Therapists as fixed versus random effects-some statistical and conceptual issues: a comment on Siemer and Joormann (2003)

The authors disagree with M. Siemer and J. Joormann's assertion that therapist should be a fixed effect in psychotherapy treatment outcome studies. If treatment is properly standardized, therapist effects can be examined in preliminary tests and the therapist term deleted from analyses if such differences approach zero. If therapist effects are anticipated and either cannot be minimized through standardization or are specifically of interest because of the nature of the research question, the study has to be planned with adequate statistical power for including therapist as a random term. Simulation studies conducted by Siemer and Joormann confounded bias due to small sample size and inconsistent estimates.     

Amelioration of transference resistance: substitute therapists in milieu group psychotherapy

Building upon Wolf's (1949) notion of the use of an alternate session in group psychotherapy, this paper suggests that an alternate therapist substituting for an absent regular therapist in milieu group psychotherapy can facilitate similar therapeutic benefits. The mechanism of this process of overcoming transference resistance is seen as twofold: (1) sessions with a substitute therapist allow patients to confront the infantilization often present in a milieu setting and experiment with more autonomous ego functioning. (2) Sessions with a substitute therapist create conditions which are apart from the ongoing process of the therapy group, thereby allowing for a therapeutic splitting process to develop wherein transference feelings about the regular therapist can be expressed to his or her "alter ego." Several case vignettes are presented in order to illustrate the clinical utility of a substitute therapist.     

Treatment preference and acceptability: Epistemology and locus of control

Abstract

Treatment preference and acceptability were investigated in 397 female university students. Three audiovisual vignettes depicting a client and therapist discussing a body image disturbance problem were presented to subjects. Predictions were that subjects would prefer one of three therapy approaches—behavioral, cognitive—rational, or cognitive—constructivist—as a function of personal epistemology and locus of control. Overall, subjects rated the constructivist therapy approach more favorably than either the cognitive—rational or behavioral approach. Similarly, subjects evaluated the constructivist therapist more positively than either the rational or behavioral therapist. After degree of subject identification with the target problem was controlled, results indicated that matching subjects who had an external locus of control orientation to a behavioral or cognitive-rational therapist resulted in more favorable assessments of that therapist. Matching subjects who had an internal locus of control orientation to a constructivist therapist resulted in more positive assessments of that therapist. Implications for matching in clinical practice are discussed.     

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.     

Group processes and the therapist's subjectivity: interactive transference in analytical group psychotherapy

Interactions among the group therapist, the group members, and the group as a whole, especially enactments, are conditioned by the therapist's identity, defenses, and present relationships within his or her social networks. It follows from these considerations that difficulties in a group process stem from the group therapist's inability to understand well-enough what the group members are acting out and that they can be overcome only if the therapist extends the limits of his or her identity. Therefore, it has to be taken into account that the leader of a group is always a member of other groups whose dynamics in turn determine one's capability to understand the interactions in the group in which he or she is a therapist.     

Factors That Predict Premature Termination Among Mexican-American Children in Outpatient Psychotherapy

The role of demographic variables, acculturation, and therapy attitudes and expectations in predicting treatment dropout for Mexican-American families who presented for mental health treatment for a young child at a community mental health center was examined. Univariate analyses indicated that less educated parents who felt that they should be able to overcome their child's mental health problems on their own, and who felt that emotional and behavioral problems should be handled by increasing discipline were more likely to terminate prematurely. In addition, parents who perceived more barriers to treatment and expected their child to recover quickly were more likely to drop out of treatment after attending just one session. Measures of household income, acculturation, therapist–client ethnic match, perceptions of stigma, and expectations of therapist directiveness were not related to treatment dropout. When multivariate analyses were examined, parental education, perceived barriers to treatment, and belief in increased discipline remained significant predictors of treatment dropout, and client–therapist ethnic match became a significant predictor of dropout. Results are discussed in terms of implications for culturally-sensitive interventions.     

Feeling like a good psychotherapist — Or a bad one: Critical incidents in psychotherapists' experiences

What makes a therapist feel competent or incompetent in a session, a concept related to the good — or bad — hour, is an implication of what the therapist believes is good therapy and therefore is trying to do — or believes is bad and therefore tries to avoid doing. In an attempt to infer covert processes in therapists, twenty-seven psychoanalytically-oriented psychotherapists furnished written accounts of sessions when they had felt like good — or bad — therapists. Accounts were analysed and interpreted to uncover the varieties of good and bad experiences and their grounds. Resistance and countertransference were found to be critical phenomena. When the therapist was able to cope with such complications, good feelings were generated, and when he was unable, bad ones — provided he became aware of this inability. If not, the therapist acted out patient-specific or unspecific countertransference feelings in ways that made him feel like a good therapist.     

Therapist response modes in the exploration stage: timing and effectiveness

In an investigation of the exploration stage of single counselling sessions with 26 anxious female volunteer clients and 13 female doctoral student therapists, no overall association was found between client narrative processing modes and subsequent therapist verbal response modes. There was evidence in a third of the sample for an association between therapist response modes and subsequent client narrative modes, such that clients used more internal than external or reflexive narrative processing modes when therapists used open questions about feelings and reflections of feelings. Client and therapist helpfulness ratings did not differ for different therapist response modes or client narrative process modes. Hence, overall results suggested that all four therapist response modes (open questions about thoughts, open questions about feelings, restatements, reflections of feelings) are effective during the exploration stage.     

The therapist's responsibility: a systemic approach to mobilizing family creativity

Three techniques, sculpting, geneograms, and family drawing are considered within a systemic approach to therapy. Frequently, emphasis is laid on either the activity of the therapist or the behaviour of the family in treatment. We focus on ways in which the therapist draws on the clients' creativity, relying for this on a correct assessment of their 'language' or 'idiom'. Certain assumptions are proposed, and case illustrations are used in their support. Our approach is that any material, or apparently no material, produced when using these techniques represents essential information which can be turned to therapeutic advantage by means of positive reframing. Although a framework within which to practise is viewed as essential, a 'game-plan' will almost certainly result in sterility and impasses in therapy. Therapist flexibility, it is proposed, is a prerequisite for creativity. We prefer to label resistance to treatment as failure by the therapist to recognize the clients' needs.     

Therapist Factors Matter: A Systematic Review of Parent Interventions Directed at Children’s Behavior Problems

The present review systematically explored research examining the relationship between therapist‐related factors and the outcomes of parent interventions directed at children’s behavior problems. A systematic search of the literature was conducted with online scientific databases, parenting programs, web sites, and bibliographic references of the selected articles, according to PRISMA guidelines. A total of 24 quantitative studies met the inclusion criteria. Although some methodological limitations were identified with respect to the measurement of therapist factors, the reviewed research strongly suggests that the therapist plays a critical role in parent interventions directed at behavior problems. In particular, many parent outcomes are found to be related to the parent–therapist alliance, the therapist’s fidelity to the intervention, specific therapist’s in‐session actions, and the therapist’s personal variables. The parent–therapist alliance and therapist fidelity to the intervention consistently relate to changes in parenting practices, and alliance additionally relates to fewer perceived barriers to participation in treatment, more treatment acceptability, and greater parenting satisfaction and self‐efficacy. In addition, specific in‐session therapist interpersonal actions relate to parents’ engagement and satisfaction, while both the therapist’s interpersonal actions and more active skills relate to parent change. Therapist’s personal variables have been scarcely or poorly studied to date, but the results found justify the need to develop further research in this area. In conclusion, more attention should be given to the role of the therapist when implementing parenting programs directed at behavior problems, and more and better research is needed that can overcome the methodological limitations identified.     

The effect of supervisor and trainee therapist gender on supervision discourse

The effects of supervisor and trainee therapist gender on supervision discourse were examined in this study. Forty episodes of supervision discourse, with ten drawn from each of four types of supervision systems were videotaped. The systems were (1) male supervisor and male trainee therapist; (2) male supervisor and female trainee therapist; (3) female supervisor and male trainee therapist; and (4) female supervisor and female trainee therapist. The episodes of supervision discourse were analysed using a supervision discourse coding system which showed adequate inter-rater reliability. For supervisors, the coding system allowed a directive discourse style and a collaborative discourse styled to be coded. A cooperative discourse style and a resistant discourse style could be coded for trainee therapists. Two statistically significant findings of considerable theoretical and clinical importance emerged. First, contrary to stereotypic expectations, discourse characterized by a directive supervision style and a resistant trainee therapist style was more common for systems containing a female supervisor than for those containing a male supervisor. Second, for same gender supervisor-trainee-therapist supervision systems, a collaborative systemic supervision style was correlated with both cooperative and resistant trainee therapist styles. This discourse pattern did not occur for opposite gender supervision systems, indicating that a collaborative supervision discourse style is consistently associated with trainee therapist parti-cipation (either cooperatively or resistantly) within same gender pairings of supervisors and trainee therapists. These results are discussed in light of relevant literature on gender, power and supervision process and the limitations of the study are considered.     

Is touch a valid therapeutic intervention? Early returns from a qualitative study of therapists' views

Findings are reported from six semi‐structured interviews with experienced psychotherapists, focusing on the reasons for using touch and the sort of touch used. They suggest that there is a distinction being made by therapists between ‘social space’ and ‘therapeutic space’, and a different view of touch taken if it is judged by the therapist to be ‘out of the therapeutic environment’. Whether or not touch was initiated by the therapist or the client would also appear to influence its further discussion by the therapist, either in processing it with the client or in supervision. What also emerged from the interviews was the finding that an exploration of touch in supervision was unusual. The implications for practice, supervision and training are discussed as areas for further exploration in the main survey, which will be conducted in the second year of the research.     

Narcissistic leadership in psychotherapy groups

Narcissistic leaders in groups are capable of impeding progress of their patients and, at worst, can produce iatrogenic effects. Significant interferences may occur when the therapist is unable to tolerate the expression of negative transferences and when they need to be idealized by their patients. The rare therapist who is a malignant narcissist is capable of inflicting severe damage by sadistically exploiting the group to satisfy his or her own pathological needs. Less severe interferences consist of inhibition in making transference interpretations, reluctance to seek out training or supervision, and a difficulty in protecting patients against being scapegoated as a result of the displacement of negative feelings toward the therapist onto a member. The universality of these issues among therapists is discussed and possible remediation is proposed.     

Rebuilding family relationship bridges

This paper describes two techniques that the family therapist can use to help families in emotional crisis change and heal. They require the family therapist to persuade family members to view the therapy sessions as a project in building or rebuilding their family relationship bridges. An essential component of these approaches is the value placed by the family therapist on building rather than destroying family relationship bridges. Four themes are suggested as building blocks for healing dysfunctional family relationships: Love, Anger, Loss and Forgiveness. Vignettes of several family problems are presented accompanied by an intervention demonstrating an aspect of family bridge building.     

The development and content of an interpersonal psychotherapy group for postnatal depression

Postnatal depression (PND) usually causes distressing symptoms for sufferers and significant impairments in relationships. Group Interpersonal Psychotherapy (IPT-G) provides the experienced therapist with a brief, focused, and manualized approach to helping women recover from the debilitating effects of PND. This paper describes the background and development of IPT-G for PND. The evidence for the effectiveness of individual and group IPT formats with this population is summarized. The triad of theories underpinning IPT are discussed with an emphasis on the important role of attachment styles during the transition to parenthood. Its strengths, which include its unique package of targets, tactics, and techniques, are highlighted. The benefits and challenges of IPT-G are also explored, and the results of a randomized controlled trial are summarized. Finally, a case study illustrates how IPT-G specifically addresses the social role transitions, conflicts, losses, and social isolation that mothers commonly experience.     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

Avoiding Expert Testimony About Family Therapy

Although the family therapist may prefer to not be involved in legal proceedings, it is common for attorneys and judges to use the legal process (e.g., a subpoena or court order) to obtain testimony. This article considers how the family therapist should respond to a legal process that seeks to expand testimony from facts about the treatment to expert opinions. Ethics and legal considerations are discussed, and recommendations are offered.     

The Greek Chorus and Other Techniques of Paradoxical Therapy

This paper has described some of the interventions developed at the Ackerman Brief Therapy Project in treating the families of symptomatic children. The interventions are based upon a differential diagnosis of the family system and upon an evaluation of that system's resistance to change. They are classified as compliance-based or defiance-based, depending upon the family's degree of anxiety, motivation, and resistance. Paradoxical interventions, which are defiance-based, are used as a clinical tool in dealing with resistance and circumventing the power struggle between therapist and family. A consultation group acting as a Greek chorus underlines the therapist's interventions and comments on the consequences of systemic change. This group is also sometimes used to form a therapeutic triangle among the family, therapist and group, with the therapist and group debating over the family's ability to change.     

Thinking and Working Relationally: Interviewing and Constructing Hypotheses to Create Compassionate Understanding

In the initial interviews of family therapy sessions, the therapist faces the challenge of obtaining and organizing the information that is most relevant toward understanding the essential concerns that families and couples bring to therapy. This article describes the process of clinical interviewing and case conceptualization used in training family therapists at the Ackerman Institute for the Family. This approach helps the therapist bring forward, and organize, specific information into relational hypotheses, or systemic‐relational conceptualizations, that allow both family members and the therapist to understand presenting problems within their relational contexts. While always provisional, relational hypotheses help anchor the therapist in a systemic‐relational frame and provide a conceptual through‐line to guide the ongoing work of the therapy. The process of interviewing and the construction of clear and complex conceptualizations of presenting problems are illustrated through case examples.