Client outcomes in psychology training clinics have been shown to be generally worse than other outpatient settings. Although this finding has been repeatedly demonstrated, no consensus of cause has emerged in the literature. One possible explanation of such findings may relate to psychotherapist effects, a historically neglected variable that has received increased attention in more recent literature. Among psychotherapist effects researched, competency has emerged as a compelling factor worthy of more research. Given that most growth in competence occurs during graduate training, investigating the relationship between competency and client outcome offers great potential benefit for informing optimal training, nature of client symptom improvement, and a more accurate depiction of differences in psychotherapist effects across training and non-training settings. The purpose of this study was to explore the trajectory of competence development during doctoral training in health services psychology and to investigate the association of trainee competency to the psychotherapy outcomes evidenced by their clients. Practicum evaluations of 36 trainees and outcome data (using the Outcome Questionnaire-45.2) from 244 adult clients were included in analyses. Results of the study suggest there is a positive relationship between cumulative semesters of training and competency scores (rs[118]= .34, p < .001). Notably, there was no significant difference in psychotherapy outcome between low and high trainee competence. The results of the current study, relevant literature and limitations are discussed. Suggestions for future research are proposed.

Client outcome research focuses primarily on three specific aspects of therapy: therapist technique, client behaviors and therapeutic interaction. The term "therapeutic interaction" focuses on the relationship between the counselor and the client, and is often ignored in client outcome research. Counselor specific contributions to the therapeutic process are called therapist characteristics may be an innovative way to assess how counselors' impact clients' outcomes in counseling. For the purposes of this study administering the Five Factor Wellness Evaluation of Lifestyle and the Outcome Questionnaire to master's level student counselors assessed therapist characteristics. The Outcome Questionnaire was administered to clients at a community-counseling clinic at two points and a delta score was calculated to create the variable "client outcome." In order to test the research hypotheses, 70 master's level counseling students completed both the Five Factor Wellness Evaluation of Lifestyle and the Outcome Questionnaire. These scores were then matched with master's level counseling students' client delta scores, which created the dependent variable. The results of the multiple regression analysis indicated no statistically significant relationship; therefore the null hypotheses were accepted as the constructs student counselor wellness and client outcomes were not related. Results of the study were summarized and discussed, limitations of the study were explored and recommendations for future research were proposed.

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This thesis follows the paper-based format and papers one and two have been prepared for submission to Attachment and Human Development and the British Journal of Clinical Psychology, respectively. The relevant submission guidelines are included in the appendices (Appendix A and B).Attachment theory (Bowlby, 1977a) has prompted a wealth of empirical research in its contribution to adult attachment patterns and subsequent psychopathology in mental health (Holmes, 2001; Wallin, 2007). More recently, attachment theory has been proposed as a suitable framework by which to inform the organisation, design and delivery of mental health services (Goodwin, 2003; Seager et al., 2007) but it is unclear what this would look like in practice. Adopting an attachment-informed service model has key implications for individual and service outcomes and the two papers presented in this thesis aim to contribute to research in this area, followed by a critical review of the research, its relevance and future implications. Paper one is a narrative overview of the literature discussing the practice implications of services adopting an attachment-informed framework, and describes how this might be conceptualised in front-line service delivery. Articles reviewed described the influence of attachment theory in predominantly inpatient, secure forensic and/or psychiatric rehabilitation services, and its application within more generic community mental health services was explored. Paper two aimed to investigate the importance of individual attachment and service attachment to client psychopathology, quality of life, service utilisation and service costs in community-based mental health services. The final section, the Critical Review, critiqued the literature review and aimed to place the research within a wider context. This section considers the findings from the research and the limitations of the study, while also highlighting important issues for services, with implications for clinical practice and future research.

Motivational Interviewing (MI) is an evidence-based practice that focuses on working through client ambivalence and increasing clients' motivation to change. The purposes of this study were to investigate the effect that a unique student-based training in MI had on counselor trainees' ability to perform MI, and on client outcomes. This training program consisted of one initial four-hour training session, two hours of follow-up supervision, and formal feedback via MITI 3.0 scores. Counselor-trainee skill was assessed via the MI Knowledge Questionnaire, the Helping Responses questionnaire, and the Motivational Interviewing Treatment Integrity code 3.0. In addition, the following instruments were used to assess client outcomes ; attendance via observation assessments, the Session Summary, the Outcome Questionnaire-45.2, and the Client Satisfaction Questionnaire. The sample consisted of 43 graduate-level counselor trainees in their first or second semesters of practicum and 81 adult clients being seen in a university-based graduate student-training counseling clinic. Participants were purposefully assigned to either a treatment or control group. The counselor trainees in the treatment group received the unique training program, follow-up supervision, and feedback whereas the participants in the control group received a four-hour orientation to the student-training counseling clinic. There were four primary hypotheses proposed for analysis within this study (a) How does a brief training in Motivational Interviewing given to counselor trainees affect their ability to accurately perform MI?, (b) How does a brief training in Motivational Interviewing given to counselor trainees affect client functioning?, (c) How does a brief training in Motivational Interviewing given to counselor trainees affect client adherence?, and (d) How does a brief training in Motivational Interviewing given to counselor trainees affect client satisfaction with treatment? The statistical analysis of these variables yielded significant findings. Specifically, counselor-trainee skill in MI significantly improved in the treatment group as compared to the control group as assessed by the MITI with regard to the following variables: evocation, collaboration, autonomy/support, empathy, direction, MI non-adherent giving information, closed questions, simple reflections, complex reflections, total reflections, global scores, ratio of open questions, ratio of reflections, and ratio of MI adherent behavior. In addition, analysis revealed significant between group differences with client attendance. Specifically, between group-differences suggested that clients in the MI treatment group attended more sessions, missed fewer sessions, and completed therapy more frequently than clients in the control group. Detailed procedures and results as well as implications for the counseling profession and future research are explored within this study.

Mindfulness is a practice that has the potential to help counseling students build a variety of skills that are necessary for clinical efficacy, including therapeutic presence, attunement, empathy, cognitive flexibility, and non-reactivity. However, mindfulness is rarely taught to students in mental health training programs, which makes it an untapped possibility to improve counselor education. Additionally, rarely do researchers explore the role of counselor mindfulness and counselor trauma on clients' perceptions of therapeutic presence. Therefore, the purpose of this study is to explore the effects of a 15-week mindfulness training program for counseling students to understand its effect on client's perceptions of therapeutic presence, counselor state mindfulness development, and counselor trauma symptoms. Participants in this cluster-randomized controlled intervention were masters counseling students currently enrolled in clinical practicum accredited by the Counsel for the Accreditation of Counseling and Related Educational Programs (CACREP). Counselors provided data at three timepoints on their state mindfulness, trauma symptoms, and therapeutic presence. Clients provided data at three timepoints on their perceptions of their counselor's therapeutic presence. We analyzed data through repeated measures ANOVA and two-level longitudinal hierarchical linear models. Implications for counselor education, professional counselor development, and future research are offered and limitations are discussed.