Themes in Therapist Development During the First Three Months of Clinical Experience

The results of a qualitative research study designed to better understand the developmental processes active in beginning therapists during the first three months of clinical contact is reported. Thirteen beginning therapists were asked to complete a monthly log describing experiences impacting their clinical work and themselves as therapists during their first three months of client contact. Data analysis revealed that the primary developmental theme active during this period of time is the development of therapist confidence. Two additional themes, the development of an internal gauge on which to evaluate current experiences and the development of boundaries around the self as a professional, were also found to be active during this time. These additional themes support the development of therapist confidence. Implications for training and research are identified.     

Therapists’ understandings and experiences of working with clients with problems of addiction: A pilot study using Q methodology

This pilot study aims to increase our understanding of therapists’ subjective attitudes, beliefs, and experiences of working with clients with problems of addiction. The study yielded useful clarifications, arising from the finding that opinions about the nature of addiction support different approaches to therapy. In addition, it seems that diverse or conflicting attitudes and beliefs are likely to impact on the ability of therapists to work together effectively. Another objective was to test the feasibility of using Q methodology in this study and more broadly in qualitative research in psychotherapy. Participants were 13 therapists from a variety of backgrounds and working in a range of agencies. Using Q methodology, four distinctive factors were identified, indicating divergent understandings of addiction. Each factor is shown to be a multifaceted construct which does not correspond to any single theory or therapeutic orientation. It is suggested that the results have significant implications for therapists’ training and supervision. In addition, this study demonstrates the capacity of Q methodology to identify commonalities and diversity in viewpoints which do not conform to a priori conceptualisations. As a pilot study, this paper invites further discussion and research.     

‘Coming out’ in therapy? Perceived risks and benefits of self‐disclosure of sexual orientation by gay and lesbian therapists to straight clients

Primary objective: The study's primary objective was to investigate the experiences of gay and lesbian therapists, when considering self‐disclosure of their sexual orientation to straight (i.e. heterosexual) clients. This qualitative study set out to ascertain the key factors gay therapists take into account when considering this decision and to explore the effects this self‐disclosure may have on themselves, their clients and their therapeutic relationships. Research design: The research design was based on the use of semi‐structured interviews, undertaken with a non‐random, purposive sample of counsellors and psychotherapists (n=8) in current practice. The rationale for this method was to aid exploration of therapists' experiences of the process of self‐disclosure. Methods and procedures: Inclusion criteria were for therapists who self‐identified as being gay or lesbian, and who were experienced in clinical work with straight clients. Transcribed data was analysed using inductive thematic analysis. Main outcomes and results: Some therapists reported being confident with self‐disclosure relating to their own sexual orientation. However, a common theme related to the reportedly high levels of anxiety and vulnerability, which therapists identified. Key themes emerged around: respondents' fears of client judgement; a need for therapist self‐protection; self‐awareness of the potential impact of their own fears and prejudices on the therapeutic relationship; and the potential relevance of internalised homophobia, as an overall constraining factor. Conclusions: Self‐disclosure of their sexual orientation to straight clients is constructed, in this initial survey, as being potentially problematic and risky for some gay therapists.     

Therapist training in video chat technology for use in an adaptive digital mental health intervention: Challenges,facilitators and implications for training models

Objective

This qualitative study investigated therapist training experiences, elements of skill acquisition, and barriers and facilitators associated with conducting assessments, and the delivery of low- and high-intensity therapist assistance delivered via video chat technology, adjunctive to a transdiagnostic digital mental health intervention programme for anxiety and depression.

Methodology

In total, 34 semistructured interviews were conducted with 20 therapists. Twenty interviews explored experiences of training to administer a clinical assessment tool, and 14 additional interviews explored training experiences of delivering low- and high-intensity therapist assistance via video chat technology.

Results

Reflexive thematic analysis identified three themes: video chat skill acquisition, competencies transferrable to video chat and video chat service quality. Training and supervision were identified as important to scaffold skill development, and therapists described surprise that their skill set was transferrable to video chat. The most cited barrier to the adoption of video chat was the management of risk and distress, along with environmental suitability. Frequently cited facilitators to the adoption of video chat included stable Internet connection, protocols and resources.

Conclusion

The benefits of video chat technology and digital mental health interventions can be maximised through the expansion and integration of training into existing teaching curricula. If therapists are familiarised and competent to deliver mental health services via the Internet, as well as in person, the future adoption of blended and stepped-care models is likely to be increased.     

Women’s preference of therapist based on sex of therapist and presenting problem: An analog study

An analog study was conducted to examine differences in women’s preference for and anticipated comfort self-disclosing to hypothetical therapists of different sexes based on the type of hypothetical presenting problem. The impact of general level of self-disclosure was also examined. Participants included female college students (n?=?187). Anticipated comfort self-disclosing to male or female therapist was rated by subjects when presented with therapists of each sex with the same qualifications. Women preferred and reported higher levels of anticipated comfort self-disclosing to a female therapist. The type of hypothetical presenting problem and general level of self-disclosure also impacted anticipated comfort self-disclosing. There was an interaction between general level self-disclosure and the sex of therapist on anticipated comfort self-disclosing. General level of self-disclosure only impacted anticipated comfort self-disclosing when the therapist was male. This information is relevant for therapists or organizations that provide psychosocial services to women. Organizations may want to inquire about a client’s preferences about sex of therapist beforehand and, if possible, cater to the client’s preference.     

Aspiring to become a therapist: Personal strengths and challenges,influences, motivations,and expectations of future psychotherapists

Ten female students who were considering therapy as a career path wrote self-reflection papers and were interviewed regarding their career choice. Consensual qualitative research was used to analyze the data. These participants all indicated a passion for helping others, believed in the importance of giving back, and had prior experiences in helping activities. They considered themselves to have personal helping-related strengths (e.g. empathy) as well as challenges (e.g. avoidance of interpersonal conflict), and worried about potential problems they would encounter as therapists (e.g. being too emotionally invested). Participants expressed both other-oriented (e.g. to help others who had similar painful experiences) and self-oriented (e.g. to help self) motivations for wanting to become therapists. Implications for helping undergraduate students reflect about therapy as a career choice are offered.     

The Relationship Between Momentary States of Therapist Self-Awareness and Perceptions of the Counseling Process

To investigate the role of momentary self-awareness, beginning therapists and their volunteer clients participated in a postsession process recall in which therapist helpfulness and momentary self-awareness were assessed along with client reactions. Therapist anxiety levels and strategies used to manage hindering self-awareness were also examined. Results suggest that momentary states of heightened therapist self-awareness may be hindering. Specifically, when therapists rated themselves as more self-aware from moment to moment during counseling sessions, they also rated themselves as more anxious before the session and their clients rated them as less helpful during the session. In addition, therapists reported using a variety of strategies to manage distracting self-awareness, including focusing on intervention planning and focusing on the client. Implications for therapist training are discussed.     

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.     

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.     

Teaching mindfulness to psychotherapists in clinical practice: The Mindful Therapy Programme

Introduction: Initially proposed as a treatment modality for psychological disorders, mindfulness is now being promoted as a means of enhancing both therapist self care and therapeutic efficacy. The degree to which mindfulness can be learned by therapists to manage their own and clients' processes in therapy is as yet unknown. This study examines training outcomes of a standardised introductory mindfulness programme for mental health professionals. Methods: Forty-seven mental health professionals completed an eight-week mindful therapy (MT) training programme and associated measures. Results: Compared with baseline scores, participants demonstrated knowledge acquisition on all measures, including increased mindfulness in clinical work, increased capacity to intentionally invoke mindful states of consciousness, and higher participant ratings of well-being over the course of training sessions. Discussion: This research provides preliminary evidence that a brief, standardised mindfulness training programme can achieve acceptable knowledge and skills outcomes for therapists that can aid their therapeutic practice. Of note, increased ‘therapeutic mindfulness’ in this study resulted from changed mindfulness ‘attitudes’ (i.e. a more accepting and equanimous orientation within therapeutic work) as opposed to a clear demonstration of increased attention-regulation skills. The implications of these and other results for programme development and wider research are discussed.     

Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial

Efforts to improve the implementation of evidence-based treatments (EBT) have recently made important strides. One such example is understanding the vital role that weekly consultation plays as therapists learn to deliver an EBT. Because mechanism-based research can further support EBT implementation, the present study sought to examine the potential relationship between therapist self-efficacy in relation to treatment fidelity and outcomes.We examined therapist self-efficacy ratings from 80 therapists working with 188 patients. These data were collected as part of a randomized controlled implementation trial testing cognitive processing therapy (CPT). Across post-workshop training conditions, we ran multilevel models to assess (1) changes in therapist self-efficacy, (2) therapist self-efficacy in relation to treatment fidelity, and (3) therapist-self-efficacy in relation to patient PTSD symptom outcomes.We found that therapist self-efficacy significantly improved over the course of 6 months of CPT training. Baseline therapist self-efficacy was differentially associated with client outcomes based on post-workshop training condition. Specifically, therapists with low self-efficacy that did not receive post-workshop consultation tended to have poorer outcomes than therapists with low self-efficacy that received consultation. In the present sample, therapist self-efficacy was not related to treatment fidelity.As this was the first study to examine therapist self-efficacy in the implementation of an evidence-based treatment, our findings suggest that self-efficacy may be an important implementation factor in treatment outcomes and worthy of ongoing research.     

Ethical Issues and At-Risk Behaviors in Marriage and Family Therapy: A Qualitative Study of Awareness

This exploratory study investigated perceptions of and relationship with professional ethics of therapists-in-training. A focus group of marriage and family therapy doctoral students explored self-awareness and at-risk behaviors regarding ethical competence and compliance. A grounded theory analysis of data is presented as a conditional matrix, which offers a theory of development between therapists and their perception of ethics. The Practitioner-Relationship Ethics Model represents findings of interaction between confidence in ethical principles, field experience, use of justification, and at-risk behaviors. Implications and limitations of these findings are presented, as are suggestions for research.     

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.     

Online Cognitive Behavioural Therapy Training for Therapists: Outcomes,Acceptability, and Impact of Support

The objectives of the present study were to assess the effects of online cognitive behavioural therapy (CBT) training for therapists on measures of CBT knowledge, skills, confidence, and utilisation; to determine what differences might exist between a group supported by regular telephone contact and an independent group who undertook online training without additional support; and to determine the acceptability of CBT online training among rural and remote mental health professionals. Mental health practitioners were randomly allocated to a supported training group (six sessions of 15‐min support) or an independent group. They undertook a 12‐week online CBT training program. The two groups showed similar gains on an objective test of knowledge of CBT, and on self‐report measures of knowledge, skills, confidence levels, and utilisation of skills. However, the supported training group had a significantly higher program completion rate than the independent group. Participants evaluated the program favourably. The results suggest that online CBT training represents a promising and cost‐effective approach to training the mental health workforce, and may be particularly attractive for those who live in regional, rural, and remote communities. A challenge is to determine the most cost‐effective ways to enhance program completion rates and trainee skills.     

Therapist interventions in short-term dynamic psychotherapy: six expert treatments

This paper describes the profile of verbal response modes utilised in the expert application of Short-Term Dynamic Psychotherapy (STDP). One hundred and fifteen randomly selected segments from six treatments of STDP were analysed. Trained raters used a verbal response mode coding system to examine the individual speaking turns of an expert therapist. Based on the profile of therapist interventions reported, it was concluded that the actual conduct of this treatment in routine practice illustrates the empirically informed modifications to STDP technique integrated alongside the common characteristics of STDP based on the therapist (i) adopting an active stance, (ii) maintaining treatment focus using frequent confrontations and the ‘Triangle of Conflict’, and (iii) tailoring treatment to participant functioning using a combination of supportive and expressive interventions. Furthermore, specific differences in therapist activity were observed across treatment phases as well as between participants.