Expression and interpretation of emotions in multilingual psychotherapy: A literature review

This review aimed at presenting the findings of 19 original studies that were published in the period from 2000 to 2022 in order to outline the current state of the art in the field of emotion communication (i.e., expressing and interpreting emotions) in multilingual psychotherapy. This analysis involves in particular the studies that investigate multilingual phenomena (e.g., code-switching and language-mixing) that occur during psychotherapeutic sessions when client and therapist can speak more than one language, as well as the articles that research emotion communication in this multilingual setting. With this in mind, the articles selected for this review are divided into two main categories: linguistic phenomena in multilingual psychotherapy and emotion communication in multilingual psychotherapy. Results of the studies in the current analysis reveal that code-switching remains one of the main linguistic phenomena that arises in the area of multilingual psychotherapy. Switching languages in therapy tends to be considered as beneficial for both client and therapist. Besides, findings suggest a connection between speaking L1/LX and one's identity (e.g., feeling different depending on the language). Additionally, studies that investigate emotion communication in multilingual psychotherapy show that an individual's first language (L1) is predominantly viewed as more emotionally charged than their language(s) learned later in life (LX). However, some studies also demonstrate that the relationship between L1 and LX is more fluid and context-dependent than it has traditionally been regarded. Propositions are given for future research in the field of emotion communication in multilingual psychotherapy.     

‘Coming out’ in therapy? Perceived risks and benefits of self‐disclosure of sexual orientation by gay and lesbian therapists to straight clients

Primary objective: The study's primary objective was to investigate the experiences of gay and lesbian therapists, when considering self‐disclosure of their sexual orientation to straight (i.e. heterosexual) clients. This qualitative study set out to ascertain the key factors gay therapists take into account when considering this decision and to explore the effects this self‐disclosure may have on themselves, their clients and their therapeutic relationships. Research design: The research design was based on the use of semi‐structured interviews, undertaken with a non‐random, purposive sample of counsellors and psychotherapists (n=8) in current practice. The rationale for this method was to aid exploration of therapists' experiences of the process of self‐disclosure. Methods and procedures: Inclusion criteria were for therapists who self‐identified as being gay or lesbian, and who were experienced in clinical work with straight clients. Transcribed data was analysed using inductive thematic analysis. Main outcomes and results: Some therapists reported being confident with self‐disclosure relating to their own sexual orientation. However, a common theme related to the reportedly high levels of anxiety and vulnerability, which therapists identified. Key themes emerged around: respondents' fears of client judgement; a need for therapist self‐protection; self‐awareness of the potential impact of their own fears and prejudices on the therapeutic relationship; and the potential relevance of internalised homophobia, as an overall constraining factor. Conclusions: Self‐disclosure of their sexual orientation to straight clients is constructed, in this initial survey, as being potentially problematic and risky for some gay therapists.     

Popular or unpopular? Therapists' use of structured interviews and their estimation of patient acceptance

An accurate diagnosis is an important precondition for effective psychotherapeutic treatment. The use of structured interviews provides the gold standard for reliable diagnosis. Suppiger et al. (2009) showed that structured interviews have a high acceptance among patients. On a scale from 0 (not at all satisfied) to 100 (totally satisfied) patients rated overall satisfaction with a structured interview at M = 86.55. Nevertheless, therapists rarely seem to use structured interviews in clinical practice. The aim of this study was to assess how frequently therapists use structured interviews in daily practice. Secondly, we hypothesized that therapists underestimate patient acceptance of structured interviews. As a third goal, we explored further reasons why therapists choose not to use structured interviews. We conducted an online survey of 1,927 psychiatrists and psychotherapists in Switzerland and asked them how frequently they used structured interviews and how they estimated patient satisfaction with these interviews. Furthermore, we asked therapists why they chose to use or not use structured interviews. Therapists reported using structured interviews on average with about 15% of their patients. Furthermore, therapists estimated significantly lower patient acceptance than patients themselves indicated (M_therapist = 49.41, M_patient = 86.55). Our data suggest lack of familiarity with these instruments as well as an overestimation of the utility of open clinical interviews as further reasons for not using structured interviews.     

Intimate boundaries: Therapists’ perception and experience of erotic transference within the therapeutic relationship

Aim: This study explored therapists’ understanding and experiences of erotic transference within therapeutic relationships. Method: A small‐scale qualitative research project was undertaken with six therapists working within different counselling contexts. Data was collected through semi‐structured face‐to‐face interviews, and an Interpretative Phenomenological Analysis used for analysis of individual perception and experience. Findings: All participants had experienced what they understood to be erotic transference and/or sexual and loving feelings within therapy. There was little differentiation between the two phenomena, and both were often referred to interchangeably. There were contradictory views as to whether using the phenomena would be beneficial to client work, but there was a strong motivation to learn more about it. Therapists who encountered sexual attraction within therapy experienced feelings including shame and embarrassment. Supervisory support was seen to be beneficial. Implications/conclusion: The importance for therapists to acknowledge a lack of clarity that exists around the understanding of erotic transference and its relationship to sexual attraction within therapy is noted. Also, a recognition that better access to training regarding erotic transference and sexual responsibility within client relationships might be helpful to therapists in their work.     

Psychologists' and counsellors' perspectives on prolonged grief disorder and its inclusion in diagnostic manuals

Introduction: In this research, proposed criteria for what has been termed ‘Prolonged Grief Disorder’ (PGD) (more recently termed, ‘Persistent Complex Bereavement‐Related Disorder’ (PCB‐RD) in the proposed DSM‐V), were presented to psychologists and counsellors. Method: Participants were asked about their views on the ‘disorder’ and whether they considered its inclusion in diagnostic manuals was justified. A total of 185 participants, (147 psychologists, specialist and general, and 38 counsellors) responded to an online survey (part of a larger research project), concerning their attitudes, choices and activities regarding bereavement therapy. In this part of the research, therapists’ perspectives about pathological grief, the recognition of PGD and its inclusion in diagnostic manuals were explored. Fifty‐nine participants took the option of adding written remarks to the survey to expand on their opinions regarding PGD. Results/Conclusions: Tentative support for the inclusion of PGD in diagnostic manuals was given; however many therapists indicated considerable reservations about potential negative repercussions of using such a diagnosis. One‐way between‐groups analysis of variance was undertaken to determine whether participants' opinions varied according to main occupation or specialism; however, no significant difference was found. This research was conducted prior to the latest update to the proposed revision and diagnostic category concerning bereavement in the DSM‐5 of April 2012, but many observations and recommendations concerning PGD made by the therapists participating in this research can be seen to be applicable to PCB‐RD. Implications: The implications of this research for assessing and diagnosing grief, and ways of working with bereaved clients, are discussed.     

We have travelled a long distance and sorted out the mess in the drawers: Metaphors for moving towards the end in psychotherapy

Aim: To explore the process of ending in psychotherapy, in particular how clients and therapists draw on their notions of client improvements and prepare for the upcoming end. Data: The data comes from an intensive process‐outcome study at the University of Oslo, Norway. The study includes audio‐recording from all sessions and separate post‐therapy interviews with clients and therapists. Twelve psychotherapy dyads were selected because they had reached a ‘good enough’ ending. Therapy duration ranged from 7–43 months. The number of sessions ranged from 10–67. Method and analysis: A hermeneutical‐phenomenological approach analysed and combined the observational and reflexive data. The analysis was carried out using a method for systematic text condensation and through reflexive dialogues with the material and between the researchers. Findings and discussion: The language of improvement towards the end of treatment seemed packed with metaphors conveying growth in both affective and relational management. Metaphors based on travel (how they have moved); cleaning (how they have cleaned up and sorted out things); sensing (how the clients have grown stronger, got their heads above water and see things differently); and the clients’ feeling of having received something (gifts or tools) are widely used. Such metaphors are created in the interaction with a mutual sensitivity to their capacity to confirm and regulate affect towards the end. In this sense, the metaphors celebrate accomplishments in a way that exceeds therapy, and the client can keep them to use afterwards.     

Psychotherapists' dreams about their patients

Abstract This study examines therapists’ dreams about their patients from the Jungian and the relational perspectives. Few clinical and empirical references to this subject are to be found in the literature. In the present study 31 dreams were collected from 22 therapists. Dreams were collected using anonymous self‐report inventory. The research focused on three theoretical research questions: 1. What themes appear in the manifest content of therapists’ dreams about their patients? 2. What contributions are made by Jungian interpretation of therapists’ dreams about their patients? 3. To what extent are masochistic contents present in the manifest content of therapists’ dreams about their patients? The first question was addressed using categorical content analysis of a) themes common to different dreams and b) pre‐determined themes for all dreams. The third research question was addressed using Beck's (1967) ‘Masochistic Dream’ measure. Results: Among the themes common to different dreams were: therapist‐patient role reversal; therapist and/or patient attends and remains in meeting, departs/doesn’t depart; cancellation of therapy session; sexuality between therapist and patient; aggression; presence vs. absence; non‐verbal relationship and communication; time; driving vs. stopping. With regard to pre‐determined themes it was found that in 20 of the 31 dreams, the therapist had a negative experience and was characterized as vulnerable. Likewise it was found that 26 out of 31 dreams took place in either a) a street, a road, a route, a corridor; b) en route to somewhere; c) a therapy room and/or building; d) a house. With regard to the contribution of Jungian interpretations of the dreams it was found that 17 of the dreams had diagnostic and prognostic elements, 4 of which were initial dreams, 9 of them were compensatory dreams and in 14 it was found that the patient represents the shadow of the therapist. With regard to the third question it was found that 18 of the 31 dreams met Beck's (1967) criteria for masochistic dreams. The theoretical discussion examines the findings from a Jungian perspective, with an emphasis on also understanding the dream in terms of its expression of relational aspects of the therapist‐patient relationship. The findings affirm the presence of the ‘wounded healer’ archetypes in therapists’ dreams about their patients. The results of the study indicate that therapists’ dreams about their patients can be a valuable tool for deepening understanding of the therapeutic relationship and process.     

The missing explanation of the false‐belief advantage in bilingual children: a longitudinal study

Bilingual preschoolers often perform better than monolingual children on false‐belief understanding. It has been hypothesized that this is due to their enhanced executive function skills, although this relationship has rarely been tested or supported. The current longitudinal study tested whether metalinguistic awareness was responsible for this advantage. Further, we examined the contributions of both executive functioning and language ability to false‐belief understanding by including multiple measures of both. Seventy‐eight children (n = 40 Spanish‐English bilingual; age M = 49.29, SD = 7.38 and, n = 38 English monolingual; age M = 47.75, SD = 6.86) were tested. A year later the children were tested again (n = 22 bilingual, n = 25 monolingual). The results indicated that language and executive function (inhibitory control) at time 1 were related to false belief in monolinguals at time 2. In contrast, bilinguals' metalinguistic performance at time 1 was the sole predictor of false belief at time 2. The different linguistic and cognitive profiles of monolinguals and bilinguals may create different pathways for their development of false‐belief understanding. A video abstract of this article can be viewed at: https://youtu.be/vILn2gKjFxw     

Person‐centred counsellors' experiences of working with clients in crisis: A qualitative interview study

Aims: This study aims to explore and understand person‐centred therapists’ experiences and work with clients at the pivotal point of crisis. Specifically: how do person‐centred therapists experience working with clients in crisis? Do they identify differences in crisis intervention compared to non‐crisis work? What do they perceive as helpful to crisis clients? How relevant are therapists' own experiences of crisis? Method: Participants were all experienced person‐centred therapists. Qualitative, semi‐structured interviews were conducted and the data were analysed qualitatively using person‐centred/phenomenological methodology. Results: Respondents identified differences in their experiences. Typically, therapists described polarity in their experience of danger and opportunity, also heightened energy levels within themselves, perceived higher levels of engagement, faster pace of work, experiences of reaching ‘relational depth’ earlier, and the importance of assisting symbolisation of clients' experience in awareness. Clients were experienced as vulnerable, unable to access previous coping mechanisms, in a state of breakdown and disintegration, but also as wide open, having dropped their usual defences, and more available to engage in therapy and enter the process of change and potential post‐crisis growth. Discussion: The findings are discussed in relation to prevailing models of crisis intervention, person‐centred theory and theoretical developments in post‐traumatic growth in the aftermath of crisis.     

What do psychodynamic therapists make of their reveries in the therapeutic encounter? A constructivist grounded theory study

ABSTRACT

The therapist’s mind can wander to daydreams, fantasies and preoccupations: mental events termed “reveries” in this study. As therapists attend to the current of their thought in the therapeutic encounter, the question of how to approach their reveries can arise. This qualitative study used semi-structured interviews with nine qualified psychodynamic therapists to investigate therapists’ attitudes to reveries. The research design and analysis followed the principles of Charmaz’s [Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage; Charmaz, K. (2014). Constructing grounded theory (2nd ed.). London: Sage] constructivist grounded theory. Results showed that therapists experienced diverse reveries sometimes felt to yield deeper clinical understanding. Reveries were also seen to have a “freeing-up” function for the therapist and patient, and to require mental freedom to operate. Implications for theoretical understanding and recommendations for clinical technique are discussed.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

A discourse analysis of power in relation to PSYCHLOPS (Psychological outcome profiles) in the context of CBT for psychosis

Aims: Outcome measures (OMs) and routine change measurement have developed dramatically in psychological therapies over the last two decades and some therapists have expressed concerns that this, depending on how it is handled by the parties involved, can markedly affect the therapy. However, little research has investigated this. It therefore seemed timely to explore discourses of OMs drawn upon by both parties in the therapy room. Method: PSYCHLOPS (Psychological Outcome Profiles) is a client‐centred measure which offered an opportunity to explore how therapists and clients receiving CBT for psychosis talked about OMs. A useful contrast was provided by the CORE‐OM (Clinical Outcomes in Routine Evaluation‐Outcome Measure). The discourses drawn upon by clients (n=4) and therapists (n=4) were analysed, informed by a Foucaultian framework. Results: OMs were constructed as empowering or disempowering of clients, as being able to do therapeutic work of engagement and containment, and as part of the apparatus of service power, positioning therapists as relatively powerless to question their use. Discussion: It is suggested that client‐centred measures like PSYCHLOPS, although partly aligned with a recovery framework, may become part of top‐down state and service power, and there is a need for more research into the different ways in which OMs are used in therapy and the impacts on therapists, clients and their relationships.     

The Individualised Patient‐Progress System: A decade of international collaborative networking

Background: The backstage of research projects is seldom presented to the general audience, in particular, how the research questions emerged, how the team interacted and how the methods and design were decided upon. Aim: In this paper we will recount the story behind an international practice‐based research network for personalising health assessment, the joint journey of researchers and therapists from three different countries in creating the Individualised Patient‐Progress System (IPPS). Results: We first describe how the idea of the IPPS emerged; then we show how IPPS is being piloted and integrated into clinical practice. Next, we present the views of therapists and researchers who have been part of this project. Conclusions: We discuss some lessons learned from this 14‐year collaborative research programme.     

The Embodied Attunement of Therapists and a Couple within Dialogical Psychotherapy: An Introduction to the Relational Mind Research Project

In dialogical practice, therapists seek to respond to the utterances of clients by including in their own response what the client said. No research so far exists on how, in dialogs, therapists and clients attune themselves to each other with their entire bodies. The research program The Relational Mind is the first to look at dialog in terms of both the outer and the inner dialogs of participants (clients and therapists), observed in parallel with autonomic nervous system (ANS) measurements. In the ANS, the response occurs immediately, even before conscious thought, making it possible to follow how participants in a multiactor dialog synchronize their reactions and attune themselves to each other. The couple therapy case presented in this article demonstrates how attunement is often not a simple “all at the same time” phenomenon, but rather a complex, dyadic or triadic phenomenon which changes over time. In the case presented, there was strong synchrony between one therapist and one client in terms of their arousal level throughout the therapy session. It was also observed that high stress could occur when someone else was talking about something related to the participant, or if that person mirrored the participant's words. Overall, it seems that in evaluating the rhythmic attunement between therapists and clients it is not enough to look at single variables; instead, integrated information from several channels is needed when one is seeking to make sense of the embodiment.     

The Variability of Criterion‐Related Validity Estimates Among Interviewers and Interview Panels

The authors examined differences in criterion‐related validity estimates among ratings from individual interviewers and interview panels within a structured interview. Senior non‐commissioned officers (NCOs) in the U.S. Army (N=64) conducted panel interviews with 944 junior NCOs during a concurrent validation project. Analysis of the data revealed considerable variation in interviewer validity coefficients in relation to multiple performance criteria. Results also indicated the importance of adopting a multivariate perspective when evaluating interviewer validity differences in that the amount of variation in validity coefficients differed both by interview dimension and criterion. A similar pattern of findings emerged when analyses were performed on ratings averaged within interview panel. Nonetheless, when meta‐analysis was used to estimate the amount of true variance in interviewer‐ and panel‐level validity coefficients, most or all of the variance for some interview‐criterion combinations appeared to be due to statistical artifacts.     

‘Learning from research’: Therapist perspectives on the benefits and challenges of participating in a longitudinal,systematic case‐study

Objectives: In psychotherapy research we have often neglected to examine the impact of research procedures on therapy process and outcome. Such information is extremely important in helping us evaluate the validity of our findings, increase relevance of research for practice, and choose appropriate methods for future projects. The aim of this paper is to share the experience of six person‐centered therapists, who participated in a longitudinal, systematic study, and present their reflections about the impact of research on therapy process, therapeutic engagement and professional development. Methods: The findings have emerged from semi‐structured interviews that took place after the first, sixth (middle) and last therapy session. In total 18 interviews were conducted. These data were part of a much larger research protocol that included a number of outcome and process measures. Results & Conclusions: The analysis of therapist narratives revealed important benefits for those participating in systematic case study research. The use of Brief Structured Recall methods and qualitative interviewing was an important factor in promoting therapist reflexivity and professional development. The importance of a strong research alliance and the active involvement of the client in the research process is discussed.