UMD Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/3
New submissions to the thesis/dissertation collections are added automatically as they are received from the Graduate School. Currently, the Graduate School deposits all theses and dissertations from a given semester after the official graduation date. This means that there may be up to a 4 month delay in the appearance of a given thesis/dissertation in DRUM.
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Item Design And Evaluation of A Conversational Agent for Mental Health Support: Forming Human-Agent Sociotechnical And Therapeutic Relationships(2021) Liao, Yuting; Vitak, Jessica; Library & Information Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Many people with mental health disorders face significant challenges getting the help they need, including the costs of obtaining psychological counseling or psychiatry services, as well as fear of being stigmatized. As a way of addressing these barriers, text-based conversational agents (chatbots) have gained traction as a new form of e-therapy. Powered by artificial intelligence (AI) and natural language processing techniques, this technology offers more natural interactions and a “judgment-free zone” for clients concerned about stigma. However, literature on psychotherapeutic chatbots is sparse in both the psychology and human computer interaction (HCI) fields. While recent studies indicate that chatbots provide an affordable and effective therapy delivery method, this research has not thoroughly explained the underlying mechanisms for increasing acceptance of chatbots and making them more engaging. Don Norman (1994) has argued the main difficulties of utilizing intelligent agents are social—not technical—and particularly center around people’s perceptions of agents. In exploring the use of chatbots in psychotherapy, we must investigate how this technology is conceptually understood, and the thoughts and feelings they evoke when people interact with them. This dissertation focuses on two types of relationships critical to the success of utilizing chatbots for mental health interventions: sociotechnical relationships and therapeutic relationships. A sociotechnical relationship concerns technology adoption, usability, and the compatibility between humans and chatbots. A therapeutic relationship encompasses people’s feelings and attitudes toward a chatbot therapist. Therefore, this dissertation asks: What are the optimal design principles for a conversational agent that facilitates the development of both sociotechnical and therapeutic relationships to help people manage their mental health? To investigate this question, I designed an original conversational system with eight gendered and racially heterogeneous personas, and one neutral robot-like persona. Using a mixed-method approach (online experiment and interviews), I evaluated factors related to the adoption and use of conversational agents for psychotherapeutic purposes. I also unpacked the human-agent relational dynamics and evaluated how anthropomorphism and perceived racial similarity impact people’s perceptions of and interactions with the chatbot. These findings contributed to the wider understanding of conversational AI application in mental health support and provided actionable design recommendations.Item Changing Attachments: The Client-Therapist Relationship and Outcome(2020) Hillman, Justin William; Kivlighan, Jr., Dennis M; Counseling and Personnel Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)From the perspective of attachment theory (Bowlby, 1988), this study examined if client attachment to therapist developed over the course of psychotherapy and if changes in attachment to therapist were associated with treatment outcomes. Clients (N = 112), receiving psychodynamic therapy from trainee therapists (N = 29), completed the Client Attachment to Therapist Scale (Mallinckrodt, Gantt, & Coble, 1995) and the Outcome Questionnaire-45 (Lambert et al., 1996) at baseline and every eighth session. Multilevel linear growth curve analyses showed that secure attachment to therapist increased and avoidant-fearful attachment to therapist decreased. Multilevel linear regression showed that when within-client secure attachment to therapist was higher, subsequent symptoms improved more. Client-level and therapist-level effects were explored. Results suggest that the development of a secure attachment to therapist is important for positive treatment outcomes. Implications for practice and research are discussed.Item PHYSICAL HEALTH IN PSYCHOTHERAPY: AN EXAMINATION OF DISCUSSION AND RESPONSE FROM THERAPIST AND CLIENT PERSPECTIVES(2017) Fuhrmann, Amy Carr; Hoffman, Mary Ann; Counseling and Personnel Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study investigated if and how physical health is discussed in open-ended psychotherapy in a naturalistic setting, including identifying frequency and content of reported physical health issues, in-session responses to these reports, decisions not to report a physical health issue, and relationships with other session variables. Participants were 54 clients and 11 doctoral therapists-in-training engaged in open-ended treatment at a low-fee, community psychotherapy clinic. Data about physical health was collected for each client at intake, and data on report of a physical health issue, characteristics of the report, therapists’ response during the session, decision not to report, working alliance, real relationship, and session evaluation were collected after each session. Data were analyzed using descriptive statistics, mean comparison, and linear regression. Results indicate that while talking about a physical health issue was relatively infrequent, clients had physical health issues that they found distressing. The most common physical health issues discussed were sleep, weight, and pain. Clients were more likely to share issues in session that they rate as more distressing and related to their mental health than those they chose not to share. Clients were three times more likely than therapists to initiate discussion about physical health in session, and issues that were discussed usually came up in the early phase of long-term, open-ended treatment, and were discussed in more than one session. In sessions when a physical health issue was discussed, depth of the discussion varied greatly, but when clients’ understanding of their physical health issue was evolving or unclear, they more consistently talked about the issue in depth. When talking about physical health, therapists reported helping clients draw connections with their mental health through insight, while clients felt therapists focused more on exploration of the issue. Qualities of the discussion about physical health in session related to client-rated working alliance, real relationship, and session evaluation. Implications for training, research and practice are discussed.Item Secrets in Psychotherapy: A Longitudinal Study of Client Concealment and Disclosure(2017) Marks, Ellen Christina; Hill, Clara E.; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study investigated how secrets unfold over the course of therapy in a naturalistic setting, including identifying longitudinal patterns and investigating relationships with other session-level variables. Participants were 39 client and graduate student therapist dyads in open-ended therapy at a community psychotherapy clinic. Data on concealment, disclosure, working alliance, real relationship, and session evaluation were collected after each session. Data were analyzed using Hierarchical Linear Modeling (HLM). Results demonstrated that disclosure and concealment of secrets are relatively infrequent occurrences, with disclosure occurring more often than concealment. Over time, clients became less likely to disclose a secret and less likely to conceal a significant secret. Clients rated the working alliance as lower for sessions where secrets were disclosed, but this relationship was less pronounced when the disclosed secret was viewed as significant. Clients rated session quality as higher for sessions in which they both concealed and disclosed secrets, as well as for sessions in which a preoccupying secret was shared. Clients tended to feel neutral or positive about their disclosures and believe that the disclosure had no change on how they were viewed by their therapist. Implications for practice and research are discussed.Item Client Laughter, Not a Laughing Matter: The Interpersonal Role of Client Laughter in Psychotherapy(2017) Gupta, Shudarshana; Hill, Clara E; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The purpose of this study was to investigate the presence of 5 characteristics (cheerfulness, politeness, reflectiveness, nervousness, and contemptuousness) in client laughter, and to examine the relationship between the presence of these 5 laughter characteristics and client attachment styles as observed in psychotherapy. The primary investigator, and 6 undergraduate students coded 813 laughter episodes, which were nested within 33 clients, nested under 16 therapists, in one psychotherapy clinic. Judges rated the intensity of each laughter episode in terms of the presence of these 5 laughter characteristics. Initial client attachment style was measured using a self-report measure. Laughter occurred on average, in 9 out of 10 sessions, and was rated highest on politeness and reflectiveness, followed by cheerfulness and nervousness, and was rated lowest on contemptuous. Initial attachment style of the clients influenced the characteristic observed in client laughter, throughout therapy. As theorized by Nelson (2012) clients seemed to use laughing to both connect and disconnect with the therapist. Implications for practice and research are discussed.Item Client Concealment and Disclosure of Secrets in Outpatient Psychotherapy(2014) Baumann, Ellen Christina; Hill, Clara E; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study investigated client motivations for concealing versus disclosing secrets in therapy as well as how this negotiation process relates to therapeutic process and outcome. About half of the participants had both revealed a secret and were concealing a secret in therapy. Disclosed secrets were most likely to be related to relationships and were disclosed because the clients felt they could trust their therapists and because they thought they could benefit from sharing the secret. Concealed secrets were most likely to be sexual in nature and to be concealed due to shame or embarrassment. Clients initially experienced comparable levels of negative and positive emotions when they first disclosed their secret. However, over time, their feelings about the disclosure became more positive and less negative. Concealment was negatively related to the real relationship.Item CLIENT ATTACHMENT AS A PREDICTOR OF THERAPIST INTERVENTIONS, THE WORKING ALLIANCE, AND THE REAL RELATIONSHIP IN THE INITIAL, MIDDLE, AND FINAL PHASES OF PSYCHOTHERAPY(2013) Jackson, John Lawrence; Hill, Clara E; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study investigated client attachment style as a predictor of (a) therapist interventions in an early, middle, and late session of psychotherapy; (b) client and therapist post-session ratings of the working alliance over the course of therapy; and (c) client and therapist post-session ratings of the real relationship over the course of therapy. A total of 41 clients and 14 therapists completed measures prior to and throughout open-term courses of psychotherapy ranging from 8 to 106 sessions. Client attachment style was measured using the anxiety and avoidance subscale scores from the Experiences in Close Relationships scale (ECR; Brennan, Clark, & Shaver, 1998). Therapist interventions were coded by trained observers using the Psychotherapy Q-Set (PQS; Jones, 2000). A factor analysis of therapist interventions revealed four factors: Therapist Facilitative Approach (TFA), Therapist Psychodynamic versus Behavioral Interventions (TPB), Therapist Supportive Approach (TSA), and Therapist Process Comments (TPC). Client attachment avoidance was positively associated with Therapist Supportive Approach (TSA), such that therapists were more likely to use directly supportive interventions with clients who endorsed higher levels of attachment avoidance at the outset of therapy. Otherwise, client attachment ratings were not significantly associated to overall levels of therapist interventions or change in therapist interventions over the course of therapy. Neither client attachment anxiety nor avoidance significantly predicted initial levels, mean levels, or patterns of change in client or therapist ratings of the working alliance or the real relationship over the course of psychotherapy. The findings are discussed in the context of findings and methodological differences from other investigations of client attachment, therapist interventions, and client and therapist ratings of the working alliance and the real relationship. Implications for future research and clinical practice are also discussed.Item Earliest Remembered Dreams versus Recent Remembered Dreams(2013) Gupta, Shudarshana; Hill, Clara E; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study is to compare the effects of working with Earliest Remembered Dreams (ERD) of individuals to more recent remembered dreams (RRD). A limited body of research examining the characteristics of ERDs (Bulkeley et al. 2005) suggests that many individuals remember a dream from between the age of 3-12 years, and these dreams very often vivid and intense and therefore might facilitate an exploration of salient aspects of the dreamer's early emotional life. However ERDs have never been compared with RRDs to examine if differences exist in their therapeutic value. Each participant was involved in one session with an ERD and one session with an RRD, using the Hill (1996, 2004) model of dream work. The session outcome of these sessions was compared. The study shows that the ERDs reported were 4 times more likely to be nightmares and 2.6 times more likely to be recurrent dreams when compared to RRDs. In terms of session outcome, working with both ERDs and RRDs were found to be equally effective, however the salience of the dream was a significant predictor of the benefit reported by clients.Item Trainees' Use of Supervision for Clinical Work with Lesbian, Gay, and Bisexual Clients: A Qualitative Study(2010) McGann, Kevin; Hoffman, Mary Ann; Counseling and Personnel Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Most studies considering lesbian, gay, and bisexual (LGB) clients and their therapists have primarily focused on the clients' experience in therapy (Israel, Walther, Gorcheva, & Sulzner, 2007; Liddle, 1996) or on the therapist's experience of the client (Bieschke & Matthews, 1996; Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). However, the role that clinical supervision plays in therapists' development in working with LGB clients is rarely studied. Not enough is known about how supervision is perceived from the perspective of the supervisee who is developing skills in working with LGB clients. The current study examined 12 interviews with randomly selected predoctoral interns at APA-accredited counseling centers around the country, to explore how they made use of the clinical supervision they received for their work with LGB clients. The single previous qualitative investigation of this topic (Burkard, Knox, Hess, & Shultz, 2009) examined interviews with LGB advanced doctoral students. The current study extends the investigation of this topic by interviewing six heterosexual-identified trainees in addition to six trainees who identified as LGB or queer (Q), and by investigating a more geographically heterogeneous sample. The interviews explored various aspects of the supervision experience, including trainees' expectations of their supervisor for supervision of their work with their LGB client, the contributions of trainees and their supervisors to the supervision process, and the impact of supervision on work with the LGB client and other clients. The data were analyzed using Consensual Qualitative Research (CQR; Hill, Knox, Thompson, Williams, Hess, & Ladany, 2005; Hill, Thompson, & Williams, 1997). All participants valued their supervision relationship, and found their supervisors helpful in assisting them in their therapeutic work with their LGB client. Trainees typically experienced their supervisors as multiculturally sensitive, and some felt that their supervisors helped them with LGB-specific interventions and case conceptualizations. Some differences between how heterosexual and LGB-identified trainees used supervision for their work with their LGB clients. All participants reported gains from their supervision experience with their LGB client that positively affected their work with other clients, regardless of these clients' sexual orientation.Item Relation of Efficacy Beliefs and Working Alliance to Psychotherapy Outcomes: A Multilevel Analysis(2007-07-16) Sheu, Hung-Bin; Lent, Robert W.; Counseling and Personnel Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The purpose of the study is to investigate the contributions of several common factor variables to individual psychotherapy outcomes at both individual and dyad levels. Two dyad-level variables (i.e., the working alliance and collective counseling efficacy) were hypothesized to mediate the relation of client individual-level predictors (i.e., coping efficacy, adult attachment, positive and negative affect) to outcomes (i.e., client-rated progress and session quality). The study involved a naturalistic research design in which no variables were manipulated and psychotherapy occurred without alteration. A novel instrument - the Collective Counseling Efficacy Scale (CCES) - was developed to measure the concept of collective counseling efficacy. Data collected from 73 dyads of clients and therapists were analyzed using multilevel structural equation modeling (SEM) techniques. Results of principal axis factoring procedures revealed a 1-factor structure for the CCES, and internal consistency estimates of the total scores were .96 and .93 for clients and therapists, respectively. Based on data from both clients and therapists, intraclass correlations showed that 59% and 34% of the variances of the alliance and collective counseling efficacy, respectively, occurred at the dyad level as opposed to the individual level. To model them as dyad-level factors, 2nd-order intercepts and slopes were created to represent the midpoint and the discrepancy of clients' and therapists' ratings of the two constructs. The alliance and collective counseling efficacy were further integrated by a set of 3rd-order intercept and slope, denoted relational factors. Multilevel SEM analyses provided evidence for the mediating effect of relational factors on the relation of pre-therapy client predictors to post-therapy client-rated outcomes. Specifically, client coping efficacy indirectly predicted client-perceived progress and session quality through the 3rd-order intercept. Also, client coping efficacy (positively) and avoidance attachment (negatively) were indirectly predictive of session quality through the 3rd-order slope. Post-hoc analyses indicated that clients' ratings of the alliance and collective counseling efficacy were significantly higher than those of therapists, and this pattern was positively associated with session quality. In conclusion, the importance of modeling common factor variables at different levels and the inclusion of collective counseling efficacy in psychotherapy research were initially supported by the findings of the study.