A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 2. Qualitative studies

Scope of review: The paper reports a meta‐synthesis of 13 qualitative studies of counselling and psychotherapy with people at risk of suicide. Publication time span: The studies considered were reported between 1997 and 2006. Publication origin: Seven studies were conducted in the UK, four in the USA, one in Canada, and one in Sweden. Findings: Themes in clients' and therapists' accounts of the process of counselling or psychotherapy were therapist qualities; therapy components; theoretical framework; and therapy techniques. Themes in their accounts of the effectiveness of counselling and psychotherapy were decrease in self‐destructive behaviour, and quality of life. Themes in clients' views of barriers to effective counselling or psychotherapy were therapist characteristics; therapy components; secrecy; and transferring to the real‐life situation. Secrecy was also identified as a barrier by therapists, as were responsibilities of the profession; training; and the nature of suicide and self‐harm. Facilitators of successful counselling and psychotherapy as identified by clients were responsibility; support; and teaching therapy skills to family members, the latter also being identified by therapists.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

CREATIVITY IN EXPERIENTIAL PERSONAL CONSTRUCT PSYCHOTHERAPY

We propose that experiential personal construct psychotherapy demands therapist creativity in engaging clients, beginning with the initial diagnosis and continuing through the entire therapy process. We suggest a number of ways of enhancing therapist creativity in the therapy room. We discuss making time for aloneness, seeking particular kinds of interactions with others, fantasizing, having a passion for one's work, trying on roles, exposing oneself to literature and the arts, leading a balanced life, reducing time pressures, making judgments, focusing on process, and seeing client growth. Finally, we consider creativity in the life of the therapist beyond the therapy room. We explore how the therapist's desire to be a part of lifechanging psychotherapy mandates the personal pursuit of creativity.     

The Edge of Chaos: Enactment,Disruption, and Emergence in Group Psychotherapy

The author outlines his approach to the theory and practice of group psychotherapy. The emphasis is on therapy by the group rather than therapy in the group. The therapist's task is to help the group itself become the agent of change. The group is conceived as being composed of many multiple selves. The process of group psychotherapy unfolds through enactments that involve the whole group and the group therapist entering into the grip of repetitive and unmentalized self-states. These enactments are resolved when the group members, with the therapist's help and containment, can access alternative self-states that allow for new and unformulated experience to emerge. This dialectical movement between the rigid “familiar chaos” of enactment and the reflective and related working through is compared to the dynamic systems theory articulation of the tension between rigidity and chaos captured by Kauffman's notion that “life exists at the edge of chaos.” A group session is described that involves a painful enactment. It illustrates how the therapist allows the enactment to unfold by holding and containing intense affect and how the group members are helped to find their own meaning and new experience in interaction with each other.     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

Therapiewechsler

At least 30% of the patients, currently in psychotherapy, have been in one or more psychotherapeutic treatments before the beginnig of the actual treatment. A great number of these patients decided as a consequence of their experiences with the former therapeutic treatments to change not only the therapist but also the form of the psychotherapy. The task was to find out the reasons for this. 25 patients who had changed from one of the Guideline Therapies into a client-centred therapy (CCT) were interviewed about their reasons for this change. It was assumed, that the failing of earlier therapies was caused by a lack of matching between patient and therapist, treatment and disorder in the sense of the Generic Model of Psychotherapy (GMP) conceptualized by Orlinsky and Howard. The results support this hypotheses: For most of these patients CCT turned out to be a necessary and successful alternative to the previous treatments. Most of the patients reported that they responded better to the therapeutic offer of CCT. The reasons mentioned for choosing another form of psychotherapy support the necessity of a differential indication for psychotherapy on the basis of the GMP.     

Der ausreichend gute Therapeut

Psychotherapists show a great variation in their ability to achieve positive outcomes in therapy. Specifically, they vary in terms of their ability to identify and repair ruptures in the therapeutic alliance. Alliance ruptures are a frequent phenomenon but often go undetected; however, repairing alliance ruptures represents a great opportunity to improve the psychotherapy process and therapy outcome. Empirical research suggests that patient feedback should be included in the psychotherapy process to be able to detect alliance ruptures better. From a psychodynamic point of view, a “sufficiently good” therapist is a therapist who can acknowledge the countertransference-based limitations in evaluating the therapeutic alliance with patients and the need to use feedback in order to detect and repair inevitable alliance ruptures. The consequences for research, practice and psychotherapy training are considered.     

The Relationship Between Dropout and Outcome in Naturalistic Cognitive Behavior Therapy

Dropout from psychotherapy is frequent and limits the benefits patients can receive from treatment. The study of factors associated with dropout has the potential to yield strategies to reduce it. This study analyzed data from a large sample of adults (N = 1,092) receiving naturalistic cognitive behavioral therapy (CBT) to test the hypotheses that dropouts, as compared to completers, had (1) higher symptom severity at treatment termination, (2) a slower rate of symptom change during treatment, and (3) a higher odds that the therapist rated treatment as ending for reasons related to poor outcome. Results showed that although dropouts ended treatment with higher symptom severity than completers, dropouts and completers did not differ in their rate of symptom change during treatment, suggesting that dropouts had higher symptom severity at termination because they received fewer sessions of treatment, not because their symptoms changed at a slower rate. Dropout was also associated with a higher odds of having a therapist-rated termination reason indicating a poor outcome, suggesting that dropout is more likely if patients are dissatisfied with some aspect of the therapy outcome or process. These findings suggest that strategies for monitoring and enhancing patient satisfaction with the process and outcome of treatment may help patients stay in treatment longer and end treatment with fewer symptoms than if they had dropped out.     

The Psychotherapeutic Utility of the Five-Factor Model of Personality: A Clinician's Experience

This article summarizes experience using the five-factor model of personality, operationalized by the NEO Personality Inventory (NEO-PI), to facilitate psychotherapy treatment with 119 private-practice, outpatient, psychotherapy patients and their family members over a period of 2 years. Trait theories such as the five-factor model implicitly challenge the premises of much clinical theory, yet they can be useful to clinicians, as they provide a detailed, accurate portrait of the client's needs, feelings, proximate motives, and interpersonal style. I suggest that: Neuroticism (N) influences the intensity and duration of the patient's distress, Extraversion (E) influences the patient's enthusiasm for treatment, Openness (O) influences the patient's reactions to the therapist's interventions, Agreeableness (A) influences the patient's reaction to the person of the therapist, and Conscientiousness (C) influences the patient's willingness to do the work of psychotherapy. Fundamental questions raised by the five-factor model about the nature of psychopathology and psychotherapy are discussed.     

Matching Patient and Therapist Anaclitic–Introjective Personality Configurations Matters for Psychotherapy Outcomes

Decades of psychotherapy research suggest that patient–therapist match accounts for outcome beyond single patient or therapist variables. This study examines the associations between different patterns of patient–therapist matching (in terms of orientation on relatedness or self-definition) and outcomes at termination of psychoanalytic psychotherapy with young adults. Thirty-three patients and their therapists were classified as predominately anaclitic or introjective at baseline. Patients in the convergent patient–therapist dyads (both anaclitic or both introjective) showed significantly greater symptom reduction and increased developmental levels of representations of mother than patients in the complementary dyads (opposite personality configurations). Moreover, convergent patient–therapist match was connected with larger effect sizes on all outcome measures and lower proportion of non-improved patients. These findings suggest the importance of the therapists’ early adjusting their orientation on relatedness or self-definition to their patients’ predominant personality configuration in order to enhance treatment outcomes.     

Counting black sheep: Contextualizing therapeutic relations

In this paper we draw on feminist and post-colonial theory to situate an account of a six-month therapy between a black, Asian woman therapist and a woman patient of mixed parentage, within contemporary Britain. We draw on this analysis to further the debates between psychotherapeutics and social theory, challenging each in three ways. First, in relation to the literature on culture, class, gender and sexuality in psychotherapy, we indicate how these enter into the therapeutic relation in distinct and intersecting ways, which, second, challenge the separation between inner and outer worlds frequently maintained within psychotherapy circles. Third, in terms of the correlative challenge psychotherapeutic perspectives pose for social theorists and activists, we highlight how the therapist's constructive and explicit use of her power and socio-cultural position was central to the progress of this client's therapy. Finally, we reflect on the broader questions around the theorizing of culture and gender within psychotherapy, including the available positions and representations of black therapists as well as black patients.     

Being a Therapist: Contributions of Heidegger's Philosophy and the Buddha's Teachings to Psychotherapy

Is there a place for Heidegger's philosophy and the Buddha's teachings (dhamma) in contemporary psychotherapy? The simple answer is yes. This article explores how the ideas of Being-in-the-world, Openness, Being-With, anticipatory care, letting be and letting go, cultivating a meditative attitude and a beginner's mind—promoted in Heidegger's philosophy, daseinsanalysis, and the Buddha's teachings—inform my approach to therapy and ground my Being as a therapist, and how this embodiment has been received by clients. Some important parallels and differences between Heideggerian and Buddhist ideas and practices are also discussed. Heidegger's philosophy, the Buddha's teachings, and daseinsanalysis provide therapists with important foundations for understanding their roles as cojourneyers with their clients, and embracing this attitude in therapy can make therapy truly a healing, rather than a curing, process.     

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.     

Relationship between response to graded exposure and marital satisfaction in agoraphobics

Agoraphobics who were satisfied in their marriage responded well to graded exposure and maintained their improvement to 3-months follow-up. Satisfaction with self and partner remained unchanged in patient and spouse. Agoraphobics who were dissatisfied with their marriage improved initially with graded exposure but later lost most of their gains and reported no change in general neurotic symptoms. Marital dissatisfaction also remained unchanged. Patients' dissatisfaction with their spouses, measured before therapy, predicted outcome in the sample as a whole.     

Patientensicht zur Qualität in der Psychotherapie

Concerning the discussion about the quality of psychotherapy, the different perspectives in the definition of quality are rarely considered. Especially the patients’ perspective is barely respected although quality assurance of psychotherapy should be for their benefit. Patients were interviewed (n=8) to answer the question which criteria of quality are relevant in their view. Using the grounded theory a variety of quality criteria was found. The interviewees emphasized the relationship between therapist and patient, the empathy of the therapist, the scheduling of appointments and the progress in therapy. The results suggest that when judging the quality of psychotherapy clients do not only focus on the outcome of psychotherapy, as presumed by some experts, but also on the dimensions structure and process. Professionals have to consider this fact when designing and applying methods of quality assurance.     

Is how it is said important? The association between quality of therapist interventions and client processing

This study examined the association between the quality of therapist interventions and client in‐session processing using the York Therapist Process Measure (YTPM; Toukmanian and Armstrong, 1998). The instrument's three dimensions — attunement, tentativeness and meaning exploration — were tested separately for their impact on clients' manner of processing and depth of experiencing. For each of the 20 mild‐moderately depressed clients, treated in short‐term experiential therapy, a high and a low client‐process segment was isolated from a session that was judged by an experienced therapist to manifest the greatest amount of “good therapy moments”. Therapist interventions within these segments were then rated on the YTPM. Results revealed significant differences in the quality of therapist interventions between high and low segments. Attunement and tentativeness were associated significantly with greater complexity in manner of processing, and meaning exploration with greater depth in experiencing. The implications of these findings for psychotherapy research and practice are discussed.