Therapist Response Research Articles

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder

Objective: The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists’ understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist’s use of MOTR. Method: The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session. Results: Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition. Conclusions: The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

Patient–therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder

Objective: Although patients and therapists aligning over time on their perceptions of alliance quality is regarded as clinically important, few studies have examined the influence of such dyadic convergence on psychotherapy outcomes. This study tested whether early treatment convergence in patient–therapist alliance ratings was associated with subsequent worry and distress reduction in psychotherapy for generalized anxiety disorder (GAD), and whether treatment type and the dyad members’ initial alliance perceptions moderated these associations. Method: Data derived from a randomized trial for which patients with severe GAD received either 15 sessions of standard cognitive-behavioral therapy (CBT; n = 43) or CBT integrated with motivational interviewing (n = 42). Patients and therapists rated the alliance after each session. Patients rated worry after each session, and their distress multiple times. Results: As predicted, dyadic multilevel modeling revealed that early alliance convergence was associated with greater subsequent worry (p = .03) and distress (p = .01) reduction, and the combination of low initial patient-rated alliance and low convergence was associated with the worst outcome for the distress variable (p = .04). Conclusions: Results suggest that alliance convergence may be an important clinical process that bears on outcome, rendering it an important marker for therapist responsiveness.

You Won't Get Me: Therapist Responses to Patient Impression Management Tactics.

In psychotherapy, therapist and patient influence each other constantly. We aimed to investigate how therapists respond to patient impression management and influence tactics. For 60 videotaped intake interviews, judges rated therapist responses to patient tactics as neutral, desired, or undesired from the patient perspective. Judges rated the therapist responses in 57% as neutral, in 40% as desired, and in 2% as undesired by the patients. The proportions of response outcomes varied across tactics. Therapist responses were unrelated to therapist and patient sex. Therapist experience was related to their responses to the tactic Supplication. Overall, some patient tactics seem to be more challenging for therapists than others. Awareness of such response tendencies can help therapists prepare their reactions to certain patient impression management and influence tactics. Implications for training and research are presented.

Psychiatrists' emotional reactions: Useful for precise diagnosis in adolescence?

Therapist response (countertransference) can be defined as the range of emotions a clinician experiences when interacting with a patient. Previous research has shown that this reaction plays an important role in the establishment of the therapeutic relationship, and that certain psychiatric disorders are systematically related to strong countertransference reactions in clinicians. For this study, 30 videotaped sessions were retrospectively analyzed by one observer using the Therapist Response Questionnaire (TRQ). The authors aimed to investigate the differences in therapist response between an adolescent case group consisting of 19 patients diagnosed with a cluster B personality disorder (PD), and a control group composed of 11 adolescents diagnosed with anorexia nervosa. The PD group scored significantly higher on the hostile/mistreated, helpless/inadequate, disengaged and overwhelmed/disorganized factors. This study adds evidence to the preexisting empirical literature on therapist response in regard to personality disorders and emphasizes the continuing need for recognition of countertransference across all psychotherapy orientations.

Prevalence, job risk factors and coping strategies of Work Related Musculoskeletal Disorders among Physiotherapists

Background: Physiotherapists, despite having good knowledge of work related musculoskeletal disorders, are not immune to it. As literature related to these injuries in Physiotherapy profession in India is scarce, this study aims to investigate prevalence of work related musculoskeletal disorder, job risk factors commonly involved and coping strategies used among Physiotherapist in India.&#x0D; Methods: A semi structured questionnaire adopted from questionnaires used for similar studies around the world was circulated to 314 Physiotherapists. A total of 271 questionnaires were received back with a response rate of 86%. Mean, standard deviation, frequency, percentage and chi square test were used as appropriate for data analysis.&#x0D; Results: Prevalence of work related musculoskeletal disorders was found to be 62.73%. Lower back region was affected the most (65.3%) followed by neck (41.8%) and shoulder (26.5%). As per response of therapists in this study, the most common risk factors were: working in static positions for longer periods (77%), treating large number of patients in single day (68.2%) and bending and twisting back in awkward positions (65.8%).Common coping strategies adopted by respondents were: modifying positions of patient and self (54.1%), adjusting height of treatment surface (47.1%) and selection of techniques that does not aggravate or provoke discomfort (41.8%).&#x0D; Conclusion: This study has identified the prevalence of work related musculoskeletal disorders among Physiotherapists in India and possible risk factors associated with this profession. It has also identified the common coping strategies utilized by therapists. These findings would be significant in modifying risk factors to prevent and/or minimize work related musculoskeletal disorders among physiotherapists.

Matching and accepting assistive technology in multiple sclerosis: A focus group study with people with multiple sclerosis, carers and occupational therapists.

To explore experiences and perceptions of assistive technology, 14 people with multiple sclerosis, 5 carers and 4 occupational therapists participated in focus groups. Transcripts were analysed thematically drawing from illness self-regulation theory. Identified themes are as follows: critical multiple sclerosis events (developing symptoms/disability, delayed diagnosis and coping, public reaction and multiple sclerosis progression to assistive technology), matching assistive technology for continued use (acceptance of multiple sclerosis and assistive technology, realistic expectations, occupational therapist responsiveness, timing is crucial and carers and others) and impact of assistive technology (promoting or losing independence, stigma and embarrassment and redefining the carer). Acceptance and communication among those involved ensures assistive technology matches needs and maximises health and psychosocial outcomes.

Imagery Rescripting and Psychophysical Relations Based on the ImRs-Therapy Concept Used for Test Anxiety: Review and First Experience

Imagery Rescripting (ImRs) is an emotion-focused treatment technique, which was developed for persons suffering from traumatic experiences. ImRs includes imaginary exposure and rescripting alongside cognitive re-structuring. The principle of ImRs is based on the activation of emotions and the structuring of dysfunctional affective-cognitive schemata. ImRs is an effective treatment for PTSD and could be adapted to suit other psychological disorders. The current state of research focuses primarily on the wide range of uses. To date, physiological processes during the imagery rescripting have not been explored. Because of this, together with the cooperation of colleagues at Bar-Ilan University in Israel, we have conducted a pilot study to investigate psychophysiological patterns during ImRS sessions. Specifically, we examine the effectiveness of a targeted 6-session protocol developed for the treatment of test anxiety on a student sample, during which we monitor the sympathetic response of both clients and therapists. First feedback from the participants supports the power of imagery.

Resistance, early engagement and outcome in psychoanalytic psychotherapy of patients with psychosomatic disorders

AbstractBackgroundDifficulties engaging people with psychosomatic disorders in psychotherapy are widely recognised. Such patients are often reluctant to participate in psychotherapy and to consider the contribution of psychological factors to their somatic experience. However, less is known about effective ways to address what is commonly referred to as resistance to psychotherapy among this population.ObjectivesTo study early engagement, client resistance and the impact of therapist response on outcome in treatment of psychosomatic disorders.MethodologyMixed methods were used in a naturalistic longitudinal study of 22 psychotherapeutic treatments of patients with psychosomatic disorders.ResultsPersistence with treatment was associated with better outcome. The extent to which therapists addressed patients’ in‐session distress was associated with persistence with treatment, even when distress was not resolved.DiscussionResults do not allow attribution of causality but indicate that further research investigating therapist recognition of and response to client distress may be important in the development of more effective psychotherapeutic response to people with psychosomatic disorders.

Preparing for community development practice: A Delphi study of Canadian occupational therapists

Increasingly, community development is recognized as an important process for occupational therapy practice. However, occupational therapists working in community development report feeling unprepared. This study aimed to identify the knowledge, skills, and experiences that occupational therapists need for practice in community development. Using the Delphi technique, the researchers developed statements from the Round 1 (n = 8) responses of occupational therapists involved in community development practice or scholarship. Rounds 2 (n = 14) and 3 (n = 12) sought to establish consensus among the occupational therapists on the areas of focus. Participants rated the importance of 64 statements grouped into 11 domains. After three rounds, researchers eliminated six statements by analyzing the median, interquartile range, and percentage of agreement. Participants reached consensus on 58 statements. Many of the competencies identified were relevant to all areas of practice, while others were specific to community development, suggesting a need for specialized education and training in this area. The results provide information that can be used to enhance the preparation of occupational therapists for practice in community development.

Occupational therapy in Australian acute hospitals: A modified practice.

Ongoing changes to health-care funding Australia wide continue to influence how occupational therapists practise in acute hospitals. This study describes the practice challenges experienced by Western Australian acute care occupational therapists. Then, it explores if and how acute care occupational therapists are modifying their practice in response to these practice changes. This study used a qualitative grounded theory approach. Semi-structured interviews were completed with 13 purposively selected acute care occupational therapists from four Western Australian metropolitan hospitals. Data were analysed using a constant comparative method to provide detailed descriptions of acute care occupational therapy practice and to generate theory. Five conceptual categories were developed. The first two addressed practice challenges: pragmatic organisational influences on client care and establishing a professional identity within the multidisciplinary team. Three categories related to therapist responses are as follows: becoming the client advocate, being the facilitator and applying clinical reasoning. Finally, modified practice was identified as the core category which explains the process whereby acute care occupational therapists are ensuring they remain relevant and authentic in the acute care context. Western Australian acute care occupational therapists are practising in a highly complex health context that presents many challenges. They are responding by using a modified form of practice that ensures occupational therapy skills remain relevant within the narrow confines of this health setting.

Assimilation, reflexivity, and therapist responsiveness in group psychotherapy for social phobia: A case study

Objective: This case study examined reflexivity and the assimilation of problematic experiences, especially its progress within and between the Assimilation of Problematic Experiences Scale (APES) Stages 2–3, in group psychotherapy for social phobia. Method: The data consisted of all of one client's turns expressing the two voices of her main problematic experience in 12 sessions, and all replies by the therapist in direct connection to them. The client's utterances were rated on the APES. Results: A detailed analysis of 13 conversational passages revealed that progress in assimilation happened only when the client took a reflexive stance towards her inner experience or outer actions. There were a few instances when she took a reflexive stance, but no progress in assimilation could be noted. A qualitative analysis of three conversational episodes showed how therapist responsiveness facilitated the client's increased reflexivity and progress in assimilation. Conclusions: Reflexivity appears to be a necessary condition for progress in assimilation both at APES Stages 2 and 3, but the model should recognize that reflexivity can appear in diverse forms and at different levels. Therapist responsiveness and sensitivity to the client's assimilation process is crucial for a successful transition from Stage 2 to Stage 3.

Sustainability in a Fragile Ecological Era: A Gestalt Therapist's Response

This article provides a Gestalt therapist's perspective on the ways we can understand individuals' responses to the current ecological crisis and the challenge of sustainability. Some of the underlying assumptions that appear to shape our creative adjustments are insufficient in and of themselves. The author develops aspects of Gestalt therapy theory's radical epistemology, elicited by field theory and the wisdom of the body, as an alternative to the prevailing rationalised and reasoned view that has informed current responses. Hope is maintained that our Gestalt therapy practice may foster novel responses that sustain and nourish our planet and all who inhabit her by: (1) extending the field to include a wider ecology of relational interactions; (2) moving from configuring our ecological problem as a crisis to one of supporting creativity; (3) attending to our sensorial, animating intersubjective bodies rooted in a relational field; (4) fostering a practice of radical inclusion.

Factor structure, reliability, and validity of the Therapist Response Questionnaire.

The aim of this study was to examine the stability of the factor structure and psychometric properties of the Therapist Response Questionnaire (Betan, Heim, Zittel Conklin, & Westen, 2005; Zittel Conklin & Westen, 2003), a clinician report instrument able to measure the clinician's emotional reactions to the patient in psychotherapy. A national sample of psychiatrists and clinical psychologists (N = 332) of psychodynamic and cognitive-behavioral orientation completed the Therapist Response Questionnaire, as well as the Shedler-Westen Assessment Procedure-200 (Westen & Shedler, 1999a, 1999b), to assess personality disorders and level of psychological functioning, regarding a patient currently in their care. They also administered the Symptom Checklist-90-Revised (Derogatis, 1994) to the patients. Exploratory and confirmatory factor analyses revealed 9 distinct countertransference factors that were similar to 8 dimensions identified in the original version of the measure: (a) helpless/inadequate, (b) overwhelmed/disorganized, (c) positive/satisfying, (d) hostile/angry, (e) criticized/devalued, (f) parental/protective, (g) special/overinvolved, (h) sexualized, and (i) disengaged. These scales showed excellent internal consistencies and good validity. They were especially able to capture the quality and intensity of emotional states that therapists experience while treating personality-disordered patients, as well as to better differentiate them; additionally, they tapped into the complexity of clinicians' reactions toward patients experiencing severe psychiatric symptomatology. Results seem to confirm that Therapist Response Questionnaire is a valid and reliable instrument that allows to evaluate patterns of countertransference responses in clinically sensitive and psychometrically robust ways, regardless of therapists' orientations. The clinical and research implications of these findings are addressed.

A developmental perspective on adolescent psychoanalytic psychotherapy. An Italian study with the Adolescent Psychotherapy Q-Set

Introduction: despite large and widely accepted research on effectiveness, most of psychotherapy research has been done with adults; few studies have been published on the process of adolescent psychotherapy, due to the complexity of the subject and the absence of instruments sensitive enough to empirically capture its nuances. Within psychoanalytic framework, a developmental approach is particu-larly helpful in the psychotherapy of adolescents. Objective: the purpose of this study was to investigate the typical features of Italian Adolescence Psychodynamic Psychotherapy and its similarities and differences with other adolescence psycho-therapeutic approaches; We also aimed at analyzing typical therapists’ responses to adolescent patients. Method: 50 italian adolescence psychotherapists filled a brief questionnaire about their clinical expertise, completed the Adolescent Psychothe-rapy Q – Set (APQ) and the Therapist Response Questionnaire (TRQ) in order to describe their “actual” practice with adolescents. Results: therapeutic process is characterized by a priority to helping adolescent make sense of his own experience, it focuses on present relationships and emotions rather than on past. Strong similar-ities with Mentalization Based Therapy, mild and no correlations with Cognitive-Behavioral Therapy and Classical Psychoanalysis respectively were found; towards adolescents therapists generaly display positive and protective countertransference responses. They less frequenlty show negative responses as overprotection, hostility or feeling of overwhelming. Conclusions: APQ and TRQ can provide meaningfull information about adolescent psychotherapy process. Instruments’ improvement (i.e. reviewd items for APQ) and future perspectives are also discussed.

Eating Disorders and Therapist Emotional Responses.

The aims of this study were to identify (a) patterns of clinicians' emotional responses to patients with eating disorders (ED); (b) patient, clinician, and treatment variables associated with therapist emotional responses; and (c) the influence of patient personality on therapist emotional responses. A random national sample of psychodynamic and cognitive-behavioral psychotherapists (N = 149) was asked to examine one patient (>18 years old) with an ED. Clinicians completed the SWAP-200, the Therapist Response Questionnaire, and the Clinical Questionnaire-Eating Disorder Form to provide general information about themselves, patients, and therapies. Results suggested a therapist pattern of emotional response in relation to different ED diagnosis and indicated meaningful influence of therapist experience and patient variables (such as sexual abuse, dissociative symptoms, and self-harm) on therapist emotional reactions. Finally, regression analysis suggested that therapist responses are more related to patient personality than ED symptoms. This study confirms the importance of patient personality in evoking specific therapists' reactions.

Improving the yield of psychotherapy research

Objective: Although the effectiveness of psychotherapy is well documented, little progress has been made in elucidating mechanisms of change. Major impediments to progress are the homogeneity assumptions evident in many psychotherapy studies. Case-specific research strategies avoid treating patients, therapists, and treatments as homogeneous variables and such studies are more successful at elucidating the link between psychotherapy processes and treatment outcome. Method: A case-specific, process-outcome study comprised of 39 patients treated by experienced therapists is presented. We did not focus on a supposedly homogeneous diagnostic group of patients (e.g., depressed patients) or particular manualized brands of therapy. Instead, we identified each patient's particular problems and conflicts (plan formulation) and then determined the degree to which therapists effectively addressed the patient's problems—that is, the degree to which therapists' interventions were compatible with (i.e., responsive to) the patient's plan. Results: Correlations between ratings of therapist responsiveness (plan compatibility of interventions) and a variety of outcome assessments were significant and substantial (accounting on average for 25% of outcome variance). Conclusion: The findings presented here suggest that the extent to which therapists are responsive to their patients' plans is a strong predictor of treatment outcome and of patients feeling positively about their therapy experience.

The responsiveness problem in psychotherapy: A review of proposed solutions.

Therapist responsiveness is defined as therapist behavior being influenced by emerging context. Responsiveness is ubiquitous and creates serious problems for a ballistic, cause–effect understanding of how psychotherapy works. This conceptual literature review examines ways psychotherapy researchers have constructively engaged the responsiveness problem. We note classical approaches to the responsiveness problem and review all available citations of the formulation of the problem by Stiles, Honos-Webb, and Surko (1998, p. 439), focusing on proposed solutions. We identified N = 58 studies that cited the 1998 article and engaged with the responsiveness problem. These along with additional engagements with the responsiveness problem identified by us and by colleagues were reviewed. We distinguished six categories of ways researchers have addressed the responsiveness problem: (a) demonstrating effects of responsiveness, (b) measuring responsiveness quantitatively, (c) describing responsiveness qualitatively, (d) using evaluative measures, (e) developing responsive clinical interventions, and (f) extending responsiveness concepts to related domains. There are ways to engage the responsiveness problem that are scientifically productive. However, appropriately engaging the problem may require some psychotherapy researchers to ask different questions than they have previously asked.

Considering the Role of Physical Therapists Within the Treatment and Rehabilitation of Individuals With Eating Disorders: An International Survey of Expert Clinicians.

Recent research has demonstrated that physical therapy may benefit the physical and mental health of people with eating disorders (EDs). Because this is a new and developing field, this study aimed to investigate the experience, practices and knowledge of international physical therapy experts to inform clinical practice, education and research. An international cross-sectional survey design was undertaken with experienced physical therapists within the field of EDs. Physical therapist responses were analysed with descriptive statistics and thematic analysis as appropriate. Twenty-eight international physical therapists participated. On average, participants had 6.9 years (95% confidence interval: 3.1-10.7, n = 27) of clinical experience working in ED settings and devoted approximately 39.3% (95% confidence interval: 23.8-54.8, n = 27) of their time to treating individuals with EDs. Participants reported that physical therapy interventions have a diverse range of benefits on the physical, mental and disease-specific factors (e.g. binges) in people with EDs. The key role of physical therapists includes improving body awareness, especially during physical activity combined with psycho-education about healthy doses of physical activity. Physical therapists were able to identify a range of barriers and facilitators to physical activity in people with EDs. This paper provides a first step towards understanding the role and value of physical therapists working with individuals with EDs. Copyright © 2015 John Wiley & Sons, Ltd.

Clinicians’ emotional responses and Psychodynamic Diagnostic Manual adult personality disorders: A clinically relevant empirical investigation.

The aim of this study is to explore the relationship between level of personality organization and type of personality disorder as assessed with the categories in the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) and the emotional responses of treating clinicians. We asked 148 Italian clinicians to assess 1 of their adult patients in treatment for personality disorders with the Psychodiagnostic Chart (PDC; Gordon & Bornstein, 2012) and the Personality Diagnostic Prototype (PDP; Gazzillo, Lingiardi, & Del Corno, 2012) and to complete the Therapist Response Questionnaire (TRQ; Betan, Heim, Zittel-Conklin, & Westen, 2005). The patients' level of overall personality pathology was positively associated with helpless and overwhelmed responses in clinicians and negatively associated with positive emotional responses. A parental and disengaged response was associated with the depressive, anxious, and dependent personality disorders; an exclusively parental response with the phobic personality disorder; and a parental and criticized response with narcissistic disorder. Dissociative disorder evoked a helpless and parental response in the treating clinicians whereas somatizing disorder elicited a disengaged reaction. An overwhelmed and disengaged response was associated with sadistic and masochistic personality disorders, with the latter also associated with a parental and hostile/criticized reaction; an exclusively overwhelmed response with psychopathic patients; and a helpless response with paranoid patients. Finally, patients with histrionic personality disorder evoked an overwhelmed and sexualized response in their clinicians whereas there was no specific emotional reaction associated with the schizoid and the obsessive-compulsive disorders. Clinical implications of these findings were discussed.

Knowledge and attitudes of occupational therapists to giving advice on fitness to drive

Introduction A range of medical conditions can affect driving, and health professionals should advise patients accordingly. This study examined the knowledge of occupational therapists, other therapists and psychologists regarding medical standards for driving, their attitudes to advising patients about driving, and barriers to giving that advice. Method A structured questionnaire measured knowledge of medical standards and attitudes to advising patients about driving. Analyses compared responses of occupational therapists with those of other therapists and psychologists. Semi-structured interviews were carried out with therapists and psychologists after they had watched a video-taped clinical consultation with an actor–patient who was unfit to drive. Interviewees, unaware that the study was about driving, were asked how they would advise the patient. Focus groups were held with a range of health professionals to discuss facilitators and barriers to giving driving advice. Results Eighty-two questionnaires were completed. Occupational therapists were most aware of driving guidelines and most likely to advise patients to stop driving ( p &lt; 0.01). A total of 98% of occupational therapists believed they should discuss driving compared with 68% of other therapists and psychologists ( p &lt; 0.01). Therapists were more likely than psychologists to spontaneously raise the issue of driving after viewing the video-consultation. Conclusion Occupational therapists are well placed to expand their role in advising patients about fitness to drive. For this they require additional training and clarification of their role and legal responsibilities.