A constructivist approach to supervision: Some preliminary thoughts

Supervision from a constructivist point of view is explored. Supervision processes with three different therapists are presented to exemplify this constructivist stance. In this approach the relation between supervisor and therapist is seen as similar to that between therapist and client. Thus, a “therapist-centered” approach for supervision is outlined, the main points of which are as follows: The main focus of a constructivist supervision is the therapist, supervision should be centered on the therapist's complaint, supervision should generate a learning context, the therapist and supervisor have different types of expertise, the supervising context should generate alternative views about the problem, and the supervision context should be reflexive.     

Treatment preference and acceptability: Epistemology and locus of control

Abstract

Treatment preference and acceptability were investigated in 397 female university students. Three audiovisual vignettes depicting a client and therapist discussing a body image disturbance problem were presented to subjects. Predictions were that subjects would prefer one of three therapy approaches—behavioral, cognitive—rational, or cognitive—constructivist—as a function of personal epistemology and locus of control. Overall, subjects rated the constructivist therapy approach more favorably than either the cognitive—rational or behavioral approach. Similarly, subjects evaluated the constructivist therapist more positively than either the rational or behavioral therapist. After degree of subject identification with the target problem was controlled, results indicated that matching subjects who had an external locus of control orientation to a behavioral or cognitive-rational therapist resulted in more favorable assessments of that therapist. Matching subjects who had an internal locus of control orientation to a constructivist therapist resulted in more positive assessments of that therapist. Implications for matching in clinical practice are discussed.     

The effects of therapist-client age similarity on pretherapy expectations

The present study investigated the effects of similarity between psychotherapist age and client age on client's preference for a therapist, willingness to disclose, expected therapeutic climate, and perceptions of therapist competence. Similarity theory provided a rationale for the hypothesis that prospective clients would perceive a psychotherapist similar in age more favorably than a therapist dissimilar in age. Support for the hypothesis was obtained on the dimensions of client preference, willingness to disclose, and therapist competence. Also, consistent with previous research, high experienced therapists were viewed more favorably than low experienced therapists.This research is based on a doctoral dissertation submitted by Kathleen M. Tall under the direction of Michael J. Ross to Saint Louis University.     

Ethical Considerations for Therapists Working With Demographically Similar Clients

The increasing emphasis on multicultural competence within psychotherapy continues to highlight the need for being sensitive to key differences between therapist and client. However, this attunement to the psychotherapeutic impact of therapist–client differences may obscure the equally critical need to evaluate ethical problems associated with therapist–client similarities. It will be argued that therapists treating clients who are demographically similar to themselves encounter a unique set of ethical challenges that warrant careful consideration and caution precisely because of therapist–client matching. The extant research on matching therapists and clients based on demographic similarities is discussed, with a particular emphasis on psychotherapeutic outcomes and client preferences. Attention then turns to the nonrational heuristics and biases that can often cloud therapists’ ethical decision making regarding the appropriate uses versus contraindications for demographically matching therapists and clients. Within the discussion of nonrational heuristics and biases, suggestions are offered for managing related challenges for ethical decision making.     

Racial/ethnic disparities in therapist effectiveness: a conceptualization and initial study of cultural competence

As a result of mental health disparities between White and racial/ethnic minority clients, researchers have argued that some therapists may be generally competent to provide effective services but lack cultural competence. This distinction assumes that client racial/ethnic background is a source of variability in therapist effectiveness. However, there have been no direct tests of the therapist as a source of health disparities. We provided an initial test of the distinction between general and cultural competence by examining client racial/ethnic background as a source of variability in therapist effectiveness. We analyzed cannabis use outcomes from a psychotherapy trial (N = 582) for adolescent cannabis abuse and dependence using Bayesian multilevel models for count outcomes. We first tested whether therapists differed in their effectiveness and then tested whether disparities in treatment outcomes varied across therapist caseloads. Results suggested that therapists differed in their effectiveness in general and that effectiveness varied according to client racial/ethnic background. Therapist effectiveness may depend partially on client racial/ethnic minority background, providing evidence that it is valid to distinguish between general and cultural competence.     

Divergent ethical perspectives on the duty-to-warn principle with HIV patients

This article presents the case of an HIV-positive client who reported having sexual relations with an unknowing partner. The issue raised is whether the therapist was required to warn the unknowing partner, similar to the Tarasoff mandate that is imposed on therapists. The case is analyzed from an ethical framework similar to that presented by Beauchamp and Childress (1994). Two opinions are presented, each leading to different conclusions about whether the therapist should inform the unknowing partner. It is concluded that although such analysis is valuable in aiding the therapist in his or her decision-making process, no clear professional standard for the management of the problem is evident.     

Response to Lazarus's " How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness"

This article presents the case of an HIV-positive client who reported having sexual relations with an unknowing partner. The issue raised is whether the therapist was required to warn the unknowing partner, similar to the Tarasoff mandate that is imposed on therapists. The case is analyzed from an ethical framework similar to that presented by Beauchamp and Childress (1994). Two opinions are presented, each leading to different conclusions about whether the therapist should inform the unknowing partner. It is concluded that although such analysis is valuable in aiding the therapist in his or her decision-making process, no clear professional standard for the management of the problem is evident.     

Beyond neutrality – a politically oriented systemic intervention

This paper focuses on the necessity to expand some perspectives of systemic interventions beyond the therapeutic room. It relates to situations where the problem presented by the client system arises from a political ideology that marginalizes the client system. The consideration of new alternatives requires a dialogue about the ideology of the client system and the ideologies held by others – the therapist, the people in the main stream, etc. Balancing between sharing therapist prejudices, i.e. political ideology, being neutral in understanding the narrative and meaning of the client system ideology, and being irreverent towards all ideologies, is useful in enabling the consideration of new alternatives. This is illustrated by the case of a supervisor/dialogue process with a group of Jewish family therapists living in the situation of political uncertainty on the West Bank of the Jordan, an area that has been occupied by Israel for three decades and a focal point of the changes proscribed by the Oslo Peace Agreement.     

Overcoming the self-promotion dilemma: interpersonal attraction and extra help as a consequence of who sings one's praises

Prior research has shown that positive information presented by a third party shields people from the negative consequences of being perceived as self-promoting. But in many contexts, those third parties are intermediaries with a financial interest in the person being promoted rather than neutral parties. In three experimental studies, the authors demonstrate that even when intermediaries are not neutral, they can be helpful for overcoming the self-promotion dilemma--the need to assert one's competence but not be harmed by the fact that people who self-promote are viewed negatively. The authors find that hiring an agent to sing one's praises results in more favorable perceptions of the client, which contributes, in turn, to a greater willingness to offer that person assistance. It is also shown that even when the intermediary is physically present and seen to be complicit with the client, the positive effects of having someone else speak on one's behalf persist.     

Qualitative meta-analysis of insight events in psychotherapy

Purpose: This study reports on a qualitative meta-analysis examining the phenomenon of insight into psychotherapy. Method: Studies (n?=?7, covering 15 insight events of 15 clients) were selected that examined significant events in psychotherapy leading to insight using session recordings and Interpersonal Process Recall interviews with clients and therapists. A conceptual organization of the data using a matrix grid consisting of three domains according to data origin (client process, therapist process, and their interaction) and three domains according to events’ sequence (context, event and key intervention, and impact) was established. Results: Key processes were identified that lead to insight events in psychotherapy. Two distinct types of events according to their main impacts as reported by the clients were identified: Painful/Poignant Insight where clients realized something that was painful, often evoking feelings of sadness or undifferentiated upset containing sadness and hurt; and Self-Asserting/Empowering Insight that led to an impact characterized by a sense of self-assertion and empowerment on the client’s part. A reasonably good alliance and vulnerability on the client’s part represent the context for insight events as does the client’s quest for self-understanding. The therapists’ key interventions in the event leading to poignant/painful insight contain either empathic reflection or collaborative interpretation. In empowerment/self-assertive insight events the therapists offer supportive, validating reframing promoting positive experience. In both types of events the therapist and the client work on consolidating insight. In some events, therapists emphasized cognitive or problem solution focused impacts, while clients emphasized emotional impacts. Some events contained emotional avoidance on the part of the client or therapist thus not realizing the full potential of the event.     

An Existential Perspective of Body Beliefs and Health Assessment

Successful health assessments are ongoing and rely on a clinician/client interaction, which is influenced by both the client’s and the clinician’s beliefs about their bodies. These beliefs about the human body arise out of religious and cultural contexts. Theories often explain cultural context by comparison of differences and similarities between the client and the clinician and/or between the client and the dominant culture. This approach can carry a bias inherent in the comparison to dominant beliefs held by those with the most power and economic advantage. The author suggests an existential approach in which client and clinician bodies interact each as adept, autonomous individuals with a conglomerate of beliefs about body and health.The author is an Interdisciplinary PhD candidate in Music Therapy and Health Psychology at the University of Missouri-Kansas City Conservatory of Music. Her research goals include the interrelationship of music, spirituality, and cardiovascular health. She is a Board Certified music therapist and has served in that capacity since 1980 in mental health facilities, hospice, and private practice.     

'But they aren't motivated …' issues concerned with encouraging motivation for change in families

This article is an attempt to provide some frameworks for understanding aspects of the context of families which support or constrain motivation for change. A theme of the entire paper is that ambivalence is normal and that it is therefore useful to regard families both as motivated to change and motivated to maintain stability. Part I focuses particularly upon family–referrer– therapist relationships and Part II upon family–therapist relationships. Part I begins with an exploration of the idea of motivation as a process and outlines the usefulness of the concept of ambivalence. Its main focus however is upon the importance of considering referrers when attempting to assess the motivation of family members for change.
Part II considers the relationship between the family and the therapist and takes account of some important aspects of the contexts of both. It ends with a summary of some experiential exercises which enable one's personal understanding of motivation issues to develop.     

Fighting for Freedom: A Collaborative Success Story

This article is co-authored by the client and the therapist. The occasion is created by the desire to explain and understand a success story: a success for the client that was a surprise for the therapist. A dialogue is presented in which the therapist using a solution focus/narrative frame interweaves comments on the process. Final reflections are also offered.     

Dilemmas in brief therapy

This paper examines three central concerns for the short-term therapist at a time when therapy is widely available free of charge in the community, in a model that has been called ‘ serial life-span therapy’. Issues of referral-on, topping-up or extending contracts are experienced as dilemmas or as temptations, depending on what therapists believe their clients need and what their clients may demand of them. Short-term therapy has become accepted in many contexts, with therapy no longer used as a once-and-for all solution to clinical problems, but as a serial method over time which includes topping up and re-contracting. After an initial agreement of brevity, depending on the client's disturbance levels at assessment and on availability, there may be the need for referral-on at the end of a brief contract, when clients may be offered a different, long-term service, or they may be recommended to return later in life for more, if and when this becomes necessary. Flexible contracts rather than rigid rules about the termination of therapy are being practiced in many contexts, depending on ‘what works’ and how methods can be adjusted to new evidence. There is danger of collusion or control, and this can lead to therapeutic dilemmas, which involve taking acceptable risks, or to therapeutic temptations, which are due to the desire for narcissistic gratification, benefiting the therapist rather than the client in terms of power or Eros. Being able to let go of clients and manage issues of loss, grief and greed requires a measure of maturity in the therapist that aims for good-enough results rather than striving for perfect endings.     

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.     

Women’s preference of therapist based on sex of therapist and presenting problem: An analog study

An analog study was conducted to examine differences in women’s preference for and anticipated comfort self-disclosing to hypothetical therapists of different sexes based on the type of hypothetical presenting problem. The impact of general level of self-disclosure was also examined. Participants included female college students (n?=?187). Anticipated comfort self-disclosing to male or female therapist was rated by subjects when presented with therapists of each sex with the same qualifications. Women preferred and reported higher levels of anticipated comfort self-disclosing to a female therapist. The type of hypothetical presenting problem and general level of self-disclosure also impacted anticipated comfort self-disclosing. There was an interaction between general level self-disclosure and the sex of therapist on anticipated comfort self-disclosing. General level of self-disclosure only impacted anticipated comfort self-disclosing when the therapist was male. This information is relevant for therapists or organizations that provide psychosocial services to women. Organizations may want to inquire about a client’s preferences about sex of therapist beforehand and, if possible, cater to the client’s preference.     

To switch or not to switch: Inviting bilingual clients to switch languages in psychotherapy

In the present study, we used an audio-analog design to test whether exposing bilingual participants to a therapist who invited a bilingual client to switch languages in a psychotherapy session would have a positive effect on participants’ perceptions of the therapist. We also explored whether participants’ sense of belonging to their ethnic group and to the larger US culture would enhance or attenuate this effect. Sixty-three bilingual Latino/a university students listened to one of two recordings of a simulated psychotherapy session with a bilingual Latina therapist and client. In one recording, the therapist invited the client to switch from English to Spanish when the client had trouble expressing complicated feelings; in the other, the therapist did not invite the client to switch. When listening, participants were asked to imagine themselves in the role of client and to rate the credibility and multicultural competence of the therapist, and the emotional bond they would anticipate with her. Contrary to expectation, only participants who expressed a greater sense of belonging to US culture rated the therapist who invited the client to switch as being more multiculturally competent. We discuss how these findings contribute to the literature on language switching and bilingualism in psychotherapy.     

Commentary: is collaboration a viable target for family therapists?

It is hoped that this commentary might serve to begin a discussion regarding collaboration, what is meant by it and whether it is a worthy goal for family therapists. I present the varying and sometimes contradictory meanings of the word, ‘collaboration’, as it is used in the therapy literature. Many of these meanings incorrectly imply an equality of the therapist–client relationship that only obscures the power differential that exists in the therapeutic relationship. A linguistic analysis of the primary meaning of ‘collaboration’ as ‘work with’ is presented. It is argued that equality between therapist and client cannot be achieved and need not be strived for. Therapists are encouraged to focus on the quality rather than the equality of their relationships.     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

Utilizing artistry in a therapeutic relationship

Abstract

In many humanistic approaches, therapeutic change involves utilizing the relationship between the client and therapist as a tool for personal growth. Like any relationship, the therapeutic relationship is one that is co‐created between those engaged in it, namely, the client and the therapist. Utilizing this co‐created relationship requires a sense of artistry on the part of the therapist. A therapist must be willing to engage in this meaningful relationship with the client. A therapist must also be aware of the personal values that he or she brings into therapy, and how they influence the therapeutic relationship. Finally, a therapist must acknowledge the power that the therapist and the client possess in the relationship, and understand how that power can be used to validate and invalidate the therapist's and the client's personal meanings. These aspects of therapeutic artistry are discussed and the use of therapeutic artistry in Eron and Lund's (1996) narrative solutions approach is presented.