The relationship between therapist behaviors and outcome for middle- and lower-class couples in marital therapy

Treated a sample of 77 distressed middle- and lower-class couples by 19 therapists using conjoint therapy. Batteries of tests that assessed marital satisfaction and communications skills were given pre- and posttherapy plus 3 and 6 months later. Couple and therapist therapy behavior were assessed using audio tapes of interview sessions. A variety of sex and social class differences were found that correlated with therapy outcome. The overall thrust of the findings suggests that no one marital therapy technique will be appropriate for the different sexes and with those of different SES backgrounds.     

A narrative view of art therapy and art making by women with breast cancer

Art therapy (with an art therapist) and art making (without an art therapist) show promise as avenues for psychosocial support for women with breast cancer. The purpose of this study was to gain an in-depth understanding of how 17 women with breast cancer in Canada and the USA used art therapy and their own art making to address their psychosocial needs, focusing particularly on meaning making. Narrative analysis of interviews yielded four storylines: Art and Art Therapy as a Haven; Getting a Clearer View; Clearing the Way Emotionally; and Enhancing and Enlivening the Self. The storylines show existence being affirmed, confirmed and proclaimed through visual artistic expression and meaning making being achieved through physical acts of making.     

ASSESSMENT FOR COUPLE PSYCHOANALYTIC PSYCHOTHERAPY

ABSTRACT A therapist assessing with a view to couple psychoanalytic psychotherapy needs to hold several potentially conflicting points of view in mind simultaneously. Firstly the therapist attends to the experience of the session as an interaction with the 'shared internal world' of the couple, in the present, seeking to understand the dynamic meaning of whatever happens in the course of the meeting. At the same time the assessor needs to explore the question of appropriateness of different possible treatments, which may necessitate explicitly seeking certain kinds of information, relating, for example, to early experience or to risk assessment.
The various points of view can be felt to be in conflict with each other, and I suggest that different parts of this complex enterprise are unfamiliar to, and may be neglected by different professional groups.     

THE USE OF VIDEO IN PSYCHOTHERAPY SUPERVISION

This article provides a rationale for the increased use of video recording psychotherapy sessions in clinical supervision and training, including psychodynamic and psychoanalytic training. Social and cognitive psychology research on memory shows that it is limited in a number of ways and, because of this, supervision that solely depends on second‐hand reporting of session events in supervision can be equally limited. Additionally, second‐hand reporting and audiotapes of session material are often not able to adequately shed light on the nonverbal behaviour exhibited by the patient and therapist. Video recording allows a supervisor to view the session material as it happened during the session so as to provide more effective supervision and psychotherapy training. Examples are given from face‐to‐face once‐weekly work, in a training clinic which uses non‐mandatory video recording. Concerns about confidentiality and ethics are discussed, along with potential objections to video recording.     

Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement

Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence–outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness‐based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory‐II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in‐session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.     

The Psychotherapist's Erotic Subjectivity

The therapist's erotic desires towards the client is a much tabooed and little discussed subject within psychoanalysis and psychotherapy. It is suggested that this topic needs to be opened up for scientific exploration and discussion. This paper is an investigation into the nature of the therapist' s erotic subjectivity. A review of the literature suggests how difficult it is for many analysts to deal with their erotic desires towards the client completely successfully. Some clinical examples are given to illustrate how the therapist's erotic desires may make a positive contribution to the analysis. It is suggested that erotic desires are inevitable and are part of a healthy Oedipal development. The child needs to internalise and identify with the opposite sex parent's ability to contain incestuous longings. Like the parent, the therapist can expect to have sexual feelings for his or her clients. It is further suggested that objective erotic desires can be as useful as any other feeling the therapist might experience so long as they are analysed and understood in the client's interest.     

Psychotherapy in Japan: the case of Mrs. A

The problems of Mrs. A's children are the initial focus of professional work. Her depression receives professional attention in the course of treatment of the children. Mrs. A is most likely working individually with an eclectic therapist, with increasing her awareness and insight as treatment goals. Developing a good working relationship with the client is of prime importance to the therapist. Projective as well as objective psychological tests may be used. Her psychiatrist prescribes antidepressant and sleep-inducing medications. Mrs. A's family may not be involved in her treatment; group therapy and self-help resources are also unlikely to be used. I argue that to understand psychotherapy in Japan, the context of psychotherapy practice as well as cultural influence needs to be considered.     

Some Observations on Studying Therapists Instead of Treatment Packages

Some practical problems are highlighted with regard to studying the outcomes of individual therapists, including the long and inconsistent success in finding therapist variables that explain differential client treatment response. Research on the individual therapist makes it clear that considerable variability in outcome exists at the extreme ends of the normal distribution of therapist effects. Much less is known about the variability of client outcomes within specific therapists' clients. We encourage further research on therapist effects, but concede that such research is not likely to provide actionable information for routine clinical care. In the meantime, client treatment response needs to be monitored if positive outcomes are to be maximized.     

Adult Development and the Transformative Powers of Psychotherapy

This article explores the ways in which receiving, providing, and teaching others to do psychotherapy have influenced my adult development. In my 70s, I arrived at the conviction that at every stage of adulthood, practicing psychotherapy has had a direct and causal influence on my efforts to fill my personal life with meaning, virtue, and maturity. The first section of this article focuses on the ways in which learning to be a particular kind of psychoanalytic therapist facilitated my transition into early adulthood. The middle sections describe how I have used the professional practice of psychotherapy to integrate or dissolve the boundaries between work and play, and science and art, in the everyday conduct of my life. My psychobiographical analysis concludes with some reflections on a professional failure and the compensations of being an aging therapist.     

Therapy with eight schizophrenic and borderline patients: summary of a therapy approach that employs a semi-symbiotic bond between patient and therapist.

In conclusion, it appears to this therapist that working through a semi-symbiotic union is a useful and perhaps essential therapy technique with both schizophrenic and borderline patients. The essential ingredients of this technique include: (1) open expression of feelings by the therapist; (2) consistency and reliability by the therapist; (3) understanding and acceptance of schizophrenic jargon; (4) acceptance of the patient's ambivalent feelings about closeness and distance and allowing distancing tactics; (5) interpreting and working through distancing needs as an on-going process -- understanding that they generally indicate both fear of rejection and of incorporation; (6) acceptance of a long-term semi-symbiotic responsibility to the patient; (7) expression of the therapist's own legitimate limits and of his inability to meet all the patient's needs; (8) allowing and encouraging the patient the freedom to grow toward increasing independence with security.     

The Treatment of Acute Schizophrenic Patients in Private Practice

There are more schizophrenic patients outside hospitals than in them. Acute schizophrenics are a varied group of patients who very frequently may be best treated in outpatient office practice. They need a therapist who is strong enough to be a protective object and an auxiliary ego and who will deal with the unconscious meaning of the hallucinatory and delusional experiences. Relatives may provide support and housing for patients who would otherwise be hospitalised. Relatives can tolerate a psychotic individual surprisingly well if they see this as a response to an emergency situation which will be necessary for only a month or two at most. The availability of the therapist to the patient by telephone also permits the patient to deal with experiences and situations that would otherwise overwhelm him and require hospitalisation, or end in suicide. How to deal with patients without medication or how optimally to use medication, if that is the therapist's or the patient's preference, is discussed. In the light of current evidence it is clear that prolonged and continuous medication is not neurologically in the patient's best interest.     

Dissemination and Implementation of Evidence–Based Practices: Training and Consultation as Implementation Strategies

To provide effective treatment for individuals with mental health needs, there is a movement to deploy evidence‐based practices (EBPs) developed in research settings into community settings. Training clinicians in EBPs is often used as the primary implementation strategy in these efforts, despite evidence suggesting that training alone does not change therapist behavior. A promising implementation strategy that can be combined with training is consultation, or ongoing support. This article reviews the literature on consultation following initial training. A model of consultation is presented as well as preliminary findings regarding effective consultation techniques. Future directions are offered.     

心理治疗与咨询中临床督导工作的探讨

本文对国外临床督导的相关问题进行回顾,针对目前我国心理咨询和心理治疗专业发展要求,心理咨询和心理治疗职业培训中对临床督导工作的大量需求、意义、目标和内容等进行了讨论,并探讨了适合我国临床督导工作的思路.     

Teaching problem-oriented therapy

The therapeutic concept is problem- and patient-oriented. In analogy to it the didactic concept is problem- and therapist-oriented. The essential point is learning in groups from practical cases. Problem-oriented in this context means that the problems-solving process in which the patient and the therapist are engaged is supported by the observer group. Therapist-oriented means that the learning process should take account of the different preferences and experiences of the therapists. That can only be accomplished by problem-oriented learning. Each psychotherapy training group consists of 4 assistant doctors and a supervisor and stays together about 1 year. The strongly structured concept of problem-oriented therapy (POT) [Blaser et al., 1988] offers the beginner a framework by which he can guide the dialogue with the patient. The eclecticism of POT allows the more experienced therapist to try out new methods without losing track of the problem. The constantly changing role of being observer or therapist supports the group coherence, and furthermore it promotes an important element of therapeutic competence, the ability to get into a close relation with the patient and at the same time being able to observe oneself, the patient and the therapeutic process from a more distant view. In addition to the POT training group tutorials in special psychotherapy methods and single supervision sessions are offered.     

An Attachment-Based Approach to Working with Clients Affected by HIV and AIDS

This paper examines the relevance of attachment theory in the provision of psychological support to people who are affected by HIV. It highlights the themes of change, loss and vulnerability as central to the issues which confront members of this client group. Indications are provided of a range of attachment-related behavioural responses which can be activated by these conditions, and illustrations are provided of how the activation of attachment behaviour can destabilize the relationships of some clients who are anxiously attached. The concept of a secure base, a term first coined by Mary Ainsworth and developed as a theme by the originator of attachment theory, John Bowlby, is presented as being a central provision by the therapist in work with clients who are affected by HIV, and illustrations are given of how the therapist might begin to help build a secure base for clients who have anxious, internal working models of attachment. The paper concludes with an indication of how an attachment-based approach might be used in working with clients in the terminal stages of HIV-related illness.     

What do these sounds tell us about the therapeutic alliance: Acoustic markers as predictors of alliance

Predicting the trajectories of alliance formation that the patient is likely to establish with the therapist during treatment, even before their first meeting, can help prevent the potentially harmful consequences of deterioration in alliance, such as poor outcome and premature dropout. The present study aimed to examine the ability of four pretreatment acoustic markers to predict the alliance that is likely to be formed in the course of treatment: F0 span, speech rate, pause proportion and jitter. Data from 560 observations of 38 patients were collected as part of an ongoing randomized clinical trial of short-term psychotherapy for major depressive disorder. The acoustic markers were measured using high-quality recordings at baseline, before the patient and therapist ever met or had any type of communication. A multilevel model was used to examine the ability of the four acoustic markers to predict the slopes of alliance formation in the course of treatment, all markers being introduced in the same model. The clinical utility of the acoustic markers was explored in two case studies. The model explained 22% of the variance in alliance formation. Higher levels of both jitter and pause proportion at baseline predicted less strengthening of the alliance in the course of treatment. The findings, which should be replicated in larger samples, suggest that much of the therapeutic alliance can be predicted based on the acoustic characteristics of the patient's voice in the first 3 min of their intake, before they even meet their therapist.     

Supervision: A Choice between Equals?

ABSTRACT. The two main functions of supervision are safeguarding the patient and training the therapist. When difficulties arise in therapy the supervisor faces the dilemma of which of these is his priority. The purpose of this paper is to suggest a solution to this by focusing on the role responsibilities of the supervisor.     

Using the primary process emotional–behavioural system to better meet patient needs in psychotherapy

In order to increase therapeutic impact by enhancing awareness of clients' nonverbal communications, this article operationalizes the therapeutic alliance as a needs‐satisfaction process. The client's competence as a needs seeker and the therapist assisting with the client's expression and satiation of basic social needs are proposed as being key mechanisms of change. Functional model of primary emotions derived from Panksepp's seven primary emotional systems (care seeking, caretaking, lust, fear and anxiety, anger, play, seeking, plus dominance and disgust) is integrated with Functional Analytic Psychotherapy's emphasis on in‐session contingent natural reinforcement of clients' target behaviours. By identifying in‐the‐moment cues of underlying emotional–behavioural functions drawn from a categorization of clients' nonverbal communication can bridge the gap between client private events and therapist observables, in order to maximize therapist attunement and responsiveness to clients, and to increase the effectiveness of clinical interventions.     

Implications of therapist effects for the design and analysis of comparative studies of psychotherapies

Technical reasons are presented as to why therapist should be included as a random design factor in the nested analysis of (co)variance (AN[C]OVA) design commonly used in psychotherapy research. Incorrect specification of the ANOVA design can, under some circumstances, result in incorrect estimation of the error term, overly liberal F ratios, and an unacceptably high risk of Type I errors. Review of studies indicates that the great majority of investigators continue to ignore this issue. Computer simulation studies revealed that considerable bias can be introduced by not specifying therapist as a random term. Finally, a reanalysis is presented of data from 10 psychotherapy outcome studies that indicated that therapist effects vary considerably and at times can be large. More recent studies that implement better quality controls appear to demonstrate less variance due to therapist. The implications of these results for the design of future studies are discussed.