New Patient-Rated Scale Measures How Well Therapists Communicate

What makes a therapist good at their job? Decades of psychotherapy research suggest that the answer lies not only in the school of therapy a clinician follows, but in the concrete interpersonal behaviors they deploy in the room: how they ask questions, how they hold eye contact, how the tone of their voice softens or firms. A new study published in the journal Trends in Psychology takes this idea seriously enough to measure it, presenting the first Brazilian instrument designed to assess therapist communication skills directly from the patient’s point of view.

The study, conducted by Marcelo Leonel Peluso, Angela Donato Oliva, and Luiz Fellipe Dias da Rocha at the State University of Rio de Janeiro, describes the construction and content validation of the Therapist Communication Skills Inventory – Patient Version, abbreviated in Portuguese as the IHCT-P. Rather than asking therapists to rate themselves or relying on expert observers watching recorded sessions, the instrument puts the evaluation in the hands of the people with the most ecologically valid vantage point: the patients themselves. This choice reflects a growing consensus in the field that patient reports are less biased than therapist self-perceptions or observer judgments, particularly when the goal is to understand the interpersonal fabric of therapy.

The theoretical foundation of the work rests on the concept of social skills, and more specifically communication skills, which psychologists define as the linguistic and paralinguistic behaviors that make clear, positive, and attuned interpersonal relationships possible. The researchers adopt a competence-based view of psychotherapy, one that sees effectiveness not as loyalty to a theoretical tradition but as the therapist’s ability to enact specific, observable interpersonal behaviors that facilitate change. Within this framework, communication skills are not a stylistic flourish; the authors argue they are foundational mechanisms of therapeutic action, tied to the strength of the therapeutic alliance, the expression of empathy, and ultimately to treatment outcomes.

To give the construct a measurable structure, the team organized therapist communication skills into three dimensions. Verbal skills cover the therapist’s choice and structuring of words: asking and answering questions, requesting and providing feedback, opening and closing sessions, and making empathic verbalizations. Non-verbal skills encompass facial expressions, posture, gestures, eye contact, and other bodily cues that signal presence and emotional resonance. Paraverbal skills, the third dimension, involve the features of speech that sit outside the literal content: tone, pace, volume, rhythm, latency, and fluency. These channels are distinct but complementary, and empirical work on clinical communication has consistently treated them as separable yet interacting routes through which therapists convey attunement and intent.

The construction of the inventory began with a narrative review of the literature, drawing on Portuguese and English-language books and articles indexed in SciELO and Google Scholar, searching for concepts linking communication, skills, and therapy while excluding work focused on patient-directed communication or non-clinical settings. From seven reviewed sources, the authors identified recurring skill clusters and translated them into items. The preliminary version of the IHCT-P contained 40 items, with 17 covering verbal skills, 13 covering non-verbal skills, and 10 covering paraverbal skills. Each item then went through internal discussion among the authors regarding clarity, spelling, length, adequacy, and scope before facing external scrutiny.

That scrutiny came in two phases. In the first, five professionals with clinical and empirical expertise in the topic evaluated every item on three criteria: language clarity, practical pertinence, and theoretical relevance, each rated on a five-point scale. The researchers computed a Content Validity Coefficient for each criterion, applying a widely used threshold requiring values above 0.8. The results were strong across the board: 0.945 for practical pertinence, 0.930 for theoretical relevance, and 0.927 for language clarity. Even so, the judges’ comments drove substantial refinement. Three items were cut, fourteen were revised to sharpen clarity and precision, and two new items were added, leaving the instrument with 39 items. For its response format, the judges unanimously favored a five-point Likert scale ranging from ‘it does not apply at all’ to ‘it applies almost all the time.’

The second phase tested whether ordinary people, including those with limited formal education, could actually understand what the items were asking. Thirty adult participants, evenly split between women and men and aged between 19 and 42, with an average age of 28.3, assessed each item for clarity and comprehension rather than answering it. Here the coefficients were even higher: 0.980 for language clarity and 0.981 for comprehension. No items were removed at this stage, though three items fell below a 90 percent approval threshold on the need for change and were reworked in line with participants’ suggestions, while two others were modified based on feedback from both phases. The instrument’s instructions, rated at the maximum for both language and understanding, survived unchanged. The study received ethics approval from the State University of Rio de Janeiro, and informed consent was obtained from all participants.

The authors are candid about the limitations of what they have built. Although the scale was designed to be usable by people with lower educational attainment, the pilot sample was predominantly well-educated, with 63.3 percent holding complete higher education, a mismatch that could limit generalizability. Patient-reported measures also inherit the quirks of the respondent: individuals with personality disorders may struggle to form a stable alliance, coloring their judgments of the therapist’s communication, and the stage of therapy at assessment may shape perceptions. To blunt these biases, the team plans to have at least two patients per therapist complete the questionnaire in future studies, averaging out idiosyncratic views.

Why does this matter beyond psychometrics? The researchers position the IHCT-P as a practical tool with several clinical applications. Therapists can use it for self-assessment by inviting patients to complete it, gaining a window into how their communication actually lands with each individual. Because the instrument itself models a core communication skill, requesting feedback, its use reinforces collaborative empiricism and gives patients a structured, potentially less intimidating channel for critical or negative feedback than face-to-face conversation. In psychotherapy supervision, particularly during clinical internships, the scale can help trainees monitor their own practice and help supervisors spot gaps, while its items can serve as prompts for reflective discussion. It could also anchor intervention studies, since social skills training programs typically require pre- and post-intervention measurement to demonstrate gains.

The work is explicitly a first step rather than a finished product. The authors state that upcoming studies will pursue additional sources of validity evidence under the Standards for Educational and Psychological Testing, including exploratory and confirmatory factor analyses of the internal structure, convergent and divergent validity against established measures of therapeutic alliance and outcomes, and internal consistency and test-retest reliability. They also plan to develop and validate a therapist-report version, enabling comparisons between how therapists see themselves and how patients perceive them. Those studies are already underway, with completion expected within 18 to 24 months. If they succeed, the field will gain something it has long lacked in Brazil: a validated, patient-centered yardstick for one of the quiet but decisive ingredients of effective psychotherapy, the everyday communicative craft of the person in the therapist’s chair.

Subject of Research: Development and content validation of a patient-report psychometric inventory assessing therapists' communication skills in psychotherapy.

Article Title: Therapist’s Communication Skills Inventory – Patient Version: Construction and Content Validity

Article References: Peluso, M. L., Oliva, A. D., & Rocha, L. F. D. D. (2026). Therapist’s Communication Skills Inventory – Patient Version: Construction and Content Validity. Trends in Psychology. https://doi.org/10.1007/s43076-026-00531-w

Image Credits: AI Generated

DOI: 10.1007/s43076-026-00531-w

Keywords: psychotherapy, communication skills, psychometrics, content validity, therapeutic alliance, patient-reported outcomes, test construction, social skills, verbal communication, non-verbal communication, clinical psychology, Brazil