A Survey of the Attitudes and Practice Experiences of Home-Based Practitioners

This article reports on the findings from a study that assessed the attitudes and practice experiences of home-based therapists. Existing research in the field of couple and family therapy encompasses largely qualitative information detailing the experiences of this therapist population. We explored several hypotheses generated from the qualitative literature on home-based therapy. Study results corroborated much of the qualitative data on home-based therapists’ experiences and reveal the profile of today’s home-based therapists along with their attitudes and therapeutic practices. A surprising result was that various aspects of home-based therapy models seem incongruent with therapist attitudes about the delivery of home-based services.     

The Therapist’s Needs: Beyond Mutual Recognition

Abstract

As early as 1965, Harold Searles argued that therapists’ needs for healing and growth are part and parcel of their work with patients. Since then, the relational movement has corroborated this idea by articulating the healing function of treatment for both patient and clinician. In this article, the authors examine therapists’ needs that have been overlooked or those that have not been considered fully in the literature. Using various ideas related to the concept of what the authors call therapeutic freedom, this article argues that clinicians must strive to adopt a therapeutic vision that aims to loosen their own ties to safe, familiar modes of engaging with patients, particularly in moments of enactment or impasse. The authors elucidate these ideas with case material from their clinical work and show how embracing various forms of therapeutic freedom results in a type of mutual surrender on the part of both patient and therapist, creating opportunistic conditions that generate therapeutic action and new possibilities for the dyad.     

Creating a Safety Net: Transferring to a New Therapist in a Training Setting

Transferring clients to new therapists is a common necessity in training settings, agencies, and private practices. However, there is a paucity of empirical studies that examine the process of client transfer and its impact on the client. This qualitative study explored the experience of clients who had successfully transferred from graduating practicum students to incoming practicum students in a COAMFTE accredited MFT master program in the southeastern region of the US. The resultant grounded theory consisted of a central category (Creating a Safety Net), a paradigm (Professionalism), and two main categories (Structure and Trust). Clients described an overall process of initial disclosure of the pending transfer, their affective response, the therapist’s response, a period of co-therapy with incoming and outgoing therapists, and continuation of therapy with the new therapist.     

Therapeutic Utility of Discussing Therapist/Client Intersectionality in Treatment: When and How?

The impact of the therapeutic alliance on positive clinical outcomes has been established in the literature; however, literature is lacking on how the intersection of therapist and client identities influences this process. We propose that the relational intersectionality resulting from similarities or differences in therapist and client identities has the potential to impact the bonds, tasks, and goals of treatment (key components of the therapeutic alliance; Bordin, 1979) depending on how it is addressed or avoided in therapy. In this paper, we present a model containing pragmatic steps therapists can follow to navigate these conversations with clients in a way that is therapeutically beneficial and culturally sensitive and attuned. Additionally, we provide suggestions for using the proposed model to train new student therapists (or expose experienced therapists) to ideas of intersectionality and social justice by reflecting on the intersection of their own identities, acknowledging dynamics of power and oppression, and understanding how this could shape their relationship with clients.     

The facilitative interpersonal skills method: Difficult psychotherapy moments and appropriate therapist responsiveness

The Facilitative Interpersonal Skills (FIS) task is a performance test of therapists’ use of common relational skills (e.g. empathy, building expectations). The FIS method includes (a) materials that simulate difficult client moments on video, which are used to collect therapists’ responses to these situations; and (b) independent ratings of these responses. Many of the FIS items are informed by psychotherapy processes that have been linked to outcome and facilitative conditions that have been reframed as individual therapist skills (e.g. alliance bond capacity). Overall, the FIS has predicted psychotherapy outcome. A single study is described in which FIS predicted the therapist effect using multilevel modelling of a large sample of clients who were nested within therapists. We also summarise two additional outcome studies that used experimental designs. One future direction is to better understand how therapists form responses to these difficult moments. We conclude that forming an optimal therapeutic response during challenging, emergent in‐session situations involves responsiveness (Stiles et al., 1998), or finding a response that fits the clients’ needs within any moment.     

Beyond Theory and Practice: A Postmodern Perspective

The insights of chaos theory and postmodernism can be applied by therapists to resolve the apparent conflict between theory and practice. Using the example of the modern scientist, the argument is made that for therapy to have integrity the therapist needs a theoretical foundation. This theoretical orientation, however, is tempered by a postmodern perspective that recognizes the finite nature of all theories. The therapist is encouraged to have a theoretical orientation, but not to become that orientation.     

Death of a Clinician: The Personal, Practical and Clinical Implications of Therapist Mortality

Death is inevitable and yet in US culture the discussion of death is somewhat taboo. Marriage and Family therapists are trained in the implications of grief and loss for clients who lose loved ones and yet examination of the impact of therapist mortality on clients is lacking in the clinical literature. This article examines ways that private practice therapists can both protect their client’s confidentiality and mitigate the impact of therapist sudden death on their clients with planning and forethought. In addition, the factors influencing the lack of empirical research on this topic is discussed in the context of social mores on death and how therapists’ own denial of mortality may impact their ability to connect with clients through the pain of grief and loss. Recommendations are made for therapists to evaluate their own attitudes towards mortality and develop a plan for client care in the event of their death.     

The development of psychotherapists' theoretical orientation and clinical practice

There is a growing recognition on the part of psychotherapy researchers of the importance of studying therapist variables, recognising that they have a sizeable influence on both therapeutic process and outcome. A model of the development of therapists' theoretical orientation and clinical practice is outlined, based on the integration of data from 161 Portuguese therapists with the extant literature. The selection of initial orientation is addressed, showing that, regarding this choice, therapists from different persuasions appear to emphasise different variables. In terms of changes in the initial theoretical orientation, it seems not only that 'clinical experience' plays a central role, but also that therapists subscribing to different orientations may find different solutions to their theoretical development. Implications and suggestions for improving training are oudined.     

Tales of a Therapist

ABSTRACT

Historically, theorists and clinicians from various schools of family therapy have discussed therapist self-disclosure in terms of either helping or inhibiting therapeutic progress. Although postmodern language-based theorists and therapists accept and encourage its use, few clinical examples of therapist self-disclosure exist in the family therapy literature. In this paper, a postmodern family therapist working within the language-based tradition describes the use of self-disclosures with a couple. The therapist then reviews the effects of those self-disclosures through the eyes of husband, wife, and therapist.     

Therapist Self-Efficacy in Delivering Cognitive Processing Therapy in a Randomized Controlled Implementation Trial

Efforts to improve the implementation of evidence-based treatments (EBT) have recently made important strides. One such example is understanding the vital role that weekly consultation plays as therapists learn to deliver an EBT. Because mechanism-based research can further support EBT implementation, the present study sought to examine the potential relationship between therapist self-efficacy in relation to treatment fidelity and outcomes.We examined therapist self-efficacy ratings from 80 therapists working with 188 patients. These data were collected as part of a randomized controlled implementation trial testing cognitive processing therapy (CPT). Across post-workshop training conditions, we ran multilevel models to assess (1) changes in therapist self-efficacy, (2) therapist self-efficacy in relation to treatment fidelity, and (3) therapist-self-efficacy in relation to patient PTSD symptom outcomes.We found that therapist self-efficacy significantly improved over the course of 6 months of CPT training. Baseline therapist self-efficacy was differentially associated with client outcomes based on post-workshop training condition. Specifically, therapists with low self-efficacy that did not receive post-workshop consultation tended to have poorer outcomes than therapists with low self-efficacy that received consultation. In the present sample, therapist self-efficacy was not related to treatment fidelity.As this was the first study to examine therapist self-efficacy in the implementation of an evidence-based treatment, our findings suggest that self-efficacy may be an important implementation factor in treatment outcomes and worthy of ongoing research.     

The effect of supervisor and trainee therapist gender on supervision discourse

The effects of supervisor and trainee therapist gender on supervision discourse were examined in this study. Forty episodes of supervision discourse, with ten drawn from each of four types of supervision systems were videotaped. The systems were (1) male supervisor and male trainee therapist; (2) male supervisor and female trainee therapist; (3) female supervisor and male trainee therapist; and (4) female supervisor and female trainee therapist. The episodes of supervision discourse were analysed using a supervision discourse coding system which showed adequate inter-rater reliability. For supervisors, the coding system allowed a directive discourse style and a collaborative discourse styled to be coded. A cooperative discourse style and a resistant discourse style could be coded for trainee therapists. Two statistically significant findings of considerable theoretical and clinical importance emerged. First, contrary to stereotypic expectations, discourse characterized by a directive supervision style and a resistant trainee therapist style was more common for systems containing a female supervisor than for those containing a male supervisor. Second, for same gender supervisor-trainee-therapist supervision systems, a collaborative systemic supervision style was correlated with both cooperative and resistant trainee therapist styles. This discourse pattern did not occur for opposite gender supervision systems, indicating that a collaborative supervision discourse style is consistently associated with trainee therapist parti-cipation (either cooperatively or resistantly) within same gender pairings of supervisors and trainee therapists. These results are discussed in light of relevant literature on gender, power and supervision process and the limitations of the study are considered.     

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.     

The role of personal practice in therapist skill development: a model to guide therapists,educators, supervisors and researchers

Prior to 2000, personal practice (PP) for therapists mostly meant personal therapy. Recently a new landscape of PPs has emerged, with meditation-based programs and therapy self-practice/self-reflection (SP/SR) programs playing an increasing role in training and personal/professional development. The challenge now for practitioners and researchers is to refocus on the role of PPs in training and professional development. Are PPs of value - or not? Do they have a role in therapist development? How might PPs enhance therapist skilfulness? Do different PPs act in similar or different ways? Currently, the PP literature lacks a theoretical framework to guide practitioners in their choice of PPs or researchers in their choice of research questions and measures. The purpose of this article is to provide such a framework, the Personal Practice (PP) model. The PP model proposes primary impacts of PPs in four domains: personal development/wellbeing, self-awareness, interpersonal beliefs/attitudes/skills and reflective skills. The model also suggests a secondary impact on therapists’ conceptual/technical skills when therapists use reflection to consider the implications of their PP for their “therapist self”. We offer some suggestions to enhance the quality of future research, and conclude that PPs may play an important and perhaps unique role in therapist training.     

Managing Anxiety: A Therapist Common Factor

In this paper, we propose that therapist anxiety in the therapy room, especially anxiety stirred up by difficult or triggering clients, represents a challenge to effective therapy, and that effective management of this anxiety be considered as a necessary therapist skill for conducting quality couple and family therapy (CFT). We propose that effective therapists need to be able to manage their emotions, especially their anxiety, in order to truly help their clients. The failure to do this can lead to break downs in the alliance and the flow of therapy, and these deleterious effects can be prevented when therapists actively navigate their internal states through self-awareness and ongoing introspection. Bridging psychotherapy literature, we discuss specific strategies to this end, and make clinical recommendations for CFTs and CFT training programs.     

“You Didn’t Cause Racism,and You Have to Solve it Anyways”: Antiracist Adaptations to Dialectical Behavior Therapy for White Therapists

There are currently no published studies that investigate or discuss the cultural responsiveness of Dialectical Behavior Therapy (DBT) to the needs of Black/African-American clients. In addition, no published scholarly works offer guidance to therapists on how to practice antiracism within the context of delivering evidence-based treatment. Methods for developing a culturally responsive antiracist treatment are discussed within a dialectical framework and from the perspective of critical race psychology. We propose that an antiracist adaptation to DBT is needed to correct for context minimization errors in the DBT model that create an invisibility of racism. Recommendations are made for an additional DBT Therapist Agreement that encourages labeling and targeting therapist treatment-interfering racist behavior. An additional Therapist Consultation Agreement is also proposed to guide therapist antiracist advocacy and functional validation for Black/African-American clients. The DBT technology is used in conjunction with other multicultural theoretical models to recommend strategies for developing White DBT therapists’ antiracist competencies. Future directions for developing critical race psychological research are discussed.     

The variability of client,therapist and clinic in psychotherapy outcomes: A three-level hierarchical model

This article investigates the percentage of variance in psychotherapy outcomes explained by the case-mix variables for individual cases, by the therapist (therapist effects), and what additional variance is explained by the clinic with which the therapist is affiliated. While there has been substantial recent research regarding therapist effects, very little has been published regarding clinic-level effects after controlling for therapist effects. The study utilised the largest sample reported to date, using data from 28 clinics with a minimum of 2,000 cases in a clinical range of severity of symptoms with pre-post change scores on an outcome questionnaire. Only cases treated by a therapist with at least 30 cases were included. These selection criteria resulted in a case count of 156,258 clients treated by 874 therapists located at 28 clinics. After controlling for differences in case mix using diagnosis and intake score (severity of symptoms), the resulting analyses indicated that 5.21% of the variance in treatment outcome was explained by the therapist, while another 1.13% of the variance was associated with the clinic. Findings are discussed with implications for practice and policy.     

On the witness stand:

Abstract

The family therapist is frequently called upon to testify as an expert witness. For many family therapists, the courtroom is an unfamiliar environment with different ground rules and basic assumptions. Testifying can be a difficult experience as the mental health professional faces different situational role demands than those encountered in usual therapeutic settings. If the family therapist can transfer to the court context the art of influencing interpersonal situations, the effectiveness of his/her testimony will be enhanced. This paper describes predictable legal behaviors and suggests to the family therapist strategic responses to improve skills as an expert witness.     

The Effects and Effectiveness of Marital Therapy A Review of Outcome Research

The literature on outcome research in marital therapy is reviewed. Issues considered include the nature of outcome criteria, the need to establish a base line against which to measure improvement, and therapeutic effectiveness as a function of treatment type and time-in-therapy. The overall improvement rate across a heterogeneous collection of patients, therapists, and treatment modalities was 66 per cent, suggesting, conservatively, at least a moderately positive therapeutic effect in light of the judgment that “spontaneous” rates appear to be much lower in marital than in individual therapy. Evidence of deterioration in marital therapy also was discovered. No support was found for the contention that co-therapy is more effective than treatment of the couple by a single therapist. The needs of future research in the outcome of marital therapy are discussed and possible fruitful directions for such investigations suggested.     

Psychotherapists' dreams about their patients

Abstract This study examines therapists’ dreams about their patients from the Jungian and the relational perspectives. Few clinical and empirical references to this subject are to be found in the literature. In the present study 31 dreams were collected from 22 therapists. Dreams were collected using anonymous self‐report inventory. The research focused on three theoretical research questions: 1. What themes appear in the manifest content of therapists’ dreams about their patients? 2. What contributions are made by Jungian interpretation of therapists’ dreams about their patients? 3. To what extent are masochistic contents present in the manifest content of therapists’ dreams about their patients? The first question was addressed using categorical content analysis of a) themes common to different dreams and b) pre‐determined themes for all dreams. The third research question was addressed using Beck's (1967) ‘Masochistic Dream’ measure. Results: Among the themes common to different dreams were: therapist‐patient role reversal; therapist and/or patient attends and remains in meeting, departs/doesn’t depart; cancellation of therapy session; sexuality between therapist and patient; aggression; presence vs. absence; non‐verbal relationship and communication; time; driving vs. stopping. With regard to pre‐determined themes it was found that in 20 of the 31 dreams, the therapist had a negative experience and was characterized as vulnerable. Likewise it was found that 26 out of 31 dreams took place in either a) a street, a road, a route, a corridor; b) en route to somewhere; c) a therapy room and/or building; d) a house. With regard to the contribution of Jungian interpretations of the dreams it was found that 17 of the dreams had diagnostic and prognostic elements, 4 of which were initial dreams, 9 of them were compensatory dreams and in 14 it was found that the patient represents the shadow of the therapist. With regard to the third question it was found that 18 of the 31 dreams met Beck's (1967) criteria for masochistic dreams. The theoretical discussion examines the findings from a Jungian perspective, with an emphasis on also understanding the dream in terms of its expression of relational aspects of the therapist‐patient relationship. The findings affirm the presence of the ‘wounded healer’ archetypes in therapists’ dreams about their patients. The results of the study indicate that therapists’ dreams about their patients can be a valuable tool for deepening understanding of the therapeutic relationship and process.