Therapist Actions Research Articles

A mixed-method investigation of patient monitoring and enhanced feedback in routine practice: Barriers and facilitators

Objective: To investigate the barriers and facilitators of an effective implementation of an outcome monitoring and feedback system in a UK National Health Service psychological therapy service. Method: An outcome monitoring system was introduced in two services. Enhanced feedback was given to therapists after session 4. Qualitative and quantitative methods were used, including questionnaires for therapists and patients. Thematic analysis was carried out on written and verbal feedback from therapists. Analysis of patient outcomes for 202 episodes of therapy was compared with benchmark data of 136 episodes of therapy for which feedback was not given to therapists. Results: Themes influencing the feasibility and acceptability of the feedback system were the extent to which therapists integrated the measures and feedback into the therapy, availability of administrative support, information technology, and complexity of the service. There were low levels of therapist actions resulting from the feedback, including discussing the feedback in supervision and with patients. Conclusions: The findings support the feasibility and acceptability of setting up a routine system in a complex service, but a number of challenges and barriers have to be overcome and therapist differences are apparent. More research on implementation and effectiveness is needed in diverse clinical settings.

Perceptions of the First Family Counseling Session: Why Families Come Back

This article reports the findings of a study that examined why families choose to return to family therapy after their first family therapy session. The 87 families that were referred to a university family counseling center for assistance with their children’s behavioral problems at school completed an author-developed survey in which they rated the influence of various therapist-related and family-related factors on their decision to return for a second session. Factor analysis of the survey data revealed that the families’ positive experience of the therapist during the first session had the strongest influence on their continuation decision. The findings suggest that family therapists are not helpless victims to client attrition after the first session, but rather, have the strongest potential for influencing client decisions to come back. Specific family therapist actions for maximizing family continuation after the first session are described.

Understanding advocacy in action: A qualitative study

Introduction Occupational therapists advocate with/for people with disabilities. In the occupational therapy literature, advocacy is mentioned within the context of specific populations or practice settings and thus there is no consistent way of describing advocacy itself. The objective of this article is to describe advocacy in action for occupational therapists who report engaging in advocacy with/for people with disabilities. Method In this hermeneutic phenomenological study, 13 occupational therapists were interviewed about their advocacy experiences. Data analysis was completed using a Gadamerian-based approach. Findings Advocacy is complex given that the specific tasks, the third party to whom advocacy is directed and the individual(s) advocating with the therapist vary greatly. Many skills used for advocacy are already part of the therapist’s practice, such as defining the problem, acquiring information, communicating and providing education. In this study, occupational therapists describe advocating as assisting clients who are struggling with access to equipment, services or funding. Also, they advocate by fostering the development of self-advocacy, rather than representing people with disabilities on an ongoing basis. Conclusion While these findings provide some insights about how advocacy is currently practiced, a detailed framework is needed to further guide therapists through this complex area of practice.

How do art therapists act in relation to people who experience borderline personality disorder? A review of the literature

The difficulties described by the term borderline personality disorder represent a significant clinical population. The British Association of Art Therapists has prioritised the use of research to improve the effectiveness of art therapy. Defining therapist action in relation to the condition treated is an important part of theory building for such research, but this preparatory stage has arguably been underestimated in many art therapy outcome studies. The present study therefore used a literature review to ask how art therapists act in relation to borderline personality disorder. An international search between 1980 and 2014 revealed 17 relevant studies. Data relevant to the research question were extracted from each paper, grouped thematically and developed into nine propositions that linked therapist action with the condition-specific difficulty they claimed to address. This identified a practice concerned with the process rather than the content of thought. Avoiding interpretation of unconscious symbolism, art was used to enhance joint attention in a teleologically sympathetic process of thinking together with things. This differentiated it from a number of major art therapy models. While propositions were developed, they were not tested in the present study.

Addressing Mental Health Disparities With Asian American Clients: Examining the Generalizability of the Common Factors Model

Although mental health disparities for Asian Americans are known, reasons for the disparities are not well understood within the counseling process. This study coded Asian American and White clients' reports of helpful counselor actions into empirically supported common factors to determine which within‐session processes might reduce mental health disparities for Asian American clients. Asian American clients' reports of helpful therapist actions did not differ from those of White clients, suggesting that disparities do not originate in differences in the foundational aspects of counseling. Implications for addressing disparities are discussed.

Student perceptions and understanding of client-therapist interactions within the inpatient acute care environment: qualitative study.

Physical therapists practicing in inpatient acute care settings in the United States work in a 21st century health care system that requires professional competence in clinical reasoning and decision making. For doctor of physical therapy (DPT) students, the development of confidence in the patient evaluation and the professional skills necessary for managing the inpatient environment can be challenging. The study's purpose was to understand whether the early exposure of students to inpatient settings informed their understanding of the thought processes and actions of experienced clinicians during client interactions. A qualitative design was used. Thirty-three DPT students working in inpatient settings were recruited from 15 unique inpatient hospital (acute care and rehabilitation) facilities with a convenience sampling technique. Reflective data were collected for 1 month with clinician-facilitated discussion boards. Four themes emerged: environment, communication, evaluation, and client-therapist interaction. The themes informed a conceptual model depicting the observation by DPT students of factors that influenced interactions between clients and experienced clinicians in inpatient settings. Reflection on the what, the how, and the why that informed clinical decisions enabled students to recognize the situated nature of evaluation and treatment approaches. The use of a sample from 1 year of a DPT program at one university reduced the generalizability of the results. Limited research has examined student perceptions of the interactions of experienced clinicians with clients in inpatient acute care settings. More research is needed to understand the impact of exposing students to the thoughts and actions of therapists working in such settings earlier within DPT curricula.

Vicarious resilience from attachment trauma: reflections of long-term therapy with marginalized young people

The concept of vicarious resilience captures the therapist's emotional growth occurring as a direct result of therapeutic engagement with traumatized clients. Three chronological case scenarios are presented for exploration of vicarious resilience in relation to attachment trauma. The purpose is to increase awareness and appreciation of the positive functions it serves for client mentalization, therapist skill and resilience factors for both parties. The reflective methodology considers the intrapsychic worlds of the client and the therapist and details how the therapist comes to experience the client's distressing projections. The potential for vicarious resilience begins from the outset of the therapist's actions of containment upon these projections. Advancing early ideas, it is advocated that vicarious resilience requires the therapist to have both the capacity and willingness to maintain a constant reflective stance.

Music therapists’ attitudes and actions regarding the LGBTQ community: A preliminary report

This is a preliminary report on survey research currently being conducted by a team of music therapists across the United States. The study's purpose was to explore the attitudes and actions of music therapists across the globe in regards to lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) clients, coworkers, and students. The survey questions were designed to explore areas of knowledge as well as deficits in order to direct future educational offerings for music therapists and music therapy students. These results are preliminary, reflecting the first 2 months the survey was open representing a total of 409 respondents. Results indicate a need for further education and training of music therapists regarding LGBTQ issues.

Características das ações desenvolvidas por terapeutas ocupacionais nas capitais da região sudeste

The study aims to describe and analyze the characteristics of actions of Occupational Therapists (O.Ts) from the capitals of Southeast region. This is a descriptive and exploratory search, with 17 O.Ts It used a questionnaire self-administered and for data analysis, discourse analysis matrix pêcheutiana. The discursive formations found evidence that the act ions taken by O.Ts comprise a joint of efforts aimed at individuals and their context both individual and collective, demonstrating the uniqueness professional clinical practice, as well as understanding the concept of completeness was present in thespeeches differently showing that cultural differences, length of training and professional development infl uence the understanding of the process of care in Occupational Therapy. We conclude that there is need for further studies to map and deepen knowledge about the actions of O.Ts in order to further discuss this issue.

Trying to be useful: Three different interventions for one therapeutic stance.

This article is an attempt to analyze therapist's actions or strategies that contribute to an effective therapy session and are clinically useful to the therapeutic process. To link the clinical practice to the empirical research, three kinds of therapist interventions, based on the Psychotherapy Process Q-Set, are described. They include (1) an empathic attitude in dealing with the difficulties of the patient and his or her affective experience, (2) the identification and exploration of recurrent themes in the patient's experience or conduct, and (3) addressing a patient's defenses, to ward off awareness of threatening feelings. For each of these interventions, the author provides both clinical and research data that support their use, as well as verbatim clinical exchanges, which allow a better understanding of the mechanisms of therapeutic actions in real clinical practice.

Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD.

Various factors contribute to the effective implementation of evidence-based treatments (EBTs). In this study, cognitive processing therapy (CPT) was administered in a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinic in which training and supervision were provided following VA implementation guidelines. The aim was to (a) estimate the proportion of variability in outcome attributable to therapists and (b) identify characteristics of those therapists who produced better outcomes. We used an archival database of veterans (n = 192) who completed 12 sessions of CPT by therapists (n = 25) who were trained by 2 nationally recognized trainers, 1 of whom also provided weekly group supervision. Multilevel modeling was used to estimate therapist effects, with therapists treated as a random factor. The supervisor was asked to retrospectively rate each therapist in terms of perceived effectiveness based on supervision interactions. Using single case study design, the supervisor was interviewed to determine what criteria she used to rate the therapists and emerging themes were coded. When initial level of severity on the PTSD Checklist (PCL; McDonald & Calhoun, 2010; Weathers, Litz, Herman, Huska, & Keane, 1993) was taken into account, approximately 12% of the variability in the PCL at the end of treatment was due to therapists. The trainer, blind to the results, identified the following characteristics and actions of effective therapists: effectively addressing patient avoidance, language used in supervision, flexible interpersonal style, and ability to develop a strong therapeutic alliance. This study adds to the growing body of literature documenting the importance of the individual therapist as an important factor in the change process.

“Nondirectivity” in the theory of Carl R. Rogers: An unprecedented premise

The unprecedented premise of the self-authority and self-determination of the person is that of the therapist's nondirective attitude. The dedication of Rogers to the value laden concept of nondirectivity throughout his life is reviewed. In Rogers' theory, the client is the director of her/his own life when facilitated through a psychological environment characterized by the congruent therapist experiencing of unconditional positive regard and empathy towards the client. Nondirectivity refers to the therapist's actions, attitudes, and demeanor that maximize the opportunity for the client/participant to direct her/his own life. The misunderstandings of nondirectivity lie within the interface with the deviations from Rogers' theory, the conventional mental health treatment model, and the characterization of Rogers' theory as a form of response repertoire. Those who disagree with the nondirective value laden principle of the theory disagree with the foundational value of Rogers' theory, a value that represents a different paradigm.

Different processes for different therapies: Therapist actions, therapeutic bond, and outcome.

Therapeutic bond, as a component of the alliance, is considered a common factor in psychotherapy; however, it may operate differently in various treatments. This article investigates therapist actions, particularly affect focus, in the formation of the bond and on reduction of symptoms in short-term dynamic psychotherapy (STDP) and cognitive therapy (CT) for cluster C patients. Forty-six cases (23 STDP and 23 CT) were assessed using the Psychotherapy Process Q-Sort, the Helping Alliance Questionnaire, and the Symptom Checklist 90. These scores were used to determine (a) therapist actions that predict formation of the bond, (b) the relation of the bond to symptom reduction, and (c) how therapist actions and bond interacted to reduce symptoms. Multiple regressions were applied to the total sample and to the STDP and CT cases. Psychotherapy Process Q-Sort items describing avoidance of affects were positively related to the bond in the total sample, STDP and CT. However, the relation between therapist actions, bond, and symptom reduction differed for the two treatments. For STDP, avoidance of affect suppressed the relation of bond to symptom reduction and also negatively influenced symptom reduction. On the other hand, in CT, avoidance of affect was positively related to both the formation of the bond and to symptom reduction. Although the bond is a common factor and important component of the alliance, it appears to operate differently in STDP and CT. A focus on affect is important to the benefits of STDP but interferes with the benefits of CT.

Supporting Parent-Child Interactions: Music Therapy as an Intervention for Promoting Mutually Responsive Orientation

Music therapists working with families address relationship and interpersonal communication issues. Few controlled studies exist in the literature but a growing body of documented practice is emerging. This study makes a contribution by documenting how music therapy supports mutuality and reciprocity in parent-child interactions. This study investigated mutually responsive orientation (MRO) behaviors of young children (aged 3-5) and their family members during music therapy. Participants were 4 families with low income and history of maternal depression as common risk factors. Data were collected by videotaping sessions, creating field notes and analytic memos, conducting parent interviews and reviewing parent journals. A cross-case analysis using MRO theory as a conceptualizing framework was used for the purpose of data reduction. Greeting and farewell rituals, and the flexibility of music-based therapeutic applications facilitated development of coordinated routines. Therapist's actions (e.g., encouraging and modeling musical interactions) and bidirectional parent-child actions (e.g., joint attention, turn-taking, being playful) facilitated harmonious communication. Behaviors promoting mutual cooperation were evident when adults attempted to scaffold a child's participation or when children sought comfort from parents, engaged in social referencing and made requests that shaped the direction of the session. The novelty of musical tasks captivated attention, increasing impulse inhibition. Parent actions (e.g., finding delight in watching their child participate, acting silly) and parent-child interactions (e.g., play exploration, shared excitement, cuddling) contributed to positive emotional ambiance. Music therapy assisted development of MRO within parent-child dyads by providing opportunities to rehearse adaptive ways of connecting with each other. Results of this study may serve as an archetypal model guiding clinical treatment planning.

The Changing Face of Psychiatry Training

Back to table of contents Previous article Next article Residents’ ForumFull AccessThe Changing Face of Psychiatry TrainingAlik Widge, M.D., Ph.D.Alik WidgeSearch for more papers by this author, M.D., Ph.D.Published Online:17 Aug 2012https://doi.org/10.1176/pn.47.16.psychnews_47_16_9-b You’ll see many articles in this paper on changes in psychiatry—a new DSM, new treatments, and new laws and regulations. There is a bigger change happening too, a change in how we train psychiatrists and what it will mean to be a psychiatrist during our professional lifetimes.As the member-in-training trustee on the APA Board, I serve as a liaison to the psychiatry residency directors’ association, and I also happen to serve on the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for psychiatry, giving me an advance view of what’s on the horizon.The role of doctors overall is shifting, and psychiatry is along for the ride. As health systems rely more on allied health professionals (physician assistants, nurse practitioners, and social workers, for example) to deliver routine care, it’s no longer enough for a physician to be a skilled clinician.The expectation is that we will come out of residency prepared to be managers and leaders, trained to direct and coordinate an integrated mental health team. Many of us experience this on inpatient rotations, where we learn to coordinate the actions of nurses, therapists, social workers, and others. Tomorrow’s psychiatrists will do that across care settings, and our program directors are trying to figure out how to prepare us for that role.Within the ACGME, two big projects will support that change. First, starting in 2014, every resident in every specialty will be evaluated against standardized “Milestones”—a set of specific knowledge domains, skills, and behaviors that describe that specialty’s expected development trajectory. The psychiatric curriculum won’t change much, but that early and frequent feedback will help residents see their skills (and needs) in a new way, and it will help programs train their residents more efficiently. It will also produce a generation of physicians who are much more prepared for the continual monitoring and evaluation that the Maintenance of [Board] Certification process requires.Second, a set of ACGME initiatives focuses on improving skills in “systemsbased practice”—that is, working in a large medical-financial-legal network, allocating resources, and advocating for patients.These initiatives are driven in large part by resident leaders within the ACGME, based on that vision of physicians as team leaders. Even more initiatives will come as the data accumulate; when the ACGME is receiving individual reports every six months on every resident in the country, and the American Board of Psychiatry and Neurology is getting something similar through its Maintenance of Certification process, we will have unprecedented tracking of psychiatrists across their careers.Can we as a profession and as individuals use that information to become better clinicians and leaders? Might it be misused by payors or credentialing bodies? Could education researchers find trends that predict patient outcomes?Furthermore, all of that is happening as the bedrock of residency training, the federal graduate medical education funding that pays our salaries, is under threat. Tracking outcomes through the Milestones will help our institutions make the case for continued funding. Still, if the cuts happen, we may need to rethink psychiatric residency itself. If we can track residents’ competency, does everyone need to spend four years in training? For that matter, since the PGY-4 year is mainly electives, should we have it at all? There is no formal proposal on the table, but it has been studied and argued, and it might be again.These aren’t easy questions, and all this change will produce unintended consequences.The one constant is that APA will be there throughout all of it. We have representatives on every committee that’s influencing this work, and through writings such as this column, we report back to the community. We take the input you give us and weave it together to develop residency training in the direction our professional needs. (A large part of that is trying to minimize burdens; trainees and attendings alike have been very clear that there is just too much paperwork and bureaucracy in our lives.) As the changes are implemented, we’ll build resources to help residents prepare and manage them, just as we’ve done in creating online modules that will help psychiatrists maintain Board certification.APA is here for you during your training, but it will also be there for you after, and will continue to be the forum where trainees and trainers can come together to find new solutions. Alik Widge, M.D., Ph.D., is APA’s member-intraining trustee and is a PGY-4 resident at the University of Washington. ISSUES NewArchived

The Impact of Therapist Actions on the Balance of Power Within the Couple System: A Qualitative Analysis of Therapy Sessions

Power inequality is an important concern in couple therapy, yet little research addresses how therapists deal with this issue. This qualitative, grounded theory analysis of 21 transcripts of couple therapy sessions examined how therapist actions influenced the balance of power between partners in the moment to moment processes of therapy. The analysis identified five kinds of therapist actions that perpetuated power imbalances: (a) discounting the person in the one-down position, (b) allowing the one-up person to define the conversation, (c) reinforcing dominant person's negative comments about partner, (d) using professional privilege to assume experience of the one-down person, and (e) speaking as though the relationship was equal when it was not. Six other actions helped interrupt current power imbalances and encouraged more equal power: (a) using therapist voice to create balance, (b) creating space for one-down voice, (c) naming power discrepancies, (d) validating competence of the one-down person, (e) suggesting new options, and (f) encouraging powerful partner to shift to a relational perspective. The results help couple therapists develop greater sensitivity and awareness of the impact of their interventions on the power balance of the couple.

Taking a Lesson From Patients' Recovery Strategies to Optimize Training During Robot-Aided Rehabilitation

In robot-assisted neurorehabilitation, matching the task difficulty level to the patient's needs and abilities, both initially and as the relearning process progresses, can enhance the effectiveness of training and improve patients' motivation and outcome. This study presents a Progressive Task Regulation algorithm implemented in a robot for upper limb rehabilitation. It evaluates the patient's performance during training through the computation of robot-measured parameters, and automatically changes the features of the reaching movements, adapting the difficulty level of the motor task to the patient's abilities. In particular, it can select different types of assistance (time-triggered, activity-triggered, and negative assistance) and implement varied therapy practice to promote generalization processes. The algorithm was tuned by assessing the performance data obtained in 22 chronic stroke patients who underwent robotic rehabilitation, in which the difficulty level of the task was manually adjusted by the therapist. Thus, we could verify the patient's recovery strategies and implement task transition rules to match both the patient's and therapist's behavior. In addition, the algorithm was tested in a sample of five chronic stroke patients. The findings show good agreement with the therapist decisions so indicating that it could be useful for the implementation of training protocols allowing individualized and gradual treatment of upper limb disabilities in patients after stroke. The application of this algorithm during robot-assisted therapy should allow an easier management of the different motor tasks administered during training, thereby facilitating the therapist's activity in the treatment of different pathologic conditions of the neuromuscular system.

Leadership through an occupational lens: Celebrating our territory

This paper addresses key qualities of leadership and describes leadership through an occupational lens. It aims to encourage individuals to identify themselves as leaders wherever they are positioned within organisations or in their professional lives. Leadership vignettes are used to highlight and celebrate how occupational therapy philosophies, as well as our theoretical and practical knowledge assisted these leaders in their current and emerging leadership roles. A number of issues that are affecting us as global citizens, including natural disasters and humanitarian crises in third world contexts are highlighted. The potential for our profession to take a leadership role in these issues is proposed. Finally, there is a call to action for all occupational therapists whatever their professional roles, recommending that all members of the profession embrace leadership opportunities no matter how big or small. In so doing it is argued that leadership will be recognised and celebrated as being very much part of our profession's territory.

Conceptualizing the therapist's role in therapy in psychosis

This paper reports on a subset of findings from a wider ranging grounded theory analysis of therapy and recovery processes in psychosis. It describes therapist activities involved in maintaining an observational perspective during therapy and the links between these and other therapist activities. Grounded theory was used to examine the qualitative data collected. An initial sample of 19 taped therapy sessions and 23 interviews with psychologists and their clients was collected. This sample was extended through the collection of three further interviews with psychoanalytically aware psychologists. The data were analysed using grounded theory. A grounded theory model of therapy processes in psychosis was developed that conceptualized therapist actions as providing an observational scaffold to support the client's efforts in moving to new perspectives on their situation. Consistent with the understanding of the core therapy activity as a dialogical process, this set of therapist actions was understood as occurring alongside other therapist activities involved in managing emotion and building a relationship in therapy. The central activity of therapy in psychosis was understood as a dialogical process continuously negotiated between therapist and client in conversation and was conceptually summarized in the grounded theory as 'building bridges to observational perspectives'. However, the active and strategic efforts of psychologists to sustain the dialogue implied a particular assumption of responsibility for maintaining this process. In particular, therapists appeared to be 'working to maintain observational perspectives', 'managing emotion', and 'doing relationship' during the therapy conversation as part of the joint effort with clients to build bridges to new observational perspectives on distress and psychosis.

General Principles for Treating Personality Disorder with a Prominent Inhibitedness Trait: Towards an Operationalizing Integrated Technique

Psychotherapists need to perform tasks such as being empathetic, performing an ongoing assessment of cases, self-disclosing, making explicit treatment contracts, validating patients' experiences and promoting awareness of psychological experience, if they are to be effective in treating personality disorder (PD). Successful therapy also requires a systematic accurate PD model. We suggest here that it is still unclear how, when, and according to what session markers therapists need to perform specific operations to maximize therapeutic gains. This article describes and operationalizes a step-by-step procedure for organizing and delivering the interventions necessary for effective outcomes, such as maintaining a good therapeutic relationship, increasing understanding of mental states, reducing symptoms and improving social adaptation. The procedure is illustrated by reference to the treatment of cases of emotionally overly-constricted PDs. We include a theoretical proposal to facilitate the development of measures for evaluating the efficacy of therapist actions.