Specific Therapist Research Articles

What does the research tell us about couple and family therapies?

This article overviews for the practicing clinician the research assessing couple and family therapies. Research on couple and family therapies has established the overall efficacy of these forms of intervention as a general grouping, their value both as treatments and parts of treatments in ameliorating a number of disorders and difficulties, and the efficacy of a number of specific therapies aimed at specific difficulties. However, there remain several prominent couple and family therapies that have yet to be assessed through research, and the research has only begun to be able to inform specific therapist decision making. Findings from research assessing family process are cited that can prove useful to therapists.

The correlates of phone‐in frequency, duration and the number of suggesdtions made in live supervision

The relationship between the parameters of live supervisory phone‐ins and particular supervisory and therapy processes were examined in this study. The frequency of phone‐ins and the number of suggestions made by supervisors were associated with specific therapist, supervisor and client behaviours. Less frequent phone‐ins (five or fewer per session) were associated with greater client cooperation, greater supervisor collaboration and, surprisingly, less therapist collaboration with clients. There was also a trend for client cooperation to occur more frequently following phone‐ins in which four or more suggestions were made. The duration of phone‐in events was not significantly associated with the supervisory and therapy processes examined in this study.

Therapist Effects in Three Treatments for Alcohol Problems

Prior research indicates that therapist effects can be sizeable in substanceabusetreatment. Therapist differences were examined within a multisite(N = 1726) randomized trial of three psychosocial treatments for alcoholproblems: twelve-step facilitation (TSF), cognitive-behavioral skillstraining (CBT), and motivational enhancement therapy (MET). Therapists(N = 80) were nested within treatments, selected and trained forexpertise in a specific approach. This report describes: (1) differencesin therapist characteristics across the three treatments; (2) the magnitudeof therapist effects within each treatment; and (3) exploratory analysesof therapist attributes associated with successful outcomes. Therapistcharacteristics differed between TSF and the other two conditions.Significant therapist effects were found in client satisfaction and outcomes,even after covarying for effects of treatment sites and clientbaseline characteristics. Specific therapist attributes were predictive ofclient outcomes. Outlier therapists whose caseloads showed unusuallypoor outcomes accounted for most of the observed effects.

Working with Resistance to Experiencing and Expressing Emotions in Group Therapy

ABSTRACTEmotional insight, is essential in order for therapeutic change to take place. Profound resistances to experiencing expressing, and understanding emotions are present in group members, the group as a whole, and the group therapist. Reasons for the three types of resistances are described. Specific therapist attitudes and therapeutic techniques are suggested to understand and effectively work through resistances at individual, interpersonal, and whole-group levels. Examples are given from an ongoing therapy group to illustrate the processes of understanding and working through resistances. Resistances on the part of the group therapist are identified and their possible effects on the group's resistance are explored.

Treatment manuals in clinical practice

Hickling and Blanchard (1997) [ Behaviour Research and Therapy, 35, 191–203] summarize the results of treating PTSD patients with a highly structured treatment manual. Presenting a ‘clinician's reaction’ they argue for the added value of modifying treatment manuals based on the therapist's clinical experience and claim that manuals do not provide complete treatment of patients' multiple problems. In response, I reiterate that actuarial prediction is usually superior to clinical judgment, address the treatment of co-morbid psychopathology, underscore the importance of specific therapist skills in implementing manual-based treatment, and point out ways in which manual-based treatment can be more flexible and individualized than Hickling and Blanchard imply.

Assessment Interview Processes:

Initial assessment interviews from two brief therapies were compared using both context sensitive and more standard process measures. The clients are treated by the same therapist for post elective abortion distress. One therapy was successful, lasting twelve sessions; the other, failed, therapy was prematurely terminated after six sessions. Outcome was measured by therapist assessment of symptom change and clients' reports of satisfaction. Process measures designed for use in the assessment interview were better predictors of divergent outcomes than were standard therapy process measures. Low therapist activity, client reaction of therapist's floated interpretations, and client dominance of the interaction characterized the failed case assessment interview. The successful case assessment interview revealed a more balanced and reciprocal interaction between client and therapist, including early and specific therapist goal clarification with client agreement and elaboration. The findings are compared with ...

Effects of training in time-limited dynamic psychotherapy: changes in therapist behavior.

Sixteen therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant-observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways.

Research on Therapist Techniques in Brief Individual Therapy

Research on therapist techniques (defined as verbal response modes) in brief individual therapy is reviewed in terms of its implications for practice Four areas are covered: (a) the overall effectiveness of therapist techniques; (b) the effectiveness of the specific therapist techniques of interpretation and self-disclosure; (c) factors moderating the effects of therapist techniques such as individual differences between clients, individual differences between therapists, and the context within therapy; and (d) the importance of therapist and client covert processes. Several conclusions are drawn: (a) which therapist techniques are used in therapy does make a difference; with interpretation and self-disclosure being particularly helpful; (b) therapists should be aware of their intentions in using different interventions; (c) client type and client state seem to predict the effectiveness of different techniques; (d) clients often hide negative reactions; and (e) when therapists are aware of negative client reactions, there may be negative effects on the therapy.

Perceptions of General and Specific Therapist Behaviors

In the process of developing a two-part therapist rating scale, we obtained questionnaire responses from a large sample of subjects who had undergone one of a variety of psychotherapies. Our data support the importance of perceived therapist care as a strong correlate of patient satisfaction, and patients seemed able to discriminate clearly between psychodynamic and cognitive-behavioral therapies. In the first (nonspecific) questionnaire, we derived five dimensions (Care-Concern, Directive-Control, Critical-Confronting, Understanding, and Charisma) from principal-components analyses, with the first two dimensions being relatively independent of each other. A multiple-regression analysis revealed that combined scale scores accounted for 50% of the variance of patient satisfaction ratings, with the Care dimension accounting for most of this effect. In the second questionnaire, data were analyzed from respondents who had undergone therapy with known cognitive-behavioral or psychodynamic therapists; but, in a minority of subjects who were recruited through the media, we depended on detailed descriptive vignettes to allocate them to one or another of these "specific" types of psychotherapy. Six scales emerged, three characterizing cognitive-behavioral therapies (Behavioral Task Orientation, Organization, and Cognitive Focus) and three representing psychodynamic therapies (Transference, Inner Conflict, and Relationship). Subjects' ratings on all scales strongly discriminated between the two broad modalities of therapy, suggesting that patient reports may provide valid measures of therapist styles. We conclude that questionnaires such as the one we are developing may provide economical measures for assessing therapist consistency when comparing different modalities of psychotherapy.

Stress and Coping in Families with Ill or Disabled Children:

Chronic illness or disability of a child is a specific stressor affecting the entire family. To analyze the factors influencing the family's stress response, the ABCX and Double ABCX Models of Family Stress are reviewed. Four factors of the model which are particularly relevant when applied to the experience of the family with a chronically ill or disabled child are discussed: the specific characteristics of the child's disorder, the family's perception of the stressor, the chronicity of the problem, and the social network of the family. Therapists having frequent and intimate contacts with families may benefit from knowledge of the factors of the model to enhance their ability to reduce family stress. Specific therapist roles in reducing stress are respecting the parents' emotional and social needs, interpreting and anticipating medical and developmental events, and facilitating functional adaptation of the child. Health care professionals in pediatrics frequently encounter families under tremendous stress related to serious health problems in a child. The professionals' words and actions, their management of the family and the child, their responses to the parents' behaviors all are potential sources for ameliorating or increasing stress on the family. Professionals who deal with children with chronic disabilities or illnesses, and with their families, must empathize with the experience of parents in the foreign world of medicine and disability, respect the immediacy and gravity of their concern, and tolerate their occasional confusion and irrational behavior. Physical therapists and occupational therapists in pediatrics have both the opportunity and responsibility to enhance the effective coping of parents who struggle to deal with their child's difficulties and the stress their child's problems place on the entire family. To be effective, therapists must understand the factors and processes of family coping. Models which structure family response to stressors and coping efforts have been developed to facilitate analysis of the complex processes. Hill developed the original ABCX model of family stress, which McCubbin and Patterson expanded into the Double ABCX Model of Adaptation, identifying factors affecting a family's adjustment to a severe ongoing stressor (Figure 1). The expanded model includes the family's adjustment to cumulative effects of the stressor after the impact of the original crisis. Both the original ABCX and the expanded Double ABCX models identify variables which account for observed differences among families' adaptations to stressful situations.

Reality creation versus reality confirmation: A process study in marital therapy

Abstract This study examined differences between two specific marital therapist intervention strategies, reflection (reality confirmation) and reframing (reality creation), on husbands' and wives' immediate patterns of relating. Moreover, this study examined marital therapists' choice of either reflection or reframing immediately following different spousal interaction patterns. Two videotapes of 13 marital therapy cases were rated using the Brown-Standridge Marital Therapy Interaction Scale. In all, a total of 628 pre- and postintervention sequences were coded. Reflection was implemented more often following defensive spousal behaviors, while reframing occurred more when spouses appeared openminded. Husbands were rated more responsive to reframing; wife ratings favored reflection.

Therapist and patient factors in the behavioural treatment of phobic patients.

Thirty-five phobic patients were assessed in order to investigate the specific therapist and patient factors operative within treatment. Although the factors were highly correlated, they did distinguish between those patients who benefited differentially from treatment.

Families-at-risk and home-based intervention: A therapist training model

Home-based family therapy programs are designed to provide intensive family intervention for at-risk children and adolescents. However, examination of the literature reveals limited publications about training therapists for this difficult task. The purpose of this paper is to describe a therapist training model based upon a family-as-context approach to crisis intervention. Specific units covered during the course include: family-as-a-system, structural family therapy, family crisis intervention, family assessment and simulation. It is concluded that the effective prevention of placement for at-risk children and adolescents requires both a home-based family treatment program and a specific therapist training model for family intervention.

?Involvement? in cognitive-behavioral therapy with children: Process and its relationship to outcome

The rates of specific therapist and client verbal behaviors were examined within the context of behavioral, cognitive-behavioral, and attention-control interventions with children exhibiting classroom behavior problems. The 27 third- through sixth-grade children were referred by their teachers for participation in a treatment outcome study (Kendall & Braswell, 1982). All subjects were exposed to identical training materials and were seen for 12 50-minute sessions conducted over 7 weeks. All sessions were audiotaped. Seven-minute samples from the beginning, middle, and end of sessions 1, 2, 3, 10, 11, and 12 were scored according to a 13-category coding system. Correlations between these process categories and independent measures of treatment outcome suggested that child and therapist behaviors indicating active, positive “involvement” with the therapy tasks were associated with improvement and maintenance of therapy gains as assessed by teacher ratings of classroom behavior, while there were few significant relationships between the processes categories and the task performance and self-report measures of outcome and maintenance. In addition, in-session behavior was, for the most part, consistent with therapy labels. The importance of involvement in treatment, as a key factor in the quality of treatment, is discussed.

Preferences, expectations, and behaviours in interpersonal interaction

AbstractThis study is concerned with the relationship between expectations and preferences prior to an interaction, and their effects on behaviours enacted during the interaction. Expectations and preferences of therapists regarding several specific therapist's and client's behaviours were assessed prior to a therapy meeting. After that meeting, the therapists described the behaviours that had occurred during the meeting. It was found that the correspondence between expectations and preferences is affected by the amount of control one has over the behaviours. There seems also to be a clear indication that expectations predict the behaviours better than preferences. Still, it should be noted that preferences do predict behaviours, and this relationship, although weak, holds even after the effect of expectations is removed.

Client evaluations of therapeutic processes and outcomes in a university mental health center.

Abstract Evaluations of therapeutic processes and outcomes by clients, therapists, and independent third parties are all important dimensions in an overall system of accountability for a college mental health facility. This study focused on client evaluation. All clients (N = 287) who used mental health services in a large midwestern university during a two-week period completed an evaluative questionnaire. In contrast to previous satisfaction studies that focused on overall satisfaction, this study examined specific therapist and client tasks and their relationship to outcomes. The findings indicate that different types of client evaluation items yield somewhat different results. Those specific evaluation items have varying relationships with overall measures of client satisfaction and problem improvement. The study also pointed to the importance of looking at sex differences in client evaluations of therapy and at differences among therapists in their relative success in working with clients with differing problems. “The Diagnosis of Testicular Torsion,” Bruce E. Haynes, Howard A. Bessen, and Vital E. Haynes. Prompt diagnosis of testicular torsion remains difficult. Since warning symptoms occur in one third of patients and salvage rates correspond to the interval between symptom onset and operation, higher salvage rates should be achievable. Separating torsion from epididymitis is complicated by overlapping ages of peak incidence, shared symptoms, and the need for rapid distinction of the two. Doppler studies (88% accuracy) and nuclear scans (95% accuracy) help confirm the diagnosis, but correct technique is essential, and their use should not delay prompt operation. The diagnosis of epididymitis should be made cautiously in persons younger than the age of 35 years. (Journal of the American Medical Association 1983;249:2522–2527.) “Hepatitis and Jaundice Associated with Measles in Young Adults: An Analysis of 65 Cases,” Dov Gavish, Yosef Kleinman, Abraham Morag, Tova Chajek-Shaul. We analyzed the clinical course of 65 adult patients hospitalized because of measles during the years 1975 and 1981–1982. Liver involvement was found in 80% (52/65) of the patients, five patients had clinical jaundice. The disturbances of liver function tests reached their peak values between days 5 and 10 of the disease. In this study of measles in adulthood we have three observations of unusual interest: (1) hepatitis occurs commonly in the more severely ill patients and it may manifest clinically as jaundice; (2) long-term follow-up (up to seven years) shows a clear tendency to complete resolution of the liver damage; (3) there is a clear correlation between the severity of hepatic involvement and the occurrence of secondary bacterial infections. (Archives of Internal Medicine 1983;143:674–677)

Therapeutic alliance scales: development and relationship to psychotherapy outcome.

The authors describe the development of patient and therapist alliance scales and their application to the therapies of selected patients with good and poor outcomes following brief psychodynamic psychotherapy. They focus on therapist and patient contributions to the attitudinal-affective climate of the therapy rather than on specific therapist techniques. The findings support the value of separating the contributions to the therapeutic alliance made individually by the therapist and the patient. Only the patient's contribution to the therapeutic alliance was predictive of outcome. Patients who developed and maintained positive attitudes toward the therapist and the work of therapy achieved the greatest gains.

Problem Centered Systems Therapy of the Family*

The demands upon clinicians, teachers and researchers in the family therapy field all point to the need for clear descriptions of conceptual orientations and the specifics of the therapy process. The model presented in this article grew out of research and clinical work which led to a shift in focus from specific therapist interventions to the major steps in the overall treatment process. The major stages of Assessment, Contracting, Treatment and Closure each contain a sequence of sub‐steps. Each step is operationally described and has clear objectives which facilitate open collaboration between therapist and family, and provide the family with a problem solving model. The model developed in the context of short term and focused clinical work. It offers a guide for the basic treatment approach to be used by beginners as well as the foundation and infrastructure for the work of advanced therapists.

Field differentiation in inpatient psychotherapy.

Field differentiation was examined as a factor in the treatment of hospitalized patients. After measuring the differentiation of therapists and patients, three categories were established: differentiated (D), undifferentiated (U), and middle (M). It was found that differentiation of the therapist was significantly correlated with outcome as measured by length of stay in the hospital and likelihood of substantial clinical improvement. Further, a trend was manifested toward a correlation between therapist differentiation and likelihood of readmission. In contrast the field differentiation of the patient seemed to have little impact on the outcome variables. While some tendencies were noted with regard to therapist-patient matches according to the differentiation, the numbers were too small to come to any conclusion. The value of assigning specific therapist types to specific clinical populations where success is more likely was emphasized.