Therapist-client Interaction Research Articles

Collaboration with clients to create journal notes: A mixed methods evaluation of a pilot intervention study in a municipality mental health services team

AbstractIntroductionThe purpose of this study was to evaluate an intervention designed to encourage therapists in a municipality mental health services team to collaborate with their clients when writing journal notes. The team was part of a low‐threshold mental health service for children, adolescents and their parents. The therapists offered individual therapeutic sessions with children, adolescents and parents, as well as family sessions. The therapists documented their encounters in the clients' electronic health records.MethodsThe study used a convergent mixed methods design. First, the quality and quantity of documented therapist–client interactions were measured before and after the intervention using the Scale for the Evaluation of Staff‐Patient Interactions in Progress Notes (SESPI). Cross‐tabulation and logistic regression analyses were used to examine potential differences in the recording of therapists' approaches before and after intervention. Second, we explored the therapists' experiences of participating in this project by conducting individual in‐depth interviews. Qualitative interviews were analysed by systematic text condensation. Finally, the quantitative results from assessing the journal notes were contextualised with the qualitative results from the interviews.ResultsThe number of journal notes describing therapist approach and client response increased by 25% points after the intervention. In the interviews, the therapists acknowledged the intervention's relevance to their practice. However, they invited only a limited number of clients to co‐create journal notes. The clients welcomed the invitation.ConclusionCollaborative documentation challenges established journal documentation practices and may strengthen the client's voice. This study provides suggestions for strengthening the intervention in the future full‐scale studies.

Therapist's positive evaluation of children with hearing impairment: A conversation analysis perspective

In speech-language therapy, the evaluation of children with atypical speech embodies the practical expertise of the therapist and the therapeutic goal of facilitating rehabilitation by guiding these children toward more typical speech behaviors. This study aims to provide an interactional explanation of how positive evaluations given by speech therapists are sequentially formatted, constructed, and oriented in therapy practice and what interactional consequences they have on the interpretation and learning of children with hearing impairment. Adopting conversation analysis as a methodology, this empirical study delves into naturally occurring conversations between speech therapists and children with hearing impairment within the context of Chinese speech-language therapy, focusing specifically on instances of positive evaluations in the third-turn position. The analysis reveals a prevalent occurrence of positive evaluations during therapeutic interactions, showcasing a diverse range of formats employed, spanning from explicit to implicit expressions. A fine-grained conversation analysis demonstrates the delicate and intricate nature of therapists’ positive evaluations, in terms of their indexicality (the function of being referential), and sensitivity to local contingencies. Furthermore, these positive evaluations serve as a critical site for displaying the epistemic asymmetry and its negotiation in and through therapist-client interactions. By providing an empirical demonstration of the interactional skill involved in speech-language therapy and advocating for evaluations characterized by clear indexicality and recipient-orientedness, this study contributes to enhancing the efficiency and effectiveness of rehabilitation practices while shedding new light on the atypical interactions involving people with communicative impairments.

Exploring the Counselors and Psychotherapists Perceptions of Therapeutic Errors in the Treatment Room

A therapeutic error as a multifactorial phenomenon in psychotherapy and counseling is an action and behavior that is committed by the therapist and leads to treatment failure or client dissatisfaction with the treatment process. Thus, the treatment method deviates from the intended practical and scientific techniques. To this end, the present study aimed to identify the counselor’s perceptions of therapeutic errors in the treatment room. This qualitative study was conducted using conventional content analysis. The data were collected through in-depth and semi-structured interviews with counselors and psychotropics with at least 3 years of experience in psychotherapy and counseling in various fields. They were selected through purposive sampling in 2021 in Tehran. The data were saturated by interviewing 24 counselors and psychotherapists and analyzed by the content analysis approach. The findings showed that therapeutic errors occur for different reasons and in various forms and involve different aspects of the therapist-client interaction. The most important therapeutic errors were intrapersonal and organizational errors including; treatment errors, lack of practicality of the treatment, the therapist’s errors, mistakes committed due to the treatment space, non-compliance with ethical principles and standards, and not informing the clients. The occurrence of these errors and mistakes in the treatment session leads to the abandonment of the session by clients, negative experiences invoked by treatment sessions, and most importantly damage to clients and a range of negative consequences. The findings of this study can have some implications for understanding various forms of treatment errors, preventing errors in treatment sessions, and avoiding harm to clients in treatment sessions.

Observation of Art Therapy Relationships (OART): An observational tool for the research of therapist-client and client-artwork relationships in art therapy

Theories of art therapy cite the complex triangular relationship of this discipline that includes the therapist-client, client-artwork and therapist-artwork relationships. Yet, despite its importance, this triangular relationship has been insufficiently investigated. In this paper, we describe the development of a tool for the Observation of Art Therapy Relationships (OART) that assesses client-artwork and client-therapist interactions in art therapy based on conceptualizations of Attachment Theory. The development of the OART included three stages: a) An inductive stage in which researchers and experienced art therapists collaborated in defining observable phenomena that may shed light on the nature of the therapist-client and client-artwork relationships; b) A deductive stage, in which the phenomena defined in the inductive stage were incorporated into the structuring of an observational tool. 3. A qualitative examination of the OART in therapeutic settings. Challenges that have arisen and that may indicate the need for further work on the OART are discussed.

Machine-Learning-Based Prediction of Client Distress From Session Recordings.

Natural language processing (NLP) is a subfield of machine learning that may facilitate the evaluation of therapist-client interactions and provide feedback to therapists on client outcomes on a large scale. However, there have been limited studies applying NLP models to client outcome prediction that have (a) used transcripts of therapist-client interactions as direct predictors of client symptom improvement, (b) accounted for contextual linguistic complexities, and (c) used best practices in classical training and test splits in model development. Using 2,630 session recordings from 795 clients and 56 therapists, we developed NLP models that directly predicted client symptoms of a given session based on session recordings of the previous session (Spearman's rho =0.32, p<.001). Our results highlight the potential for NLP models to be implemented in outcome monitoring systems to improve quality of care. We discuss implications for future research and applications.

A Dynamic Autocatalytic Network Model of Therapeutic Change.

Psychotherapy involves the modification of a client’s worldview to reduce distress and enhance well-being. We take a human dynamical systems approach to modeling this process, using Reflexively Autocatalytic foodset-derived (RAF) networks. RAFs have been used to model the self-organization of adaptive networks associated with the origin and early evolution of both biological life, as well as the evolution and development of the kind of cognitive structure necessary for cultural evolution. The RAF approach is applicable in these seemingly disparate cases because it provides a theoretical framework for formally describing under what conditions systems composed of elements that interact and ‘catalyze’ the formation of new elements collectively become integrated wholes. In our application, the elements are mental representations, and the whole is a conceptual network. The initial components—referred to as foodset items—are mental representations that are innate, or were acquired through social learning or individual learning (of pre-existing information). The new elements—referred to as foodset-derived items—are mental representations that result from creative thought (resulting in new information). In clinical psychology, a client’s distress may be due to, or exacerbated by, one or more beliefs that diminish self-esteem. Such beliefs may be formed and sustained through distorted thinking, and the tendency to interpret ambiguous events as confirmation of these beliefs. We view psychotherapy as a creative collaborative process between therapist and client, in which the output is not an artwork or invention but a more well-adapted worldview and approach to life on the part of the client. In this paper, we model a hypothetical albeit representative example of the formation and dissolution of such beliefs over the course of a therapist–client interaction using RAF networks. We show how the therapist is able to elicit this worldview from the client and create a conceptualization of the client’s concerns. We then formally demonstrate four distinct ways in which the therapist is able to facilitate change in the client’s worldview: (1) challenging the client’s negative interpretations of events, (2) providing direct evidence that runs contrary to and counteracts the client’s distressing beliefs, (3) using self-disclosure to provide examples of strategies one can use to diffuse a negative conclusion, and (4) reinforcing the client’s attempts to assimilate such strategies into their own ways of thinking. We then discuss the implications of such an approach to expanding our knowledge of the development of mental health concerns and the trajectory of the therapeutic change.

Multi-label Multi-task Deep Learning for Behavioral Coding.

We propose a methodology for estimating human behaviors in psychotherapy sessions using mutli-label and multi-task learning paradigms. We discuss the problem of behavioral coding in which data of human interactions is the annotated with labels to describe relevant human behaviors of interest. We describe two related, yet distinct, corpora consisting of therapist client interactions in psychotherapy sessions. We experimentally compare the proposed learning approaches for estimating behaviors of interest in these datasets. Specifically, we compare single and multiple label learning approaches, single and multiple task learning approaches, and evaluate the performance of these approaches when incorporating turn context. We demonstrate the prediction performance gains which can be achieved by using the proposed paradigms and discuss the insights these models provide into these complex interactions.

Distributing Agency and Experience in Therapeutic Interaction: Person References in Therapists' Responses to Complaints.

The primary means for psychotherapy interaction is language. Since talk-in-interaction is accomplished and rendered interpretable by the systematic use of linguistic resources, this study focuses on one of the central issues in psychotherapy, namely agency, and the ways in which linguistic resources, person references in particular, are used for constructing different types of agency in psychotherapy interaction. The study investigates therapists' responses to turns where the client complains about a third party. It focuses on the way therapists' responses distribute experience and agency between the therapist and the client by comparing responses formulated with the zero-person (a formulation that lacks a grammatical subject, that is, a reference to the agent) to responses formulated with a second person singular pronoun that refers to the client. The study thus approaches agency as situated, dynamic and interactional: an agent is a social unit whose elements (flexibility and accountability) are distributed in the therapist-client interaction. The data consist of 70 audio-recorded sessions of cognitive psychotherapy and psychoanalysis, and the method of analysis is conversation analysis and interactional linguistics. The main findings are that therapists use the zero-person for two types of responses: affiliating and empathetic responses that distribute the emotional experience between the client and the therapist, and responses that invite clients to interpret their own experiences, thereby distributing control and responsibility to the clients. In contrast, the second person references are used for re-constructing the client's past history. The conclusion is that therapists use the zero-person for both immediate emotional work and interpretative co-work on the client's experiences. The study suggests that therapists' use of the zero-person does not necessarily attribute “weak agency” to the client but instead might strengthen the clients' agency in the sense of control and responsibility in the long term.

How do you feel? Using natural language processing to automatically rate emotion in psychotherapy.

Emotional distress is a common reason for seeking psychotherapy, and sharing emotional material is central to the process of psychotherapy. However, systematic research examining patterns of emotional exchange that occur during psychotherapy sessions is often limited in scale. Traditional methods for identifying emotion in psychotherapy rely on labor-intensive observer ratings, client or therapist ratings obtained before or after sessions, or involve manually extracting ratings of emotion from session transcripts using dictionaries of positive and negative words that do not take the context of a sentence into account. However, recent advances in technology in the area of machine learning algorithms, in particular natural language processing, have made it possible for mental health researchers to identify sentiment, or emotion, in therapist-client interactions on a large scale that would be unattainable with more traditional methods. As an attempt to extend prior findings from Tanana et al. (2016), we compared their previous sentiment model with a common dictionary-based psychotherapy model, LIWC, and a new NLP model, BERT. We used the human ratings from a database of 97,497 utterances from psychotherapy to train the BERT model. Our findings revealed that the unigram sentiment model (kappa = 0.31) outperformed LIWC (kappa = 0.25), and ultimately BERT outperformed both models (kappa = 0.48).

Exploring Culture and Therapeutic Communication: Therapeutic Mode Use by Occupational Therapists in the United States and Singapore.

According to the Intentional Relationship Model, six therapeutic modes characterize client-therapist interactions in occupational therapy: advocating, collaborating, empathizing, encouraging, instructing, and problem solving. However, whether these modes hold across cultural contexts is not clear. To compare therapeutic mode use in occupational therapy interactions in the United States and Singapore. Cross-sectional observational study; questionnaires were collected and compared from two convenience samples of occupational therapists from the United States and Singapore, and results were analyzed using t tests and general linear modeling. Large tertiary hospitals. Occupational therapists were recruited if they had at least 6 mo experience in their clinical specialty. Adult client participants were recruited if they had or planned to have at least three occupational therapy sessions. The therapist version of the Clinical Assessment of Modes (CAM-T) was used to assess occupational therapists' therapeutic mode use in interactions with specific clients. A total of 74 U.S. and 39 Singaporean client-therapist interactions were assessed. U.S. therapists were more likely to use the upper end of the response scale; after we corrected for this, the pattern of mode use was similar in both cultural contexts, with instructing mode used the most. In absolute terms, U.S. therapists used the instructing mode more frequently than Singaporean therapists. Further research should be done to examine the sociocultural factors that affect responses on the CAM-T and mode use. This study is the first to compare therapeutic mode use in different cultural settings. With the globalization of occupational therapy practice, it is important to consider the generalizability of occupational therapy concepts across cultures.

Utilizing multi-user virtual reality to bring clinical therapy into stroke survivors' homes

IntroductionLifespans after the occurrence of a stroke have been lengthening, but most stroke survivors will experience chronic impairment. Directed, repetitive practice may reduce deficits, but clinical access is often limited by a variety of factors, such as transportation. Purpose of the StudyTo introduce a multiuser virtual reality platform that can be used to promote therapist-client interactions when the client is at home. MethodsThe Virtual Environment for Rehabilitative Gaming Exercises encourages exploration of the hand workspace by enabling multiple participants, located remotely and colocated virtually, to interact with the same virtual objects in the shared virtual space. Each user controls an avatar by corresponding movement of his or her own body segments. System performance with stroke survivors was evaluated during longitudinal studies in a laboratory environment and in participants' homes. Active arm movement was tracked throughout therapy sessions for both studies. ResultsStroke survivors achieved considerable arm movement while using the system. Mean voluntary hand displacement, after accounting for trunk displacement, was greater than 350 m per therapy session for the Virtual Environment for Rehabilitative Gaming Exercises system. Compliance for home-based therapy was quite high, with 94% of all scheduled sessions completed. Having multiple players led to longer sessions and more arm movement than when the stroke survivors were trained alone. ConclusionsMultiuser virtual reality offers a relatively inexpensive means of extending clinical therapy into home and enabling family and friends to support rehabilitation efforts, even when physically remote from each other.

Reliability and Validity of the Clinical Assessment of Sub-Optimal Interaction in Outpatient Pediatric Rehabilitation

Externalizing behaviors are prevalent in pediatric and mental health settings and may lead to sub-optimal therapist-client interaction. The Clinical Assessment of Sub-optimal Interaction – Short Form (CASI-SF) evaluates therapist-child interactions that may pose a barrier to the therapeutic relationship. Reliability and validity of the CASI-SF was evaluated in outpatient pediatric rehabilitation. The CASI-SF demonstrated good internal consistency and inter-rater reliability. There was no evidence of differential item functioning, ceiling, or floor effects. Rating scale functioning, dimensionality, item and person fit, and item separation supported structural validity; person separation was low. These findings support the reliability and validity of the CASI-SF.

Linha de pesquisa "delineamento experimental de caso-único em sessões de psicoterapia": decisões metodológicas

&#x0D; O objetivo é o relato da experiência acumulada pelo grupo de pesquisa Metodologias de pesquisa e produção de evidências em Terapia Analítico-comportamental, da Universidade de São Paulo. Os dados de 28 pesquisas desde 2001 foram analisados em aspectos metodológicos. Foram analisados: Criação de sistemas de categorização ou utilização de sistemas de categorização existentes; Unidades de análise; Análise dos dados por frequência, duração e análise sequencial; Delineamentos de pesquisa experimentais, de caso único. As medidas de comportamento de terapeutas alcançaram estabilidade, o que permite comparação entre estudos. As medidas de comportamentos de clientes apontam necessidade de individualizações, mas com modelos nos quais basear. As medidas são predominantemente para comportamentos ocorridos em sessão. Para observarmos tendências de mudança são necessárias várias sessões; três costumam ser insuficientes. A análise dos dados foi feita com base em frequência de ocorrência ou duração. Dados de sequências de comportamentos foram mais informativos de interações entre terapeuta e cliente que possam ser responsáveis por mudanças ocorridas na psicoterapia. Estudos descritivos forneceram a base para alcançar um modelo de pesquisa, o delineamento experimental de caso único como forma promissora de produzir dados mais conclusivos. Este delineamento já foi replicado diversas vezes.

Critical Appraisal of a Research report of Student Perceptions and Understanding of Client-Therapist Interactions within the Inpatient Acute Care Environment: Qualitative Study

The aim of this appraisal was to assess the validity and reliability of this qualitative research report. In general, this qualitative research study shows its appropriateness and credibility. Data collection procedure was seemed unclear but sampling strategy and sample size, data collection time, study group and settings were clearly described. Inductive analytical process was applied during analysis of data. The researchers showed their understanding of data through description of coding and theme based charting. The authors used quotations from different participants to validate their transparency and trustworthiness. The reliability between the data presented and study findings were clearly examined. The summary findings and interpretations were clearly described and presented in qualitative research journal.

Finding a Common Ground: Therapist Responsiveness to Male Clients Who Have Acted Violently Against Their Female Partner

Men in treatment for intimate partner violence (IPV) do often present with problem formulations that do not fit the therapeutic endeavor of personal change and may, therefore, challenge therapists in their effort to build an alliance. However, the therapist's initial contributions are also likely to influence whether the client finds it worthwhile to become involved in a working alliance. In a qualitative study of the in-session interactions between experienced therapists and men in IPV individual therapy, we looked for variations in therapist responsiveness to the client's initial invitations to identify whether and, eventually, how the two parties were able to reach common ground for working together. We studied therapist-client interactions in 20 therapy cases, including 10 completed cases with good outcomes and 10 dropout cases. Two sessions during the early phase of the therapy and the final session were audiotaped and transcribed verbatim. The transcriptions were analyzed following the guidelines of constructivist grounded theory. The analysis revealed three interactional patterns: co-creative exploration, pull-avoid repetitions, and tiptoeing softly around, each of which was associated with a distinctive set of therapist strategies. Clients participating in the co-creative pattern appeared to experience the most successful treatment. Our findings suggest that a model of therapist responses to client invitations is valuable for the conceptualization of the therapeutic alliance during the early sessions of psychotherapy. The findings also highlight the importance of clarifying and expanding upon the client's personal experience with his abuse to form a viable working alliance.

Psychometric properties of the self-efficacy for therapeutic mode use tool in a mixed sample of occupational therapists: a pilot study

Background/A Skills that enable the maintenance of productive relationships with clients are an essential aspect of therapeutic practice and include the use of therapeutic modes appropriate to clients' needs. The therapist requires a certain level of self-efficacy in order to use therapeutic modes in client–therapist interactions. Recently, a tool was developed to assess therapists' self-efficacy in the use of therapeutic modes. The structure of factors within and internal consistency of the self-efficacy for therapeutic mode use tool was examined. Methods Occupational therapists (n=51) from the UK and Iran completed the self-efficacy for therapeutic mode use assessment tool and provided sociodemographic information. The structure of factors was examined using principal component analysis and parallel analysis; internal consistency was assessed using Cronbach's α and inter-item correlation. Results Parallel analysis suggested that the preferred structure has only one factor, explaining 55.2% of data variance. The items' factor loadings ranged between 0.67 and 0.80, and the scale had a Chronbach α of 0.83. Conclusions The sum of the scale scores can be useful in occupational therapy research and audits focusing on self-efficacy in the use of therapeutic modes in practice.

The Impact of Therapists’ Responses to Resistance to Change: A Sequential Analysis of Therapist Client Interactions in Motivational Interviewing

The study aims to examine how therapists trained in motivational interviewing (MI) respond to resistance and whether this has an impact on subsequent client speech. Fifty recorded Motivational Enhancement Therapy sessions were examined using a sequential behavioural coding method for speech. Client counter-change talk formed the baseline for coding and categorizing subsequent therapist speech and the following client speech. Transitional analysis identified the probable occurrence of specific therapist and client utterances at each stage. Following client expressed resistance or counter-change talk, MI consistent therapist utterances were most commonly observed. A moderate to strong predictive relationship was found between MI-consistent therapist speech and subsequent client change talk. A moderate predictive relationship was found between therapist MI-consistent behaviours and client ambivalence. A moderate to strong predictive relationship was found between MI-inconsistent therapist speech and subsequent client counter-change talk and a weak negative predictive relationship was found between MI-inconsistent therapist speech and client expressed ambivalence. In the face of initial expressed resistance to change, MI-consistent therapist speech appears to increase subsequent client utterances regarding intentions to change drinking behaviour.

Exploring verbal assistance used by occupational therapists to improve financial management skills after brain injury: A case study

Cognitive difficulties following a brain injury can impact an individual's capacity to complete activities of daily living (ADLs). Combining metacognitive strategies, such as those parts of the Cognitive Orientation to Daily Occupational Performance (CO-OP) approach and assistive technology for cognition (ATC) can facilitate financial management (Poncet, 2017). The objective of this study was to examine how the COOP approach was implemented by paying attention to the type of verbal assistance (VA) provided by the therapist throughout the intervention and how it affected the participant's process of taking ownership of the CO-OP approach and therefore improving his ability to manage his finances. Case study of a 41-year old man, XC, who suffered a moderate traumatic brain injury (TBI). He participated in 10 individual therapy sessions where he learned to use CO-OP in combination with ATC. Throughout the sessions, an emphasis was placed on his personal goal of managing his grocery expenses. A qualitative analysis of the verbatim of the therapist-client interactions was completed. Two (representative) extracts from sessions 6 (first independent use of CO-OP) and 9 were selected to illustrate how XC established a goal to improve the management of grocery expenses. The quantity and type of VA changed between sessions 6 and 9 (i.e. n = 8 VA to 2). In session 6, the therapist provided several restarting and scaffolding assistances in order for XC to formulate a goal (Le Dorze, 2014). However, in session 9, the therapist only used restarting and explicit advice to support XC in formulating a goal, indicating improvement. This study begins to fill a gap with regards to the use of CO-OP by examining how a therapist assisted an individual with TBI in taking ownership of cognitive strategies for managing expenses. A more in-depth understanding of the use of VA could benefit therapists in their clinical practice.

Empathy, Challenge, and Psychophysiological Activation in Therapist-Client Interaction.

Two central dimensions in psychotherapeutic work are a therapist’s empathy with clients and challenging their judgments. We investigated how they influence psychophysiological responses in the participants. Data were from psychodynamic therapy sessions, 24 sessions from 5 dyads, from which 694 therapist’s interventions were coded. Heart rate and electrodermal activity (EDA) of the participants were used to index emotional arousal. Facial muscle activity (electromyography) was used to index positive and negative emotional facial expressions. Electrophysiological data were analyzed in two time frames: (a) during the therapists’ interventions and (b) across the whole psychotherapy session. Both empathy and challenge had an effect on psychophysiological responses in the participants. Therapists’ empathy decreased clients’ and increased their own EDA across the session. Therapists’ challenge increased their own EDA in response to the interventions, but not across the sessions. Clients, on the other hand, did not respond to challenges during interventions, but challenges tended to increase EDA across a session. Furthermore, there was an interaction effect between empathy and challenge. Heart rate decreased and positive facial expressions increased in sessions where empathy and challenge were coupled, i.e., the amount of both empathy and challenge was either high or low. This suggests that these two variables work together. The results highlight the therapeutic functions and interrelation of empathy and challenge, and in line with the dyadic system theory by Beebe and Lachmann (2002), the systemic linkage between interactional expression and individual regulation of emotion.

CoCAL -- Constructive Conversation Analysis: Applications to Therapeutic Settings (White Paper)

This paper presents theory and practice of Constructive Conversation Analysis, when applied into therapeutic settings—such as psychotherapeutic, counseling and assessment sessions, client-therapist interactions or even client’s written memoirs. In particular, through the individuation of the linguistic construction, it is possible to put in evidence the felicity conditions of the speech act and hence to facilitate the setting itself, e.g., obtaining conversations free from obstacles and misunderstandings. The results of the analysis performed by the linguist let the therapist to assess—or repair—the therapeutic alliance with the client in order to let emerge insights, ‘good hours’, restructurations, more quickly and precisely. Finally, if applied to more case studies, e.g., different clients, it can improve the therapist’s conversational style in the therapeutic interaction as well as the comprehension of clients’ memoirs.