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.     

Ethnotherapeutic empathy (EthE)—Part II: Techniques in interpersonal cognition and vicarious experiencing across cultures

Too much of what happens between patient and therapist in cross-cultural therapy is left to chance. No wonder so many experienced cross-cultural therapists are searching for answers to therapeutic failures with their ethnic patients. This article sets out to eliminate some of the guess work, and to leave less of the initial psychotherapeutic process to chance. As one way to actualize latent theory into practical application, the techniques of ethnotherapeutic empathy involve experience-near interactions that offer opportunities for patients to feel they share in shaping the therapeutic venture. Through knowledge of relevant real-life experiences about their therapists, patients learn to feel at ease and empathize with their therapists in cementing the ethnocultural alliance. Though seeming to be unusual and for some, even radical, the complexities of intercultural treatment requires another close look at the therapeutic interface, and the development of strategies to overcome the early profound sense of ethnocultural alienation between patient and therapist. The position here is that bicultural dynamics can be positively influenced by systematic insertion of specific exercises into the fabric of ongoing psychotherapy to hopefully bring about a better gluing interface between patient and therapist.     

Amelioration of transference resistance: substitute therapists in milieu group psychotherapy

Building upon Wolf's (1949) notion of the use of an alternate session in group psychotherapy, this paper suggests that an alternate therapist substituting for an absent regular therapist in milieu group psychotherapy can facilitate similar therapeutic benefits. The mechanism of this process of overcoming transference resistance is seen as twofold: (1) sessions with a substitute therapist allow patients to confront the infantilization often present in a milieu setting and experiment with more autonomous ego functioning. (2) Sessions with a substitute therapist create conditions which are apart from the ongoing process of the therapy group, thereby allowing for a therapeutic splitting process to develop wherein transference feelings about the regular therapist can be expressed to his or her "alter ego." Several case vignettes are presented in order to illustrate the clinical utility of a substitute therapist.     

COURTING THERAPY: FROM ADVERSARY TO ALLY

Within the working life of the psychotherapist, court attendance deserves special consideration. Viewed often with trepidation, the therapist is forced to step outside the therapeutic setting and into an exposing, adversarial experience. Court may then be seen as an untimely impediment to the progress of psychotherapy. In other instances the appearance becomes a discrete pursuit, dislocated from the work of psychotherapy proper, transported to the courtroom and subsumed under the ‘opinion of the expert witness’ .

This paper examines what the patient gains if the therapist less readily adopts these common approaches. Using clinical examples, we may learn how aspects of court work can serve the therapeutic process, rather than being detrimental to developments. In doing so, we hope to begin a guide to successful practice.     

The therapeutic use of self in constructionist/systemic therapy

The introduction of a constructivist orientation to family therapy has promoted a reconceptualization of the therapeutic use of self. The multiply-engaged therapist is seen as positioned within rather than as acting upon a system. Such a therapist facilitates change through participation in, and active engagement with, each system member's perceptions and experience. Multiple engagement synthesizes the "instrumental" and "noninstrumental" perspectives through use of the idea of systemic influence, or systemic positioning. Multiple engagement stresses the relational perspective over the extremes of either pure interventionism or pure facilitation. Five specific therapeutic stances are introduced and are clinically illustrated; taken together, these stances articulate one model for a constructivist family therapy.     

Group psychotherapy and Parkinson's disease: when members and therapist share the diagnosis

This report describes a psychosocial therapy group for Parkinson's patients, focusing on the therapeutic processes arising when group members and therapist share the diagnosis of Parkinson's disease. The paper explores the question, "What is the therapeutic effect on the group when the therapist suffers and displays the same illness as members of the group"? Countertransference issues are described.     

Couples' Experience of Enactments and Softening in Marital Therapy 1

Abstract

Beginning therapists are not prepared to deal with the complexity that families bring to the therapeutic setting and have a reductionistic approach to understanding what is occurring in a family. In order to move beyond a simplified approach, therapists with the assistance of a supervisor have the power to leave the security of their own being and can learn to take risks. This paper explores the development of a “therapeutic story” with the goal of assisting the beginning therapist in approaches that can be utilized to incorporate all available resources that will help to empower a family to change.     

‘WITH PSYCHOSIS IN MIND’ – the reverberations of the psychotic encounter

Psychoanalytic theory offers a varied conceptual system for considering psychosis by providing a coherent representation of the anxieties and processes at work in adult patients. But at the practical clinical level, it is not enough simply to ‘think about psychosis’ and have a theoretical system in place. The therapist must also ‘have psychosis in mind’, that is, get to grips with its forms of logic, gain familiarity with its workings, and learn to understand and accept the effects it has on the therapeutic relationship and on their own expectations. Clinicians engaged in this type of work must be able to tolerate getting back in touch with processes deemed archaic at the core of their own psychological functioning, which will impact their ability to listen and think. These chaotic processes demand a change of approach since they cause a ‘desymbolisation’ that perturbs the internal mental structure of the therapist. This ‘desymbolisation’ is therefore the locus of the therapeutic work, which must attempt to render it comprehensible and represent it. A case study illustrates these processes.     

Informed by the ancients: Norse mythology and psychotherapy

The myth of Kvasir is presented, in part. Through hermeneutic discourse, a case is made that the ancient Norseman had an understanding of the psychotherapeutic arts which finds parallel in contemporary thought. The myth evidences the distinction between: (1) the offering of needed information; and (2) the facilitation of personal, growth-oriented exploration. In contemporary terms, this is the distinction sometimes drawn beween "counseling" and "psychotherapy", respectively. More thorough and careful exegesis of the myth reveals the ubiquitous importance of the personhood of the therapist. It is through the "person of the therapist" that the therapeutic techniques are given life. The ancient wisdom contained in the myth of Kvasir may server as inspiration and guidance for the contemporary psychotherapist.     

Die Therapeutenvariable

Background

The objective of this study was to investigate the therapeutic attitude as a self-contained dimension of the therapeutic process.

Patients and methods

The psychotherapists’ beliefs and attitudes in therapeutic matters are measured according to the Therapeutic Attitude Scales (TASC) of the Therapeutic Attitude Questionnaire (ThAt) and were applied to investigate the therapist variable. The investigation concentrated on the therapist’s belief in the curative value of a number of ingredients of psychotherapy, on the therapist’s individual style of conducting psychotherapy and on basic assumptions about the nature of psychotherapy and the nature of the human mind. A total of 451 psychotherapists (81 psychodynamic psychotherapists, 208 psychoanalytic psychotherapists and 162 behaviour therapists) were investigated.

Results

There were highly significant differences between the three groups of therapists, a finding which is in line with the basic theory. Adaptation and insight of the assumed curative factors as well as supportiveness and neutrality of the technique factors, differentiate the groups highly significantly. The multivariate analysis underlines the importance of adaptation and insight to differentiate between all groups.

Conclusion

The results by and large confirm the general assumptions held on the differences between the groups. Thus the ThAt appears to be a valid instrument to grasp more subtle features of the therapist variable that may influence the outcome of psychotherapy.     

Couple Therapy Research and the Practice of Couple Therapy: Can We Talk?

As has been true in every other realm of psychotherapy, couple therapy research generally has had very little impact on the day-to-day practice of couple therapists. To a significant degree, this unfortunate disconnection may be attributable to an overemphasis by researchers in the field on treatment packages and therapeutic methods/techniques. Insufficient attention has been paid to other important sources of influence on treatment outcomes, especially the couple therapist herself/himself. It is argued that effective couple therapy requires a good "fit" between the person of the therapist and her primary theoretical orientation, and that couple therapists may be more influenced by research that addresses process aspects of the therapeutic approaches to which they have their primary theoretical allegiances.     

Some Historical Conditions of Narrative Work

Written to honor the immense contribution of Michael White as a leader in the development of narrative therapy, this historical essay contrasts the origins of psychoanalysis, family therapy and narrative therapy. Changes in the understanding of therapeutic strategies, methods of training and supervision, styles of leadership, the involvement of audiences in the therapeutic and training processes, and conceptions of the nature of the mind are described. A style of direct demonstration of methods, especially of the formulation of questions, is important in narrative work. The central master-role of the therapist in analysis and family therapy is replaced in narrative work by eliciting local knowledge, and the recruitment of audiences to the work. This is consistent with narrative therapy's "de-centered" image of the therapist.     

Cognitive-Behavioral Treatment of Social Phobia

Social phobia can be a chronic disorder, capable of restricting a client's social and occupational functioning. Cognitive-behavioral therapy can help many clients learn to overcome their social inhibitions, and make lasting changes in their interpersonal style. Cognitive-behavioral therapy for social phobia includes four general components for helping clients learn to manage their social anxiety. First, therapy begins with the establishment of a sound therapeutic alliance, a focus on assessment, diagnostic interviewing, and education regarding anxiety symptoms and their treatment. Second, the therapist helps clients to develop competence in social skills, relaxation training, and cognitive restructuring. Third, therapy uses exposure to social situations in order to help clients confront their fears and refine their coping skills. Fourth, relapse prevention strategies are used to help clients learn to tolerate feelings of discomfort and confront challenging social interactions. This treatment framework can be adapted to the specific needs of different clients.     

Utilizing artistry in a therapeutic relationship

Abstract

In many humanistic approaches, therapeutic change involves utilizing the relationship between the client and therapist as a tool for personal growth. Like any relationship, the therapeutic relationship is one that is co‐created between those engaged in it, namely, the client and the therapist. Utilizing this co‐created relationship requires a sense of artistry on the part of the therapist. A therapist must be willing to engage in this meaningful relationship with the client. A therapist must also be aware of the personal values that he or she brings into therapy, and how they influence the therapeutic relationship. Finally, a therapist must acknowledge the power that the therapist and the client possess in the relationship, and understand how that power can be used to validate and invalidate the therapist's and the client's personal meanings. These aspects of therapeutic artistry are discussed and the use of therapeutic artistry in Eron and Lund's (1996) narrative solutions approach is presented.     

The multi-level approach: a road map for couples therapy

This paper presents a multi-level framework and road map to guide the therapeutic process. Starting with the couple's reactive pattern, the multi-level approach first orients the therapist on how to create a "holding environment." It then suggests how the therapist, in collaboration with the couple, can proceed to explore interactional, sociocultural/ organizational, intrapsychic, and intergenerational processes that might be fueling the couple's dynamics. Central to this approach is the construct of the vulnerability cycle, a nexus of integration that helps the therapist stay anchored while moving through the many layers of therapeutic work. The overall goal is to help the partners move from reactivity to responsibility for their own feelings and behavior; from impasse to a greater ability to reflect, express feelings, listen, negotiate, and make choices about how to be in the relationship. This paper describes a range of concepts and interventions from basic to complex; it is intended as an organizational tool for practice and clinical training.     

Maintaining Therapeutic boundaries: The Motive Is Therapeutic Effectiveness,not defensive Practice

In his article "How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness," Lazarus asserts that many clinicians are adhering to strict therapeutic boundaries and ethics in a fear-driven effort to avoid unwarranted malpractice claims. Although I agree that maintenance of conventional therapeutic boundaries is apt to minimize malpractice claims in most cases, I believe that is because such boundaries are critical to protect patients' welfare and thereby promote effective treatment. My reasoning, discussed next, revolves around the following premises: 1. For many, if not most, types of patient problems and patient populations, boundaries and the personal meaning of the therapeutic boundaries are an arena in which critical emotional issues are manifested and worked through. 2. Clear, consistent boundaries provide a structure and safety for many patients that is a curative factor in itself. 3. Patients' reactions to alterations in usual therapeutic boundaries are often unpredictable ahead of time (even if requested by the patient) and typically complex, ambivalent, and heavily colored by transferential meaning. 4. Because alterations in therapeutic boundaries typically add a new therapist role or activity that involves potential gratification of personal needs of the therapist, objectivity in evaluating such a change may be compromised by the inherent self-interest. 5. Consistent, clear boundaries need have no impact on therapist warmth and empathy.     

Exploration of the Unknown in a Safe-Enough Environment

This paper considers specific problem areas inherent in psychoanalytic approaches to therapy and suggests an approach of respect and concern that can serve as a starting point for psychoanalytically oriented social work. Particular focus is on Winnicott's notion of a "facilitating environment" and Bion's understanding of the therapist as "container" within the therapeutic context.     

Working with child sexual abuse: a systemic perspective on whether children need to tell their therapist details of the abuse for healing to take place

As clinicians working with children who have been sexually abused we have observed that many children choose not to give the therapist a detailed account of their abuse. ^{1 1}‘Children’ refers to children and adolescents.
Our hypothesis is that whether or not children tell their story to the therapist hinges upon several factors: whether they have been believed by their significant (non‐abusing) carer(s); their developmental stage; the therapeutic context; and whether they feel their therapist is available to hear the distressing details of the abuse. We explore this through two case studies and conclude that while children's ability to use therapy is affected by multiple factors – societal, cultural, personal, life histories and beliefs about the value of therapy – telling their therapist the details of their abusive experiences is not necessarily a part of effective therapy.