On wisdom

This article explores some of the features involved in making wise decisions in couples and family therapy. Delineating what qualities are involved in making wise decisions in life--so as to live the "good life" in the polis, and the necessary contributions of life experiences in this task--was first discussed by Aristotle. A major problem that therapists face today is that our society offers many different ways of living well--or for that matter, badly--and our theories do the same. Family therapy theories are not value free. I clarify that different family theories embody different values: clear boundaries, good attachments, the ability to communicate, and so on. If our theories foster certain values, then, as Isaiah Berlin has made clear, seeking to achieve a particular value leads to placing less value on another. The article concludes with some thoughts about values that therapists could appropriately follow in their work.     

CAN RATIONAL-EMOTIVE BEHAVIOR THERAPY (REBT) AND ACCEPTANCE AND COMMITMENT THERAPY (ACT) RESOLVE THEIR DIFFERENCES AND BE INTEGRATED?

Rational-Emotive Behavior Therapy (REBT) is a pioneering form of Cognitive Behavior Therapy (CBT). Acceptance and Commitment Therapy (ACT) is part of the new wave of CBTs. In this article, I discuss the papers of Ciarrochi, Robb, and Godsell, and of Ciarrochi and Robb, who propose that REBT and ACT can be quite suitably integrated, and the paper of Steven Hayes, the originator of ACT and of Relational Frame Theory, who is skeptical about the feasibility of Ciarrochi, Robb, and Godsell’s proposals. My own view is that ACT and REBT significantly overlap in their theory and practice and that they can be successfully integrated if both therapies make some changes.     

Reshaping Couple Configurations that Get in the Way of Relationship Repair and Healing

In the context of relationship trauma, partners' reactive patterns of engagement can disrupt and derail attempts at relationship correction and healing. A circumplex typology of couple patterns of engagement in relational trauma context is defined in terms of partners' underlying views of self in relation to other (VSIRO). VSIRO is conceptualized along a continuum anchored at opposite poles by inflated (self-aggrandizing) versus collapsed (self-abnegating) VSIRO, with a balanced (egalitarian) VSIRO, characterized by accountability and forbearance, as the target position. The circumplex model delineates four problematic couple configurations—a dejected couple, a taker–enabler couple, an ultimate fighting couple, and a debtor–collector couple. Where problematic engagement occurs, therapists need to reshape couple engagement toward the balanced, egalitarian position prior to relational trauma work. Clinical vignettes depict these couples and springboard an analysis of unique needs and interventions associated with each couple configuration. Reshaping couple patterns of engagement using a circumplex model of couple configurations is an essential prerequisite to effective and ethical relational trauma work.     

The Impact of Treatment Components Suggested by the Psychological Flexibility Model: A Meta-Analysis of Laboratory-Based Component Studies

An important aspect of psychotherapy research is the examination of the theoretical models underlying intervention approaches. Laboratory-based component research is one useful methodology for this endeavor as it provides an experimental means of testing questions related to intervention components and the change process they engage with a high level of control and precision. A meta-analysis was conducted of 66 laboratory-based component studies evaluating treatment elements and processes that are suggested by the psychological flexibility model that underlies Acceptance and Commitment Therapy (acceptance, defusion, self as context, committed action, values, and present moment), but also touches on a variety of contextual forms of cognitive behavior therapy. Significant positive effect sizes were observed for acceptance, defusion, present moment, values, mixed mindfulness components, and values plus mindfulness component conditions compared to inactive comparison conditions. Additional analyses provided further support for the psychological flexibility model, finding larger effect sizes for theoretically specified outcomes, expected differences between theoretically distinct interventions, and larger effect sizes for component conditions that included experiential methods (e.g., metaphors, exercises) than those with a rationale alone. Effect sizes did not differ between at-risk/distressed and convenience samples. Limitations with the meta-analysis and future directions for laboratory-based component research are discussed.     

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1–3 and one session from Sessions 4–7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18–0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.     

Client Versus Clinicians’ Standards of Clinically Meaningful Change and the Effects of Treatment Expectations on Therapeutic Outcomes in Individuals With Posttraumatic Stress Disorder

There is limited research on the concordance between client perceptions and clinician standards of the degree of symptom change required to achieve meaningful therapeutic improvement. This was investigated in an adult sample (N = 147) who received trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD). We examined whether clients’ benchmarks of change were related to actual outcomes and the relationship between client expectations and their treatment outcomes. Clients completed measures indexing the level of symptom reduction required (in their view) to reflect a benefit or recovery from treatment and treatment expectations. Actual PTSD severity was indexed pre- and posttreatment via self-report and clinician-administered interview. Results demonstrated that the amount of change clients said they required to experience a benefit or recovery was significantly larger than typical clinical research standards. Nonetheless, the majority of client benchmarks of change (79.7–81.8%) were consistent with clinical research standards of what constitutes benefit or recovery. Client benchmarks were generally positively correlated with their actual outcomes. Clients’ belief that treatment would be successful was associated with greater reductions in PTSD symptoms. These findings provide preliminary evidence that the standards used to determine clinically significant change are somewhat consistent with clients’ own perceptions of required symptom change.     

Applications of Collaborative Helping Maps: Supporting Professional Development,Supervision and Work Teams in Family‐Centered Practice

Collaborative, family‐centered practice has become an influential approach in helping efforts across a broad spectrum of human services. This article draws from previous work that presented a principle‐based, practice framework of Collaborative Helping and highlighted the use of Collaborative Helping maps as a tool both to help workers think their way through complex situations and to provide a guideline for constructive conversations between families and helpers about challenging issues. It builds on that work to examine ways to utilize Collaborative Helping maps at worker, supervisory, and organizational levels to enhance and sustain collaborative, family‐centered practice and weave its core values and principles into the everyday fabric of organizational cultures in human service agencies and government agencies that serve poor and marginalized families and communities.     

Intervenciones psicológicas para cuidadores con síntomas depresivos: revisión sistemática y metanálisis

It has been well determined that nonprofessional caregiving, which is a fundamental component of care to dependent persons, may lead to an increased risk for mental disorders in caregivers, especially depression. This paper sought to conduct a systematic review and meta-analysis to determine the efficacy of psychological interventions to reduce depressive symptoms aimed at nonprofessional caregivers. A comprehensive search of studies published from 1980 to 2013 was conducted in Medline and PsycInfo databases, as well as in the references of other reviews, meta-analysis and relevant book chapters, thereby shortlisting 13 papers. Although most of the interventions reached positive results in decreasing depressive symptomatology, their effects in general were moderate (ES = −0.49, 95% CI [−0.62, −0.36]). Important advances have been produced regarding the quality of the studies, but some limitations are still found which restrict the scope of their findings. It is necessary to conduct further studies that meet excellence standards and, more concretely, regarding indicated prevention of depression.     

The 'storied' helper: narrative ideas and practices in counselling and psychotherapy

This paper is intended as an introduction to the use of narrative ideas, languages and practices in counselling and psychotherapy. It explores the skills and knowledges that are involved in narrative ways of working for bothpractitioners and those who consult them. Counselling is understood as comprising a social process within a ‘storied world’. These ideas are illustrated through one particular ‘shortstory’. A narrative perspective enables us to consider the stories that are hidden as well as the stories that are privileged within the both contemporary cultural discourse and the professional discourses of counselling and psychotherapy.