Barriers to Using Immediacy Scale (BUIS)

Abstract

The Barriers to Using Immediacy Scale (BUIS) is a psychometrically validated self-report instrument engineered by Justin W. Hillman, Judith A. Gerstenblith, Greta Jankauskaite, Jonathan J. Mohr, and Clara E. Hill (2023) to assess psychotherapists’ perceived cognitive, affective, and technical impediments to employing immediacy in clinical practice. Grounded in Hill’s (2020) conceptualization of helping skills, immediacy denotes an in-vivo therapeutic technique wherein clinicians openly explore the immediate client–therapist relationship, disclose phenomenological feelings regarding the relational dynamic, or invite client metacommunication regarding relational ruptures. Despite strong empirical support associating relational immediacy with therapeutic alliance strengthening and clinical breakthroughs, clinicians systematically underutilize the skill.

The BUIS was developed across three sequential psychometric studies, refining an initial pool of 50 items through expert consensus review to 45 items, and subsequently isolating 16 items via rigorous exploratory and confirmatory factor analyses. The scale evaluates four empirically and theoretically distinct dimensions: Concerns About Client Reactions, Concerns About Therapist Reactions, Negative Beliefs About Immediacy, and Lack of Skills for Using Immediacy. Confirmatory factor analysis verified an outstanding multidimensional fit (Comparative Fit Index [CFI] = .96, Root Mean Square Error of Approximation [RMSEA] = .05, Standardized Root Mean Square Residual [SRMR] = .05), while bifactor modeling affirmed a robust overarching general barriers factor alongside salient domain-specific variances.

The BUIS exhibits exemplary internal consistency (Cronbach’s α = .87–.89 for the total score) and high 2-to-4-week test-retest stability (total r = .80; subscales ranging from .68 to .86). Construct and incremental validity were substantiated by significant inverse correlations with self-efficacy for immediacy (SEIm) and years of clinical experience, as well as positive correlations with therapist attachment anxiety (measured via the Experiences in Close Relationships scale), which uniquely predicted therapist reaction barriers beyond self-efficacy alone. The instrument provides clinical supervisors, psychotherapy researchers, and educators with an indispensable diagnostic framework for resolving clinician avoidance and optimizing process-oriented clinical training.

Keywords

Barriers to Using Immediacy Scale, Immediacy, Metacommunication, Therapeutic Alliance, Helping Skills, Therapist Self-Efficacy, Therapist Anxiety, Psychotherapy Process, Psychometrics, Clinical Supervision

Authors

The Barriers to Using Immediacy Scale was developed and standardized by a research team at the University of Maryland, College Park:

• Justin W. Hillman, Ph.D. — Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park. ORCID: 0000-0002-7457-0570. Email: [email protected].
• Judith A. Gerstenblith, Ph.D. — Department of Psychology, University of Maryland, College Park. ORCID: 0000-0003-3763-8932.
• Greta Jankauskaite, M.S. — Department of Psychology, University of Maryland, College Park. ORCID: 0000-0003-1120-7536.
• Jonathan J. Mohr, Ph.D. — Department of Psychology, University of Maryland, College Park. ORCID: 0000-0002-3350-5860.
• Clara E. Hill, Ph.D. — Department of Psychology, University of Maryland, College Park. ORCID: 0000-0003-4334-0825.

Correspondence Address: Justin W. Hillman, Ph.D., Department of Counseling, Higher Education, and Special Education, 3115 Benjamin Building, 3942 Campus Drive, University of Maryland, College Park, MD 20742, United States.

Purpose

The primary purpose of the Barriers to Using Immediacy Scale (BUIS) is to provide an empirically grounded, multidimensional diagnostic instrument that elucidates why mental health professionals frequently avoid or struggle to implement immediacy during clinical sessions. In psychotherapy process literature, immediacy—alternatively termed metacommunication, relational communication, or here-and-now processing—is widely regarded as one of the most powerful, high-impact clinical interventions available to practitioners (Hill, 2020; Safran & Muran, 2000). By inviting immediate exploration of the unfolding interpersonal dynamic between client and therapist, immediacy allows dyads to resolve micro-ruptures in the working alliance, dismantle entrenched relational enactments, and model transparent, corrective emotional interactions.

Nevertheless, naturalistic investigations of psychotherapy process repeatedly reveal a striking paradox: despite its documented therapeutic potency, immediacy is employed with astonishing infrequency, typically accounting for less than 1% to 5% of all therapist interventions across major therapeutic orientations. Historically, researchers hypothesized that this clinical reticence was primarily a function of novice status or poor foundational training. However, qualitative inquiries highlighted that even seasoned practitioners often experience visceral dread, acute vulnerability, and apprehension when confronting interpersonal friction in real time. Prior to the construction of the BUIS, clinical researchers lacked a standardized, psychometrically validated tool to dissect the multifaceted nature of this resistance.

In clinical supervision and professional training programs, the BUIS fulfills an essential diagnostic and formative function. Rather than treating a trainee’s reluctance to intervene in the relational present as general noncompliance or generalized incompetence, clinical educators can utilize BUIS subscale profiles to identify precise cognitive-affective bottlenecks. For example, a trainee who scores high on technical skill deficits requires targeted behavioral rehearsal and micro-skills coaching, whereas a trainee elevated on therapist-directed emotional apprehension warrants targeted supervision centered on countertransference, distress tolerance, and personal vulnerability. In the research domain, the BUIS facilitates sophisticated mechanistic investigations into therapist-level variables that moderate treatment outcomes, providing a quantitative bridge between therapist personality characteristics, relational competencies, and the empirical resolution of alliance ruptures.

Psychological Construct

The psychological construct assessed by the BUIS is perceived barriers to using immediacy, defined as the constellation of anticipatory cognitive appraisals, affective anxieties, technical skill deficits, and theoretical belief systems that inhibit or deter a therapist from executing in-vivo relational interventions. Immediacy requires the clinician to move outside the safer, distal role of an objective observer and step into the immediate, mutual vulnerability of the therapeutic dyad. Consequently, barriers to immediacy do not reflect a monolithic construct; rather, the BUIS operationalizes this phenomenon across four distinct yet correlated dimensions:

1. Concerns About Client Reactions

This dimension captures the clinician’s anticipatory catastrophic cognitions regarding how the client will perceive, interpret, and emotionally react to relational metacommunication. Therapists who score high on this subscale harbor profound fears of causing iatrogenic distress or precipitating unilateral premature termination. They perceive immediacy as inherently confrontational, intrusive, or boundary-violating, projecting fragility onto their clients. Core latent fears include the dread that the client will perceive the therapist as unprofessional, feel judged or rejected, experience overwhelming affective destabilization, or develop personal antipathy toward the therapist (e.g., “My clients might not continue therapy if I implement immediacy”, “If I use immediacy, my clients might develop a dislike for me”).

2. Concerns About Therapist Reactions

This subscale assesses the clinician’s self-directed affective distress, perceived vulnerability, and apprehension regarding their own capacity to maintain emotional equilibrium during relational inquiries. Inquiring into the here-and-now relationship frequently exposes the therapist to direct client appraisal, potential criticism, and intense emotional intimacy. Clinicians elevated on this construct struggle with somatic and psychological manifestations of anxiety, reporting intense fears of appearing incompetent, feeling exposed, or having unresolved countertransference conflicts reignited (e.g., “I might feel excessively vulnerable if I use immediacy”, “I might encounter difficulty managing my anxiety if I use immediacy”). This dimension reflects the clinician’s emotional distress tolerance and affective self-regulation capacities.

3. Negative Beliefs About Immediacy

The negative beliefs subscale captures conceptual, theoretical, and philosophical skepticism regarding the clinical utility and legitimacy of relational processing. Therapists scoring high on this dimension view immediacy as non-therapeutic, unnecessary, distracting, or diametrically opposed to their core therapeutic approach. Rather than feeling personally inadequate or fearful, these clinicians rationalize avoidance through pedagogical or philosophical opposition (e.g., “There is no sound justification for employing immediacy”, “The application of immediacy does not align with my theoretical orientation”, “Generally, immediacy is not beneficial for clients”). It reflects an intellectualized devaluation of process-oriented interventions.

4. Lack of Skills for Using Immediacy

This behavioral-technical dimension operationalizes the therapist’s perceived behavioral deficits, procedural unclarity, and lack of specialized operational competence required to execute immediacy interventions effectively. Unlike general communicative skills, immediacy requires sophisticated timing, non-defensive framing, and the agile capacity to navigate emergent affective reactions following the opening inquiry. Clinicians scoring high on this construct report feeling unprepared by their graduate training, lacking structured technical templates, and fearing conversational paralysis immediately following an initial relational intervention (e.g., “I would not know how to proceed with the discussion after initiating immediacy”, “I currently lack the requisite skills to use immediacy in a manner that aids my clients”).

Theoretical Framework

The Barriers to Using Immediacy Scale is rooted in several converging paradigms within clinical psychology, most notably Clara E. Hill’s Helping Skills Model, interpersonal psychotherapy theory, and alliance rupture-repair frameworks.

Hill’s Helping Skills Model and the Three-Stage Paradigm

In Hill’s (2020) seminal Three-Stage Helping Skills Model (Exploration, Insight, and Action), immediacy is categorized as an advanced, high-level intervention nestled within the Insight Stage. According to Hill, while lower-risk interventions (e.g., open questions, reflections of feelings, restatements) allow the therapist to remain an external facilitator of client processing, immediacy demands collaborative exploration of the interpersonal reality occurring within the consulting room. Hill distinguishes between two primary forms of immediacy: therapist-focused immediacy (where the therapist discloses ongoing affective responses toward the client, such as “I am feeling a bit shut out right now”) and dyad-focused immediacy (where the therapist invites the client to process relational dynamics, such as “How is it feeling between us today?”). Because immediacy inherently disrupts defensive conversational routines, Hill posits that clinicians experience heightened cognitive load and psychological risk, rendering them vulnerable to avoidance unless adequately scaffolded.

Interpersonal Theory and Metacommunication

From the perspective of interpersonal psychoanalysis and communication theory (Kiesler, 1996; Sullivan, 1953), human beings continuously engage in reciprocal, nonverbal, and implicit relational maneuvers. In psychotherapy, clients inevitably pull therapists into familiar interpersonal patterns through the process of complementary behavioral pulls (interpersonal enactments). Metacommunication—communication about communication—is the explicit tool utilized to unhook the clinician from these maladaptive enactments. Donald Kiesler posited that when a therapist metacommunicates, they introduce a meta-perspective on the transaction, compelling both parties to examine relational games in real time. However, this disrupts interpersonal homeostasis, inevitably evoking anxiety in both therapist and client. The BUIS draws directly upon this theoretical premise: barriers arise precisely because metacommunication demands the dismantling of interpersonal defenses.

Alliance Ruptures, Attachment Theory, and Countertransference

The contemporary theoretical underpinnings of the BUIS also draw extensively from Safran and Muran’s (2000) relational model of alliance rupture and repair. Safran and Muran demonstrated that therapeutic progress is critically dependent upon identifying and resolving withdrawal and confrontation ruptures. Immediacy is the primary technical vehicle through which therapists invite clients to acknowledge unexpressed disappointment, resentment, or mistrust. When a therapist possesses high levels of attachment anxiety—characterized by hyperactivating strategies, hypervigilance toward interpersonal rejection, and chronic fear of abandonment (Bowlby, 1988)—the prospect of directly inviting client dissatisfaction is perceived as an existential threat. Consequently, attachment-anxious clinicians experience intense internal resistance, manifesting as elevated scores on the Concerns About Client Reactions and Concerns About Therapist Reactions subscales.

Validity

The psychometric evaluation of the BUIS demonstrates strong construct, criterion-related, and incremental validity across multiple independent samples of practicing clinicians and trainees (Hillman et al., 2023).

Criterion-Related and Convergent Validity

The construct validity of the BUIS was initially established by evaluating its associations with therapist self-efficacy. Self-efficacy for immediacy (SEIm) demonstrated robust, statistically significant negative correlations across all four BUIS subscales and the total scale score:

• BUIS-Total and SEIm: Highly negative correlation, indicating that therapists who perceive fewer barriers possess substantially greater confidence in their execution of relational skills.
• BUIS-Lack of Skills exhibited the strongest inverse correlation with SEIm, confirming that procedural confidence strongly buffers against perceived technical incompetence.

Therapist developmental level, measured via cumulative years of clinical practice, revealed significant negative correlations with the BUIS-Total score, BUIS-Concerns About Client Reactions, BUIS-Concerns About Therapist Reactions, and BUIS-Lack of Skills. Seasoned practitioners perceive significantly fewer emotional and behavioral impediments to executing immediacy. Interestingly, years of experience did not significantly correlate with the BUIS-Negative Beliefs subscale, suggesting that theoretical skepticism regarding immediacy is a philosophical stance independent of career longevity.

Theoretical Orientation Differences

Predictive and known-groups validity were underscored by analyzing therapist theoretical orientations. Clinicians identifying with a cognitive-behavioral therapy (CBT) orientation exhibited statistically significant positive associations with the BUIS-Total score, BUIS-Negative Beliefs, and BUIS-Lack of Skills. Because traditional CBT curricula prioritize structured, symptom-focused, didactic, and behavioral change mechanisms over experiential relational dynamics, CBT practitioners report elevated philosophical doubts and less specialized training in here-and-now processing. Conversely, therapists endorsing a psychodynamic orientation exhibited significant negative correlations with both BUIS-Negative Beliefs and BUIS-Lack of Skills, consistent with psychodynamic training’s explicit focus on transference, countertransference, and relational interpretation. No significant associations were observed among humanistic clinicians, who historically value here-and-now encountering but may diverge regarding structured confrontation.

Incremental Validity and Attachment Anxiety

Incremental validity was rigorously evaluated by examining adult attachment dimensions via the Experiences in Close Relationships (ECR) inventory. Therapist attachment anxiety (ECR-Anxiety) demonstrated significant positive bivariate correlations with BUIS-Total (r = .28, p = .02) and BUIS-Concerns About Therapist Reactions (r = .39, p = .001). Crucially, hierarchical multiple regression analyses revealed that after controlling for general self-efficacy for immediacy (SEIm), ECR-Anxiety continued to account for unique, incremental variance in BUIS-Total (partial r = .26, p = .03) and BUIS-Concerns About Therapist Reactions (partial r = .37, p = .002). This demonstrates that therapist-directed emotional apprehension is not merely a manifestation of skill deficit, but is fundamentally driven by therapist-specific interpersonal attachment vulnerabilities.

Reliability

The BUIS exhibits robust psychometric reliability across internal consistency metrics and temporal stability indices across diverse cohorts of mental health professionals.

Internal Consistency

Across the development and validation cohorts reported by Hillman et al. (2023), the BUIS total score demonstrated high internal consistency, with Cronbach’s alpha coefficients consistently ranging between α = .87 and .89. Subscale internal consistencies uniformly demonstrated strong psychometric reliability, satisfying standard clinical and research thresholds (≥ .75 to .85):

• Concerns About Client Reactions: α values ranged from .79 to .83.
• Concerns About Therapist Reactions: α values ranged from .78 to .82.
• Negative Beliefs About Immediacy: α values ranged from .77 to .81.
• Lack of Skills for Using Immediacy: α values ranged from .84 to .88.

Test-Retest Stability

Temporal stability was evaluated across a 2-to-4-week administration interval among practicing clinicians. The test-retest reliability coefficient for the BUIS-Total score was r = .80 (p < .001), demonstrating remarkable stability over time in the absence of targeted educational interventions. Individual subscales exhibited similarly high temporal stability coefficients:

• BUIS-Client Reactions: r = .74 (p < .001)
• BUIS-Therapist Reactions: r = .70 (p < .001)
• BUIS-Negative Beliefs: r = .68 (p < .001)
• BUIS-Lack of Skills: r = .86 (p < .001)

These findings substantiate that perceived barriers reflect enduring cognitive, affective, and behavioral tendencies rather than transient, state-dependent session fatigue.

Factor Analysis

The structural dimensionality of the BUIS was systematically established through a rigorous progression of Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across independent clinical cohorts.

Exploratory Factor Analysis (EFA)

The scale development commenced with an initial item pool of 50 items derived from an extensive literature review and theoretical modeling of therapist reluctance. Content validity evaluations conducted with a panel of psychotherapy process faculty and advanced doctoral researchers reduced the pool to 45 candidate items. An initial EFA utilizing principal axis factoring with promax (oblique) rotation was executed to evaluate the latent factor structure. Stringent psychometric elimination criteria were implemented:

• Items failing to achieve a primary factor loading of at least |.50| were eliminated.
• Items failing to maintain a minimum cross-loading differential of .20 between the primary factor and secondary factors were discarded to ensure conceptual purity.
• Items displaying semantic redundancies or complex, ambiguous language were removed.

This pruning process resulted in a parsimonious, psychometrically pristine 16-item scale, exhibiting an unmistakable four-factor latent architecture accounting for substantial common variance.

Confirmatory Factor Analysis (CFA)

To cross-validate the structural architecture isolated during the EFA phase, CFA was conducted on an independent cohort of practicing and trainee psychotherapists. Evaluating the four-factor correlated model against contemporary structural equation modeling benchmarks (Kline, 2016) demonstrated exceptional model fit:

• Chi-Square: χ²(98) = 190.96, p < .001 (a statistically significant chi-square statistic is standard in sample sizes exceeding N > 200).
• Comparative Fit Index (CFI): .96 (exceeding the rigorous ≥ .95 cut-off for outstanding fit).
• Root Mean Square Error of Approximation (RMSEA): .05 (90% Confidence Interval: [.041, .063]), falling well within the excellent fit boundary (≤ .06).
• Standardized Root Mean Square Residual (SRMR): .05 (well below the ≤ .08 conservative threshold).

Higher-Order and Bifactor Modeling

Because the four subscales demonstrated moderate intercorrelations, Hillman et al. (2023) examined competing structural models, specifically testing a second-order hierarchical model and a bifactor model. Both models yielded acceptable goodness-of-fit indices. Analysis of the Item Explained Common Variance (I-ECV) established that the BUIS is a genuinely multidimensional instrument characterized by a strong, unifying general factor (representing generalized resistance to relational confrontation) alongside robust specific factors that capture unique, non-redundant variance across the four domains. Researchers and supervisors are thus empirically justified in interpreting both the aggregate total score and the distinct profile of subscale scores.

Instrument / Measurement Tool

The operational specifications of the Barriers to Using Immediacy Scale (BUIS) are summarized below:

• Test Type: Standardized self-report inventory / psychological rating scale.
• Target Population: Psychotherapy practitioners, clinical and counseling psychologists, licensed professional counselors, clinical social workers, marriage and family therapists, and mental health trainees (adulthood, 18 years and older).
• Item Count: 16 items.
• Response Scale: 5-point Likert-type scale ranging from 1 to 5:
  • 1 = Strongly disagree
  • 2 = Disagree
  • 3 = Neutral
  • 4 = Agree
  • 5 = Strongly agree
• Subscale Composition (4 items per dimension):
  • Concerns About Client Reactions: Items 1, 4, 9, 12.
  • Concerns About Therapist Reactions: Items 3, 5, 8, 15.
  • Negative Beliefs About Immediacy: Items 2, 7, 11, 13.
  • Lack of Skills for Using Immediacy: Items 6, 10, 14, 16.
• Scoring Procedure:
  • All items are keyed in a positive direction (no reverse-scored items).
  • Subscale scores are derived by calculating the arithmetic mean of the 4 items within each respective domain (score range: 1.00 to 5.00).
  • The BUIS-Total score is computed by calculating the arithmetic mean across all 16 items (or summing all items, range: 16 to 80; mean score range: 1.00 to 5.00).
  • Higher scores uniformly indicate a greater magnitude of perceived barriers, apprehension, theoretical skepticism, or technical avoidance regarding immediacy.
• Administration Time: Approximately 3 to 5 minutes.

Permissions & Fee and Test Year

The Barriers to Using Immediacy Scale (BUIS) was developed, standardized, and published in 2023 by Justin W. Hillman, Judith A. Gerstenblith, Greta Jankauskaite, Jonathan J. Mohr, and Clara E. Hill.

• Copyright & Permissions: The instrument is copyrighted by the American Psychological Association (APA). However, the original authors have explicitly granted permission for clinicians, educators, and academic researchers to utilize, reproduce, and administer the BUIS for research and pedagogical/supervisory purposes without prior individual communication or payment of licensing fees, provided proper APA academic citation is maintained.
• Commercial Status: Non-commercial instrument.
• Fee: Free of charge ($0.00) for research and non-profit educational applications.

References

• Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. Basic Books.
• Hill, C. E. (2020). Helping skills: Facilitating exploration, insight, and action (5th ed.). American Psychological Association. https://doi.org/10.1037/0000147-000
• Hillman, J. W., Gerstenblith, J. A., Jankauskaite, G., Mohr, J. J., & Hill, C. E. (2023). Development and validation of the Barriers to Using Immediacy Scale (BUIS). Journal of Counseling Psychology, 70(5), 571–583. https://doi.org/10.1037/cou0000685
• Kiesler, D. J. (1996). Contemporary interpersonal theory and research: Personality, psychopathology, and psychotherapy. John Wiley & Sons.
• Kline, R. B. (2016). Principles and practice of structural equation modeling (4th ed.). Guilford Press.
• Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press.
• Sullivan, H. S. (1953). The interpersonal theory of psychiatry. W. W. Norton & Company.

13. Items of the Scale (Questionnaire)