The Cost of Client Transfer

Clients undergoing transfer from one counselor to another were compared on the Generalized Contentment Scale and a DSM-III-R measure with clients staying with the same counselor over the same length of treatment. In three 12-week blocks, the clients with the same counselor made the greatest progress in the first 12 weeks, making less progress in each successive block. The clients who were transferred in the middle of the second 12-week block also made the greatest progress in the first time block, lost some of the progress in the transfer block, and made significant progress with the new counselor in the third time block, ending with no significant differences in either generalized contentment or DSM-III-R outcome from clients who had not been transferred.     

Affect at the different phases of cognitive behavioral therapy: An evaluation of psychotherapy provided by candidates

The purpose of this study was to investigate the affect, as measured by “Positive and Negative Affect Schedule” (PANAS), its influence on psychopathology, and to examine the effect of changing affect during cognitive behavioral therapy (CBT). The study was carried out at the psychotherapy training center, Karlstad University. The hypothesis was whether clients with mental disorders have a self‐destructive affective personality (low PA and high NA) and healthy individuals have a self‐actualizing personality (high PA and low NA). Thirty‐two healthy participants and 44 clients participated in the study. The clients were asked to fill in the PANAS once throughout CBT, either during evaluation, treatment or finishing phase, accordingly there were three different groups at different therapy phases. The healthy subjects were also asked to fill in the self‐report scale once. The comparison of the three phases of therapy and the four affective personality types showed a significant difference between the phases of therapy and the four affective personality types: totally 16 (of 22) and eight (of nine) clients measured at the evaluation and treatment phases, respectively, had a self‐destructive personality. However, at the end of therapy five (of 13) clients had a self‐actualizing personality characteristics, while only three of them were self‐destructive. Furthermore, the results indicate that affective personality does not seem to be a basic and stable personality trait, which could be altered by therapy. The affections measured by PANAS may be influenced by psychopathology and CBT, when conducted by candidate therapists it can be effective in terms of affect changes.     

The Psychoanalytic Study of the Child,Volume VI Edited by Ruth S. Eissler,Anna Freud,Heinz Hartmann,Ernst Kris

Abstract

The effect of affective group bibliotherapy (GB) was compared to affective group therapy (GT) on patients’ functioning in therapy and their session impression. Three small groups totaling twenty–five in–patients in a hospital in Israel participated in the study. Clients concurrently participated in both group types, undergoing three sessions in each condition. In–therapy behaviors were assessed through the Client Behavior System (CBS; Hill &; O’Brien, 1999). Results indicated that in the GB condition compared to the GT condition, clients showed less resistance, used simple responses less frequently, and expressed greater affective exploration. The Session Evaluation Questionnaire (SEQ; Stiles et al., 1994) was used to measure clients’ impressions of the sessions. Results indicated that patients evaluated the two treatment conditions equally. Overall, the results support earlier findings, suggesting that affective bibliotherapy can be an effective method of treatment.     

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.     

Treatment of Excessive Interpersonal Dependency: A Cognitive-Behavioral Model

Clients with excessive dependency often seek treatment for an Axis I anxiety or mood disorder. Simply providing treatment for the Axis I disorder may fail to address the long-standing personality factors that may underlie the acute anxiety and depression. A four-stage model has been proposed for the treatment of excessive interpersonal dependency. This model describes strategic ways therapy content and style should change over the course of treatment. Despite the apparent utility of the four-stage treatment model, it may be difficult to apply in many sites that now emphasize short-term approaches to treatment. In many cases, therapy can be designed to address themes that are relevant to both dependency and the Axis I syndrome. Therapy can be focused around helping clients make improvements in stabilizing emotional reactions, enhancing views of the self, and improving social functioning. Treatment focused on stabilizing emotional reactions can help clients confront and develop tolerance for feelings of depression and anxiety. Treatment focused on enhancing views of the self can help clients improve their self-esteem, self-reinforcement and reduce self-criticism. Treatment focused on improving social functioning can enhance social skills, reduce social anxiety and challenge feelings of loneliness. In addition, treatment can focus on reducing specific aspects of interpersonal dependency and confronting developmental antecedents that may underlie the dependency.     

Couples’ Experiences of Hope When Participating in the Reflecting Team Process: A Case Study

Hope is believed to be influential to therapeutic change. However, no studies have explored couples’ experiences of hope during participation in a reflecting team process. This exploratory case study attends to this gap in the research literature. Three couples reported on their experiences of hope in relation to participating in the reflecting team process as part of their couple therapy. Themes related to hope were identified during three separate stages of the intervention: anticipating, participating in, and debriefing the reflecting team process. Reflecting team experiences related to hope included: seeking new perspectives, maintaining a positive momentum, identifying strengths, normalizing difficulties, presenting inspiring possibilities, providing support, highlighting growth, and strengthening resolve. These findings serve as a foundation for attending to clients’ hope as an active force during the reflecting team process.     

Three Aspects of the Therapeutic Conversation in Couples Therapy

Abstract

Feminist scholars have revealed the importance of examining the influence of gender on the therapeutic process. Gender differences in the treatment of clients may reveal inequitable or traditionally Stereotypie treatment of clients by therapists. This study examined gender differences in three conversational strategies widely used by therapists: expressions of empathy or understanding, compliments or praise, and challenges or requests for change. Fourteen tapes of live therapy sessions conducted by “master” therapists were examined using an exploratory, qualitative methodology based on Conversation Analysis. Results of this exploration revealed that therapists who are not self identified as “feminist challenged female clients more than male clients, and complimented male clients more than female clients. Feminist therapists challenged male clients more than female clients, and complimented female clients more than male clients. Feminist therapists used more challenges designed to facilitate non-stereo-typic gender behavior in both male and female clients. Only male therapists used disrespectful challenges of female clients, and were more often disrespectful to female clients than to male clients. Implications for the therapist-client relationship and the feminist critique are provided.     

Ex-hospital clients evaluate their aftercare experiences

Seventy-two previously hospitalized clients of an inner-city community clinic, assigned to three treatment groups - medication-only, medication plus individual therapy, and medication plus therapy plus group experiences - evaluated their respective aftercare programs by responding to five questions. As compared with the others, medication-only clients were less inclined to see either the clinic or the medication as preventing rehospitalization, were alone in reporting that the clinic was responsible for preventing rehospitalization to the extent that the medication was effective, and responded to the question of rehospitalization by emphasizing worsening symptoms. Others emphasized therapy failure. Clients agreed with the professionals - aftercare should not be medication alone.     

Symptom reduction and termination: client change and therapist identified reasons for saying goodbye

Empirical efforts have focused on predicting whether or not clients prematurely terminate therapy, with nonattendance of last session equated to premature termination. However, this fails to explore the relationship between clients’ distress reduction and reasons for termination. With this study, we aimed to understand how clients’ distress change relates to premature termination and examine clients’ distress change in conjunction with therapists’ perceptions of termination reasons. We collected data from 797 clients who prematurely terminated or attended termination but completed therapy a minimum of three individual sessions provided by 38 therapists. Clients completed an assessment of psychological symptoms before each session. At the end of treatment, therapists identified the reasons they believed termination occurred for all clients in the sample. Results demonstrate that total sessions attended and missed predict premature termination, whereas distress change does not. Additionally, clients who were believed to accomplish goals do show greater change. However, therapists’ indicated that over half of clients did not reach goals at termination and they did not perceive nonattendance at last session to equate to drop out in all cases. Implications are discussed with respect to understanding why clients’ terminate, therapeutic goal conceptualization, and review of goals during termination in time-limited psychotherapy.     

Évaluation de l’efficacité d’un traitement cognitif-comportemental pour le trouble d’anxiété généralisée combiné à des stratégies de régulation des émotions et d’acceptation et d’engagement expérientiel

The objective of this article is to examine the efficacy of a new cognitive-behavioral treatment, which combines emotion regulation strategies, and acceptance and commitment-based strategies to cognitive-behavioral supported treatment for generalized anxiety disorder (GAD). A single-case multiple baseline design was used to measure the effect of a 19-week treatment on three participants. Semi-structured interviews, self-report questionnaires, and daily self-monitoring were used to assess symptoms of GAD, general anxiety, depression, and quality of life. These instruments were administered at different times. At post-treatment, two out of the three participants showed a clinically significant improvement and no longer met GAD criteria. These results were maintained at the three-month follow-up. For the third participant, a considerable improvement was observed at the end of treatment but only reached clinical significance at the follow-up. The results of this study suggest that this type of treatment was effective in reducing anxiety and depression symptoms and in improving quality of life of GAD patients. Controlled studies involving bigger sample sizes are needed to determine the efficacy of this new treatment. Future research should also examine the separate and specific contribution of each therapy component in treatment efficacy.     

Valuing clients' perspective and the effects on the therapeutic alliance: a randomized controlled study of an adjunctive instruction

The patterns of growth and development of the therapeutic alliance over the course of therapy have been of continued interest to psychotherapy researchers. The purpose of this study was to investigate whether a simple institutional metacommunication intervention with clients had an effect on the development of the alliance. This adjunctive instruction involved inviting therapy clients to take a proactive role in their treatment by encouraging feedback to their therapist about various aspects of the therapy process. In this randomized controlled study (N = 94), clients were assigned to 1 of 2 conditions: (a) an institutional adjunctive instruction condition in which patients were contacted by clinic personnel at the beginning of the remediation phase (Session 5) and encouraged to take a proactive role in their treatment and (b) a control condition that contained no institutional adjunctive instruction. Between-condition differences in the alliance were tested, controlling for baseline influences and the early therapeutic alliance. Clients' postsession reports from Sessions 1 to 24 indicated that the adjunctive instruction increased the alliance over the course of therapy vis-à-vis the control condition. The adjunctive instruction appeared to have fostered clients' evaluation of their therapists' interest in their welfare. The results indicate that interventions, even brief or subtle, can produce lasting benefits in the alliance when targeted at specific psychological processes. Systematic metacommunication from the institutional level appeared to reinforce clients' therapeutic alliance with their therapists in individual treatment.     

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.     

Cognitive-Behavioral Treatment of Social Phobia

Social phobia can be a chronic disorder, capable of restricting a client's social and occupational functioning. Cognitive-behavioral therapy can help many clients learn to overcome their social inhibitions, and make lasting changes in their interpersonal style. Cognitive-behavioral therapy for social phobia includes four general components for helping clients learn to manage their social anxiety. First, therapy begins with the establishment of a sound therapeutic alliance, a focus on assessment, diagnostic interviewing, and education regarding anxiety symptoms and their treatment. Second, the therapist helps clients to develop competence in social skills, relaxation training, and cognitive restructuring. Third, therapy uses exposure to social situations in order to help clients confront their fears and refine their coping skills. Fourth, relapse prevention strategies are used to help clients learn to tolerate feelings of discomfort and confront challenging social interactions. This treatment framework can be adapted to the specific needs of different clients.     

Beyond beliefs: Challenging obsessive thoughts and compulsive behaviours within a collaborative counselling relationship

Three clients with obsessive‐compulsive disorder were studied using a multiple case study approach. Clients' experiences of cognitive‐behavioural therapy, in particular the impact of having their beliefs challenged, and their responses to self‐monitoring tasks and behavioural experiments were investigated. Data included case notes made during therapy, pre‐ and post‐therapy questionnaires, and post‐therapy semi‐structured interviews. Qualitative analysis of the data identified clients' obsessive beliefs, general negative beliefs and meta‐cognitive beliefs, and explored any post‐therapy changes in these beliefs. The results demonstrated similarities between cases in obsessive beliefs (e.g. inflated responsibility for harm), general negative beliefs (e.g. feelings of failure), meta‐cognitive beliefs (e.g. the need to control thoughts) and affect (e.g. guilt). Questionnaire data from all three clients suggested no clinically significant post‐therapy changes in general negative beliefs and meta‐cognitive beliefs. However, idiosyncratic changes in obsessive beliefs were reported during therapy and at post‐therapy interview, and clients reported improved functioning and decreased levels of distress during therapy and at interview. Responses to challenge were uniformly positive, but reactions to self‐monitoring and behavioural experiments varied across cases. The implications of these findings for the treatment of obsessive‐compulsive disorder using cognitive behavioural techniques are discussed.     

Tigers are something else: A case for family play

This paper is an attempt to bridge the two worlds of family therapy and filial play therapy, introducing the complementary idea of play in therapy. Family play therapy challenges the idea that play is only useful in the treatment of children. Clinical examples are given and uses of play are discussed, including evaluation, play as a therapeutic tool, and the development of themes. The authors believe that therapists who are willing to be playful offer their clients a new world of therapeutic experiences.     

Short-term desensitization therapy

R has raised the possibility that behavior therapy procedures can benefit from even further departures from traditional psychotherapy formats. Although behavioral approaches such as desensitization therapy are distinctive departures from the verbal psychotherapies, there is still an implicit commitment to one traditional approach: the reliance upon one or two weekly appointments. Clients being treated for phobias, for example, are typically seen for desensitization sessions twice weekly. Yet, both theory and current research argue for more frequent meetings as being more effective. Robinson and Suinn (1969) saw clients with spider phobia daily for five consecutive days, meeting one hr per day. Clients were tested on a behavioral task prior to and following massed treatment. Results showed that prior to therapy, none of 20 clients were able to place their hands near the spider; following massed treatment, all clients improved, 13 clients placed their hands within 12 in. of the spider, 2 touched the spider and 1 client stroked the 4 in. spider twice as it moved across the cage. Suinn and Hall (1970) relied upon an even shorter treatment period: students with test-taking anxiety were desensitized completely within 24 hr. These clients were trained to relax and exposed to hierarchy items from 1–4 p.m. on Friday and 8–12 noon the next day. Results showed that the marathon treated clients showed recoveries to the same degree as that achieved in a group treated over a course of 4 weeks. Theoretically, massed treatment should be more effective than spaced treatment. This is based on the view that massed practice would lead to the extinction of fear or anxiety responses since this method capitalizes upon two factors: (1) counterconditioning, whereby the fear stimulus becomes conditioned to relaxation instead of anxiety, and (2) conditioned inhibition, whereby the anxiety responses become ‘fatigued’ and non-responding is reinforced. Implosive therapy (Stampfl and Levis, 1967) appears to be basically a type of massed practice in which the client is continuously exposed to extremely frightening scenes to extinguish the fear. In implosive therapy the client is kept anxious during the treatment; in massed or marathon desensitization, the client is relaxed throughout the sessions. The purpose of this report is to summarize some results achieved through massed desensitization.