Three Aspects of the Therapeutic Conversation in Couples Therapy

Abstract

Feminist scholars have revealed the importance of examining the influence of gender on the therapeutic process. Gender differences in the treatment of clients may reveal inequitable or traditionally Stereotypie treatment of clients by therapists. This study examined gender differences in three conversational strategies widely used by therapists: expressions of empathy or understanding, compliments or praise, and challenges or requests for change. Fourteen tapes of live therapy sessions conducted by “master” therapists were examined using an exploratory, qualitative methodology based on Conversation Analysis. Results of this exploration revealed that therapists who are not self identified as “feminist challenged female clients more than male clients, and complimented male clients more than female clients. Feminist therapists challenged male clients more than female clients, and complimented female clients more than male clients. Feminist therapists used more challenges designed to facilitate non-stereo-typic gender behavior in both male and female clients. Only male therapists used disrespectful challenges of female clients, and were more often disrespectful to female clients than to male clients. Implications for the therapist-client relationship and the feminist critique are provided.     

An experimental inquiry into transference roles and age

In this psychotherapy analogue investigation, the effects of client age and therapist age on transference-like projections onto therapists were examined. Young (25-35) and older (60-70) pseudoclients compared paraprofessional therapists to significant figures in their own lives after a dyadic "helping" interview. The results provide empirical support for the phenomenon of reverse transference in therapy with older patients. Older clients were more inclined than young clients to view therapists, particularly younger therapists, as similar to their children. Young clients more willingly attributed parental qualities to older therapists. Both old and young clients may see therapists more as peers or friends than as family members.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

THE EGALITARIAN RELATIONSHIP IN FEMINIST THERAPY

Feminist therapy has revolutionized clinical practice and offered a model of empowerment for all therapy approaches. However, the long-assumed claim that feminist therapists are more likely to engage in power-sharing behaviors with their clients has not been supported by published quantitative research. In the current study, 42 female therapists who were asked whether or not they self-identified as feminist therapists completed measures assessing their use of feminist therapy behaviors (Feminist Therapy Behavior Checklist) and power-sharing behaviors (Therapy with Women Scale). One of each therapists' current female clients completed measures assessing her perceptions of both treatment collaboration (Working Alliance Inventory) and power-sharing behaviors (Client Therapy with Women Scale). As hypothesized, participants who identified as feminist therapists were more likely to report engaging in power-sharing behaviors when compared to participating therapists who did not. Furthermore, as hypothesized, clients of feminist therapists were more likely to report that their therapists engaged in power-sharing behaviors.     

Psychotherapy as a Process of Value Stabilization

The Rokeach Value Survey (RVS) and a confidence rating scale (CRS) were given to 13 experienced psychotherapists and 62 of their clients in field settings at the beginning and termination of therapy, or after 6 months. Results from the RVS demonstrate that therapists are more value stable than their clients and that clients shift their value systems toward their therapists' value configurations. Results from the CRS indicate that therapists are more confident than are clients and that clients' confidence increases across therapy.     

Client Aggression Towards Therapists: Is It More or Less Likely with Transgendered Clients?

ABSTRACT

It is well known that clients occasionally threaten or assault their therapists. No studies to date have attempted to systematically measure client aggression by transgender patients towards clinicians. One of the major questions of this study was to determine if clients with gender dysphoria have greater levels of aggression towards therapists than non-gender dysphoric clients. One hundred and fourteen professional therapists who are members of the Harry Benjamin International Gender Dysphoria Association responded to a questionnaire that addressed aggression by both transgender and non-transgender clients. Transgender clients were shown to commit significantly less acts of aggression than did non-transgendered clients (p = 0.0094). Within the relatively small subgroup of transgender clients that did commit acts of aggression, male-to-female transgender clients were significantly more likely to do so than female-to-male clients (p = 0.002). While the transgendered client undergoes significant suffering in violating inviolable gender boundaries, this suffering, in general, does not translate into acting out behaviors directed towards their therapists.     

Ethnic variations in the initial phase of mental health treatment: a study of Sami and non-Sami clients and therapists in northern Norway

Several studies indicate that mental health and mental health service vary with ethnicity. Ethnically linked social differences affect these results. We examined the multiethnic population in northern Norway where social inequalities between the Sami and the non-Sami population are not prominent. Clients (N=347) and therapists (N=32) in outpatient treatments reported demographics, ethnicity and the therapeutic alliance. Clients also reported pretreatment psychosocial status, service utilization and the type of help requested. Therapist recorded clinical and diagnostic assessments and treatment plans. The Sami and non-Sami client groups were similar in demographics and pretreatment psychosocial characteristics. However, the therapists prescribed more sessions and more socially focused interventions when clients were Sami. Verbal therapy was more often used by the non-Sami therapists. Alliance ratings were positively correlated only between Sami therapists and their clients, and Sami therapists rated the largest initial clinical improvement. Clinics located in the high Sami density areas offered their clients more therapy sessions, than in clinics in the high non-Sami density areas. Ethnic similarity between client and therapist were associated with more frequent use of medication and less frequent use of verbal therapy.     

PSYCHOTHERAPISTS'KNOWLEDGE ABOUT AND ATTITUDES TOWARD SEXUAL ASSAULT VICTIM CLIENTS

The present research investigated the question of how therapists'attitudes toward sexual assault victims predict their inferences about and treatment of clients. In addition, this study asked the following questions: (a) What percentage of female psychotherapy clients have been victims of sexual assault? (b) What treatment approaches are therapists using with victims and what attitudes toward victims do these therapists hold? (c) On the average, which demographic groups of therapists hold the most positive views of victims and are the most knowledgeable about working with victims? The results of the study indicated that therapists who held negative attitudes toward victims were more likely to endorse victim-blaming themes and therapeutic treatments which blame victims for sexual assault. Of therapists'current female clients, 18.5% ( n = 257) had been sexually assaulted at some point in their lives. On the average, therapists were knowledgeable about working with victims and showed positive attitudes toward victims.     

Chinese clients' belief systems about psychological problems in Singapore

This study explores Singaporean Chinese clients' beliefs about psychological problems by comparing their beliefs with those of non-clients and professional counsellors. These three samples were asked to indicate the extent to which they would agree with three belief models, the Chinese indigenous model, the Western psychological model, and the other model. It was found that clients and non-clients were more likely than therapists to endorse the indigenous belief model. Amongst the indigenous sub-models, Chinese medicine was the most endorsed across the three samples; and clients and non-clients endorsed Chinese medicine more than therapists did. The indigenous belief model, especially Chinese medicine was endorsed more by Buddhist and Taoist clients than Christian or non-religionist clients; and by clients holding lower educational qualifications.     

Negativity in psychotherapists' evaluations of clients and personal acquaintances

Forty-seven psychotherapists were studied to determine if they construed their clients more negatively than personal acquaintances. The sample included personal construct therapists, psychoanalytic candidates, and therapists from a community mental health center; they varied in terms of sex, age, years of experience, and clinical discipline. Subjects chose six personal acquaintances and six nonpsychotic individual-therapy clients who were then used as elements in a repertory grid. Constructs were elicited by comparing pairs of elements; all elements were rated on the constructs. Elements were also directly rated on several dimensions, including liking and similarity to self. Results indicated that therapists selectively focused on clients' negative characteristics and acquaintances' positive characteristics. Clients were liked less than acquaintances and were judged to be less like the self. The correlations between valuative variables tended to be higher in the construing of clients than in the construing of acquaintances, whereas expected improvement with therapy was not related to affective evaluation. There were no gender differences in these effects. Although there were no differences in degree of negative construal of clients among the therapist subgroups, the psychoanalytic candidates construed acquaintances less positively than did other therapists. The results suggest that deviancy may be a major dimension distinguishing therapists' construal of clients from their construal of acquaintances. This dimension may result from both therapeutic ideology and the fact that clients selectively present negative aspects of themselves in therapy, producing a bias in the information therapists receive. Possible negative implications for the therapeutic relationship are discussed.     

Fat Women’s Experiences in Therapy: “You Can’t See Beyond…Unless I Share It with You”

Abstract

This article reports the results of a qualitative exploration of fat women’s experiences with weight-related microaggressions in psychotherapy. We conducted semi-structured interviews with 15 women about their weight-related experiences as therapy clients and asked for their advice to therapists who work with fat women. We used a general inductive approach to code the data into themes and found that common microaggressions included therapists who overly focused on weight, therapists who appeared to be less interested in clients because of their weight, and dissatisfaction with waiting room seating options. Participants advised therapists to allow their clients to initiate conversations about weight. Results suggest the need for increased awareness of: (a) how clients’ weight may impact therapists’ attitudes and choice of interventions and (b) how weight might influence fat clients’ in-session presentations.     

The Relationship Between Momentary States of Therapist Self-Awareness and Perceptions of the Counseling Process

To investigate the role of momentary self-awareness, beginning therapists and their volunteer clients participated in a postsession process recall in which therapist helpfulness and momentary self-awareness were assessed along with client reactions. Therapist anxiety levels and strategies used to manage hindering self-awareness were also examined. Results suggest that momentary states of heightened therapist self-awareness may be hindering. Specifically, when therapists rated themselves as more self-aware from moment to moment during counseling sessions, they also rated themselves as more anxious before the session and their clients rated them as less helpful during the session. In addition, therapists reported using a variety of strategies to manage distracting self-awareness, including focusing on intervention planning and focusing on the client. Implications for therapist training are discussed.     

Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists’ Observable Behaviors

This study aimed to compare therapists’ observable behaviors to promote alliances with involuntary and voluntary clients during brief family therapy. The therapists’ contributions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 families who were observed in brief therapy. Using the System for Observing Family Therapy Alliances, trained raters searched for specific therapist behaviors that contributed to or detracted from the four alliance dimensions: engagement in the therapeutic process, an emotional connection with the therapist, safety within the therapeutic system, and a shared sense of purpose within the family. The results showed that when working with involuntary clients, therapists presented more behaviors to foster the clients’ engagement and to promote a shared sense of purpose within the family. However, in the fourth session, the therapists in both groups contributed to the alliance in similar ways. The results are discussed in terms of (a) the therapists’ alliance‐building behaviors, (b) the specificities of each client group, and (c) the implications for clinical practice, training, and research.     

Recording therapy sessions: What do clients and therapists really think?

Aims: Recording therapy sessions has become part of routine practice amongst trainee psychotherapists. To date most research has focused on the benefits of recording sessions to support clinical supervision. There are few data about the benefits or risks for clients. This study aimed to explore the views of clients who had had their therapy sessions recorded and therapists who had recorded sessions. Design: Five clients and 25 therapists completed a qualitative survey, the results of which were analysed using thematic analysis. Findings: All clients and several therapists reported that the recording devices are soon forgotten. Both therapists and clients reported the benefits of recording as being purely for the therapist with none identified for clients. Conclusions: It was observed that clients perhaps did not always understand how recordings were used, suggesting the need for clearer practice guidance.     

Helping construct desirable identities: a self-presentational view of psychotherapy

The author reviews the research demonstrating not only that clients withhold personal information and reactions from their therapists but also that such discretion is associated with positive therapy process ratings and outcomes. These results run counter to traditional approaches to psychotherapy, which demand a high degree of openness from clients. These puzzling findings can be explained by conceptualizing psychotherapy as a self-presentational process, wherein clients come to benefit from therapy by perceiving that their therapists have favorable views of them. Creating these favorable impressions can involve clients' hiding some undesirable aspects of themselves from their therapists. The author offers findings from the psychotherapy and social-psychology literatures in support of this view and makes suggestions concerning what clients and therapists might optimally reveal in therapy.     

Therapist Judgments of Clients' Sex-role Problems

Thirty therapists belonging to the Michigan Society of Consulting Psychologists rated the bipolar adjectives of the Sex-Role Stereotypes Questionnaire as to which pole was a problem for their average male and female clients. Female clients were viewed as too feminine on both socially desirable and socially undesirable adjectives. The problems of male clients were not viewed in sex stereotypic ways on the specific stereotypes. Asked directly, therapists reported that sex-role expectations create problems for both male and female clients. The findings contradict the hypothesis that therapists see the problems of women in therapy as nonconformity to the feminine stereotype.     

The frequency and effect on outcome of different types of interpretation in psychodynamic and cognitive-behavioral group psychotherapy

The therapeutic effects of interpretations by both therapists and other clients were recorded by observers in three cognitive-behavioral and three psychodynamic groups over a period of thirty one-and-one-half-hour group therapy sessions. There was no significant difference in the overall frequency of interpretations made in the two different therapy modalities; however, there was the expected difference in the types of interpretations made. Cognitive-behavior therapists and group members tended to interpret patterns of behavior or impact on others more frequently than did psychodynamic therapists and group members; while psychodynamic therapists and group members made more historical cause interpretations. However, contrary to expectations, both therapy modalities made more interpretations of patterns of present behavior than any other type. When these interpretations were converted into problem statements that were sent to outside raters after the termination of the groups, the outside raters judged that clients improved most when interpretations of a pattern of behavior were made; next most when interpretations of impact on others were made; and did not improve when interpretations of motive were employed in either modality.     

Bulletin Board

Abstract

When psychotherapy is viewed as shared reconstruction, there are implications for both clients and therapists. My clients become sources of expectations, myths, thought, and feelings about themselves and their therapists. I, as therapist, become a source of intentions and reflections, with capacities for self-awareness and abilities to construe my clients and their constructs, languages, and metaphors. Both participants in psychotherapy can then be seen as involved in reconstruction through the sharing and rebuilding of narratives. It is the life stories of clients that are likely to be more changed in therapy, but my life stories and my stories about the therapeutic process are also open to change     

How common is sexual attraction towards clients? The experiences of sexual attraction of counselling psychologists toward their clients and its impact on the therapeutic process

This study investigated counselling psychologists' experiences of sexual attraction to their clients. Self-reported incidence of this phenomenon, the reaction that it provokes in therapists, the way they manage their feelings, and the potential impact of their sexual attraction on the therapeutic process, were assessed. On the basis of previous studies of psychotherapists, it was hypothesized that sexual attraction toward clients is common, and that these perceived feelings are not necessarily negative to the therapeutic process or professional relationship; also, it was hypothesized that the disclosure of these feelings to the client could nevertheless lead to a positive therapeutic outcome. Questionnaires were sent to the 286 chartered counselling psychologists included in the British Psychological Society Register. The results showed that significantly more therapists were attracted to at least one client than not. Furthermore, half of the respondents who reported attraction to clients believed that their feelings had a positive impact on the therapeutic process. Therapists who had disclosed their feelings to their clients found significantly more frequently that the impact of their sexual attraction had been positive to the therapeutic process (87.5%), than therapists who did not disclose their sexual attraction (47.1%). The implications of these results for training, supervision and professional issues are discussed.     

Therapeutic Multiple Family Groups

The therapeutic effects of interpretations by both therapists and other clients were recorded by observers in three cognitive–behavioral and three psychodynamic groups over a period of thirty one-and-one-half-hour group therapy sessions. There was no significant difference in the overall frequency of interpretations made in the two different therapy modalities; however, there was the expected difference in the types of interpretations made. Cognitive–behavior therapists and group members tended to interpret patterns of behavior or impact on others more frequently than did psychodynamic therapists and group members; while psychodynamic therapists and group members made more historical cause interpretations. However, contrary to expectations, both therapy modalities made more interpretations of patterns of present behavior than any other type. When these interpretations were converted into problem statements that were sent to outside raters after the termination of the groups, the outside raters judged that clients improved most when interpretations of a pattern of behavior were made; next most when interpretations of impact on others were made; and did not improve when interpretations of motive were employed in either modality.