Examining How CBT Interventions for Anxious Youth Are Delivered Across Settings

Most efforts to assess treatment integrity—the degree to which a treatment is delivered as intended—have conflated content (i.e., therapeutic interventions) and delivery (i.e., strategies for conveying the content, such as modeling). However, there may be value in measuring content and delivery separately. This study examined whether the quantity (how much) and quality (how well) of delivery strategies for individual cognitive behavioral therapy (ICBT) for youth anxiety varied when the same evidence-based treatment was implemented in research and community settings. Therapists (N = 29; 69.0% White; 13.8% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.4% white; 52.9% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols for therapists were comparable across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess the quantity and quality of delivery of interventions found in ICBT approaches. Overall, both the quantity and quality of delivery of interventions found in ICBT approaches were significantly lower in the community settings. The extent to which didactic teaching, collaborative teaching, and rehearsal were used systematically varied over the course of treatment. In general, differences in the quantity and quality of delivery observed between settings held when differences in youth characteristics between settings were included in the model. Our findings suggest the potential relevance of measuring how therapists deliver treatment separate from the content.     

Psychotherapie mit Migranten

After an introduction and presentation of the influence of immigration on psychological health, the present overview focuses on several models of psychological development in immigration. Cross-cultural psychodynamics and culturally conditioned transference in ethnically mixed cultural psychotherapy settings are explored. The effectiveness of Western therapy methods based on Christian – Jewish values is discussed with regard to the therapy of patients from different ethnic backgrounds, i. e. so-called traditional societies. In Western cultures, proximity in object relations is based on autonomy whereas in traditional societies proximity is based on relatedness. Knowledge of specific cultural issues are considered to be an important instrument in cross-cultural therapies. Joining, activation of ethnic resources, and culture-sensitive interventions are considered to be helpful psychotherapeutic interventions. Specialized therapy settings, e.g. integration of ethnic therapists in established institutions, mono-cultural ethnic settings and collaborative projects are described. Last but not least, the authors point out the necessity of cross-cultural therapeutic competence because of an expanding cultural heterogeneity of society.     

Using Motivational Monitoring to Evaluate the Efficacy of Self-disclosure and Self-involving Interventions

Self-disclosures and self-interventions are generally considered useful, although their role remains controversial. This is mainly due to the heterogeneity of research findings on this topic, characterized by the lack of a clear definition of self-disclosure and of systematic and effective methods to evaluate the short- and long-term effects of such interventions. To clarify the concept of self-disclosure, it is essential to understand whether its definition comprehends different interventions, which may have different effects. An accurate and reliable evaluation of such effects may allow clinicians and researchers to differentiate among different kinds of self-disclosures. In this theoretical article, we propose a method to evaluate the clinical efficacy of self-disclosures interventions. This method is based upon the monitoring of motivational systems (Liotti, 2005), which allows therapists to assess the cooperative attunement between patient and therapist in real-time. Our central assumption is that the evaluation of the cooperative attunement between patient and therapist, as well as the patient’s metacognitive functioning, is primary to assess the use of clinical interventions. Indeed, these factors – either acting on their own or synergistically – are the mark, the essence, and the reflection of the therapeutic alliance, which is the strongest predictor of treatment’s outcome.

     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Therapists’ perspectives about working with meaning in life in psychotherapy: A survey

Of 212 practicing therapists who completed a survey about working with meaning in life (MIL) in psychotherapy, 129 (61%) had recently worked with MIL with at least one client and reported on their work with a client in this survey. Those therapists who had worked with a client on MIL as compared with those who had not were older, more experienced, more humanistic/existential/experiential in orientation; reported more MIL training; and felt more competent working with MIL. Clients reported on primarily had internalizing, interpersonal, and career issues. Only 12% of clients explicitly labeled MIL as an issue coming into therapy. The three most frequently used interventions involved offering support; helping clients examine thoughts, feelings, and behaviors to discover hopes and goals; and facilitating exploration of MIL cognitions and experiences. Therapists reported many positive consequences from working with MIL. Therapists reported minimal training in MIL and moderate competence in working with MIL. Implications for practice, training, and research are presented.     

Reflections under the lens: observations of a systemic therapist on the experience of participation and scrutiny in a research project

The London Depression Intervention Trial (LDIT) was set up in the early 1990s by Professor Julian Leff ( Leff et al., 2000 , and in this issue) to compare the relative efficacy and costs, in work with depressed adults, of systemic couple therapy, drug treatment and individual cognitive behaviour therapy (CBT). The research found that systemic therapy compared favourably with the other modalities in respect of fewer drop‐outs, improvement in measured depression at the end of therapy and on follow‐up after a second year without therapy, and was not – contrary to the usual assumptions – more expensive. I was one of the two therapists, together with Eia Asen ( Jones and Asen, 2000 , and Asen in this issue) practising systemic therapy with diagnosed depressed patients and their partners. In this paper I will discuss the experience of being the object of research scrutiny, and the reflections that have come to me during and subsequent to the research period. To put it more challengingly: What are the consequences for systemic psychotherapists of co‐operation with researchers? Can a circular epistemology survive being scrutinized through a lineal grid?     

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.     

A Balancing Act: Integrating Evidence‐Based Knowledge and Cultural Relevance in a Program of Prevention Parenting Research with Latino/a Immigrants

Family therapists have a unique opportunity to contribute toward the reduction of widespread mental health disparities impacting diverse populations by developing applied lines of research focused on cultural adaptation. For example, although evidence‐based prevention parent training (PT) interventions have been found to be efficacious with various Euro‐American populations, there is a pressing need to understand which specific components of PT interventions are perceived by ethnic minority parents as having the highest impact on their parenting practices. Equally important is to examine the perceived cultural relevance of adapted PT interventions. This qualitative investigation had the primary objective of comparing and contrasting the perceived relevance of two culturally adapted versions of the efficacious parenting intervention known as Parent Management Training, the Oregon Model (PMTO). According to feasibility indicators provided by 112 Latino/a immigrant parents, as well as findings from a qualitative thematic analysis, the core parenting components across both adapted interventions were identified by the majority of research participants as relevant to their parenting practices. Participants exposed to the culturally enhanced intervention, which included culture‐specific sessions, also reported high satisfaction with components exclusively focused on cultural issues that directly impact their parenting practices (e.g., immigration challenges, biculturalism). This investigation illustrates the relevant contributions that family therapy scholars can offer toward addressing mental health disparities, particularly as it refers to developing community‐based prevention interventions that achieve a balance between evidence‐based knowledge and cultural relevance.     

Interventions in everyday lives: How clients use psychotherapy outside their sessions

The purpose of psychotherapy is to help clients address and overcome problems troubling them in their everyday lives. Therapy can therefore only work if clients include it in their ongoing lives to deal with their problems. Detailed, systematic research is needed on how clients do so in their everyday lives outside their sessions. A design of exploratory case studies on this topic is presented in this article. The main outcomes of such a case study on family therapy are then laid out in general terms. They highlight how treatment practices and clients’ ordinary everyday practices interact when clients change their everyday lives to overcome their troubles. They also highlight what it involves for clients to accomplish this. It is concluded that we need more research on how to understand intervention; on the interaction between interventions and clients’ conduct of their everyday life; on sessions as a particular, secluded part of clients’ ongoing everyday lives, and on how to consider therapists’ procedures and conduct of sessions accordingly.     

The Art of Living in Otto Rank’s Will Therapy

Otto Rank's approach to psychotherapy, developed after his separation from Freud, encourages living life fully in spite of death and limitation. In his emphasis on the here and now, new experience in the therapeutic relationship, and collaboration and creativity in the therapy process, Rank was ahead of his time. As a theorist of personality and of creativity, his work is well known, but his influence on the practices of humanistic, existential, and post-psychoanalytic relational therapists is largely unacknowledged. Rank's creative legacy is an approach to psychotherapy that calls forth artistry and collaboration between therapist and client.     

Relational consciousness and the conversational practices of Johnella Bird

In this article we review Johnella Bird's notion of relational consciousness, explaining it in terms of an ethnomethodologically informed social constructionist theory. We extend this notion to her conversational practices in therapy, examining first her general practice (and focus) on relational language‐making. We then turn to describing three of her specific conversational practices – negotiating conflicting discursive positions between partners in a relationship, exploring a partner's experience of hurt in a relationship, following unspoken assumptions, and negotiating power relations. We conclude by relating relational consciousness to an attendance to language as it is used by clients and by therapists in dialogue with clients.     

The experiences of therapists using a new client‐centred psychometric instrument,PSYCHLOPS (Psychological Outcome Profiles)

PSYCHLOPS (‘Psychological Outcome Profiles’) is a newly developed client‐generated psychometric instrument which can be used as an outcome measure. Uniquely, it asks clients to state their own problems, in their own words. As part of its validation, we used it alongside an existing measure, CORE‐OM (‘Clinical Outcomes Routine Evaluation – Outcome Measure’). Based on a qualitative methodology, we report here on the first‐hand experiences of four therapists using both instruments. The key themes that emerged from therapists’ responses were feasibility, validity and usefulness. Both questionnaires were perceived as complementing each other, the qualitative information from PSYCHLOPS balancing the quantitative information from CORE‐OM and that both could contribute to the therapist‐client interaction. The key features of PSYCHLOPS are likely to prove attractive to therapists and should increase acceptance and uptake of outcome measures.     

A Survey of the Attitudes and Practice Experiences of Home-Based Practitioners

This article reports on the findings from a study that assessed the attitudes and practice experiences of home-based therapists. Existing research in the field of couple and family therapy encompasses largely qualitative information detailing the experiences of this therapist population. We explored several hypotheses generated from the qualitative literature on home-based therapy. Study results corroborated much of the qualitative data on home-based therapists’ experiences and reveal the profile of today’s home-based therapists along with their attitudes and therapeutic practices. A surprising result was that various aspects of home-based therapy models seem incongruent with therapist attitudes about the delivery of home-based services.     

Celibacy and male psycho-sexual development

This prospective, observational pilot study was conducted on an academic inpatient rehabilitation unit. Ninety-three persons with spinal cord dysfunction or severe neurological illness participated. All completed admission surveys; 46 completed surveys six months after discharge. The aims were to describe admission and post-discharge spirituality and associations between spirituality and rehabilitation outcomes. At admission, participants reported spirituality similar to that of other samples of medical patients. After discharge, frequency of private spiritual practices increased and spiritual and existential well-being decreased. No significant associations were detected between spirituality and rehabilitation outcomes. Findings suggest the importance of spirituality to the participants and future research with a larger sample and modifications to the methodology.     

Psychodrama: Rehearsal for Living

Abstract

The current study examined therapist characteristics that are related to the use of spiritual and religious interventions in group therapy and to perceived barriers to attending to spirituality in group therapy among a sample of experienced group therapists. Results demonstrated that greater therapist spirituality was associated with more frequent use of both spiritual and religious interventions, as well as lower perceived barriers to attending to spirituality in group therapy. Religious commitment was only uniquely related to perceived barriers, such that therapists with higher religious commitment actually perceived greater barriers. Training in religion and spirituality and comfort with spiritual discussions was also related to therapists’ use of religious and spiritual interventions and perceived barriers.     

It’s not what you said,it’s how you said it: An analysis of therapist vocal features during psychotherapy

Psychotherapy is a conversation, whereby, at its foundation, many interventions are derived from the therapist talking. Research suggests that the voice can convey a variety of emotional and social information, and individuals may change their voice based on the context and content of the conversation (e.g. talking to a baby or delivering difficult news to patients with cancer). As such, therapists may adjust aspects of their voice throughout a therapy session depending on if they are beginning a therapy session and checking in with a client, conducting more therapeutic ‘work’ or ending the session. In this study, we modelled three vocal features—pitch, energy and rate—with linear and quadratic multilevel models to understand how therapists’ vocal features change throughout a therapy session. We hypothesised that all three vocal features would be best fit with a quadratic function—starting high and more congruent with a conversational voice, decreasing during the middle portions of therapy where more therapeutic interventions were being administered, and increasing again at the end of the session. Results indicated a quadratic model for all three vocal features was superior in fitting the data, as compared to a linear model, suggesting that therapists begin and end therapy using a different style of voice than in the middle of a session.     

Secret passages: the theory and technique of interpsychic relations

Semi-structured interviews were carried out with six individuals who unilaterally discontinued long-term psychoanalytic psychotherapy. Their six therapists were separately interviewed. The twelve interviews were analysed using qualitative methodology. The results suggest that individuals who ‘drop-out’ of therapy could be seen as having ‘dropped-in’ – as part of shopping around for a therapy that suits them or in order to explore a particular therapeutic approach and the extent to which they can tolerate or benefit from it. Most of the therapists felt intensely affected by their patient's decision to leave, and the paper examines how they manage these feelings.     

Projective identification and the therapist's use of self

This article addresses how therapists can recognize and therapeutically utilize client projective identification in therapy. Splitting and projective identification are conceptualized as occurring in sequence. Transference, countertransference, and projective identification are discussed as interrelated phenomena, which underlie the therapist's effective use of self as an instrument in therapy. A three phase intervention process, which emphasizes the importance of the timing of interventions, is introduced.