Recognizing social class in the psychotherapy relationship: a grounded theory exploration of low-income clients

The process of psychotherapy among 16 low-income clients was explored using grounded theory (Charmaz, 2006; Glaser & Strauss, 1967) in order to understand and identify their unique experiences and needs. Semistructured interviews were conducted with 12 women and 4 men who had attended at least 6 sessions of psychotherapy within 6 months of the interview. Our grounded theory that evolved depicted a tapestry of the dynamic process by which low-income clients experience social class within psychotherapy. Specific therapist behaviors that contribute to more and less positive experiences emerged from the data and pointed to the importance of acknowledging social class within the therapy room. The significance of therapists enhancing the 50-min hour via advocacy and meaningful moments within and outside of the therapy room was highlighted among all participants. Implications for practice with low-income clients and directions for future research are provided.     

Keeping connected: Family therapists' experiences of working online during the COVID-19 pandemic

For this qualitative study, eight family therapists were interviewed about their experiences of practising online during the pandemic. Findings are organised using a framework of problems, possibilities, resources and restraints (PPRR, Neden & Burnham, 2007). Despite variation in therapist confidence in online practice, all participants found new possibilities in this way of working, including connecting family members across distance, increased co-construction within therapeutic relationships and engaging clients who would not usually attend appointments. Therapeutic alliance was generally possible to establish online, though felt more challenging with whole families than individuals. Problems and restraints included therapist fatigue, risk and safety management, and attuning to nuanced expression of emotion. Implications for practice and future research are proposed. It is suggested that systemic practice has unique qualities to offer the field of online psychotherapy.     

An initial study of transgender people's experiences of seeking and receiving counselling or psychotherapy in the UK

Background: There are no published empirical research studies exploring transgender people's experiences of seeking and receiving counselling or psychotherapy outside of gender identity clinics within the UK. As a result, counsellors know little about why transgender people seek counselling, who they seek counselling from, and what their experiences are of receiving counselling. Aim: To address this gap in the literature, this study investigated transgender people's experiences of seeking and receiving counselling or psychotherapy outside of gender identity clinics within the UK. Funding for this study was provided by a BACP Seedcorn grant. Method: A mixed method small‐scale qualitative research design was employed, comprising an online survey and five semi‐structured interviews. Findings: Participants tended to seek counselling on two or more occasions and received between 2 and 12 sessions. Participants sought counselling for common psychological concerns as well as gender identity and coming out issues. A fear of being discriminated against and exploring gender for the first time were significant barriers in seeking help. Participants reported mixed experiences of counselling but valued a therapeutic relationship in which they felt affirmed, listened to and understood. Discussion: The findings from this study mirror aspects of previous research conducted in the USA concerning transgender clients' experiences of counselling. However, these findings point to the importance of recognising the potential vulnerability transgender clients experience when seeking counselling and the need for therapists to develop greater awareness, knowledge and competence regarding working with transgender clients.     

Playing with Fire: Countertransference and Clinical Epistemology

This article explores both theoretical and practical concepts related to the therapist's use of the self in psychotherapy. Particular emphasis is placed on the potential clinical value of countertransference. It is argued that awareness and resolution of personal issues are required for therapists to draw profitably from their own experiences in working with clients. Specific steps in translating the concept of the wounded healer into clinical practice are offered, along with examples from the author's own practice.     

Changes in meaning in life across the course of psychodynamic psychotherapy

Using the Meaning in Life Questionnaire (MLQ), we studied Presence and Search for meaning for 34 adult clients in psychodynamic psychotherapy. Clients completed the MLQ and Outcome Questionnaire (OQ) before intake and after every eight sessions. Variance in Presence scores was mostly attributable to clients; variance in Search scores was mostly attributable to clients and therapists. Clients initially high in Presence decreased and then increased back to initial levels; clients initially low in Presence increased and then decreased back to initial levels. Clients initially low in Search increased and then leveled off; clients initially high in Search decreased and then leveled off. In lagged cross panel analyses, when clients decreased in psychological distress during one eight-week time period, they increased in Presence during the next eight-week time period; when they increased in psychological distress during one eight-week time period, they increased in search in the next time period. Excerpts from post-therapy interviews illustrate the process of working with meaning in life in psychotherapy. Implications for practice and training are discussed.     

Experiences of Altruism in the Therapeutic Relationship: Perspectives of Counselors‐in‐Training and Their Clients

The purpose of this phenomenological investigation was to explore experiences of altruism in the therapeutic relationship to better understand how counselors‐in‐training (CITs) and their clients mutually perceived the construct in sessions. Findings from interviews with clients (n = 14) included emotional–relational characteristics and cognitive–behavioral aspects of altruism by their counselors. Findings from interviews with CITs (n = 10) included explorations of the role of altruism in counseling, overall experiences of altruism in counseling sessions, and experiences of altruism with specific clients. Implications for practice and research are discussed.     

Experiences of Christian clients in secular psychotherapy: a mixed-methods investigation

Eleven Christian former clients were sampled to uncover factors contributing to positive versus negative experiences in secular psychotherapy. The qualitative results indicated that although many participants felt hesitant to discuss their faith due to uncertainty about their therapists' reactions, positive experiences were reportedly facilitated by therapists' openness to understanding clients' faith and giving clients control over how much, when, and how to discuss their religious beliefs and practices. Dissatisfied clients reported that their therapists expressed opposing religious views or avoided discussing religious or spiritual issues. Participants' self-reports of the working alliance and of their therapists' expertness, attractiveness, and trustworthiness were largely consistent with the narrative data, but the alliance scores were somewhat more sensitive to participants' positive versus negative evaluations of their therapy experience. That is, several participants rated their therapists' personal characteristics quite favorably but indicated poor agreement with their therapists on the goals or tasks of treatment.     

Clients' experiences of online therapy in the early stages of a COVID-19 world: A scoping review

The emergence of the COVID-19 pandemic in 2019 forced an abrupt shift in the modality through which psychotherapy was delivered and online therapy became the only viable option for clients. Research regarding experiences of online therapy during the early stages of the COVID-19 pandemic is minimal, however, and has largely focussed on therapists' experiences of delivering online treatment, as opposed to clients' experiences of receiving it. A scoping review was undertaken to establish what is known from the existing literature about clients' experiences of online therapy during the initial stages of the COVID-19 pandemic and identify gaps in the current knowledge. Searches were conducted across four academic databases: Scopus, EBSCO CINAHL Complete, EBSCO MEDLINE and OVID PsycInfo; the literature was excluded based on established PICOS criteria. Data were summarised through data charting and synthesised by way of inductive content analysis. A total of five articles were identified. All articles focussed on online therapy using video or audio conferencing, and four of the five studies examined clients with eating disorders. Inductive content analysis identified seven categories, as follows: preference for face-to-face therapy; appreciation of accessibility and convenience; online format hindered connection; positive experience of online therapy; individual client differences impacted experience; strong therapeutic alliance indicative of positive experience; and gratitude for continuation of treatment. Future research could explore clients' experiences of online therapy in a “post-pandemic” world and include a broader range of client populations and online therapy approaches in the COVID-19 context.     

Using a cross‐contextual qualitative diary design to explore client experiences of psychotherapy

Qualitative research in counselling and psychotherapy has largely been based on interviews carried out with clients and therapists. However, other approaches to qualitative data collection are possible. The present paper uses a diary design to explore the connection between what goes on in therapy sessions, and client activities and experiences in other contexts. Clients and counsellors kept diaries about significant aspects of therapy sessions, while clients also kept diaries about new and different experiences in other contexts in their lives. Ethical and practical issues involved in the use of diaries are discussed, and the methods that were employed to analyse diary‐based data are described. The types of findings that the study generated are presented, along with discussion of their implications for research into client experiences of therapy.     

Clients’ perceptions of personal psychotherapy or counselling for therapists

The purpose of this study was to examine clients’ opinions of therapists’ personal use of psychotherapy or counselling. Participants in this study, a nationwide sample of clients recruited through Amazon’s MTurk system, were asked to complete an online survey assessing their attitudes towards treatment use by therapists as well as their general attitudes towards psychological help-seeking and perceptions of stigma (social and self) with psychological treatments. In this study, we found that clients generally had positive views about therapists’ personal use of psychotherapy or counselling. Although overall positive attitudes were found, the results from repeated measures ANOVAs indicated that attitudes depended somewhat on whether the therapist had sought out treatment as part of a training requirement for self-enrichment, or for the treatment of a psychological problem. In addition, participating clients were less supportive of therapists disclosing a treatment use history with their clients. Regression analyses also indicated that attitudes towards treatment use by therapists were significantly predicted by general help-seeking attitudes and perceptions of stigma (social and self), but attitudes towards disclosure were not. The findings from this study have important implications regarding therapist treatment use and disclosure in practice.     

Clients’ Experiences of Disengaged Moments in Psychotherapy: A Grounded Theory Analysis

The study offers an empirically derived model of clients’ experiences of disengaged moments, defined as moments when clients withdraw, distance, or lessen their intensity of involvement with therapy-relevant material or relationships. Interpersonal Process Recall (IPR) interviews were conducted with nine psychotherapy clients of therapists with varied orientations and experience. The interviews were transcribed verbatim and subjected to qualitative analysis using grounded theory analysis (Glaser and Strauss, The discovery of grounded theory: Strategies for qualitative research, 1967) methodology. The results suggested that clients use disengagement for protection from pain, strategic retreat, relationship management, self-through-other discovery, and self-betterment. The core category across all of the experiences of disengagement relates to communicating difficulties and experimenting within the therapy relationship toward self-change. Recommendations are offered for research and practice.     

Clinical experiences during the COVID-19 pandemic

Most of the clinical experiences discussed in this article arose from monthly Zoom meetings at Rome’s Italian Centre of Analytical Psychology (CIPA). We set up a discussion group in April 2020, one month after lockdown began in Italy, and these monthly online meetings continue to this day. All senior analysts and analysts-in-training at Rome’s CIPA, whose backgrounds range from child and adolescent psychotherapy to adult psychotherapy and analysis, to sandplay therapy and medicine and psychiatry, have been participating in these meetings. The group discussions focus on the present time and its impact on us, as well as on our relationships with patients. By further developing these reflections during the lockdown in Italy (9 March - 3 May 2020), it is fair to ask whether a sense of unreality, depersonalization, or derealization has occurred, either in the therapist or patient, and if so, whether it is possible that therapists miss the human contact more than clients. We will mainly refer to clinical and personal experiences as our most precious guidelines.     

Tom Thumb in hospital: The fairy tale workshop in a paediatric oncology and haematology ward

Abstract

Definitions of and attitudes towards countertransference have changed throughout the twentieth century. From being seen as a contaminant in the analytical process, countertransference has come to be seen by many therapists as a potentially useful source of information about a client and his or her problems. There are dangers as well as benefits associated with analysis and utilization of countertransference. This article reviews these issues and proposes some guidelines that therapists may find useful when contemplating their countertransference reactions to clients, and when considering how best to utilize these.     

“I’ve got you under my skin”: Relational therapists’ experiences of patients who occupy their inner world

The aim of this study was to conduct an in-depth exploration of therapists’ experiences of patients who affect them more than others and occupy their inner world beyond the context of therapy sessions. A phenomenological analysis was performed on semi-structured interviews with five relational therapists. All the therapists had a strong experience of a particular patient getting “under their skin.” In all these cases, the patient was a traumatized woman. The distinctive characteristic of the phenomenon was a sense of blurred or too permeable boundaries between the therapist and the patient. This was associated with fear and anxiety, but also with feelings of love. The therapists’ reactions to having a patient “under their skin” varied from resistance to symbiotic relatedness. The therapists’ ideas of their professional role influenced how the experience of carrying the patient’s suffering was interpreted. The phenomenon of the patient’s presence in the therapist’s representational world might be interpreted as a distinct countertransference phenomenon when working in a more “thin boundary” manner with particular cases. The therapists’ ability to effectively manage their vulnerabilities, activated in the countertransference, seems to be crucial for therapeutic progress. Implications for research, clinical practice, and training are discussed.     

Iraqi refugee men’s experiences of psychotherapy: clinical implications and the proposal of a pluralistic model

The psychotherapy experiences of a sample of Iraqi refugee men, in later stages of exile, were explored with the aim of shedding some light on how this client group can experience therapy. Ten adult male Iraqi refugees – who had lived in Sweden for at least five years and had been psychotherapy clients at some point during that time – were recruited for this study. Using individual semi-structured interviews (in Arabic), three main areas were explored with each participant: (1) reasons for seeking psychotherapy; (2) perceptions of the psychotherapy professional; and (3) experiences of the psychotherapy process and outcome. The interviews were then translated into English, transcribed, and then analysed using Interpretative Phenomenological Analysis (IPA). Most participants/clients described exile-related stressors as their main reason for seeking psychotherapy, but some described distress due to a combination of pre-migration trauma and post-migration stress. They also found some aspects of therapy to be positive (mainly verbalising ones thoughts and feelings, and feeling less marginalised) and some negative (mainly experiencing racist or culturally insensitive treatment by therapists, and experiencing a lack of competence and transparency in therapists). The findings were explored in terms of clinical implications and a pluralistic model was proposed to address the identified needs.     

Speaking Up:

This article challenges the lack of attention to issues of class in psychotherapy. It calls attention to the sociopolitical nature of therapy and defines some ways in which current therapeutic practices can become oppressive when class differences between client and therapist are ignored. I draw upon my own experience with clinical training and professional practice and invite other white, working class women, through narrative interviews, to share their experiences. Through this collaborative effort, I am able to suggest some ways in which therapy may better meet the needs of working class clients.     

Therapist attitudes and countertransference as predictors of professional quality of life and burnout among psychotherapists

This study aimed to examine the role of attitudes towards psychotherapy and countertransference dimensions as predictors of professional quality of life and burnout among psychotherapists in Iran. Participants were 259 psychotherapists who worked in mental health centres in Tehran (Iran), and they completed the Professional Quality of Life questionnaire, the Therapist Response Questionnaire and the Therapist Attitudes Scale. Professional quality of life was associated with countertransference dimensions and attitude towards psychotherapy. This study concludes that psychotherapists can benefit from working on their specific countertransference issues and re-evaluating their basic attitudes towards psychotherapy to achieve the highest levels of professional satisfaction. Culture may play a role in a specific therapist's attitude and difficulties in addressing certain aspects of countertransference.     

Therapists’ experiences of alliance formation in short-term counselling

While therapeutic alliance formation has been widely researched over many sessions of psychotherapy, the question of alliance formation in short-term counselling has been less explored. Given the increasing evidence in the literature for the positive impact of alliances on therapy outcomes, providing counsellors – who may work with clients for a limited number of sessions – with enhanced insight into alliance formation will be of value. This qualitative study investigated the experiences of eight counsellors forming alliances with clients over short periods. Semi-structured interviews were analysed using interpretive phenomenological analysis. Five major themes emerged, that while congruent with the alliance literature, add some details relevant to day-to-day practice. These themes included: the importance of strong alliances; the need for psychologically comfortable environments; the timing of alliance formation; and the impact of counsellor personal qualities – such as being real – in strengthening and maintaining alliances. In addition, an unexpected sixth theme revealed that body language was highly valued as an indicator of strong or weak alliances. Implications for increasing the use of body language to enhance counselling practice and education are discussed.     

“Out on the edge of my comfort”: Trainee counsellor/psychotherapists' experiences of spirituality in therapy—A qualitative exploration

The integration of spirituality into counselling and psychotherapy poses complex challenges. Personal spirituality, professional competency and ethical considerations may impact on trainees' experiences of integrating spirituality into therapy. This study adopted an inductive, qualitative approach to explore trainee counsellor/psychotherapists' experiences and perceptions of integrating spirituality into therapy. Six trainee counsellors and psychotherapists were recruited using purposive sampling from a professional counsellor and psychotherapist training institution in the UK. In‐depth, semi‐structured interviews were conducted, audio‐recorded and transcribed verbatim. Thematic analysis of the interviews revealed two overarching themes: spirituality provides support but needs a warning; and spirituality is relevant but undervalued. These themes encompass a wide range of trainee concerns associated with integrating spirituality into therapy. Participants reported that they felt unprepared to work therapeutically with clients' spiritual beliefs. However, the value of spirituality in providing support to both the trainee and their clients was highlighted by several participants. Some participants described integrating clients' spirituality as having a positive impact on the therapeutic relationship, but often felt threatening to the trainee. This research has implications that are important for counselling and psychotherapy training and developing enhanced consideration of client spirituality and the interpersonal environment in which therapy is delivered.