Volunteer client attachment moderates the relationship between trainee therapist attachment and therapist interventions

Abstract

This study explored the association between attachment security of therapists (alone and in interaction with clients' attachment) and therapist interventions in early sessions of short-term psychotherapy. Trainee therapists and volunteer clients (N=24) in short-term therapy completed the Experiences in Close Relationship Scale (Brennan, Clark, & Shaver, 1998) as a measure of adult romantic attachment orientations. Therapist interventions were identified and related to client and therapist attachment orientation. Results indicated that in early therapy sessions client attachment moderated the relationship between therapist attachment and therapist interventions. Specifically, avoidantly attached therapists intervened with more directive interventions when clients were high in attachment avoidance.     

A comparison of client and therapist goals for people with aphasia: A qualitative exploratory study

Background: A considerable body of literature attests to the efficacy of client and therapist collaborative goal setting to achieving optimal rehabilitation outcomes. Collaborative goal setting and shared decision making relies on good communication, thus potentially disadvantaging people with aphasia.

Aims: This study aims to identify the similarities and differences between client goals and therapist goals in rehabilitation for people with aphasia and to explore reasons why any differences occur.

Methods & Procedures: Three speech-language pathologists and four people with aphasia participated in in-depth semi-structured interviews to identify rehabilitation goals. All the interviews were transcribed and analysed using qualitative content analysis.

Outcomes & Results: Results indicated both matching and mismatching of goals between the clients and the speech-language pathologists. Matched goals tended to focus on communication outcomes. Mismatched goals were those associated with the client's desire to return to previously valued activities. Reasons for the mismatching included: impaired communication made collaboration on goal setting difficult, the service-delivery approach, the goal was perceived to be outside the speech-language pathologist's scope of practice, and the goal was not considered to be appropriate within the confines of the rehabilitative situation.

Conclusions: This study highlights the need for speech-language pathologists to understand their clients' goals and how these can be incorporated into rehabilitation. A re-examination of some professional beliefs was highlighted. Future research may lead to educational resources that enable better collaborative goal setting between therapist and client so that outcomes of rehabilitation are optimised.     

Pilot test of a measure to assess therapeutic distance and its association with client attachment and corrective experience in therapy

Abstract

Objectives: The Therapeutic Distance Scale (TDS) was developed in this project to assesse clients' experiences of distance versus engagement with their therapist. Method: In a survey study of 47 university clients at the “mid-stage” and 34 of these clients at termination, four TDS subscales were identified: Too Close, Too Distant, Growing Autonomy, and Growing Engagement. Results: TDS subscales were correlated as expected with working alliance and Client Attachment to Therapist. As hypothesized, (i) pre-therapy attachment Avoidance was significantly correlated with perceptions of therapists as Too Close (but not Too Distant), (ii) pre-therapy Anxiety was significantly correlated with Too Distant (but not Too Close); furthermore, among clients who developed a secure attachment to their therapist, (iii) pretherapy Avoidance was significantly correlated with Growing Engagement; however, (iv) contrary to expectations, pre-therapy anxiety was not significantly associated with Growing Autonomy. Conclusions: The TDS is a promising measure for assessing the in-therapy corrective emotional experiences of clients with hyperactivating attachment (i.e. increasing autonomy) and deactivating attachment (i.e. increasing engagement).     

Unpacking the therapist effect: Impact of treatment length differs for high- and low-performing therapists

Objective: Differences between therapists in their average outcomes (i.e., therapist effects) have become a topic of increasing interest in psychotherapy research in the past decade. Relatively little work, however, has moved beyond identifying the presence of significant between-therapist variability in patient outcomes. The current study sought to examine the ways in which therapist effects emerge over the course of time in psychotherapy. Method: We used a large psychotherapy data set (n?=?5828 patients seen by n?=?158 therapists for 50,048 sessions of psychotherapy) and examined whether outcomes diverge for high-performing (HP) and low-performing (LP) therapists as treatment duration increases. Results: Therapists accounted for a small but significant proportion of variance in patient outcomes that was not explained by differences between therapists' caseload characteristics. The discrepancy in outcomes between HP and LP therapists increased as treatment duration increased (interaction coefficient?=?0.071, p?p?=?.040). Conclusions: Indeed, patterns of change previously described ignoring between-therapist differences (e.g., dose-effect, good-enough level model) may vary systematically when disaggregated by therapist effect.     

Clients' Perceptions of Marriage and Family Therapists Addressing the Religious and Spiritual Aspects of Clients' Lives

Abstract

As marriage and family therapists are emphasizing the actual contexts of clients' lives, religion and spirituality are being addressed as important aspects of culture. This pilot study investigated whether clients felt their therapist adequately addressed the religious and spiritual aspects of their lives according to their desires for such. Thirty-eight clients who attended therapy at university clinics were surveyed using a questionnaire about their own religiosity and spirituality, about their preferences to have religion and spirituality addressed, and whether they perceived their therapist addressed religion and spirituality in the therapy process according to their desires. Results show these family therapists did rather well at addressing the religious and spiritual aspects of their clients' lives. Demographic correlations showed that the gender of the client and whether the university clinic they attended was affiliated with a religious denomination were each positively correlated to whether the clients wanted religion and spirituality addressed and whether their therapist adequately addressed these issues. Detailed limitations are noted.     

Evaluating staff training: Taking account of interactions between staff and clients with intellectual disability and challenging behaviour

Abstract

Background Hastings (2010) has recently emphasised 3 aspects in the training of staff who serve clients with mild to moderate intellectual disability and challenging behaviour (CB): Staff attitudes, self-awareness, and clients' perspectives. This study investigates whether programs include these aspects.

Method A systematic search yielded 11 relevant articles.

Results Generally, all programs aimed to improve staff knowledge and skills. Client variables concerned frequencies and severities of CB. None of the studies included clients' perspectives or staff attitudes and self-awareness.

Conclusions The fact that staff attitudes and awareness or clients' perspectives were not among the main goals of the training studies suggests that recent views of effective treatment of CB are not yet the object of scientific study. Given the acknowledgment of these aspects, it is warranted that future research focuses upon these recent insights.     

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa

Objective: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. Method: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. Results: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. Conclusions: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.     

The therapist's attachment representation and the patient's attachment to the therapist

Abstract

This study examines the relationship between the therapist's own attachment representation (Adult Attachment Interview, AAI) and the patient's attachment relationship to the therapist (client's attachment to the therapist, CATS). The attachment representations of n=22 psychotherapists who treated n=429 patients were assessed. A general effect of the secure/insecure therapist attachment status on the attachment of the patient to the therapist was not found whereas the more specific effects expected could be confirmed: The more preoccupied the therapist's attachment status was, the more the patient experienced a preoccupied-merger attachment to the therapist. The more dismissing the therapist's attachment status was, the more the patient experienced an avoidant-fearful attachment to the therapist. In summary, not the general security/insecurity of the therapist's attachment representation but rather the type of the insecurity is associated with the subjective patient's attachment-related experience of the therapeutic dyad.     

Sexual boundaries in the relationship between clients and clinicians practising sexology in the UK

Abstract

A survey was carried out with the collaboration of seven European countries to identify clinicians working within the field of sexual and psychosexual medicine, and to gain insight into the varied practices of physicians, psychologists, nurses and therapists in this area. In the UK a questionnaire was sent to 2352 potential practitioners working in the field of human sexuality, of which 814 responded detailing their training, professional practice and opinions about sexology. Clinicians were categorised by their initial training as either physicians or non-physicians. A total of 279 physicians responded and 535 non-physicians. One area of investigation was the relationship between clients and their doctor or therapist, exploring the extent to which boundaries and in particular sexual boundaries are appropriately maintained. This paper seeks to explore the issues surrounding breach of boundaries by therapists and doctors working in sexology, including our findings on the extent to which various sexual practices or clients' sexual experiences have made clinicians feel uncomfortable.     

Immediate therapist self-disclosure bolsters the effect of brief integrative psychotherapy on psychiatric symptoms and the perceptions of therapists: A randomized clinical trial

Objective: We report a first randomized clinical trial examining the effect of immediate and non-immediate therapist self-disclosure in the context of a brief integrative psychotherapy for mild to moderate distress. Method: A total of 86 patients with mild to moderate forms of distress were randomly divided into three 12-session integrative psychotherapy conditions based primarily on [Hill, C. E. (2009). Helping skills: Facilitating, exploration, insight, and action (3rd ed.). Washington, DC: American Psychological Association.] three-stage model. Therapists trained in this treatment modality were instructed to use either immediate self-disclosure (expressing feelings towards the patient/treatment/therapeutic relationship) or non-immediate self-disclosure (expressing personal or factual information regarding the therapist's life outside the treatment). In the comparison condition, the therapists were instructed to refrain from self-disclosure altogether. Results: Immediate therapist self-disclosure reduced psychiatric symptoms among patients with elevated pretreatment symptoms (as assessed by the Brief Symptoms Inventory) and bolstered a favorable perception of the therapist. Therapists in both the immediate and non-immediate self-disclosure group evaluated themselves more favorably than their counterparts in the non-disclosure group. Conclusions: Therapist self-disclosure, particularly of the immediate type, might enhance the effect of brief integrative treatment on psychiatric symptoms of high symptomatic patients and contribute to favorable perception of therapists.     

Clients' and therapists' perceptions of intrasessional connection: An analogue study of change over time,predictor variables,and level of consensus

Abstract

Clients' and therapists' within-session experiences of relational connection were investigated using an analogue design. Eighty “therapist–client” dyads rated, on a minute-by-minute basis, their levels of connection to the other over a 20 minute counselling session. Therapists' and clients' feelings of connection increased over time with a negatively accelerating curve. Clients experienced a greater increase in feelings of connection with therapists that they perceived as less anxious; while older therapists, and therapists who believed they were perceived as more agreeable, experienced a deeper connection. Clients' and therapists' perception of connection were significantly associated, with a median within-dyad correlation of .76.     

Dominance and Nurturance in the Figurative Expressions of Psychotherapy Clients

It has been recognized that clients' figurative expressions can be a window into the central themes of therapy and can reveal much about clients' affective experiences, thought processes, and perceptions of self and others. However, there have been few attempts to study the use of figurative expressions within a theoretical or conceptual framework that links the content of clients' figurative expressions to therapy outcome. In this article, we present the results of a study in which all client-generated figurative expressions relating to interpersonal actions from 21 cases of psychotherapy were selected and coded on Kiesler's (1985) Acts Version of the Interpersonal Circle. Results revealed a fairly clear and theoretically consistent relationship between therapy outcome and the location on the interpersonal circumplex of clients' figurative expressions of self actions.     

Patient Responsiveness to Therapist Values and Outcome in Group Cognitive Therapy

This study examined the relations between therapy outcome and the following predictor variables: the initial similarity of patient and therapist values; patient responsivity/sensitivity to therapist values; value convergence; changes in dysfunctional beliefs; and patients' ability to identify their therapists' values. Depressed older adults (n = 29) were randomly assigned to cognitive therapy (CT) or to a pharmacotherapy/supportive therapy condition. Responsiveness to therapist values was significantly related to improvement in depression, as measured by the Beck Depression Inventory. Initial value similarity was associated with value convergence. Subjects in the CT condition evidenced greater value convergence and more accurately identified therapist values than those in the pharmacotherapy condition.     

Specific and common processes as mediators of the long-term effects of cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder

Objective: A trial of psychotherapy for generalized anxiety disorder (GAD) demonstrated that motivational interviewing (MI) integrated with cognitive-behavioral therapy (CBT) outperformed CBT alone on clients’ worry reduction across a 12-month follow-up. In the present study, we hypothesized and tested that less client resistance and greater client-perceived therapist empathy (specific foci of MI) would account for MI’s additive effect. Exploratory analyses assessed whether the common processes of homework completion and therapeutic alliance quality mediated the treatment effect. Method: Clients with GAD were randomized to 15 sessions of MI-CBT (n?=?42) or CBT alone (n?=?43). Worry was assessed throughout treatment and follow-up. Observers rated resistance at midtreatment, and clients reported on perceived therapist empathy, alliance, and homework completion throughout treatment. Mediation was tested with bootstrapping methods. Results: Expectedly, MI-CBT clients evidenced less resistance and perceived greater therapist empathy, each of which related to lower 12-month worry. However, when both variables were tested simultaneously, only resistance remained a significant mediator of treatment. No indirect effects through homework completion or alliance emerged. Conclusions: Reducing client resistance may be a theory-consistent mechanism through which integrative MI-CBT promotes superior long-term improvement than traditional CBT when treating GAD.

Clinical or methodological significance of this article: This study further supports the long-term clinical benefit of integrating MI into CBT when treating the highly prevalent and historically difficult-to-treat condition of GAD. In particular, it points to the theory-specific mechanism of MI (helping to reduce/resolve patients’ in-treatment resistance) as accounting for the integrative treatment’s additive effect on worry reduction across a follow-up period. Therapists using CBT to treat patients with GAD should be trained to incorporate MI principles (e.g., empathy, collaboration, autonomy support) in general and in response to explicit markers of resistance.     

Does shape matter? preferences for a female therapist's figure among patients with eating disorders

Abstract

Although the female therapist's figure has been a topic of discussion with regard to psychotherapy for eating disorders, it has not yet been addressed empirically. In this study, participants with eating disorders (n =34) and a control group of participants with anxiety disorders (n =30) were asked to indicate how important the therapist's figure is to them and what shape they would prefer a therapist to have. The therapist's figure was more important among participants with eating disorders than among those with anxiety disorders. Participants in both groups favored a therapist with an average figure. Within both groups, participants preferred their therapist to have a shape similar to their own. Clinical implications are discussed.