Working through: in-session processes that promote between-session thoughts and activities

This study examined whether clients' ratings of the working alliance as well as their perception of cognitive-behavioral (CB) and psychodynamic-interpersonal (PI) techniques (delivered by therapists who used both) were associated with clients' intersession processes (i.e., their thoughts about therapy and therapeutic activity between sessions). Seventy-five clients who were currently in therapy at a large university counseling center participated in the current study. Multilevel regression analyses demonstrated that alliance and clients' perceptions of their therapists' use of PI techniques were positively associated with clients' general thoughts about therapy between sessions. Also, stronger alliances were associated with more therapeutic activities between sessions and more positive (and less negative) thoughts about therapy between sessions. In addition, clients at later sessions who described their therapists as using more PI techniques also reported engaging in more therapeutic activities between sessions (after controlling for the variance in the other variables, such as use of CB techniques). Clients' perceptions of their therapists' use of CB techniques in the most recent session were not related to thinking about therapy or therapeutic activities after controlling for the variance in the other variables.     

The relationship between alliance ruptures and hope for change through counseling: A mixed methods study

The negative impact of alliance ruptures on clients’ experiences within the therapeutic process is well documented. One such negative influence may include clients’ hope for counseling as a helpful process. This study used a mixed methods design to explore how alliance ruptures are related to hope for change through counseling. Quantitative data (N = 105) indicated that those who experienced ruptures reported lower levels of the components of hope for change through counseling, (a) pathways and agency, and (b) goal identification. More frequent ruptures and rupture repairs were significantly related to participants’ (n = 35) pathways and agency. Phenomenological analysis of qualitative participants’ (N = 5) experiences elicited 218 meaning units grouped into four themes: disengagement and mistrust in therapy, deepened distress, questioning one’s hope for and belief in therapy, and resilience for therapy. Qualitative and quantitative data indicate that alliance ruptures are related to lower degrees of hope for change through counseling. Results suggest that clients’ perceptions of ruptures fostered disengagement and mistrust of therapists. However, when therapists act to repair ruptures, they may effectively re-engage some degree of hope for change through counseling in clients. Lastly, the role of clients’ persistence in therapy despite experiencing ruptures is discussed.     

'Good morning, Sir!'Axe handle.' Talking at cross-purposes in family therapy

This paper will examine how therapists can make sense of and use some of the incongruous and apparently absurd replies which clients sometimes make to their therapists' questions. It will be argued that the convention of relying on therapist questions can create its own problems, not least because clients often feel at a disadvantage. Careful attention to the question_answer process in therapy can play an essential part in the therapeutic alliance and can give us clues as to what may be some of the often unstated preoccupations of our clients.     

Client and therapist variability in clients' perceptions of their therapists' multicultural competencies

This study examined therapist differences in their clients' ratings of their therapists' multicultural competencies (MCCs) as well as tested whether therapists' who were rated as exhibiting more MCCs also had clients who had better therapy outcomes (N = 143 clients and 31 therapists). All clients completed at least 3 sessions. Results demonstrated that therapists accounted for less than 1% of the variance in their clients' Cross-Cultural Counseling Inventory–Revised (CCCI-R; T. D. LaFromboise, H. L. K. Coleman, & A. Hernandez, 1991) scores, suggesting that therapists did not differ in terms of how clients rated their MCCs. Therapists accounted for approximately 8.5% of the variance in therapy outcomes. For each therapist, their clients' CCCI-R scores were aggregated to provide an estimate of therapists' MCCs. Therapists' MCCs, based on aggregate CCCI-R scores, did not account for the variability in therapy outcomes that were attributed to them. Additionally, clients' race/ethnicity, therapists' race/ethnicity, or the interaction of clients'–therapists' race/ethnicity were not significantly associated with clients' perceptions of their therapists' MCCs.     

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.     

Ayahuasca in Western society and the metacognitive counselling approach

Ayahuasca is a hallucinogenic plant used throughout South America for religious, cultural and healing ceremonies. Previous studies have analysed it as a therapy method from either the microperspective, such as physiological and psychological effects of substance use, or the macroperspective, such as legal issues or cultural appropriation of ayahuasca by Westerners. There is a need to combine those two aspects to fully understand the effects of ayahuasca for therapists and clients in Western communities. By utilising an autoethnographic instrumental case study, we discuss the possible risk of ayahuasca gaining popularity in Western societies without an understanding of how the social context plays a tremendous part in healing using this method. We also discuss the risk of intrapsychic experiences brought about by ayahuasca that may deter individuals from seeking appropriate treatment. It is not our intention to present ayahuasca as an illegitimate or invalid method of healing; rather, we emphasise the importance of integrating micro- and macroperspectives in psychotherapy practice. We suggest that the metacognitive counselling approach be taken by both clients and therapists when adopting indigenous methods of therapy which may add a significantly positive effect. Although we hope this study offers realistic and lived experiences to generate pragmatic solutions for therapists and clients, we recognise that it is necessary to collect data from a larger number of both clients and therapists to better support our suggestion of the metacognitive counselling approach.     

Therapists' Integration of Religion and Spirituality in Counseling: A Meta‐Analysis

The authors conducted a 26‐study meta‐analysis of 5,759 therapists and their integration of religion and spirituality in counseling. Most therapists consider spirituality relevant to their lives but rarely engage in spiritual practices or participate in organized religion. Marriage and family therapists consider spirituality more relevant and participate In organized religion to a greater degree than therapists from other professions. Across professions, most therapists surveyed (over 80%) rarely discuss spiritual or religious issues in training. In mixed samples of religious and secular therapists, therapists' religious faith was associated with using religious and spiritual techniques in counseling frequently, willingness to discuss religion in therapy, and theoretical orientation.     

Relationships among client and counselor agreement about the working alliance, session evaluations, and change in client symptoms using response surface analysis

Two studies explored how counselor and client agreement on the therapy alliance, at the beginning of treatment, influenced early session evaluations and symptom change. Unlike prior studies that operationalized alliance convergence as either a profile similarity correlation or a difference score, the present study used polynomial regression and response surface analysis to examine agreement. Study 1 explored the impact of working alliance congruence on session depth and smoothness at the 3rd session of treatment with 36 client-counselor dyads. Results revealed that session smoothness was greater when clients' and therapists' perceptions of the working alliance were in agreement and high compared with when they were in agreement and low. In addition, clients rated sessions less smooth when their ratings of the alliance were lower than their therapists' ratings of the alliance, and they rated sessions as more smooth when their ratings of the alliance were higher than their therapists' ratings of the alliance. The authors did not find a significant relationship with session depth. In Study 2, the authors explored the impact of working alliance congruence, at the 3rd session of therapy, on symptom change for 63 client-counselor dyads. Results revealed that as the therapist and client have more positive agreement on the perceived alliance at the beginning of the treatment, there is greater symptom change. The authors also found that the consequences of alliance disagreement are the same regardless of who rated the alliance higher than the other. Implications and recommendations for future research are discussed.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

Client-therapist intimacy: responses of psychotherapy clients to a consumer-oriented brochure

Psychotherapy clients read two consumer-oriented brochures: a general brochure on psychology and a brochure on the topic of client-therapist intimacy. Half of the participants read the general brochure first and the brochure on client-therapist intimacy second, and half the participants did the reverse. Participants reported favorable reactions to the brochures, indicating they thought both should be made available to psychotherapy clients; that neither were too long, too sensitive, or too difficult to read; and that the brochures should be made available early during the therapeutic process. After reading the client-therapist intimacy brochure, participants also showed some changes in Likert-type scores measuring attitudes regarding intimate contact between clients and therapists. Although participants were more negative about issues of sexual misconduct after reading the client-therapist intimacy brochure, they did not indicate a decrease in trust of therapists, nor did they indicate a greater likelihood of filing a false complaint. We concluded that therapists' reservations about presenting clients with factual information regarding therapist sexual exploitation of clients are not empirically founded.     

THE EGALITARIAN RELATIONSHIP IN FEMINIST THERAPY

Feminist therapy has revolutionized clinical practice and offered a model of empowerment for all therapy approaches. However, the long-assumed claim that feminist therapists are more likely to engage in power-sharing behaviors with their clients has not been supported by published quantitative research. In the current study, 42 female therapists who were asked whether or not they self-identified as feminist therapists completed measures assessing their use of feminist therapy behaviors (Feminist Therapy Behavior Checklist) and power-sharing behaviors (Therapy with Women Scale). One of each therapists' current female clients completed measures assessing her perceptions of both treatment collaboration (Working Alliance Inventory) and power-sharing behaviors (Client Therapy with Women Scale). As hypothesized, participants who identified as feminist therapists were more likely to report engaging in power-sharing behaviors when compared to participating therapists who did not. Furthermore, as hypothesized, clients of feminist therapists were more likely to report that their therapists engaged in power-sharing behaviors.     

Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

     

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 Effect of Therapist–Client Racial Similarity on Client Satisfaction and Therapist Evaluation of Treatment

Client satisfaction with therapy services and therapists' perspectives of treatment evaluation were examined in relation to therapist and client racial similarity. Secondary data from a university marriage and family therapy clinic located in the southeast was used to pair therapists and clients on racial similarity or difference. Statistical analyses revealed no major differences in clients' perceptions of satisfaction based on similarity to therapists' race. Therapists indicated some differences in their perceptions of the success of services provided to clients based on similarity to client's race. Implications for researchers, clinicians, and educators are included.     

Therapist perspectives on using silence in therapy: A qualitative study

Twelve experienced therapists were interviewed about their perceptions of why they used silence in therapy. Qualitative analyses revealed that these therapists typically perceived themselves as using silence to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings, or take time for themselves to think of what to say. Therapists generally indicated that a sound therapeutic alliance was a prerequisite for using silence, and they typically educated their clients about how they used silence in therapy. Therapists typically believed they did not use silence with clients who were psychotic, highly anxious, or angry. They typically thought they now used silence more flexibly, comfortably, and confidently than when they began doing therapy. Therapists typically believed they learned how to use silence from their own experience as a client and from supervision.     

Client experience of gender in therapeutic relationships: an interpretive ethnography.

The purpose of this study was to explore clients' experiences of gender in therapeutic relationships in order to inform therapists of critical issues from clients' perspectives. To capture clients' views, the researchers chose an interpretive ethnographic design that used unstructured, collaborative interviews with clients who had worked with both female and male therapists. The interviews were analyzed using procedures developed by Kvale (1996), who emphasizes the importance of including the client's voice in data gathering, analysis, and final presentation. The results were reviewed with the clients to insure accurate presentation of their views. The final results were organized into six themes: client-therapist connection, male therapists, female therapists, topics discussed, effectiveness, and confounding factors. Researchers discuss the implications of gender-stereotyped behavior in therapy, the relationship between therapist gender and therapeutic alliance, and recommendations for practicing gender-sensitive therapy.     

Gender and conversational behaviour in family therapy and live supervision

The association between supervisors' and therapists' gender and the conversational behaviour of four supervisors, nineteen trainee family therapists and twenty clients before, during and after eighty-eight live supervisory phone in events were examined in this study. Clients' co-operation was not directly related to the gender of therapists and supervisors. The quality of supervisors' collaborative behaviour was highest for events in systems where male supervisors were supervising male therapists and lowest for events in systems where male supervisors were supervising female therapists. In systems containing female supervisors and male therapists, therapists engaged in frequent collaborative behaviour and less frequent teaching behaviour with their clients. The quality of therapists' collaborative and supportive behaviour was highest in these systems. The unexpected results of this study suggest that the way supervisors interact with therapists and therapists interact with clients does not conform to gender stereotypic conversational behaviour in which males are directive and females affiliative. It may be that individuals whose conversational behaviour does not conform to gender stereotypes decide to become family therapists or that family therapy training helps people develop alternatives to gender-stereotypical conversational behaviour.     

PSYCHOTHERAPISTS'KNOWLEDGE ABOUT AND ATTITUDES TOWARD SEXUAL ASSAULT VICTIM CLIENTS

The present research investigated the question of how therapists'attitudes toward sexual assault victims predict their inferences about and treatment of clients. In addition, this study asked the following questions: (a) What percentage of female psychotherapy clients have been victims of sexual assault? (b) What treatment approaches are therapists using with victims and what attitudes toward victims do these therapists hold? (c) On the average, which demographic groups of therapists hold the most positive views of victims and are the most knowledgeable about working with victims? The results of the study indicated that therapists who held negative attitudes toward victims were more likely to endorse victim-blaming themes and therapeutic treatments which blame victims for sexual assault. Of therapists'current female clients, 18.5% ( n = 257) had been sexually assaulted at some point in their lives. On the average, therapists were knowledgeable about working with victims and showed positive attitudes toward victims.     

Therapists' Use of Religious and Spiritual Interventions in Christian Counseling: A Preliminary Report

This study explored the use of religious and spiritual interventions in counseling by Christian therapists (N = 100). Use of religious and spiritual interventions correlated with personal religiousness and clinical training involving religious clients and religious and spiritual interventions. Course work involving either psychology or theology did not correlate with use of or self‐reported competency in using religious and spiritual interventions. Self‐reported competency was associated with personal religiousness; professional beliefs, attitudes, and values; personal experiences with counseling; and clinical training involving religious clients and religious and spiritual interventions. It is suggested that training programs incorporate clinical rotations, workshops, and supervision involving religious clients and religious and spiritual interventions to teach therapists to use religious and spiritual interventions in counseling.