Constructing desirable identities--self-presentation in psychotherapy and daily life: comment on Kelly (2000)

A. E. Kelly's (2000) thesis that psychotherapy clients benefit from withholding negative information is considered in light of current social-psychological theory and research. Positive illusions about oneself are associated with indexes of mental health; this is consistent with treating therapy as positive identity development. Self-presentation can shape self-concept, even apart from the feedback that an audience might provide; the social construction of identity is a powerful process, suggesting that withholding negative and presenting only positive information is adaptive. However, evidence concerning the level of identification of one's actions suggests complexities in understanding ways clients might deal with disclosing negative information; the authors argue that the impact on self-concept is probably more complex than A. E. Kelly's characterization and that the implications are of a broader scope than indicated so far.     

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.     

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.     

Helping construct desirable identities: a self-presentational view of psychotherapy

The author reviews the research demonstrating not only that clients withhold personal information and reactions from their therapists but also that such discretion is associated with positive therapy process ratings and outcomes. These results run counter to traditional approaches to psychotherapy, which demand a high degree of openness from clients. These puzzling findings can be explained by conceptualizing psychotherapy as a self-presentational process, wherein clients come to benefit from therapy by perceiving that their therapists have favorable views of them. Creating these favorable impressions can involve clients' hiding some undesirable aspects of themselves from their therapists. The author offers findings from the psychotherapy and social-psychology literatures in support of this view and makes suggestions concerning what clients and therapists might optimally reveal in therapy.     

The effects of feedback self-consistency, therapist status, and attitude toward therapy on reaction to personality feedback

Individuals' reactions to interpersonal feedback may depend on characteristics of the feedback and the feedback source. The present authors examined the effects of experimentally manipulated personality feedback that they--in the guise of therapists--e-mailed to participants on the degree of their acceptance of the feedback. Consistent with Self-Verification Theory (W. B. Swann Jr., 1987), participants accepted feedback that was consistent with their self-views more readily than they did feedback that was inconsistent with their self-views. Furthermore, the authors found main effects for therapist's status and participant's attitude toward therapy. Significant interactions showed effects in which high-status therapists and positive client attitudes increased acceptance of self-inconsistent feedback, effects that were only partially mediated by clients' perceptions of therapist competence. The present results indicate the possibility that participants may be susceptible to self-concept change or to self-fulfilling prophecy effects in therapy when they have a positive attitude toward therapy or are working with a high-status therapist.     

Client concealment and self-presentation in therapy: comment on Kelly (2000)

The authors disagree with A. E. Kelly's (2000) conclusions that clients conceal things from therapists primarily for self-presentational reasons and that client concealment is positively related to positive therapy process and outcome. They also disagree with A. E. Kelly regarding the implications of self-presentation theory for therapy. Their review of the research suggests that clients do not conceal much from therapists, that what they do conceal involves many different kinds of information hidden for many different reasons, that therapists have wide variability in being able to detect hidden client material, and that the relationship of client concealment and therapist awareness of client concealment with therapy process and outcome is not clear. Finally, the authors discuss their views about implications of client concealment and self-presentation for therapy.     

'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.     

Writing in therapy: a participatory approach

This paper explores the potential of writing with rather than to or about clients, an approach which may foster new responses to clients' dilemmas in the face of institutional, cultural, ethnic, class and gender discrimination. A selective review of literature about writing in therapy and vignettes from my own work in a community mental health clinic support this enquiry. Some implications for training are also addressed.     

Assessment feedback integrating MMPI-2 and Rorschach findings

Many clinicians are committed to giving feedback to clients about assessment results, but puzzle over how to integrate Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Rorschach findings when talking to clients. When the two tests agree, findings may be combined and assessors may use the language of clients' Rorschach percepts to frame findings from the MMPI-2 or the Structural Summary. When the Rorschach shows more disturbance than the MMPI-2, assessors may discuss "levels of personality," praise clients for their usual coping mechanisms, and raise the possibility of underlying problems. When the Rorschach depicts less psychopathology than the MMPI-2, clinicians may talk with Clients about factors influencing them to present as needing help. Alternatively, assessors may hypothesize that clients constrict emotionally in interpersonal, unstructured situations.     

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.     

A qualitative understanding of reflective-teams II: Therapists' perspectives

A research team developed and asked questions to a reflective-team about their clinical practice. The purpose of the questions was to better understand reflective-team members' experiences, beliefs, and aspirations. A participant/observation methodology was used in formulating the questions to the therapists. Therapists stated that reflective-teams were valuable in resolving impasses, developing multiple perspectives on clients' problems, and encouraging interaction among team members, but were problematic if clients were unaccustomed to team practice or if there were physically too many people in the interviewing room. Therapists believed that reflective-teams as a team practice was not practical in typical practice settings.     

A discourse analysis of power in relation to PSYCHLOPS (Psychological outcome profiles) in the context of CBT for psychosis

Aims: Outcome measures (OMs) and routine change measurement have developed dramatically in psychological therapies over the last two decades and some therapists have expressed concerns that this, depending on how it is handled by the parties involved, can markedly affect the therapy. However, little research has investigated this. It therefore seemed timely to explore discourses of OMs drawn upon by both parties in the therapy room. Method: PSYCHLOPS (Psychological Outcome Profiles) is a client‐centred measure which offered an opportunity to explore how therapists and clients receiving CBT for psychosis talked about OMs. A useful contrast was provided by the CORE‐OM (Clinical Outcomes in Routine Evaluation‐Outcome Measure). The discourses drawn upon by clients (n=4) and therapists (n=4) were analysed, informed by a Foucaultian framework. Results: OMs were constructed as empowering or disempowering of clients, as being able to do therapeutic work of engagement and containment, and as part of the apparatus of service power, positioning therapists as relatively powerless to question their use. Discussion: It is suggested that client‐centred measures like PSYCHLOPS, although partly aligned with a recovery framework, may become part of top‐down state and service power, and there is a need for more research into the different ways in which OMs are used in therapy and the impacts on therapists, clients and their relationships.     

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.     

Clients' treatment expectations at a community mental health center

Clients' expectations about mental health care, particularly differences in these expectations as a function of social class, and the relationship of discrepancies between expectations and perceptions to treatment outcome, is examined in this study with 317 Caucasian clients. In contrast to the majority of studies, no differences in treatment expectations relating to clients' social class, sex, or marital status were found. Nor were discrepancies related to course or outcome of therapy. Discussion focuses around explanation and interpretation of these findings. Particularly relevant is the need to determine the extent to which nonusers in the community share the attitudes and expectations of clients.     

Construct validity of the MMPI-2 College Maladjustment (Mt) Scale

The construct validity of the MMPI-2 (Minnesota Multiphasic Personality Inventory-2) College Maladjustment (Mt) Scale was examined using 376 student clients at a university psychological clinic. A principal components analysis and correlations of Mt scale scores with clients' and therapists' ratings of symptoms and functioning showed that the Mt scale identifies the presence of maladjustment as defined in terms of depressive and anxious symptoms. There is no evidence to show that the scale is specific to college students or that it is sensitive to severe psychological disturbance. The Mt scale does not inform the clinician as to why a person is distressed. In addition, there is no evidence from this study to suggest the superiority of the Mt scale over other MMPI-2 maladjustment measures. Therapists should use the entire MMPI-2 profile, not just the Mt scale, to gain the most comprehensive and specific understanding of clients.     

Managing resistance in cognitive behavioural therapy: the application of motivational interviewing in mixed anxiety and depression

While cognitive behavioural therapy is highly effective in the treatment of anxiety and depression, a substantive number of individuals either refuse treatment, fail to respond to treatment or respond only partially. Arguably, ambivalence about change or about engaging in treatment tasks may in part be related to incomplete recovery rates in cognitive behavioural therapy. Motivational interviewing is a client-centred, directive treatment originally developed in the addictions domain whose goal is to enhance motivation for change by understanding and resolving ambivalence. This method has consistently received support for enhancing outcomes in the addictions domain, particularly when used as an adjunct to further treatment. As yet, motivational methods have not been generalized to the treatment of prevalent mental health problems, such as anxiety and depression. The present paper presents the application of a treatment targeting motivation (motivational interviewing adapted for anxiety and depression) to the management of resistance in cognitive behavioural therapy for 3 clients with mixed anxiety and depression. Motivational interviewing is conceived as an adjunct to highly effective traditional cognitive behavioural therapy methods, which is indicated for use with clients resistant to and significantly ambivalent about change-based techniques for managing anxiety or alleviating depression.     

Aspects of the Client's Conscious Control of the Psychotherapeutic Process

An analysis is made of the opening moments of dialogue between and a client and her therapist in the light of the client's commentary given during an Interpersonal Process Recall interview about the moments. These moments are drawn from a study of 14 clients' reports on their experiences of therapy, thus particularizing the general understanding derived in the larger project. This passage of dialogue was chosen because the client's commentary revealed that, in the brief space of time involved, she had exerted control in terms of the three main relationships as experienced by all clients in the larger study: the relationship with the self, the therapist, and the therapist's techniques. Such control is understood to be an expression of clients' reflexivity, defined as self-awareness and agency within that self-awareness. The understanding that there is an agential involvement in reflexivity is based on both the participants' reports and the author's examination of his own consciousness. The study is discussed in terms of clients' covert experience of therapy and ways of gaining greater access to the unspoken in order to facilitate the working alliance.     

Emotions in solution-focused therapy: a re-examination

This article re-examines whether and how emotions are an aspect of solution-focused therapy. A major theme in the article focuses on the usual ways that therapists define and discuss emotions in solution-focused and other therapies. We argue that these discussions are a source of much confusion about emotions and about solution-focused therapy, including the confusing idea that emotions are neglected in solution-focused therapy. The second major theme describes an alternative approach to these issues, one that we believe better fits with the assumptions and concerns of solution-focused therapy. The approach is based on Wittgenstein's writings about language games, private experience, and how emotions are rule-following activities. Viewed from this perspective, solution-focused therapists take account of their clients' emotions by helping clients to create new emotion rules to follow.