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The Session Rating Scale: Preliminary
Psychometric Properties of a “Working”
Alliance Measure
Barry L. Duncan, PsyD
Scott D. Miller, PhD
Institute for the Study of Therapeutic Change
Chicago, Illinois
Jacqueline A. Sparks, PhD
David A. Claud, MS
The Center for Family Services of Palm Beach County
Palm Beach, Florida
Lisa Rene Reynolds, MS
Nova Southeastern University
Ft. Lauderdale, Florida
Jeb Brown, PhD
Center for Clinical Informatics
Salt Lake City, Utah
Lynn D. Johnson, PhD
Brief Therapy Center
Salt Lake City, Utah
Over 1,000 research findings (Orlinsky, Rønnestad, & Willutzki, 2004) demonstrate that
a positive alliance is one of the best predictors of outcome. Paradoxically, despite the
robust connection between the alliance and outcome, no alliance measures have been
developed specifically as clinical tools for therapists to use on a day-to-day basis with their
clients. This article describes the development and validation of an ultra-brief alliance
measure, the Session Rating Scale Version 3 (SRS). The instrument’s psychometric prop-
erties are examined and reported. Based on experience with the instrument at the various
sites in the study, the feasibility of the scale is also considered. Results indicate that the
SRS, a clinical rather than research tool, represents a balanced tradeoff between the relia-
bility and validity of the longer research measures, and the feasibility of this brief scale.
Results and implications for clinical practice and future research are discussed.
© 2003 Springer Publishing Company
Journal of Brief Therapy
Volume 3, Number 1 • Fall/Winter 2003
3
JBT 3(1) 3-12 12/14/04 3:53 PM Page 3
Over 1,000 research findings, and counting (Orlinsky, Grawe, & Park, 1994; Orlinsky,
Rønnestad, & Willutzki, 2004), demonstrate that a positive alliance is one of the best
predictors of outcome. Horvath and Symonds (1991), summarizing 24 studies, showed
that the average effect size of the correlation between the alliance and outcome was conserva-
tively estimated at r= 0.26. Krupnick and colleagues (1996) analyzed data from the landmark
NIMH depression study that compared cognitive behavioral, interpersonal, and antidepressant
therapies with a placebo condition, and found that the alliance was predictive of success for all
conditions—the treatment models were equally efficacious and did not predict outcome.
In another large study of diverse therapies for alcoholism, the alliance was also signifi-
cantly predictive of success (sobriety), even at 1-year follow-up (Connors, DiClemente,
Carroll, Longabaugh, & Donovan, 1997), when none of the models under study could be
differentiated from one another. Furthermore, in a meta-analysis of alliance research,
Wampold (2001) portioned 54% of the variance of the impact of therapy to the alliance.
Putting this into perspective, the amount of change attributable to the alliance is about seven
times that of a specific model or technique.
Moreover, client ratings of the alliance are far better predictors of outcome than thera-
pist ratings (Bachelor & Horvath, 1999). Therapists, then, cannot assume that their evalua-
tion of the quality of the therapy climate corresponds to their clients’ perceptions. Clearly,
then, it is critical for therapists to attend closely to the alliance developed with their clients,
and regularly monitor its quality. Influencing the client’s perceptions of the alliance repre-
sents the most direct impact that mental health professionals can have on change (Duncan,
Miller, & Sparks, 2004).
Despite the robust connection between the alliance and outcome, no alliance measure
has been developed specifically as a clinical tool for day-to-day use. Description and meas-
urement of the therapeutic alliance has been a major focus of theoretical and empirical stud-
ies in the last two decades. Presently, a variety of approaches exist for evaluating the alliance.
While these multi-dimensional assessments of the alliance are valid and reliable, they were
developed largely for research purposes and are not intended to be used as everyday clinical
tools. Consequently, their complexity and length of administration often render them infea-
sible for many service providers and settings. The average therapist’s caseload is already over-
loaded with paperwork or other non-direct service related activities (e.g., phone calls, team
meetings, treatment planning, progress notes, etc.). Brown, Dreis, and Nace (1999) found
that the majority of clinicians did not consider any measure or combination of measures that
took more than five minutes to complete, score, and interpret practical.
An example of the resistance of therapists to longer research-based alliance instruments can
found in the study of Whipple and colleagues (2003). Through e-mails, therapists were contin-
ually reminded that a 19-item alliance measure and other clinical support tools were available
for those clients at risk of negative or null outcomes. Moreover, supervisors and clinicians pre-
sented several cases in which the measures had clearly assisted therapists in turning around the
treatment of at-risk clients. Nevertheless, therapists used such measures only 40% of the time
with at-risk clients. This level of use is surprising in view of the fact that Whipple and colleagues
(2003) found clients of therapists who had access to outcome and alliance information were less
likely to deteriorate, more likely to stay longer, and twice as likely to achieve a clinically signifi-
cant change. These findings make a strong argument for developing not only a reliable and valid
alliance measure, but one that is feasible in therapists’ minds for routine clinical use.
The purpose of this article is to describe the development and validation of an ultra-brief
alliance measure, the Session Rating Scale Version 3.0 (SRS [Johnson, Miller, & Duncan,
2000] see Appendix),1a “working” alliance measure designed specifically for every session
clinical use. The SRS’s psychometric properties are examined and its relationship to a wide-
ly used measure of the alliance, the Revised Helping Alliance Questionnaire (HAQ-II)
(Luborsky et al., 1996) is reported. This article also considers the scale’s feasibility based on
4 Session Rating Scale
JBT 3(1) 3-12 12/14/04 3:53 PM Page 4
experience with the instrument at the various sites in the study. Results and implications for
clinical practice and future research are discussed.
DEVELOPMENT OF THE SESSION RATING SCALE
Recognizing that different therapies achieved similar results and that the therapeutic alliance
seemed paramount, Johnson created the Session Rating Scale in the early 1990s to help track his
own progress with clients (see Johnson, 1995). The SRS was specifically designed to be a clini-
cal tool, not a research instrument. Several measures influenced its construction: The Working
Alliance Inventory (Horvath & Greenberg, 1989), which directly translates Bordin’s (1979)
description of the alliance (see below); the Session Evaluation Questionnaire (Stiles & Snow,
1984), which assesses the depth and smoothness of the session; and finally, the Empathy Scale
(Burns & Nolen-Hoeksema, 1992), which specifically addresses the relationship, and is perhaps
the only other scale assessing any part of the alliance that is intended for regular clinical use.
The SRS combined elements of each measure into a 10-item, Likert-scaled instrument.
This original version of the SRS was examined with 39 clients in a brief psychotherapy
clinic in the western United States (Stanford, 1999). Item analysis of the SRS provided a
Cronbach’s alpha reliability coefficient of .89. The first six items measuring therapeutic
alliance also returned a high alpha of .86, while items 7, 9, and 10, measuring session impact,
provided an alpha of .75. Concurrent validity was not addressed.
The first two authors were familiar with the SRS, having used it in their own practices
as well as in consultation with numerous mental health agencies and a number of third-party
payers. Despite the fact that the SRS was only 10 items, in virtually all instances, complaints
regarding the time needed to complete the SRS were quick to surface among clinicians and
clients (mainly clinicians). Similar difficulties were experienced implementing the 12-item
WAI, making the 19-item HAQ II infeasible as well. Because of the unequivocal link between
the alliance and outcome, the SRS V.3 was developed as a brief alternative to longer research
oriented alliance measures to address the complaints of clinicians and to encourage routine
conversation with clients about the alliance.
The SRS is a four-item visual analogue instrument designed from several influences. Bordin
(1979) classically defined the alliance with three interacting elements: (a) a relational bond
between the therapist and client; (b) agreement on the goals of therapy; and (c) agreement on
the tasks of therapy. A slightly different perspective is provided by Gaston (1990) who reiterates
the major alliance themes, but also emphasizes that the congruence between the client’s and the
therapist’s beliefs about how people change in therapy is essential for a strong alliance. The SRS
was adapted from the classical definition of the alliance by Bordin, with a focus on the client’s
theory of change (Duncan & Miller, 2000) as suggested by Gaston.
The fourth item reflects guidance received from a factor analysis of the major alliance
scales in use (i.e., the HAQ, the WAI, and the California Psychotherapy Alliance Scales
[Gaston, 1991]). Hatcher and Barends (1996) discovered that in addition to the general fac-
tor measured by all alliance scales (i.e., strength of the alliance), two other factors were pre-
dictive: confident collaboration and the expression of negative feelings. Confident collaboration
speaks to the level of confidence that the client has that therapy and the therapist will be
helpful. Although overlapping with question three on the SRS (the fit of the therapist’s
approach), the fourth scale of the revised SRS directly addresses this factor, and measures the
client’s view of the session ranging from “There was something missing in the session today”
to “Overall, today’s session was right for me.”
The other factor predictive beyond the general strength of the alliance is the client’s free-
dom to voice negative feelings and reactions to the therapist. This factor suggests that clients
who express even low levels of disagreement with their therapists report better progress
(Hatcher & Barends, 1996). The entire SRS is based on encouraging clients to identify
B. L. Duncan et al. 5
JBT 3(1) 3-12 12/14/04 3:53 PM Page 5
alliance problems and eliciting client disagreements about the therapeutic process so that the
clinician may change to better fit client expectations. Research had long identified these fac-
tors as important, but until Johnson’s pioneering work, no clinical measure had proactively
provided alliance feedback to the therapist in real time so that problems may be addressed.
The SRS simply translated these theoretical ideas into four 10-cm visual analog scales,
with instructions to place a hash mark on a line with negative responses depicted on the left
and positive responses indicated on the right (see Appendix). First, a relationship scale rates
the session on a continuum from “I did not feel heard, understood, and respected” to “I felt
heard, understood, and respected.” Second is a goals and topics scale that rates the session
on a continuum from “We did not work or talk about what I wanted to work on or talk
about” to “We worked on or talked about what I wanted to work on or talk about.” Third is
an approach or method scale requiring the client to rate the session on a continuum from
“The therapist’s approach is not a good fit for me” to “The therapist’s approach is a good fit
for me.” Finally, and reiterating, the fourth scale looks at how the client perceives the session
in total along the continuum: “There was something missing in the session today” to
“Overall, today’s session was right for me.”
The SRS is scored by simply summing the marks made by the client measured to the
nearest centimeter on each of the four lines. Based on a total possible score of 40, any score
lower than 36 overall, or 9 on any scale, could be a source of concern and therefore prudent
to invite the client to comment. Clients tend to score all alliance measures highly, so the ther-
apist should address any suggestion of a problem.
To explain the basic components of the measure and the alliance to students and line
therapists, an analogy to a three-legged stool is employed (see Figure 1). Set against a back-
drop of client strengths and resources, each leg of the stool stood for one of the core ingre-
dients of the therapeutic alliance (a) shared goals; (b) consensus on means, methods, or
tasks of treatment; and (c) an emotional bond (Bordin, 1979). Holding everything together
was the client’s theory of change, the other alliance component suggested by Gaston (1991).
Consistent with this stool metaphor, goals, methods, and a bond that were congruent with
the client’s theory were likely to keep people comfortably seated (i.e., engaged) in treatment.
Similarly, any disagreement between various components destabilized the alliance either
making the stool uncomfortable or toppling it completely.
Research has demonstrated the reliability and validity of ultra-brief visual analog scales
in several areas including: assessment and management of pain (Ger, Ho, Sun, Wang, &
Cleeland, 1999; Zalon, 1999), perceived quality of care (Arneill & Devlin, 2002), psychoed-
ucation (Dannon, Iancu, & Grunhaus, 2002), the assessment of change in response to med-
ical treatments (Grunhaus, Dolberg, Polak, & Dannon, 2002), and with psychotherapy out-
come (Miller, Duncan, Brown, Sparks, & Claud, 2003). In addition to their ease of adminis-
tration and scoring, such scales enjoy face validity typically missing from longer and more
technical measures that seem distant from the client’s experience.
METHODS
Participants
Participants in this study were recruited from three clinical sites:
Group One. Eighty-one participants were randomly selected from an outpatient mental
health counseling agency2to study the reliability and concurrent validity of the SRS. These
agency clients requested traditional individual, couple, or family therapy services and pre-
sented with a variety of presenting complaints and goals for treatment. All of the therapy ses-
sions were conducted in the typical clinical office setting. The age range of the client sample
was between 18 and 74. Court-mandated clients were omitted from the sample, leaving only
those clients who were self-referred for therapy.
6 Session Rating Scale
JBT 3(1) 3-12 12/14/04 3:53 PM Page 6
Group Two. One hundred participants were randomly selected from cases closed from
January 2003 through August 2003 in a community family service agency (CFS) to study the
construct validity of the SRS. CFS clients were enrolled in traditional office-based counsel-
ing and came to the agency presenting a typical range of initial difficulties.3Clients from the
agency’s substance abuse recovery program were excluded. Since substance abuse clients, in
general, were mandated, outcome measurements might reflect concerns other than actual
progress in counseling (e.g., referral issues), or clients might not be motivated to accurately
rate their psychological states (see Lambert et al., 1996), thereby confounding any relation-
ship between the SRS and outcome. A total sample of 1368 adults between the ages of 18 and
83 were available for the random selection of closed cases for analysis.
Group Three. To assess the feasibility of the SRS, participants were recruited from two
different settings using two different measures. The first setting was a home-based interven-
tion program at CFS, and included all the closed cases from January 2003 to October 2003
(50 cases). In that program, use of the SRS was mandatory. Participants were also obtained
from closed cases of a previous study conducted at Family Therapy Associates (FTA) at Nova
Southeastern University from June 1998 to May 1999 (106 cases). FTA is a community men-
tal health agency similar in nature and scope to CFS. Like the CFS participants, the FTA ther-
apists were mandated to use the Working Alliance Inventory (WAI).
Measures
The Helping Alliance Questionnaire II. The HAQ-II (Luborsky et al., 1996) is a widely
used 19-item questionnaire that measures the strength of the client therapist alliance. Each
item is rated on a 6-point Likert scale (1 = I strongly feel it is not true to 6 = I strongly feel
it is true); negatively worded items are reversed scored.
The Outcome Rating Scale. The Outcome Rating Scale (Miller et al., 2003) is a 4-item
visual analogue self-report outcome measure designed for tracking client progress in every
B. L. Duncan et al. 7
Figure 1. Measuring the alliance.
JBT 3(1) 3-12 12/14/04 3:53 PM Page 7
session. Each item requires the client to make a mark on a 10-cm line where marks to left indi-
cate more difficulties in the particular domain and marks to the right depict less problems.
The Working Alliance Inventory. The WAI (Horvath & Greenberg, 1989) is a widely used
12-item questionnaire that measures the strength of the therapeutic alliance. Each item is
rated on a 7-point Likert scale (1 = Does not correspond at all; 7 = Corresponds exactly).
Procedure
Group One. Eighty-one participants received six concurrent administrations of the SRS and
HAQ-II measures over a period of time ranging from 4 weeks to 3 months, dependent on the
frequency that each client was seen for therapy. The participants’ therapists were responsible for
administering the measures at the conclusion of each session and delivered them immediately
to the agency’s clinical supervisor. The therapists’ degrees, training, and professional experience
varied. The supervisor then scored and entered the data onto a spreadsheet. Only clients’ scores
who completed all six administrations were included in the database; 70 of the original 81
clients (86%) who began this study completed the six SRS and HAQ-II measures. Reasons for
not completing the measures included terminating therapy, moving, or relapsing and reentering
a substance abuse facility or inpatient treatment program.
Group Two. The random selection of the 100 cases was based on the following criteria: pre-
and post-Outcome Rating Scale (ORS) scores, and either a second or third session SRS score.
Given that the use of the SRS was not mandated at this time, many cases were discarded before
the 100 cases were accumulated; if a selected case did not have an SRS completed in session two
or three, then the next case was pulled for examination. The therapists’ degrees, training, and
professional experience varied. Session two or three SRS scores were paired with endpoint out-
come scores on the ORS from the existing data base and entered on a spreadsheet for analysis.
Group Three. Feasibility was retrospectively assessed by looking at utilization data from
two similar clinical sites with similar mandates administering two different alliance meas-
ures. In the CFS sample of 50 closed cases, the therapists were trained in the use of the meas-
ure (SRS) and received ongoing supervisory encouragement. The FTA sample of 106 closed
cases came from a pilot study examining the incorporation of client feedback in therapy
using the WAI. The FTA therapists were part of an ongoing research team and compliance
was expected. Therapists were masters and doctoral students with close supervision and sup-
port provided throughout the research project. Utilization was simply computed by deter-
mining the percentage use of the measures across cases.
RESULTS
Reliability of the SRS
Both test-retest and internal consistency reliability were evaluated using group one (N = 70).
Cronbach’s coefficient alpha was calculated as the estimate of internal consistency. The coef-
ficient alpha for all administrations (N= 420) was .88. The coefficient alpha for the SRS com-
pared favorably with that reported for the HAQ II (.90). As a rule, one would expect a meas-
ure with only four items to have a lower reliability than a measure of containing 19 items.
This high degree of internal consistency reflects the fact that the four items correlate quite
highly with one another, indicating that the measure can perhaps best be thought of as a
global measure of the alliance, much like all of the other alliance measures that load on a
general strength of the alliance factor.
An estimate of test-retest reliability was computed by calculating the Pearson product-
moment correlations between the test scores at each administration (with the exception of the
last) with the score at the subsequent administration. Since each of the 70 clients had a total
8 Session Rating Scale
JBT 3(1) 3-12 12/14/04 3:53 PM Page 8
of six administrations, the pairing of test scores from each administration with those of the
subsequent administration produced a total of 350 paired administrations for both the SRS
and the HAQ II. It would be expected that an ultra brief measure would possess lower rest-
retest reliability than a longer measure. However, the overall test-retest reliability (Pearson’s r)
for the SRS was .64, while the HAQ-II was .63 (p< .01). If the test-retest estimate is limited
to the first and second administrations, a Pearson’s rof .70 is obtained for the SRS and .75 for
the HAQ-II (p< .01). Measures of the alliance tend to change over time, so the fact that lower
test-retest reliability occurred over multiple administrations is not surprising.
Validity of the SRS
Concurrent Validity. Concurrent validity was computed using Pearson product-moment
correlations between the SRS total score and HAQ II total score. The data from all six admin-
istrations were combined to create a sample of 420 paired administrations for the 70 sub-
jects. The correlation between the two measures is .48 (p< .01), providing evidence of con-
current validity for the SRS. Correlations were also performed between each of the individ-
ual SRS items and the HAQ II score at each administration. All correlations between SRS
items and total HAQ-II scores were within a range of .39 to .44. These correlations provide
evidence that the SRS items are assessing the same construct as the HAQ-II and that the SRS
is an ultra brief alternative for assessing global strength of the alliance similar to that meas-
ured by other longer, research oriented alliance measures.
Relationship to Outcome. The SRS, if valid, would correlate with outcome similar to
other research oriented alliance scales. Research has established a robust relationship
between early ratings of the alliance and treatment outcome. If the SRS demonstrated a rela-
tionship to outcome similar to other established alliance measures, it would be an indication
of construct validity. Therefore, it was expected that SRS scores in the random sample of 100
clients in group two would positively correlate with outcome on the ORS. And indeed that
was the case. The analysis revealed a correlation of .29 (p< .01) between the second or third
session SRS scores and the final session ORS scores, indicating that the SRS functions in
much the same way as other alliance measures.
Feasibility of the SRS. Feasibility of an alliance instrument involves the likelihood that the
instrument will, in fact, be used. If an alliance measure that is expected to be a used as a clin-
ical tool does not meet the time demands of actual clinical practice, it will be met with resist-
ance by staff and clients alike. Comparing the utilization or compliance rates on all the com-
pleted cases in two clinical sites using different alliance measure was used to assess the feasi-
bility of the SRS. The two samples had markedly different results. The SRS enjoyed a 96% (48
of 50 cases) compliance rate while the WAI was used only 29% (31 of 106 cases) of the time.
DISCUSSION
Virtually all alliance measures were designed for research and theoretical purposes, not for
everyday use for mental health professionals working in the trenches. This article reports on the
development of an ultra-brief alliance scale that is meant to be used on a session by session
basis—a “working” alliance measure. The SRS was designed for use by clinicians to assess the
therapeutic alliance during therapy so that changes in the approach or style of the therapist can
be implemented if a negative experience is reported by the client. Although a short measure can’t
be expected to achieve the same precision or depth of information as a longer measure like the
HAQ II, this study found that the SRS has solid reliability, adequate validity, and high feasibility.
The results demonstrate that the SRS possesses moderate stability as reflected by the
test-retest coefficients. The internal consistency was very high for the overall SRS as well as
the subscale scores. The high intercorrelations among the subscale scores suggest a single
B. L. Duncan et al. 9
JBT 3(1) 3-12 12/14/04 3:53 PM Page 9
underlying factor, not unlike the single underlying factor of “strength of the alliance” asso-
ciated with the HAQ-II and other alliance measures.
Although not as strong as hoped, the overall correlation with the HAQ-II demonstrates that
the SRS is moderately related to this gold standard of alliance self-report scales. Given that 19
items were reduced to 4, a correlation of .48 indicates concurrent validity meets expectations.
Further, the SRS is found to be related to outcome similar to other alliance measures.
Obviously, no matter how reliable and valid a measure is, if it is not used, the benefits of
alliance monitoring will not be realized, and the benefits are considerable as evidenced by
research results over the years demonstrating that as much 25% to 45% of outcome variance
can be attributed to the alliance. More specifically, Miller, Duncan, Brown, Sorrell, and Chalk
(in press) found that clients of therapists who opted out of completing the SRS were twice
as likely to drop out of treatment and three to four times more likely to have a negative or
null outcome.
Gains in feasibility offset losses in reliability and validity. Higher compliance rates were
observed for the SRS in a comparison with the longer WAI. Many therapists see any meas-
urement as an encumbrance to forming alliances with clients. In such settings, measures that
are easy to integrate encourage a partnership between the client and therapist for monitor-
ing the alliance. The alliance becomes a truly joint endeavor, integral to positive outcome,
rather than simply more paperwork.
Limitations of this study include those inherent to self-report measures (Boulet & Boss,
1991) as well as the relatively small samples used for analyses. Research with larger and more
diverse clinical samples is under way and should further identify the strengths and weakness
of the SRS, as well as its predictive ability of outcome.
NOTES
1. A working copy of the instrument may be downloaded and used for free at: www.
talkingcure.com/measures.htm.
2. Danbury Catholic Family Services, Danbury, Connecticut.
3. The Center for Family Services of Palm Beach County, Inc. is a not-for-profit family services
agency serving Palm Beach County of South Florida. The agency provides an array of services includ-
ing individual and family counseling, substance abuse treatment, sexual abuse and domestic violence
treatment, EAP services, homeless assistance/shelter, and a school readiness program.
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B. L. Duncan et al. 11
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Acknowledgments. The authors wish to thank Anne M. Allison, BA, who assisted with data collection and sta-
tistical analysis, and Karen Kinchin, MS, and Pat Scholl who helped with data management.
Offprints. Requests for offprints should be directed to Barry L. Duncan, PsyD, 8611 Banyan Ct., Tamarac, FL
33321. E-mail: barrylduncan@cs.com
12 Session Rating Scale
APPENDIX
Session Rating Scale (SRS V.3.0)
Name ________________________Age (Yrs):____
ID# _________________________ Sex: M / F
Session # ____ Date: ________________________
Please rate today’s session by placing a hash mark on the line nearest to the description
that best fits your experience.
Relationship
I———————————————I
Goals and Topics
I———————————————I
Approach or Method
I———————————————I
Overall
I———————————————I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Lynn D. Johnson, Scott D. Miller and Barry L. Duncan
Licensed for personal use only
I did not feel heard,
understood, and
respected.
We did not work on or
talk about what I
wanted to work on and
talk about.
The therapist’s
approach is not a
good fit for me.
There was something
missing in the session
today.
I felt heard,
understood, and
respected.
We worked on and
talked about what I
wanted to work on and
talk about.
The therapist’s
approach is a good fit
for me.
Overall, today’s
session was right for
me.
JBT 3(1) 3-12 12/14/04 3:53 PM Page 12
