The pregnant therapist and the psychotic client: A phenomenological understanding of the impact of the therapist’s pregnancy on the therapeutic process

This original paper examines the underresearched area of therapist pregnancy. It explores the impact of psychosis as an additional complicating factor to the therapeutic process and the experience of one British counselling psychologist working in the National Health Service whilst pregnant. Five brief client summaries/clinical examples are presented to explore the common themes of anger, rejection, abandonment and envy that often emerge following the disclosure of a therapist’s pregnancy or the opposite reactions of over-protectiveness and an unwillingness to engage in therapy for fear of harming the therapist. Recommendations are made for further research within this neglected area and the need to incorporate the themes within training for therapists and training for supervisors.     

Leaving whom? Motherless families: problems of termination for the female family therapist

The issue of planned termination is seldom addressed by family therapists. Given the goals and assumptions of most family work the concept may indeed be irrelevant, but there are circumstances where it is necessary not only to understand the principles of planned termination, but the factors in client, family and therapist which can make it difficult to terminate at all. This may be the case where a female therapist has been working with a family where father is the single parent (motherless family): the family may experience itself as incomplete and attempt to draw the therapist into the family to fill the gap left by mother and marital partner, and pari passu the therapist may assume that the family cannot well cope without her. Some strategies for resolving the problems of termination which may arise from such assumptions are described.     

Engaging men in family therapy: does the gender of the therapist make a difference?

The results of this exploratory Delphi study provide a beginning formulation of a gender-sensitive approach to working with men in the specialized field of couple and family therapy. The research specifically investigated what a panel of thirty-six 'expert' family therapists believed would be appropriate and effective techniques to engage men in therapy and in the process of family change. This report focuses on findings highlighting differences between what female and male therapists preferred as techniques to work with men in family therapy.     

The incremental validity of the MMPI-2: when does therapist access not enhance treatment outcome?

The present study examined whether therapist access to the Minnesota Multiphasic Personality Inventory (MMPI-2) predicted favorable treatment outcome, above and beyond other assessment measures. A manipulated assessment design was used, in which patients were randomly assigned either to a group in which therapists had access to their MMPI-2 data or to a group without therapist access to such information. Illness severity, improvement ratings, number of sessions attended, and premature termination were indicators of therapy outcome. Results indicated that therapist access to the MMPI-2 data did not add to the prediction of positive treatment outcome beyond that predicted by other measures in this setting. Findings from this initial study suggest that, compared with other resources, perhaps in clinical settings with an emphasis on diagnosis-based and evidence-based treatment, the MMPI-2 may not provide incrementally valid information. However, these effects warrant replication across different settings and samples. Guidelines for future studies are discussed.     

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.     

When do trauma experts choose exposure therapy for PTSD patients? A controlled study of therapist and patient factors

To investigate when and why therapists opt for or rule out imaginal exposure (IE) for patients with posttraumatic stress disorder (PTSD), 255 trauma experts were randomized to two conditions in which they were presented with four cases in which the patients' comorbidity and treatment preferences were manipulated. The results confirmed IE to be an underutilized approach, with the majority of professionals being undertrained in the technique. As predicted, the patient factors influenced the expert's choice of therapy: in case of a comorbid depression, IE was significantly less preferred than medication. Also, IE was significantly more likely to be offered when patients expressed a preference for trauma-focused treatment. The therapist factors were also found to be importantly related to treatment preferences, with high credibility in the technique being positively related to the therapists' preference for IE. Perceived barriers to IE, such as a fear of symptom exacerbation and dropout, were negatively related to the perceived suitability of the treatment when patients had suffered multiple traumas in childhood. The results are discussed in the light of clinical implications and the need of exposure training for trauma professionals.     

How a therapist survives the suicide of a patient—with a special focus on patients with psychosis

The article draws from a personal clinical experience of two suicides, not far removed from each other in time. The first patient was a 33-year-old intellectual suffering from depression with narcissistic traits but no psychotic elements, while the second patient was a 21-year-old student with a manifest psychotic episode behind him and with characteristics of post-psychotic depression at the time of suicide. The two suicides had very different impacts on the therapist: the first left open some “space” for reflection, communication, and working-through, while the second closed such a “space,” leaving only a tiny door to the existential roots of human beings and suffering. The therapist was able to find some “shelter” by talking to supervisors, colleagues, and friends in the first case; in the second, the only possible “shelter” was glimpsed in the philosophy of groundlessness (Ungrund) of the Russian existentialist Nicolai Berdyaev. The personal experiences of the therapist, along with some theoretical interpretations of the after-effects of both suicides, are presented using a psychodynamic and existential–phenomenological understanding of the therapeutic relationship with a psychotic and a non-psychotic patient. The main dilemmas exposed by a patient’s suicide, especially if the patient suffers from psychosis, are difficult to deal with in the usual clinical settings and call for resources beyond it. The authors propose that these can be found in philosophical and theological insights.     

Intersubjectively oriented,time-limited psychotherapy with children: how does the therapist evaluate the therapeutic process and what are the therapist’s tasks?

Based on the therapist’s evaluations of three therapies, this research aims to study the therapeutic process in intersubjectively oriented, time-limited psychotherapy with children. A primary objective is to further develop the therapy method. The study comprises therapies with children 6–11 years of age, who had experienced difficult family situations. Each child received 12 therapy sessions. The number of therapy sessions with children and parents was agreed upon beforehand, and the therapeutic objectives were approved by the parents. Each of the therapy processes were evaluated by the therapist by answering three questions and filling in three forms after each therapy session. The forms were: The Feeling Word Checklist; an alliance form for the child; and a process form. The therapeutic alliance and the behaviour of the therapist during the therapy sessions are discussed on the basis of the total material. The following main tasks for the child therapist emerged: structuring the therapy sessions; following the child’s initiatives; participating and cooperating with the child; exploring the child’s expressions; and understanding and regulating emotions.     

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.     

Cross-racial psychotherapy with the borderline patient: Should the patient fire the therapist?

The purpose of this paper is to examine the effects of race on the psychotherapy of a white borderline patient treated by a black therapist. Some authors state that effective cross-racial psychotherapy is unattainable because of a marked divergence in the psychological biases of patients and therapists, while others feel that there is a more rapid unfolding of the transference in cross-racial therapy. While racial homogeneity may be desirable for some therapeutic issues, it is clearly not a prerequisite for effective therapy, nor is it realistic to assume that you've got to be one to treat one.     

Socialization toward a career as a marriage and family therapist: How is our profession doing?

To date, marriage and family therapy does not have formal socialization programs at the undergraduate level. Socialization activities may include career classes, advising, providing internships, or actively recruiting the most talented and qualified students. These socialization activities may also aid in the recruitment of minority students. A survey of the accredited programs revealed that most programs do not have formal opportunities for the faculty to interact and discuss therapy as a career option. While most programs have at least one faculty member who teaches undergraduates, this contact alone is not very good in terms of socializing students into choosing therapy as a career option. While there are some valid concerns about undergraduates, marriage and family therapy as a distinct discipline may benefit from actively recruiting the best students.     

Does theoretical background influence therapists' attitudes to therapist self‐disclosure? A qualitative study

Aims: This study investigated therapists' attitudes towards therapist self‐disclosure over different theoretical orientations and to establish how classical theoretical background and training effected and informed practice. Classical theoretical background was intended to refer to traditional Psychodynamic understanding. Method: Participants were experienced therapists drawn from four groups by a recruitment screening measure. Three groups were from the students’ cohort within a university Masters programme in Psychological Therapies. Participants were practicing from CBT, Systemic and Psychodynamic orientations. A further group was drawn from Person‐Centred therapist/trainers at a further education College. Data was gathered using focus groups and analysed using thematic analysis. Findings: Three major and one lesser theme emerged. These revealed that there was a spectrum of willingness to disclose throughout all groups, classical training influenced all participants; total restriction of TSD was impracticable and attitudes were affected by concerns for the therapeutic relationship. Implications for practice: TSD needs to be more thoroughly explored within therapy training and supervision. A structured framework could help inform practice. Conclusions: The study supported the idea that Classical Training influenced TSD.     

Activity/nonactivity and the group therapist: “Don't just do something,sit there”

The abstinent stance of psychoanalytically-oriented clinicians is often confused with passivity or coldness toward the patient or the group. Given the current move toward more active, shorter-term treatment, this paper offers a reaffirmation of the value of the abstinent analytic stance. The theoretical rationale for the technique is reviewed, and some specific arguments are made to illustrate the continuing importance of the method in the treatment of patients in psychodynamic group psychotherapy.Reputed to be Adlai Stevenson's advice to President John F. Kennedy during the Cuban Missile Crisis.     

Should your lips be zipped? How therapist self‐disclosure and non‐disclosure affects clients

Is therapist self‐disclosure a therapeutic technique or a therapeutic mistake? Is it useful? Is it ethical? This study attempts to address this controversy among therapeutic modalities by asking clients about their perceptions of self‐disclosure and non‐disclosure. Eighteen people (16 women, two men), currently in therapy in two Canadian cities, generated 157 incidents of both disclosure and non‐disclosure. The incidents were first coded as helpful or unhelpful. Cross‐tabulation of the results showed that disclosures were more than twice as likely to be experienced as helpful; non‐disclosures were twice as likely to be unhelpful (χ² (3, N=157) = 14.439, p≤0.002). One‐quarter of these incidents was coded by two independent raters; inter‐rater reliability was high (Pearson corr. ranged from 0.755 to 1.0, p≤0.01). The data was then sorted, using the Constant Comparison method, into themes, starting with, but not limited to, the themes suggested by the literature. The greatest single effect was on the therapeutic alliance, both positive and negative. Clients’ perceptions of helpful disclosures and non‐disclosures generally supported therapists’ rationales. There was also some evidence that when clients found disclosures unhelpful, the reasons also supported theoretical rationales against disclosing. Rather than simply supporting either position in the controversy, this study suggests that skill, or lack of it, was the intervening variable that affected the perceptions of both techniques. Further research on the effects of skill on both disclosure and non‐disclosure are warranted. This study has implications for both researchers and practitioners.     

Sliding doors: some reflections on the parent–child–therapist triangle in parent work–child psychotherapy

The parental presence as therapy agents, namely as a medium and support for the therapeutic process, is one of the paradoxical parameters of working with children. Parental presence serves as a reminder of the need to find a balance between inner and outer reality. The door that is closed in the therapy room leaves a parent on the other side but at the same time provides the child’s inner world with more latitude to reveal itself. This paper examines the fabric of relations created in the therapeutic parent–child–therapist triangle (analogous to Britton’s conceptualisation of the parent–parent–child link). How does this triangular connection affect the ability to be with the silent self (Winnicott) when the parent remains (tangibly and symbolically) on the other side of the therapy door? This paper presents two clinical examples to illustrate the complex fabric of relations created in the therapeutic parent–child–therapist triangle and the interactions between the internal and external reality of the parent–child relationship.