Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.     

Cognitive errors,coping patterns,and the therapeutic alliance: A pilot study of in‐session process

Aim: This exploratory study examined the association between clients’ assessment of the therapeutic alliance and their cognitive errors (CE) and coping action patterns (CAP). Method: Selected therapy sessions of clients (N = 26) were rated for cognitive errors and coping action patterns using the CERS and CAPRS methods (Drapeau, Perry, & Dunkley, 2008; Perry, Drapeau, & Dunkley, 2005). The therapeutic alliance was assessed using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Results: Following Bonferroni corrections, no significant relationship was found between clients’ CEs and their ratings of the WAI. However, the ‘Negotiation’ CAP was associated with the total alliance score, and with the Task and Goal subscales. Implications: A better understanding of the cognitive processes presented by clients in session can enable clinicians to address these factors early on when the alliance is most critical.     

Therapeutic alliance and progress in couple therapy: multiple perspectives

Therapeutic alliance research in couple therapy using multiple perspectives and longitudinal data has been sparse. This study used structural equation modelling to explore relationships between changes in alliance and in progress from clients' and therapists' perspective in a fairly large sample of couples (N=195) during the initial stage of therapy at an on‐campus training clinic. Self‐rated alliance was measured after sessions 2 through 4 with the Working Alliance Inventory. There was very little change in alliance over the early sessions of therapy, and changes in alliance did not always account for changes in relationship satisfaction. Husbands' perceptions of satisfaction and alliance seem to play an important role in the dynamics of the therapeutic process. Findings suggest a reciprocal relationship between perceptions of alliance and progress in therapy when combining perceptions of therapists and couple clients. Clinical implications and future research are discussed.     

The Perceived Relative Strength of the Therapeutic Alliance

ABSTRACT

The association between the perceived relative strength of the therapeutic alliance in couples therapy and psychotherapeutic outcome was investigated. The perceived relative strength of the couples therapeutic alliance was classified into three categories: a balancedalliance (an individual perceives his/her own alliance and the partner's alliance as approximately equal in strength), a positively biasedor blessedalliance (an individual perceives his/her alliance as stronger than the perception of the partner's alliance) and a negatively biasedor just biasedalliance (an individual perceives his/her alliance as weaker than the perception of the partner's alliance). The impact of a consensus or non-consensus within each partner about the perceived relative strength of the alliance on outcome was also investigated. The Alliance Inventory for Couples was used as a measure of the alliance and outcome was assessed with the Family Environment Scale and the Marital Satisfaction Scale. No statistically reliable relation was found between perceived relative strength of the alliance and improved outcome. Consensus was also not predictive of outcome. These findings failed to confirm previous theoretical propositions and empirical research. Possible reasons for discrepancies between the current findings and previous research are provided. The distinction between perceived strength and strength based upon independent self-report measures; and the designation of biased, blessed and balanced alliances merit future research.     

A practice-based exploration of therapeutic change in a charitable,community-based person-centred counselling service using routine outcome measures of anxiety and depression. I: Statistical and clinically significant change

Background

Establishing the value of differing treatments for depression and anxiety is crucial in a climate of delimited spending and increased demand. Drawing from a well-founded, diverse evidence base is salient to constructive evaluation and any subsequent recommendations being fit for purpose.

Design

This study employed a practice-based quantitative design to explore therapeutic gains in adult counselling clients attending person-centred therapy (n = 301), delivered in a charitable, community-based UK service.

Measures

Outcome measures PHQ-9 and GAD-7 were used from three time points: initial assessment (IA), first ongoing session and last or 6th ongoing appointment (whichever occurred first; T1, T2 and T3).

Analysis

Repeated measures ANOVA, CSI, RI and RCSI calculations were used to consider significant change in clients.

Findings

Reductions in PHQ-9 and GAD-7 outcome measures were observed over time (between T2 & T3 and T1 & T3) and were all statistically significant (p = <0.001). By T3: CSI was achieved by 48.1% of clients on PHQ-9 and 50.8% of clients on GAD-7, RI was achieved by 47.8% of clients on PHQ-9 and 60.5% of clients on GAD-7, and RCSI was achieved by 32.6% of clients on PHQ-9 and 41.2% of clients on GAD-7.

Conclusions

The treatment observed resulted in effective outcomes equivalent to other therapies reviewed in the literature for clients' symptoms of anxiety and depression as measured by GAD-7 and PHQ-9.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

Quantity and Quality of Homework Compliance: A Meta-Analysis of Relations With Outcome in Cognitive Behavior Therapy

Homework assignments have been shown to produce both causal and correlational effects in prior meta-analytic reviews of cognitive behavior therapy (CBT), but this research area has been characterized by a focus on the amount of compliance (i.e., quantity), and little is known about the role of skill acquisition (i.e., quality). A landmark study by Neimeyer and Feixas (1990) showed stronger homework-outcome relations when quality was assessed, but previous reviews have not considered whether the same pattern is evident across studies. Seventeen studies of CBT (N = 2,312 clients) published following calls for research on homework quality were included in the current meta-analysis. In the present review, homework compliance relations were demonstrated when outcome was assessed at posttreatment (quality Hedges’ g = 0.78, 95% Confidence Interval [CI] = 0.03 to 1.53, k = 3, n = 417; quantity g = 0.79, 95% CI = 0.57 to 1.02, k = 15, n = 1537) and at follow-up (quality g = 1.07, 95% CI = 0.06 to 2.08, k = 3, n = 417; quantity g = 0.51, 95% CI = 0.28 to 0.74, k = 7, n = 1291). All effect sizes were different from 0, ps < .05. Differences that were obtained in homework-outcome relations among sources of compliance data (client, therapist, objective) were tentative due to overlapping CIs, but suggest a potential moderating effect. If confirmed by further research, the present findings would suggest that trial methods capable of assessing both quantity and quality have been an important omission in research on homework-outcome relations in CBT.     

What Cognitions Predict State Anger?

This study evaluated the relationship between specific cognitions and state anger. Clinical outpatients (23%), workplace recruits (37%), and college students (40%) (N = 236, mean age = 31.68) completed a questionnaire, the Anger Episode Record (AER), which asked them to describe an experience that elicited feelings of irritation, annoyance, anger, fury, or rage. They rated the intensity of their anger, cognitions, physiological responses, behaviors, and consequences for the specific episode. A stepwise multiple regression suggests that cognitions for revenge accounted for the greatest variance in predicting state anger, R = .26, p = .00, followed by demands on event, R = .32, p = .00, self-efficacy, R = .37, p = .00, and demands of others, R = .39, p = .04, respectively. The role of these cognitions in psychotherapy and interventions for angry clients is discussed.     

Communication Questions for Couples

ABSTRACT

In this article, I share a series of questions to help couples, either in therapy or as a homework assignment, reflect upon various aspects of their relationship. The questions also provide the less articulate, less emotionally available partner a structured platform to share and connect. This activity gives many couples a sense of hope since it provides opportunities to practice relating more intimately and to experience the closeness that often results.     

Examining the help-seeking intentions of Chinese individuals in the United States

The underutilization of mental health services by Chinese individuals in the United States is concerning. In this study, we examined Chinese individuals’ help-seeking intentions utilizing the theory of planned behavior. Two hundred fifty-one participants were recruited for this study. The results revealed that help-seeking attitudes (β = 0.28, p < 0.001), perceived behavioral control (β = 0.21, p < 0.001), and subjective norms (β = 0.13, p < 0.001) were found to be significant predictors of help-seeking intentions. The implications of the results are discussed.     

Revisiting Bordin's Theory on the Therapeutic Alliance: Implications for Family Therapy

Because of the belief that relationships are a major contributor to problems as well as the avenue for bringing about change, the alliance between therapists and clients is important in family therapy. Writings and ideas on the therapeutic alliance from psychoanalytic theory were used by Edward Bordin to develop a working theory in 1979, and later adapted to the field of family therapy. However, the adaptation did not account for many variables unique and important to family therapy. This article describes the therapeutic alliance and the necessity of creating a theory of therapeutic alliance that accounts for family therapy concepts. Future ideas for scholarship are presented.     

Basic psychological needs satisfaction,working alliance,and early termination in psychotherapy

The goal of this study was to evaluate the relationship between basic psychological needs satisfaction and working alliance in psychotherapy and to determine whether client ratings of basic needs and working alliance during psychotherapy were associated with early termination of therapy. Former psychotherapy clients (n = 87) completed a semi-structured interview regarding basic needs satisfaction in therapy, working alliance and dropout status. Participant ratings on the Basic Needs Satisfaction in Psychotherapy scale (BNSP) and the Retrospective Working Alliance Inventory – Short (RWAI-S) were significantly correlated (r = .77) in our sample. A comparison of intercorrelations between working alliance subscales and basic needs subscales indicated higher factorial distinctiveness within the basic needs measure. T-tests comparing those who terminated psychotherapy early with those who had planned endings on scores on the BNSP and RWAI-S were significant (Cohen’s d = .65 and 1.82, respectively). Results suggest that the basic needs measure might tap into a wider breadth of the therapist and client interaction than the RWAI-S.     

Does community violence exposure moderate the associations between maternal spanking and early child behavior problems?

A robust research literature links parental spanking with negative behavioral outcomes for children, however, it remains unclear whether conditions in the community may moderate the associations between spanking and behavior problems in early childhood. In the current study, we examined whether community violence exposure moderated the associations of maternal spanking with externalizing and internalizing behavior problems of young children. The sample used in this study was urban families and their children ages 3–5 (n = 2,472). We used fixed effects regression models, which yield stronger statistical control for baseline behavior problems, selection bias, and omitted variables bias. Mother's spanking was associated with elevated levels of both externalizing (β = .037, p < .001) and internalizing (β = .016, p < .001) behavior problems. Community violence exposure also predicted higher levels of externalizing (β = .071, p < .01) and internalizing (β = .043, p < .05) behavior problems. Community violence exposure did not moderate the associations between maternal spanking and behavior problems. Professionals working with families should promote the use of nonphysical disciplinary practices, regardless of the level of violence and crime in the community in which the family resides.     

Psychological Distress in Australian Clients Seeking Family and Relationship Counselling and Mediation Services

There is little published data on the prevalence of psychological distress among individuals and couples seeking counselling and mediation services from non‐government organisations (NGOs). This national cross‐sectional study establishes the prevalence of psychological distress among clients seeking family and relationship counselling and mediation services from Relationships Australia. A national sample of 1,365 clients attending services in April to May 2012 completed the 10‐item Kessler Psychological Distress Scale (K10) after their first counselling or mediation session. Individual counselling (M = 23.01, SD = 8.97, 95% CI [22.05–23.97]) and couple counselling (M = 21.63, SD = 8.10, [20.86–22.41]) clients reported a mean K10 score comparable to those reported by clinical studies of clients with anxiety or affective disorders. One quarter to one fifth of these clients reported very high psychological distress. Clients accessing mediation services had a mean score of 18.13 (SD = 7.76; [17.51–18.75]), and one tenth of clients reported very high distress. These elevated rates of very high psychological distress suggest that mental health issues may be a significant problem for a large proportion of clients accessing counselling and mediation NGO services provided under Family Support Programs (FSP) funding. Implications for screening for mental health and appropriate treatment planning are discussed.     

The Journal of Couples Therapy Entelechy Institute CEU Quiz

SUMMARY

The majority of gay male couples are not monogamous. Relationship clinicians can help gay male couples to have a healthy sexually open relationship by working from a family systems perspective. This approach requires the therapist to have an understanding of family systems theory, the Enneagram (a personality topology), gay male sexual culture, as well as being clear of negative countertransference. Assessment of functionality of sexually open gay male relationships is described.     

Clinicians’ Attitudes Toward Therapeutic Alliance in E-Therapy

Although therapeutic alliance is a crucial factor in face-to-face therapies, no data exist on clinicians’ attitudes towards alliance in E-therapy. The study explored clinicians’ perceived importance of alliance in E-therapy, clinicians’ confidence in their skills to develop alliance in E-therapy, and whether attitudes towards alliance in E-therapy are associated with intended E-therapy practice. Clinicians (n = 106) responded to an online survey. The majority of clinicians considered alliance to be extremely important in both face-to-face therapy and E-therapy. However, clinicians’ ratings of the importance of alliance in face-to-face therapies were significantly higher than their ratings of the importance of alliance in E-therapy. Clinicians reported less confidence in their skills to develop alliance in E-therapy than in face-to-face therapy. Intended E-therapy practice correlated with confidence in one's ability to develop alliance in E-therapy and with previous E-therapy practice.     

Student clinicians’ and clients’ perceptions of the therapeutic alliance and outcomes in stuttering treatment

PurposeThe purpose of this study was to examine how the therapeutic alliances (TA) of graduate student clinicians and adult clients who stutter relate to perceived treatment outcomes.MethodsStudent clinicians (N = 42) and adult clients who stutter (N = 22) completed a survey assessing their TA strength and perception of treatment outcomes. Responses were analyzed to determine similarities and differences in how clinicians and clients relate the TA to perceptions of treatment effectiveness, progress, and outcome satisfaction.ResultsResults suggest that clinicians and clients who stutter both relate the TA to treatment outcome, but in different ways. While clinicians associate the TA most with treatment effectiveness and client progress, clients relate the TA most to outcome satisfaction.ConclusionClinicians should be aware that for adult clients who stutter, outcome satisfaction is related to the degree of shared understanding, agreement on daily tasks, and bond they experience with their clinician. To ensure a strong TA and client satisfaction, clinicians should actively seek their clients’ perspective regarding TA status.     

Strengthening Couples from a Single-Parent Household Using Relational Cultural Therapy

ABSTRACT

Individuals initially learn about intimate relationships from observing others, such as their parents or caregivers’ relationship, which may positively or negatively affect their own romantic relationship. This article focuses on the application of Relational-Cultural Therapy (RCT) concepts to establish resilience among couples with at least one partner from a single-parent household. Some individuals from single-parent households may not have witnessed romantic relationships to confidently engage in adult romantic relationships. Additionally, clinicians may not consider family background as a source of contention for a couple’s presenting concerns. Thus, this article provides creative interventions and implications to assist counselors in working with couples.     

The Sexual Orientation Matrix for Supervision

SUMMARY

The Sexual Orientation Matrix for Supervision (SOMS) was created in order to assist supervisors and trainers in preparing supervisees to work with lesbian, gay, and bisexual (LGB) clients. The SOMS was developed around two core concepts: (1) degree of heterosexual bias, and (2) degree of acceptance of LGB orientations and behavior. Supervisors can employ the matrix to explore both their own and their supervisee's levels of comfort, knowledge, and experience in working with LGB clients including same-sex couples. This article describes the development of the matrix, an exploration of the concepts underlying this tool, and an explanation of how to use the matrix, including suggested tasks for supervision of therapists working with same-sex couples.