Successful psychotherapy

This paper develops an existential explanation for the position that different psychotherapeutic modalities enjoy comparable success rates. The explanation provides necessary and sufficient conditions for a successful outcome, related to the actualization level of both client and therapist, and is shown to imply equal theoretical probability of success across modalities.     

The Non-Indian Therapist Working with American Indian Clients

Abstract

The lack of success non-Indian therapists have had in working with American Indian clients has perpetuated a repetitive cycle of poor mental health services with this population. Although we cannot change the historic distrust that exists, we can begin to understand cultural differences and how they can impact treatment to obtain positive results. Acknowledgment of these differences can promote trust, a core ingredient that must be established between the client and therapist. This paper offers guidelines to assist the non-Indian therapist in working with the American Indian client.     

Diagnostic judgments as a function of client and therapist race

The purpose of the present investigation was to examine the process of differential evaluation of clients as a function of client and therapist race. It was hypothesized that race of client and therapist would interact, influencing the judgments of client psychopathology, appropriateness for therapy, verbal facility, and likelihood of treatment success despite standardization of the clinical stimuli. Graduate students in clinical psychology and with varying levels of training (i.e., 1 to 5 years) were asked to rate videotaped interviews of clients in which race of the client and level of psychopathology (i.e., normal, neurotic, and psychotic) were systematically varied. There were significant differences in ratings as a function of race of client, race of therapist, and level of psychopathology observed. Black clients were not rated differently on degree of psychopathology but were rated as less verbally skilled and less appropriate for treatment but more likely to benefit from treatment than white clients. Contrary to expectations, white therapists tended to underrate the pathology of black clients. On the other hand, black therapists tended to overrate the pathology of white clients and made mixed judgments of black clients. The implications of these findings are discussed.This study was supported in part by NIMH Research Centers in Minority Institutions (RCMI) Grant G12RR03206-2.     

Therapist responses to requests for disclosure of therapeutic records: An introductory study

This paper describes a questionnaire survey of therapists in the UK who have been subject to requests for disclosure of client records as part of a legal process. Therapist responses are outlined in terms of the perceived effect of such disclosure on the client, therapist and the therapeutic relationship. Negative effects included the experience of exposure of sensitive client material in an adversarial legal system, of powerful emotional responses by therapists, and a sense of feeling professionally de‐skilled in an unfamiliar and often challenging legal environment. Positive effects for the client included the achievement of valued outcomes such as compensation, and, for the therapist, the facilitation of support for the client in this process. These findings are discussed in terms of a contrast between therapist perceptions of consensual and contested disclosure. In the former, therapist and client are in agreement about the restorative value and outcome of disclosure. In contested disclosure, the process is experienced as disrupting therapeutic privacy, undermining professional self‐confidence and introducing an unwelcome element of critical re‐evaluation of client motives for undertaking therapy.     

The Therapeutic Alliance: Implications for Therapeutic Process and Therapeutic Goals

Interest in the importance of the therapeutic alliance to the psychotherapeutic process has recently grown across theoretical domains. Through a case example the author demonstrates that in some cases a familiar pattern of relating with the therapist may be more important for the client in terms of treatment success than positive regard early in treatment. Also, charting shifts in the quality of the relationship rather than quantitative changes in the alliance may help the therapist navigate the recursive emergent properties of relationship, goals of treatment and choice and timing of interventions. Finally, the author suggests that the therapist’s internalization of the client may represent a significant leap in the relationship, and help reduce some of the “sloppiness” that is inherent in the therapeutic process.     

Therapeutic Relationship

This article addresses the important role of the therapeutic relationship in cognitive-behavioral therapy (CBT). As has been noted from the inception of CBT, there are critical features of both the therapist and the relationship that optimize the likelihood of therapeutic success, and this article briefly describes these features. It is further argued that a successful therapeutic relationship in CBT is not static but is flexible and adaptive both across and within clients, as their needs and concerns vary. A positive therapeutic relationship is viewed within CBT as a necessary but insufficient condition for change, as the relationship serves as a foundation upon which interventions are scaffolded, but that the client’s response to various interventions itself shapes the interactions between therapist and client. Finally, it is argued that the key therapeutic ingredients of CBT are largely teachable, and the article provides several suggestions to promote an effective therapeutic relationship in CBT.     

Therapist activities preceding therapy setbacks in a poor-outcome case

Progress in psychotherapy is typically irregular, as advances alternate with setbacks. This study investigated the therapist’s activities prior to two main types of setbacks, one involving the client following therapist proposals and one involving the client failing to follow from therapist proposals, in the case of a poor-outcome client treated with a linguistically-oriented kind of cognitive therapy. Setbacks were defined as decreases of at least one level on an index of therapeutic progress, the 8-level Assimilation of Problematic Experiences Scale (APES), in adjacent client passages. Therapist activities were coded in 361 setback episodes that each included a client pre-setback passage, a therapist passage, and a client setback passage; both client passages had been previously rated on the APES. The main categories of therapist activities showed distinctive patterns in relation to the two main types of setbacks, the therapeutic zone of proximal development and the balance strategy. The two main patterns were described as an exploratory and a challenging configuration. These patterns of therapist activities and setbacks showed how the therapist seemed to persevere with approach-guided interventions while this poor-outcome client continued to have setbacks to low APES levels.     

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.     

The therapeutic alliance in adolescent substance abuse treatment: a one-with-many analysis

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes.     

Premature termination as a function of intake data based on ethnicity, gender, socioeconomic status, and income

Although it is acknowledged that premature termination is detrimental to the therapy process, there is limited information on how to utilize client demographic data to indicate which clients have greatest potential to prematurely terminate. The study assessed how client ethnicity interacts with client gender, therapist gender, therapist ethnicity, and client socioeconomic status (education and income) to affect premature termination. The study consisted of 527 cases which received therapy services from the Auburn University Marriage and Family Therapy Center from October 1993 to October 1999. The three definitions of premature termination used were termination after one session, prior to six sessions, and by therapist report. Results indicated that interactions of client income and ethnicity and therapist gender and ethnicity were the most useful demographic data indicators of premature termination.     

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.     

Therapy Outcomes: Client Perception and Similarity with Therapist View

This study examined clients' perceptions of therapy outcome and how those perceptions related to therapist views. Additionally, the effects of client and therapist gender and ethnicity, and the match on these variables (e.g., female therapist-female client) were examined. Results showed that clients generally improved from both the client and therapist perceptions, although therapists' views were influenced by client ethnicity. There was no difference between gender or ethnicity matches on perception of outcome. Further examination showed that gender and ethnicity interacted to influence both client and therapist perceptions of outcome. The authors discuss the research and practice implications of these findings.     

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.     

Therapeutic popularity and personality: Association between peer therapist nominations and the “Big Five” personality factors

The “Big Five” personality factors of three groups of psychology students differing in popularity as therapist among their peers were compared (n=33). In agreement with earlier research, popular therapists are “agreeable”, “conscientious” and “stable”. However, popular therapists are not “surgent/extravert” and especially not “dominant” and “talkative”. No support was found for the hypothesis that similarity in “agreeableness” or dissimilarity in “surgency” (the complementarily hypothesis derived from interpersonal theory) predicts therapist popularity. However, similarity between client and therapist in “stability” was predictive of nominations for therapist. On the assumption that therapist popularity predisposes good therapeutic alliances, the results indicate that therapists agreeableness, conscientiousness and emotional stability are relative to success in therapeutic interventions.     

Finding God in the Silence: Contemplative Prayer and Therapy

In this paper the author shares some of his experiences of using silence in therapy. He presents one of the modes of practicing silence, namely the meditation technique known as Contemplative Prayer, and shows advantages of using this technique in the process of self-purification and self-balancing of the therapist. The author stipulates that silence is a royal way to discovering God. Finding this divine particle within oneself and client changes the whole outlook of therapy. The therapist is no longer alone with the client, but God becomes an active participant in the therapeutic process through His love for both therapist and client.     

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.     

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.     

Therapist response modes in the exploration stage: timing and effectiveness

In an investigation of the exploration stage of single counselling sessions with 26 anxious female volunteer clients and 13 female doctoral student therapists, no overall association was found between client narrative processing modes and subsequent therapist verbal response modes. There was evidence in a third of the sample for an association between therapist response modes and subsequent client narrative modes, such that clients used more internal than external or reflexive narrative processing modes when therapists used open questions about feelings and reflections of feelings. Client and therapist helpfulness ratings did not differ for different therapist response modes or client narrative process modes. Hence, overall results suggested that all four therapist response modes (open questions about thoughts, open questions about feelings, restatements, reflections of feelings) are effective during the exploration stage.