Case Formulation and the Therapeutic Relationship: The Role of Therapist Self‐Reflection and Self‐Revelation

This article examines the role of the therapist's self‐reflection and self‐revelation in case formulation. We believe that a collaboratively constructed case formulation must always be considered in the context of an evolving therapeutic relationship. Further, self‐reflection and self‐revelation on the part of the therapist are critical for a more elaborate and nuanced case formulation and for understanding the patient. This highlights the importance of attunement to the here and now and the evolving therapeutic relationship. From this attunement, the therapist's self‐reflection and self‐revelation can emerge further, which can lead to the patient's personal growth and increased self–other awareness. To illustrate our point, we present an integrative, relational model in the case of a patient who has been in treatment.     

Integrating Between‐Session Interventions (Homework) in Therapy: The Importance of the Therapeutic Relationship and Cognitive Case Conceptualization

Between‐session interventions, or homework, are crucial to a range of psychological therapies, including cognitive behavior therapy (CBT). Therapeutic interventions often involve experiencing emotions and situations, or examining strongly held views about their problems, that clients can find distressing. Hence, the clinician faces a particular challenge in collaborating with the client to carry out these interventions between sessions. In this article, we convey how this process in CBT requires not only a consideration of the theoretically meaningful determinants of adherence behavior but also a sophisticated cognitive case conceptualization. Using case material, we illustrate the interplay between in‐session design, planning, and review of between‐session interventions and the conceptualization. We also include a distinction between generic elements of the therapeutic relationship and CBT‐specific elements. The case material also attends to the person of the therapist, and his or her own cognitive and emotional reactions occurring throughout the process of discussing between‐session interventions.     

Becoming a self‐therapist: Using cognitivebehavioural therapy for recurrent depression and/or dysthymia after completing therapy

Objectives: To explore the ways in which people use cognitive‐behavioural therapy (CBT) for recurrent depression and/or dysthymia after leaving therapy. Design: A qualitative interview was used in this study. Method: Semi‐structured interviews were carried out with nine people who had completed a course of CBT at least three months previously. The interviews explored their use of CBT techniques or models outside of therapy and their everyday management of depression. Results: Eight of the nine participants reported engaging in some self‐therapeutic activity, and identified depression, or the threat of depression, as a continuing presence in their lives. They used a range of techniques, either directly transferred from therapy or modified in some way, and identified a number of changes in the way they reacted to difficult situations or negative emotions. These included enactive responses such as leaving the room, making self‐efficacy statements, or remembering what the therapist had said to them. Participants also described situations in which they could not use the things they had learnt in CBT. Finally, a range of factors that influenced the ways in which participants became self‐therapists were identified. Conclusions: A number of implications for clinical practice are described. An understanding of how people modify CBT and use it (or not) in their everyday lives is important to understanding and improving effectiveness.     

Trainees' self‐evaluation of their development as psychotherapists: An Italian contribution to an international collaborative study on psychotherapy training

This study presents a pilot contribution to the new collaborative, multinational study of psychotherapy trainee development that was undertaken by the Society for Psychotherapy Research Interest Section on Therapist Training and Development (see Orlinsky, Strauss, Rønnestad, et al., 2015 ). Although the main project is longitudinal in design, this preliminary study investigated cross‐sectional differences between trainees in different years of training and explored the influence of core training experiences—including supervision and personal therapy—on their perceived development as therapists. Using the trainee current‐progress report that was designed for the Society for Psychotherapy Research Interest Section on Therapist Training and Development project, 90 trainees at 4 different 4‐year training programs in Italy provided self‐evaluations of their development and of their therapeutic work experiences. Perceived development included overall change, progress, deterioration, overcoming past limitations, and realization of potential as a therapist. Therapeutic work experiences were assessed using scales of healing and stressful involvement (Orlinsky & Rønnestad, 2005 ). Year in training and support in supervision predicted perceived development and healing involvement, whereas experiencing criticism in supervision was associated with stressful involvement. Having had personal therapy, and especially ratings of benefit from personal therapy, was also associated with perceived development and healing involvement. Results are discussed with regard of their implications for psychotherapy training.     

A survey of influences on the practice of psychotherapists and clinical psychologists in training in the UK

A questionnaire survey of 95 qualified psychotherapists of various therapeutic orientations and 69 psychologists in clinical training was carried out to investigate the main influences on their clinical practice, using the Questionnaire of Influencing Factors on Clinical Practice in Psychotherapies (QuIF‐CliPP). For the qualified group the most highly rated factors were current supervision, client characteristics, client feedback, psychological formulation, intuition/judgement, professional training and post‐qualification training. For the trainees, those rated highest were current supervision, past supervision, client characteristics, client feedback, psychological formulation and professional training. Evidence based factors such as treatment manuals and evidence based guidelines were rated relatively low for both groups, although the cognitive behaviour therapists rated them significantly higher than the other groups. Personal therapy was rated highly by the psychodynamic, psychoanalytic, person centred and eclectic therapists but not by CB therapists. The implications of these findings for the application of evidence based practice and the need to evaluated supervision, personal therapy and training are discussed. Copyright © 2006 John Wiley & Sons, Ltd.     

Collaboration in Cognitive‐Behavioral Therapy

Collaborative empiricism, which involves a systemic process of therapist and patient working together to establish common goals in treatment, has been found to be one of the primary change agents in cognitive‐behavioral therapy (CBT). This article focuses on the development of a therapeutic relationship and implementation of collaborative empiricism along with the elements that lead to success in treatment. This method is used to uncover patients’ automatic thoughts and underlying beliefs in treating an array of emotional and behavioral disorders. The role of the therapist is discussed in developing, promoting, and maintaining therapeutic collaboration and what is constituted by the empirical process. A case study illustrates the use of collaborative empiricism with a patient suffering from panic disorder. The article concludes with a series of clinical practices that will enhance collaborative empiricism and collaboration in CBT, and thereby treatment outcomes.     

Witnessing Clients’ Emotional Transformation: An Emotion‐Focused Therapist's Experience of Providing Therapy

Emotion‐focused therapy (EFT) is an integrative–humanistic, research‐informed, psychological intervention characterized by sustained focus on the client's emotional pain and its transformation. This article discusses the impacts on the therapist when encountering and transforming the client's vulnerability. It is organized around the different phases of the therapy process: meeting a new client, accessing the client's core emotional pain, transforming the client's emotional pain, and ending the therapeutic work. The article also contains personal experiences of the author and provides illustrations of impactful events from therapy sessions. The work, it is suggested, provides significant learning for the therapist on both a personal and a professional level, leading, for example, to the therapist's maturation, better connection with personal hurts and vulnerabilities, greater courage in regard to sharing such feelings, greater kindness toward others and the self, and greater determination to be braver when facing adversity or injustice.     

Metabolizing Difficult Doctor–Patient Relationships: Reflections on A Balint Group for Higher Trainees

This paper describes a Balint group in Leeds which, so far as we are aware, is unique in the UK for being aimed at higher level trainees. The paper is written from the trainee's perspective. The experience has been so useful that the group has concluded that this should be an integral part of all higher training schemes. The paper discusses two cases we brought to the group which illustrate some of the challenges faced by trainees at this level of their training. It also aims to inform the reader of the need for such an experience for higher level trainees. The cases presented were experienced by the doctors involved as troubling and disturbing to their sense of self. The Balint group provides a safe environment for discussion of the most disturbing cases, especially those which involve a hard‐to‐bear countertransference, and as such, fosters ongoing personal development. Standard supervisory models are considered unable to provide such a space. The Leeds group, which is made up of trainees from all specialties, have rated the Balint experience as one of the most important in their professional lives.     

Training and disillusion in Counselling Psychology: A psychoanalytic perspective

In this paper, I argue * that Counselling Psychology's professional identification with pluralism poses significant emotional problems for trainees. An important factor in such problems may be the trainee's sense of disappointment and disillusion that the route to professional and personal self‐transformation will not be achieved via a set of universal theoretical principles and established clinical ‘rules’. I draw on recent psychoanalytic theory to suggest that the task facing trainees involves balancing pluralism, characterized as an ‘external’ third position, with an ‘internal’ third space indexing an awareness of subjectivity and intersubjectivity. Maintaining a dialogical‐dialectical perspective on these two positions allows for a creative space in which the trainee may be transformed from lay helper into professional counselling psychologist via a personal engagement with theoretical, clinical and academic material presented during training.     

Corrective Experiences of Psychotherapists in Training

Although the concept of corrective experiences (CEs) is usually linked to the process of change in psychotherapy patients, we investigated them in the professional development of therapists‐in‐training. Inasmuch as psychotherapy is a relational process, it is important to look closely at how therapists reach the position of a competent partner in corrective experiencing. In this study, we interviewed 10 therapists‐in‐training undergoing their own training therapy. Responses to these semistructured interviews were analyzed using a computer‐assisted grounded theory method. The 499 first‐level categories were grouped into 5 main themes: therapist characteristics, therapist technical interventions, therapist relational interventions, relationship experience, and outcome experience. Two core categories representing corrective experiencing were (a) unexpected unconditional support from and trust in their own therapist and (b) unexpected confrontation and limitation with their therapist as well as awareness of self–other boundaries. Results are discussed in the broader context of the CE literature, relational theory, and relational practice.     

A controlled trial of personal construct psychotherapy for deliberate self‐harm

Evidence for the effectiveness of psychological therapies for people who self‐harm is limited. Personal construct theory provides a model of self‐harm and a framework for therapeutic intervention, which was evaluated in the present study. Sixty‐four adults presenting to Accident and Emergency departments following self‐harm were allocated to a personal construct psychotherapy or a ‘normal clinical practice’ condition. They completed various measures at assessment points pre‐ and post‐therapy. Repetition of self‐harm was assessed over a 3‐year period. Participants in the intervention condition showed significantly greater reduction in suicidal ideation, hopelessness and depression post‐treatment than the control group; and significantly more reconstruing at this point and 6‐month follow‐up. There was some evidence suggestive of a lower frequency of repetition of self‐harm in the intervention than in the control group. It is concluded that brief personal construct psychotherapy may be effective for people who self‐harm and merits further exploration.     

Cognitive‐behaviour therapy with youth: advances,challenges, and future directions

Cognitive‐behavioural therapy (CBT) is one of the most widely‐researched therapies for children and adolescents. In this paper, the general tenets of CBT are described, followed by a review of the treatment outcome literature. Overall, there is strong empirical support for CBT with internalizing disorders such as anxiety and depressive disorders whereas more moderate empirical support exists for CBT with externalizing disorders such as attention‐deficit hyperactivity disorder and conduct disorder. The relative efficacy of individual, family, and group forms of CBT is also examined. Finally, future directions for research on CBT are discussed, including (a) determining the focal person(s) of treatment; (b) the importance of field effectiveness trials; and (c) the integration of CBT with other approaches (e.g. function analytic techniques, acceptance‐based approaches). Copyright © 2000 John Wiley & Sons, Ltd.     

Strengthening competence of therapists‐in‐training in the treatment of health anxiety (hypochondriasis): Validation of the Assessment of Core CBT Skills (ACCS)

Although the observation and assessment of psychotherapeutic competences are central to training, supervision, patient care, quality control, and life‐long practice, structured instruments are used only occasionally. In the current study, an observation‐based tool for the Assessment of Core CBT Skills (ACCS) was translated into German and adapted, and its psychometric properties were pilot evaluated. Competence of therapists‐in‐training was assessed in a random sample of n = 30 videos on cognitive behavioural therapy including patients diagnosed with hypochondriasis. Two of three raters independently assessed the competences demonstrated in the entire, active treatment sessions (n = 60). In our sample, internal consistency was excellent, and interrater reliability was good. Convergent validity (Cognitive Therapy Scale) and discriminant validity (Helping Alliance Questionnaire) were within the expected ranges. The ACCS total score did not significantly predict the reduction of symptoms of hypochondriasis, and a one‐factorial structure of the instrument was found. By providing multiple opportunities for feedback, self‐reflection, and supervision, the ACCS may complement current tools for the assessment of psychotherapeutic competences and importantly support competence‐based training and supervision.     

Exploring the personal and professional impact of reflective practice groups: a survey of 18 cohorts from a UK clinical psychology training course

Objectives: Given the importance of reflective practice within clinical psychology and a lack of empirical research, this study aimed to investigate the personal and professional impact of reflective practice groups (RPGs) for former trainees. Design: This study followed an analytic survey design utilizing a convenience sample of qualified clinical psychologists from a UK training programme. Methods: A RPG questionnaire (RPGQ) was developed for the purposes of the study. Following initial pilot work, 297 qualified psychologists were invited to complete the RPGQ. Results: One hundred and twenty‐four psychologists (42%) completed the RPGQ. Factor analysis yielded two underlying constructs labelled ‘value’ and ‘distress’. The RPGQ demonstrated significant internal and test–retest reliability. The majority rated the RPGs as valuable for personal and professional development and learning about group processes. Just under half however reported distress as a result of the groups. Whilst some trainees, who reported distress, were able to view the challenges positively, one‐sixth were not. Potency of facilitation and group size significantly predicted levels of perceived value and distress. Conclusions: In view of the ethical issues raised by compulsory RPGs, recommendations were made to keep group sizes within an average of 10–13, utilize facilitators with sufficient training in group processes and ensure additional methods of reflective practice development are available. Further suggestions and recommendations for future research in relation to coping and personal learning style were also made. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message:

• This study has addressed a significant gap in the clinical psychology literature in relation to the personal and professional impact of reflective practice groups during training.
• It was found that whilst, in retrospect, the majority of former trainees found the challenges of reflective practice groups worthwhile, a significant minority did not.
• Group size, potency of facilitation and previous RPG experience significantly predicted levels of perceived value and distress.
• There is now a need for more research in order to explore the mechanisms involved to maximize potential for value from reflective practice groups.

     

The Quest for Tailored Treatments: A Meta‐Discussion of Six Social Cognitive Therapies

In this commentary on the 6 articles comprising this In Session issue on metacognition and mentalizing in the psychotherapeutic treatment of severe mental disorders, we strive to contextualize and bring together salient issues reflected in these articles. In the foreground of our discussion is the point that the commonalities of these and related social cognitive treatments far outweigh their differences. We attempt to pinpoint some of the more specific tailored treatment elements described by the authors and relate these to empirical findings and theoretical and practical problems. Among the key issues addressed in this commentary are conceptual fallacies, therapist transparency, personality disorder and self‐harm in adolescence, therapeutic alliance, and a metacognitive‐informed group psychotherapy practice for patients with avoidant personality disorder or alexithymia.     

Transference‐focused Psychotherapy for Patients with Personality Disorders: Overview and Case Example with a Focus on the Use of Contracting

Transference‐focused psychotherapy (TFP) is a manualized treatment for patients with a personality disorder based on 18 months of once‐weekly or twice‐weekly therapy. TFP is suitable for publicly funded psychotherapy and private practice. Devised by Kernberg and colleagues, its conceptual framework is based on Kleinian theory of primitive defences in the paranoid schizoid position. A TFP ‘structural assessment’ is carried out before negotiating a treatment contract, which must be agreed before therapy can begin. Contracting addresses destructive acting‐out and isolative lifestyles, and requires a commitment to active engagement with therapy and its agreed aims. The therapist closely attends to relationships outside therapy and transference parallels. The goal is greater integration of the self and self‐object relations. In addition to changes in symptoms, TFP can lead to changes in patients’ defensive structures with concomitant shifts in personality structure, improved satisfaction in life, and fuller engagement in work and relationships. A case example is given of a patient with a withdrawn lifestyle. Her object relationships were interpreted as they unfolded in life outside therapy and in the transference, leading to personality structure changes which enabled her to be able to function successfully in work and in her personal relationships.     

Recognizing the True Norm: Commentary on “Toward Defining,Measuring, and Evaluating LGBT Cultural Competence for Psychologists”

In this commentary, the author discusses the difference between aspirational guidelines and enforceable standards of professional practice and argues that the 28 recommendations proposed by Boroughs, Bedoya, O’Cleirigh, and Safren (Clinical Psychology: Science and Practice, 22, 2015) contain both. The ultimate goal of developing cultural competence training and evaluating cultural competence is to create a professional psychology workforce of people committed to the lifelong practice of self‐evaluation when it comes to the inevitable biases engrained through learning and development within the limitations of our own cultures. The damage of decades of marginalization of sexual and gender minority communities can be ameliorated by improvements in multicultural training and by establishing an expectation that adequate representation of sexual and gender minority participants be included in research on therapeutic practices that will be recognized as treatments with empirical support. The development of criteria for instruction in cultural competence at all levels of psychological training will improve our research and clinical training to be inclusive of sexual minority and gender identity minority individuals, rather than continuing considerations of this population as an out‐group.     

The mindfulness‐based cognitive therapy adherence scale: inter‐rater reliability,adherence to protocol and treatment distinctiveness

The development of the Mindfulness‐Based Cognitive Therapy Adherence Scale (MBCT‐AS) is described. This 17‐item scale measures therapist adherence to the treatment protocol for Mindfulness‐Based Cognitive Therapy (MBCT), a treatment for the prevention of recurrence in Major Depressive Disorder. The MBCT‐AS assesses therapist behaviours specific to (MBCT) as well as therapy practices that MBCT shares with Cognitive Behaviour Therapy (CBT). To determine the utility of this scale, we compared delivery of group MBCT against group CBT, with independent ratings of taped sessions provided to measure adherence to MBCT and CBT for therapists in both groups. The results showed that: (a) raters can reliably use the MBCT‐AS; (b) MBCT therapists demonstrated adherence to the treatment protocol, as measured by the MBCT‐AS; and (c) MBCT is distinguishable from CBT on both the MBCT‐AS and a scale measuring adherence to CBT (CBT‐AS). These findings indicate that the MBCT‐AS may be a useful tool for ensuring the proper delivery of MBCT in future research, and may be helpful in determining the elements of MBCT that are unique to that treatment. Copyright © 2002 John Wiley & Sons, Ltd.     

Comparison of therapeutic action,style and content in cognitive–behavioural and psychodynamic group therapy under clinically representative conditions

It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive–behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy. The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non‐participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self‐efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy—as shown in prior research—but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines. Copyright © 2008 John Wiley & Sons, Ltd.     

The therapist–client relationship,computerized self‐help and active therapy ingredients

There is strong evidence that a good relationship between therapist and client is associated with positive outcomes after all types of psychological therapy. There is also strong evidence that computer‐guided cognitive behaviour therapy (CCBT), in which there may be little or no face‐to‐face contact, is associated with outcomes that are as good as outcomes after conventional therapy. These two sets of findings can be reconciled by reference to the common factors debate, in that common factors may be as important in CCBT as in conventional therapy; and by reconstruing the therapist–client relationship as a channel through which common and specific factors are brought into play. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? Computer‐guided CBT may benefit from a more explicit inclusion of common factors. ? A greater focus on methods of improving the transmission of active therapy ingredients through the therapist‐to‐client channel may be helpful in research and training.