Assessment of Subjective Client Agency in Psychotherapy: A Review

Theoretical accounts of psychotherapy, especially of a constructivist or humanistic sort, often assert the importance of the client's active efforts in “making therapy work.” Psychotherapy research also supports the importance of the client's contribution to therapy outcomes. Research on subjective client agency, defined as a client's expectations for taking an active role in psychotherapy, is limited, however. This review describes and evaluates the psychometric qualities of six measures of this construct and provides recommendations for future research. Three of these measures are particularly suitable for further work by constructivist investigators of therapy process and outcome, a topic too rarely studied in the literature to date. Those studies that exist suggest that agency is positively related to the therapeutic alliance but does not directly affect therapy outcome. Additional process-outcomes studies in this area are warranted and could benefit from placing client agency in a broader framework that views therapy, and even therapy supervision, as an active process of mutual inquiry.     

Jung's Lament

This article has two premises. First, that depth psychology is more an art than a science, and second, that expanding imagination is the primary method of therapy. Both Jung and Freud considered themselves scientists, yet both had ambivalent relationships with artists and writers. Freud was given the Goethe award for literature and never the Nobel Prize for medicine, whereas Jung was confronted by both his anima and Herbert Read concerning his devaluation of his own artistic direction as well as of modern art generally. I am proposing through the article's fictional style, that in this age of evidenced-based medicine, we, as therapists, have much more to learn from writers and their fictional stories than from the abstract fantasies of science. I believe we have made an error in our field by turning so completely to developmental theories and object-relation theorists for our method. Jung hinted as early as 1916, in his paper “The Transcendent Function,” that there was a way of engaging the soul directly and allowing its voice and character to emerge. I am proposing that if we truly believe that the psyche is autonomous, then all therapy should be an encounter with “the other.” If this were the case, then active imagination could be developed as a wider and more inclusive method.

Everywhere I go I find a poet has been there before me.

―Sigmund Freud     

Marital therapy outcome measured by therapist, client, and behavior change

The present research examined marital therapy outcome, in a sample of 88 couples and 22 therapists, through the use of multidimensional criteria from multiple perspectives. Three paper-and-pencil patient self-report instruments were used to measure different aspects of the couple relationship. In addition, therapist post-therapy ratings and objective observer ratings of the couple behavior during therapy were obtained. Past debates about what the "right" criteria might be for measuring therapeutic change prompted our strategy. Special attention was focused on those criteria that could be classified as "inside" or "outside" of the couple relationship. Data analysis revealed a significant relationship between the couples' and therapists' ratings of improvement in therapy. Additionally, husband and wife negative acts (behaviors) in therapy were also significantly correlated with therapists' ratings of improvement. Both statistically significant and clinically significant criteria were employed to evaluate the therapy outcome. Improvement due to therapy as measured by the three self-report instruments varied from 38% to 58%. These differences appeared to stem from the different kinds of information yielded by the specific tests.     

A dialogic perspective for family therapy: the contributions of Martin Buber and Gregory Bateson

This paper concerns the philosophies of Martin Buber and Gregory Bateson, and the application of their philosophies to family therapy. The relevance of Buber's philosophical concepts to a social constructionist perspective in family therapy is given particular attention. Central points of Buber's and Bateson's theoretical perspectives are reviewed and compared. Both thinkers believe that relationship is the primary ingredient in the world of the living, and both have a commitment to the concept that difference is the essential building block of the world of the living. Buber and Bateson, as philosophical anthropologists, are concerned with questions of how their ontologies or epistemologies can be applied to the domain of human interactions, including various healing relationships such as family therapy. This paper shows how their theoretical ideas fit into family therapy thinking and practices, particularly from a social constructionist perspective.     

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.     

Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring

Advances in the medical treatment of HIV have made it clear that adherence to highly active antiretroviral treatment is a crucial feature for treatment success. The present paper had two goals: (1) to examine psychosocial predictors of adherence in persons receiving HIV antiretroviral therapy; (2) to compared two minimal-treatment interventions to increase HIV medication adherence in a subset of persons who self-reported less than perfect adherence. One of the interventions, Life-Steps, is a single-session intervention utilizing cognitive-behavioral, motivational interviewing, and problem-solving techniques. The other intervention, self-monitoring, utilizes a pill-diary and an adherence questionnaire alone. Significant correlates of adherence included depression, social support, adherence self-efficacy, and punishment beliefs about HIV. Depression was a significant unique predictor of adherence over and above the other variables. Both interventions yielded improvement in adherence from baseline, and the Life-Steps intervention showed faster improvements in adherence for persons with extant adherence problems.     

Efficacy and predictors of long-term treatment success for Cognitive-Behavioral Treatment and Behavioral Weight-Loss-Treatment in overweight individuals with binge eating disorder

ObjectiveThe aim of the study was to assess the long-term efficacy of Cognitive-Behavioral Treatment (CBT) and Behavioral Weight-Loss-Treatment (BWLT) in patients with binge eating disorder (BED) and to identify potential predictors of long-term treatment success.MethodIn a sample of overweight to obese BED patients from a randomized comparative trial we evaluated the efficacy of four months of CBT or BWLT, followed by 12 months extended care, and a final follow-up assessment 6 years after the end of active treatment. Outcomes included binge eating, eating disorder pathology, depressive feelings, and body mass index.ResultsAfter a strong improvement during active treatment, outcomes worsened during follow-up, yet remained improved at 6-year follow-up relative to pretreatment values. Long-term effects between CBT and BWLT were comparable. Rapid response during the early treatment phase was the only characteristic that was predictive of favorable treatment outcome in the long term.ConclusionsBoth CBT and BWLT can be considered to be comparably efficacious in the long-term. Patients not responding strongly enough during the first four therapy sessions might be in need of tailored interventions early during the treatment phase.     

Mending the Mind

Cognitive behavior therapy (CBT) offers an alternative paradigm to psychoanalysis for understanding human behavior and the mechanisms of change. Dialectical behavior therapy (DBT) grew out of this tradition conceived originally for the treatment of suicidal patients with borderline personality disorder. Unlike psychoanalysis, DBT does not recognize unconscious meanings or motivations and instead focuses on sequences of measurable behavior and the contingencies that reinforce them. The treatment protocol emphasizes a deficit model and is structured around specific targets and goals combined with “skills” training (i.e., specific skill sets to help with emotional, cognitive, and behavior dysregulation) Combining an overarching dialectical philosophy, emphasis on the therapeutic relationship and mindfulness, DBT offers a comprehensive therapeutic approach including individual sessions and group work.

The directive methods of CBT have often been viewed as antithetical to analytic reflection; such active therapeutic techniques on the part of the psychoanalyst are often seen as impeding the necessary free associative processes necessary for the acquisition of insight and for change. Whereas psychoanalysts help patients recognize dysfunctional patterns of behavior within the transference and alternative ways to view the transaction, they often do not help a patient implement new behaviors into their lives in systematic ways.

Both psychoanalysis and DBT have much to offer and to gain. In time translation and mutual inclusion of new ideas may help bridge the gap.     

Expanding Uses of the Telephone in Family Therapy

The telephone has been used as an instrument for live supervision. This article describes innovative uses of the telephone by a family therapy training team, including (a) strategic calls to the therapist; (b) calls from the team to family members; and (c) calls between family members. Case examples describing the interventions and their impact are given. Both training and therapeutic benefits are discussed.     

Rational-emotive therapy and the reduction of interpersonal anxiety in junior high school students

This study evaluated the effectiveness of rational-emotive therapy and rational-emotive imagery. Fifty-nine junior high school students who volunteered to participate in treatment for interpersonal anxiety were randomly assigned to rational-emotive therapy without imagery (RET), rational-emotive therapy with imagery (REI), relationship-oriented counseling (ROC), and waiting-list control (WLC) groups. Groups met for seven 50-minute treatment sessions during a three-week period. Assessments were conducted at pretreatment, posttreatment, and three-week follow-up. Both self-report and sociometric measures were used to evaluate treatment outcome. At postassessment, both the RET and REI groups were rated on sociometric measures as significantly less interpersonally anxious than the WLC group. Mean scores favored the RET and REI groups, but no significant differences between these groups and the ROC group were obtained. The self-report measure did not significantly differentiate between groups, but the REI group demonstrated significant pre- to follow-up changes. Both the RET and REI groups yielded greater reductions in irrational thinking than did the ROC and WLC groups. In addition, the pattern of the results supported the use of rational-emotive imagery as a component of rational-emotive therapy. The practical implications of these findings are discussed.     

Controlled comparison of aversive therapy and covert sensitization in compulsive homosexuality

Ethical objections to the use of behaviour therapy in homosexuality are discussed. It is pointed out that these objections were often based on a limited view of the aims of the therapy. The need for evaluating such therapy, as it is currently used, is elaborated.Twenty subjects requesting behaviour therapy to reduce compulsive homosexual urges were randomly allocated, half to receive aversive therapy using electric shocks and half to receive covert sensitization. Both groups were studied for one year. There was no consistent trend for one therapy to be more effective than the other in reducing the strength of compulsive homosexual urges, and the response to both was similar to that reported in previous studies. It was considered that aversive therapies in homosexuality do not act by establishing a conditioned aversion, nor by altering the subjects' sexual orientation. They reduce aversive arousal produced by behaviour completion mechanisms when subjects attempt to refrain from homosexual behaviour in response to stimuli which have repeatedly provoked such behaviour in the past.     

Family therapy and the notion of accountability: With reference to trends in individual psychotherapy

Family therapy both overseas and within Australia has seen a rapid rise in popularity and general acceptance as an important therapeutic intervention. Along with the growth in interest, however, has come an increased demand for accountability. The foundation stone for the accountability issue surrounds the questions of therapy efficacy. How effective is family therapy, and, indeed, if it is effective, what are the active elements or ingredients which facilitate positive client change? Three groups, in particular, have vested interests in questions relating to the effectiveness of family therapy: researchers, therapists, and consumers. Although both researchers and therapists, for a variety of reasons, have been concerned with the effectiveness of treatment for some time, it has only been relatively recently that there has been a concerted push from various sections of the consumer group, including administrators, legislators, and policy makers. The consumer group is now providing pressure on professionals as to what we have done, and are doing, to demonstrate that family therapy really “works.”     

Wie wirksam sind psychoanalytisch orientierte Therapie und Verhaltenstherapie bei Persönlichkeitsstörungen?

This meta-analysis adresses the effectiveness of psychodynamic therapy and cognitive-behavioral therapy in personality disorders. Included were 14 studies of psychodynamic therapy and 11 studies of cognitive-behavioral therapy from 1974 to 2001. There is evidence that both psychodynamic therapy and cognitive-behavioral therapy are effective treatments of personality disorders. As the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies which examine specific forms of psychotherapy in specific types of personality disorders using criteria of core psychopathology are necessary. Both longer periods of treatment and follow-up studies should be included.     

The use of a double-blind drug trial in family therapy to demedicalize a problem

A family therapy approach to a problem that had led previous clinicians to diagnose and treat a child as 'hyperkinetic', is described. The resistance to change that the preceding diagnosis had inculcated, is described. A method of overcoming this resistance by active involvement of the family in a double-blind trial of the drug treatment, was devised and used concurrently with a structural form of family therapy.     

Critical comments on the theory and practice of behavior therapy from the viewpoint of Marxist-Leninist philosophy

By analyzing previous critical studies of the theoretical and methodological positions of behavioral therapy, which were conducted on Marxist-Leninist principles, the authors discuss the complex relationship of one-sided philosophical assumptions, simplifying elements of psychological theories, and radional moments of successful practical application in certain fields. Both critical delimitation from untenable theoretical interpretations and the inclusion of rational forms of therapy in a complex system of psychotherapy are considered essential.     

Nonspecific elements in therapy with stutterers

Currently, many different strategies are employed by respected professionals working in the area of therapy for persons who stutter. This phenomenon serves as a point of departure for reflections on the nonspecific elements involved in therapy. Drawing on the literature of holistic medicine and psychotherapy these elements are identified as follows: (1) active participation of the client in the therapy process; (2) role of self-management skills; (3) influence of client's expectations regarding treatment; (4) suggestion as a factor in therapy; and (5) the therapeutic relationship.     

The number of active sweat glands (PSI, palmar sweat index) as a psychophysiologic parameter

Two laboratory studies were carried out to assess the behavior of the active palmar sweat glands in both an active and a passive coping situation. Stressor in study I was watching a distressing film, in study II mental arithmetic. Subjects were male students, 17 in experiment I, 20 in experiment II. Both experiments involved a 10-minute baseline phase, a 10-minute stress period, and a follow-up of 10 minutes. PSI was assessed at 90-sec intervals and averaged across phases, as were readings in SCL, SCR, heart rate, diastolic and systolic blood pressure. PSI could be determined in 16 subjects of each study. In both experiments PSI increased significantly from baseline to stress (p less than 0.1%) and decreased from stress to follow-up (p less than 0.1%), and thus proved to be the most sensitive indicator for stress. The interrater reliability for counting the number of active sweat glands was high when the area for evaluation was defined unambiguously. Since the assessment of the PSI does not require a sophisticated technology and is thus also applicable in field research, we suggest giving more consideration to this variable.