The unsaid in the psychotherapy narrative: Voicing the unvoiced

In research interviews, psychotherapy clients, from different therapeutic approaches, identified silent moments entailing processes that facilitated their therapeutic progress. A grounded theory method was used to analyse these interviews resulting in three categories of productive pauses: emotional, expressive and reflective pauses. This study examines these categories in relation to their narrative context, and, more broadly, to narrative theory. It highlights what remains unsaid in the psychotherapy narrative, describes these silent processes that transform narration into a therapeutic experience and reframes the therapeutic narrative as a method for structuring introspective silences.     

Running: An adjunctive group therapy technique

Group therapists who work with severely disturbed patients know that group sessions are often characterized by verbal rambling, frequent and prolonged pauses and high levels of anxiety on the part of group members. This article focuses on the use of a group activity— namely, running—as an adjunct to group psychotherapy. A brief case report will illustrate the application of this innovative treatment technique; then issues that may arise when one leads a running group are dealt with in a question- and -answer format.The author wishes to express his appreciation to Mrs. Vera Kohn for editorial assistance in the preparation of this article.     

Therapeutic factors in two forms of inpatient group psychotherapy: Music therapy and verbal therapy

Therapeutic processes in one type of creative arts group psychotherapy, music therapy, were compared with verbal group psychotherapy. Sixty-one short-term inpatients ranked group psychotherapy curative factors and completed satisfaction ratings. Therapists rated 201 group therapy sessions— 109 music therapy and 92 verbal therapy. Statistical analysis revealed that patients highly valued both group formats. The mean curative factor rankings for both groups included cohesiveness, instillation of hope, and altruism among the most helpful factors. Therapists' ratings indicated qualitative differences between the two groups. Music therapy involved more therapeutic interaction among patients and emotional expression, whereas verbal therapy emphasized concrete problem solving.Supported in part by Biomedical Research Support Grant Program grant #S07-RR05755 from the Division of Research Resources, National Institutes of Health.     

Innovative moments and poor outcome in narrative therapy

Aims: To analyse a poor outcome case of narrative therapy with a woman victim of intimate violence. Method: The Innovative Moments Coding System: version 1 was applied to all sessions to track the innovative moments (i‐moments) in the therapeutic process. I–moments are the narrative details that occur in psychotherapeutic conversations that are outside the influence of the problematic narrative. This research aims to describe the processes involved in the stability of meanings in psychotherapy through a dialogical approach to meaning making. Findings: Contrarily to what usually occurs in good outcome cases, re‐conceptualization i‐moments are absent. Moreover, two specific types of i‐moments emerged with higher duration: reflection and protest. Qualitative analysis showed that the potential meanings of these i‐moments were surpassed by a return to the problematic narrative. Conclusion: The therapeutic stability seems to be maintained by a systematic return to the problematic narrative after the emergence of novelties. This process was referred from a dialogical perspective as a mutual in‐feeding of voices, one that emerges in the i‐moment and another one that supports the problematic narrative, which is maintained by an oscillation between these two types of voices during therapy.     

Leadership behavior,group climate and outcome in group psychotherapy: A study of outpatient psychotherapy groups

A recent clinical study of outpatient psychotherapy groups in a community mental health center explored the linkage between group leadership variables, group climate, and outcome. The study involved nine outpatient therapy groups, over 50 group clients, and several group therapists. A repeated measures design involving assessment of clients' outcome and level of functioning, group leadership style, and group climate was used to assess changes over a 6-month period. The findings suggest: 1) a reduction in symptoms and improved functioning for clients; 2) a similarity of perceptions by members and leaders of perceived leadership behaviors and group climate; 3) the presence of direct and indirect influences of group climate and leadership behavior on clients' outcome; and 4) a linkage between leadership behavior and group climate with the theoretical orientation of the group. The findings of the research are discussed in relation to the understanding of specific effects in group psychotherapy and the implications for construction of group psychotherapy theory.The authors would like to thank Robert Dies, Ph.D., for his helpful suggestions in the early phase of this study; Roy MacKenzie, M.D., for permission to use the Group Climate Questionnaire; Diane DePalma, Ph.D., for permission to use the Global Leadership Behavior Index; Chris Boltwood, B.A., for her untiring efforts in administering the instruments and coding and entering the data; and most importantly, the psychotherapy group members and the group therapists for their cooperation in this endeavor—without their help, this clinical study would not have been possible.A version of this paper was presented at the Annual Meeting of the American Group Psychotherapy Association, 1987, New Orleans, Louisiana. Lenore Phipps, R.N., M.S., C.S., was formerly Director, Group Psychotherapy Program at Park Ridge Mental Health Center, Rochester, now in private practice at Guild Medical Center, Norwood, MA 02062.     

Hope as empowerment model: A client-based perspective on the process of hope development

Abstract

Research on the relationship of client hope to successful therapy outcome underlines the need to discover the processes and conditions when hope flourishes. Snyder’s Hope Theory has been applied to psychotherapy but client subjective experiences are needed to illuminate nuances in the process. The present study examined the trajectory of hope development in psychotherapy using interviews with 18 counseling clients, analyzed using grounded theory methodology. Findings were synthesized into a dynamic model titled hope as empowerment model (HEM) that shares features of Snyder’s Hope Theory. HEM introduces patterns of particular salience to psychotherapy. The compatibility of client preferences with therapist input raised faith in the process of counseling and, in turn, hope in a positive outcome. A number of conditions, including the flexibility of client role preferences and the directiveness of hope-inspiring therapeutic strategies, influenced the nature and strength of client hope. Implications for therapy and positive psychology are considered.     

Some comments on the role of cotherapists in group psychotherapy with borderline patients

This paper points out examples of patients in a psychotherapy group who meet DSM-III criteria for the diagnosis of borderline personality disorder and who are treated by cotherapists utilizing object relations theory. Interpretations of phenomena shown by borderline patients—splitting, projective identification and denial—are illustrated. How cotherapy lends itself to the recognition and management of the problems these patients bring to group psychotherapy is illustrated.Hope Aspell assisted in the editing of this paper.     

Peak Performance of Business Leaders: An Experience Parallel to Self-Actualization Theory

To investigate peak performance, 40 business leaders described personal experiences through interviews and the Privette Experience Questionnaire. In order to discriminate processes of peak performance from personality attributes of business leaders, their questionnaire data were compared with parallel data from a sample of 41 university men. Multivariate analyses of variance of factors and items and follow-up analyses indicated that scores differed but not on defining attributes. The peak performance dyad—full focus and clear sense of self—and aspects of peak experience—significance and fulfillment—were endorsed by both samples. Business leaders endorsed sociability and personal discipline and denied playfulness more than the university men, who endorsed fluidity. The relation of peak performance to self-actualization theory is discussed.     

My Perspective on Psychotherapy Integration: An Outsider Who's Out of It

My rejoinder is a response to two commentaries on my SEPI keynote in 1997: commentaries written by Goldfried and Cullari. Instead of grappling with the ideas I presented, both respondents were distracted by my satirical beginning. In my talk I proposed a method for studying psychotherapy integration. I am not pessimistic about the potential for integration, nor am I pessimistic about psychotherapy. But I am a skeptic, and science is driven—and indeed advance—by skepticism. In fact, psychotherapy integration requires that its advocates be skeptics. I still do not know what psychotherapy integration is, and remain confused. I can only conclude that I am not only an outsider, but out of it.     

Journeys through the valley of death: multimethod psychological assessment and personality transformation in long-term psychotherapy

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is based on the assumption that an in-depth understanding of clients' underlying emotional, personality, and interpersonal patterns will facilitate their treatment. In this article I show how such an understanding can be achieved through multimethod psychological assessment, and how useful such information can be in long-term psychotherapy with high-achieving, successful clients who struggle with forming and maintaining intimate relationships. Such treatments are extremely difficult, because when these clients attach to their psychotherapists, many of them temporarily become more symptomatic. I illustrate these points with a detailed account of my long-term therapy with a resilient but highly traumatized young man. Repeated use of the Minnesota Multiphasic Personality Disorder-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and Rorschach with my client helped guide us in our work, and also helped create an important therapeutic "opening" into the underlying traumatic material. This and other experiences have convinced me that it is extremely useful for psychologists to have training in both assessment and psychotherapy.     

Is rational-emotive therapy (RET) “rationalist” or “constructivist”?

Conclusion Mahoney, Guidano, and other modern constructivists and process-oriented therapists are partly on the right track and are making some interesting additions to traditional cognitive therapy. But they sometimes also revert to inefficient and side-tracking psychoanalytically-oriented methods of therapy. RET, in both its individual and family therapy approaches, attempts to use the most effective and hardheaded of the so-called rationalist methods—including active—directive changing of unrealistic and irrational Beliefs, skill training, problemsolving, bibliotherapy, in vivo desensitization, and reinforcement procedures-and it also employs many of the methods of the cognitive constructivists—including the disclosing of tacit philosophies; the achievement of a profound philosophical change in clients' attitudes toward themselves, toward others, and toward life situations; the use of the therapist's relationship with clients to show them how to unconditionally accept themselves; and the employment of many dramatic, emotive, and experiential exercises to change clients' feelings as well as their thoughts and behaviors. RET is particularly interested in effecting both individual and familial change as quickly and as efficiently as feasible. It is therefore rational (efficaciously hedonic)and emotive (energetically experiential). Or at least tries to be!Keynote address to World Congress of Cognitive Therapy, Oxford, England June 29, 1989     

Aspects of the Client's Conscious Control of the Psychotherapeutic Process

An analysis is made of the opening moments of dialogue between and a client and her therapist in the light of the client's commentary given during an Interpersonal Process Recall interview about the moments. These moments are drawn from a study of 14 clients' reports on their experiences of therapy, thus particularizing the general understanding derived in the larger project. This passage of dialogue was chosen because the client's commentary revealed that, in the brief space of time involved, she had exerted control in terms of the three main relationships as experienced by all clients in the larger study: the relationship with the self, the therapist, and the therapist's techniques. Such control is understood to be an expression of clients' reflexivity, defined as self-awareness and agency within that self-awareness. The understanding that there is an agential involvement in reflexivity is based on both the participants' reports and the author's examination of his own consciousness. The study is discussed in terms of clients' covert experience of therapy and ways of gaining greater access to the unspoken in order to facilitate the working alliance.     

Ethical considerations in the use of nonerotic touch in psychotherapy with children

Although touch frequently occurs in psychotherapy with children, there is little written on the ethical considerations of therapeutic touch. Because physical contact does occur, therapists must consider if, how, and when it is used, for both their clients' safety and their own. In this review, I further develop the issues suggested by Aquino and Lee (2000) in the use of nurturing touch in therapy by considering many types of touch that occur in psychotherapy with children; the possible positive role of touch; clients' perception of touch in therapy; considerations related to the therapist, the child's safety, and any history of abuse in the child's and family's background; and other practical considerations. I list guidelines.     

The Impact of Specific Psychotherapist Beliefs Regarding Managed Care on Prospective Psychotherapy Clients

The purpose of this study was to investigate the separate impact of each of thirteen therapist beliefs that, presented collectively, were previously found to have a significantly negative impact on prospective clients' attitudes toward managed care psychotherapy (Pomerantz, 2000). Participants in this study initially completed a brief questionnaire measuring their willingness to enter psychotherapy and their expectations regarding psychotherapy under managed care. Participants subsequently completed the same brief questionnaire again after being instructed to imagine seeing a hypothetical psychologist and being presented with the psychologist's supposed beliefs regarding managed care (which were actually derived from survey data by Murphy et al., 1998). Results suggest that almost every discrete therapist belief had a significantly negative impact on participants' attitudes toward managed care psychotherapy. Several specific therapist beliefs produced particularly salient negative effects. Implications regarding ethics and informed consent are discussed.     

Effects of unit formation on the perception of a changing sound

The effects of subunit formation on adult listeners' ability to notice changes in a continuous spectral gradient of sound were studied. Results of this experiment support the idea that the auditory system processes information differently within a unit, and that this processing does not occur unless the perceptual system detects unit boundaries. In this experiment, silences were inserted into a continuously changing sound to cause the formation of short units. Listeners noticed the change earlier in conditions with silences inserted than in to conditions where the transition was either unbroken or broken by loud noise bursts. Results are discussed in terms of two processes, one that accentuates stimulus properties present at moments of onset and offset, and a second that uses onsets and offsets to signal the beginnings and ends of units and reduces the change perceived within units.     

A Social Constructionist Model of Therapeutic Factors

Evidentiary support for the efficacy of therapeutic models has been a contentious issue since the professionalization of psychology. Despite advances in evidence-based practices in psychology and common factors research, discontent still exists among postmodern psychotherapists in that evidence is mainly defined in modernist/positivistic terms, thereby excluding therapeutic models based on alternative nonpositivistic epistemologies. I proposes a model, which is based on social constructionist theories, for investigating the therapeutic efficacy of various approaches. This article evaluates and differentiates between two models for viewing the efficacy of psychotherapy, namely outcome versus process efficacy. A social constructionist model of therapeutic factors is proposed as a means to incorporate therapeutic factors into psychotherapy processes that are consistent with a social constructionist theory of change. Three main therapeutic elements, which are identified as central to an effective psychotherapy process, are outlined in the model. The proposed model may be useful as a guide to efficacious psychotherapy and as a means for investigating the efficacy of social constructionist therapies.     

Cross-fertilization versus transmission: Recommendations for developing a bidirectional approach to psychotherapy dissemination research

Psychotherapy researchers are increasingly engaged in collaborations with clinical practitioners and mental health administrators. Each party brings its own perspectives, values, and agendas to bear in these encounters. Viable research—practice collaborations depend on understanding and negotiating some of the tensions in these relationships. In this article, we discuss the contexts that prevail for various participants in a psychotherapy dissemination study as well as the values, goals, costs, and benefits related to research participation. This article is a collaboration among the researchers, mental health administrators, therapists, and clients involved in an ongoing treatment dissemination study. Our recommendations for research—practice collaborations are based on our experiences and dialogues over the course of this study.     

Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Strategies for counseling protestant evangelical families

A significant segment of the population—evangelical Christians—has historically been underrepresented in psychotherapy and in the treatment literature. Consequently, few guidelines for therapeutic decision making and intervention have been articulated. Because the clergy are showing an increasing willingness to refer these people to human service professionals, it is important that clinicians be informed about this group of potential clients. Therapeutic strategies whick take into account the unique characteristics of this population are discussed in light of four stages in the development of the helping relationship.Portions of this paper were presented at the meeting of the American Association of Marriage and Family Counselors, Philadelphia, October 1976.