Exploring client contribution in a cognitive intervention for test anxiety

Aim: To study client contributions in cognitive therapy. Specifically, to study ways of making an intervention against test anxiety work, based on interviews with 32 test‐anxious university students. Method: Interviews after their first examination following the intervention were analysed using a thematic analysis. Results: Although most participants reacted positively to the intervention, concerns emerged that adopting positive self‐statements might be deceptive. Concerns about the untruthfulness of positive self‐statements led clients to generate several possible resolutions, namely, to examine flaws in negative self‐statements, to realise that there is more than one realistic way to construe things, to consider the evidence in the form of reduced anxiety, to consider manageable steps, and to seek interpersonal validation of positive self‐statements. Conclusions: The results offer concrete resolutions developed by clients that might be useful for other clients who have reservations about positive self‐statements.     

A qualitative study of client experiences of working with novice counsellors

Aims: This paper reports on a qualitative analysis of written accounts by clients who participated in a counselling relationship with beginning-level trainees. The purpose of the study was to explore how clients experience the process of counselling with novice practitioners. Method: Consensual qualitative research was used for data analysis. Findings: Three general thematic categories were identified – client perceptions of self in counselling; client perceptions of the counsellor; and client perception of the counselling process. Conclusions: Overall, the findings suggest that these clients saw the interpersonal qualities and skills of the counsellor as major contributors to their experience. Implications: Clinical training of novices should start by developing the interpersonal and collaborative skills of trainees.     

‘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.     

‘My language thing … is like a big shadow always behind me’: International counselling trainees' challenges in beginning clinical practice

Background: While counsellor education becomes increasingly culturally diverse, little is known about international trainees' experiences of training. Objective: The present study explores one aspect of training, namely clinical practice from the perspective of international, non‐native speaking trainees. In particular, this paper focuses on the challenges this group encounters when practicing in a second language. Methodology: Semi‐structured interviews with four non‐native English‐speaking trainees were conducted and analysed following the principles of interpretative phenomenological analysis (IPA). Results: Findings suggest that participants encounter practical difficulties related to their non‐native/foreign identity in practice, such as problems with articulate self‐expression and understanding the client's speech. These difficulties generate anxiety and impact on the trainees' confidence. Conclusions and implications for counsellor training: This study elucidates language as a fundamental aspect of culture, and identifies second language use as a significant source of difference in counselling practice. This paper highlights the need for attention to linguistic diversity and for appropriate support during counsellor education. This will improve international trainees' experiences of training, but also enhance all trainees' understanding of difference, resulting in better service provision for the community.     

A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 2. Qualitative studies

Scope of review: The paper reports a meta‐synthesis of 13 qualitative studies of counselling and psychotherapy with people at risk of suicide. Publication time span: The studies considered were reported between 1997 and 2006. Publication origin: Seven studies were conducted in the UK, four in the USA, one in Canada, and one in Sweden. Findings: Themes in clients' and therapists' accounts of the process of counselling or psychotherapy were therapist qualities; therapy components; theoretical framework; and therapy techniques. Themes in their accounts of the effectiveness of counselling and psychotherapy were decrease in self‐destructive behaviour, and quality of life. Themes in clients' views of barriers to effective counselling or psychotherapy were therapist characteristics; therapy components; secrecy; and transferring to the real‐life situation. Secrecy was also identified as a barrier by therapists, as were responsibilities of the profession; training; and the nature of suicide and self‐harm. Facilitators of successful counselling and psychotherapy as identified by clients were responsibility; support; and teaching therapy skills to family members, the latter also being identified by therapists.     

What difference does counselling make? – The perceptions of drug‐using clients on low incomes

Context: This paper reports on a qualitative study looking at the perceptions of clients who use drugs and are on low income. Research suggests that counselling services can experience difficulties in reaching and retaining such clients, and outcomes of counselling can be disappointing. Aim: To learn from clients who had engaged in counselling for over six months what difference it had made to their lives. Method: Grounded theory methodology was used to analyse semi‐structured interviews with six participants. Findings: Findings included changes in the clients’ internal world, their connectedness with society, their familiarity with counselling, and their perception of the relationship with the counsellor. Factors within the counselling process which helped and hindered change were identified. The study documents how participants were able to use counselling to improve their lives.     

The manifestation of transference during early psychotherapy sessions: Exploring an alternate data source for therapist narratives in transference research

Introduction: Previous transference studies have compared in‐session client narratives about significant others to in‐session client narratives about the therapist, limiting data to the information that clients are willing to share with the therapist. Method: The first three sessions of 30 therapies with high‐functioning individuals were examined using the Core Conflictual Relationship Theme (CCRT) method. Client narratives about others were drawn from the psychotherapy sessions and client narratives about the therapist were drawn from a Participant Critical Event (PCE) interview conducted after the third session of therapy. Results: Factor analyses of the CCRT components indicated several relational patterns: a complementary pattern of relating characterised by a devaluation of the therapist and idealisation of others; a concordant relational transfer where clients feel bad with both the therapist and others; and as clients experience control issues with significant others, they wish to adopt a submissive stance toward the therapist. The results suggest that the source of therapist narratives may influence the results of transference research.     

Client perspectives: The therapeutic challenge of domestic violence counselling – a pilot study

Aims: This qualitative pilot study explored the perceptions of four female domestic violence clients regarding counselling they had concluded in order to identify a preliminary client‐preferred domestic violence counselling approach. Method: Semi‐structured interviews asking about significant events during counselling were held. An adapted grounded theory and narrative methodology was used. Results from the analysis were reviewed with two of the participants. Participants were offered additional counselling support if required after the research interview. Results/Findings: Domestic violence clients found starting counselling particularly difficult after years of keeping the abuse to themselves. Participants actively withheld and managed information for several sessions and needed to know they had time to explore their experiences. The counsellor being consistent and non‐judgemental, and understanding domestic violence and its effects was helpful. Having a clear ending was appreciated by the participants. Discussion: The initial development of the therapeutic relationship benefited from active discussion of how domestic violence could affect behaviour and emotions. Good early therapeutic relationships showed elements of the three main psychological schools. Participants benefited from a pro‐active discussion of endings. A key limitation of this research is the small sample size. Implications for practice: The research suggests that counsellors would benefit from knowledge and skills from different psychological schools and specific training in domestic violence. Allowing flexibility on the number of sessions available to clients may be helpful. Conclusions: Further work is required to explore these preliminary findings. However, early indications suggest that domestic abuse clients may benefit from non‐time‐limited specialist counselling services.     

Outcomes in clients transitioning from in-person counselling to telehealth counselling with trainees

The onset of the 2020 COVID-19 pandemic necessitated a rapid transition of mental health services from in-person to telehealth counselling. Despite the far-reaching impact of this transition, we know little about the impact of this transition on outcomes for clients working with counsellor trainees. The present study utilised longitudinal data collected from a counselling training centre at a major U.S. university to compare client ratings of depression, anxiety and working alliance across 1) in-person services delivered (i.e. pre-pandemic) and 2) telehealth services delivered after the pandemic began (i.e. intra-pandemic) among the same group of clients. Results support our hypothesis that changes in clients' self-reports would be generally equivalent across in-person and telehealth services. Depression and anxiety symptoms decreased, and working alliance tended to increase during both in-person and telehealth care; however, these trends were only statistically significant during telehealth services. Limitations related to sample size (N = 15 clients; up to 17 sessions per client) and low statistical power are discussed. Nonetheless, this study supports the growing body of literature supporting the efficacy of telehealth counselling services. We provide suggestions for future telehealth research and discuss implications for counsellor training.     

A meditation on the nature of self‐healing and personality change in psychotherapy based on Gendlin's theory of experiencing

Abstract

From a humanistic point of view psychotherapy is a creative transformational process in which therapists assist clients’ intrinsic self‐healing tendencies. However the nature of the self‐healing process is poorly understood. I briefly consider two theories of self‐healing, Rogers’ self‐actualization theory and dialectical theory, but focus on Gendlin's theory of experiencing as providing a more complete explanation. I consider the fundamentally implicational nature of change and portray personal change as “paradigm evolution” rather than paradigm revolution. I conclude with an examination of the self‐healing process in therapies that provide minimal prosthetic assistance to the client: client‐centered therapy, eye movement desensitization and reprocessing, and focusing‐oriented therapy. I conclude that the self‐healing/self‐change process occurs when intellectual, “top‐down” cognitive and self‐critical activity is interrupted, and when clients adopt a receptive, listening attitude towards inner experience.     

Client attendance measures in counselling psychology trainees

Counselling supervisors and educators have yet to reach a consensus about standard measures for evaluating the performance of graduate student therapists. Compared to self‐reports and rater judgements, client attendance records provide low‐inference behavioural data partially reflective of clients’ engagement with therapists. This naturalistic study evaluates client attendance data using archival records of 92 doctoral students in beginning and advanced counselling practica who produced data for 771 clients, 3,949 scheduled sessions and 3,186 attended sessions. Providing evidence of the sample representativeness for clinicians, results indicated that the mean number of sessions attended per client for student therapists (5.65) was very similar to that reported in the literature for outpatient therapists (<6). As expected because of structural differences in client assignment, beginning and advanced students evidenced statistically significant differences on attendance variables such as number of clients and scheduled sessions. In contrast, attendance ratios were equivalent across counsellor experience, suggesting that these individual difference variables could be useful for evaluation of therapist competencies related to client engagement.     

Toward the re‐enchantment of psychotherapy: Stories as container

Abstract

Storytelling by a therapist to clients may serve to increase clients’ ability to bear pain, to increase self‐complexity, and expand clients’ senses of the allowable. A model delineating the therapeutic impact of therapist storytelling in psychotherapy is proposed. Stories may change clients’ selves so that they may accommodate traumatic experiences and internal complexity. Stories increase clients’ capacity to tolerate painful experience and therefore serve as a container of tragic life experiences. The artistry of therapeutic story selection is defined as choosing stories consonant with clients’ strengths, rather than with the nature of the trauma. The power of story‐listening to alter consciousness in pleasant ways (storystoned) increases its usefulness as an intervention that is neither anxiety provoking nor re‐traumatizing.     

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.     

The experiences of therapy from the perspectives of carers of people with dementia: An exploratory study

Design: Interviews were conducted with six carers of people with dementia about their experience of receiving counselling/psychotherapy. Interviews were conducted in the carer's own home, and data were analysed thematically using a narrative approach. Findings: Three themes were identified from the data: ‘Still doing the best I can’ (identified as losses and processes of personal growth); ‘Feeling connected and being understood’ (identified as attributes believed to be important within the therapeutic relationship); and ‘Wanting to share information’ (identified as sharing information with someone ‘neutral’). Carers placed emphasis on the age of the therapist and the amount of therapist self‐disclosure. Attending counselling and/or psychotherapy also helped the carer to find a ‘safe space’ to disclose and share concerns. Discussion: Carer loss and personal growth are explored, together with the importance of building therapeutic relationships and, for the therapist, seeking supervision when managing personal self‐disclosure. The theme of therapist self disclosure is explored together with the importance of therapists seeking supervision when managing personal self‐disclosure.     

Australian psychologists' attitudes towards suicide and self‐harm

An exploratory study of 81 Australian psychologists' attitudes towards suicide and self‐harm was undertaken. Two attitudinal measures, one knowledge measure and demographic information, were used to assess the relationships between attitudes, knowledge, gender, age, years of professional experience, and previous experience with suicidal and self‐harming clients. Among this sample, attitudes towards suicide and self‐harm were generally positive and participants displayed high levels of knowledge of self‐harm. Age and years of experience were related to participants' attitudes, with younger psychologists reporting greater confidence in working with these clients and believing in the right of an individual to decide when to die. Future research is needed to determine the impact of psychologists' attitudes on their behaviour towards suicidal and self‐harming clients.     

Should psychotherapists disclose their own psychological problems?

Background: Self‐disclosures by psychotherapists can encompass a wide array of content, including information about the personal life of the psychotherapist. Aim: The goal of this study was to empirically assess reactions to psychotherapists disclosing their own personal problems to clients with similar problems. Methodology: This study explored participants' (n = 155) reactions to vignettes describing psychotherapists as either disclosing or not disclosing their own history of psychological problems to clients presenting with similar problems. Findings: Compared to otherwise identical vignettes featuring psychotherapists who did not self‐disclose, vignettes featuring psychotherapists who self‐disclosed were rated more positively in a variety of ways. Specifically, psychotherapists in the vignettes featuring self‐disclosure were perceived as possessing a higher level of favourable personal qualities and as more likely to establish strong working relationships with clients and achieve success in therapy. Limitations of the method and alternate explanations for the results are considered. Implications: Implications regarding the judicious use by psychotherapists of self‐disclosure regarding their own past psychological problems are discussed.     

Coming to an end: A case study of an ambiguous process of ending psychotherapy

Aim: When the duration of therapy is not preset and the outcome is a matter for negotiation, the decision to end psychotherapy will be an experiential concern for the two participants. This case study draws attention to how ambiguities may be settled in a process where ending is initiated by the therapist and resisted by the client. Method and analysis: The actual case was strategically selected as exceptional owing to a combination of circumstances. The client and the therapist had developed a ‘good enough’ alliance (WAI) and reached a ‘good enough’ outcome (OQ‐45), and still the client felt she was far from finished. A close inspection of interactional data in sessions together with both clients' and therapists' reflections in post‐therapy interviews elicited information about both substantial content and structural aspects of this complicated process of ending. Findings and discussion: The discrepancy between therapist and client was not addressed, but rather postponed and revisited again later. Structural elements like preparations for a break for vacations and reducing the frequency of sessions were used to test experiential qualities, such as how the client managed life without therapy. Carefully preserving a ‘good enough’ emotional bond through the negotiations seemed important to both parties. Significantly, the client's autonomy was interpreted as the final proof of improvement and the client came to a point where she could affirm that she had got better only by accepting that treatment was coming to an end.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.