The Contributing Factors of Change in a Therapeutic Process

The clients’ and therapists’ perceptions about the degree to which each of four common factors in therapy—extra-therapeutic factors; model/techniques; therapeutic alliance; and hope/expectancy—contribute to change in the therapeutic process were investigated in this study. In addition, the perceptions about the percentage of change attributed to clients and therapists were also explored. Results revealed that the therapists and clients have different perceptions on what factors contribute the most to change and that clients and therapists believe that the client contributes the most to change in a therapeutic process.M. L. Thomas, MSW, is a doctoral student in Marriage and Family Therapy at Florida State University.     

A Sequential Analysis of Externalizing in Narrative Therapy with Children

Externalizing, or separating the person from his/her problem-saturated story, is a central approach in narrative therapy. Michael White, one of the therapy’s founders, lately revised his map of the externalizing process in therapy according to Vygotskian theory. In this study we sought to determine whether White’s proposed process was evident in therapy sessions. Sequential analysis indicated that therapists scaffolded children’s responses according to White’s map, and therapists’ and children’s utterances tended to advance across the levels of the map over the course of a session, indicating that White’s model of narrative therapy matched the therapy’s empirical process.     

What Does the Alliance Predict in Group Interventions for Early Psychosis?

The therapeutic alliance is considered an essential component of any clinical or psychological intervention. The therapeutic alliance can however change over time, and therefore it is relevant to determine if the alliance and its variations are related to clinical outcomes. The present study had three objectives: (1) determine the impact of the alliance measured by the client and the therapist, on clinical and psychosocial outcomes of individuals with early psychosis receiving group interventions; (2) measure the concordance between the client and the therapists’ ratings of the alliance; and (3) determine the best predictor of the client’s alliance in our sample. A total of 36 individuals with early psychosis who participated in group interventions for symptom management answered the WAI three times, and so did the group therapists. Outcomes included measures of insight, symptoms (total, positive and negative), and self-esteem. Attendance and group participation were also measured. Results suggest that the overall client’s alliance predicted total symptoms and self-esteem at post-therapy, whereas both clients’ and therapists’ ratings predicted group attendance and participation. Greater variations in the alliance overtime for the clients were somewhat linked to worse negative symptoms at post-therapy. Alliance ratings were generally high and fairly concordant between therapists and clients. Only the baseline measure of capacity for attachment, predicted the client’s overall alliance scores. Clinical implications are discussed.     

Exploring Master Therapists’ Use of Power in Conversation

Various theoretical approaches to therapy place different emphases on the use of power in therapy. In this study, we explore six master therapists’ use of power via communicational control for theoretical consistency. Results indicate that all therapists, regardless of their stance on power, use the role of therapist to exert power in an initial therapy session. Master therapists, in general, did appear to be theoretically consistent with their stated philosophies of therapy. Suggestions for future studies exploring power therapists have are included.     

Therapist Use-of-Self Orientations Questionnaire: A Reliability and Validity Study

This article describes the development of the Therapist Use-of-Self Orientation Questionnaire (TUSO-Q), an instrument designed to measure therapists’ use-of-self orientations while working with clients. A total of 373 therapists participated in this study. Exploratory factor analysis in the structural equation modeling context revealed three different therapist use-of-self orientations: Transpersonal, Contextual, and Instrumental. The final model provided an excellent fit to the data. TUSO-Q scores exhibited satisfactory evidence of internal consistency reliability and construct validity. Implications for the scale’s use in clinical research and training are discussed.     

Therapist Response to Clients’ Partner Abuse: Implications for Training and Development of Marriage and Family Therapists

This qualitative study explored ecosystemic influences on therapists’ responses to partner abuse. Research questions focus on aspects of personal and professional development of attitudes and belief systems surrounding partner abuse. In-depth interviews with seven therapy trainees indicate that family of origin experiences, clinical experiences, and therapist developmental processes affect values, beliefs, and clinical reactivity to cases involving partner abuse. Implications for therapists’ self-work, clinical training, and the process of supervision are addressed.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

Caregiver Involvement in the Intensive Mental Health Program: Influence on Changes in Child Functioning

We examined behavioral markers of caregiver involvement and the ways in which family participation was related to treatment outcomes in 47 elementary school children with SED enrolled in a school-based intensive mental health program. Measures of caregiver involvement included therapeutic home visits, attendance at therapeutic meetings, completion of ratings on the daily point sheet, and extra communications with the therapeutic team on the point sheet. Greater initial impairment was associated with greater caregiver involvement. Greater caregiver involvement was linked to improvement in child thought processes, increased ability to provide emotional and social supports for the child, and greater overall child functioning at discharge. Our findings also reflected increased therapists’ attempts to provide additional in-home services in cases where caregivers demonstrated a decline in their ability to provide for their children’s physical and material needs, or in which therapists discovered that the family functioning was more impaired than what was initially assessed. We provide a case study that exemplifies many of these findings.     

Resourceful Dialogues: Eliciting and Mobilizing Client Competencies and Resources

Within the social constructionist (narrative, solution-focused and collaborative language systems) therapies, therapists have increasingly focused on identifying and mobilizing clients’ resources and competencies. How such client resources and competencies are identified and elaborated can be considered empirical matters for analysts of therapeutic discourse. The present paper examines resourceful sequences of dialogue in 12 single session lifestyle consultations for how counsellors conversationally engaged consultees, and for what transpired within these sequences of dialogue. These sequences were micro-analyzed using conversation analysis and retrospective comments from consultees and therapists involved in these sequences were solicited using a videotaped replay procedure known as comprehensive process analysis [Elliott (1989). In M. Packer & R. B. Addison (Eds.), Entering the circle: Hermeneutic investigation in psychology (pp. 165–184). Albany, NY: SUNY Press]. The combined conversation analyses and related comments for three of the 23 videotaped passages analyzed are reported with the aim of enhancing therapists’ conversational practices in hosting resourceful dialogues with clients.

The Gap Between Science and Practice: How Therapists Make Their Clinical Decisions

Recent surveys have found that many patients are not receiving empirically supported treatments and that therapists may not update their knowledge of research. Studies have found that therapists prefer to use their clinical experience rather than research findings to improve their practice, although cognitive behavioral (CB) practitioners have been found to use research more frequently than therapists of other theoretical orientations. The organization in which therapists work has been shown to impact attitudes toward working practices, but studies have not examined whether workplace requirements to use research affect therapists’ practice. Studies to date have mainly been conducted in North America. These findings may not be generalizable to the United Kingdom where there is a National Health Service (NHS), which requires the use of empirically supported treatments. The first part of this study aimed to investigate which factors were influential in therapists’ choice of theoretical orientation and to see whether CB practitioners differed from other therapists in the factors that influenced their choice of theoretical orientation. The second part tested whether therapists’ theoretical orientation or their workplace influenced the frequency with which they used research in their clinical decision-making. The final part investigated whether being a CB practitioner or working in the NHS was associated with having a favorable attitude toward research. An online survey was sent to 4,144 psychological therapists in England; 736 therapists responded (18.5%). Therapists reported that research had little influence over their choice of theoretical orientation and clinical decision-making compared to other factors, specifically clinical experience and supervision. CB practitioners and NHS therapists, regardless of their orientation, were significantly more likely to use research than other therapists and were more likely to have a positive attitude toward research.     

The Influence of Parental Factors on Therapist Adherence in Multi-systemic Therapy

Therapist treatment adherence has received a great deal of attention in recent years, in part because of its relation to treatment outcomes. Although certain therapist behaviors have been found to be associated with treatment outcomes, little is known about client factors impacting on therapists’ ability to adhere to treatment protocols. In this study, we evaluated effects of parental beliefs, psychopathology, and interaction styles on therapists’ adherence to Multi-systemic Therapy (MST) principles. Eighty-two parents participating in a clinical trial of MST completed baseline measures assessing psychopathology, family functioning, and treatment expectations. Analyses indicated that parental perceptions of therapist adherence were established within the first 4 weeks of treatment, and that parental psychopathology, motivation, expectations, and child rearing practices were related to parental ratings of therapist adherence. Results were essentially unchanged when controlling for parental positive response style. Clinical and research implications of the findings are discussed.     

Marriage and Family Therapy Students’ Change in Multicultural Counseling Competencies after a Diversity Course

Attention to diversity is required in Commission on Accreditation for Marriage and Family Therapy Education-accredited programs, yet not much research exists regarding the effectiveness of graduate training on therapists’ multicultural counseling competencies. In this study, 12 students enrolled in a masters-level diversity class were given pre- and post-tests of their multicultural counseling competencies. Results showed that students significantly increased their multicultural awareness, knowledge, and skills after completing the diversity class. The discussion includes implications for educators who seek to improve students’ multicultural counseling competencies.     

West vs. West like East vs. West? A comparison between Italian and US American context sensitivity and Fear of Isolation

Easterners tend to process information more holistically than Westerners. Kim and Markman (J Exp Soc Psychol 42(3):350–364, 2006) suggest that these differences are rooted in higher chronic levels of Fear of Isolation (FOI) for those cultures that process information more holistically. The goal of this study was to determine if these differences and their suggested cause could be found with two different Western cultures. Testing Italian (IT) and US American (US) adults, we found that IT participants processed information more holistically and had a higher chronic level of FOI than US participants; furthermore, the manipulation of FOI affected context sensitivity more for IT than for US participants. The results demonstrate that IT participants were more similar to previous research with Eastern populations than with Western populations (Kim and Markman in J Exp Soc Psychol 42(3):350–364, 2006) and indicate a within-Western culture difference for reasoning styles and support the hypothesis that this difference is due to different chronic levels of FOI.     

What Happens When Therapists Feel Bored or Anxious? A Qualitative Study of Distracting Self-Awareness and Therapists' Management Strategies

Using a qualitative methodology, we investigated novice and experienced therapists' experiences of and strategies for managing distracting self-awareness. We found that novice therapists were most aware of anxiety and critical self-talk, whereas experienced therapists were most aware of boredom and outside distracters. In addition, although therapists tended to manage distracting self-awareness through self-coaching and refocusing on the client, novice therapists specifically mentioned managing problematic self-awareness through self-disclosure. In contrast, experienced therapists tended to manage problematic self-awareness by using thought stopping techniques. The results provide new avenues for examining therapists' in-session experiences and for investigating the effectiveness of different management strategies.     

Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families

Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents’ and youths’ perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.     

Clinical Expertise in Psychotherapy: How Expert Therapists Use Theory in Generating Case Conceptualizations and Interventions

Case conceptualization is a primary skill that may be the linchpin of clinical practice as it sets the framework for making sense of a patient’s difficulties and guides a path toward change. Providing meaning and structure to often ambiguous and nuanced clinical information, an apt case conceptualization facilitates the therapist’s complex integration of core therapeutic skills to produce expert performance. Rooted in the cognitive sciences literature on expertise, we introduce the concept of metabolizing theory to capture expert therapists’ capacity to use theoretical and clinical knowledge in an intuitive, flexible manner that responds and adapts to the unique and complex context of the treatment.     

Grey Matter: Ambiguities and Complexities of Ethics in Research

Ethical dilemmas are often not discussed in the dissemination of educational research. While the ethical guidelines for research seem clear at first glance, a closer look at the intimate nature of qualitative research reveals that there are many ambiguities or ‘grey’ areas where researchers must rely on their personal value systems. This article discusses the challenges faced by an experienced educator, although novice researcher, in considering the ethical parameters of her own research with adolescents with hearing loss. In particular, the grey ethical areas identified by the researcher include: (a) vulnerable population; (b) researcher role confusion; (c) consent; (d) privacy, confidentiality, and anonymity; as well as (e) the nature of risk. Based on the author’s own reflections on beginning the research process, the article presents possible pitfalls and ways of overcoming the possibility of becoming immobilized by the ethical enigmas of research.     

Prepackaged Tour Versus Personal Journey: The Meaning of Informed Consent in the Context of the Teacher-study Group

This article discusses the specific ethical dilemma of obtaining informed consent and ensuring confidentiality and participant well-being while conducting a qualitative research study with novice ESL teachers in a Teacher Study Group. The discussion outlines their process of resolution of the ambiguities inherent in the research process – in essence the researchers’ personal journey of discovery. The article concludes with the broader implications for making the research process more transparent for other academic researchers working in the field of language-teacher cognition.     

Virginia Satir’s Family Camp Experiment: An Intentional Growth Community Still in Process

In 1976, Virginia Satir began Satir Family Camp (SFC) with therapists and their personal families. Initially, it was a context for the family to experience Satir’s concepts and techniques so that the family system would change along with the therapist. The training of therapists is no longer a significant part of camp; relationships with self, family, friends, and the community is now the main focal point. The process and governance of the camp is presented along with a lengthy anecdote of an experiential family session. These two features—community function and personal/familial growth—inextricably work together to provide a validating environment that supports desired changes.