Occupational Therapists' Perception of the Tree Theme Method™ as an Intervention in Psychosocial Occupational Therapy

This study investigated how occupational therapists experience utilization of the Tree Theme Method, an intervention based on creative activities and life-story telling and making. The Tree Theme Method is comprised of five sessions in which the therapist asks the client to paint symbolic trees, with specific themes representing their present life situation, childhood, adolescence, adulthood, and the future. Nine occupational therapists in mental health care were asked about their experiences when using the Tree Theme Method. The informants formed two focus groups and each group was interviewed twice. Qualitative content analysis was used to identify five categories including: (1) therapeutic frames, (2) therapist requirements, (3) client requirements, (4) the therapeutic relationship, and (5) the Tree Theme Method as a multi-dimensional process. Overall the informants were satisfied with the intervention with some variation as to therapists' perception about the helpfulness of the tool. The Tree Theme Method was experienced as a structured method of starting a therapeutic process and initiating a therapist–client relationship. The therapeutic attitude, self-knowledge, and expert knowledge seemed to be important prerequisites for the therapists when using the Tree Theme Method intervention.     

正式反馈的发展与临床应用

摘要:正式反馈通过系统收集当事人的效果反馈来追踪其治疗进展,进而识别缺乏治疗进展的个案,并通过促进治疗策略的调整来阻止治疗失败。正式反馈是近20年来发展出的一种循证治疗手段,其目的为进一步提高当事人的咨询效果。正式反馈的发展大致经历了临床有效性检验和实用性发展两个阶段。正式反馈可用于促进个体、夫妻和团体咨询的效果,也可用于评估临床督导效果、确定督导个案和指导临床督导。未来研究可探讨咨询师对待正式反馈的态度,拓展正式反馈的使用价值,建立正式反馈系统的本土化常模。     

An intrusive and restrictive alternative to contingent shock

A 31-year-old man, a New Zealander with severe developmental disability, engaged in life-threatening operant vomiting. His therapists and two consultant behavior analysts recommended applying for a Court order to evaluate treatment that included the short-term use of contingent shock. In Court, others gave expert testimony that positive procedures alone would be sufficient and effective. Following the Court's decision against contingent shock, professionals who were responsible for ensuring compliance with the decision did not identify a nonaversive intervention. Consequently, the client was subjected to an intrusive medical procedure (chronic nasogastric intubation) and a severely restricted environment. This intervention was continued for 1 year. Problems that resulted from conflicting expert testimony on treatment alternatives are discussed.     

A consideration of intimate and non-intimate interactions in therapy.

Viewing therapy as a conversation among participants, rather than as an interview concluding with an intervention selected by an expert, allows one to consider the contributions of each member of the conversation in comparable terms. I propose a distinction between intimate interaction, in which meaning is co-created or shared, and non-intimate interaction, in which meaning is rejected, provided, or misunderstood. I suggest that intimate interaction between therapists and clients is therapeutic and that non-intimate interaction rarely is. However, it is in the acknowledgment and repair of the inevitable lapses of intimate interaction that occur between therapists and clients that there is an opportunity for a profoundly meaningful collaboration.     

Media reviews

Abstract

Dr. Maurizio Andolfi is Director of the Family Institute in Rome, Italy. He was trained in family therapy in the United States and now frequently returns to give seminars and demonstrations of his particularly gifted systems approach in the treatment of families, and in supervision of family therapists. Dr. Joel Bergman, a member of the senior faculty at the Ackerman Family Institute, reviews two of Andolfi's videotapes dealing with the supervisory process, and illustrated by actual clinical material.

The mirroring and reduplication of patterns often occurs when systems interface. Family dynamics repeat themselves across generations, and therapists and therapeutic teams easily become enmeshed in the powerful intricacies of family systems. The work of Andolfi highlights the importance of using the therapist's self-experience to illuminate and effect change in the family interactions, and the awareness of the contextual complexities of the supervisory process provides further possibilities for more enlightened intervention.—I. A.     

Intercontinental telehealth coaching of therapists to improve verbalizations by children with autism

This study examined the effects of intercontinental telehealth coaching on the mastery of therapists’ skills and improvements in verbalizations by children with autism, testing whether telehealth can be a solution for underserved communities in developing countries such as Georgia‐Sakartvelo in Eastern Europe. Three therapists delivering and three children with autism receiving early‐intervention services from the nongovernmental organization Children of Georgia in Tbilisi participated. Experimenters provided coaching from Virginia, USA to therapists in Georgia‐Sakartvelo. Observers in Georgia‐Sakartvelo and in Virginia conducted the behavioral observations. We used inexpensive communications technology to provide the coaching and a multiple‐baseline design across participants to evaluate the effects of the intervention. Therapists demonstrated improvements in two classes of behaviors: correct command sequences and positive consequences. The children demonstrated improvements with echoics and mands. The study demonstrated that telehealth can be a good model for delivering early‐intervention services to children with autism in underserved and distant regions of the world.     

Patterns of psychotherapy development: A mixed-method analysis using assimilation indices

Understanding how assimilation develops is essential in promoting personal change. By attending to signs or indices of assimilation in the speech of clients, therapists can use this process to assess how the therapy is developing and to tailor intervention. The system of assimilation indices was developed to use assimilation to understand the process of change. This system signals five sub-processes of assimilation: external distress, pain, noticing, decentring, and action. This study consisted of a longitudinal mixed-method analysis, following a multiple cases embedded design. The system of assimilation indices was applied to the recordings of nine psychotherapies and contrasted with both the outcome of the therapy and the perspectives of the therapists and clients about their therapy process. The results show that the system of indices is useful in understanding multiple pathways for assimilation. The system of indices is seen as a useful tool for understanding assimilation and as having clinical value in anticipating challenges to the success of the therapy. This study also shows how the indices are sensitive to the nuances in the change process observed in clinical settings.     

Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events

Assessment and treatment of acute responses to traumatic stress has received much attention since September 11, 2001. This article elucidates principles of early intervention with adults in the immediate (within 48 hours) and early recovery phase (within the first week). The principles have been drawn from research on risk and recover factors, stress and traumatic stress theory, and expert consensus recommendations. The debriefing model is discussed, and principle interventions of psychological first aid, pharmacology, and mass trauma systems are described. This article concludes with brief guidelines for longer-term interventions and recommendations for future research.     

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.     

Parent Perspectives of an Evidence-Based Intervention for Children with Autism Served in Community Mental Health Clinics

Research suggests that improvements to community mental health (CMH) care for children with autism spectrum disorders (ASD) are needed. Recent research examining the feasibility of training CMH therapists to deliver a package of evidence-based practice intervention strategies (EBPs) targeting challenging behaviors for school-age children with ASD offers initial support for such efforts to improve care. Specifically, quantitative data from a recent pilot study indicate that CMH therapists with limited ASD experience can deliver an EBP intervention with fidelity and perceive it as useful to their practice. Further, client attendance is high and children demonstrate improvement on standardized measures. To further understand the feasibility and impact of training CMH therapists to deliver EBPs, this mixed-methods study examined parent perspectives of the process and impact of outpatient psychotherapy for 13 parents of children ages 5–13 with ASD whose therapists were trained to deliver the EBP intervention. Results complement and expand previously reported quantitative data on psychotherapy process indicating that parents are highly involved in treatment for their children, perceive a strong therapeutic alliance with their children’s therapist, and highlight that treatment was different once therapists began delivering the intervention. Results also indicate themes related to parents’ perceptions of positive child and parent outcomes that provide important details on the specific gains that were observed during treatment. Study findings underscore the importance of parent perspectives in understanding the process and impact of implementing EBPs in CMH settings for families of children with ASD.     

Shifting the School's Solution

A newly developing mode of brief, problem-focused intervention, known as brief strategic intervention, has begun to be used by special services practitioners to resolve persistent student problems. In this article, the brief strategic intervention approach is described and illustrated by means of a case involving a third grader who avoided doing his classwork.     

Building Alliances with (In)Voluntary Clients: A Study Focused on Therapists’ Observable Behaviors

This study aimed to compare therapists’ observable behaviors to promote alliances with involuntary and voluntary clients during brief family therapy. The therapists’ contributions to fostering alliances were rated in sessions 1 and 4 using videotapes of 29 families who were observed in brief therapy. Using the System for Observing Family Therapy Alliances, trained raters searched for specific therapist behaviors that contributed to or detracted from the four alliance dimensions: engagement in the therapeutic process, an emotional connection with the therapist, safety within the therapeutic system, and a shared sense of purpose within the family. The results showed that when working with involuntary clients, therapists presented more behaviors to foster the clients’ engagement and to promote a shared sense of purpose within the family. However, in the fourth session, the therapists in both groups contributed to the alliance in similar ways. The results are discussed in terms of (a) the therapists’ alliance‐building behaviors, (b) the specificities of each client group, and (c) the implications for clinical practice, training, and research.     

Infidelity Treatment Patterns: A Practice-based Evidence Approach

Infidelity is a common presenting problem in couples therapy and can be challenging for therapists to treat. The current zeitgeist in mental health delivery systems includes a focus on developing treatment guidelines. The essence of this movement is that therapists' practice be informed by clinical research, or at the very least, be guided by the accumulated wisdom of other therapists. Practice-based evidence has been advocated as a method using a bottom-up approach of gathering data relying on the expertise of practicing clinicians to inform treatment guidelines. The goal of this paper was to distill and disseminate such aggregated wisdom related to treating infidelity into a practice-based evidence model. We reviewed the literature related to the treatment of infidelity and identified a core set of clinical recommendations that was similar across sources. The themes and patterns that emerged are divided into the following areas: goals of treatment, treatment engagement, treatment format, assessment, process and intervention, treatment adherence, and relapse prevention. We present this as a map or guide to treatment than can be individualized to a specific clinical situation, rather than as a specific, step-by-step manualized approach. We note cultural and ethical factors that may be relevant, as well discuss areas of debate and topics for future research.     

The working through of patients' suicides by four therapists.

In 1976 four psychotherapists in training at one institution had patients who committed suicide. The therapists met as a group over a one-year period. This paper presents brief case summaries, explores the reactions of each therapist, presents conclusions regarding the mourning process following patients' suicides, and puts forth implications and suggestions for training programs. The authors conclude that it is necessary for therapists, supervisors, and training programs to recognize the inevitability of crises and tragedies when working with disturbed persons and that, though the process of mourning must be worked through individually, training settings can permit therapists to experience the pain and loneliness while providing opportunities for mastery and growth.     

The Effectiveness of Collaborative/Therapeutic Assessment for Psychotherapy Consultation: A Pragmatic Replicated Single-Case Study

This pragmatic study evaluated the effectiveness of a collaborative assessment intervention as an approach to midtherapy consultation, which has yet to be empirically tested. Ten adult participants in ongoing psychotherapy with a variety of presenting concerns, primarily consisting of general mood and adjustment issues, received a brief assessment-based intervention based on Finn's (2007) Therapeutic Assessment model. Following the collection of assessment questions and the administration of a multimethod assessment battery, clients and therapists participated in a joint feedback session with the assessor. Clients were then followed as their psychotherapy continued. The results of idiographic and aggregate analytic approaches revealed significant reductions in client-reported symptomatic distress, as evidenced by a medium effect size (d = –.50) and a significant change in the trajectory of distress. Client reports of the process of psychotherapy revealed a significant increase in the clients’ ratings of the working alliance. The findings suggest that a midtherapy consultation using collaborative/therapeutic assessment methods is beneficial but that further rigorous investigation is needed.     

Facilitating forgiveness in the treatment of infidelity: an interpersonal model

This article presents a unique clinical model of forgiveness developed specifically for use in the treatment of infidelity. The model focuses on forgiveness as a central component of the process of healing for couples who desire relationship reconciliation following an affair. Infidelity causes significant damage for couples and results in a loss of trust and relationship stability. However, couples can become reunified and trust may be restored as couples work through the process of forgiveness. Forgiveness is facilitated as therapists and clients focus on four unifying factors: empathy, humility, commitment and apology. Specific steps are outlined for therapists to help them guide clients through the process of forgiveness. The clinical application of the model is illustrated with a brief case example.     

Randomized controlled trial of a brief problem-orientation intervention for suicidal ideation

Empirical evaluations suggest that problem orientation, the initial reaction to problems, differentiates suicidal youth from nonchnical controls and nonideating psychiatric controls. One promising area for intervention with suicidal youth relates to enhancing this specific coping skill. Nonclinical participants (N = 110) with active suicidal ideation were randomly assigned to receive a brief problem-orientation intervention or a control procedure. The current study evaluated the benefits of a brief prevention intervention based on the Problem-Solving Therapy model. Exposure to a brief video intervention regarding problem solving and coping skills was sufficient to elicit significant decreases in suicidal ideation and depression, but the intervention did not elicit improvements in problem orientation or other problem-solving abilities. These findings provide preliminary support for a brief, video-based problem-solving and coping skills module. However, considerable work in developing secondary prevention interventions remains.     

The Evolution and Modern Practice of Interpersonal Process Family Therapy

This article recognizes rapprochement between intervention theories, and asserts that contemporary recognition of the effects from the therapist-client relationship supports that family therapists should embrace interpersonal process. Specific guiding principles are posited.