Client Presenting Research Articles

Differentiating authentic versus pseudo vulnerability in therapeutic practice.

The importance of empathy and attuned care as key ingredients in therapeutic healing has been widely recognized. However, empathy that is delivered in ways that are misaligned with the client's clinical presentation and emotional states or 'modes' can have the opposite effect, reinforcing unhelpful coping patterns, and hindering recovery. In this theoretical development paper, it is proposed that 'pseudo vulnerability' is an important yet overlooked source of therapeutic impasses, often resulting in unremitting clinical problems, and poor clinical outcomes. A range of commonly occurring pseudo vulnerable presentations are described, including Complaining Protector, Attention/Recognition Seeking, and Self-Pity/Victim, with the addition of a new mode Helpless Surrenderer. Guidance on differentiating pseudo vulnerable modes from each other and from the authentic Vulnerable Child mode are delineated via characteristic clinical presentations and typical therapist countertransference reactions. Methods for managing pseudo vulnerability to facilitate access to underlying authentic vulnerability are described.

Eating disorder mental health literacy: A national survey of clinical social workers in the United States

Summary Social workers’ eating disorder mental health literacy (ED-MHL) is essential to the detection, assessment, and treatment of eating disorders (EDs) and disordered eating (DE) in clinical practice. This study explored social workers’ ED-MHL, particularly the assessment practices of EDs on intake forms, and within the first two therapy sessions. Participants in this national survey were N = 316 outpatient masters-level social workers in the United States. Participants completed an online survey measuring ED assessment practices in clinical practice. Findings Results showed that 42.4% ( n = 133) of respondents did not routinely assess for EDs/DE on clinical intake forms, and 53.2% ( n = 165) did not assess within the first two therapy sessions. However, those with recent training related to EDs were more likely to assess. Participants reported low to moderate perceived comfort levels with the assessment of EDs, and training and education were identified as needed resources. Social workers reported deficits in their own assessment practices of EDs. Barriers included: lack of training about EDs/DE; uncertainty about process questions to ask; and perceptions that EDs/DE are rarely the client's primary presenting problem. Applications Difficulties with detection and screening practices appeared contingent on gaps in existing education and training related to EDs/DE. These findings suggest that future research may serve to increase social workers’ ED-MHL, as underscored by the noteworthy finding that 86.1% ( n = 229) of the sample reported that they would make proactive changes in their clinical practice, as a direct result of participating in this study.

Predicting non-initiation of care and dropout in a blended care CBT intervention: Impact of early digital engagement, sociodemographic, and clinical factors.

ObjectiveThis study examines predictors of non-initiation of care and dropout in a blended care CBT intervention, with a focus on early digital engagement and sociodemographic and clinical factors.MethodsThis retrospective cohort analysis included 3566 US-based individuals who presented with clinical levels of anxiety and depression and enrolled in a blended-care CBT (BC-CBT) program. The treatment program consisted of face-to-face therapy sessions via videoconference and provider-assigned digital activities that were personalized to the client's presentation. Multinomial logistic regression and Cox proportional hazard survival analysis were used to identify predictors of an increased likelihood of non-initiation of therapy and dropout.ResultsIndividuals were more likely to cancel and/or no-show to their first therapy session if they were female, did not disclose their ethnicity, reported poor financial status, did not have a college degree, endorsed more presenting issues during the onboarding triage assessment, reported taking antidepressants, and had a longer wait time to their first appointment. Of those who started care, clients were significantly more likely to drop out if they did not complete the digital activities assigned by their provider early in treatment, were female, reported more severe depressive symptoms at baseline, reported taking antidepressants, and did not disclose their ethnicity.ConclusionsVarious sociodemographic and clinical predictors emerged for both non-initiation of care and for dropout, suggesting that clients with these characteristics may benefit from additional attention and support (especially those with poor early digital engagement). Future research areas include targeted mitigation efforts to improve initiation rates and curb dropout.

Understanding and Incorporating God Representations Within Counseling

The religious and spiritual identity of a client may be relevant to the counseling process, and thus counselors should be prepared to integrate these components within treatment. The authors consider the assessment and exploration of God representations (i.e., God images and concepts) to understand and integrate religious and spiritual meanings within the context of a client's presenting concerns. The authors provide examples, strategies, and considerations for how to apply God representations within counseling.

The importance of using reflective practice when working with refugees, asylum seekers and survivors of torture within IAPT

AbstractThere is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

Psychologists' Willingness to Provide Services to Individuals at Risk of Suicide.

This study examined psychologists' willingness to accept a new client into their private practice as a function of the client's clinical presentation (with or without overt suicidality). Psychologists' openness to working with a client at risk of suicide was evaluated in the context of potential barriers to treatment provision, such as practitioners' endorsement of stigmatizing attitudes, concerns over liability and inadequate training, and limited access to community resources. Eighty-six licensed psychologists practicing within the United States were surveyed via e-mail and randomly assigned to one of two conditions, consisting of exposure to a vignette describing either a client reporting current suicidal ideation and a history of attempts or a client without explicitly elevated suicide risk. All participants were asked to complete a questionnaire assessing their likelihood of accepting the hypothetical client into their practice and examining possible explanations for disinclination to provide treatment. Psychologists were less willing to work with a client experiencing suicidality than an individual without elevated suicide risk. Those indicating a reluctance to provide services reported greater concerns over the adequacy of their suicide-related skills and training and fewer resources in the community. Recommendations for improving the responsiveness of private practitioners are provided, with an emphasis on enhancing clinical training and increasing the availability and accessibility of mental health resources.

From You and Me to Us and We

Drawing on a wide body of theory, including work on trauma and art therapy, this paper calls for art therapy to be considered a seminal player in the healing of childhood trauma across a range of service providers. The paper reflects on a therapeutic relationship between a recently graduated art therapist and a 7-year-old Aboriginal primary school boy living in rural Australia. Written from the therapist's point of view, this paper considers the responses of both the client and the therapist, and the transformative nature of this particular therapeutic relationship. The paper focuses on ‘Jannali’ (pseudonym) who was referred to the art therapy programme in the school, as he was distracted, difficult and disruptive in class. Struggling with his identity, his place in the community, his family and his skin, the relationship between the art therapist and Jannali developed through art and play. Reconciliation, not in terms of black and white, but in terms of relationship was a main theme: therapist and client moved from a state of ‘you and me’ to one of ‘us and we’. The paper shows how, through art making and play in a specific therapeutic context, cross-cultural relationships were forged, opening up liminal spaces in which the client's presenting issues and difficulties were both explored and supported and he was able to begin his journey as a learner where previously he was not. These changes also indicate that breaking the transmission of transgenerational trauma and its effects may be possible through art therapy.

Seven Strategies for Treating Christians with Depression

Cognitive Behavioral Therapy for Christian Clients with Depression: A Practical, Tool-Based Primer by Michelle Pearce, West Conshohocken, PA: Templeton Press, 2016. 248 pp. ISBN 978-1-59947-491-5 (paperback), $13.97; ISBN 978-1-59947-492-2 (e-book), $7.69. Michelle Pearce (Ph.D., Yale University) is an assistant professor and clinical psychologist at the Center for Integrative Medicine at the University of Maryland, Baltimore School of Medicine. Her research interests include integrating religion/spirituality into the practice of psychotherapy. Most clinicians are familiar with the effectiveness of Cognitive Behavioral Therapy (CBT), which has been adapted for Christian clients (e.g., Jennings, Davis, Hook, & Worthington, 2013). Pearce offers clinicians a primer integrating CBT with Christian spirituality (CCBT) applied by using seven specific interventions, which she calls treatment tools. Following three introductory chapters, seven chapters explain the treatment tools. Pearce begins by explaining that faith is important to psychotherapy because a religious identity and worldview govern how clients view their life experiences, including the experience of depression. She supports her claim of importance through statistics about the prevalence of depression in the context of the substantial proportion of the U.S. population who identify as Christian. Chapter two introduces assessment. Pearce explains that she and her colleagues learned from experience that not all Christians desire CCBT. Drawing on the work of Kenneth Pargament (1997), she outlines key features of spirituality, which clinicians can include when taking a client's history. Next are suggestions for assessing depression, gaining informed consent, and assessing the possible role of faith in a client's presenting problem. Chapter three completes the set of introductory chapters with guidance on introducing the CCBT model to clients. The model includes physiology with the usual CBT triad (thoughts, feelings, behavior). Following the explanation of the CCBT model, Christian spirituality is introduced by referencing three elements--beliefs, practices, resources. Part II includes the seven chapters describing the treatment tools as is organized using the following repeated subsections: chapters begin with a case study, followed by a discussion of the contribution of a Christian approach, a scientific rationale for using the tool, and Christian elements related to the specific tool (e.g., Scripture). Details on how to use the tool in therapy include activities and a sample clinician-client dialogue. I will provide a brief parenthetical description of the seven tools so you can get a sense of what to expect. I use Pearce's words for these interventions. 1. Renewing your mind: Planting truth (learning to memorize scripture and use prayer to create a positive mindset). 2. Changing your mind: Metanoia (using Christian truths to combat common maladaptive cognitions). 3. Finding God and the blessing in suffering: Redemptive refraining (look for God at work; strategies to reframe suffering). 4. Reaching out and connecting (the importance of social interaction; strategies to connect with supportive others in a faith community). 5. Letting go and letting God: Acceptance and forgiveness (assessment of hurts and resentment, a process of forgiveness and surrender to find intrapersonal freedom). 6. Saying thanks: Gratitude (the value of increasing the expression of gratitude, which can counter some dimensions of depression). 7. Giving back: Service (improve one's mental state through acts of love and kindness). Pearce concludes her text with a summary chapter and recommendations for preventing relapse such as finding ways for clients to practice their CCBT tools, developing hope, and engaging local support. Suggestions for modifying treatment and seeking clergy consultation are also included. Three appendices include: (a) a recommended role for clergy accompanied by a list of signs of depression, (b) a list of religiously integrated manuals and workbooks, and (c) client handouts (e. …

Case Mis‐Conceptualization in Psychological Treatment: An Enduring Clinical Problem

Case conceptualization, an integral component of mental health treatment, aims to facilitate therapeutic gains by formulating a clear picture of a client's psychological presentation. However, despite numerous attempts to improve this clinical activity, it remains unclear how well existing methods achieve their purported purpose. Case formulation is inconsistently defined in the literature and implemented in practice, with many methods varying in complexity, theoretical grounding, and empirical support. In addition, many of the methods demand a precise clinical acumen that is easily influenced by judgmental and inferential errors. These errors occur regardless of clinicians' level of training or amount of clinical experience. Overall, the lack of a consensus definition, a diversity of methods, and susceptibility of clinicians to errors are manifestations of the state of crisis in case conceptualization. This article, the 2nd in a series of 5 on thematic mapping, argues the need for more reliable and valid models of case conceptualization.

Innovative Moments in Humanistic Therapy I: Process and Outcome of Eminent Psychotherapists Working with Bereaved Clients

This project entailed an intensive qualitative analysis of six-session psychotherapies conducted by three eminent humanistic psychotherapists working with bereaved clients. The Innovative Moments Coding System (IMCS), rooted in narrative therapy, is designed to measure change across therapy orientations. Research using the IMCS suggests that the psychotherapy change process occurs through the emergence, elaboration, and expansion of identifiable change moments for a client—innovative moments (IMs)—which present as exceptions to a client's presenting problematic narrative. There are five identified types of IMs: action, reflection, protest, reconceptualization (RC), and performing change (PC). The current study aimed to inform theory regarding the patterns of IMs across three humanistic approaches—constructivist, person-centered, and existential—when working with bereaved clients, while linking these patterns to observable change in each client's functioning. The alliance between each client and therapist was also assessed across the therapy process, showing consistently strong alliances across the three cases. Findings from the current study reinforce the salience of reflection, RC, and PC IMs in successful grief therapy cases, and also suggest the importance of meaning-making interventions in grief therapy. Clinical implications and suggestions for future research are also addressed.

On the Varied and Complex Factors Affecting Gender Diverse People's Vocal Situations: Implications for Clinical Practice

Gender diverse people who do not or do not only identify with the gender category assigned to them at birth may experience various difficulties with their vocal communication. In this paper, I will explore the different needs and expectations with regards to professional voice support in this population and outline the implications for clinical practice. In my discussion, I will draw on an understanding of gender diverse people's vocal situations that is informed by constructionist theories of gender and by changes to the conceptualization of gender diversity included in the seventh version of the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Coleman et al., 2012). This theoretical perspective calls attention to a range of factors voice clinicians need to consider when planning and implementing intervention with gender diverse people. The most important of these factors are the client's subjective gender positioning or identity, the client's preferences for and against treatment options, and the extent to which the different treatment options can be regarded as suitable for developing the client's vocal gender presentation and improving the agreement between how the client wishes to be perceived and addressed in terms of gender and the gender attributions the client receives from others.

Measuring Subtypes of Emotion Regulation: From Broad Behavioural Skills to Idiosyncratic Meaning-making.

The current paper introduces the notion of clinically relevant subtypes of emotion regulation behaviours. A new measure of emotion regulation, the Complexity of Emotional Regulation Scale (CERS), was established as psychometrically sound. It was positively correlated with a measure of emotional awareness (r = 0.28, p < 0.001) and negatively correlated with measures of self-criticism (r = -0.28, p < 0.001) and depression (r = -0.35, p = 0.025), among others. Participants were drawn from two samples: clients from a university counselling centre and a non-clinical student sample. Comparisons were conducted between non-clinical and clinical samples to determine the effects of depression and other symptoms of psychopathology on participant's generation of strategies for emotion regulation. Participants in the clinical sample more often identified an intention to soothe but did not follow through as compared with the non-clinical group, F(1, 198) = 4.662, p < 0.04. Furthermore, individuals in the non-clinical sample were more likely to engage in specific, meaning-making strategies when compared with the clinical group, F(1, 198) = 5.875, p < 0.02. Implications from the current studies suggest the possible applicability of the CERS to clinical settings using an interview rather than questionnaire format. Copyright © 2015 John Wiley & Sons, Ltd. Emotion regulation should be thought of as being on a continuum of complexity, where strategies range from general ('one size fits all') action to specific ('personal and idiosyncratic') meaning. The best emotion regulation strategy depends on a client's presenting difficulty and level of distress.

New Developments for Case Conceptualization in Emotion-Focused Therapy.

Emotion-focused therapy (EFT) has increasingly made use of case conceptualization. The current paper presents a development in the case conceptualization approach of EFT. It takes inspiration from recent research on emotion transformation in EFT. The case conceptualization presented here can guide the therapist in listening to the client's narrative and in observing the client's emotional presentation in sessions. Through observing regularities, the therapist can tentatively determine core emotion schemes' organizations, triggers that bring about the emotional pain, the client's self-treatment that contributes to the pain, the fear of emotional pain that drives avoidance and emotional interruption strategies. The framework recognizes global distress, into which the client falls, as a result of his or her inability to process the underlying pain, the underlying core pain and the unmet needs embedded in it. This conceptual framework then informs therapists as to which self-organizations (compassion and protective anger based) have to be facilitated to respond to the pain and unmet needs, so that they might transform it. The conceptual framework can guide the therapist's thinking/perceptions and actions in the session. Therapists can better facilitate emotional transformation when they understand the dynamics involved in the client's distress. Emotion transformation is facilitated by first helping the client to access the core underlying painful feelings and unmet needs embedded in them and then by helping the client to generate adaptive emotional responses to those unmet needs.

Brukner &amp; Khan's Clinical Sports Medicine

The vision statement of the Canadian Physiotherapy Association is “Canadians are moving, moving more and moving better with the help of physiotherapy.” As physiotherapists rise to the occasion to meet this vision, sport and exercise medicine are becoming more relevant for many clinicians. Previous editions of Brukner & Khan's Clinical Sports Medicine have been considered “the bible of sports medicine,” and this new edition is no exception. The information amassed by an international group of more than 100 experienced and respected physiotherapists, physicians, and scientists makes this authoritative resource a must-have for physiotherapists serving athletes, teams, and active people in the community. This fourth edition of Clinical Sports Medicine has evolved significantly from earlier versions and includes 13 new chapters covering such topics as physical activity promotion, challenging hip pain, hand and finger injuries, medical emergencies in the sporting context, and exercise to treat neurological diseases. Many chapters have undergone major updates, resulting in a clinically relevant and comprehensive book that continues to be a respected guide to the complete medical care of people participating in physical activity and sport. Intended for use by a wide variety of health professionals and trainees, Clinical Sports Medicine adopts a broad, multidisciplinary approach that integrates best evidence and clinically relevant topics. The book is organized into five parts. Part 1, “Fundamental Principles,” provides a great foundation in sport and exercise medicine; biomechanics of sports, injury prevention, and return to sport following rehabilitation are well covered. The chapter on pain science has been significantly revamped, and chapters dedicated to integrating evidence into practice and physical activity promotion for the clinicians are well thought out and valuable additions to this section. Part 2, “Regional Problems,” outlines a symptom-oriented approach to treating sport-related musculoskeletal clinical problems. The physiotherapist can select the chapter that best describes a client's presentation (e.g., shoulder pain, acute ankle injuries) and review the likely differential diagnoses and physical examination and treatment techniques, with a particular emphasis on specific and functional exercise therapy. The emphasis on rehabilitation principles and treatment protocols for specific injuries is a major strength of this book. A notable addition to this section is the chapter on hip-related pain, which clarifies the concept of femoroacetabular impingement and its diagnosis and management. Key guest contributors offer updated approaches to specific “hot topics,” including a fully revamped discussion of neck pain (with Gwen Jull), additional tips on management of tendinopathies (with Jill Cook and others), and a discussion of whether ACL injuries should be managed conservatively or operatively (with Richard Frobell and Liza Arendt). Part 3, “Special Groups of Participants,” covers the expected populations, such as younger and older athletes and athletes with differing abilities. A new chapter on military personnel highlights important differences to consider with this group, such as the special culture of the military environment. Part 4, “Management of Medical Problems,” covers topics ranging from sport cardiology and medical emergencies in sport to managing acute and chronic symptoms with exercise. One chapter in this section offers a quick guide to exercise prescription for specific medical conditions, reinforcing the idea that exercise as medicine is important for every client. Part 5, “Practical Sports Medicine,” includes information not typically included in other sport medicine texts and deals with practical issues such as providing team care, travelling with a team, covering endurance events, and ethics and sport medicine. Readers will appreciate how easy this book is to use. The chapters are logically organized and colour coded, important concepts are reinforced with flow diagrams, and information is organized in tables throughout the chapters. The wealth of illustrations and beautiful artwork make this a very visually appealing resource. Clinical Sports Medicine is also truly a dynamic textbook. The accompanying PIN gives readers 12 months of access to online videos on physical examination, treatment techniques, and injection techniques covered in the text. These “master classes” are an exciting addition to the fourth edition. The companion Web site features podcasts and a blog, and readers can follow a Twitter feed (@CSM4ed) for regular book updates. Overall, this is an incredibly valuable and practical textbook. Its breadth of clinical application and its comprehensiveness make it suitable for seasoned and less experienced practitioners alike, whether treating elite athletes or the athlete within. Dr. John Sutton, who wrote the foreword to the first edition (1993), reproduced in the current edition, put it best: “In Clinical Sports Medicine the authors take sport and exercise medicine out of the realm of the elite athletes and place it fairly and squarely where it belongs—as a subspecialty to serve everyone in the community who wishes to be active” (p. v).1(p.v)

The Im/possibility of Race: Raising Race in Psychotherapy

This paper explores the tension between the ethical and therapeutic imperatives when the possibility of race as a motif in the client's presentation arises in the mind of the psychotherapist. This tension highlights the risk of oppression in speaking and not speaking in which the “floating” nature of race both in definition and in personal identity is revealed as compounding variables. Respect for the dignity of self-determination in relation to the conception of the self emerges to resolve the tension between the ethical and the psychotherapeutic, paving the way for reflective questions for psychotherapists. Copyright © 2013 John Wiley & Sons, Ltd.

Treatment Processes of Counseling for Children in South Sudan: A Multiple n = 1 Design

Studies into treatment processes in low-income settings are grossly lacking, which contributes to the scarcity of evidence-based psychosocial treatment. We conducted multiple n=1 studies, with quantitative outcome indicators (depression-, PTSD- and anxiety- symptoms, hope) and qualitative process indicators (treatment- perceptions, content and progress) measured before, during and after counseling. We aimed to explore commonalities in treatment processes associated with change profiles within and between cases. The study was conducted in South Sudan with children aged between 10 and 15 years. Change profiles were associated with the quality of the counselor-client relationship (instilling trust and hope through self-disclosure, supportive listening and advice giving), level of client activation, and the ability of the counselor to match treatment strategies to the client's problem presentation (trauma- and emotional processing, problem solving, cognitive strategies). With limited time, due to restricted resources in low-income settings, training courses can now be better focused on key treatment processes.

Working with borderline personality disorder: A small‐scale qualitative investigation into community psychiatric nurses' constructs of borderline personality disorder

Borderline personality disorder (BPD) is a complex presentation that can have a significant impact upon the individual and on his or her quality of life. BPD has often been associated with negative connotations (e.g. 'manipulative', 'attention seeking'). The aim of the current study was to gain a fuller understanding of how community psychiatric nurses (CPNs) make sense of the diagnosis of BPD and how their constructs of BPD impact their approach to this client group. Four CPNs, three women and one man, were interviewed using a semi-structured interview schedule. The data were analysed using interpretative phenomenological analysis, to reveal over-arching and sub-themes. The results indicated that participants attempted to ascribe meaning to the client's presentation 'in the moment'. When they had a framework to explain behaviour, participants were more likely to express positive attitudes. When they did not have such a framework, participants could view clients in more pejorative terms. As participants were deriving meaning 'in the moment', there could be fluidity with regards to participants' attitudes, ranging from 'dread' to a 'desire to help'. This could lead to participants shifting between 'connected' and 'disconnected' interactions with clients. The limitations and implications for clinical practise will also be considered.

‘Five‐Session CAT’ Consultancy: Using CAT to Guide Care Planning with People Diagnosed with Personality Disorder within Community Mental Health Teams

There are a number of clients that mental health teams (CMHTs) struggle to help. This group often have some form of personality disorder diagnosis. All workers can experience the client's presentation as challenging and this sometimes results in unhelpful repeated patterns between clients and services. Difficulties for this client group include abrupt state shifting, powerful dynamics, difficult/complex relationships with (often numerous) services, symptoms of dissociation, difficulties with emotional regulation and self abuse. Some people with these difficulties can present to services with a number of factors that mean it is hard to work helpfully with them such as having unstable and chaotic lives, experiencing significant ongoing risks from others and often coping day to day by using a variety of harmful strategies such as self-harm, planning suicide and a significant amount of alcohol and/or drug use. The group of clients who experience these difficulties are often assessed as not being able to benefit from individual psychotherapy in the community. Five-session cognitive analytic therapy (CAT) consultancy has been developed as a method to work jointly with mental health workers and their clients to develop a map to understanding their current difficulties, patterns of coping and to guide care planning. This paper describes the steps of 'five-session CAT' consultancy and the skills involved.

Therapists’ attitudes about and preferences to use Relationship Focused Interventions: New tools to measure a critical component of Functional Analytic Psychotherapy (FAP).

The role of the therapeutic relationship is emphasized as an important factor across several therapies, including newer contextual behavioral therapies such as Functional Analytic Psychotherapy (FAP). FAP exclusively focuses on the use of the therapeutic relationship as a primary mechanism of therapeutic change. FAP requires that therapists assess for and consequate in-session behaviors that are characteristic of the client's presenting problems and approximations of behaviors related to their treatment goals. The focus on in-session behavior and the use of behavioral techniques to consequate in-session behaviors is termed in-vivo (Kohlenberg & Tsai, 1991). In-vivo interventions, briefly defined as the use of moment-to-moment therapy interactions (Kanter et-al., 2009), are believed to be potent therapeutic interventions because they enable therapeutic change to occur more rapidly or enhance the effectiveness of non-FAP related techniques (e.g., cognitive disputation) (Baruch et-al., 2009; Robert J. Kohlenberg, personal communication, March 27, 2007). Currently, there are no published measures of the factors (e.g., beliefs about in-vivo interventions, attitudes about in-vivo interventions) that may promote or inhibit therapists' use of this important class of interventions. The current study was a first step toward improving our understanding of the factors related to therapists' use of in-vivo interventions. For the purposes of the paper, the term Relationship Focused Interventions (RFIs) will be used in place of in-vivo interventions. The term relationship-focused intervention better captures the role of the therapeutic relationship in FAP. Also, invivo interventions are not unique to FAP and practitioners from other therapies may be more amenable to the term Relationship Focused Interventions. Thus, it may help facilitate research on RFIs by practitioners from other theoretical orientations or therapy approaches. Relationship Focused Interventions use the live momentto-moment interactions between the client and the therapist (Kanter et-al., 2009). Maximal behavior change occurs when a reinforcer is delivered close in time and location to the behavior's occurrence; thus, maximal therapeutic change is thought to occur when behaviors are consequated close in time and location to the behavior's occurrence (i.e., in-session behaviors; R. J. Kohlenberg, personal communication, March 27, 2007; cf. Baruch et-al., 2009 for a detailed examination of the empirical literature on basic behavioral principles underlying FAP). Basic behavioral research supports the idea that relationship focused processes are powerful behavior change strategies and many therapies promote the use of these processes (e.g., Beck, Rush, Shaw, & Emery, 1979). Several empirical studies suggest that RFIs are unique to interpersonally-focused therapies and that their addition may improve outcomes. A study of cognitive therapy for depression showed that the occurrence of RFIs was rare (Bolling, Parker, & Kohlenberg, 2000). This result was replicated in a second study that found that the use of RFIs in both behavioral activation and cognitive therapy was rare (Kanter et-al., 2009). A third study (Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002) suggested that the addition of RFIs to therapies that do not typically incorporate them might increase their efficacy. In this study, incorporating RFIs into typical cognitive therapy was related to increased satisfaction with social support and increased improvements in outside relationships. Research from Goldfried and colleagues (Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997; Goldfried, Raue, & Castonguay, 1998; Wiser & Goldfried, 1998) also supports the idea that RFIs can improve therapy outcomes. In a study of expert psychodynamic therapists and cognitive-behavioral therapists, sessions that were identified as having an in-session impact on the client and that resulted in client change were found to have more in-session focus than lower clinically significant sessions (Goldfried, Raue, & Castonguay, 1998). …

How do practising clinicians and students apply newly learned causal information about mental disorders?

New causal theories explaining the aetiology of psychiatric disorders continuously appear in the literature. How might such new information directly impact clinical practice, to the degree that clinicians are aware of it and accept it? We investigated whether expert clinical psychologists and students use new causal information about psychiatric disorders according to rationalist norms in their diagnostic reasoning. Specifically, philosophical and Bayesian analyses suggest that it is rational to draw stronger inferences about the presence of a disorder when a client's presenting symptoms are from disparate locations in a causal theory of the disorder than when they are from proximal locations. In a controlled experiment, we presented experienced clinical psychologists and students with recently published causal theories for different disorders; specifically, these theories proposed how the symptoms of each disorder stem from a root cause. Participants viewed hypothetical clients with presenting proximal or diverse symptoms, and indicated either the likelihood that the client has the disorder, or what additional information they would seek out to help inform a diagnostic decision. Clinicians and students alike showed a strong preference for diverse evidence, over proximal evidence, in making diagnostic judgments and in seeking additional information. They did not show this preference in the control condition, in which they gave their own opinions prior to learning the causal information. These findings suggest that experienced clinical psychologists and students are likely to use newly learned causal knowledge in a normative, rational way in diagnostic reasoning.