Therapist Response Research Articles

Therapist technique and patient defensive functioning in ultra‐brief psychodynamic psychotherapy: a lag sequential analysis

This study examined the association between therapist interventions, including interpretations, and patient defensive functioning. The first session of 32 (n = 32) Brief Psychodynamic Interventions were rated for therapist interventions and patient defensive functioning. Lag sequential analysis was used to determine if (a) there are organized sequences of therapist interventions; (b) there are predictable sequences in the patients' level of defensive functioning; (c) there are sequences of therapist interventions leading to change in the patients' defensive functioning; and (d) there are levels of patient defensive functioning leading to organized therapist response. Results suggested that there are organized sequences in the therapists' interventions and that patient in-session defensive functioning is relatively stable. However, no chain of therapist interventions led to a predictable response in the patients' defensive functioning or vice versa.

Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study.

The purpose of this exploratory study was to identify a broad range of variables that characterize psychotherapists’ perceptions of helpful and unhelpful therapy experiences of lesbian, gay, bisexual, and transgender individuals. In-depth, semistructured interviews were conducted with a diverse sample of 14 psychotherapists to identify such variables and patterns among them. Results suggest that a wide range of variables, including the therapeutic relationship, therapist response to the client’s sexual orientation/ gender identity, type of presenting concern, and the therapy environment, may affect the therapy experiences of this population. The data also suggest that factors such as ethnicity, gender identity, therapy needs, and socioeconomic status should be considered when providing mental health services to this population. Clients dealing with multiple types of marginalization may be particularly challenging for practitioners. Implications for future research and clinical practice are discussed.

First-session pathways to the working alliance in cognitive–behavioral therapy for adolescent depression

In the current study of cognitive‐behavioral therapy for 54 depressed adolescents, chained p‐technique was applied to 14 therapist behaviors that were rated in each 10‐min segment of Session 1 provided by eight female therapists. Four underlying factors were identified: experiential socialization, therapist responsiveness, therapist lapse, and remoralization. Analysis of changes in the prominence of these factors revealed significant Factor X Session Segment trends. Therapist responsiveness and remoralization growth curves across Session 1 accounted for significant variance in Session 3 therapist‐rated alliance. Experiential socialization growth curves across Session 1 also accounted for significant variance in Session 3 adolescent‐rated alliance. Results are discussed in terms of the importance of Session 1 therapist behaviors for adolescent alliance formation.

A Qualitative Study of Intimate Partner Violence Universal Screening by Family Therapy Interns: Implications for Practice, Research, Training, and Supervision

Although a few family therapy researchers and clinicians have urged universal screening for intimate partner violence (IPV), how screening is implemented-and, in particular, client and therapist response to screening-is vaguely defined and largely untested. This qualitative study examined the dilemmas experienced by couples and family therapy interns when implementing universal screening for IPV in an outpatient clinic setting. Twenty-two graduate students in a COAMFTE-accredited program were interviewed using qualitative research methods grounded in phenomenology. Three domains, 7 main themes, and 26 subthemes were identified. The three domains that emerged in this study include (a) therapist practice of universal screening, (b) client response to universal screening, and (c) therapist response to universal screening. Implications for practice, research, training, and supervision are discussed.

Shyness 2: Treating Social Phobia Online: Replication and Extension

In a randomized controlled trial Titov et al. (2008) demonstrated significant benefit from an Internet- and email-based treatment programme for social phobia. The present study (Shyness 2) seeks to replicate that finding and compares results with benchmark data. Eighty-eight individuals with social phobia were randomly assigned to a clinician-assisted computerized cognitive behavioural treatment programme or to a waitlist control group. Participants completed the same treatment programme used in Shyness 1, consisting of six online lessons, cognitive behavioural homework assignments, email contact with a therapist, and participation in an online discussion forum. An intention-to-treat model was used for data analyses. A total of 80% of treatment group participants completed all lessons, and post-treatment data were obtained from 78/81 participants. Treatment group participants each had an average of 127 min of therapist contact over the 10 week programme, including an average of 22 email contacts plus therapist responses to forum postings. Pre- to post-treatment differences were seen between treatment and waitlist participants across two measures of symptoms of social phobia, and across a measure of disability. Mean within- and between-group effect sizes (Cohen's d) across the two primary outcome measures were 1.18, and 1.20, respectively. Quantitative and qualitative data indicate that the procedure is very acceptable to participants. These results closely replicate those obtained in Shyness 1, indicating that the treatment procedure is reliable. These results compare favourably with outcomes reported in benchmarking studies from high-quality face-to-face treatment programmes for social phobia. These results provide further positive data about the utility of Internet-based guided self-help programmes for people with social phobia.

Discussion of Judy Pickles's Case Presentation From the Perspective of Psychoanalytic Specificity Theory

The author discusses Judy Pickles's case presentation against the backdrop of the principles of specificity theory. Psychoanalytic specificity theory reflects the view that the therapeutic process comprises the operation of a unique, complex, reciprocal relational system for each analyst–patient couple. It recognizes that what each therapist distinctively offers a particular patient includes, but also transcends, considerations of both theory and technique. The therapist's responses, which effectively draw on a rich palette of both verbal and nonverbal responsiveness to promote therapeutic effect, are determined by who the therapist is as well as who the patient is in the context of their interaction. Specificity theory calls attention to the importance of improving the therapeutic fit between the analysand's particular therapeutic needs and the analyst's capacity to respond to them, simultaneously appreciating the limitations to optimal responsiveness that inevitably emerge within the specific analytic dyad.

The impact of attachment organization on potential countertransference reactions

This study sought to further examine correlations between attachment characteristics and the quality of the therapeutic relationship and interactions. Responses of medical students and therapists to the presentation of selected segments from adult attachment interviews (AAIs) were investigated. The AAIs of 3 patients were prototypically assigned to an autonomous, a dismissing, and an enmeshed–preoccupied attachment organization. Those parts of the attachment interviews comprising descriptions of the patients’ mother and father were tape-recorded in a standardized manner and presented according to a procedure used by Horowitz, Rosenberg, and Kalehzan (1992). The responses to the interview segments were assessed using the Impact Message Inventory, a well-being scale, and a countertransference questionnaire. In addition, the individuals described their own attachment styles using the Relationship Questionnaire. Results confirmed the hypothesis that the narratives of patients with different attachment organizations release specific responses in terms of interpersonal and countertransference reactions as well as listeners’ well-being. The medical students did not differ largely from the therapists. A systematic influence of listeners’ attachment style on their countertransference reactions could not be found. The results are discussed with respect to future investigations, focusing on the influence of attachment organization on the quality of the therapeutic relationship.

Occupational Therapy Practice Errors in Physical Rehabilitation and Geriatrics Settings: A National Survey Study

The purpose of this survey study was to investigate occupational therapy practice errors in physical rehabilitation and geriatric practice settings. Two hundred and forty-five (245) out of 994 surveyed occupational therapists who have practiced or currently practice in physical rehabilitation or geriatrics settings responded to a self-developed questionnaire. Descriptive statistical analysis was used to describe practice errors as to the types, causes, impact on, and responses of occupational therapists and work sites. Inferential statistical analysis was used to explore the relationships among different variables of interest including: the effect of the number of years of practice experience on the perceived impact of making errors on practice; the relationship between disclosure or nondisclosure of errors; and the types of coping strategies used by occupational therapists and work site administrators' responses to errors. The vast majority of practice errors occurred during the intervention phase of the occupational therapy process. Misjudgment, lack of preparation, and lack of experience were reported as the top three causes of practice errors. Various coping strategies-such as compensating for the errors by voluntarily devoting additional time for care of the patient, making and following a corrective plan, concentrating on the next step, or not letting errors interfere with daily work-were used by the occupational therapists when errors occurred. The types of coping strategies and work site responses appeared to be associated with the disclosure or nondisclosure of errors. Errors occur in occupational therapy practice. Making errors has considerable impact on occupational therapists as well as their future practice. However, disclosure of errors can often lead to positive outcomes.

A typology of narrative impoverishment in schizophrenia: Implications for understanding the processes of establishing and sustaining dialogue in individual psychotherapy

Following from dialogical theories that conceptualize the self as an ongoing series of conversations within and between persons, the authors hypothesize that diminishments in sense of self in schizophrenia could be the result of disruption in the flow of such conversations. In particular, it is asserted that such a disruption could result in at least three forms of disordered selves and resulting impoverished personal narratives: the barren, monological and cacophonous narrative. These phenomena are discussed and subsequently illustrated with case examples that highlight the ways in which each form of narrative impoverishment differently imperils the establishment of a therapeutic relationship. For each of these situations, alternative therapist responses that may lead to better therapeutic outcomes are also offered.

Therapist Response to Clients’ Partner Abuse: Implications for Training and Development of Marriage and Family Therapists

This qualitative study explored ecosystemic influences on therapists' responses to partner abuse. Research questions focus on aspects of personal and professional development of attitudes and belief systems surrounding partner abuse. In-depth interviews with seven therapy trainees indicate that family of origin experiences, clinical experiences, and therapist developmental processes affect values, beliefs, and clinical reactivity to cases involving partner abuse. Implications for therapists' self-work, clinical training, and the process of supervision are addressed.

Grasping the thorn: The impact and supervision of traumatic stress therapy in the South African context

The article examines the usefulness of existing theory for the supervision of clinical trainees at a Johannesburg trauma clinic, a context beset by particular sets of tensions. Concepts that contribute to a practical understanding of how therapists engage with and are affected by trauma clients in South Africa include vicarious traumatisation and countertransference, and the identification of whether therapist responses are evoked by features of the case and the traumatic event or are particular to the individual therapist. Limitations or gaps in existing conceptualisations are identified related to the sociopolitical demands of the context, including questions related to the pairing of client and therapist in terms of race, class and gender features. Factors that interfere with the provision of adequate containment in both supervision and psychotherapy include socioeconomic deprivation, inadequacies in the criminal justice system and the high prevalence of violent crime. Case examples of therapist responses in practice and of supervisory dilemmas are used to illustrate these problems. The article concludes with recommendations for the supervision of traumatic stress psychotherapy in such contexts, including strategies for preparing students for such work, for bringing up sensitive topics for discussion, for managing vicarious traumatisation and for supervisor self-care. Keywords: traumatic stress, psychotherapy, supervision Journal of Psychology in Africa 2005, 15(2): 197–207

Functional Assessment of Skills for Interpersonal Therapists: The FASIT system: For the assessment of therapist behavior for interpersonally-based interventions including Functional Analytic Psychotherapy or FAP-enhanced treatments.

Several contemporary behavior therapies exist that espouse the importance of the therapeutic relationship including Functional Analytic Psychotherapy (FAP), Dialectical Behavior Therapy (DBT), and Acceptance Commitment Therapy (ACT). Each of these therapies has described the importance of focusing on the process of what occurs in session between the client and therapist in an effort to change client behavior. This interpersonal aspect is shared not only by behavior therapies but by numerous other paradigmatically driven interventions. Functional Analytic Psychotherapy posits that the mechanism of clinical change is therapist contingent responding to client problem and improved behaviors in-session. This suggests that the therapists conducting these types of interpersonally-oriented psychotherapies possess a corresponding set of interpersonal skills to be effective. The Functional Assessment of Skills for Interpersonal Therapists (FASIT) manual presents an approach to assessment and classification of behavioral repertoire problems that can prevent effective delivery of interpersonally-oriented psychotherapies such as FAP. The manual begins with a discussion of its purpose, the selection of target therapist behaviors for improvement, therapist self-assessment questions, questions used by the supervisor to assess the therapist, and a discussion of idiographically based tracking devices that can be developed using the FASIT system. The bulk of the FASIT manual presents definitions and examples of particular therapist problems in five domains or classes of interpersonal functioning. These classes include: Assertion of needs; bi-directional communication (providing and receiving feedback); problems with conflict resolution; disclosure skills related to developing interpersonally close relationships; and difficulties with the experience and expression of emotions. There is a repeated emphasis throughout the manual on the purpose of identifying and targeting therapist skills for change. It is highlighted for the reader that therapist skills which directly impact his or her ability to conduct interpersonally-oriented psychotherapies can be reasonable behaviors targeted for change by a supervisor. The FASIT manual provides a basic behavioral approach to assessing these therapist responses in order to assist with the identification, documentation, and amelioration of such problems in the context of supervision and training. Developing more effective interpersonally-oriented psychotherapy therapy skills should continue to be driven by its direct impact on alleviating client distress with these clinical interventions. Key Words: Functional Analysis, Analytic, Psychotherapy, Assessment, Therapist, Skills, Interpersonal, Behavior, Interpersonal, Therapy ********** This system is used to assist therapists in learning interpersonally-based behavioral and cognitive behavioral interventions including Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991) or FAP-enhanced treatments such as FAP Enhanced Cognitive Therapy (FECT; Kohlenberg, Kanter, Bolling, Parker, & Tsai, 2002) and FACT (Callaghan, Gregg, Marx, Kohlenberg, & Gifford, 2004). The Functional Assessment of Skills for Interpersonal Therapists (FASIT; pronounced facet) system is designed to target therapist problem and improved behaviors relevant to effectively conducting FAP. This manual is designed to be used with the Functional Idiographic Assessment Template (FIAT) system (Callaghan, in press). The FIAT manual specifies the classes of behaviors used with the Client Forms (FIAT-C pre and FIAT-C post) and Therapist Forms (FIAT-T pre and FIAT-T post) of the assessment template. The FIAT system is more expansive than this counterpart focusing on therapist skills. However, there are both parallels and important differences between the two systems. There are many similar impersonal skills deficits that can appear with clients and with therapists alike. …

Self-Help: Towards the Next Generation

In the UK, recent guidelines on the treatment of depression and anxiety recommend CBT-based self-help materials as one important component of services. However, despite being based on specific CBT techniques or “empirically grounded interventions”, early optimism has been dented by data from recent studies that have cast doubt on the effectiveness of the current generation of these materials. As a consequence, it may be necessary to consider that other factors may contribute to the overall magnitude of CBT effects. Indeed, it is logically inconsistent to argue that specific factors are pre-eminent in CBT whilst maintaining that delivery via therapists is more likely to be effective than self-help. The contribution of “common factors” that operate in personal therapeutic encounters, for example, therapist responsiveness and the patient-therapist alliance, may be one possible overlooked reason for the reduced ef-fectiveness of self-help materials. The development of the next generation of self-help materials, therefore, may benefit from the testing of materials that combine common and specific factors, including specific measurement of the strength of common factors and their relationship to clinical outcomes. We discuss a model of such common factors and suggest how they could be incorporated into the next generation of CBT based self-help materials.

Continuing Professional Education and the Internet: Views of Alberta Occupational Therapists

Occupational therapists have identified barriers to accessing continuing professional education (CPE) in the traditional face-to-face formats. One alternative to traditional, centrally located, face-to-face CPE is course delivery through the Internet. This study examined Alberta occupational therapists' perceptions of Internet-based CPE. A questionnaire was mailed to 800 randomly sampled Alberta occupational therapists (response rate = 35.5%; n = 281). Respondents pursued CPE to increase skills, knowledge and maintain clinical competency. They reported that a face-to-face CPE course was more useful than distance courses. Although almost 90% of respondents had access to computers with an Internet connection at home or at work, and nearly 65% thought that their computer knowledge was sufficient, only 2.9% had previously taken Internet-based CPE. In order for the Internet to be accepted as a common, useful and alternative delivery tool for CPE in occupational therapy, the perceived barriers such as the lack of personal time, cost, and limited interaction with other learners and instructors will need to be addressed.

Process Differentiation by Space Differentiation in Experiential Psychotherapy / Prozessdifferenzierung durch Raumdifferenzierung in der Experienziellen Psychotherapie / La diferenciación de proceso en función de la diferenciación de espacio en la psicoterapia experiencial / Procesdifferentiatie door ruimtedifferentiatie in experiëntiële psychotherapie

Upon coming into therapy, the client first creates with the therapist a relationship space, within which the reflection space then develops. Reflecting on a felt sense occurs in the focusing space, and explicating it happens in the symbolization space. When new ideas pop up after the session, experiencing symbolizes itself in the self-symbolization space. The spaces imply each other, and can be organized into a scheme. We can differentiate distinct manners of problematic being, e.g. by the way the client enters each consecutive space. The client's manners of being are differentiated not so much on the macro-level (e.g. depressive or obsessional functioning) but on the micro-level, e.g. by self-criticism and rationalizing, which interrupt the person's experiencing. In doing so we also can refine the necessary therapist responses; for example, how the therapist can respond to the rationalizing client so that a way is opened to the client's experiential level.

Facilitating Client-Centred Practice: Insights from Clients

This paper adds to the established importance of client-centred practice in mental health programs by reporting on the outcome of client interviews in one community setting in England. The purpose of these interviews was to determine the opportunities for, and barriers to, the application of a definition of client-centred practice. Purposive sampling was used to obtain 9 clients who participated in structured interviews. A combination of methods, including template analysis and the editing approach, were employed to determine themes and sub themes that are presented within the context of the clients'reasons for attending these programs. These themes included initiating client-centred practice with the sub themes of providing information to enable choice, participate in negotiating goals, overcoming fear and the severity of illness. Other themes related to the therapist's response to the client's illness and the client's knowledge about client-centred practice. It was clear from these interviews that client-centred practice was important to this group of clients and there were both opportunities and barriers to be considered by therapists.

“If We Are All in the Same Canoe, Why Are We Using Different Paddles?”: The Effective Use of Common Themes in Diverse Group Situation

ABSTRACT This paper demonstrates several important ideas in therapeutic group work. Seemingly homogeneous groups contain a wide range of etiologies, needs, and expectations among clients. Group facilitators benefit from the perspective that while differences abound, certain interventions help establish global themes which further the progress of the group while validating the specific context of individual client situations. Nine emotion-focused, process-oriented themes that arise frequently in domestic violence, addictions, and survivorship group work are presented; samples of therapist responses illustrate how a focus on these global themes can further group process through the promotion of emotional safety, collaboration, validation and client self-disclosure.

Factors Contributing to Therapists’ Distress After the Suicide of a Patient

Factors contributing to therapists' severe distress after the suicide of a patient were investigated. Therapists for 34 patients who died by suicide completed a semistructured questionnaire about their reactions, wrote case narratives, and participated in a workshop. Thirteen of the 34 therapists were severely distressed. Four factors were identified as sources of severe distress: failure to hospitalize an imminently suicidal patient who then died, a treatment decision the therapist felt contributed to the suicide, negative reactions from the therapist's institution, and fear of a lawsuit by the patient's relatives. Although one emotion was sometimes dominant in the therapist's response to the suicide, severely distressed therapists, compared to others, reported a significantly larger number of intense emotional states. Over one-third of therapists who experienced a patient's suicide were found to suffer severe distress, pointing to the need for further study of the long-term effects of patient suicide on professional practice.

SOMEBODY ELSE'S BABY: EVIDENCE OF BROKEN RULES AND BROKEN PROMISES?

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story. Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.

Therapist responses to requests for disclosure of therapeutic records: An introductory study

This paper describes a questionnaire survey of therapists in the UK who have been subject to requests for disclosure of client records as part of a legal process. Therapist responses are outlined in terms of the perceived effect of such disclosure on the client, therapist and the therapeutic relationship. Negative effects included the experience of exposure of sensitive client material in an adversarial legal system, of powerful emotional responses by therapists, and a sense of feeling professionally de‐skilled in an unfamiliar and often challenging legal environment. Positive effects for the client included the achievement of valued outcomes such as compensation, and, for the therapist, the facilitation of support for the client in this process. These findings are discussed in terms of a contrast between therapist perceptions of consensual and contested disclosure. In the former, therapist and client are in agreement about the restorative value and outcome of disclosure. In contested disclosure, the process is experienced as disrupting therapeutic privacy, undermining professional self‐confidence and introducing an unwelcome element of critical re‐evaluation of client motives for undertaking therapy.