Attitudes of clinical psychologists towards clients with personality disorders

Previous studies have found that a variety of mental health professionals hold negative attitudes towards clients diagnosed with a personality disorder. These negative attitudes may lead to clients receiving a lower quality of service. Specialist training has been found to improve attitudes towards personality disorders but no empirical studies in Australia have examined this among clinical psychologists. In this study, the attitudes of 81 clinical psychologists towards clients with personality disorders were examined. We were specifically interested in investigating the relationship between recency of specialist training and clinician's attitudes as well as the influence of percentage of personality disorder clients on the clinician's caseload. Results demonstrated that both recency of specialist training and percentage of clients seen were associated with more positive attitudes; however, a higher caseload of clients with personality disorders was the most important predictor of positive attitudes. The implication is that recent participation in specialist training for personality disorders appears to be valuable in improving clinician's attitudes but that more positive attitudes are associated with seeing a greater number of individuals with personality disorders.     

A study of engagement and premature termination in a university counseling center

Differences between engaged (clients seen for at least two counseling sessions) and nonengaged clients, and between post-engaged premature terminators and clients who terminated with counselor knowledge at a university counseling center were investigated. Five practicum trainees, four professional counselors, and 308 college student clients participated. Professionals had higher rates of engagement and lower rates of premature termination than trainees. Engagement was positively associated with understanding and teaching the client and with longer intake interviews. Premature termination was associated with counselor attractiveness, expertness, and trustworthiness. These characteristics related to premature termination in opposite directions for professional and practicum counselors. Results are discussed in terms of possible different mechanisms operating at the beginning and end of counseling.     

Working alliance for clients with social anxiety disorder: relationship with session helpfulness and within-session habituation

It has been suggested that a strong working alliance encourages clients to take risks during therapy (Raue, Castonguay, & Goldfried, 1993). This encouragement may be important for clients who fear negative evaluations as they engage in risk-taking elements of therapy. This study examined the relationship between working alliance, session helpfulness and measures of emotional processing in 18 clients undergoing cognitive behavior therapy (CBT) for social anxiety disorder. Results indicate a positive correlation between client-rated, but not observer-rated, working alliance and session helpfulness. Moderate levels of working alliance were associated with higher initial anxiety and deeper within-session habituation. Overall, a strong alliance was associated with clients engaging with the session and finding the session helpful. Implications for the use of CBT for social anxiety are discussed.     

Assertive community treatment for frequent users of psychiatric hospitals in a large city: A controlled study

Evaluated a large-city adaptation of the assertive community treatment (ACT) model (Stein & Test, 1980). Outcomes were examined after 1 year for 82 clients, averaging over 17 lifetime psychiatric hospitalizations, randomly assigned either to ACT or to a drop-in (DI) center. After 1 year, 76% of the ACT clients and only 7% of DI clients were involved in the respective programs. The ACT team averaged 2 home and community visits per week to each client. ACT clients averaged significantly fewer state hospital admissions and state hospital days than did DI clients. ACT clients reported greater satisfaction with program services, fewer contacts with the police, and less difficulty with practical problems associated with psychiatric readmission. More ACT clients were known to have stable community housing. Annual per-client treatment costs for ACT were estimated to be $1,500 less than for DI.     

Further evaluation of a nonsequential approach to studying operant renewal

Basic‐laboratory assessments of renewal may inform clinical efforts to maintain reduction of severe destructive behavior when clients transition between contexts. The contextual changes arranged during standard renewal procedures, however, do not necessarily align with those that clients experience during outpatient therapy. More specifically, clients transition between clinical (associated with extinction for target behavior) and home/community (associated with reinforcement for target behavior) contexts during outpatient treatment. Standard renewal assessments do not incorporate these contextual alternations during treatment. The present experiment aimed to directly compare renewal of rats' lever pressing following a standard (“sequential”) ABA renewal procedure (i.e., baseline in Context A, extinction in Context B, renewal test in Context A) and a “nonsequential” renewal assessment wherein treatment consisted of daily alternation between Context A (associated with reinforcement for lever pressing) and Context B (associated with extinction). Lever pressing renewed to a greater extent for rats in the Nonsequential group than for rats in the Sequential group, suggesting the contextual changes that clients experience during outpatient treatment for severe destructive behavior may be a variable that is important to consider in translational research on renewal. Potential implications of these findings for basic and clinical research on renewal are discussed.     

The behavioral treatment of neurodermatitis through habit-reversal

Azrin and Nunn's habit-reversal technique (1973, 1977) was used to treat four clients with neurodermatitis. Following a single treatment session, scratching associated with this skin condition was markedly reduced for three clients, whereas this reduction occurred for the fourth client 4 days following treatment. Results at 6-month follow-ups showed that scratching was eliminated for the client with the mildest case, whereas this behavior remained at low levels for the other three clients.     

Therapeutic relationship and outcome seen by clients in first and third session of individual therapy

Rogers' assertion that therapeutic improvement results from clients seeing their therapist as genuinely empathic and unconditionally accepting was explored in the first and third session of individual therapy with 24 clients. This proposition was partly supported in that higher combined levels of these therapist qualities as seen by clients after session one was associated with higher self-esteem and lower need for approval after session three, when these two variables after session one were respectively controlled. However, no support for this assumption was found for depression and anxiety, in that lower depression and greater anxiety after session one was associated with higher levels of these therapist qualities after session three. These latter two findings imply that the subsequent therapist qualities may have resulted from earlier anxiety and depression.     

Client crying in the context of family therapy: an exploratory study

This study explores the crying episodes of twenty‐eight clients treated at a family therapy service in a community centre. The crying episodes were associated with some significant elements: the time of appearance, the content and triggering factor, the interpersonal context of sessions and the emotions clients had for the therapist, as well as the therapy's outcome (end of treatment and the satisfaction of clients). Crying was much more frequent during the first session. It occurred more frequently when there was another family member present. The proportion of clients who cried during the treatment was significantly higher for clients who completed it successfully. Clients who cried perceived the therapist, in all cases, as a kind person who never got annoyed with them. Crying could be considered a type of behaviour that helps the therapist to create a safe context and foster the therapeutic alliance.     

A Therapeutic Model of Self‐Forgiveness With Intervention Strategies for Counselors

Self‐forgiveness is associated with psychological and relational well‐being and may be a worthwhile treatment goal for clients who have hurt others. The authors utilized theoretical and empirical literature to describe a 4‐component therapeutic model of self‐forgiveness—responsibility, remorse, restoration, and renewal—and offer suggestions for promoting each component with clients. Finally, the authors explore potential contraindications and the applicability of self‐forgiveness for military veterans, clients in substance abuse treatment, and clients convicted of a crime.     

Evaluating the efficiency and community safety goals of the Broward County Mental Health Court

Mental health courts have developed as one response to persons with mental illness who are involved with the criminal justice system. This study investigated the efficiency and safety goals of one such court in Broward County, FL. Mental health court (MHC) clients spent significantly fewer days in jail for the index arrest associated with study enrollment than a comparison group. MHC clients had similar survival time to re-arrest up to one year after study enrollment. MHC clients did not significantly differ from the comparison group in self-reported aggressive acts over an 8 month follow-up period, while they did self-report significantly fewer acts of violence than the comparison group at the 8 month follow-up. These findings suggest that some of the benefits associated with the MHC reported in prior studies were not achieved at the expense of efficiency and safety.     

A change in frame and countertransference experiences: Transitioning from face-to-face to telepsychotherapy

Unprecedented changes in traditional psychotherapeutic practice arose from the lockdown restrictions associated with the COVID-19 pandemic. These changes to practice included the imposed change to the therapeutic frame when transitioning clients from face-to-face meetings to delivery of psychotherapy sessions via videoconferencing (defined here as telepsychotherapy). The current study conducted qualitative interviews with 16 Australian psychologists who transitioned their existing adult psychotherapy clients from face-to-face therapy to telepsychotherapy and explored their novel experiences associated with countertransference reactions during this period. Thematic analysis of the interviews revealed several unique findings. The type of countertransference reactions towards existing clients was consistent across both face-to-face and online meetings; however, the felt intensity of countertransference reactions was reduced. Psychologists reported an increased hesitance to work with intense emotions during telepsychotherapy sessions and felt increased pressure to work harder during online sessions when compared to face-to-face meetings. Exposure to their clients' personal and home environments during telepsychotherapy sessions elicited several novel reactions towards their clients. These findings on countertransference and telepsychotherapy are informative for future practice and training. Awareness of these unique countertransference experiences is recommended prior to engaging in telepsychotherapy or when transitioning clients to this modality.     

Risk Factors for Suicidality Among Clients With Schizophrenia

Among clients with schizophrenia, suicidality is associated with extreme personal distress, an increased number of inpatient hospitalizations, increased health care expenditures, and early mortality. This study attempted to identify risk factors for current suicidality in clients diagnosed with schizophrenia (N = 223). Results indicated that severity of depressive symptoms most strongly correlated with degree of suicidality. Younger age and recent traumatic stress each significantly predicted suicidality independent of depressive symptoms. Stepwise regression procedures showed that the combination of depression, younger age, and traumatic stress might provide a general prediction model for suicidality among clients diagnosed with schizophrenia. Counseling implications of these findings are outlined.     

The relationship of clients’ social class to early therapeutic impressions

Using case vignettes that differed in the presentation of the client's social class, the influence of social class on therapeutic impressions was studied in the context of just-world beliefs. Results suggested that (1) participants with higher levels of belief in a just world saw poor and working-class clients as more unpleasant to work with and more dysfunctional and (2) working-class vignettes were associated with the lowest predictions of session depth and smoothness. The findings suggest that counselors may respond differently to clients based on their social class, and in a way that negatively predisposes them toward work with poor and working-class clients.     

Family and couples therapy with gay and lesbian clients: acknowledging the forgotten minority

Family and couples therapy in the main concentrates on heterosexual clients, and has thus been described as limited in its outlook, or discriminatory. It is argued that family and couples therapy is at present not offered to gay and lesbian clients because of an absence of appropriate referrals, the inability of therapists to recognize the sexual orientation of their clients, a belief that skills held by therapists are not appropriate for this client group, or because of the homophobia of the therapist. It is suggested that family and couples therapy should be more readily available for gay and lesbian clients, and a number of different issues which these families might face are discussed. This includes problems associated with the gay adolescent and the gay or lesbian parent, as well as the gay or lesbian couple. It is concluded that established forms of intervention are effective with gay clients, provided that the specific needs and problems of the gay and lesbian community are addressed by the therapist.     

Helping construct desirable identities: a self-presentational view of psychotherapy

The author reviews the research demonstrating not only that clients withhold personal information and reactions from their therapists but also that such discretion is associated with positive therapy process ratings and outcomes. These results run counter to traditional approaches to psychotherapy, which demand a high degree of openness from clients. These puzzling findings can be explained by conceptualizing psychotherapy as a self-presentational process, wherein clients come to benefit from therapy by perceiving that their therapists have favorable views of them. Creating these favorable impressions can involve clients' hiding some undesirable aspects of themselves from their therapists. The author offers findings from the psychotherapy and social-psychology literatures in support of this view and makes suggestions concerning what clients and therapists might optimally reveal in therapy.     

Clients talk about their experience of seeking counselling

The purpose of this study was to explore the help-seeking behaviour of a sample of counselling clients using a questionnaire and follow-up, semi-structured interviews with 20 counselling clients who were seen at a walk-in, affordable counselling agency located in a mid-sized city in New Zealand. Specifically, clients were asked if they had received counselling previously, what efforts they had made to solve their problems before seeking counselling and with what success, why they chose this particular agency, their initial impression of their relationship with their counsellor, and their reactions to participating in the research. The data were analysed to ascertain themes associated with their decision-making and choices. Findings were discussed in relation to the literature on seeking counselling, how clients determine their need for counselling and the process they go through in deciding when and where to get it. Implications for counsellors are discussed.     

Independent and interdependent self-construals as predictors of multicultural case conceptualization ability in counsellor trainees

This study examined the extent to which independent and interdependent self-construals were related to counsellor trainees' multicultural case conceptualization ability (i.e., ability to conceptualize clients from a multicultural perspective). Results revealed that, after accounting for race or ethnicity and prior multicultural training, counsellor trainees' self-construal scores were significantly predictive of their ability to conceptualize clients from a multicultural perspective. Specifically, independent self-construal scores were negatively related to trainees' ability to conceptualize clients from a multicultural perspective, whereas interdependent selfconstrual scores were positively associated with multicultural case conceptualization ability. Future research directions are offered.     

Trauma and posttraumatic stress disorder in people with schizophrenia

This study evaluated the hypothesis that trauma and posttraumatic stress disorder (PTSD) severity would be positively associated with schizophrenia symptoms. Forty-seven clients with schizophrenia were assessed for schizophrenia severity and for lifetime trauma history and PTSD symptoms in 2 independent symptom interviews; 35 (74%) participants reported at least 1 event in which there was threat of harm or life threat and subjective distress, and 6 (13%) had current PTSD. Trauma across the life span was associated with greater severity of PTSD. Within the total sample, PTSD symptoms were associated with greater emotional distress, but not with schizophrenia-specific symptoms. Distress among clients with schizophrenia and PTSD suggests the need for routine assessment of PTSD and development of PTSD interventions in this population.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

Self-criticism and the therapeutic relationship

The relationship between self-criticism and the therapeutic alliance was examined in 169 clients attending counselling in a community clinic. Self-criticism was associated with lower client ratings of the working alliance, suggesting that clients with higher self-criticism had greater difficulties establishing and maintaining a therapeutic alliance. These findings extend previous studies on the working alliance and self-criticism from highly controlled clinical studies to a more ecologically valid community mental health setting. Regression analyses were conducted to examine the mediating effect of additional factors on the relationship between self-criticism and the working alliance. Sensitivity to a perceived subordinate role in therapy did not impact the working alliance, although a general resistance to subordination was related to self-criticism. Implications for counselling self-critical clients are discussed.