Therapist Awareness Research Articles

Implementaton of Strength Reimagined

The Strong Black Woman (SBW) stereotype has been consistently linked to poor mental health for African American women and its endorsement leads to anxiety, depression, and stress. African American women unknowingly subscribe to this stereotype through the exertion of strength and independence found necessary to combat oppression and gendered racism. This article explores existing literature on the SBW stereotype and suggests strategies for leveraging this stereotype to enhance mental health interventions for African American women. Utilizing an integrated conceptual framework that draws from the lens of Black Feminist Thought, Intersectionality, and Social Constructivism Theory, Strength Reimagined: A Therapeutic Framework for African American Women is proposed. This treatment framework incorporates five key aspects: therapist awareness, psychoeducation, culturally responsive psychotherapy, trauma-informed complementary interventions, and mutual support to improve mental health outcomes among African American women.

Changes in countertransference and changes in patient working alliance and outcome: An empirical study.

The American Psychological Association task force on empirically supported therapy relationships defined countertransference (CT) management (i.e., awareness of CT) as a "promising" element in psychotherapy research. The present study aimed to examine how changes in therapist CT and awareness of CT relate to therapy process and outcome. The data analysis was based on 41 treatments and used the core conflictual relationship theme to measure CT. We found that changes in therapists' Wishes from the relationship with the patient at the beginning of therapy were related to patients' working alliance and symptom changes at the end of treatment. Changes in therapist awareness of CT moderated the relationship between therapists' wishes from the therapy and patients' symptom changes during therapy. Last, we present a case study and discuss how awareness of CT can help the therapist handle the challenges that arise from it. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

“I’m a fish!” Deepening receptivity to neurodiversity: a neuroscientifically informed integration of psychoanalytic psychotherapy, reciprocal prediction, and mindfulness

ABSTRACT Receptivity to our patients’ experience is a vital aspect of the psychoanalytic endeavor. As we receive incoming transmissions, we resonate with what is active in the patient. We hope to then jointly metabolize the experience. When we meet neurodiversity, realms of experience emerge that may elude us. Precipitously formulated ideas in the therapist, based on a neurotypical frame of reference, can impinge upon the discovery of our patients’ authentic world. How do we open ourselves to receive their true experience? This clinical narrative tracks the psychoanalytic travels of an individual who identifies as neurodivergent, who helped the therapist learn to deepen receptivity by dipping into a less differentiated place to follow the here-and-now experience from the bottom up. Throughout the journey, interweaving neuroscientific and psychoanalytic perspectives offered a powerful matrix from which an enriched understanding of our process could emerge. Psychoanalytic concepts including evenly suspended attention, unconscious-to-unconscious communication, alpha function, reverie, and negative capability are explored alongside neuroscientific insights into the stress response, mirror neurons, and the default mode network. A predictive coding lens introduced a view of the therapeutic exchange as a continuous reciprocal prediction, evoking the hypothesis that deepening receptivity required opening awareness to incoming signals and lessening the hold of prior predictions. To bring greater therapist awareness to the present moment and lessen the influence of self-referential evaluation, neuroscientifically-informed reflections also inspired the practice of mindfulness. Subsequent developments suggest that these approaches helped deepen receptivity to the experiences being communicated, leading to new understandings with transformative potential.

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study

ABSTRACT Objectives To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency. Methods This study utilized survey data collected in 2020–2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency. Results Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01). Discussion/Conclusion There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system.

The US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD). This study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30-45-min semi-structured interviews with a purposive subsample of these therapists (n = 32). Combining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review. Healthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care.

Art Therapy and Beyond: Emerging Practice Innovations and Implications for Practice and Research in the Arabian Gulf

Engaging in the arts has been demonstrated scientifically to enhance brain function. Creativity can modify a person’s perspective and experience of the world. Changes in cerebrum waves impact changes in the nervous system which can raise serotonin levels. This can affect emotions positively by regulating moods and improving brain function which influences both psychological and physiological wellbeing. Creativity is part of our natural development and should be a part of our healing as a community. Art Therapy (AT) is a mental health profession which carries out innovative adaptations as it is recognized as a stand-alone clinical intervention and through community engagement and social justice. Art Therapists are collaborating within diverse fields of clinical and non-clinical practice such as neuroscience and virtual reality. Three papers explore the development of Art Therapy as a profession in Qatar and how AT is an accessible and underutilised or often misjudged profession. Paper one introduces ways that AT is practiced as a clinical, social action and community-based profession. AT might address the shame connected with psychological wellness by connecting with communities, sharing experiences of AT with the general public and by clinical professionals to support their careers, prompting less burnout. Dr. Hadi Mohamad Abu Rasheed shares the Qatar Cancer Society’s experience of using Art in psychosocial support for children living with cancer. The western trained Art Therapist's awareness of cultural competence when working in the context of non-western cultural approaches to mental health is imperative to complement the heritage, creativity and community values of the local culture. Intersectional frameworks will inform ethical professional values to be upheld. Paper two develops how AT offers context to reduce the stigma of mental health in Qatar. The first Museum and Gallery AT visit in Qatar, with patients attending a substance misuse program, saw outcomes that included increased engagement in clinical sessions and an art exhibition that was held in the hospital and at conferences within Qatar and globally. Paper three discusses the global alterations in the AT workplace following the Covid-19 epidemic; online AT; and how AT has adapted to employing technology before and after the pandemic. The technology employed in AT is not new. Art Therapists are now using Virtual Reality, where the client becomes part of the world they have created, interacting in it, with the art therapist present. The Emotion Sensing Recognition (ESRA) app is being developed by Dr. Mowafa and Dr. Jens with the consultation of an Art Therapist Trish, to ensure the ethics of working with images. This app can increase positive parent-child attachment and increase the ability to recognise and talk about feelings for parent and child. AT is a cost-effective adaptive treatment and is being prescribed by General Practitioners in the UK and USA alongside visits to museums, choirs etc. How will Qatar embrace this adaptable, unique profession and will ensure it is ethically practiced by trained licensed Art Therapists? Collaborative research and training within different fields should be encouraged.

The beginning of the end: a comparison of treatment completers and early dropouts in trainee-provided time-limited cognitive behavioral therapy

ABSTRACT About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-, and observer-based data. The sample includes five trainee therapists, each of whom worked with one patient who terminated after the first or second session, and one who completed a cognitive-behavioral therapy protocol. The session(s) preceding premature termination in the drop case and the corresponding session(s) in the completer case were examined. Rupture resolution process was prevalent in both groups, though confrontation ruptures seemed more prevalent with completers and withdrawal ruptures were more clinically impactful with dropouts. Therapist awareness of process and responsiveness or contribution to rupture were identified as potential factors contributing to patient retention.

Communication orthophoniste / adulte avec aphasie : contribution de l'analyse de corpus à la conscientisation des postures langagières professionnelles dans le soin

This study focuses on the analysis of verbal interactions in clinical contexts between aphasic adults and speech therapists. Seven speech therapists were invited to record a conversational exchange with one of their patients and to analyze their interacting communication behaviors using an observation grid, based on the watching of a video clip and the reading of its transcription. In this interaction analysis protocol, the speech therapist's attention was not focused on the patient's productions but on his or her own contribution to the exchange. The results show that the recording and the transcription of corpora of natural exchanges contribute to the speech therapist's awareness of his or her language posture and opens up prospects for the improvement of professional practices in healthcare.

Culture and therapist self-disclosure

AbstractCognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.Key learning aims(1)To develop a dialogue and practice with confidence when addressing issues of self-disclosure with diverse populations.(2)To appreciate the impact therapist self-disclosure has in early stages of engagement, in particular when working with patients from BME communities.(3)To understand the impact and role of self-disclosure as initiated by patients.(4)To increase therapist awareness on cultural differences in self-disclosure and develop ways to address this in therapy.(5)To challenge therapists to adapt psychological therapies to diverse cultures and be cognisant that ‘one size does not fit all’.

Therapeutic relationship: Riding on a bumpy road and steering through to the destination

Therapeutic relationship runs a dynamic course; it usually grows and intensifies with time, but there could be unforeseeable twists and disruptions. The course, to no small extent, is contributed by the therapist's dispositions and expertise on a particular theoretical orientation. Expertise is dependent on experience, level, and quality of training. Disruptions, although unwanted, give an opportunity to reflect upon the shortcomings and are an impetus for a course correction, which more often than not gives a desirable result. In this case discussion, I shall describe the highs and lows in a therapeutic relationship. After the initial euphoria, the therapist's inexperience, limited skills, and a wrong decision would contribute to significant disruption. However, the therapist's awareness of his/her limitations, a motivation to learn, and active help from mentors and colleagues would provide momentum in the second half of the therapy, which finally would see the daylight of success.

Knowledge of congenital cytomegalovirus (cCMV) among physical and occupational therapists in the United States.

Congenital cytomegalovirus (cCMV) infections cause more children to have permanent disabilities than Down Syndrome, Fetal Alcohol Syndrome, Spina Bifida, and pediatric HIV/AIDS combined. The risk of infection during pregnancy can be significantly decreased using universal precautions, such as thorough handwashing and cleansing of surfaces and objects that have come into contact with infected body fluids. Children under 3 years of age are commonly asymptomatic excretors of CMV, with the highest viral loads present in saliva. Pediatric therapists have regular close contact with young children, and are thus likely at elevated occupational risk of acquiring CMV. Our objective was to evaluate therapist knowledge of cCMV and its transmission. We recruited American Occupational Therapy Association (AOTA) and American Physical Therapy Association (APTA) members via electronic newsletters and printed flyers from April to September 2015. Participants completed an online, anonymous 24-question survey using Survey Monkey. We compared responses between groups and previously published CMV awareness data using binomial tests of difference of proportions and multiple logistic regression. Our study identified both a low level of therapist awareness and poor demonstrated understanding of cCMV. Self-reported cCMV awareness amongst therapists was greater than awareness in the general population, and equivalent to awareness amongst health care professionals. Whereas 52% of participants self-reported awareness of cCMV, only 18% demonstrated understanding of the behavioral modes of CMV transmission. Fewer therapists reported awareness of cCMV than other, less prevalent conditions. Higher levels of health risk knowledge were associated with greater contact with children. Most participants reported learning about cCMV from the workplace. The knowledge gaps between self-reported awareness of cCMV and demonstrated understanding of modes of transmission described by our results emphasize the need for additional training of therapists. cCMV is preventable, and accurate knowledge of modes of transmission is crucial for the health of practitioners and clients.

Directiveness in psychotherapy: A phenomenological-narrative study of therapist attitudes.

This study of directiveness draws on the literature on patient-therapist matching, neutrality, and resistance. Our aim was to investigate how psychotherapists conceptualize directiveness as an attitude, with a focus on pantheoretical aspects of directiveness. Our data are narratives from 18 interviews with psychotherapists of different theoretical orientations (cognitive-behavioural, family-systems, humanistic-experiential, and psychodynamic), and from focus-group discussions with six other psychotherapists. The analysis yielded four general themes: expression of directiveness (behaviour, agency, structure), its presence (depending on phase of and goals for therapy), its positive and negative outcomes (for patients and therapists, respectively), and therapist awareness (initial and shifting, depending on theoretical orientation). Directiveness may be construed as an attitude. It supposedly increases via certain responses, but only a few of these are considered positive by therapists at large. Directiveness may be more present in early and late phases of therapy, and more warranted with patients that function poorly. There are both positive and negative outcomes of directiveness, but therapists are more prone to disclose the former. Therapist directiveness supposedly increases via advice, questions, clarifications, steering to topics, goal setting, self-disclosure, and session management. Directiveness is seen as more present in early and late phases of therapy. Directing is more warranted with patients who function poorly. Possible positive outcomes of directiveness are clarity, feeling of security, and saving time; negative outcomes are decrease of agency, increase of resistance, and less patient self-attribution of improvement. It is unlikely that therapists disclose adverse directive behaviours. Those who do, attribute them to psychotherapy structure if their attitudes are negative, and to personal choice if they are positive. This may hamper therapists managing their own level of directiveness.

The Culturally Competent Counselor: Issues Specific to Four Minority Groups

Behavioral science helping professionals are ethically obligated to achieve cultural competence in their work with clients. The rapid rise of the minority population in the United States means that helping professionals can expect to work with clients from cultural backgrounds different from their own. This paper examines four cultural groups—African Americans, Hispanics, LGBT, and military veterans, and specific cultural concerns unique to each group. The purpose of the paper is to increase therapist awareness and knowledge of these group-specific cultural issues, thereby contributing to a greater degree of counselor cultural competence.

Concentric Circles Therapy Training: Clinical Psychology Trainee's Reflections on Participation in a Revised Interpersonal Therapy Training Group

ObjectiveThe Concentric Circles Therapy Training (CCTT) approach is a revised version of a previously developed interpersonal therapy training approach that primarily aims to develop therapist's awareness of interpersonal process. The CCTT approach enables students to take part in an interpersonal therapy training group both as a participant and as an observer. The aim of the study was to obtain in‐depth accounts of the experience of this revised approach to interpersonal therapy training.MethodsSeven Clinical Psychology post‐graduate students took part in the study, with each participant providing 6 weeks of in‐depth personal reflective journals regarding their psychotherapy training experience. Thematic analysis was used to determine the predominant themes.ResultsThree main themes emerged in the data: personal reflections, interpersonal reflections, and integration. Overall, participants indicated that being able to be both a participant and an observer was a unique and powerful learning experience, and all participants indicated that participation in the concentric circles training was an important part of their training to become psychotherapists.ConclusionThe CCTT approach was developed to provide a practical solution to enable interpersonal therapy training in clinical psychology courses where class sizes continue to increase.

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.

Axillary web syndrome self-assessment questionnaire: Initial development and validation

IntroductionDespite the great strides made in medical knowledge, surgery still remains a necessary part of the breast cancer treatment. Surgical procedures still lead to post surgical sequelae. The axillary web syndrome (AWS) is one such sequela, which can lead to disability, reduced arm mobility and compromised quality of life. It is often unidentified and the literature regarding its assessment is limited.To improve diagnosis and patient education, the Screening Test AWS (ST-AWS) questionnaire was drafted and applied at the European Institute of Oncology (EIO). Materials and methodWe prospectively recruited patients from October 2012 to December 2012. Patients who underwent sentinel lymph node biopsy and/or axillary dissection procedures were registered. Physical examination was set as a gold standard. Results88 patients completed the questionnaire. Among these, 32 patients had axillary web syndrome diagnosed, thus a 36% incidence.The questionnaire achieved a sensitivity of 94%, a specificity of 91%, a positive prevalence value (PPV) of 86%, a negative prevalence value (NPV) of 96% and an accuracy of 92%. ConclusionOur questionnaire achieves high sensitivity and predictive values, and we would recommend it as a screening-tool for auto-diagnosis of the AWS.The main objective of the questionnaire is to enhance patient and therapist awareness of the problem, and prompt management to shorten the effects of this disability. Moreover, it may offer a tool to enhance body image acceptance after surgery.Further studies whereby the efficacy of the questionnaire is investigated in a larger, heterogeneous group and in different situations are warranted.

Understanding Familial/Cultural Factors in Adolescent Depression: A Culturally-Competent Treatment for Working With Chinese American Families

A significant challenge for researchers and clinicians is in the process of determining culturally sensitive strategies to ensure treatment effectiveness with ethnic populations in the United States. This article highlights key aspects of treating Chinese American families where a child is struggling with adolescent depression. Relevant literatures associated with adolescent depression and effective treatment of Chinese Americans are reviewed and organized according to the dimensions of therapist knowledge, awareness, and skills. Therapist guidelines are provided using key aspects of cognitive behavioral therapy. Additional suggestions are presented for culturally competent therapy with Chinese American youth and their families.

Abstract P3-09-06: Development and validation of a questionnaire for axillary web syndrome self-assessment

Abstract INTRODUCTION: Despite the great strides made in medical knowledge and technology, surgery still remains a necessary part of the breast cancer treatment protocol. Even with the employment of less aggressive techniques, surgical procedures still lead to post surgical sequelae and complications. The axillary web syndrome (AWS) is one such sequela which can lead to disability, reduced arm mobility and compromised quality of life. Currently, there is no diagnostic tool such as a self-validated questionnaire to detect AWS which may help the patient to seek the opportunity for immediate treatment. To improve diagnosis and patient education, the ST-AWS questionnaire was drafted and applied at the European Institute of Oncology (IEO). MATERIALS AND METHOD: We prospectively recruited patients from October 2012 to December 2012. Groups of patients who underwent ipsilateral sentinel lymph node biopsy and/or axillary dissection with or without plastic reconstruction procedures were registered. The complete physical examination by physiotherapist was set as a gold standard to evaluate the validity and reliability of ST-AWS. Axillary Web Syndrome general table AWS EVALUATION CATEGORIESYES 32 (%)NO 56 (%)p-value §AGE*&amp;lt; 5119 (59)24 (43)0.14 ≥ 5113 (41)32 (57) SCHOOLINGHigh28 (88)42 (75)0.16 Low4 (12)14 (25) BMI≤ 18,55 (16)0 (0)0.006 18,5 - 25,022 (68)32 (57) &amp;gt; 255 (16)24 (43) TIME OF SURGERY (min)*≤ 11912 (37)33 (59)0.05 &amp;gt; 11920 (63)23 (41) PLASTIC RECONSTRUCTIONYes25 (78)29 (52)0.02 No7 (22)27 (48) BREAST SURGERYMastectomy25 (78)34 (61)0.10 Quadrantectomy7 (22)22 (39) AXILLARY SURGERYAxillary Dissection20 (63)29 (52)0.33 Sentinel Lymph Node Biopsy12 (37)27 (48) N STAGE09 (28)25 (45)0.07 115 (47)16 (28) 22 (6)10 (18) 36 (19)5 (9) SENSIBILITY LOSSYes15 (47)9 (16)0.002 No17 (53)47 (84) * median values were used as cut off points § Chi-square, Fisher exact and Mantel-Haenszel Chi-Square tests RESULTS: 88 patients completed the questionnaire and the physical examinations and were included in the study. 32 patients had axillary web syndrome diagnosed, thus a 36% incidence. Median age was 51 years (range 22-78 years). The questionnaire achieved a sensitivity of 94%, a specificity of 91%, a positive prevalence value (PPV) of 86%, a negative prevalence value (NPV) of 96% and an accuracy of 92%. Comparing Gold Standard physical Evaluation and ST-AWS Questionnaire results PHYSICAL EVALUATION (GOLD STANDARD) NEGATIVEPOSITIVETOTALQUESTIONNAIRE NEGATIVE51253POSITIVE53035TOTAL563288Sensibility: 94%, Specificity: 91%, Accuracy:92%, PPV:86%, NPV:96% CONCLUSION: Our questionnaire achieves high sensitivity and predictive values, and we would recommend it as a screening-tool for auto-diagnosis of the axillary web syndrome. Nevertheless, the results of the ST-AWS should be confirmed by a physiotherapy examination. The main objective of the questionnaire is to enhance patient and therapist awareness of the problem, and prompt management in order to shorten the effects of this disability. Moreover, it may offer a tool to enhance body image acceptance after surgery. Further studies whereby the efficacy of the questionnaire is investigated in a larger, heterogeneous group and in different situations are warranted. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-06.

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.

The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with rela- tively impaired self-reflectivity lies in explicitly focusing on a patient's intersubjective experience within psycho- therapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjec- tivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersub- jective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist's awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.