Therapist perspectives on working with fears,blocks and resistances to compassion in compassion focused therapy

Objective

A core aspect of compassion focused therapy (CFT) is addressing fears, blocks, and resistances (FBRs) to compassion. How CFT therapists do this with clients remains unclear. This study aims to explore the perspectives of well-trained, experienced CFT therapists regarding how they work with FBRs in the context of CFT.

Methods

A qualitative study was conducted. Participants were asked five open-ended questions regarding (a) their experiences of working with FBRs to compassion, (b) how they understand and formulate FBRs, (c) specific ways they address FBRs, (d) how other therapists might learn about working with FBRs, and (e) their top recommendations. A total of 64 participants completed the online questionnaire, and the qualitative data were analysed using thematic analysis.

Results

The analysis produced four interrelated superordinate themes: (a) Getting “alongside” and “behind”: The central role of formulation, (b) “It's not your fault”: Psychoeducation, (c) “Get experiential”: An emphasis on experiential interventions, and (d) “Respect the wisdom”: The importance of therapeutic process.

Conclusions

Working with FBRs to compassion is critical in CFT. Understanding the wisdom in the client's FBRs, and validating and de-shaming the client's FBRs are crucial. We provide clinical recommendations regarding working with FBRs as part of CFT.     

Client Perspectives on Spirituality in the Therapeutic Relationship

There has been increasing interest in the integration of spirituality into psychotherapy in the last 10 years, yet we have very little in-depth information about clients' perspectives on spirituality in the counseling relationship to help guide this integration. Using a narrative methodology to explore the counseling experiences of 12 spiritually-committed clients in detail, this study suggests that clients who may not identify as traditionally religious may still view the entire process of psychotherapy through a spiritual lens. Furthermore, their spirituality may guide their interpretation of therapy, their expectations of the therapist, and their choice to engage in or terminate treatment in complex ways. By exploring the experiences of this growing breed of spiritually-committed clients, the results shed new light on the dimensions that deserve consideration as we think about how to respond to a client's spiritual needs in psychotherapy.     

Therapists facing masks: A qualitative study of the nature of relationships between masks and relational depth

Background

Central to this research was exploring characteristics facilitating and disinhibiting meetings at relational depth to explore underlying driving factors of change. The overall aim was to explore relationships between masks and relational depth. Viewing masks as a characteristic sought to understand further the socio-cultural impacts of masks on client/patient care and decision-making to meet at depth. This research demonstrates immediate social and international context due to COVID-19.

Methods

A phenomenological methodology was utilised. The primary research vehicle was an examination of primary data from semi-structured interviews. Four therapists who had used masks within sessions (where both therapist and clients wore masks) provided data on meetings at relational depth.

Findings

Interpretative phenomenological analysis revealed four themes: ‘epicentre of aetiology’, ‘loss’, ‘masked-disinhibition’ and ‘disconnection paradox: depth through disconnection’. Findings suggest masks are a characteristic that can facilitate and inhibit meetings at depth—acknowledging common factors, including how therapists related to masks as an extended part of the client, and mutuality within disconnection to masks, not one another, was significant.

Conclusions

Findings suggest the exigent presence of masks could facilitate or inhibit meetings at depth, regulated by what masks represented to therapists/clients at moments of contact. Yet, when both therapist and client appeared mutually disconnected (to masks, not each other), they found moments of relational depth within the disconnection. Masks are suggested as a characteristic that can influence meetings at depth. Opportunities for depth seemed reliant on individual capabilities to offer depth, emphasising therapists' experiential awareness of their interoceptive process.     

Person‐centred counsellors' experiences of working with clients in crisis: A qualitative interview study

Aims: This study aims to explore and understand person‐centred therapists’ experiences and work with clients at the pivotal point of crisis. Specifically: how do person‐centred therapists experience working with clients in crisis? Do they identify differences in crisis intervention compared to non‐crisis work? What do they perceive as helpful to crisis clients? How relevant are therapists' own experiences of crisis? Method: Participants were all experienced person‐centred therapists. Qualitative, semi‐structured interviews were conducted and the data were analysed qualitatively using person‐centred/phenomenological methodology. Results: Respondents identified differences in their experiences. Typically, therapists described polarity in their experience of danger and opportunity, also heightened energy levels within themselves, perceived higher levels of engagement, faster pace of work, experiences of reaching ‘relational depth’ earlier, and the importance of assisting symbolisation of clients' experience in awareness. Clients were experienced as vulnerable, unable to access previous coping mechanisms, in a state of breakdown and disintegration, but also as wide open, having dropped their usual defences, and more available to engage in therapy and enter the process of change and potential post‐crisis growth. Discussion: The findings are discussed in relation to prevailing models of crisis intervention, person‐centred theory and theoretical developments in post‐traumatic growth in the aftermath of crisis.     

Suitability and context for brief therapy

Abstract

The main point of this paper is that a client's suitability for brief or time-limited therapy is determined by various factors, including context. There is still agreement on the validity of Malan's selection criteria, which included ‘mild illness, recent onset, high motivation and response to trial interpretation’, yet many additional issues have since emerged and need to be considered. For instance, the counsellor's suitability, training and work experience, the counsellor's assessment skills and ability to establish a dynamic focus, the clients' capacity for self-reflection, their ego strength and their response to a trial therapy in the first session. Then there is the importance of the various contexts in which nowadays much brief counselling is offered free to clients, whether in education, at the workplace, in primary healthcare settings or by charitable organizations. This means that issues of money and markets have come to the fore and an initial differential assessment needs to be carried out in order to decide which method or model of therapy is best for the client. Matching the counsellor's personality to the needs and to the pathology of the client, and matching the treatment to the client's developmental stage or life stage crises are other aspects of the work, which determine the issue of suitability. In the end as always there is much that remains unknown about what works for whom and how the client's decision to take up help is made.     

An empowerment model of memory training

The authors outline an empowerment model of memory rehabilitation. Unlike conventional cognitive rehabilitation methods, clients' plan and control the treatment process from the earliest stages of therapy. The client identifies functional goals and the therapy is geared to achieve those goals. The empowerment model also emphasizes domain-specific compensatory training. Memory strategies and prosthetic devices are chosen so as to maximize transfer of training in the workplace, training programme, or in the client's activities of daily living. Group therapy involves clients teaching their newly learned skills to other clients. The authors present research findings to document the efficacy of the empowerment model, describe its limitations, and discuss how the model can be implemented effectively.     

The client as a self‐aware agent in counselling and psychotherapy

Clients' recollections of their experiences of counselling and psychotherapy were stimulated using the technique of Interpersonal Process Recall. Their reports were analysed in terms of the grounded theory method of qualitative research. The analysis resulted in the interpretation that the core category of their experience is clients' reflexivity, or self‐awareness and agency flowing from it and returning to it. The focus of this paper is directed at the client's reflexivity in response to the counsellor's operations. Its organizing theme is that how clients respond to counsellors' operations depends on what clients desire and what they feel they can say safely. Particular desires arise from an over‐arching desire either to enter into or avoid inner experience. Moreover, the relation with self is influenced by the relationship with the therapist. This complexity makes it difficult to predict responses to non‐directive and directive counsellor performances alike. Vignettes selected from the participants' reports illustrate the theme. Implications for the practice of counselling and psychotherapy are discussed.     

Client perceptions of hindering experiences in counselling

The purpose of this study was to increase understanding of what clients perceive as hindering experiences in counselling. In‐depth interviews combined with concept mapping were used to gather, organize, and understand clients' perceptions of hindering aspects of therapy. In the initial data gathering stage, 8 adult client participants, aged 18 or older (average of 14.1 sessions) were asked to respond to the following open‐ended questions:

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The relationship between cognitive errors,coping strategies,and clients' experiences in session: An exploratory study

Aim: Cognitive errors (CE) and coping strategies (CS) can bear weight on how individuals relate to others and perceive interpersonal relationships. However, there is little research into how clients' erroneous beliefs and maladaptive coping strategies can interfere with the therapeutic process. This study utilised a sample of healthy clients to explore the relationship between their CEs and CSs and their evaluation of therapy. Method: Therapy sessions of undergraduate student clients (N =26) were rated using the Cognitive Error Rating Scale (CERS – 3rd edition), the Coping Patterns Rating Scale (CPRS;), the Session Evaluation Questionnaire (SEQ) and the Session Impact Scale (SIS). Results: Clients who engaged in dichotomous thinking endorsed problem solving less and were more likely to feel unsupported and misunderstood by the therapist. Clients who discounted the positive tended to feel more pressured and judged by therapists. Conversely, those who engaged in problem solving were more likely to find sessions deeper and more valuable as compared to those who reacted to stressful events by submission, escape, or opposition. Implications: Better understanding how and when a client's cognitive errors and coping mechanisms are at play during therapy can help clinicians to address them and intervene appropriately.     

A practice-based exploration of therapeutic change in a charitable,community-based person-centred counselling service using routine outcome measures of anxiety and depression. I: Statistical and clinically significant change

Background

Establishing the value of differing treatments for depression and anxiety is crucial in a climate of delimited spending and increased demand. Drawing from a well-founded, diverse evidence base is salient to constructive evaluation and any subsequent recommendations being fit for purpose.

Design

This study employed a practice-based quantitative design to explore therapeutic gains in adult counselling clients attending person-centred therapy (n = 301), delivered in a charitable, community-based UK service.

Measures

Outcome measures PHQ-9 and GAD-7 were used from three time points: initial assessment (IA), first ongoing session and last or 6th ongoing appointment (whichever occurred first; T1, T2 and T3).

Analysis

Repeated measures ANOVA, CSI, RI and RCSI calculations were used to consider significant change in clients.

Findings

Reductions in PHQ-9 and GAD-7 outcome measures were observed over time (between T2 & T3 and T1 & T3) and were all statistically significant (p = <0.001). By T3: CSI was achieved by 48.1% of clients on PHQ-9 and 50.8% of clients on GAD-7, RI was achieved by 47.8% of clients on PHQ-9 and 60.5% of clients on GAD-7, and RCSI was achieved by 32.6% of clients on PHQ-9 and 41.2% of clients on GAD-7.

Conclusions

The treatment observed resulted in effective outcomes equivalent to other therapies reviewed in the literature for clients' symptoms of anxiety and depression as measured by GAD-7 and PHQ-9.     

Moral Responsiveness and Discontinuity in Therapy: A Qualitative Study

Phenomenological qualitative methods were used to identify and describe moral elements in therapeutic relationships. Using the relational philosophy of E. Levinas (1961/1969, 1979/1987) as a base, data in which therapists and clients identified and described morally responsive experiences in therapy sessions were analyzed. These moments were often unexpected and included categories of surprise, interruption, willingness to change, and clarifications/repairs. Additional moral phenomena related to therapists' attitudes included asymmetrical indebtedness, attitude of serving, and tentativeness of diagnosis. Identified moments of moral responsiveness were frequently associated with clients' progress in therapy. This suggests that conceptually smooth and uninterrupted therapy may be less helpful than therapy that is discontinuous and able to change in the moment.     

“‘Ninja’ levels of focus”: Therapeutic holding environments and the affective atmospheres of telepsychology during the COVID-19 pandemic

The COVID-19 crisis in Australia led to a rapid increase in the use of telehealth services to offer psychological therapy (often referred to as ‘telepsychology’). In this article, we discuss the intersection of the social psychology concepts of therapeutic holding spaces and containment with more-than-human theory as it relates to Australia's mental health sector during the COVID-19 crisis. Drawing on our recent qualitative survey research into Australian psychologists' use of telepsychology during the crisis, we consider the ways that they worked to build and maintain therapeutic holding spaces and alliances over teleconferencing platforms during this extraordinary time of social crisis and isolation. We explore and contextualise three important findings from our study: 1) the limited viewing area of a flat screen makes it difficult for therapists to read and respond to their client's body language and requires different forms of returned bodily gestures in order to show empathy; 2) most respondents implemented different affective and relational strategies online to ensure they were not missing important non-verbal cues from their clients; and 3) the traditionally ‘safe’ therapeutic holding space created in face-to-face therapy can be easily subverted by client-end interruptions, and concerns around safety or personal privacy in the client's home environment. In bringing these issues to the fore, we highlight the online therapeutic holding space as a temporally and socially situated human-technological assemblage in which a series of affective, spatial, relational and sense-making agencies coverage, opening or closing off capacities for therapists and their clients.     

One of the troubles with outcome measures: Lost in translation

This paper presents the concerns of a client diagnosed with autism spectrum disorder about completing outcome measures. He was asked to complete CORE‐10 each time he attended a therapy session with the first author. This paper takes an epistemological position of co‐production, and written in response to the client's concerns, but this is limited by the client's wish and capacity to be involved in the writing up of this article. Implications of his experiences are drawn out for both clients with this diagnosis and more generally for all clients. Recommendations are made to recognise the limitations of measures and how to use outcome measures with more validity.     

A Japanese Perspective on Client Inaction: Removing Attitudinal Blocks Through Morita Therapy

Seven self-defeating attitudinal factors contributing to client inaction and procrastination are discussed from the Morita therapist's perspective. Morita therapy is briefly described, and ways of facilitating desirable action and reducing self-preoccupations are suggested. The suggested approach challenges the client's assumption that resisting and removing the unwanted feelings and imperfect psychological conditions is a prerequisite for implementing necessary action. The counselor's reinforcement of clients' mood-governed action style is also discussed as a factor contributing to the client's inaction.     

Dialogical mindfulness in supervision role-play

Aims: This exploratory pilot study investigated Mindfulness-based Role-play (MBRP) supervision to find out how therapists would experience the approach, and to what extent they would find it useful, particularly in relation to empathy toward clients. Method: Thirteen therapists participated in a workshop, introducing mindfulness and MBRP supervision, and subsequently had one individual MBRP supervision session. Data collection and analysis: Qualitative data were collected by means of semi-structured interviews and analysed with regard to participants' supervision experiences by means of a modified version of the Consensual Qualitative Research method. Findings: Participants predominantly had positive emotional and cognitive responses to their supervision experiences. The main supervision outcomes were empathy with the client's emotional experience, enhanced awareness of functioning as a therapist, and thoughts about how to proceed in therapy. A subset of participants also reported observed effects in therapy with clients. Conclusions: Even taking into account the methodological limitations of the study, these findings are promising and suggest that further research into the MBRP supervision approach is warranted.     

Cultural ruptures in short‐term therapy: Working alliance as a mediator between clients' perceptions of microaggressions and therapy outcomes

Aim: To determine whether or not clients' perceptions of microaggressions varied based on their own and the therapist's race/ethnicity and whether or not they would be negatively related to the effectiveness of therapy and if the working alliance would mediate this effect. Method: The study utilised a cross‐sectional, retrospective, methodology. Clients were recruited from a large university counselling centre in the United States (N=232 clients and 29 therapists). Results: Neither clients' race/ethnicity, therapists’ race/ethnicity, nor client‐therapist ethnic matching predicted perceptions of microaggressions. Clients' ratings of microaggressions were negatively associated with their psychological wellbeing; however, this effect was mediated by clients' ratings of the working alliance. Implications: Therapists should take into account the cultural messages they may be conveying to both white and racial/ethnic minority clients. Therapists should develop strategies that are consistent with a general therapeutic approach that promotes discussions about culture with their clients and, most importantly, should attend to the therapeutic relationship.     

Supervisees' perspectives on the contribution of supervision to psychotherapy outcomes

Objective

The aim of this study was to examine supervisees' perspectives about the contribution of two predefined aspects of supervision, supervisory bond (SB) and didactic input of supervisor (DI), to their ascribed outcome of therapy.

Method

Supervisees anonymously assessed the SB, supervisors' DI and their contribution to therapy outcome. Assessment was quantitative and qualitative. The supervisory aspects were assessed using a questionnaire constructed for this study. Perceived contribution was evaluated by two scaled questions, and themes generated by an open question. Supervisees (n = 111) evaluated 16 supervisors and supervision’s contribution to psychotherapy outcomes of 111 clients.

Findings

Hierarchical regression showed that supervisees' age, supervisors' status and frequency of supervision accounted for 24% of the variance ascribed to outcome. SB and DI accounted for 51% of the variance. These values, which are higher than reported in the literature, may be attributed to the assessment of predefined aspects of supervision by the same assessor. Thematic analysis of the didactic input produced more themes than for the supervisory bond.

Conclusion

Sociodemographic variables and supervisory relationship variables determine supervisees' evaluations of supervision’s contribution to outcome.

Implications for practice

Training and supervision may benefit from information obtained from quantitative and qualitative measures regarding these and other predefined variables related to supervision. The in-depth look at views and experiences shared by supervisees may advance training, practice and research.