Repurposing process measures to train psychotherapists: Training outcomes using a new approach

Aims: First, this paper presents the rationale for a novel approach to training counsellors in which measures for psychotherapy process research are taught to students before moving on to teaching basic empathic reflections and interventions. The rationale for this is that client process measures can be re‐purposed to help orient and sensitise trainees to key in‐session moments. Second, we present a training outcome study that assesses the effectiveness of this approach. Method: Using an experiential‐integrative therapy approach, a 13‐week training program was used to teach psychotherapy skills and process research measures to22 clinical graduate students taken from two cohorts. As part of the course, trainees conducted several single sessions with volunteer clients on four separate occasions. Training outcomes were measured using both trainee and client reports. Results: Compared to baseline, therapists reported significant and steady gains (all p's<.05) in session management, reducing their anxious self‐awareness, and in improved sense of self‐efficacy, with the latter having the largest effect (partial Eta Sq.=.381). Discussion: While the findings provide some support for a new training strategy, a dismantling design is needed next to more closely examine the process‐measure approach to training.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

How do trainees choose their first psychotherapy training? The case of training in psychotherapy integration

Future trainees go through difficult decision-making processes when starting their first psychotherapy training. The choice of training in psychotherapy integration is a specific type of this process. In this study, qualitative data were obtained from the motivational letters, in-depth semi-structured interviews and e-mail questionnaires of 26 future trainees to answer the research question, ‘How do trainees choose their first psychotherapy training?’ We primarily employed the grounded theory approach as well as consensual qualitative research to shed light on the central category of Gaining Certainty to enter the training. This category was elaborated into a four-phase model, specifically comprised of the: (1) Critical Comparison, (2) Identification, (3) Self-Confirmation and (4) Waiting phases. The model was then discussed in connection with relevant concepts, such as the degree of complexity and flexibility within the epistemological development of trainees [Vasco, A. B., &; Dryden, W. (1994). The development of psychotherapists’ theoretical orientation and clinical practice. British Journal of Guidance &; Counselling, 22(3), 327–341].     

Perceptions of psychotherapy trainees of psychotherapy research

Aims: The research‐practice gap and lack of engagement with research by trainees and qualified therapists is a widely discussed issue amongst psychotherapy researchers. The present study investigates the perceptions of psychotherapy trainees of psychotherapy research and explores what would encourage them to participate in research. Method: Two focus groups of 16 trainees in total were conducted at two separate psychotherapy training institutes to explore trainees’ attitudes and perceptions. Data was analysed using Braun and Clarke's (2006) thematic analysis. Results: Three superordinate themes emerged: negative perception of research; recognition of the importance of research; and what would be needed to facilitate engagement in research. Discussion: The results suggest that interest in and willingness to participate in research exists, however it is necessary for negative perceptions about research to be addressed and for researchers to design projects which are supportive of participants.     

Person‐Centred and Experiential Psychotherapy Scale: Development and reliability of an adherence/competence measure for person‐centred and experiential psychotherapies

Aims: This study aimed to assess the reliability of the Person‐Centred and Experiential Psychotherapy Scale (PCEPS), a new adherence/competence measure of person‐centred and experiential psychotherapies. The PCEPS consists of 15 items with two subscales: Person-Centred Process and Experiential Process. Method: One‐hundred twenty audio‐recorded segments of therapy sessions were rated independently by two teams of three raters using the PCEPS. Half of the segments were 10 minutes long and the other half were 15 minutes long. Six therapists were experienced therapists and four were counsellors in training. Seven of the therapists identified their work as ‘person‐centred’, and three identified their work as ‘process‐experiential’. Three raters were qualified and experienced person‐centred therapists and three raters were person‐centred counselling trainees in their first year of training. Results: Interrater reliabilities were good (alpha: .68–.86), especially when ratings were averaged across items (alpha: .87); interitem reliabilities were quite high (alpha: .98). Exploratory factor analyses revealed a 12‐item facilitative relationship factor that cuts across Person‐Centred and Experiential subscales (alpha: .98), and a nonfacilitative directiveness factor (3 items, alpha: .89). Conclusions/Implications: The PCEPS has potential for use in RCT research as well as in counselling training and supervision, but will require further testing and validation.     

Does participation in research lead to changes in attitudes among clinicians? Report on a survey of those involved in a French practice research network

Background/Objective: With increasing awareness of some of the limitations of randomised controlled trials as the ‘gold standard’ of psychotherapy evaluation, researchers at the start of the twenty‐first century have focused on a number of new priorities: developing studies in natural conditions; investigating the psychotherapeutic process to better understand the conditions, causes and mechanisms of change; and reducing the gap between clinicians and researchers. Can these three interrelated objectives be combined? Method: A French psychotherapy practice‐based research network (PRN) is used as a field of research for these issues. A survey was used to investigate the conditions that encouraged the clinicians to participate in the PRN study within the context of clinicians’ general opposition to research. Results: Several elements emerged as the key to clinicians’ positive involvement in research: the methodology implemented (intensive case studies during one year); the choice of measures; the constant attention to the practicalities and the potential contribution of studies to clinical practice; the organisation of work in peer groups; the training methods; the use of new information technologies and the sense of participation in a project that would support the profession. Implications: These elements are briefly discussed in relation to the question of how best to encourage clinicians to engage with research.     

‘Learning from research’: Therapist perspectives on the benefits and challenges of participating in a longitudinal,systematic case‐study

Objectives: In psychotherapy research we have often neglected to examine the impact of research procedures on therapy process and outcome. Such information is extremely important in helping us evaluate the validity of our findings, increase relevance of research for practice, and choose appropriate methods for future projects. The aim of this paper is to share the experience of six person‐centered therapists, who participated in a longitudinal, systematic study, and present their reflections about the impact of research on therapy process, therapeutic engagement and professional development. Methods: The findings have emerged from semi‐structured interviews that took place after the first, sixth (middle) and last therapy session. In total 18 interviews were conducted. These data were part of a much larger research protocol that included a number of outcome and process measures. Results & Conclusions: The analysis of therapist narratives revealed important benefits for those participating in systematic case study research. The use of Brief Structured Recall methods and qualitative interviewing was an important factor in promoting therapist reflexivity and professional development. The importance of a strong research alliance and the active involvement of the client in the research process is discussed.     

Use of Groups in Various Modalities of Hospital Treatment

The authors provide a comprehensive survey of the research literature on pretherapy training for group psychotherapy. The twenty studies identified during the twenty-five-year period 1962–1987 were fraught with various methodological and design inadequacies. Despite the widespread positive endorsement found in the clinical literature, the research evidence for the benefit of pretherapy training is not particularly impressive. While there is evidence of certain immediate effects (e.g., improved attendance), results concerning process and outcome effects are, at best, only suggestive. In the face of the disappointing findings, the authors are nonetheless optimistic regarding the potential value of pretherapy training.     

Discussion of “I’mprovisation–Therapists’ Subjective Experience during Improvisational Moments in the Clinical Encounter”

The first part of this article discusses Romanelli, Tishby, and Moran’s qualitative research on the impact of training clinicians’ “skill-sets” derived from improvisational theater. Categories of experience were discerned from the data, along with findings of the impressive positive effects from the training on the clinicians’ ability to better respond to unpredictable “improvisational moments” in psychotherapy. The second part elaborates on how the authors' research represents a welcome addition to a larger conversation about how drama theory “puts” “flesh and blood” on the “bones” of Relational Metapsychology, which entails theories of process and change, rooted in an information theory based epistemology in contrast to Freud’s archaic and deeply flawed Metapsychology ensconced in a psychic energy theory epistemology. Finally, the authors’ lends to advocacy for clinical training in drama and improvisation being added to clinically based curriculums.     

Experiences related to expert supervisors' views of ideal therapeutic practice

Aims: This study examines the relationship between expert supervisors' professional experiences and their views about the importance of different psychotherapy techniques. Method: Thirty psychodynamic‐interpersonal (PI) supervisors and 13 cognitive‐behavioural (CB) supervisors (N=43) were instructed to rate 20 therapeutic techniques according to how characteristic each technique is of an ideally‐conducted session within their theoretical orientation. The measure used for this assessment was the Comparative Psychotherapy Process Scale. Results: Findings demonstrated that supervisors' beliefs about ideal therapeutic techniques are related to their number of years in post‐graduate clinical practice, training, and supervising trainees, as well as to the number of publications they have authored. Further, experience within a given orientation tends to lead to a greater endorsement of techniques within that orientation, although this finding is more uniform for CB supervisors than PI supervisors. Finally, differential types of experience lead to differential focusing on specific techniques. Discussion: The clinical importance of these findings is explored.     

Energy psychology and psychotherapy: A study of the use of energy psychology in psychotherapy practice

Aim: The aim of the study was to increase understanding of how energy psychology informs and affects counselling/psychotherapy practice. By undertaking phenomenological interviews with experienced clinicians, the aim was to enrich and expand on the scientific approaches to energy psychology research. Method: This research is based on in‐depth semi‐structured interviews using interpretative phenomenological analysis (IPA). Five experienced psychotherapists who are also practitioners of energy psychology were interviewed. Findings: Four main themes emerged from the analysis: energy psychology as a potent intervention that facilitates shifts in emotions, cognitions, behaviours and physiology; the safety of energy psychology techniques; the role of the therapeutic relationship when using energy psychology techniques; and the challenges of integrating energy psychology into the work context, highlighting the need for more complex, systemic models to understand how people experience distress and how change is facilitated. Conclusion: Overall, participants in this study found energy psychology to be a valuable supplement to counselling and psychotherapy. The implications for current practice are discussed.     

Assessing DSM–5 Level of Personality Functioning From Videotaped Clinical Interviews: A Pilot Study With Untrained and Clinically Inexperienced Students

Several authors have raised the concern that the DSM–5 Level of Personality Functioning Scale (LPFS) is relatively complex and theory laden, and thus might put high requirements on raters. We addressed this concern by having 22 untrained and clinically inexperienced students assess the personality functioning of 10 female psychotherapy inpatients from videotaped clinical interviews, using a multi-item version of the LPFS. Individual raters’ LPFS total scores showed acceptable interrater reliability, and were significantly associated with 2 distinct expert-rated measures of the severity of personality pathology. These findings suggest that, contrary to the previously mentioned concerns, successfully applying the LPFS to clinical cases might require neither extensive clinical experience nor training.     

The path towards a professional identity: An IPA study of Greek family therapy trainees

Objective: Contemporary psychotherapy research has focused mainly on practitioners' training and education. The impact of training on professional development and the application of therapeutic skills have been the primary foci of the empirical literature. The aim of this paper is to present the experiences of seven family therapy trainees regarding their personal paths toward the development of professional identity as they underwent training in systemic psychotherapy. Method: In‐depth interviews were conducted and analysed using Interpretative Phenomenological Analysis. Results & Conclusions: Seven themes were identified: The Quest, Developing by Relating, Learnings, Personification of Training, Use of Self, Self‐Care and Empowerment, and Reflecting on the Role of the Therapist. The findings are discussed with regard to the development of the ‘therapist as a person’, gaining acknowledgement and autonomy, and the development of a community of therapeutic practice.     

The design of the MBT‐G adherence and quality scale

Few group psychotherapy studies focus on therapists' interventions, and instruments that can measure group psychotherapy treatment fidelity are scarce. The aim of the present study was to evaluate the reliability of the Mentalization‐based Group Therapy Adherence and Quality Scale (MBT‐G‐AQS), which is a 19‐item scale developed to measure adherence and quality in mentalization‐based group therapy (MBT‐G). Eight MBT groups and eight psychodynamic groups (a total of 16 videotaped therapy sessions) were rated independently by five raters. All groups were long‐term, outpatient psychotherapy groups with 1.5 hours weekly sessions. Data were analysed by a Generalizability Study (G‐study and D‐study). The generalizability models included analyses of reliability for different numbers of raters. The global (overall) ratings for adherence and quality showed high to excellent reliability for all numbers of raters (the reliability by use of five raters was 0.97 for adherence and 0.96 for quality). The mean reliability for all 19 items for a single rater was 0.57 (item range 0.26–0.86) for adherence, and 0.62 (item range 0.26–0.83) for quality. The reliability for two raters obtained mean absolute G‐coefficients on 0.71 (item range 0.41–0.92 for the different items) for adherence and 0.76 (item range 0.42–0.91) for quality. With all five raters the mean absolute G‐coefficient for adherence was 0.86 (item range 0.63–0.97) and 0.88 for quality (item range 0.64–0.96). The study demonstrates high reliability of ratings of MBT‐G‐AQS. In models differentiating between different numbers of raters, reliability was particularly high when including several raters, but was also acceptable for two raters. For practical purposes, the MBT‐G‐AQS can be used for training, supervision and psychotherapy research.     

Relational ecologies of psychotherapy: The influence of administrative attachment on therapeutic alliance

There is now vast and multi-faceted empirical literature on the impact of relational dynamics in psychotherapy, and relationality is a central theme within contemporary psychoanalytic theories. Yet, there is virtually no literature addressing the relational dynamics around outpatient psychotherapy that influence the wider therapeutic alliance, that is the relational dynamics that unfold between clients and administrative office staff in making initial contacts and appointments, completing paperwork, negotiating payment, discussing insurance coverage, working through crisis calls, and the myriad of other forms of interaction which serve to form the relational ecology of psychotherapy. Milieu therapy or the use of supportive and structured therapeutic environments has been given significant attention in inpatient settings; however, administrative relational factors or administrative staff characteristics have seemingly been ignored in outpatient psychotherapy and psychoanalysis literatures. Many outpatient clinical practice settings involve multiple levels and dimensions of relationality between clients, administrative personnel, and therapists which shape the potential for secure continuous containment and various forms of attachment to psychotherapeutic space. In this paper, we describe several clinical illustrations of relational dynamics between clients and office staff which influence therapeutic alliance and outline the contours of our emerging idea of administrative hospitality based on relational psychoanalysis, attachment theory, symbolic anthropology, and stigma research. In doing so, we draw on our collective experience working in several outpatient clinics and insights from our current context in an urban outpatient training clinic which emphasises psychodynamic practice. Our goal is not a comprehensive analysis of the relational ecology of psychotherapy but to offer an initial exploratory account of some of the administrative relational dynamics in and around outpatient psychotherapy which go beyond the therapist-client dyad. The anthropological concept of liminality is connected to relational psychoanalytic theories to describe the important dynamics of transitional space in an overall process of relational transformation.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.