Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Spontaneous Moments and the Domain of Non-Verbal Communication

Abstract

This paper investigates the impact of non-verbal interactions and spontaneous encounters on the therapeutic process and on a client's structural and behavioral patterns. The following case vignette concerns a client who presents with a pattern of non-verbal relational schemas based on his early traumatic experiences. The non-verbal and verbal role reenactments that unfold between client and therapist will be examined from an intersubjective, dialogical and self psychological perspective. Finally, the paper will explore how important therapeutic shifts may occur by attending to and working through these non-verbal aspects of the treatment, leading to new relational structures.     

Beyond the Frying Pan: Addressing Work Issues with Women in Therapy

In recent years, mental health practitioners have been exploring how women are balancing work and family. Given how this issue affects womens experiences in the corporate world and at home, marriage and family therapists are attempting to consider this concern as they treat female clients individually and within relational systems. Few articles and studies have examined the issues female employees face in the workplace and how the issues influence the therapeutic process. In this article, the authors examine the organizational, sociological, and cultural challenges women deal with at work and apply these areas to the therapeutic context. The authors present a case study of a female client enduring a difficult work situation, discussing how to view and approach this case from a feminist family therapy perspective.     

Representation and the Intrapsychic: Cartesian Barriers to Empathic Contact

This paper argues for a radical relational perspective that explicitly challenges the notion of the intrapsychic and the related Cartesian assumptions of representationalism. Conceptual tools derived from the school of embodied cognition provide an alternative theoretical language that depicts a new understanding of experience as an emergent and distributed phenomenon of a dialogic communicative system. Clinical vignettes illustrate how this new ontology of experience promotes a therapeutic ambience that dissolves the barriers to empathic contact imposed by the retention of representational modes of thought.     

The Therapeutic Use of Forgiveness in Healing Intergenerational Pain

The author discusses the therapeutic use of forgiveness in healing intergenerational pain. Forgiveness is conceptualized as a 4‐station process that is used to break unhealthy developmental and relational patterns and to promote healing. These stations can help the client gain insight and understand the intergenerational pain, provide an opportunity for compensation, and empower the client to act on the forgiveness. A case example of an adolescent is presented to illustrate the therapeutic value of encouraging exoneration and then forgiveness.     

A Relational Approach to Genetic Counseling for Hereditary Breast and Ovarian Cancer

Ethical issues arise for genetic counselors when a client fails to disclose a genetic diagnosis of hereditary disease to family: they must consider the rights of the individual client to privacy and confidentiality as well as the rights of the family to know their genetic risk. Although considerable work has addressed issues of non-disclosure from the client’s perspective, there is a lack of qualitative research into how genetic counselors address this issue in practice. In this study, a qualitative approach was taken to investigate whether genetic counselors in Australia use a relational approach to encourage the disclosure of genetic information from hereditary breast and ovarian cancer (HBOC) clients among family members; and if so, how they use it. Semi-structured qualitative interviews were conducted with 16 genetic counselors from selected states across Australia. Data collection and analysis were guided by a basic iterative approach incorporating a hybrid methodology to thematic analysis. The findings provide indicative evidence of genetic counselors employing a relational approach in three escalating stages––covert, overt and authoritative––to encourage the disclosure of genetic information. The findings lend credence to the notion that genetic counselors envision a form of relational autonomy for their clients in the context of sharing genetic information, and they depart from individualistic conceptions of care/solely client-centered counseling when addressing the needs of other family members to know their genetic status.     

Using client feedback in training of future counseling psychologists: An evidence-based and social justice practice

Training in counseling psychology has evolved to emphasize both evidence-based practice (EBP) and social justice, though these two dimensions have often seemed disconnected, or even at odds in the practice of psychotherapy. The Partners for Change Outcome Management System (PCOMS), an EBP that monitors treatment outcomes and the therapeutic alliance across treatment (often called “client feedback”), may offer a means to connect evidence-based and socially just practices. The purpose of this article was to outline how the use of PCOMS in psychotherapy and supervision can serve as a useful training tool that is a form of EBP and also promotes a socially just paradigm in psychotherapy. We also offer an implementation example from a counseling psychology doctoral program to demonstrate how PCOMS can be used with clients in psychotherapy and included within the supervisory process.     

Exploring Counselor Experiences of Training in Relational Depth: An Interpretative Phenomenological Inquiry

Relational depth is an emergent counseling construct that captures the profound connection felt by client and counselor in moments of therapeutic encounter. We used interpretative phenomenological analysis to understand how 10 doctoral counseling students perceived curricular experiences designed to facilitate their ability to engage in relational depth. We identified the following themes: mutuality, counselor growth, externalized to internalized expectations, authenticity, impact of relational depth educational experiences, and relational depth reflection and articulation.     

Seeing in the Dark: A View into Dissociation and Healing

In this paper, I will explore the role of art-making, the experience of trauma and dissociation, and the process of working with self-states from an analytic and creative frame. Relevant literature on dissociation, trauma, and the use of art will be discussed. A case involving my work with an adolescent girl who had experienced sexual abuse from a family member will be shared, with an emphasis on the meaningful role images played during the therapeutic process. Both Jungian and psychoanalytic models of conceptualizing and working with dissociation are included, following Donald Kalsched’s (2013) recommendation for a “binocular stance” to treatment, including both a focus on the inner, intrapsychic world and the interpersonal, relational realm, and how art images both illuminated and expressed these realms. Within the therapeutic process, art images allowed the therapist a view into the client’s unconscious process, and created a meeting ground for dissociative barriers to be gradually seen, felt and known, by both therapist and client. The experience of dissociation, in images and in session, provided a reference point for myself and my client, Taylor, to develop a shared understanding and a framework for growth.     

Relational Psychoanalysis Potential Usefulness with Black South African Clients

The aim of this article is to suggest that relational psychoanalysis may be a useful approach for working with clients from indigenous African cultures. In particular, the article considers the utility of relational psychoanalysis to understanding and enacting the therapeutic relationship with clients from an indigenous African cultural background. The notion of “we” self from the perspective of African cultures is a case in point for possible compatibility between relational psychoanalysis and black clients who come from background that place a high value on communal or “we” selves. An integrative therapy that combines African worldviews and relational psychoanalysis is possible.     

Constructing bridges and systemic connections: In brief dynamic therapy

The author outlines how the conceptual framework which underpins cyclical psychodynamics, a branch of relational psychoanalysis, provides an opportunity for a coherent integration of constructivist CBT principles and techniques and family systems theory within a model of brief dynamic therapy. Drawing upon Wachtel’s articulation of a more flexible notion of the internal world and one in which current interpersonal patterns are seen to shape the psyche and internal conflicts, the author goes on to identify ways in which attending to a client’s behaviour and the ways in which affective experience is expressed interpersonally can open the way to an integration of therapeutic features from constructivist CBT and family systems theory. The contribution that coaching a client in the ways in which they behave interpersonally in the context of both family and workplace relationships can make to therapeutic effectiveness is explored. These themes are illustrated with a case study.     

One Woman's Development and Resilience in the Face of Complex Trauma: A Relational–Cultural Study of Growth Through Counseling

Many counselors feel pressure to use manualized treatment approaches because of pressure from 3rd‐party payers. Unfortunately, this is not always the best practice, especially in cases of complex trauma, in which a very strong therapeutic relationship is a vital component of successful treatment. Relational–cultural theory provides an alternative conceptual lens for treating complex cases and is a natural fit for counselors' professional identity. This case illustrates how a counselor used a relational–cultural conceptualization as a guide in treating a client with complex presenting concerns.     

A narrative social constructionist approach to therapeutic empathy

The concept of empathy has been a centrol conceptual element in approaches to counselling and psychotherapy that emphasise exploration of meaning in the context of a facilitative relationship. However, the existing literature on therapeutic empathy lacks theoretical coherence. a narrative social constructionist perspective represents a theoretical approach that enables the integration of diverse strands of clinical observation and research into the creation of empathic understanding in counselling. From a social constructionist position, therapeutic empathy can be understood as a relational process, a step-by-step co-construction by counsellor and client of the life-narrative of the client. In this paper, the Barrett-Lennard (1981) cyclical model of empathy is used as a fremework for examining the counsellor and client actions, strategies and tasks that constitute empathic engagement around the task of emploring and re-authoring life-narratives. Constructionist analysis of the cultural origins of the concept of empathy suggest some limitations of this way of conceptualising what happens in therapy. The implications of these ideas for theory, training and research are discussed.     

Premature termination as a function of intake data based on ethnicity, gender, socioeconomic status, and income

Although it is acknowledged that premature termination is detrimental to the therapy process, there is limited information on how to utilize client demographic data to indicate which clients have greatest potential to prematurely terminate. The study assessed how client ethnicity interacts with client gender, therapist gender, therapist ethnicity, and client socioeconomic status (education and income) to affect premature termination. The study consisted of 527 cases which received therapy services from the Auburn University Marriage and Family Therapy Center from October 1993 to October 1999. The three definitions of premature termination used were termination after one session, prior to six sessions, and by therapist report. Results indicated that interactions of client income and ethnicity and therapist gender and ethnicity were the most useful demographic data indicators of premature termination.     

A practice-based study of cultural humility and well-being among psychotherapy clients

One trend in psychotherapy research involves examining client factors to better understand change. Some have framed client factors as virtues. Humility is one virtue that has gained attention with evidence that suggests humility may help facilitate therapeutic change. A specific type of humility, cultural humility, however, has not been closely examined as a client factor. Cultural humility is a relational virtue that addresses an individual's ability to be open towards cultural differences and can be helpful in buffering diverse relational dynamics (e.g., student and teacher, family members and friends with different beliefs). In this study, we examined client change in cultural humility and well-being using group-based trajectory modelling. We also examined differentiation as a predictor of trajectory membership and compared trajectories on levels of symptoms. Results suggested that a subgroup of clients showed significant increases in cultural humility and well-being. Further analyses found that clients with higher levels of initial differentiation were more likely to belong to the growth trajectory. This same trajectory also decreased in symptoms over time.     

Utilizing artistry in a therapeutic relationship

Abstract

In many humanistic approaches, therapeutic change involves utilizing the relationship between the client and therapist as a tool for personal growth. Like any relationship, the therapeutic relationship is one that is co‐created between those engaged in it, namely, the client and the therapist. Utilizing this co‐created relationship requires a sense of artistry on the part of the therapist. A therapist must be willing to engage in this meaningful relationship with the client. A therapist must also be aware of the personal values that he or she brings into therapy, and how they influence the therapeutic relationship. Finally, a therapist must acknowledge the power that the therapist and the client possess in the relationship, and understand how that power can be used to validate and invalidate the therapist's and the client's personal meanings. These aspects of therapeutic artistry are discussed and the use of therapeutic artistry in Eron and Lund's (1996) narrative solutions approach is presented.     

Strengthening the Strengths Perspective

Abstract

This article revisits the strengths perspective as conceptualized in social work practice. Although we find this perspective has value and utility for practitioners, we identify areas where the strengths perspective could be enhanced and augmented by integrating the contemporary relational approach exemplified by Paul Wachtel's cyclical psychodynamics. Specifically, we explore his concepts of therapeutic communication and use of language, including interventions that affirm client strengths such as reframing, searching for variations and exceptions, and reconceptualizing how transference impacts the therapeutic action. We illustrate our view with a case vignette, advocating that Wachtel's integrative approach provides a new context for psychodynamics in current social work practice.     

Short versus longer term effectiveness of an outreach program for the homeless mentally Ill

Presents 12-month follow-up results from an outreach/linkage intervention with persons who are homeless and mentally ill, contrasting these with results obtained at 4 months. Both sets reflect the success of the program in placing individuals in independent housing. However, longer term data provide useful information regarding client movement patterns and increased tenure in nonhomeless living arrangements beyond the termination of specialized services. Analyses of 12-month residential outcomes identified four variables as significant predictors: recruitment source, project service duration, CMH service duration, and client age. In contrast to 4-month predictors, variables reflecting baseline client functioning were no longer significantly related to outcome, suggesting that the positive effects of the intervention may take longer to achieve with some clients. Discussion focuses on the implications of these effectiveness results for future research designs and measures as well as the utility and limitations of preexperimental approaches for evaluating innovative service models when implementation and efficacy experiences are lacking. This research was supported in part by a grant from the National Institute of Mental Health, #H87 MH44373, to the Michigan Department of Mental Health.     

Contemporary MFT Models’ Alignment with Relational Common Factors

Common factors theorists believe that therapy is effective, not only because of model specific elements, but also, because of common factors that cut across various treatment models. Common factors include extra-therapeutic factors such as treatment setting, therapeutic alliance, therapist variables and client variables. Common factors researchers have proposed a set of relational common factors that are unique to the practice of marriage and family therapy, including the ability to conceptualize difficulties relationally and the ability to disrupt dysfunctional relationship patterns. In this paper, I analyze and compare relational common factors in three contemporary models: narrative therapy, solution-focused therapy and cognitive-behavioral therapy. Finally, I discuss significant implications for theorizing, training and supervision.