ Inter-rater reliability on the data set.
TVQ inter-rater reliability on the data set was calculated on one session for each client (N
= 63). Disagreements between the TVQ raters on the sessions used for reliability were resolved
by the expert. The categorical TVQ data were aggregated into proportions of each TVQ
category for each client. This resulted in each session being defined by its proportion of
Softened vocal quality, Irregular vocal quality, Natural vocal quality, Definite vocal quality,
Restricted-Limited vocal quality, and Patterned vocal quality. Because the TVQ hypotheses
were proportions-based, intraclass correlation coefficient (ICC) analyses were planned to
evaluate inter-rater reliability.
Before calculating inter-rater reliability, four clients were going to be removed because
the raters agreed on less than 50% of the responses. It was decided that since the TVQ raters
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rated just one session for each client for reliability calculations, if they disagreed on more than
50% of the responses for the reliability sessions, then their ratings for the other two sessions for
that client would also not be reliable. For this reason, it was decided that all three sessions for
these four clients would be excluded from the TVQ data set and further analysis.
Next, outliers in the remaining reliability sample were to be removed from the reliability
calculations in order to obtain the most representative sample of rater agreement. The
standardized residuals analysis was used to detect outlier cases. An outlier was defined as any
session in which the level of agreement exceeded plus or minus three standard deviations from
the mean. Eight outlier sessions were identified and each was an outlier due to a high level of
disagreement. It was decided that if the level of disagreement on the responses for these sessions
was so high that these sessions were outliers, then all three sessions for these clients should be
removed from the data as well. However, excluding so many clients from the data would reduce
the power of the study to an unacceptable level.
In an effort to retain the outlier clients in the TVQ data set, a cluster analysis of the
reliability sessions was run to see if ratings clustered into similar groups of vocal qualities for
both raters. A two-step cluster analysis was performed and produced two clusters of good
quality which were well-defined and the same for both raters. The clusters were differentiated
by their relative proportions of each TVQ category as displayed in Table 5. For both raters,
Cluster #1 was defined by higher mean proportions of Natural vocal quality and Definite vocal
quality than found in Cluster #2. Because of this, Cluster #1 was called Natural-Definite
Cluster. Cluster #2 was defined by higher mean proportions of Softened vocal quality and
Irregular vocal quality than found in Cluster #1. As a result, Cluster #2 is called Softened-
Irregular Cluster. Restricted-Limited vocal quality did not differentiate the clusters.
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Table 5
Results of Cluster Analysis for the TVQ Raters (N = 59 Sessions)
Rater #1 Rater #2
TVQ Categories Cluster #1 Cluster #2 Cluster #1 Cluster #2
Irregular .02 .09 .02 .09
Softened .08 .51 .10 .61
Natural .66 .30 .69 .23
Definite .19 .03 .14 .02
Restricted-
Limited .07 .06 .05 .05
Note. Cohen’s kappa for the raters on the Clusters is .76. Gray shading highlights proportions that
differentiate the clusters from one another. Patterned vocal quality was not included in the analyses
because agreement was very poor in preliminary analyses (8%) and there were few responses
classified as Patterned vocal quality.
This meant that for the inter-rater reliability set of sessions (N = 59), each raters’ ratings
resulted in each session being characterized either Natural-Definite or Softened-Irregular
Cluster. To ensure adequate agreement on the sessions as defined by the Clusters, a Cohen’s
kappa test was run on the cluster classification data for the two raters. Agreement was
substantial (κ = .76), as interpreted from Landis & Koch’s (1977) suggested ranges.
If a cluster analysis on the TVQ data set of 177 sessions (three sessions for each of the 59
clients) revealed the same two clusters as found in the reliability sessions, then the eight outlier
cases could be retained and used in the subsequent analyses. To test this, a second cluster
analysis was run on the entire TVQ data set (N = 177). The results, presented in Table 6,
revealed the same cluster types as was found for the two raters in the cluster analysis of the
reliability sessions. Based on this, the eight outlier sessions were retained the data set. However,
the clusters replaced the individual TVQ categories as a new variable called Therapist Vocal
Style. This variable had two levels: Natural-Definite Therapist Vocal Style and the Softened-
Irregular Therapist Vocal Style.
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Table 6
Results of Cluster Analysis on the TVQ Data Set (N = 177 Sessions)
Proportion of each TVQ per Therapist Vocal Style
TVQ Category Natural-Definite Therapist Vocal Style Softened-Irregular Therapist Vocal Style
Irregular .04 .07
Softened .07 .57
Natural .71 .26
Definite .12 .03
Restricted-Limited* .06 .07
Note. Gray shading highlights the TVQ proportions that differentiate Natural-Definite and Softened-
Irregular Therapist Vocal Styles from one another. *Restricted-Limited vocal quality was not significantly
different between the Therapist Vocal Styles, p = .539.
TVQ Descriptives.
An approximately equal number of sessions were classified as Natural-Definite and
Softened-Irregular Therapist Vocal Style in the sessions. More sessions were classified as
Softened-Irregular Therapist Vocal Style in the sessions with lowest change score (n = 31) than
in sessions with the highest change score (n = 24). More sessions were classified as Natural-
Definite Therapist Vocal Style in the sessions with the highest change score (n = 33) than in
sessions with the lowest change score (n = 26), as seen in Table 7. In the first report of moderate
to high change session, 29 sessions were classified as Softened-Irregular Therapist Vocal Style
and 28 as Natural-Definite Therapist Vocal Style, as seen in Table 8. In each group of sessions,
most of the Softened-Irregular Therapist Vocal Style sessions are PE-EFT sessions and most of
the Natural-Definite Therapist Vocal Style sessions are CBT sessions.
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Table 7
Crosstabulation Tables for Therapist Vocal Style by Treatment Type in Sessions with the Lowest and
Highest Change Scores
Session with the lowest
change score Therapist Vocal Style
Treatment Softened-Irregular Natural-Definite Total
CBT
Count 7 23 30
% within Tx 23.3% 76.7% 100%
PE-EFT
Count 24 3 27
% within Tx 88.9% 11.1% 100%
Total
Count 31 26 57
% within Tx 54.4% 45.6% 100%
Session with the highest
change score Therapist Vocal Style
Treatment Softened-Irregular Natural-Definite Total
CBT
Count 1 29 30
% within Tx 3.3% 96.7% 100%
PE-EFT
Count 23 4 27
% within Tx 85.2% 14.8% 100%
Total
Count 24 33 57
% within Tx 42.1% 57.9% 100%
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Table 8
Crosstabulation Tables for Therapist Vocal Style by Treatment Type in the First Report of Moderate to
High Change Session
Therapist Vocal Style
Treatment Softened-Irregular Natural-Definite Total
CBT Count 5 25 30
% within Tx 16.7% 83.3% 100%
PE-EFT Count 24 3 27
% within Tx 88.9% 11.1% 100%
Total Count 29 28 57
% within Tx 50.9% 49.1% 100%
CVQ Inter-rater reliability.
CVQ inter-rater reliability was calculated on one session for each client (N = 63). The
categorical CVQ data were aggregated into proportions of each CVQ category for each client.
This resulted in each session being defined by its proportion of Emotional, Focused, Limited, and
Externalizing vocal qualities. Because the CVQ hypotheses are proportions-based, intraclass
correlation coefficient (ICC) analyses were used to evaluate inter-rater reliability.
To obtain the most representative sample for inter-rater reliability, eight outlier cases
were removed from the ICC analyses. The standardized residuals analysis was used to identify
outliers. An outlier was defined as any session in which the level of agreement exceeded plus or
minus three standard deviations from the mean. Some sessions were outliers due to an
exceptionally high level of agreement and some were due to a low level of agreement. Table 9
shows acceptable ICC’s for all the CVQ categories except for Focused vocal quality. Because
the main rater rated the entire data set on the CVQ, it was decided to keep all three sessions for
the eight outlier cases in the data set.
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Table 9
Intraclass Correlation Coefficients (ICC) for CVQ Inter-Rater Reliability (N = 63)
CVQ ICC 95% CI Magnitutdea
Externalizing vocal quality .71** [.56, .84] Strong
Emotional vocal quality .95** [.91, .97] Strong
Limited vocal quality .88** [.80, .93] Strong
Focused vocal quality .23* [.00, .45] Weak
Note. ICCs are two-way, random, consistency. CI=confidence interval.
aThe magnitude of the correlation coefficients is based on ranges that are conventional in the behavioural
sciences and include < .30 (weak), .30-.50 (moderate), > .50 (strong) (Green & Salkind, 2004, p. 256).
* p < .05. **p < .01.
Because Focused was a category of special interest, a second test of rater reliability was
conducted. In the second test, the expert rated a set of responses, many of which consisted of
responses the main rater had classified as Focused vocal quality. The expert did not know how
the main rater had classified any of the responses. Cohen’s kappa was calculated on two
categories: Responses identified as Focused vocal quality and responses identified as not
Focused vocal quality. Cohen’s kappa for this test was .34, representing fair agreement (Landis
& Koch, 1977 in von Eye & Mun, 2005). One of the reasons reliability was not better was that
the expert rated many more responses as Focused vocal quality (n = 29) than the main rater (n =
17). Each rater’s total number of Focused vocal quality responses is highlighted in yellow in the
crosstabulation matrix in Figure 1.
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Main Rater
Focused Not Focused Total
Exp
ert Focused 12 17 29
Not Focused 5 45 50
Total 17 62 79
Figure 1. Crosstabulation matrix for the Focused vocal quality test with the main rater and expert.
The fair kappa statistic does not provide strong evidence that the main rater reliably rated the
Focused category. Also, it does not provide a statistical measure of the pattern of ratings seen in
the crosstabulation matrix in which the main rater is more conservative than the expert in
identifying Focused vocal quality. To evaluate the extent to which the expert agreed with those
responses that the main rater identified as Focused vocal quality, a third reliability test was
conducted using the weighted occurrence agreement percentage measure (House et al., 1981).
This calculation shows the percent of the main rater’s Focused responses that the expert agrees
with. This method is not conventional because it does not account for the responses which the
expert rated as Focused, but which the main rater did not. Rather, as House et al. (1981) state,
“the rationale for its use is typically that one observer is assigned a ‘criterion’ status and the only
errors processed in analysis are when the ‘regular’ observer fails to detect/record a behavior
coded by the criterion observer” (p. 45). The formula for the weighted occurrence agreement
percentage measure adapted from House et al. is where Focused-A is the number of responses
both raters agree are Focused vocal quality and Focused-M is the number of responses the main
rater says are Focused, but that the expert says are not.
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% of Main Rater’s
responses verified as
Focused vocal quality
by the Expert
=
Focused-A
X 100%
Focused-A + Focused-M
The weighted occurrence agreement was 71%, meaning that the expert agreed with 71%
of the main rater’s Focused vocal quality ratings. This level of agreement is consistent with
figures reported by other CVQ studies using percent agreement as a measure of inter-rater
reliability. These reported reliabilities range from 69% (Sarnat, 1976; Vognsen, 1971) to 75%
(Clarke, 1989; Rice & Wagstaff, 1967). Referring to the percent agreement formulas presented
in their article, House et al. (1981) write “the question of ‘how much’ agreement is necessary,
good, or reasonable is not resolved (or a priori resolvable)” (p. 46). However, they suggest that
70% is the minimum acceptable level of agreement. House et al. (1981) write, “there seems
some consensus among behavioral investigators that average agreement at or above 70% is
necessary, above 80% is adequate, and above 90% is good” (p. 46).
To summarize, the main rater was more conservative in identifying Focused vocal quality
than the expert. However, the expert agreed with 71% of the main rater’s observations of that
category. This suggests that when the main rater identified Focused vocal quality in the data set,
that Focused vocal quality was, in fact, present. Also, the level of agreement between the main
rater and expert is in line with previous research which used percent agreement as a measure of
reliability. Finally, 71% agreement meets the minimum criteria suggested by House et al.
(1981).
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Although it was decided that, based on the above, the main rater’s identification of
Focused vocal quality was sufficiently reliable to proceed with analyses of this vocal category, it
is important to state that the results of the analyses should be viewed in the context of two
limitations. First, because the main rater was conservative compared to the expert, she may have
categorized some Focused responses as another vocal quality. As a result, the actual number of
Focused responses may be underrepresented in the data set. Second, while 71% agreement just
meets the minimum standard suggested by House et al. (1981), it is still low, indicating that the
expert disagreed with some responses the main rated heard as Focused vocal quality. Given
these issues, it is suggested that results involving the Focused category be interpreted with
caution.
Boxplots of CVQ Data.
Boxplots of the CVQ categories were created to evaluate the shape of each category’s
distribution, examine outliers, and explore patterns among the categories. Boxplots for each
CVQ category were created for the first report of moderate to high change sessions. These, seen
in Figure 2, are highly skewed. Boxplots for sessions with the lowest change score and sessions
with the highest change score are displayed in Figure 3. Boxplots for each CVQ category for
both sessions appear “squashed” with many outliers, indicating highly skewed distributions
(Delucchi & Bostrom, 2004, p. 1162).
Although Externalizing vocal quality represented the highest proportion of all the CVQ
categories, the proportions of Emotional vocal quality, Focused vocal quality, and Limited vocal
quality expressed by most clients was zero, creating outliers for each of these categories. A
visual inspection of the outliers revealed two clients whose vocal patterns were distinct from the
rest. One client was an outlier on three out of the four CVQ categories for both sessions with the
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lowest and highest change score as well as the first report of moderate to high change session.
The second client was an outlier for two of the four CVQ categories in the session with the
lowest change score and on all four CVQ categories in the session with the highest change score.
Because their vocal patterns were so different from the rest, they were removed from the CVQ
data set. In order to keep groups comparable in the analyses, these two clients were removed
from the TVQ data set as well.
Emotional Focused Limited Externalizing
Vocal Quality Categories
Figure 2. Boxplots of CVQ categories in first
report of moderate to high change
sessions (N = 60). Three sessions were
removed from this group because their CTSC-R
scores were below 3.5.
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New boxplots were created without the two clients. Formal normality tests were used to
clarify whether the non-normality of the CVQ category distributions would require non-
parametric tests. There are no set rules for deciding when a distribution is so non-normal that
Emotional Focused Limited Externalizing
Vocal Quality Categories
Sessions with the lowest change score
Emotional Focused Limited Externalizing
Vocal Quality Categories
Sessions with the highest change score
Figure 3. Boxplots of CVQ categories in sessions
with the lowest change score and sessions with
the highest change score (N = 63).
90
non-parametric tests should replace parametric tests (O. Falenchuk, personal communication,
2011). However, Field (2009) suggests evaluating normality by visually comparing the
distribution in question with a normal one, plus taking into account the distribution’s skewness
and kurtosis values. A distribution is considered not symmetrical if either skewness or kurtosis
values exceed twice their standard errors (SPSS). Appendices C1-C3 present the boxplots and
skewness and kurtosis values, all of which show that the distributions for the CVQ categories are
non-normal. Because of this, non-parametric tests were used where necessary. Numerical
descriptive statistics for sessions with the lowest change score and sessions with the highest
change score are located in Appendix D. Numerical descriptive statistics for the first report of
moderate to high change session are located in Appendix E.
Lastly, because the proportions of Emotional and Focused, the CVQ categories of
interest, were so small, it was decided to combine their proportions for some analyses. This
decision was based on the comment by Rice et al. (1979) that “combining the Emotional and
Focused categories improves the predictive power for client-centered therapy” (p. 10), given the
small number of observations of each category in their research. Previous research has also
shown that the presence of both Focused and Emotional vocal qualities indicate “good contact”
with the self in gestalt conflict split work (Greenberg, 1980, p. 149), suggesting an increased
productivity.
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Chapter 3:
Results
Research Question 1-Therapist and client vocal quality and the client’s report of change
Research question 1 asks if the therapist’s and client’s vocal quality is related to the
client’s report of change. Regarding the client’s vocal quality, Hypothesis 1a states there will be
a higher proportion of productive CVQ categories (Emotional, Focused, and Emotional Plus
Focused) in high change than in low change sessions. Hypothesis 1b states that there will be a
higher proportion of unproductive CVQ categories (Limited and Externalizing) in low change
than in high change sessions.
Wilcoxon Signed-rank tests were used to address these hypotheses. The Wilcoxon test is
a non-parametric test that evaluates whether the median proportion of a CVQ category in the
sessions with the lowest change score is significantly different from the median proportion of
that CVQ category in the sessions with the highest change score. The results indicate that there
were no significant differences in the median proportions of any of the CVQ categories between
the sessions with the lowest change score and sessions with the highest change score. See Table
10 for mean ranks, Z statistics, and p values for each CVQ category. This means there is no
association between the CVQ categories and the client’s report of change in the session, i.e.,
productive CVQ categories are not associated with high change sessions and unproductive CVQ
categories are not associated with low change sessions.
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Table 10
Results for Hypothesis 1a and b: Wilcoxon Signed-rank test - Mean Ranks, Ties, Z statistics, p values
for the CVQ categories in the Highest Change Score Sessions and the Lowest Change Score Sessions
(N=61)
Negative Ranks Positive Ranks Ties Z
(r)a
p value
n Mean
Rank N
Mean
Rank
Emotional
12 8.67 6 11.17 43 -.81 .10 .420
Focused
12 13.50 16 15.25 33 -.93 .12 .350
Emotional
Plus Focused
20 17.00 16 20.38 25 -.11 .01 .912
Limited
17 19.65 21 19.38 23 -.53 .07 .596
Externalizing
24 28.13 27 24.11 10 -.11 .07 .910
Note. a Effect size is (r) = Z/√N 0.1 is small, 0.3 is medium, 0.5 is large (Field, 2009).
Regarding the therapist’s vocal quality, Hypothesis 1c states that there will be a higher
proportion of Productive TVQ (Irregular, Softened, and Natural) in high change than in low
change sessions. This hypothesis could not be tested because the individual TVQ categories
were replaced by the Therapist Vocal Style variable. However, the Therapist Vocal Style
variable was used to explore possible differences in the therapist’s vocal quality between the
high change than low change sessions.
The Therapist Vocal Style variable could be used to explore this hypothesis because the
Softened-Irregular and Natural-Definite Therapist Vocal Styles can be contrasted with each
other according to theory. Each style is composed of relatively higher proportions of two of the
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individual TVQ categories. The Softened-Irregular Therapist Vocal Style is composed of higher
proportions of two of the three Productive TVQ categories: Softened and Irregular. The
Natural-Definite Therapist Vocal Style is defined by one of the Productive TVQ categories,
Natural, as well as by Definite, which is a vocal quality that can be either helpful or unhelpful to
the client. Because of this, more instances of Softened-Irregular Therapist Vocal Style would be
expected to occur in the high change than low change sessions, while more instances of Natural-
Definite Therapist Vocal Style would be expected to occur in the low change than high change
sessions.
This question was explored in two ways. First, the Therapist Vocal Style was examined
in the lowest change score group and in the highest change score group. The non-parametric
McNemar test of dependent proportions was used to evaluate whether the proportion of sessions
classified as Softened-Irregular Therapist Vocal Style in the highest change score group was
significantly different from the proportion of sessions classified as Softened-Irregular Therapist
Vocal Style in the lowest change score group. The test simultaneously makes this comparison
for the proportion of sessions classified as Natural-Definite Therapist Vocal Style in the lowest
and highest change score groups. Instances in which one client has both sessions classified with
the same Therapist Vocal Style are excluded from the McNemar test calculations. The results
showed that 54% of the sessions classified predominantly as Softened-Irregular Therapist Vocal
Style occurred in the lowest change score group, while 42% of the sessions classified as
predominantly Softened-Irregular Therapist Vocal Style occurred in the highest change score
group. These percentages are reversed for the Natural-Definite Therapist Vocal Style. These
percentages were not significantly different (p = .092) and should be interpreted with caution
94
because there was a smaller number of pairs of non-tied scores (n = 13) than is required by SPSS
(n = 26) to conduct the z test.
The second way in which this question was explored was to determine whether there
were differences in the session in which clients first reported moderate to high change. The non-
parametric Chi Square Goodness of Fit test was used to evaluate whether the proportions of
sessions classified as Softened-Irregular and Natural-Definite Therapist Vocal Style were equal
within this first report of moderate to high change group. The results were not significant, X2 (1,
N = 57) = .018, p = .895, indicating that within the first report of moderate to high change group,
there was no statistically significant difference between the proportion of sessions classified as
Softened-Irregular Therapist Vocal Style (50.9%) and Natural-Definite Therapist Vocal Style
(49.1%). Table 7 displays these figures.
To summarize the results for Research Question 1 and its associated hypotheses, the
results indicate that the client’s vocal quality and the therapist’s vocal quality appear unrelated to
the client’s report of change in the session.
Research Question 2-Therapist and client vocal qualities and the client’s scores on outcome
measures
Research question 2 asked if therapists’ and clients’ vocal qualities are related to the
clients’ outcome at termination. For the client’s vocal quality, it was hypothesized that a higher
proportion of the productive CVQ categories (Emotional, Focused, Emotional Plus Focused)
would predict better end-of-treatment outcome. Multiple regression analyses were conducted to
test this hypothesis because the test evaluates how well a higher proportion of each CVQ
category predicts scores on the outcome measures at termination.
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The dependent variable was the client’s score on each outcome measure at the end of
treatment. The clients’ scores on these measures at pre-treatment were entered as covariates to
control for the varying baseline levels of the outcome measures for different clients. The
independent variables were the proportion of each CVQ. The regressions were conducted in the
session with the lowest change scores on the CTSC-R, the session with the highest change score
on the CTSC-R, and the first report of moderate to high change session on the CTSC-R.
The assumptions of the multiple regression analyses were tested by examining the
scatterplots of the standardized residuals versus the predicted values as recommended by
Tabachnick and Fidell (2007). Preliminary tests of normality of the outcome measure
distributions showed that eight of the outcome measures had non-normal distributions.
However, an inspection of the standard residual scatterplots, which account for the relationship
of the post-treatment scores and the independent variables, revealed no violation of assumptions
of multivariate normality, linearity, or homoscedasticity.
Hypothesis 2a-Productive CVQ categories will predict better scores for clients on
the outcome measures at the end of treatment.
There were no significant results for Emotional, Focused, or Emotional Plus Focused in
the session with the highest change score. Parameter estimates for the multiple regression
analyses for Emotional, Focused, and Emotional Plus Focused in the session with the highest
change score are found in Appendices F1 to F3 respectively. In the session with the lowest
change score there was one significant finding in which a higher proportion of Focused vocal
quality predicted better scores on the IIP Self-Sacrificing subscale at the end of treatment, R2 =
.46, Δ R2= .05, F(1, 52) = 4.88, p = .032, 95% CI [-24.50, -1.18]. This means that a higher
proportion of Focused vocal quality in the session with the lowest change score predicted the
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client’s report of fewer problems with trying to please others to one’s own detriment and being
more self-protective and cautious in trusting others. Parameter estimates for the multiple
regression analyses for Emotional, Focused, and Emotional Plus Focused vocal qualities in the
session with the lowest change score are found in Appendices G1 to G3 respectively.
All other significant results for Emotional, Focused, and Emotional Plus Focused vocal
qualities were found in the first session in which clients report of moderate to high change.
Parameter estimates for the multiple regression analyses for Emotional, Focused, and Emotional
Plus Focused vocal qualities in the first session in which clients report moderate to high change
are found in Appendices H1 to H3 respectively.
Emotional vocal quality in the first report of moderate to high change session.
When clients’ pre-treatment scores were held constant, a higher proportion of Emotional
vocal quality in this session predicted the client’s report of fewer depressive symptoms, as seen
on the BDI scores at the end of treatment, R2 = .09, Δ R
2= .08, F(1, 53) = 4.87, p = .032, 95% CI
[-104.09, -4.95]. Similarly, a higher proportion of Emotional vocal quality predicted the clients’
report of less intense psychological distress at termination on the GSI, R2 = .29, Δ R
2= .08, F(1,
49) = 5.21, p = .027, 95% CI [-8.18, -.52] and less reactivity in coping with problems, on the PF-
SOC Reactive scale, R2 = .22, Δ R
2= .08, F(1, 48) = 4.72, p = .035, 95% CI [-11.89, -.46].
A higher proportion of Emotional vocal quality also predicted the client’s report of fewer
interpersonal problems overall at termination, as seen on the IIP Circumplex total, R2 = .48, Δ
R2= .05, F(1, 49) = 5.19, p = .027, 95% CI [-6.55, -.41]. This was also the case for two IIP
subscales: Cold Distant, R2 = .51, Δ R
2= .05, F(1, 49) = 5.04, p = .029, 95% CI [-7.59, -.42], and
Socially Avoidant, R2 = .58, Δ R
2= .04, F(1, 49) = 4.27, p = .044, 95% CI [-9.53, -.13]. These
results mean that a higher proportion of Emotional vocal quality in this session predicted the
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clients’ report of fewer problems with feeling interpersonally cold, distant, and unaffectionate as
well as feeling less socially awkward at the end of treatment.
Focused vocal quality in the first report of moderate to high change session.
A higher proportion of Focused vocal quality in this session predicted the client’s report
of fewer problems with interpersonal behaviours at the end of treatment including feeling less
exploitable and gullible as well as less permissive and excessively generous with others. This
was seen on the IIP subscales of Overly Accommodating, R2 = .54, Δ R
2= .04, F(1, 48) = 4.49, p
= .039, 95% CI [-6.72, -.18], and Self-Sacrificing, R2 = .53, Δ R
2= .09, F(1, 49) = 9.33, p = .004,
95% CI [-8.22, -1.70]. Similarly, a higher proportion of Focused vocal quality also predicted
the client’s report of greater ability to cope with problems by thinking through the issues and
strategizing as seen on the PF-SOC Reflective scale, R2 = .62, Δ R
2= .04, F(1, 48) = 5.74, p =
.021, 95% CI [.66, 7.5].
Emotional Plus Focused vocal quality in the first report of moderate to high change
session.
The proportions of Emotional vocal quality and Focused vocal quality in each session
were combined because doing so improves their power to predict change (Rice et al., 1979).
When analyzed in the first report of moderate to high change session, a higher proportion of
Emotional Plus Focused vocal quality predicted the client’s report of fewer symptoms of
depression, as seen on the BDI, R2 = .14, Δ R
2= .13, F(1, 53) = 8.09, p = .006, 95% CI [-70.61, -
12.21], and psychological distress, as seen on the GSI, R2 = .32, Δ R
2= .11, F(1, 49) = 7.87, p =
.007, 95% CI [-5.36, -.89], at the end of treatment.
A higher proportion of Emotional Plus Focused vocal quality in this session also
predicted the client’s report of fewer interpersonal problems overall at termination, as seen on
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the IIP Circumplex Total, R2 = .50, Δ R
2= .08, F(1, 49) = 7.51, p = .009, 95% CI [-4.27, -.66].
Significant results were also found for four IIP subscales as well including Cold Distant, R2 =
.54, Δ R2= .08, F(1, 49) = 8.04, p = .007, 95% CI [-5.08, -.87], Nonassertive, R
2 = .51, Δ R
2= .06,
F(1, 49) = 5.63, p = .022, 95% CI [-7.41, -.61], Overly Accommodating, R2 = .57, Δ R
2= .07,
F(1, 48) = 7.47, p = .009, 95% CI [-5.93, -.90], and Self-Sacrificing, R2 = .54, Δ R
2= .10, F(1,
49) = 10.62, p = .002, 95% CI [-6.71, -1.59]. These results mean that a higher proportion of
Emotional Plus Focused vocal quality predicts the client’s report of feeling less interpersonally
cold, distant, and unaffectionate; having an easier time asserting boundaries with others; feeling
less exploitable and gullible; and being less permissive and excessively generous with others at
the end of treatment. As well, a higher proportion of Emotional Plus Focused vocal quality in
this session predicted the client’s report of being more reflective and thoughtful in terms of
coping with problems as seen on the PF-SOC Reflective scale, R2 = .62, Δ R
2= .05, F(1, 48) =
6.28, p = .016, 95% CI [.674, 6.14].
Considering these results as a whole, three aspects stand out. First, the only session in
which the productive CVQ categories predict the clients’ scores on the outcome measures at
termination is in the first report of moderate to high change session. There are no significant
results in the session with the lowest change score on the CTSC-R or in the session with the
highest change score on the CTSC-R. Second, the majority of effect sizes for the significant
results were small. However, there were some moderate effect sizes, mainly for Emotional Plus
Focused vocal quality where a higher proportion of these vocal quality categories predicted 13%
of the variance in BDI scores, 11% in GSI scores, and 10% in Self-Sacrificing scores at post
treatment. Third, a comparison of the standardised beta coefficients indicates that Emotional
Plus Focused vocal quality was a stronger predictor of better scores at termination on the BDI,
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GSI, IIP Circumplex, and the IIP Cold Distant subscales than Emotional vocal quality alone.
Similarly, Emotional Plus Focused vocal quality was a stronger predictor of lower scores at
termination on IIP subscales of Overly Accommodating and Self-Sacrificing than Focused vocal
quality alone and of higher scores on the PF-SOC Reflective scale than Focused vocal quality
alone. In summary, with one exception, all results for Emotional, Focused, and Emotional Plus
Focused vocal quality are significant in the first report of moderate to high change session. This
provides support for Hypothesis 2a, indicating that a higher proportion of productive CVQ
categories predicts a better end-of-treatment outcome.
Additional analyses of Externalizing vocal quality and Limited vocal quality in the first
report of moderate to high change session for Research Question 2a
Additional multiple regressions were conducted with proportions of Externalizing and
Limited vocal qualities in the first report of moderate to high change session and scores on the
outcome measures at termination. In the first report of moderate to high change session, a
higher proportion of Limited vocal quality predicted the client’s report of better problem-coping
skills involving strategizing and thinking through as seen on the PF-SOC Reflective scale, R2 =
.61, Δ R2= .03, F(1, 48) = 4.08, p = .049, 95% CI [.01, 3.06]. In contrast, a higher proportion of
Limited vocal quality in this session predicted the client’s report of worse dysfunctional attitudes
at the end of treatment as seen on the DAS, R2 = .64, Δ R
2= .10, F(1, 45) = 13.15, p = .001, 95%
CI [-139.95, -39.99].
A higher proportion of Limited vocal quality in this session predicted the client’s report
of fewer interpersonal problems overall, as seen in the IIP Circumplex total, R2 = .48, Δ R
2= .05,
F(1, 49) = 5.19, p = .027, 95% CI [-2.15, -.13] at the end of treatment. A higher proportion of
Limited vocal quality in this session also predicted the client’s report of fewer problems in
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several interpersonal areas at the end of treatment. These included setting boundaries and being
more assertive with others, seen on the IIP Nonassertive subscale, R2 = .56, Δ R
2= .10, F(1, 49) =
10.59, p = .002, 95% CI [-4.68, -1.11]; being less gullible and exploitable by others, seen in the
Overly Accommodating subscale, R2 = .58, Δ R
2= .08, F(1, 48) = 8.65, p = .005, 95% CI [-3.37, -
.63]; and being less permissive and overly generous with others, as seen on the Self-Sacrificing
subscale, R2 = .52, Δ R
2= .08, F(1, 49) = 8.46, p = .005, 95% CI [-3.51, -.64]. Parameter
estimates for the multiple regression analyses for Limited vocal quality in the first report of
moderate to high change session are found in Appendix I1.
Externalizing vocal quality in the first report of moderate to high change session.
A higher proportion of Externalizing vocal quality in the first report of moderate to high
change session predicted the client’s report of more depressive symptoms at the end of
treatment, as seen on the BDI, R2 = .11, Δ R
2= .10, F(1, 53) = 5.84, p = .019, 95% CI [2.67,
28.68]; more dysfunctional attitudes as seen on the DAS, R2 = .53, Δ R
2= .07, F(1, 46) = 6.72, p
= .013, 95% CI [12.92, 102.72]; and greater psychological distress as seen on the GSI, R2 = .27,
Δ R2 = .09, F(1, 49) = 6.22, p = .016, 95% CI [.22, 2.04] at the end of treatment.
A higher proportion of Externalizing vocal quality in this session also predicted the
client’s report of more interpersonal problems, as seen on the higher IIP Circumplex total at the
end of treatment, R2 = .51, Δ R
2 = .09,F(1, 49) = 9.34, p = .004, 95% CI [.40, 1.92]. A higher
proportion of Externalizing vocal quality in this session also predicted the client’s report of
greater difficulty being affectionate and generous with others; more able to set boundaries and to
be more assertive with others; being less gullible and exploitable; and with being less permissive
and being less overly generous at the end of treatment. These differences are seen in the higher
scores on the following IIP subscales: Cold Distant subscale, R2 = .53, Δ R
2 = .07, F(1, 49) =
101
7.59, p = .008, 95% CI [.33, 2.14]; Nonassertive, R2 = .58, Δ R
2 = .12,F(1, 49) = 13.83, p = .001,
95% CI [ 1.16, 3.89; Overly Accommodating, R2 = .61, Δ R
2= .11, F(1, 49) = 13.18, p = .001,
95% CI [.84, 2.91]; and Self-Sacrificing, R2 = .57, Δ R
2 = .13, F(1, 49) = 14.95, p = .000, 95% CI
[.99, 3.142].
A higher proportion of Externalizing vocal quality in this session predicted the client’s
report of greater difficulty coping with problems through strategizing and planning as seen in the
higher scores on the PF-SOC Reflective scale at termination, R2 = .63, Δ R
2 = .06, F(1, 48) =
7.29, p = .01, 95% CI [-2.73, -.40]. Externalizing vocal quality also predicted the client’s report
of lower self-esteem at termination as seen in the lower RSE score, R2 = .27, Δ R
2 = .06, F(1, 50)
= 4.16, p = .047, 95% CI [-23.94, -.18]. Parameter estimates for the multiple regression analyses
for Externalizing vocal quality in the first report of moderate to high change session are found in
Appendix I2.
Additional analyses of Limited vocal quality and Externalizing vocal quality in the
session with the lowest change score for Research Question 2a
Additional multiple regressions were conducted with proportions Limited vocal quality
and Externalizing vocal quality in the session with the lowest change score and scores on the
outcome measures at termination. There were no significant results for Limited vocal quality in
the session with the lowest change score. Parameter estimates for the multiple regression
analyses for Limited vocal quality in the session with the lowest change score are found in
Appendix J1.
A higher proportion of Externalizing vocal quality in the session with the lowest change
score predicted the client’s report of greater difficulty with excessive giving and trying hard to
please others than other clients at termination. This was seen on the IIP Self-Sacrificing
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subscale, R2 = .46, Δ R
2 = .04, F(1, 52) = 4.16, p = .047, 95% CI [.02, 1.93]. Parameter
estimates for the multiple regression analyses for Externalizing vocal quality in the session with
the lowest change score are found in Appendix J2.
Additional analyses of Limited vocal quality and Externalizing vocal quality in the
session with the highest change score for Research Question 2a
When multiple regression analyses were conducted for Limited vocal quality in the
session with the highest change score and scores on the outcome measures, several significant
results were found. A higher proportion of Limited vocal quality in this session predicted the
client’s report of coping with problems with greater reactivity and avoidance at termination, as
seen on the PF-SOC Reactive, R2 = .25, Δ R
2 = .11, F(1, 51) = 7.55, p = .008, 95% CI [.79,
5.09], and PF-SOC Suppressive scales, R2 = .32, Δ R
2 = .15, F(1, 51) = 11.18, p = .002, 95% CI
[1.62, 6.50]. Parameter estimates for the multiple regression analyses for Limited vocal quality
categories in the session with the highest change score are found in Appendix K1.
When multiple regression analyses were conducted for the Externalizing category in the
session with the highest change score and scores on the outcome measures at termination, there
were several significant results. A higher proportion of Externalizing vocal quality in this
session predicted the client’s report of dealing with problems in a less reactive and avoidant
manner at the end of treatment, as seen on the PF-SOC Reactive, R2 = .21, Δ R
2 = .07, F(1, 51) =
4.89, p = .032, 95% CI [-3.73, -.18], and PF-SOC Suppressive scales, R2 = .26, Δ R
2 = .09, F(1,
51) = 5.91, p = .019, 95% CI [-4.56, -.43]. Parameter estimates for the multiple regression
analyses for Externalizing vocal quality in the session with the highest change score are located
in Appendix K2.
103
In summary, the results of the additional analyses of Externalizing vocal quality and
Limited vocal quality show that in the session with the highest change score, a higher proportion
of Limited vocal quality predicts higher, meaning worse scores on the PF-SOC Reactive and
Suppressive styles of coping at the end of treatment. In contrast, a higher proportion of
Externalizing vocal quality predicts lower, meaning better scores on these measures at the end of
treatment. In the session with the lowest change score, a higher proportion of Externalizing
vocal quality predicts higher, worse scores on a measure of interpersonal problems.
Table 11 summarizes the results of all of the multiple regression analyses. In all, there
were very few significant results in the session with the lowest change score and session with the
highest change score. In contrast, many significant results were found in the first report of
moderate to high change session. A higher proportion of the Emotional Plus Focused category
in this session predicted better scores for the client at the end of treatment on the BDI, GSI, IIP
Circumplex, and some IIP subscales, and the PF-SOC Reflective scale. While the proportion of
Emotional vocal quality and Focused vocal quality alone also predicted better scores on the
outcome measures at the end of treatment, Emotional vocal quality combined with Focused
vocal quality (Emotional Plus Focused vocal quality) was the better predictor as seen by that
variable’s higher standardized beta coefficients. Results of the additional analyses also show that
a higher proportion of Limited vocal quality in the first session in which clients report moderate
to high change predicts better scores at termination on several outcome measures. In contrast, a
higher proportion of Externalizing vocal quality in this session predicts worse scores at
termination on several outcome measures.
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Hypothesis 2b-Productive TVQ categories will predict better scores for clients on the
outcome measures at the end of treatment.
Hypothesis 2b states that a higher proportion of productive TVQ (Softened, Natural, and
Irregular) will predict better scores for clients on the outcome measures at termination. Because
the individual TVQ categories were replaced by the Therapist Vocal Style variable, this
hypothesis could not be tested directly. Instead, the relationship of the Therapist Vocal Style and
the clients’ scores on the outcome measures at post-treatment was explored. Specifically,
Table 11
A Higher Proportion of CVQ Category Predicts Outcome Scores at Post Treatment
First reported moderate-high
change session
Session with the lowest
change score
Session with the highest
change score
Em
otional
Focu
sed
Em
otional
+ F
ocu
sed
Lim
ited
Ext
ern
aliz
ing
Em
otional
Focu
sed
Em
otional
+ F
ocu
sed
Lim
ited
Ext
ern
aliz
ing
Em
otional
Focu
sed
Em
otional
+ F
ocu
sed
Lim
ited
Ext
ern
aliz
ing
BDI
DAS
GSI
Circumplex
VC
CD
SA
NA
OA
SS
IN
DC
Reactive
Reflective
Suppressive
RSE
Note. “” indicates that a higher proportion of CVQ in that session predicts lower scores on the outcome
measure at termination compared to other clients. “” indicates that a higher proportion of the CVQ in that
session predicts higher scores on the outcome measure at termination compared to other clients.
BDI=Beck Depression Inventory; DAS= Dysfunctional Attitudes Scale; GSI=General Symptom Index;
Inventory of Interpersonal Subscale abbreviations are as follows: Circumplex=Total; VC=Vindictive;
CD=Cold Distant; SA=Socially Avoidant; NA=Nonassertive; OA= Overly Accommodating; SS=Self-
Sacrificing; IN=Intrusive-Needy; DC=Domineering/Controlling; Reactive, Reflective, and Suppressive refer
to the Problem-Focused Style of Coping scales; RSE=Rosenberg Self-Esteem Scale.
105
multiple regression analyses were conducted to evaluate whether having at least one session
(either the session with the lowest change score or the session with the highest change score)
characterized as Softened-Irregular Therapist Vocal Style was related to having better scores on
the outcome measures at post-treatment compared to having no sessions classified as Softened-
Irregular Therapist Vocal Style.
To do this, two dummy variables were created. One represented clients for whom both
the session with the lowest change score and the session with the highest change score on the
CTSC-R were characterized by the Softened-Irregular Therapist Vocal Style. This dummy
variable was called Softened-Irregular Both. The second represented clients for whom one of
these sessions was characterized by the Softened-Irregular Therapist Vocal Style and the other
by the Natural-Definite Therapist Vocal Style. This dummy variable was called Mix Softened-
Irregular and Natural-Definite. The reference category represented clients for whom both the
session with the lowest change score and the session with the highest change score were
characterized by the Natural-Definite Therapist Vocal Style, or Natural-Definite Both.
The clients’ pre-treatment scores on these measures were entered as covariates to control
for varying baseline levels of the outcome measures for different clients. Next, Softened-
Irregular Both and Mix Softened-Irregular and Natural-Definite were entered as one block. The
dependent variables were the clients’ scores at post-treatment on the outcome measures.
The assumptions of the multiple regression analyses were tested by examining the
scatterplots of the standardized residuals versus the predicted values. An inspection of the
standard residual scatterplots, which account for the relationship of the post-treatment scores and
the independent variables, revealed no violation of assumptions of multivariate normality,
linearity, or homoscedasticity.
106
Appendix L1 displays parameter estimates for the multiple regression analyses with the
Therapist Vocal Style in the session with the lowest change score and session with the highest
change score. None of the results were significant, with the exception of a significant test
parameter for the IIP Overly Accommodating subscale. Although the results of the regression
analysis were significant for the overall model, R2 = .48, F(2, 47) = 14.28, p = .000, after
controlling for the pre-treatment scores, the block of Softened-Irregular Both and Mix Softened-
Irregular and Natural-Definite did not add significantly to explaining the model, Δ R2 = .05, p =
.12. Interestingly, however, the parameter estimate did show that Softened-Irregular Both made
a significant contribution to the prediction equation t = -2.09, p = .042. The finding that the
block of Softened-Irregular Both and Mix Softened-Irregular and Natural-Definite did not
explain the model could be an artifact of insufficient sample size in this analysis. However, the
finding that Softened-Irregular Both significantly contributes to the prediction equation suggests
a relationship worth further investigation.
Though this result is very weak, it suggests that Softened-Irregular Both is significantly
different from Natural-Definite Both in predicting lower post-treatment scores on the Overly
Accommodating subscale. This finding tentatively suggests that clients having both the session
with the lowest change score and session with the highest change score classified as Softened-
Irregular Therapist Vocal Style, as opposed to having both sessions classified as Natural-
Definite Therapist Vocal Style, have fewer interpersonal problems at the end of treatment with
worrying about offending others as well as feeling less gullible and exploitable.
Another multiple regression analysis was conducted for the Softened-Irregular and
Natural-Definite Therapist Vocal Style in the first report of moderate to high change session.
The clients’ pre-treatment scores on these measures were entered as covariates to control for
107
varying baseline levels of the outcome measures for different clients. Because the first report of
moderate to high change session would be classified as either Softened-Irregular or Natural-
Definite Therapist Vocal Style, one dummy variable was created for the Softened-Irregular
Therapist Vocal Style, using the Natural-Definite Therapist Vocal Style as a reference category.
The Softened-Irregular Therapist Vocal Style variable was entered after controlling for the pre-
treatment scores. The dependent variables were the clients’ scores at post-treatment on the
outcome measures.
There were no significant results, indicating that in the first report of moderate to high
change session, the Softened-Irregular Therapist Vocal Style is not significantly different from
the Natural-Definite Therapist Vocal Style in predicting clients’ scores on the outcome measures
at post treatment. Appendix L2 displays parameter estimates for the multiple regression
analyses with the Therapist Vocal Style in the first report of moderate to high change session.
In summary, the results of the analyses exploring how well the Therapist Vocal Style
predicts the client’s scores on outcome measures at termination suggest only a weak association
between having both the session with the lowest change score and the session with the highest
change scores being classified as Softened-Irregular Therapist Vocal Style and improvement on
the IIP Overly Accommodating subscale, when compared to having both of these sessions
classified as Natural-Definite Therapist Vocal Style.
Research Question 3-Differences between therapist and client vocal qualities and treatment
types.
Research question 3 asks if there is a difference in the TVQ and CVQ categories
primarily expressed in PE-EFT and CBT. For the client’s vocal quality, Hypothesis 3a states
that CBT clients will have a lower proportion of Focused vocal quality than PE-EFT clients. A
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Mann-Whitney U test was conducted to evaluate whether the CBT clients would have a lower
proportion of Focused vocal quality than PE-EFT clients. When the proportions of Focused
vocal quality in the session with the lowest change score on the CTSC-R were combined with
the proportions of Focused vocal quality in the session with the highest change score on the
CTSC-R, the results were not significant, z = .88, p = .377. CBT clients had an average rank of
29.30, while the PE-EFT clients had an average rank of 33.00. Table 12 shows the mean ranks,
Z statistics, effect sizes and p values for the proportion of CVQ categories by treatment type in
the session with the lowest change score plus session with the highest change score.
Table 12
Results for Hypothesis #3a: Mean Ranks, Z statistics, Effect Sizes, and p values of CVQ Categories in
Lowest plus Highest Change Score Sessions by Treatment Type (N=61 Clients)
CVQ Categories in
Lowest +Highest
CBT (n = 33)
Mean Rank
PE-EFT (n = 28)
Mean Rank Z (r)a P
Emotional
27.67 36.11 2.57 .33 .010
Focused
29.30 33.00 .88 .11 .377
Emotional+Focused
27.02 35.70 1.97 .26 .049
Limited
30.08 32.09 .454 .06 .650
Externalizing
35.23 26.02 -2.02 .26 .043
Note. aEffect size is (r) = Z/√N 0.1 is small, 0.3 is medium, 0.5 is large (Field, 2009).
A second Mann-Whitney U test was conducted to evaluate the proportions of Focused vocal
quality between CBT and PE-EFT in the session in which clients first report moderate to high
change on the CTSC-R. The test results were not significant, z = .98, p = .326. CBT clients had
an average rank of 27.27, while the PE-EFT clients had an average rank of 31.41. Table 13
shows the mean ranks, Z statistics, effect sizes and p values for the proportion of CVQ categories
109
by treatment type in the first report of moderate to high change sessions. In sum, there are no
differences between clients in CBT and PE-EFT in their use of Focused vocal quality.
Table 13
Results for Hypothesis #3a: Mean Ranks, Z statistics, Effect Sizes, and p values of CVQ Categories in
First Report of Moderate to High Change Score Sessions by Treatment Type (N=58 Clients)
CVQ Categories
CBT (n = 30)
Mean Rank
PE-EFT (n = 28)
Mean Rank Z (r) a P
Emotional
27.38
31.77
1.50
.20
.133
Focused
27.72
31.41
.982
.13
.326
Emotional+Focused
26.68
32.52
1.44
.19
.149
Limited
26.70
32.50
1.45
.19
.149
Externalizing
33.77
24.93
-2.06
.27
.040
Note. a Effect size is (r) = Z/√N 0.1 is small, 0.3 is medium, 0.5 is large (Field, 2009).
Additional tests addressing Research Question 3 and the client’s vocal quality.
Additional Mann-Whitney U tests were conducted to evaluate if there were differences in
the proportions of the other CVQ categories between the two treatment types. The Mann-
Whitney U tests were run on the combined proportions of each CVQ category in the session with
the lowest change score and session with the highest change score. The combination of these
sessions is referred to here as lowest plus highest change score group. The tests were also run on
the proportions of each CVQ category in the sessions in which the client first reported moderate
to high change.
When the proportions of each CVQ were combined, in the lowest plus highest change
score group, there were three significant results. PE-EFT clients expressed a significantly higher
proportion of Emotional vocal quality than CBT clients, z = 2.57, p = .010, r =.33. The mean
rank of the PE-EFT clients was 36.11, while for the CBT clients it was 27.67. PE-EFT clients
110
also expressed a higher proportion of Emotional Plus Focused vocal quality than the CBT
clients, z = 1.97, p = .049, r =.25. PE-EFT clients had a mean rank of 36.11, while the CBT
clients had a mean rank of 27.02. However, the CBT clients expressed a significantly higher
proportion of Externalizing vocal quality than the PE-EFT clients, z = -2.02, p = .043, r =.26.
The mean rank of the CBT clients was 35.23, while for the PE-EFT clients it was 26.02. There
were no significant differences for Limited vocal category, z = .45, p = .650. The mean rank of
the CBT clients was 30.08 and for the PE-EFT clients it was 32.09.
When the Mann-Whitney U test was conducted on the proportions of each CVQ category
in the session in which the client first reported moderate to high change, there was only one
significant result. CBT clients expressed a significantly higher proportion of Externalizing vocal
quality than the PE-EFT clients, z = -2.06, p = .040, r =.27. The mean rank for the CBT group
was 33.77, while for the PE-EFT group, it was 24.93. There was no difference in the proportion
of Emotional vocal quality, z = 1.50, p = .133 in which the CBT group had a mean rank of 27.38
and the PE-EFT group had a mean rank of 31.77. The proportions of Emotional Plus Focused
vocal quality were also not significantly different between the two groups, with the CBT group
having a mean rank of 26.68 and the PE-EFT group having a mean rank of 32.52, z = 1.44, p =
.149.
To summarize the results for Research Question 3 and Hypothesis 3a, there was no
support for the hypothesis that CBT clients will have a lower proportion of Focused vocal
quality than PE-EFT clients. This means that clients in both treatment groups expressed the
same proportion of Focused vocal quality in sessions with the lowest and highest change scores.
Results of the additional analyses for proportions of categories in the lowest plus highest change
111
score group show that CBT and PE-EFT clients expressed statistically equivalent proportions of
Limited vocal quality.
However, the additional analyses for Emotional, Emotional Plus Focused, and
Externalizing vocal qualities in the lowest plus highest change score group showed statistically
significant differences for the PE-EFT group which expressed a higher proportion of Emotional
vocal quality than the CBT group. When the proportion of Emotional vocal quality was
combined with the proportion of Focused vocal quality (Emotional Plus Focused), results
showed that the PE-EFT group expressed a significantly higher proportion of Emotional Plus
Focused vocal quality than the CBT group. However, this result was due to the significantly
higher proportion of Emotional category for the PE-EFT condition only as can be seen from the
Z statistic, which is higher for Emotional than Emotional Plus Focused vocal quality. Lastly,
CBT clients expressed a higher proportion of Externalizing vocal quality than PE-EFT clients
when the proportion of Externalizing in the session with lowest change score was combined with
the proportion of Externalizing in the session with the highest change score. This was also the
case in the first report of moderate to high change session.
Exploration of Hypothesis 3b-Therapist Vocal Style and treatment types.
Hypothesis 3b states that CBT therapists will have a higher proportion of Natural vocal
quality than PE-EFT therapists. Even though the Therapist Vocal Style variable replaced the
individual TVQ categories, it was possible to test this hypothesis by comparing the proportion of
sessions classified as Natural-Definite Therapist Vocal Style between the treatment groups. A
two-way contingency table analysis was conducted to evaluate whether the proportions of
sessions classified as Natural-Definite and Softened-Irregular Therapist Vocal Style was the
same in the CBT and PE-EFT conditions. The two variables were treatment condition (CBT and
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PE-EFT) and Therapist Vocal Style (Natural-Definite and Softened-Irregular). The analysis was
run in the first report of moderate to high change session and in the session with the lowest
change score and the session with the highest change score.
Results show that the Therapist Vocal Style was significantly related to treatment type,
with the CBT group having significantly more Natural-Definite Therapist Vocal Style sessions
than the PE-EFT group and the PE-EFT group having significantly more Softened-Irregular
Therapist Vocal Style sessions than the CBT group. The effect size was large in the session with
the lowest change score, Pearson 2(1, N = 57) = 24.62, p = .000, = -.66, and in the session
with the highest change score, Pearson 2(1, N = 57) = 39.06, p = .000, = .83.
The analysis was also run in the first report of moderate to high change session. The
results in this session also showed the CBT group having significantly more Natural-Definite
Therapist Vocal Style sessions than the PE-EFT group and the PE-EFT group having
significantly more Softened-Irregular Therapist Vocal Style sessions than the CBT group. The
result also had a large effect size, Pearson 2(1, N = 57) = 29.66, p = .000, = .72.
Taken together, these results indicate that a significantly higher proportion of CBT
sessions are characterized by the Natural-Definite Therapist Vocal Style than PE-EFT sessions
and that a significantly higher proportion of PE-EFT sessions are characterized by the Softened-
Irregular Therapist Vocal Style than the CBT sessions.
Summary of results
Regarding Research Question 1, there was no support for the hypothesis that there would
be a higher proportion of productive CVQ categories (Emotional, Focused, Emotional Plus
Focused) in high change than low change sessions. Results of the additional analyses showed
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that there were no significant differences between Externalizing and Limited vocal qualities
either in the high and low change sessions.
In terms of the Therapist Vocal Style, there were a statistically equivalent number of
sessions classified as Natural-Definite and Softened-Irregular Therapist Vocal Style in the group
of sessions with the lowest change score and the group of sessions with the highest change score.
Also, the proportion of sessions classified as Softened-Irregular and Natural-Definite Therapist
Vocal Style was not statistically different within the first reported moderate to high change
session. These results do not provide support for the hypothesis that there will be a higher
proportion of productive TVQ categories in high change rather than low change sessions.
Regarding Research Question 2, the proportions of productive CVQ categories in the
session with the highest change score did not significantly predict clients’ scores on the
outcomes measures at termination in the multiple regression analyses. However, a higher
proportion of Focused vocal quality in the session with the lowest change score did predict better
scores at termination on the IIP Self-Sacrificing subscale. There were many significant results
for Emotional, Focused, and Emotional Plus Focused vocal qualities in the first session in which
clients report moderate to high change. Specifically, clients who expressed a higher proportion
of these productive CVQ categories had better scores on outcome measures at termination than
other clients. Also, although Emotional vocal quality and Focused vocal quality alone predicted
better scores at the end of treatment, combining these CVQ categories made them better
predictors of scores for some measures than either category alone.
Additional multiple regressions with the Externalizing and Limited categories showed
that a higher proportion of Limited vocal quality in the first report of moderate to high change
session predicted better scores on outcome measures at the end of treatment, while a higher
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proportion of Externalizing vocal quality predicted worse scores. Taken together, these results
show that a higher proportion of each CVQ category discriminated between clients, in terms of
their outcome scores at termination, in the first report of moderate to high change session.
Additional multiple regressions with Externalizing vocal quality and Limited vocal
quality in the session with the highest change score show that a higher proportion of
Externalizing vocal quality predicted the client’s report of less reactivity and suppressive styles
of coping at termination, while a higher proportion of Limited vocal quality predicted the
opposite, meaning these clients reported experiencing more reactivity and suppressive coping
behaviours than other clients at the end of treatment. Additional tests in the session with the
lowest change score showed one significant result in which a higher proportion of Externalizing
vocal quality predicted worse scores on a measure of interpersonal problems at the end of
treatment.
In terms of the Therapist’s vocal style, exploratory multiple regression analyses were
conducted in the session with the lowest change score and the session with the highest change
score. The purpose of the test was to see how well having at least one session classified as
Softened-Irregular Therapist Vocal Style predicted the client’s scores on the outcome measures
at the end of treatment, when compared with having both sessions classified as Natural-Definite
Therapist Vocal Style. None of the results were significant, although a significant test parameter
suggests that having both the session with the lowest change score and session with the highest
change score classified as Softened-Irregular Therapist Vocal Style is related to better post-
treatment scores on the IIP Overly Accommodating subscale than having both sessions classified
as Natural-Definite Therapist Vocal Style. This finding suggests that the Softened-Irregular
Therapist Vocal Style may be important for clients having this interpersonal style.
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Regarding Research Question 3, there was no evidence to support the hypothesis that
CBT clients expressed less Focused vocal quality than PE-EFT clients. However, results from
the additional analyses showed that Emotional vocal quality and Externalizing vocal quality
discriminated between the treatment approaches. Specifically, when the proportion of each CVQ
category in the session with the lowest change score was combined with the proportion of the
proportion of that CVQ category in the session with the highest change score, the results showed
that PE-EFT clients expressed more Emotional vocal quality than CBT clients and that CBT
clients expressed more Externalizing vocal quality than PE-EFT clients. In the first report of
moderate to high change session, however, only Externalizing vocal quality discriminated
between the groups.
In terms of the therapist’s vocal quality, a new variable called the Therapist Vocal Style
replaced the individual TVQ categories in the analyses in order to keep the study’s power as high
as possible after the outlier cases were removed. Although the hypothesis that CBT therapists
would have a higher proportion of Natural vocal quality than PE-EFT therapists could not be
directly tested because of this change, it was explored using the Therapist Vocal Style variable.
The exploratory analyses showed that Therapist Vocal Style discriminated between treatment
approaches. Specifically, there were far more CBT sessions classified as Natural-Definite
Therapist Vocal Style than PE-EFT sessions, while there were far more PE-EFT sessions
classified as Softened-Irregular Therapist Vocal Style than CBT sessions. These results provide
support for the hypothesis that the CBT therapists spoke in Natural vocal quality more than the
PE-EFT therapists.
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Chapter 4:
Discussion
The purpose of the current study was to explore the clients’ and therapists’ vocal qualities
in the CBT and PE-EFT treatments for major depression. As Greenberg (1984) explains, “voice
is a subtle, moment-by-moment indicator of change which is not easily subjected to conscious
control or external influence and is therefore a good cue of the ‘true’ process” (p. 109). Previous
research demonstrated that some vocal qualities are associated with productive client processes
(e.g., Wexler, 1974) and good treatment outcomes (e.g., Butler, et al., 1962), while others are
not.
One of the most important findings in the current study to be discussed was that the
client’s vocal quality predicted scores on outcome measures at termination. The CVQ categories
with the smallest proportions, Emotional, Focused, and Limited predicted better scores when
they occurred in the first report of moderate to high change session. On the other hand, a higher
proportion of the predominant vocal category, Externalizing vocal quality, in this session
predicted worse scores at termination when it occurred in this session. Also, it seems important
to explain how it was that there was no difference in the proportions of any CVQ category
between the session with the lowest change score and the session with the highest change score.
Another key finding to be discussed was that the client’s and therapist’s vocal quality
differentiated the treatment types from one another. In the PE-EFT group, clients expressed
more Emotional vocal quality and therapists spoke more in the Softened-Irregular Therapist
Vocal Style. In the CBT group, clients spoke mostly in Externalizing vocal quality and
therapists spoke predominantly in Natural-Definite Therapist Vocal Style.
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CVQ predicts clients’ scores on outcome measures at termination
Although Rice et al. (1979) explained that combining Emotional vocal quality with
Focused vocal quality increases their “predictive power” (p. 10), it is important to reflect on
why that might be the case in the current study and why this was found only in the first report of
moderate to high change session. Also, given that Limited vocal quality is regarded as a vocal
quality that does not generate new experience (Wexler, 1974) and therefore suggests a poor
prognosis (Wexler & Butler, 1976), it is telling that in the current study Limited vocal quality
predicts better scores on the outcome measures at termination in the first report of moderate to
high change session, but predicts worse scores in the session with the highest change score. The
question also arises of how it could be that Externalizing vocal quality in the first report of
moderate to high change session predicts worse scores on the outcome measures at termination,
but predicts better scores in the session with the highest change score.
Emotional Plus Focused vocal quality predict more favourable treatment outcomes in
the first report of moderate to high change session only.
Focused vocal quality and Emotional vocal quality, individually, in the first report of
moderate to high change session predicted better treatment outcomes. Focused vocal quality
predicted the client’s report of greater ability to express anger without fear of offending others;
being more caring for oneself in relation to meeting other people’s demands; and coping with
problems using a more deliberate, thoughtful approach. Although other studies using the CVQ
did not include these outcome measures, the results of the current project are consistent with the
findings from Butler et al. (1962) and Rice and Wagstaff (1967) in which more Focused vocal
quality was associated with favourable treatment results in client-centered therapy.
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Similarly, in the current study, a higher proportion of Emotional vocal quality was
associated with less depression, less psychological distress, fewer interpersonal problems, and
less reactivity in dealing with problems at the end of treatment. These findings are consistent
with those obtained by Nixon (1980) in which the expression of Emotional vocal quality in
wholistic primal therapy “was significantly and positively correlated with many of the outcome
measures, with a significant correlation of .42 with the global outcome measure” (Rice & Kerr,
1986, p. 85). In client-centered therapy however, Rice et al. (1979) did not find enough
Emotional vocal quality to analyze and suggested that “it seems probable that combining the
Emotional and Focused categories improves the predictive power for client-centered therapy” (p.
10).
In the current study as well, Emotional vocal quality and Focused vocal quality were
present in very small amounts. Even though the number of observations for these CVQ
categories was the smallest of all four categories, they significantly predicted better scores on
outcome measures at termination. Furthermore, when their proportions were combined,
consistent with Rice et al. (1979), Emotional Plus Focused vocal quality was a stronger predictor
of scores than either Emotional vocal quality or Focused vocal quality alone. However,
Emotional Plus Focused vocal quality predicted treatment results only in the first report of
moderate to high change session and not in either the session with the lowest change score or the
session with the highest change score.
Together, these findings suggest there may be something unique about the confluence of
a higher proportion of Emotional vocal quality and Focused vocal quality, occurring within the
session that the client first reports experiencing moderate to high change, that predicts better
scores on the outcome measures at termination. The client who is working in therapy using both
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of the vocal qualities may have a better chance of experiencing the significant shift “in terms of
their understanding of their problems, how they are treating themselves, and how they are feeling
about themselves and others” (p. 19) described by Watson, Goldman, and Greenberg (2007) as
the meaning of a CTSC-R score of 5 or more.
One reason for this may be that while emotional expression, on its own, may not
necessarily be enough for change to occur (e.g., Kennedy-Moore & Watson, 1999), it is a key
element in the change process. Regarding emotional arousal, which would be heard as
Emotional vocal quality, Murray and Segal (1994) referred to Daldrup, Beutler, Engle, and
Greenberg (1988) and Greenberg and Safran (1987) when they wrote, “there is a good deal of
emphasis in the clinical literature on the capacity of vocal expression to arouse emotion in
various forms of psychotherapy” (Murray & Segal, 1994, p. 393). Further, it is widely accepted
by proponents of diverse psychotherapies that expressing emotion is “a common factor crucial to
psychotherapeutic change” (Iwakabe, Rogan, & Stalikas, 2000, p. 376, referring to Frank &
Frank, 1991, and Garfield, 1989).
Researchers think change occurs with the arousal of emotion for several reasons. From
the PE-EFT perspective, emotional expression arouses the “client’s emotional schemes in order
to restructure old meanings and to create new ones” (Greenberg & Paivio, 1997 as cited in
Samoilov & Goldfried, 2000, p. 375). From the cognitive therapy perspective, Peternelli (1999)
described Beck et al.’s (1979) attitude that although “the meaning or emotional response of an
event depends upon the perception one has about this event…. The counsellor should first allow
the patient to experience and express his genuine emotion” (Peternelli, 1999, p. 13) as this
provides the client with relief.
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Other researchers have discussed how emotional arousal plus another client processing activity
creates a more powerful predictor of change. For example, Diamond et al. (2010), referring to
Missirlian, Toukmanian, Warwar, Greenberg (2005) and Pos, Greenberg, Goldman, and Korman
(2003), found that emotional expression “has been most strongly correlated with outcome when
it occurs in conjunction with cognitive exploration and reflection” (Diamond et al., 2010, pp.
402-403). Wawar (2005), too, found that “combining [emotional arousal] mid-therapy with EXP
predicted outcome on the SCL-90-R and BDI better than either of these variables alone” (p. iii).
Kennedy-Moore and Watson (1999) explained that while people can learn about themselves by
expressing their emotions, the amount of expression is not what is important. Instead, the
benefits of emotional expression depend on people’s abilities to “integrate their thinking and
their feeling, to draw upon their emotional experience without being driven blindly by it, and to
consider the interpersonal impact of their emotional behavior without discounting their own
experience” (Kennedy-Moore & Watson, 1999, p. 6).
In terms of Emotional and Focused vocal qualities, once emotions have been aroused,
speaking in Focused vocal quality indicates that the client is involved in a reflective-type of
process to form fresh, novel emotional experience (e.g., Wexler, 1974). For example, Watson
and Greenberg (1996) stated that Focused vocal quality represents the “tracking of inner
experience and clients’ attempts to symbolize it in words” (p. 265). Wexler (1974) wrote that
Focused vocal quality signals “an involved and fluid mode of processing where experience is
being created” (p. 48). Wexler studied vocal quality and the processing activities of students
who gave a personal speech about sadness. He found significant and positive relationships
between the processes of differentiation, in which a person describes a more general experience
in finer-grained terms; integration, in which the person abstracts new meaning from discrete
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experience; and vividness and variety of language used to describe experience. Wexler (1974)
summarized the results of his study by writing that:
Although the differentiation and integration of meaning is certainly a pervasive
characteristic of adult human functioning, the results show that the use of these
operations varies directly with the degree to which voice quality indicates involvement in
creating new experience…the relationship between the two is so strong as to suggest that
they are tapping the same phenomenon. (p. 51)
Taken together, these clinical meanings for Emotional vocal quality and Focused vocal quality
suggest that when they occur in higher proportions in the same session, they boost the client’s
ability to experience the kind of shifts in personal meaning described by Watson et al. (2007) in
“their understanding of their problems, how they are treating themselves, and how they are
feeling about themselves and others” (p. 19).
Limited Vocal Quality predicts more favourable treatment outcomes in the first
report of moderate to high change session.
Previous research associated Limited vocal quality with a personality type in which the
speaker is aware of a great deal of emotion, but is so overwhelmed by it that deeper
psychological exploration is hindered (Rice & Gaylin, 1973). This constricted and limited way
of relating to one’s own experience was inversely related to the creation of new, alternative
views (Wexler, 1974) and was linked to unsuccessful treatment outcomes (Rice & Wagstaff,
1967). One finding in the current study supports these results in that a higher proportion of
Limited vocal quality predicted the client’s report of avoidance and reactivity in coping with
problems at the end of therapy. However, this occurred in the session with the highest change
score and not in a low change session as would be predicted from theory. This scenario in which
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the client experienced the session as high change, but still had a poor treatment outcome points
to Limited vocal quality as a trait or “enduring style” of speech (Rice & Kerr, 1968, p. 74) that
impedes the process of change.
However, Rice and Kerr (1986) explained that the Vocal Quality measures are also
“flexible enough to reflect moment-to-moment shifts in participation” (p. 74) suggesting more of
a state than trait. Rice and Koke (1981) stated that the “CVQ was originally designed as a state
rather than a trait measure, that is, it was intended to assess the quality of client’s involvement in
the therapy process at any given moment” (p. 161). Results for Limited vocal quality in the first
report of moderate to high change session predicting better scores on the outcome measures at
termination suggest that Limited vocal quality in this situation represents a client state rather than
a trait. These results also provide some support for ambiguous findings for Limited vocal quality
speakers in Rice and Wagstaff’s (1962) pilot study. They found that some Limited vocal quality
speakers had successful treatment outcomes, while others did not.
One explanation for this is that Limited vocal quality represents a temporary, surmountable
state of anxiety in certain contexts. Support for this comes from the similarity of the
paralinguistic descriptions of Limited vocal quality to Scherer’s (1986) prediction of how a
person’s vocal quality would sound if he or she felt powerless to deal with the outcome of an
event. Scherer (1986) suggested that a person who feels unable or powerless to deal with a
situation will likely speak in a “thin voice” (p. 156). A thin vocal quality has “shallow resonance
and low energy” and gives the impression of little self-confidence (Morreale, Spitzberg, &
Barge, 2007, p. 196). This description of thin vocal quality is consistent with descriptions of
Limited vocal quality as sounding thin, having low energy, and above-platform pitch (e.g., Rice
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& Kerr, 1986). Scherer (1986) listed emotional states that would sound thin including
“anxiety/worry” and “grief/desperation”, with the thinnest being “fear/terror” (p. 157).
The results of the Diamond et al. (2010) study, which used technology to detect changes in
paralinguistic characteristics, support the view of Limited vocal quality as a transient state. In
the Diamond et al. study, clients received one of two treatments for unresolved anger toward a
significant other. In one treatment, clients spoke about their feelings. In the second, clients
participated in the gestalt empty-chair intervention in which they spoke directly to a significant
other in imagination. Although Diamond et al. (2010) did not relate their findings to clients’
resolution of the problems, they found that paralinguistic indicators of fear were higher in the
emotionally arousing condition. “During the arousal of fear/anxiety,…F0 range values increased
due to increased muscle tension caused by the activation of the sympathetic nervous system”
(Diamond et al., 2010, p. 408). A higher pitched frequency, described here, can make a person’s
vocal quality sound Limited as if it is “not resting on [its] own platform” (Rice et al., 1979, p. 6,
see Volume II, Figure 4).
Diamond et al. (2010) concluded from this that “during empty-chair enactments,
participants faced their fear/anxiety that the significant other might respond in an indifferent,
rejecting, or even punitive manner” (p. 408) and that:
Facing and overcoming one’s fears of accessing and experiencing painful threatening
primary emotions, as well as one’s fears of being vulnerable while expressing hurt and
longing to the significant other, is a purported core change mechanism in relationally
oriented experiential therapies. (p. 408)
The idea of arousing or activating feared thoughts, images, memories, emotions, etc. in order to
heal emotional problems has a long history. Hunt (1998) explained Foa and Kozac’s (1986)
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theory about this: “the cognitive structure underlying the pathological fear must be activated” so
that it can be changed by “new cognitive and affective information, which is incompatible with
the underlying structure” and “if this does not happen, then the cognitive structure will remain in
storage, unavailable for modification” (Hunt, 1998, p. 370).
Perhaps when Limited vocal quality is associated with treatment success, it may be that
the client came into contact with his or her fears, but was not immobilized by them. Instead, it
seems that clients expressing a higher proportion of Limited vocal quality in the current study
were able to overcome, work with, or work in spite of their anxiety and fear in such a way that
the problem was resolved. Although the CTSC-R score does not give information about a shift
in or resolution of the individual’s specific problem, the fact that a higher proportion of Limited
vocal quality predicts better treatment outcomes when it occurs in the first report of moderate to
high change session suggests this possibility.
Externalizing Vocal Quality predicts worse treatment outcomes in the first report of
moderate to high change session.
In contrast to Emotional, Focused, and Limited vocal qualities, a higher proportion of
Externalizing vocal quality in the first report of moderate to high change session predicted worse
scores on the outcome measures at termination. Clients expressing more Externalizing vocal
quality in this session reported worse depression, greater dysfunctional attitudes, higher
psychological distress, more interpersonal problems, lower self-esteem and less use of a
reflective, thoughtful coping style at the end of treatment. Though other studies using the Client
Vocal Quality (CVQ) measure did not use these same outcome measures, these results are
consistent with the findings (Butler et al., 1962) in which Externalizing vocal quality was
associated with unsuccessful results in client-centered therapy. The current study’s results are
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also consistent with Wexler’s (1974) observation that Externalizing vocal quality speakers have a
“style where little new experience is generated” (p. 48).
However, in the session with the highest change score, a higher proportion of
Externalizing vocal quality predicted better scores at the end of therapy in terms of coping with
problems with less reactivity and with greater awareness. It could be that in the session with the
highest change score, clients were more relaxed, perhaps reflecting on work accomplished in
previous sessions (J.C. Watson, personal communication, May, 2011). This kind of attitude
could be heard as Externalizing vocal quality and may be associated with a more comfortable
and accepting style of dealing with problems.
No difference in Client Vocal Quality Categories in the session with the lowest change score
and the session with highest change score
Contrary to expectations, there were no differences in the proportion of CVQ categories
between the session with the lowest change score and the session with the highest change score.
One reason for this may be that the session with the highest change score reflected the client’s
experience of “consolidated change” (J.C. Watson, personal communication, May, 2011). It
could be that in this session, the client was not engaged in the deep exploration which would
theoretically produce productive vocal qualities. Instead the client could be reviewing his or her
progress or noting new personal strengths and accomplishments. This could leave the client
feeling he or she changed substantially, which could show up on the CTSC-R measure as a high
score.
Client and therapist vocal qualities differentiate the treatment types
While the results showed no difference between the treatments for Focused vocal quality,
which will be discussed later, findings from the additional analyses showed significant
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differences between the treatment types. PE-EFT clients expressed a significantly higher
proportion of Emotional vocal quality than CBT clients and CBT clients expressed a
significantly higher proportion of Externalizing vocal quality than PE-EFT clients. These
differences in the CVQ categories logically flow from the contrasting treatment demands of CBT
and PE-EFT. While these results support the findings of others studies below, it is also
important to understand how Externalizing vocal quality, traditionally viewed as an unproductive
vocal quality and also found in the current study to predict worse treatment results, could be
related to change processes in the CBT condition. Lastly, explaining how it could be that there
were no differences between the treatment groups for Focused vocal quality is important.
Indirect support for other studies comparing different treatment types.
Because this is the only study conducted so far comparing client vocal quality in an
outcome study of CBT and PE-EFT, the results provide indirect support for earlier research
comparing CBT to more emotionally evocative treatments. For example, Burgoon et al. (1993)
studied clients’ nonverbal arousal in two group therapy conditions. One was the emotionally
evocative focused expressive therapy (FEP) condition (Daldrup, Beutler, Engle, & Greenberg,
1988) and the second was the cognitive therapy (CT) condition. They found that FEP clients
who were working on their own problems in the group were rated higher on a Vocal Tension
scale than their CT counterparts. Also, Mackay, Barkham, Stiles, and Goldfried (2002) studied
depressed clients’ emotional arousal over the course of the session in two conditions. One was
the CBT condition and the other was the psychodynamic-interpersonal (PI) condition in which
therapists “often encourage clients to experience and explore their emotions deeply, particularly
in the context of the relationship with the therapist” (Mackay, Barkham, Stiles, & Goldfried,
2002, pp. 376-377, referring to Shapiro & Firth, 1987). The researchers found that over the
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course of the session, while clients in both conditions expressed negative emotions, the intensity
was greater for the PI clients.
CBT clients expressed a higher proportion of Externalizing Vocal Quality than PE-
EFT clients.
The finding that CBT clients expressed a higher proportion of Externalizing vocal quality
than PE-EFT clients provides indirect support for other studies which did not use vocal quality,
but used other indicators of clients taking an external focus. For example, Goldfried,
Castonguay, Hayes, Drozd and Shapiro (1997) contrasted CBT with psychodynamic
interpersonal therapy (PI), which is similar to PE-EFT in that it is an emotionally evocative
treatment. They found that CBT sessions were characterized by a “greater emphasis on external
circumstances and clients’ ability to make decisions” (p. 740). In a study of insight events in
CBT and PI psychotherapy for clients with mood disorders, Elliott et al. (1994) found that
therapists in both groups made interpretations, but that CBT therapists made “key therapist
responses were external reattributions, which shifted blame from the client to others” (p. 458).
Elliott et al. (1994) explained that the clients then did the same thing by attributing the causes of
their problems to factors outside of themselves.
Even though Externalizing vocal quality has been associated with an external focus, “little
new experience”, and generally unproductive processes (Wexler, 1974, p. 48), clients in the
current study, in both treatment groups, had similar results at the end of therapy (Watson et al.,
2003). This suggests that Externalizing vocal quality does not necessarily indicate poor
processing activity. One reason for this could be that Externalizing vocal quality may be a
broader category than was previously thought. Issues arising during the rating process suggested
this might be the case. For example, during the rating process in the current study, the CVQ
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raters commented that there were a number of instances in which the client’s vocal quality
verged on Focused but did not quite meet the criteria for that category. In the majority of these
cases, Externalizing vocal quality was selected instead. Also, there were instances in which a
response seemed to require a different category, sometimes because of poignancy or a serious
intensity that was not described in any of the CVQ categories. Rice and Kerr (1986) explain that
the CVQ categories were the most representative of the vocal patterns found in client-centered
therapy, but that other patterns may exist. They encouraged researchers to use the scale with
other treatment modalities including CBT for this reason.
Also, it is possible that there are Externalizing vocal quality subgroups related to different
processing activities. Although Fosha (2000) did not refer to Externalizing vocal quality, she
alluded to a way of speaking that would be rated this way according to the CVQ manual’s rules.
She warned the listener to pay closer attention to not miss what the speaker is actually
conveying:
When someone is calm and speaks in measured tones it does not mean that affect is
absent and that we are in the realm of defenses; quiet and simple communication can be a
statement of affective truth, a declaration of deeply felt personal meaning, which is an
aspect of core state functioning. (Fosha, 2000, p. 160)
Fosha (2000) continued, “it is important that these highly meaningful declarations not be
mistaken for defensive intellectualization” (p. 160). It could be that some Externalizing vocal
quality responses in the current study were used to identify these types of vocalizations which,
instead of reflecting an external or disengaged focus, actually signified important change
processes that could not be detected with the CVQ measure.
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There was no difference between the treatment types for Focused Vocal Quality.
Contrary to prediction, CBT clients expressed statistically equivalent proportions of Focused
vocal quality to the PE-EFT clients. One reason for this may be that a person’s ability to do the
inward-directed activities associated with the Focused vocal quality may be a trait and not
dependent on the different treatment demands of CBT and PE-EFT. Support for this explanation
comes from Wexler’s (1974) study in which the voice quality system developed by Rice and
Wagstaff (1967) was used to rate the vocal qualities of university students, each of whom gave a
four minute extemporaneous speech about sadness. Wexler (1974) commented that:
Although the differentiation and integration of meaning is certainly a pervasive
characteristic of adult human functioning, the results show that the use of these
operations varies directly with the degree to which voice quality indicates the
involvement in creating new experience…the relationship between the two is so strong as
to suggest that they are tapping the same phenomenon. (p. 51)
The current study’s test results suggest that CBT and PE-EFT clients were equally engaged in
the types of processing activities indicated by Focused vocal quality. Also, both treatment
groups had “generally equivalent” results in the depression study (Watson et al., 2003). Taken
together, this suggests that clients working in both treatment types have different styles of doing
the work that achieves the same goal, which is recovery from depression.
Natural-Definite and Softened-Irregular Therapist Vocal Style and the treatment
types.
There were a significantly higher number of Natural-Definite Therapist Vocal Style
sessions in the CBT condition and a significantly higher number of Softened-Irregular Therapist
Vocal Style sessions in the PE-EFT condition. These differences can be explained by the
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contrasting approaches each treatment takes toward emotion. PE-EFT therapists assist their
clients in processing emotional experience by arousing emotions so that they can be expressed,
symbolized, and differentiated (e.g., Watson & Geller, 2005). To facilitate this, PE-EFT
therapists aim to make clients feel “safe…and sufficiently accepted by their therapist, so that
they are not monitoring what they are saying, designing things to please the therapist, or
protecting themselves from potential criticisms” (Iwakabe et al., 2000, p. 377).
The Softened-Irregular therapist vocal style, defined by its higher proportion of Softened
vocal quality and Irregular vocal quality, matches these therapist intentions. The Softened vocal
quality is thought to communicate “to the client that the situation is safe, that the therapist can be
trusted, and that the client is prized” (Rice & Kerr, 1986, p. 96), so that the client feels
sufficiently secure and supported to explore painful experience. Irregular vocal quality is the
pattern made by the therapist as he or she attempts “to get the exact flavour of each feeling or
described event” (Kerr, 1980, p. 46). This describes one of the key therapist interventions in PE-
EFT which is empathic reflection. Because these therapist behaviours are emphasized in PE-
EFT, it makes sense that Softened-Irregular Therapist Vocal Style would be spoken more by PE-
EFT therapists than CBT therapists.
In contrast, CBT therapists traditionally work to dial down clients’ distressing emotion by
“managing or containing affective arousal” (Samoilov & Goldfried, 2000, p. 373). Instead of
treating emotional problems by concentrating on emotion, CBT therapists help their clients use
reason, logic, and behavioural experiments to challenge those thoughts and beliefs that lead to
distress in the first place (Beck & Weishaar, 1989 as cited in Burgoon et al., 1993). These
therapist behaviours correspond well with Mackay et al.’s (2002) remark that the CBT session is
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generally “conducted in a businesslike manner, with little expressed emotion” (p. 376, referring
to Shapiro & Firth, 1985).
Bolinger (1978) refers to the speaker’s attitude as “the running commentary that
intonation adds to the propositional content of sentences” (p. 484). If the therapist’s attitude is
that the client will benefit from “a structured form of therapy” (Josefowitz & Myran, 2005, p.
330) that facilitates “active problem-solving strategies” (Wilson & Evans, 1977, p. 560 as cited
in Raue & Goldfried, 1994, p. 133), then it follows that the therapist’s intonation would reflect
this. These attitudes, plus the expectation that the CBT “therapists’ behaviour should be honest
and warm” (Hoffman & Asmundson, 2008, p. 3) make it is easy to see how Natural-Definite
Therapist Vocal Style, defined by its higher proportion of Natural vocal quality and Definite
vocal quality, is a logical fit for the CBT therapist.
Natural vocal quality is referred to as the “working factor” because this is the way the
therapist’s vocal quality sounds when he or she is speaking “on topic” and not about the
therapeutic relationship or the “process of exploration” (Rice & Kerr, 1968, p. 96). Rice and
Kerr (1986) also described this vocal quality is “nonthreatening” and “relaxed” (p. 96). The
Definite category, however, can be either helpful or not to the client. This vocal quality is partly
defined by its downward-sloping terminal contours, which are thought to convey authority,
confidence, and also finality (Rice & Kerr, 1986). Ohala (1994), an intonation phonology
researcher, referred to Bolinger (1978) when he wrote, “it seems safe to conclude that such
‘social’ messages as ….assertiveness, authority, aggression, confidence, threat are conveyed by
low/or falling F0 [fundamental frequency]” (Ohala, 1994, p. 327). Also, the falling pitch in some
Definite vocal quality utterances does not leave room for the listener to differ with the speaker.
This is supported by Bolinger’s (1978) observation that, “the two intonational shapes that are
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found everywhere are fall and rise, with their targets, low and high. The meanings are as
uniform as the shapes: falls for ‘being through,’ rises for ‘not being through’” (p. 516).
These characteristics of Definite vocal quality could make it an effective vocal quality
for instructing and guiding, both of which are likely to be found in CBT where clients are
“encouraged to ask questions to make sure that they understand and agree with treatment”
(Hoffman & Asmundson, 2008, p. 3). This Definite vocal quality could also be used to calm the
client down because it makes the therapist sound like an expert which could be “very reassuring”
to a vulnerable client (Rice & Kerr, 1986, p. 96).
Strengths of the current study
The current study added to the vocal quality literature in several ways. First, the finding
that CVQ categories predict the clients’ scores on the outcome measures at termination, but
primarily in the first report of moderate to high session, suggests that the client’s vocal quality
does indicate whether or not he or she is working in a way that will lead to a feeling of change in
the session and that will be related to change at the end of treatment.
Second, prior to the current study, Limited vocal quality tended to be regarded as a
personality or trait variable, indicating that the client was distant from his or her experience,
fragile and vulnerable, ultimately unable to engage in therapy in a beneficial way. The findings
in this study, however, suggest that Limited vocal quality may also reflect an anxious state
signalling, for example, intense fear or terror. Diamond et al. (2010) explained that fear of
confronting an important attachment figure can prevent the client from accessing his or her
primary experience of feeling “worthlessness, loss, longing, and sadness” (p. 402). However,
facing this fear and overcoming it allows the client to access to these painful emotions, enabling
him or her to learn what it is he or she needs and freeing him or her from having to “defend”
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against these difficult feelings (Diamond et al., 2010, p. 402). Limited vocal quality in this
context could be a sign that the client is in fact in a state in which he or she is engaging in the
treatment, as in facing one’s fears, as opposed to expressing a trait that keeps him or her at a safe
distance from psychological experience.
Third, results for the Therapist Vocal Style and the CVQ shows how CBT and PE-EFT
sessions can be characterized by the therapists’ and clients’ predominant use of certain vocal
qualities. These vocal qualities logically flow from the unique demands of each approach.
Finally, the proportions of the productive CVQ categories (Emotional, Focused, and
Emotional Plus Focused) in the current study were very small and yet they still predicted the
clients’ scores on the outcome measures at post treatment. This finding provides support for
both Emotional and Focused categories as indicators of important change processes.
Limitations of the study
There were several limitations to the current study including the sample size,
generalizability of the sample, moderate to small effect sizes, and the portion of the session rated.
Regarding generalizability, there are two possible problems. The first is that the data for this
vocal quality study were drawn from a homogenous sample, consisting mostly of woman, and
people who report having a postsecondary/college education, as seen in Table 2. Because of this,
the results of the current study may not be as applicable to men or people with other types of
education.
The second problem has to do with the very small proportions of Emotional, Focused,
and Limited vocal qualities. Most of the clients in the study spoke in Externalizing vocal quality
most of the time. The remaining CVQ categories had very small proportions, with many outliers
in the distribution of each. Because of this it is unclear whether the categories of Emotional,
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Focused, and Limited vocal qualities are rare in the population or if the session selection for the
current study only captured some instances of these vocal qualities. It is possible that if the
sessions had been selected based on work done on specific client problems or the occurrence of
particular treatment interventions that there would have been more instances of these categories.
Another limitation was the size of the sample. Although the sample size from which the
data for the current study were drawn is larger than that of previous research (Watson & Bedard,
2006), the size was further reduced in the current study due to damaged or inaudible audio or
videotapes. Also, some of the audio was excluded because the client’s and/or therapist’s vocal
qualities were so soft that it was not possible to rate. Had these cases been included in the data
set, the results may have been different.
A third issue is that most results had small to moderate effect sizes. One reason for this
could be that vocal quality is just one of several indicators of client and therapist processes.
Ritchie (1998) wrote, “another problem with the TVQ is that the effect of therapy on the client is
dependent on many variables other than voice quality such as body language and verbal
language” (p. 32). Along these same lines, Kinseth (1989) explained that “human
communication is a multichannel process, involving not only intentional verbal expression but
also simultaneous multiple nonverbal channels such as body movement, nonlinguistic
vocalization, and body orientation” (p. 6).
While there is complementary information streaming through these other nonverbal
channels, likely adding to the overall presentation of the clients, there are other, covert activities
that are also probably contributing to the variance in scores. Rice and Kerr (1986) wrote that “to
understand what makes therapy good or bad, we must be able to follow all of the important
elements in the interaction” (p. 101). Safran, Muran, and Samstag (1994) agreed, “the use of
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converging measurement procedures…is important since no one measure can comprehensively
capture the important features of any given aspect of clinical process” (p. 231).
As a result, research has included other measures of client activity alongside the CVQ.
Examples include the CVQ alongside SASB (Benjamin, 1974) and EXP (Klein et al., 1986) in a
study of alliance ruptures (Safran & Muran, 1996) and Client Emotional Arousal Scale-revised
(CEAS-r) (Machado, 1992) in the investigation of resolvers and nonresolvers in the empty chair
task for unfinished business (Greenberg & Malcolm, 2002). The TVQ was investigated along
with the Level of Client Perceptual Processing (LCCP) (Toukmanian, 1994) in the study of the
therapist’s vocal quality in the treatment of hyperphagia (Ritchie, 1998).
A fourth limitation is the section of the session that was rated. The middle 20 minutes of
each session was chosen for rating because this section has been considered the “working phase”
of a session (Watson & Bedard, 2006, p. 154). However, rating only the middle 20 minutes of a
session can truncate important therapeutic activity, such as the client’s calming down from a cry
just as the middle 20 minutes begins or the client’s just beginning to speak in Focused vocal
quality at the 19th
minute. The data for the study may have been more representative of the vocal
character of the sessions if the entire session had been rated.
The results of the Mackay et al. (2002) study support this idea. They found that
depressed clients receiving CBT and psychodynamic interpersonal (PI), which is an emotionally
evocative treatment, expressed equivalent amounts of negative emotion, but at different points in
the session. Emotional arousal in the CBT condition tended to be shaped like a U, with less
arousal in the middle of the session, while the PI clients’ arousal patterns tended toward an
upside down U, with greater arousal in the middle of the session. The authors attributed these
differences to the contrasting treatment demands. However, in the current study, only the middle
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20 minutes were rated on the CVQ, which may have been the main reason the PE-EFT group
was found to have expressed a higher proportion of Emotional vocal quality than the CBT group.
It could be that meaningful instances of the Emotional vocal quality category for the CBT group
were missed because of the middle 20 minute limitation.
Future Research
Three results in particular merit further research. The first stems from the finding
suggesting that having both the session with the lowest change score and the session with the
highest change score classified as the Softened-Irregular Therapist Vocal Style predicts better
scores on the IIP Overly Accommodating subscale at the end of treatment, when compared to
having both of these sessions rated as Natural-Definite Therapist Vocal Style sessions. Clients
in the Depression Project, from which data for the current study were drawn, improved about the
same amount by the end of treatment in both the CBT and PE-EFT treatment condition. There
was one exception to this, which was on the Inventory of Interpersonal Problems (IIP). On this
measure, the PE-EFT clients had greater improvement than the CBT clients. Furthermore, on the
IIP subscale called Overly Accommodating, while the PE-EFT clients reported improvement,
“the CBT group did not change at all” (Watson et al., 2003, p. 777).
Watson et al. (2003) attributed this difference on the IIP to two factors: “The type of
therapeutic relationship that is modeled, with its emphasis on empathy, acceptance and positive
regard, and the nature of the therapeutic tasks” (pp. 779-780). This reasoning links well with the
finding from the current study that PE-EFT therapists spoke predominantly in the Softened-
Irregular Therapist Vocal Style, while CBT therapists spoke predominantly in the Natural-
Definite Therapist Vocal Style. Possible influences of these vocal styles on the interpersonal
style of the Overly Accommodating client suggest a direction for future research on this topic.
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Clarkin and Levy (2004) asked, “which client and therapist characteristics interact most
saliently and forcefully to produce symptom decline?” (pp. 194-195). The Softened-Irregular
Therapist Vocal Style can be seen as a strong healing match to the needs of the client presenting
with the Overly Accommodating interpersonal style based on theoretical and clinical
considerations. One way to understand the treatment needs of the Overly Accommodating client
is to view his or her behaviour in the context of interpersonal theory. High scorers on this
subscale report feeling gullible, easily exploited by others, and not only “assume that assertive
acts offend” (Schneider, Huprich, & Fuller, 2008, p. 19), but are so afraid of having this effect on
others that they will not express anger.
These are submissive behaviours (e.g., Pincus & Gurtman, 1995) which, seen through the
lens of interpersonal theory, help the client by protecting him or her from feeling anxious (e.g.,
Bernier & Dozier, 2002, referring to Leary, 1957). Anxiety in this case could arise from the
client’s fear of damaging or losing important relationships if the client were to express his or her
true feelings. People tend to respond to submissive behaviour according to the principle of
complementarity in which “interpersonal actions are designed to elicit, entice, or evoke restricted
classes of reactions from persons with whom we interact, especially from significant others”
(Kiesler & Auerbach, 2003, p. 1716). The complementary behaviour to submission is control or
domination (e.g., Benjamin, 1994), meaning that one person’s submissive behaviour elicits
dominant or controlling behaviour from another person. Benjamin (2003) saw the
submit/control transaction as “an example of a highly enmeshed, unhealthy interpersonal
interaction that is very stable (Benjamin, 1994), creating a ‘self-fulfilling prophecy’ experience”
(Benjamin, 2003, p. 48). In addition, the submissive interpersonal style is a form of “passive,
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avoidant coping that is a central causal factor in depression” (Pearson, Watkins, & Mullan, 2010,
p. 971, referring to the work of Ferster, 1973).
Importantly, the push and pull of the submit/control dynamic is not only pervasive, but it
is also played out in the human vocal quality. As Gregory and Webster (1996) explained, “it is
common knowledge that power and status identifications are communicated through the voice
channel. Authoritative voices vocal quality and deferent voices are easily recognized as such”
(p. 1232). Referring to this phenomenon, Schwartz (1996) wrote, “there’s a hidden battle for
dominance waged in almost every conversation—and the way we modulate the lower
frequencies of our voices shows who’s on top” (no page number).
The Definite vocal quality, along with the Natural vocal quality, characterizes the
Natural-Definite Therapist Vocal Style. Definite vocal quality is partly defined by its falling
frequencies at the ends of statements (Rice & Kerr, 1986). This fall to a lower vocal frequency
imparts an authoritative and potentially controlling tone to the speaker’s message. Ohala (1994),
referring to Bolinger (1978) wrote, “it seems safe to conclude that such ‘social’ messages as
….assertiveness, authority, aggression, confidence, threat are conveyed by low/or falling F0
[fundamental frequency]” (p. 327). These aspects of the Definite category help it exert control
over the listener, which could be helpful, but could also shut down a budding client process. In
the latter case, the therapist using the Natural-Definite Therapist Vocal Style with the Overly
Accommodating client could theoretically perpetuate the client’s submissive interpersonal cycle.
In client-centered therapy, a cornerstone of PE-EFT, the therapist’s vocal quality is
believed to transmit core humanistic values to the client. Rogers (1947) wrote, “the one value or
standard held by the therapist which would exhibit itself in his tone of voice, responses, and
activity, is a deep respect for the personality and attitudes of the client as a separate person” (p.
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358). This relationship message would seem to provide a direct antidote to the Overly
Accommodating client whose behaviour with others is distorted by the sense that the client, just
as he or she is, is insufficient for others to stay in a close relationship with him or her.
This attitude of the therapist’s acceptance of the client as a separate, valued person is
conveyed in what Truax and Carkhuff (1967) refer to as “nonpossessive warmth” (p. 328).
Rogers (1957) described nonpossessive warmth as “caring for the client as a separate person,
with permission to have his own feelings, his own experiences” (p. 98). This attitude is also
referred to in more contemporary terms as unconditional positive regard and acceptance. The
therapist conveys these attitudes by maintaining a “consistent, genuine, noncritical interest and
tolerance for all aspects of the client” (Elliott et al., 2004, p. 10). Truax and Carkhuff (1967)
described the vocal quality of nonpossessive warmth as “low-pitched, full vocal tones in a
slowed rate of speech, communicating the intentness and seriousness of the therapist’s response”
(p. 245). This description is very similar to Rice and Kerr’s (1986) Softened vocal quality.
If all of these therapist attitudes are conveyed to the client through Softened vocal quality,
then the client is likely to feel secure with the therapist--possibly secure enough that he or she
could express anger, or take other interpersonal risks, without fear of the therapist leaving or
rejecting him or her. Feeling interpersonally secure “allows an adult to consider alternative
perspectives… to reflect on, discuss, and so revise realities…to self-disclose and assert one’s
needs” (Johnson, 2005, p. 411). In addition, contact with a supportive other “tranquilizes the
nervous system” (Schore, 1994, p. 244). These may be among the reasons Benjamin (1979)
wrote that “if a submissive patient who deals with ‘oughts and shoulds’ by total compliance
meets the therapist in the classic Rogerian posture, he/she is thereby encouraged to self-define in
a friendly way” (p. 308). These explanations for the contrasting influences of Therapist Vocal
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Style on client processes may account for the finding suggesting that Softened-Irregular
Therapist Vocal Style predicts the client’s report of less overly accommodating behaviors at the
end of treatment. Importantly, the results of the current study were suggestive of this and require
further study.
As Rice and Kerr (1986) explained, “in studying the therapist’s process in an
interview…one is interested basically in the client’s change” (p. 94) [italics in original]. Because
of this, a second related area of further investigation could include looking at the Softened-
Irregular Therapist Vocal Style, with its overall non-threatening, soothing tone, as representing
“almost constant ameliorative processes” (Henry, Schacht, & Strupp, 1990, as cited in Henry,
1997, p. 391). These “constant ameliorative processes” have been associated with good
treatment results (Henry, 1997, p. 391). This could be investigated along with the Natural-
Definite Therapist Vocal Style which, because of its authoritative, assertive quality, Definite
vocal quality might close down a client’s emotional experiencing. Experiencing is a process that
has been associated with successful outcomes in different treatment approaches (see Wiser &
Goldfried, 1998, for a list of studies).
Indirect support for this comes from the study done by Wiser and Goldfried (1998).
Although the authors did not investigate vocal qualities, they did find that “personally controlling
interventions were more often followed by shifts away from deeper affective exploration than by
maintenance of the affective focus” (Wiser & Goldfried, 1998, p. 639). Wiser and Goldfried
(1998) explained that:
These highly affiliative but moderately interpersonally controlling interventions were not
harsh, critical, or inappropriate; rather, such utterances received low ratings of affiliation.
Instead, these interventions had a guiding or challenging aspect, such as, “You’re sad,
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yes, but perhaps you’re angry too?”; “You don’t seem impulsive to me, as you state, you
actually seem quite cautious”; and “What might be a different way of looking at that?”
Such comments are a large part of clinical work wherein therapists respectfully
encourage clients to consider their experience from a new vantage point. (p. 639)
Investigating these effects could be part of a third and larger effort to continue the work
of Wiseman and Rice (1989) who demonstrated through sequential analysis that the therapist’s
use of Irregular vocal quality can shift the client’s vocal quality from unproductive to
productive. Future studies should also include the bi-directional influence between the client and
therapist. As Rice (1965) explained, it is not only the therapist who can affect the client’s
behaviour in the session, but that the therapist’s “style of participation” could be influenced by
the client (p. 160). Because vocal quality is such a revealing nonverbal behaviour (e.g., Perls,
1969), it is worth investigating how the client’s vocal quality might influence the therapist’s
vocal quality as well. Butler et al. (1962) stated that a very depressed, dull-sounding client could
drag down the energetic and focused therapist, which would, in response, influence the
therapist’s “style of participation” to become flatter and less stimulating to the client.
For therapists to gain an awareness of how their own vocal qualities and “styles of
participation” are influenced by their client’s vocal qualities and styles (Butler et al., 1962, pp.
188-189) seems like an obvious part of being an effective therapist. As Fosha (2000) explained:
The change occurring in oneself as a result of closely relating with another, where each
influences the other, “provides a behavioral basis for knowing” the other, thus enabling
one to enter “into the other’s perception, temporal world and feeling state” (Beebe &
Lachmann, 1988, p. 331). (Fosha, 2000, p. 152)
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In addition, Pally (2001) wrote that, “since nonverbal mechanisms can be activated without
conscious awareness, neither patient nor analysand may be directly aware of their impact” (p.
71). The subtlety of these interpersonal transactions places a special responsibility on the
therapist to not unwittingly engage the client in his or her depression-sustaining interpersonal
cycle. Kiesler (1979) warns therapists that they “must break the vicious circle by not continuing
to be ‘hooked’ or trapped by the client’s engagement or pull” and that “it is essential that the
therapist not respond in the same locked-in and overdetermined manner as have others in the
client’s life” (p. 307) [italics in original].
Implications for practice
Elliott et al. (2004) wrote, “therapists can…enhance their responsiveness to clients by
being alert to the possible meanings inherent in different vocal qualities” (p. 61). The authors
provide guidelines about what clients may need depending on the vocal quality they express.
One of the most important findings of the current study is that depressed clients’ use of
Emotional vocal quality, Focused vocal qualitly, and Limited vocal quality in the first report of
moderate to high change session, predicts better scores on the outcome measures at the end of
treatment. In contrast, the use of a higher proportion of Externalizing vocal quality in this
session predicts worse scores. These results provide some support for the guidelines offered by
Elliott et al. (2004):
Clients who demonstrate little or no focused or emotional voice are seen as less
emotionally accessible and in need of further work to help them process internal
experiential information. Clients with a high degree of external vocal quality can
generally benefit from being helped to focus inward, whereas those with a high degree of
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limited vocal quality need a safe environment to develop trust in the therapist and allow
them to relax. (p. 61)
Although attending to clients’ nonverbal cues is regarded as very important in the
psychotherapy hour, to prevent, for example “reinforce[ing] dysfunctional behaviour patterns”
(Kinseth, 1989), paying attention to and understanding the meaning of the client’s nonverbal
behaviour, such as vocal quality, is not an easy or natural thing to do for everyone. Rice and
Kerr (1986) suggested that raters have an “ear” or “sensitivity” for discerning vocal quality (p.
98). They add that some people do not have this ability and that they may not be able to acquire
it.
Along these lines, there is a research trend toward using technology to replace human
listening when it comes to treating clients. For example, Rochman, Diamond, and Amir (2008)
examined the acoustic parameters of the clients’ vocal qualities while they were expressing
emotions. Rochman et al. (2008) wrote that:
In terms of clinical practice, [their] research represents a first step toward the
development of a new measurement technology that, in the future, would enable
therapists (and clients) to continuously monitor clients’ emotional states online over the
course of therapy. Such a technology could be used to inform the therapist of clinically
significant changes in clients’ emotional states, changes that might not be evident on the
basis of client behaviour alone. Such information could be used to guide moment-to-
moment intervention strategies. (pp. 515-516)
At the entrepreneurial level, a “biocommunication” company called ZYTO (2012)
developed a product called EVOX to assist health care professionals, such as medical doctors,
address their clients’ “static perceptions” (no page number). The way it works is that during an
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office visit, the patient wears a head set with a mouth piece and places his or her hand in a
“cradle” (no page number). These devices transmit physical data, such as vocal frequencies, to a
computer, as the client speaks about painful or troubling issues. After about half an hour, there is
enough data for the doctor to show the patient various charts on the computer screen that will
display his or her “stuck” areas in the narrative, as indicated mainly by vocal frequencies and
other data from the hand cradle. This seems like a technological parallel to Elliott et al.’s (2004)
comment that “clients’ vocal quality can …provide clues concerning unacknowledged feelings”
(p. 61).
While using technology this way could make a therapist feel more confident about his or
her next step, it seems that it could also make the client lack confidence in the therapist’s ability
to connect with him or her on an essential level. Also, if a therapist relies on a computer screen
to tell him or her when the client is experiencing meaningful emotion, how can the therapist ever
really listen to what the client is saying? Being truly “heard” by a caring other can be a healing
experience in itself. While treating a client’s changing emotional states like heart beats on an
EKG printout may make the psychology profession seem more medical or scientific, it would
also impersonalize one of the core healing aspects of the therapy session, which is the therapeutic
relationship. It seems like a more genuine approach is for therapists to learn how to listen to
their clients’ vocal qualities for the wealth of information they offer.
However, technology could play a very substantial role in teaching practitioners how to
listen. It could be that lacking an “ear” for vocal quality (Rice & Kerr, 1986, p. 98) could be a
research and training issue rather than some inherent deficit in a person’s ability to hear. Belin,
Fecteau, and Bedard (2004) wrote that “abilities involved in perceiving paralinguistic
information in voices—or ‘voice perception’ abilities – have been far less investigated than
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speech perception” (p. 129). While the paralinguistic aspects of discrete emotions have been
studied a great deal (e.g., Patel, Scherer, Bjorkner, & Sundberg, 2011), other less-studied aspects
of vocal quality may only be distinguishable to the human ear after being pointed out with the
help of technology.
Given the results of the current study, it would be particularly helpful for example to
identify the paralinguistic aspects of Limited vocal quality as a trait and as a state, if these are
different at the paralinguistic level. Therapists might respond somewhat differently if these types
of Limited vocal qualities are distinct and if they can be discerned by the human ear. Also, since
CBT clients spoke mainly in Externalizing vocal quality and since the treatment outcomes for the
CBT and PE-EFT clients are about equal (Watson et al., 2003) a paralinguistic analysis of
Externalizing vocal quality could reveal subcategories that account for change processes in the
CBT group. If therapists can learn to hear these variations, they would have even more
information available to guide their treatment interventions.
There are audiotapes to accompany the CVQ and TVQ manuals, however both should be
updated with more current vocal examples. Also, it might help teach listening skills if new
manuals included audio examples of the individual paralinguistic characteristics described in the
manual, such as rising and falling fundamental frequency as well as wordless, vocal quality
“melodies” typifying each vocal pattern. Creating a manual or catalogue of sounds such as this
could facilitate training for research purposes and the development of clinical skills. This
possibility becomes even more intriguing given Rice and Koke’s (1981) observations from
supervising students. Rice and Koke (1981) educated student-therapists about vocal quality to
help them understand their clients’ problematic “habitual processing styles” as opposed to the
more commonplace understanding of “psychotherapy process as a series of motivated
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interpersonal acts, such as defence, manipulation, and so on” (p. 163). Moreover, “therapists, in
turn, often handle such acts by challenging or interpreting the defenses” (Rice & Koke, 1981, p.
163).
The work of Henry and colleagues (1986, 1994) suggest that these kinds of therapist
responses are negative interpersonal processes which are related to poor treatment outcomes.
Referring to the work of Henry, Schacht, and Strupp (1986), Henry and Strupp (1994) wrote of
their results: “In poor-outcome cases, the frequency of complementary exchanges between
therapist and patient that were negative (interpersonally disaffiliative and/or separating) was
significantly higher” (p. 65). An example of interpersonally disaffiliative and separating
behaviours would be the therapist’s responding to the client as if he or she is being defensive or
manipulative. Benjamin (1996), referring to the SASB measure, stated that “tone of voice and
the context are very important in assessing affiliation and interdependence” (p. 39). Reframing
vocal behaviour in terms of processing styles, as opposed to the client’s being manipulative for
example, would presumably shift the therapist’s intervention in a different direction.
Conclusion
The results of the current exploratory study indicate that the client’s and therapist’s vocal
qualities differentiate the CBT and PE-EFT treatments. Because both treatments were found to
be approximately equal in their effectiveness in treating depression in the Depression Project
(Watson et al., 2003), the differences in vocal qualities, as in the Mackay et al. (2002) study,
suggest that the treatments work by different “mechanisms” (p. 380, referring to Stiles, 1983).
As recommended by Watson et al. (2003), “future work needs to be concerned with identifying
more precisely what is differentially effective in each treatment and common to all to further our
understanding of treatment efficacy” (p. 780).
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Knapp and Hall (2010) wrote, “you should be quick to challenge the cliché that vocal
cues only concern how something is said—frequently they are what is said” (p. 396). However,
psychotherapy researchers view communication in the psychotherapy setting as a multiple level
process (e.g., Kinseth, 1989). Specifying the change mechanisms and their interactions with one
another is an ongoing process.
The results also indicate that just the presence of Emotional vocal quality and Focused
vocal quality is not necessarily enough for change to occur. However, the presence of these
vocal qualities together in a session which the client first reports moderate to high change was
sufficient, in the current study, to predict better treatment outcomes. However, exploring the
ways in which Externalizing vocal quality and Limited vocal quality can predict both better and
worse treatment outcomes would be valuable in terms of expanding the CVQ scale and
understanding what factors make a vocal quality productive in one setting, but not in another.
Finally, understanding how the therapist’s vocal style influences the client’s vocal quality
as well as changes in interpersonal problems continues to be important. The current research
suggests that the therapist’s Softened-Irregular vocal style may play a unique role in helping
clients with these problems. Identification of the Natural-Definite and Softened-Irregular
Therapist Vocal Styles may be an important clue to understanding how the “work” of therapy is
achieved in PE-EFT and CBT.
148
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Appendix A
Ranges for Interpretation of Statistics
Percent Agreement from House, House, & Campbell, 1981, p. 46.
> 70% necessary, > 80% adequate, > 90% good
Guideline for evaluating agreement with Cohen’s Κ from Landis & Koch
(1977) in von Eye & Mun, 2005, p. 6.
Κ < 0.00 poor agreement
0.00 < Κ < 0.20 slight
0.21 < Κ < 0.40 fair
0.41 < Κ < 0.60 moderate
0.61 < Κ < 0.80 substantial
0.81 < Κ < 1.00 almost perfect agreement
Strength of a correlation coefficient (r or ICC) adapted from Green & Salkind,
2004, p. 256.
< .30 is weak; .30 - .50 is moderate; > .50 is strong
Strength of Effect Size (r2) (based on Green and Salkind, 2004, p. 256)
.00 - .09 is weak; .09-.25 is moderate; > .25 is strong
Appendix B
Spearman’s Rho Correlations Between Outcome Measures
Note. Acronyms refer to the following measures: BDI = Beck Depression Inventory; RSE = Rosenberg Self-Esteem; DAS = Dysfunctional Attitudes Scale; DAS Perf = DAS Perfectionism
subscale; DAS SA = DAS Social Anxiety subscale. Regarding the Inventory of Interpersonal Problems (IIP): Circumplex = IIP Circumplex Total. The following are the IIP subscale names:
DC = Domineering; VC = Vindictive Self-Centered; CD=Cold Distant; SI = Socially Inhibited; NA = Nonassertive; OA = Overly Accommodating; SS = Self-Sacrificing; IN = Intrusive.
Symptom Checklist 90 Revised (SCL-90-R) indices are as follows: GT = Grand Total; GSI = Global Symptom Index; PST = Positive Symptom Index; PSDI = Positive Symptom Distress
Index. SCL-90-R subscales include: DEP TOT = Depression Total; DEP MN = Depression Mean. Levels of the Problem-Focused Style of Coping scale include: REFLEC = Reflective Style of
Coping; SUPP = Suppressive Style of Coping; REACT = Reactive Style of Coping.
174
170
171
Appendix C
Emotional Focused Limited Externalizing
Skewness/
SE 23.2 15.86 82.45 -12.74
Kurtosis/
SE 87.4 47.61 41.77 27.35
Figure C1. Boxplots of CVQ categories in sessions with the
lowest change score (N = 61). Skewness and kurtosis values
are calculated by dividing the statistic by its standard error. The
distribution is non-normal if one of these values exceeds + 2.00
(SPSS).
172
Emotional Focused Limited Externalizing
Skewness/
SE 10.50 8.05 9.31 -8.26
Kurtosis/
SE 17.72 9.31 12.38 19.78
Figure C2. Boxplots of CVQ categories in sessions with the
highest change score (N = 61). Skewness and kurtosis values are
calculated by dividing the statistic by its standard error. The
distribution is non-normal if one of these values exceeds + 2.00
(SPSS).
173
Appendix C
Emotional Focused Limited Externalizing
Skewness/
SE 8.80 7.34 8.74 -7.99
Kurtosis/
SE 1.62 8.88 12.39 13.11
Figure C3. Boxplots of CVQ categories in first report of moderate to
high change session (N = 58). Skewness and kurtosis values are
calculated by dividing the statistic by its standard error. The distribution is
non-normal if one of these values exceeds + 2.00 (SPSS).
174
Appendix D
Means, Standard Deviations, and Medians for CVQ Categories in the Session with the Lowest
Change Score and the Session with the Highest Change Score
CVQ
Categories Session with the…
CBT (n = 33 Clients) PET (n = 28 Clients) Total
(N = 61 Clients)
M SD Mdn M SD Mdn M SD Mdn
Emotional
lowest change score .03 .14 .00 .01 .04 .00 .02 .11 .00
highest change score .00 .01 .00 .01 .03 .00 .01 .02 .00
Lowest + Highest .01 .07 .00 .01 .02 .00 .01 .05 .00
Focused
lowest change score .01 .02 .00 .02 .04 .00 .01 .03 .00
highest change score .01 .03 .00 .02 .04 .00 .02 .04 .00
Lowest + Highest .01 .02 .00 .02 .03 .00 .01 .02 .00
Emotional+
Focused
lowest change score .03 .14 .00 .03 .05 .01 .03 .11 .00
highest change score .01 .03 .00 .03 .06 .00 .02 .05 .00
Lowest + Highest .02 .07 .00 .03 .04 .01 .03 .06 .01
Limited
lowest change score .04 .12 .00 .04 .09 .00 .04 .11 .00
highest change score .04 .10 .00 .05 .10 .01 .04 .10 .00
Lowest + Highest .04 .09 .01 .04 .08 .01 .04 .08 .01
Externalizing
lowest change score .93 .20 1.00 .93 .09 .97 .93 .16 .98
highest change score .95 .11 .98 .92 .13 .98 .93 .12 .98
Lowest + Highest .94 .12 .99 .93 .09 .95 .93 .11 .98
175
Appendix E
Means, Standard Deviations, and Medians for Treatment Groups by CVQ Category in the First Report of
Moderate to High Change Session
CVQ
Categories
CBT (n = 30 Clients) PET (n = 28 Clients) Total (N = 58 Clients)
M SD Mdn M SD Mdn M SD Mdn
Emotional .01 .02 .00 .02 .04 .00 .01 .03 .00
Focused .02 .05 .00 .02 .04 .00 .02 .04 .00
Emotional+
Focused .03 .05 .00 .04 .06 .01 .03 .06 .00
Limited .04 .10 .00 .06 .11 .01 .05 .10 .00
Externalizing .93 .14 1.00 .90 .12 .96 .92 .13 .98
176
Appendix F
Table F1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Emotional Vocal Quality in the Session with the Highest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression
Inventory 61 -.92 60.17 .00 .988
Dysfunctional Attitudes
Scale 54 -103.51 234.92 -.05 .661
General Symptom Index
of the SCL-90-R 55 -2.09 3.39 -.07 .539
IIPb-
Circumplex Total 55 -1.83 2.76 -.07 .511
IIP subscale-
Vindictive/Self-Centeredc 54 -.81 2.53 -.04 .750
IIP subscale-
Cold Distant 55 -.88 3.12 -.03 .779
IIP subscale-
Socially Avoidant 55 -4.46 4.10 -.10 .281
IIP subscale-
Nonassertive 55 -5.52 4.99 -.11 .274
IIP subscale-
Overly Accommodatingc 54 -.74 3.82 -.02 .847
IIP subscale-
Self-Sacrificing 55 1.35 4.01 .04 .738
IIP subscale-
Intrusive-Needyc 54 -1.80 2.31 -.07 .439
IIP subscale-
Domineering-Controlling 55 -2.83 2.00 -.16 .164
Problem-Focused Style of
Coping-Reactive 54 -3.98 6.00 -.09 .510
Problem-Focused Style of
Coping-Reflective 54 3.11 4.54 .06 .497
Problem-Focused Style of
Coping-Suppressive 54 -3.93 7.05 -.07 .580
Rosenberg Self-Esteem
Scale 56 -25.57 40.62 -.07 .532
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. b IIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
177
Appendix F
Table F2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Focused Vocal Quality in the Session with the Highest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -5.37 31.81 -.02 .866
Dysfunctional Attitudes Scale 54 52.65 95.67 .06 .584
General Symptom Index of
the SCL-90-R 55 -1.34 1.95 -.08 .494
IIPb-
Circumplex Total 55 -.02 1.46 .00 .990
IIP subscale-
Vindictive/Self-Centeredc 54 .50 1.32 .04 .707
IIP subscale-
Cold Distant 55 -.43 1.64 -.03 .795
IIP subscale-
Socially Avoidant 55 -1.43 2.18 -.06 .515
IIP subscale-
Nonassertive 55 1.53 2.65 .06 .566
IIP subscale-
Overly Accommodatingc 54 1.13 2.01 .00 .578
IIP subscale-
Self-Sacrificing 55 .48 2.11 .02 .820
IIP subscale-
Intrusive-Needyc 54 -1.25 1.22 -.09 .312
IIP subscale-
Domineering-Controlling 55 -.22 1.08 -.02 .842
Problem-Focused Style of Coping-
Reactive 54 1.83 2.72 .09 .503
Problem-Focused Style of Coping-
Reflective 54 1.09 2.07 .05 .600
Problem-Focused Style of Coping-
Suppressive 54 .48 3.20 .02 .881
Rosenberg Self-Esteem Scale 56 -8.76 21.51 -.05 .685
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. b IIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
178
Appendix F
Table F3
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Emotional Plus Focused Vocal Quality in the Session with the
Highest Change Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -3.45 24.90 -.02 .890
Dysfunctional Attitudes Scale 54 22.76 76.81 .03 .768
General Symptom Index of the
SCL-90-R 55 -1.12 1.44 -.09 .442
IIPb-
Circumplex Total 55 -.31 1.13 -.03 .781
IIP subscale--
Vindictive/Self-Centeredc 54 .17 1.02 -.02 .872
IIP subscale-
Cold Distant 55 -.40 1.27 -.03 .753
IIP subscale-
Socially Avoidant 55 -1.60 1.68 -.09 .344
IIP subscale-
Nonassertive 55 .00 2.06 .00 .999
IIP subscale-
Overly Accommodatingc 54 .55 1.55 .03 .752
IIP subscale-
Self-Sacrificing 55 .51 1.63 .03 .755
IIP subscale-
Intrusive-Needyc 54 -1.02 .93 -.10 .276
IIP subscale-
Domineering-Controlling 55 -.59 .83 -.08 .474
Problem-Focused Style of Coping-
Reactive 54 .64 2.17 .04 .768
Problem-Focused Style of Coping-
Reflective 54 1.11 1.65 .06 .505
Problem-Focused Style of Coping-
Suppressive 54 -.20 2.55 -.01 .937
Rosenberg Self-Esteem Scale 56 -9.49 16.59 -.07 .570
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. b IIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
179
Appendix G
Table G1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Emotional Vocal Quality in the Session with the Lowest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -8.07 10.53 -.10 .446
Dysfunctional Attitudes Scale 54 -10.78 32.48 -.04 .741
General Symptom Index of the
SCL-90-R 54 -.22 .61 -.04 .714
IIPb-
Circumplex Total 55 -.33 .49 -.07 .501
IIP subscale-
Vindictive/Self-Centeredc 54 -.47 .44 -.12 .296
IIP subscale-
Cold Distant 55 -.27 .56 -.05 .630
IIP subscale-
Socially Avoidant 55 -.79 .73 -.10 .284
IIP subscale-
Nonassertive 55 -.16 .90 -.02 .856
IIP subscale-
Overly Accommodatingc 54 -.08 .69 -.01 .911
IIP subscale-
Self-Sacrificing 55 -.57 .71 -.09 .425
IIP subscale-
Intrusive-Needyc 54 .27 .41 .06 .516
IIP subscale-
Domineering-Controlling 55 -.47 .36 -.15 .191
Problem-Focused Style of Coping-
Reactive 54 -.09 .94 -.01 .927
Problem-Focused Style of Coping-
Reflective 54 -.27 .72 -.03 .713
Problem-Focused Style of Coping-
Suppressive 54 -.09 1.09 -.01 .934
Rosenberg Self-Esteem Scale 55 6.47 7.23 .10 .375
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. b IIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
180
Appendix G
Table G2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Focused Vocal Quality in the Session with the Lowest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -12.53 38.65 -.04 .747
Dysfunctional Attitudes Scale 54 -63.44 125.41 -.06 .615
General Symptom Index of the
SCL-90-R 54 -.92 2.34 -.05 .696
IIPb-
Circumplex Total 55 -6.65 4.02 -.17 .104
IIP subscale-
Vindictive/Self-Centeredc 54 -3.49 3.79 -.11 .362
IIP subscale--
Cold Distant 55 -5.37 4.65 -.12 .254
IIP subscale-
Socially Avoidant 55 -5.38 6.17 -.08 .388
IIP subscale-
Nonassertive 55 -11.59 7.33 -.16 .120
IIP subscale--
Overly Accommodatingc 54 -.08 .69 -.01 .911
IIP subscale-
Self-Sacrificing 55 -12.84 5.81 -.23 .032
IIP subscale-
Intrusive-Needyc 54 -2.04 3.42 -.06 .553
IIP subscale-
Domineering-Controlling 55 -3.18 3.00 -.12 .294
Problem-Focused Style of Coping-
Reactive 54 5.47 3.46 .20 .120
Problem-Focused Style of Coping-
Reflective 54 .66 2.67 .02 .806
Problem-Focused Style of Coping-
Suppressive 54 -.37 4.15 -.01 .929
Rosenberg Self-Esteem Scale 55 10.71 28.22 .04 .706
Note. a Different sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. b IIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
181
Appendix G
Table G3
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Emotional Plus Focused Vocal Quality in the Session with the
Lowest Change Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -8.19 10.03 -.10 .418
Dysfunctional Attitudes Scale 54 -13.70 30.99 -.05 .660
General Symptom Index of the
SCL-90-R 54 -.26 .58 -.05 .655
IIPb-
Circumplex Total 55 -.41 .48 -.09 .399
IIP subscale-
Vindictive/Self-Centeredc 54 -.49 .43 -.13 .262
IIP subscale-
Cold Distant 55 -.33 .54 -.06 .548
IIP subscale-
Socially Avoidant 55 -.82 .71 -.10 .253
IIP subscale-
Nonassertive 55 -.31 .87 -.04 .723
IIP subscale-
Overly Accommodatingc 54 -.22 .67 -.03 .745
IIP subscale-
Self-Sacrificing 55 -.71 .69 -.11 .308
IIP subscale-
Intrusive-Needyc 54 .23 .40 .05 .574
IIP subscale-
Domineering-Controlling 55 -.49 .35 -.16 .163
Problem-Focused Style of Coping-
Reactive 54 .27 .90 .04 .763
Problem-Focused Style of Coping-
Reflective 54 -.20 .69 -.03 .774
Problem-Focused Style of Coping-
Suppressive 54 -.11 1.04 -.01 .919
Rosenberg Self-Esteem Scale 55 6.55 6.90 .11 .347
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIIP is Inventory of Interpersonal Problems. c Indicates the removal of one outlier case.
182
Appendix H
Table H1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values for Emotional Vocal Quality in the Session with the First Report
of Moderate to High Change
Outcome Measures Na B SE Β p value
Beck Depression Inventoryb 56 -54.52 24.71 -.29 .032
Dysfunctional Attitudes Scale 51 -92.55 107.70 -.10 .394
General Symptom Index of the
SCL-90-R 52 -4.35 1.91 -.28 .027
IIPc-
Circumplex Total 52 -3.48 1.53 -.23 .027
IIP subscale-
Vindictive/Self-Centeredd 51 -2.68 1.36 -.23 .055
IIP subscale-
Cold Distant 52 -4.00 1.78 -.22 .029
IIP subscale-
Socially Avoidant 52 -4.83 2.34 -.19 .044
IIP subscale-
Nonassertive 52 -5.70 2.86 -.20 .052
IIP subscale-
Overly Accommodatingd 51 -3.49 2.17 -.16 .115
IIP subscale-
Self-Sacrificing 52 -2.82 2.29 -.13 .224
IIP subscale-
Intrusive-Needy 52 -2.18 1.30 -.16 .100
IIP subscale-
Domineering-Controlling 52 -1.05 1.19 -.11 .381
Problem-Focused Style of Coping-
Reactive 51 -6.18 2.84 -.28 .035
Problem-Focused Style of Coping-
Reflective 51 2.18 2.39 .09 .367
Problem-Focused Style of Coping-
Suppressive 51 -4.27 3.30 -.17 .201
Rosenberg Self-Esteem Scale 53 17.70 23.56 .09 .456
Note. a Different sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of two outlier cases. cIIP is Inventory of Interpersonal Problems. dIndicates
the removal of one outlier case.
183
Appendix H
Table H2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values for Focused Vocal Quality in the Session with the First Report of
Moderate to High Change
Outcome Measures Na B SE Β p value
Beck Depression Inventoryb 56 -35.23 19.45 -.25 .076
Dysfunctional Attitudes Scale 51 -28.78 78.56 -.04 .716
General Symptom Index of the
SCL-90-R 52 -2.51 1.48 -.21 .095
IIPc-
Circumplex Total 52 -1.92 1.19 -.17 .112
IIP subscale-
Vindictive/Self-Centeredd 51 -.33 1.08 -.04 .762
IIP subscale-
Cold Distant 52 -2.41 1.39 -.18 .089
IIP subscale-
Socially Avoidant 52 -.85 1.89 -.04 .653
IIP subscale-
Nonassertive 52 -3.12 2.21 -.15 .164
IIP subscale-
Overly Accommodatingd 51 -3.45 1.63 -.21 .039
IIP subscale-
Self-Sacrificing 52 -4.96 1.62 -.30 .004
IIP subscale-
Intrusive-Needy 52 -1.04 1.00 -.10 .303
IIP subscale-
Domineering-Controlling 52 .35 .91 .05 .699
Problem-Focused Style of Coping-
Reactive 51 2.20 2.26 .13 .335
Problem-Focused Style of Coping-
Reflective 51 4.08 1.70 .21 .021
Problem-Focused Style of Coping-
Suppressive 51 -.97 2.73 -.05 .725
Rosenberg Self-Esteem Scale 53 24.52 17.80 .17 .174
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of two outlier cases. cIIP is Inventory of Interpersonal Problems. dIndicates
the removal of one outlier case.
184
Appendix H
Table H3
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values for Emotional Plus Focused Vocal Quality in the Session with the
First Report of Moderate to High Change
Outcome Measures Na B SE Β p value
Beck Depression Inventoryb 56 -41.41 14.56 -.37 .006
Dysfunctional Attitudes Scale 51 -48.83 62.08 -.09 .435
General Symptom Index of the
SCL-90-R 52 -3.13 1.11 -.33 .007
IIPc-
Circumplex Total 52 -2.46 .90 -.28 .009
IIP subscale-
Vindictive/Self-Centeredd 51 -1.18 .84 -.17 .165
IIP subscale-
Cold Distant 52 -2.98 1.05 -.28 .007
IIP subscale-
Socially Avoidant 52 -2.30 1.44 -.15 .117
IIP subscale-
Nonassertive 52 -4.01 1.69 -.24 .022
IIP subscale-
Overly Accommodatingd 51 -3.42 1.25 -.26 .009
IIP subscale-
Self-Sacrificing 52 -4.15 1.27 -.32 .002
IIP subscale-
Intrusive-Needy 52 -1.44 .78 -.17 .069
IIP subscale-
Domineering-Controlling 52 -.16 .72 -.03 .828
Problem-Focused Style of Coping-
Reactive 51 -.86 1.77 -.07 .628
Problem-Focused Style of Coping-
Reflective 51 3.41 1.36 .23 .016
Problem-Focused Style of Coping-
Suppressive 51 -2.18 2.05 -.14 .292
Rosenberg Self-Esteem Scale 53 21.78 13.99 .19 .126
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of two outlier cases. cIIP is Inventory of Interpersonal Problems. dIndicates the
removal of one outlier case.
185
Appendix I
Table I1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values for Limited Vocal Quality in the Session with the First Report of
Moderate to High Change
Outcome Measures Na B SE Β p value
Beck Depression Inventoryb 56 -13.07 8.63 -.21 .136
Dysfunctional Attitudes Scalec 48 -89.97 24.82 -.3 .001
General Symptom Index of the
SCL-90-R 52 -.60 .66 -.12 .365
IIPd-
Circumplex Total 52 -1.15 .50 -.24 .027
IIP subscale-
Vindictive/Self-Centerede 51 .07 .47 .02 .876
IIP subscale-
Cold Distant 52 -1.12 .59 -.19 .063
IIP subscale-
Socially Avoidant 52 -1.10 .79 -.13 .173
IIP subscale-
Nonassertive 52 -2.89 .89 -.31 .002
IIP subscale-
Overly Accommodatinge 51 -2.00 .68 -.28 .005
IIP subscale-
Self-Sacrificing 52 -2.08 .72 -.29 .005
IIP subscale-
Intrusive-Needy 52 -.14 .44 -.03 .757
IIP subscale-
Domineering-Controlling 52 .04 .39 .01 .929
Problem-Focused Style of Coping-
Reactive 51 -1.06 .99 -.14 .293
Problem-Focused Style of Coping-
Reflective 51 1.54 .76 .18 .049
Problem-Focused Style of Coping-
Suppressive 51 -.62 1.14 -.07 .593
Rosenberg Self-Esteem Scale 53 12.93 7.59 .21 .094
Note. a Different sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of two outlier cases. cIndicates the removal of three outlier cases. dIIP is
Inventory of Interpersonal Problems. eIndicates the removal of one outlier case.
186
Appendix I
Table I2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values for Externalizing Vocal Quality in the Session with the First
Report of Moderate to High Change
Outcome Measure Na B SE Β p value
Beck Depression Inventoryb 56 15.67 6.49 .32 .019
Dysfunctional Attitudes Scaleb 49 57.82 22.31 .26 .013
General Symptom Index of the
SCL-90-Rc 51 1.13 .45 .31 .016
IIPd-
Circumplex Total 52 1.16 .38 .31 .004
IIP subscale-
Vindictive/Self-Centeredb 50 .32 .33 .12 .335
IIP subscale-
Cold Distant 52 1.24 .45 .27 .008
IIP subscale-
Socially Avoidant 52 1.10 .61 .17 .078
IIP subscale-
Nonassertive 52 2.53 .68 .35 .001
IIP subscale-
Overly Accommodatingc 51 1.87 .52 .33 .001
IIP subscale-
Self-Sacrificing 52 2.07 .54 .37 .000
IIP subscale-
Intrusive-Needy 52 .37 .35 .10 .290
IIP subscale-
Domineering-Controlling 52 .01 .31 .00 .973
Problem-Focused Style of Coping-
Reactive 51 .84 .77 .14 .287
Problem-Focused Style of Coping-
Reflective 51 -1.56 .58 -.24 .010
Problem-Focused Style of Coping-
Suppressive 51 .82 .90 .12 .366
Rosenberg Self-Esteem Scale 53 -12.07 5.92 -.25 .047
Note. a Different sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of two outlier cases. cIndicates the removal of one outlier case. dIIP is
Inventory of Interpersonal Problems.
187
Appendix J
Table J1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Limited Vocal Quality in the Session with the Lowest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 2.18 10.57 .03 .837
Dysfunctional Attitudes Scale 54 -1.64 32.57 -.01 .960
General Symptom Index of the
SCL-90-R 54 .17 .61 .03 .785
IIPb-
Circumplex Total 55 -.33 .49 -.07 .499
IIP subscale-
Vindictive/Self-Centeredc 54 .48 .44 .13 .284
IIP subscale-
Cold Distant 55 -.24 .55 -.04 .671
IIP subscale-
Socially Avoidant 55 .24 .73 .03 .741
IIP subscale-
Nonassertive 55 -1.07 .88 -.12 .232
IIP subscale-
Overly Accommodatingc 54 -1.23 .67 -.18 .074
IIP subscale-
Self-Sacrificing 55 -1.31 .70 -.19 .068
IIP subscale-
Intrusive-Needyc 54 .08 .42 .02 .841
IIP subscale-
Domineering-Controlling 55 .01 .36 .00 .983
Problem-Focused Style of Coping-
Reactive 54 .54 .91 .08 .560
Problem-Focused Style of Coping-
Reflective 54 -.07 .70 -.01 .920
Problem-Focused Style of Coping-
Suppressive 54 1.10 1.08 .13 .311
Rosenberg Self-Esteem Scale 55 6.55 7.29 .10 .373
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIIP is Inventory of Interpersonal Problems. cIndicates the removal of one outlier case.
188
Appendix J
Table J2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Externalizing Vocal Quality in the Session with the Lowest
Change Score
Outcome Measures Na B SE Β p value
Beck Depression Inventoryb 60 10.24 6.84 .19 .140
Dysfunctional Attitudes Scale 54 7.94 22.43 .04 .725
General Symptom Index of the
SCL-90-R 54 .06 .42 .02 .891
IIPc-
Circumplex Total 55 .37 .34 .11 .285
IIP subscale-
Vindictive/Self-Centeredb 54 .02 .31 .01 .959
IIP subscale-
Cold Distant 55 .28 .39 .07 .469
IIP subscale-
Socially Avoidant 55 .30 .51 .05 .562
IIP subscale-
Nonassertive 55 .67 .61 .11 .280
IIP subscale-
Overly Accommodatingb 54 .68 .46 .14 .149
IIP subscale-
Self-Sacrificing 55 .98 .48 .21 .047
IIP subscale-
Intrusive-Needyb 54 -.16 .29 -.05 .586
IIP subscale-
Domineering-Controlling 55 .25 .25 .11 .331
Problem-Focused Style of Coping-
Reactive 54 -.40 .64 -.08 .534
Problem-Focused Style of Coping-
Reflective 54 .13 .48 .03 .786
Problem-Focused Style of Coping-
Suppressive 54 -.47 .74 -.08 .534
Rosenberg Self-Esteem Scale 54 -7.79 4.52 -1.82 .091
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIndicates the removal of one outlier case. cIIP is Inventory of Interpersonal Problems.
189
Appendix K
Table K1
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Limited Vocal Quality in the Session with the Highest Change
Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 7.42 10.92 .09 .500
Dysfunctional Attitudes Scale 54 54.59 39.64 .15 .175
General Symptom Index of the
SCL-90-R 55 -.02 .75 .00 .982
IIPb-
Circumplex Total 55 .16 .61 .03 .794
IIP subscale-
Vindictive/Self-Centeredc 54 .50 .62 .09 .426
IIP subscale-
Cold Distant 55 -.41 .69 -.06 .553
IIP subscale-
Socially Avoidant 55 .21 .91 .02 .817
IIP subscale-
Nonassertive 55 .34 1.11 .03 .759
IIP subscale-
Overly Accommodatingc 54 .14 .93 .02 .878
IIP subscale-
Self-Sacrificing 55 .03 .89 .00 .978
IIP subscale-
Intrusive-Needyc 54 .22 .57 .04 .710
IIP subscale-
Domineering-Controlling 55 -.45 .45 -.12 .318
Problem-Focused Style of Coping-
Reactive 54 2.94 1.07 .34 .008
Problem-Focused Style of Coping-
Reflective 54 -.50 .86 -.05 .562
Problem-Focused Style of Coping-
Suppressive 54 4.06 1.22 .39 .002
Rosenberg Self-Esteem Scale 56 -8.10 8.95 -.10 .369
Note. a Different sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIIP is Inventory of Interpersonal Problems. cIndicates the removal of one outlier case.
190
Appendix K
Table K2
Results for Hypothesis 2a: Standard (β) and Unstandardized (B) Regression Coefficients, their
Standard Errors, and p values Externalizing Vocal Quality in the Session with the Highest
Change Score
Outcome Measures Na B SE Β p value
Beck Depression Inventory 61 -4.12 9.35 -.06 .661
Dysfunctional Attitudes Scale 54 -37.93 32.24 -.13 .245
General Symptom Index of the
SCL-90-R 55 .23 .61 .04 .709
IIPb-
Circumplex Total 55 -.02 .49 .00 .971
IIP subscale-
Vindictive/Self-Centeredc 54 -.38 .45 -.10 .403
IIP subscale-
Cold Distant 55 .39 .56 .07 .483
IIP subscale-
Socially Avoidant 55 .23 .74 .03 .762
IIP subscale-
Nonassertive 55 -.18 .90 -.02 .844
IIP subscale-
Overly Accommodatingc 54 -.25 .68 -.04 .710
IIP subscale-
Self-Sacrificing 55 -.14 .71 -.02 .851
IIP subscale-
Intrusive-Needyc 54 .532 .44 .11 .229
IIP subscale-
Domineering-Controlling 55 .44 .36 .14 .223
Problem-Focused Style of Coping-
Reactive 54 -1.96 .89 -.28 .032
Problem-Focused Style of Coping-
Reflective 54 .14 .70 .02 .843
Problem-Focused Style of Coping-
Suppressive 54 -2.50 1.03 -.29 .019
Rosenberg Self-Esteem Scale 56 6.41 7.23 .10 .379
Note. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier
cases. bIIP is Inventory of Interpersonal Problems. cIndicates the removal of one outlier case.
191
Appendix L
Table L1
Results for Hypothesis #2b: Standard (β) and Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Post-Treatment Scores for Outcome Measures by Therapist Vocal Style (Softened-Irregular and Natural-Definite)
for Sessions with the Lowest and Highest Change Scores
Outcome
Measure Na
Therapist Vocal Style in Lowest and
Highest Change Sessions B SE β p value
BDIb 56
Both sessions are Softened-Irregular -3.45 2.37 -.21 .152
One is Softened-Irregular and one is
Natural-Definite 3.00 2.67 .16 .266
DAS 50
Both sessions are Softened-Irregular 2.58 8.28 .04 .757
One is Softened-Irregular and one is
Natural-Definite .06 9.73 .00 .995
GSI 51
Both sessions are Softened-Irregular -.25 .16 -.21 .136
One is Softened-Irregular and one is
Natural-Definite -.01 .18 -.01 .941
IIPc Circumplex
Total 51
Both sessions are Softened-Irregular -.24 .13 -.23 .064
One is Softened-Irregular and one is
Natural-Definite -.25 .15 -.21 .098
IIP Vindictive-
Self-Sacrificingb 50
Both sessions are Softened-Irregular .08 .12 .09 .513
One is Softened-Irregular and one is
Natural-Definite .06 .14 .06 .682
IIP Cold Distant 51
Both sessions are Softened-Irregular -.23 .15 -.17 .141
One is Softened-Irregular and one is
Natural-Definite -.21 .17 -.14 .223
IIP Socially
Inhibited 51
Both sessions are Softened-Irregular -.22 .20 -.12 .277
One is Softened-Irregular and one is
Natural-Definite -.13 .23 -.07 .563
IIP Nonassertive 51
Both sessions are Softened-Irregular -.45 .24 -.22 .065
One is Softened-Irregular and one is
Natural-Definite -.51 .27 -.23 .063
IIP Overly
Accommodating 51
Both sessions are Softened-Irregular -.41 .20 -.25 .042
One is Softened-Irregular and one is
Natural-Definite -.27 .22 -.15 .223
IIP Self-
Sacrificing 51
Both sessions are Softened-Irregular -.23 .19 -.15 .222
One is Softened-Irregular and one is
Natural-Definite -.29 .21 -.17 .179
IIP Intrusive-
Needy 51
Both sessions are Softened-Irregular -.15 .11 -.15 .150
One is Softened-Irregular and one is
Natural-Definite -.12 .12 -.11 .294
Note. Dummy variables were used in the multiple regression analysis. The reference category was Natural-Definite for both
sessions. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier cases. bOne
outlier removed. cIIP is Inventory of Interpersonal Problems.
192
Appendix L
Table L1 continued
Results for Hypothesis #2b: Standard (β) and Unstandardized (B) Regression Coefficients, their Standard Errors, and
p values for Post-Treatment Scores for Outcome Measures by Therapist Vocal Style (Softened-Irregular and Natural-Definite)
for Sessions with the Lowest and Highest Change Scores
Outcome
Measure Na
Therapist Vocal Style in Lowest and
Highest Change Sessions B SE β p value
IIP Domineering-
Controlling 51
Both sessions are Softened-Irregular -.07 .10 -.10 .458
One is Softened-Irregular and one is
Natural-Definite -.08 .11 -.10 .476
PF-SOC Reactive
Style 50
Both sessions are Softened-Irregular .14 .24 .08 .580
One is Softened-Irregular and one is
Natural-Definite -.07 .29 -.04 .804
PF-SOC
Reflective Style 50
Both sessions are Softened-Irregular .07 .19 .04 .702
One is Softened-Irregular and one is
Natural-Definite .15 .22 .07 .504
PF-SOC
Suppressive 50
Both sessions are Softened-Irregular -.42 .27 -.23 .125
One is Softened-Irregular and one is
Natural-Definite -.09 .31 -.04 .768
RSE 52
Both sessions are Softened-Irregular 2.13 1.96 .15 .283
One is Softened-Irregular and one is
Natural-Definite .54 2.20 .03 .809
Note. Dummy variables were used in the multiple regression analysis. The reference category was Natural-Definite for both
sessions. aDifferent sample sizes are the result of missing data for some clients and/or the removal of outlier cases. bOne
outlier removed.
193
Appendix L
Table L2
Results for Hypothesis #2b: Standard (β) and Unstandardized (B) Regression Coefficients, their Standard Errors, and p
values for Post-Treatment Scores for Outcome Measures by Therapist Vocal Style (Softened-Irregular and Natural-Definite) in
First report of Moderate to High Change Session
Outcome Measure Na B SE β p value
BDIb 54 1.22 1.81 .10 .502
DAS 49 -5.84 7.45 -.09 .437
GSI 50 .08 .15 .07 .575
IIPc Circumplex Total 50 .13 .12 .12 .276
IIP Vindictive-Self-Sacrificingd 49 -.12 .10 -.14 .268
IIP Cold Distant 50 .13 .13 .10 .343
IIP Socially Inhibited 50 -.04 .18 -.02 .836
IIP Nonassertive 50 .35 .21 .18 .105
IIP Overly Accommodating 50 .34 .18 .21 .062
IIP Self-Sacrificing 50 .22 .17 .14 .216
IIP Intrusive-Needy 50 -.03 .09 -.04 .713
IIP Domineering-Controlling 50 .03 .08 .05 .698
PF-SOC Reactive Style 49 -.21 .22 -.13 .342
PF-SOC Reflective Style 49 -.01 .17 -.01 .939
PF-SOC Suppressive 49 .27 .24 .15 .272
RSE 51 -2.54 1.71 -.19 .144
Note. Dummy variables were used in the multiple regression analysis. The reference category was Natural-Definite for both
sessions. bTwo outliers removed. cIIP=Inventory of Interpersonal Problems. dOne outlier removed.