Constructing Nonagency at the Beginning of Psychotherapy: The 10DT model

This study examined how nine clients discursively constructed non-agency in their first session of individual psychotherapy. With open reading and linguistic analysis of the transcribed first sessions, combined with theory-based considerations, we created a model of discursive means for ascribing agentic and non-agentic positions, the 10 Discursive Tools model (10DT). There was large variability in how the tools functioned to create the impression of problematic agency, and the clients could not be classified according to their tool use patterns. The study shows the potential of the 10DT model for the detailed examination of presentations of “not-being-able” produced by psychotherapy clients.     

Styles of Suicide Intervention: Professionals' Responses and Clients' Preferences

As the rates of suicide in America continue to rise, suicide recently has been declared to be a national public health concern. The crisis intervention model, which has dominated the treatment of suicidal individuals in America since the 1950s, is currently believed to be the most effective model for suicide intervention. This study examined this belief by taking a more complex look at professionals' responses to suicidal clients both by investigating the existence of different ways in which professionals interpret the crisis intervention model. In one interpretation (the "fight" response), the professional takes power and agency away from the client and does what is perceived to be "best" for the client. An alternate interpretation, the "ideal" response, allows for a respectful engagement with the client. Professionals also can act contrary to the model (i.e., the "flight" response). In addition, based on the humanistic notion that clients are the experts of their own experience and that their voices are a very valuable part of evaluating the treatment process, this study investigated which response style clients report to be most helpful and most desired. The results suggest that while the typical response of mental health professionals to suicidal clients is most characteristic of the "fight" response style, clients overwhelmingly report that the contrasting "ideal" response style is most helpful. The findings are discussed along with implications for practice, research, and training.     

Need for approval and counseling outcomes

The intent of this study was to determine the effects of a clients' need for approval on the outcomes of counseling. The expectation was that clients who have a high need for approval by others would cooperate more with the counseling process and would more often be successful in the sense of being rehabilitated. The Marlowe-Crowne Social Desirability Scale was administered to 167 applicants at a state rehabilitation agency immediately after the initial interview. It was hypothesized that successfully rehabilitated clients would obtain significantly higher social desirability scores than those clients who were not successful. The results confirmed the hypothesis at the .01 level of significance.     

Factors influencing the attitudes and commitment of volunteer alcohol counsellors

The attitudes of volunteer counsellors towards clients with alcohol problems and the counsellors' commitment to their agencies were investigated. A questionnaire was devised, incorporating the Alcohol and Alcohol Problems Perception Questionnaire, and was distributed to volunteer counsellors working within Volunteer Alcohol Counsellors' Training Scheme (VACTS) recognised agencies in England. Two hundred and thirty counsellors were eligible to complete questionnaires, representing approximately half of the total population of volunteer counsellors in VACTS agencies; 141 questionnaires were completed. The results indicated the importance of role recognition by agencies in enhancing counsellor attitudes towards their work; levels of experience, in terms of length of service and the number of clients seen, also appeared to be significant. Future agency commitment seemed to be positively influenced by four agency incentives, defined as role recognition, role support, training, and accreditation. Differing modes of supervision correlated positively with counsellors' attitudes towards clients and with their future agency commitment. It is concluded that voluntary agencies have an important role to play in maintaining positive attitudes and retaining their volunteer staff.     

Counseling the Hispanic Client: Cuban Americans,Mexican Americans,and Puerto Ricans

This article describes a general framework that may be used when counseling Cuban American, Mexican American, and Puerto Rican clients. The psychological and sociocultural characteristics of these populations are described. Both differences and similarities among the 3 groups are reviewed. The identification of the client's worldview, cultural values, and family values provides a specific framework for counseling these clients. Specific and general guidelines are provided for the psychological assessment of Cuban American, Mexican American, and Puerto Rican clients.     

Traumas With and Without a Sense of Agency

The authors differentiate two types of traumatic experience: trauma with agency and trauma without agency. The types are different despite the fact that the symptoms of both look similar enough to fall within the diagnosis of post-traumatic stress disorder (PTSD). The differentiating factor is the sufferer's sense of agency during the circumstances surrounding the trauma. What is traumatizing is that the individual acted in some way that, however adaptive in the moment of threat and crisis, was ultimately loathed simultaneously or subsequently by the person's larger self and seen by this larger self as defining of character. Traumatized clients with a sense of agency require treatment that comes from being cared for and loved despite this hated facet of self.     

Relationships among experience level and value orientation and the performance of paraprofessional telephone counselors

The effectiveness of indigenous paraprofessional helpers is thought to be partially due to the similarity in style and values between then and their clients. However, there is a concern that as they gain experience in an agency, their identification may shift from the clients to the agency. Also, there is a question as to how effective paraprofessionals (selected due to their shared values with a target population) are with value-dissimilar clients. Truax and Carkhuff's scales of facilitative conditions as well as a technique functioning scale were used to assess the helping behavior of paraprofessional telephone counselors at three levels of experience in response to value-similar and value-dissimilar simulated calls. The results indicate that performance generally improved with training and experience and that instead of a uniform deterioration with dissimilar value calls, a complex relationship existed between performance, values, and experience level.     

EXPERIMENTS IN A COMMUNITY MENTAL HEALTH CENTER: INCREASING CLIENT PAYMENTS FOR OUTPATIENT SERVICES

Although public health care systems often depend on revenue generated from client payment for services, inadequate agency fee payment systems continue to create substantial administrative problems. The first study examined the effects of implementing a system for producing and maintaining routine client fee payment. The second study was a replication of the first study. The Credit Criterion System was designed to: (a) allow clients to establish intra-agency credit by paying cash for each of the first three visits; and (b) pay for services monthly after credit was established. The system resulted in a baseline collection rate of 20%, compared with the Credit Criterion rate of 96.6%. The Credit Criterion System did not create additional administrative costs and it had no effect on attendance. Thus, the Credit Criterion System appears to be a reasonable set of procedures for allowing clients to meet their financial obligations to an agency.     

Baseline Client Interpersonal Agency Moderates the Indirect Effect of Treatment on Long-term Worry in Variants of CBT for Generalized Anxiety Disorder

In a recent trial for generalized anxiety disorder (GAD), cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) promoted more long-term worry reduction than CBT alone (Westra, Constantino, & Antony, 2016). A follow-up analysis found that CBT vs. MI-CBT clients evidenced greater increases in friendly submissiveness (FS) across treatment, which in turn promoted lower long-term worry (Constantino, Romano, Coyne, Westra, & Antony, 2018). It was unsurprising that traditional directive CBT promoted more FS than when person-centered MI was integrated; however, given that problematic low agency characterizes GAD, that greater FS promoted better outcome was unexpected. To further unpack this unexpected result, we tested the following moderated mediation hypothesis: for clients with more vs. less problematic low agency at baseline, CBT would still promote more in-session FS than MI-CBT, but this increase would in turn predict increased worry over follow-up. Clients receiving CBT (n = 43) or MI-CBT (n = 42) rated their interpersonal problems at baseline and their worry after treatment and across 12-month follow-up. Therapists rated clients’ in-session FS multiple times. As predicted, multilevel modeling revealed that for clients with more problematic low agency, CBT vs. MI-CBT facilitated greater FS, which in turn related to increased worry across follow-up. For clients with more problematic high agency, CBT’s facilitation of greater FS related to reduced worry across follow-up. A baseline interpersonal problem characteristic of GAD may have implications for treatment matching and for appreciating different pathways to long-term improvement, or deterioration, for different GAD subgroups.     

The Effects of Modeling and Instructions on High and Low Verbal Family Members

This study attempts to generalize the findings of laboratory studies of modeling and instructions by comparing their effects for modifying verbal behavior of actual clients referred to a family service agency. The findings suggest that in a population with less homogeneous verbal skills than found in a typical college population, verbal fluency will influence response to these interventions. Specifically, when a rule is supplemented by either verbal examples (instructions) or behavioral examples (modeling), both interventions have utility. However, for highly verbal clients, verbal examples are appropriate. For less verbal clients, more elaborate audiotape or videotape examples represent the more useful strategy.     

Tailoring computerised interventions to client needs

The results are reported of an experimental study in which 91 subjects rated the perceived helpfulness of three computerised interventions - a work values inventory (WAPS), a job-bank (JOB), and a decisions exercise (DECISIONS) - for hypothetical clients with identity, self-awareness, opportunity-awareness, decision-making and implementation problems. As predicted, WAPS was perceived as most helpful for clients with a self-awareness problem, JOB for clients with an opportunity-awareness problem, and DECISIONS for clients with a decision-making problem. Potential applications of the model implicit in the study to counsellor training, to the assessment of client problems and to careers education programmes are discussed.     

Assessment and Development of Rehabilitation Plans for Counselors Who Have Sexually Exploited Their Clients

Counselors who have sexually exploited clients require rehabilitation if they are to return to practice. The authors present a model, derived from their clinical experience with more than 1,000 cases, for the assessment and development of rehabilitation plans for impaired practitioners who have sexual contact with their clients. They present a classification system for the perpetrator, an assessment process that leads to the development of a rehabilitation plan, and a method for deciding if rehabilitation has been successful.     

Clients talk about their experience of the process of counselling

The purpose of this study was to ascertain clients’ experiences of their counselling. This was done through use of a questionnaire and follow-up, semi-structured interviews with 20 counselling clients who were seen at a walk-in agency located in a mid-sized city in New Zealand. Several themes were identified and discussed in relation to the literature on clients’ perceptions of their own counselling. Specifically, clients were asked to comment on whether their counselling was effective, how much of their improvement was due to counselling versus other factors, the quality of the relationship with their counsellor, specific in-counselling events that were helpful or unhelpful, and how their counselling was terminated. Implications for practice were suggested.     

Gender and Wellness: A Multidimensional Systems Model for Counseling

An expanded view of health is advocated for assessment and treatment of individual clients in helping them achieve and maintain their maximum potential for high-level wellness. In addition, moderating variables, such as culture, age, and gender differences, have an impact on every dimension of health and wellness. In this article a multidimensional systems model for wellness is described, and gender differences along those dimensions are reviewed. Application of the model and implications for counseling are discussed. Finally, two illustrative case examples, one man and one woman, are described.     

NONCONTINGENT PRESENTATION OF ATTENTION AND ALTERNATIVE STIMULI IN THE TREATMENT OF ATTENTION-MAINTAINED DESTRUCTIVE BEHAVIOR

Previous research has demonstrated that destructive behavior may be reduced through noncontingent presentation of attention when attention is identified as the stimulus responsible for behavioral maintenance. Because it may not always be possible to deliver attention in all situations, we examined the extent to which alternative stimuli that have been identified through a choice assessment would substitute for attention (the functional analysis—based reinforcer) in a noncontingent reinforcement procedure. Prior to treatment, functional analyses demonstrated that the destructive behavior of 2 clients with mental retardation was maintained by adult attention. Next, a stimulus choice assessment identified highly preferred tangible items for the 2 clients. Finally, we compared the effectiveness of two noncontingent reinforcement procedures: continuous noncontingent access to attention and continuous noncontingent access to the tangible item identified in the choice assessment. For both clients, these noncontingent reinforcement procedures reduced destructive behavior. The results are discussed in terms of the clinical implications for the treatment of destructive behavior using functional and alternative stimuli.     

Who drops-out? Do measures of risk to self and to others predict unplanned endings in primary care counselling?

Aims: Unplanned endings, where clients unilaterally end therapy, are of concern for psychological therapy services generally as they raise questions about the appropriateness of the treatment and it's delivery for some clients. Limited available data indicates that those who drop-out often have more severe symptoms at entry, and have poorer clinical outcomes. This raises further questions about risk to self and others for those clients who leave therapy prematurely and how these clients might be identified and kept engaged. Method: This paper uses a large dataset of CORE data collected routinely in a primary care counselling service between 2000 and 2003. Logistic regression was utilised to consider different measures of risk and other client characteristics recorded at assessment to predict drop-out from the service. Results: These indicate that younger age, greater psychological distress at assessment, an addiction problem and greater risk to others, are associated with an unplanned ending. However, no reliable logistic regression model could be produced. This may be partly due to data quality issues or important characteristics not being available in the data. Implications for practice: The paper concludes that counsellors should actively seek to minimise unplanned endings, as amongst them may be represented the more distressed and risky clients referred to primary care counselling.     

Therapeutic Assessment "on the Front Lines": comment on articles from WestCoast Children's Clinic

I comment on the articles by Mercer (2011/this issue); Guerrero, Lipkind, and Rosenberg (2011/this issue); and Haydel, Mercer, and Rosenblatt (2011/this issue), which describe their practice of collaborative and therapeutic psychological assessment in a community mental health setting. These articles demonstrate that collaborative and Therapeutic Assessment can be used successfully with clients from underprivileged, high-risk backgrounds. Such assessments are rigorous for both clients and assessors, and their success depends on the ability of clinicians to form trusting relationships with clients. In fact, empathic disruptions by assessors are almost inevitable during the collaborative assessment process, especially if assessors' backgrounds and contexts are quite different from those of their clients. However, if assessors receive enough support to "take off their white coats" and reach into their clients' worlds, such disruptions can be repaired, leading to positive changes in both clients and assessors. This kind of assessment work is not for the faint of heart, but it is immensely rewarding.     

Therapeutic tasks: what kind of help is sought in psychotherapeutic sessions?

One of the main conditions for a good psychotherapeutic alliance is the agreement on therapeutic tasks and goals. This article explores the kind of help that clients expect from therapeutic sessions. By means of a written questionnaire, the clients of a private psychotherapy center, prior to the sessions, expressed their priorities regarding the work to be carried out in them. The assessment of 873 questionnaires showed that clients prefer to participate in therapeutic work that helps them plan actions, understand what is happening, and assess possibilities for change. Also important are therapeutic tasks that help clients evaluate their own actions, both past and planned. The importance that clients attach to different kinds of help varies above all according to how near they feel to resolving their problems. Nine different kinds of psychotherapeutic tasks are identified, which cover the possible requests a client can make of his/her therapist. This article discusses the clinical application of this model as a basis for planning and classifying psychotherapeutic interventions.     

Ego Development and a General Model for Counseling and Psychotherapy

Swensen describes a general model within which various techniques of counseling and psychotherapy may be integrated. This model is based on Lewin's formula, B = f (P, E), that is, behavior is a function of the person and the environment. Therapists should assess both the personality of the client and the environment. Client assessment is based on the concept of ego development. The behavior of clients who are at simpler levels of ego development is determined largely by reward and punishment in the environment. As a consequence, professionals should direct therapy with these clients toward changing the reinforcement contingencies in the environment. On the other hand, behavior of clients at more complex levels of ego development is more self-controlled. Therefore, therapy with these clients should concentrate on self-directed and self-controlled change.