A contextual behavioral approach to the role of emotion in psychotherapy supervision.

As behavior therapy expands to address problems related to private events, appropriate methods of supervision must be developed to train individuals to work with the full range of human experience, using a behavioral model. The authors suggest that therapists’ in-session emotions are an important source of information about the impact of clients’ behavior on others. Contextual behavior therapists may enhance their effectiveness in meeting clients’ needs by attending to the therapist’s own emotional responses. This paper provides a contextual behavioral rationale for including a focus on emotion in supervision, with a four-phase model for shaping early trainees’ ability to use their emotional reactions to facilitate therapy in a coherent manner. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists’ views on working with bilingual Spanish–English speaking clients: A qualitative investigation.

Through semistructured interviews, language switching in therapy was examined with 9 bilingual Spanish and English therapists. Therapists were asked about how and when they switched from one language to another during treatment, as well as the ways in which their clients’ switched languages. After the use of consensual qualitative research methods (C. E. Hill et al., 2005; C. E. Hill, B. J. Thompson, & E. N. Williams, 1997), the results revealed that therapists used language switching as a mechanism to establish trust, bond with clients, and promote disclosure through the use of specific phrases or specific words; particularly, the use of Spanish idiomatic expressions (dichos) served to engage, redirect, and increase client self-understanding and awareness. Therapists reported that their clients switched from English to Spanish when recounting experiences that involved certain emotions (e.g., anger) and represented themselves differently depending on the language they were speaking. Therapists also reported that their clients switched from English to Spanish to improve communication and to connect with them. Future directions for research and implications for training and practice are outlined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Harmful effects of posttermination sexual romantic relationships between therapists and their former clients": Erratum.

Reports an error in "Harmful effects of posttermination sexual and romantic relationships between therapists and their former clients" by Laura S. Brown (Psychotherapy: Theory, Research, Practice, Training, 1988[Sum], Vol 25[2], 249-255). Reference was made to the Minnesota law regarding reporting of "any sexual or romantic relationship in which the parties were once therapist and client" (p. 250). Upon further review by the author, it was determined that the law is more complicated than conveyed in the article. A detailed explanation of the law is provided in the erratum, although legal counsel is suggested for further interpretation. (The following abstract of the original article appeared in record 1989-02991-001.) Examines anecdotal evidence regarding the harmful effects of posttermination sexual or romantic relationships between therapists and clients, focusing on relationships between female therapists and former clients who are also women. The question of equality of power between therapists and former clients is addressed. The impact of these relationships on the community in which they occur is considered. It is concluded that posttermination relationships between therapists and clients have the potential to do as much harm as relationships initiated during therapy and that such relationships should be defined as unethical. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stages of therapist comfort with sexual concerns of clients.

Discusses the necessity for therapists in training to go through a process of examining their personal sexual beliefs and attitudes before they can be comfortable with the kind of sexual material brought up by many clients. The reactions of therapists in training to a course in which they use methods that are specifically intended to help them with the process of becoming comfortable with client sexual concerns are described. Feedback from students suggests that they go through at least 4 overlapping stages of comfort with the kind of sexual material that is likely to be presented by their clients. These stages are (1) an examination of their views and concerns about their own personal sexual issues, (2) increasing awareness and appreciation of problems and emotional reactions as the clients experience them, (3) a new freedom in discussing sexual matters, and (4) an awareness of a new level of comfort with clients and increased willingness to share sexual material. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy of the victims of massive violence: countertransference and ethical issues

Psychotherapy with severely traumatized patients is a long, draining process that often produces strong countertransference reactions. It is difficult to therapeutically and ethically handle these personal responses. We feel that at different stages in therapy different ethical principles should guide the therapy. At the early stages, fidelity and nonmaleficence should be the guiding principles. As trust and confidence develop, therapists may have more personal freedom to act; beneficence, i.e., providing specific confident care then becomes the primary ethical principle. In later stages of therapy, promoting the principles of autonomy and justice come into play. As therapy further progresses, therapists' own needs, the principle of self-interest, may be utilized in the therapeutic relationship. Throughout therapeutic contacts with traumatized patients, therapists need to monitor their own needs, and find appropriate ways outside of therapy to cope with these often intense feelings. Continuing to feel therapeutically competent and ethically grounded, yet maintaining the personal strength and balance to treat traumatized patients, pose major challenges for therapists.     

Therapist interventions and client emotional experiencing in expert psychodynamic–interpersonal and cognitive–behavioral therapies.

Eighteen sessions of cognitive–behavioral (CB) and 13 sessions of psychodynamic–interpersonal therapy obtained from experienced clinicians in a naturalistic setting were investigated to determine the various therapeutic interventions associated with high and low emotional experiencing (EXP). Clients receiving reflections and acknowledgments, affiliative and noncontrolling interventions, or interventions highlighting nonspecific client content were associated with maintained high EXP. Lengthier interventions and interventions rated as affiliative but moderately controlling were associated with shifts to low EXP. For clients of CB therapists, questions, interventions rated affiliative but controlling, and highlighting minimal emotional content were also associated with shifts to low EXP. Male therapists were associated with clients who maintained high EXP and female therapists were associated with clients who shifted to low EXP. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

First pregnancy: Therapeutic issues for both female and male psychotherapists.

Discusses the reactions of psychotherapy clients to their therapist's 1st pregnancy, including the stimulation of unresolved oedipal and early developmental conflicts, fear of rejection and abandonment, and separation anxiety. Intensification of a maternal transference, sexual identity issues, and maternal loss and deprivation issues, along with hostile fantasies toward the unborn child and envy of the therapist as a mother and a sexual and fertile person, may arise. The reactions of the female therapist to her pregnancy may include emotional changes related to hormonal fluctuations, fatigue, and a growing sense of physical vulnerability; distraction due to the kicking of the fetus; and reduced functioning as a therapist due to feelings of fear, anger, guilt, and confusion over leaving her patients. Despite the paucity of research into the impact of impending parenthood on male therapists, it is suggested that they may experience many of the same role changes and conflicts, emotions, and reactions experienced by female therapists. Two case vignettes are presented to illustrate patient and therapist reactions to pregnancy, and suggestions to help both therapists and clients prepare to deal with issues surrounding the pregnancy are offered. (12 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Remembering childhood sexual abuse: A national survey of psychologists' clinical practices, beliefs, and personal experiences.

A national survey of 1,000 psychologists, to which 223 responded, assessed professionals' clinical practices and beliefs about the treatment of adult survivors of childhood sexual abuse (CSA), personal CSA history, and the phenomenon of clients remembering CSA in therapy. Results indicated that over 25% of therapists reported using guided imagery, dream interpretation, bibliotherapy regarding sexual abuse, referral to sexual abuse survivors' group, and free association of childhood memories as memory retrieval techniques with clients who had no specific memory of CSA. However, the majority of therapists reported that they had not seen any cases of adult clients entering therapy with no memory of CSA and subsequently recalling abuse in the course of therapy. A personal history of CSA was not associated with most clinical practices related to treating sexual abuse survivors. The implications for training and establishing scientific standards of psychological practice are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Vicarious traumatization, spirituality, and the treatment of sexual abuse survivors: A national survey of women psychotherapists.

Should psychotherapists limit their clinical work with trauma survivors to avoid being traumatized themselves? Vicarious traumatization (VT—the symptoms similar to posttraumatic stress disorder and the disruption in cognitive schemas reported in clinicians who are exposed to the trauma material of their clients—was assessed in a national survey of 1,000 women psychotherapists. Therapists with higher levels of exposure to sexual abuse material reported significantly more trauma symptoms but no significant disruption of cognitive schemas. Spiritual well-being, a key area thought to be damaged by VT, was found to be higher for those clinicians who saw more sexual abuse survivors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A pilot study of psychotherapist trainees' alpha-amylase and cortisol levels during treatment of recently suicidal clients with borderline traits.

Psychotherapists often experience stress while providing psychotherapy, in particular when working with difficult presentations such as suicidality. As part of a larger study on the treatment of recently suicidal college students with borderline traits, 6 therapists in training collected their own salivary samples for alpha-amylase (AA) and cortisol (C) analyses immediately before and after sessions with 2 selected clients. On average, samples were collected for the same therapist–patient dyad throughout the year-long study to ensure that data reflected therapist responses across stages of treatment. Therapists also completed a working alliance questionnaire and rated perceived session difficulty immediately after each selected session. Contrary to expectations, therapists demonstrated elevated levels of stress as measured by AA and C at presession relative to postsession levels. Greater session difficulty was related to more pronounced declines in AA, whereas a stronger working alliance was linked to more pronounced reductions in C. Results suggest that physiological stress responses while working with recently suicidal clients with borderline traits occur primarily in terms of session anticipatory anxiety, whereas AA and C changes may be affected differently by factors such as session difficulty and working alliance. This is a pilot study, limited by its sample size, but the design, findings, and inclusion of physiological measures present an initial step in an essential line of research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Working with dreams in psychotherapy: What do psychoanalytic therapists report that they do?

Forty-seven psychoanalytic therapists completed a questionnaire about dream work. Overall, results indicated that therapists had very positive attitudes toward dreams, worked with their own dreams, sought out dream training, and felt competent working with dreams. Therapists estimated that they worked with dreams with about half of their clients about half of the time in psychotherapy. They were most willing to work with dreams when clients had recurrent or troubling dreams or nightmares, were psychologically minded, were seeking growth, were interested in dreams, and were willing to work with dreams. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beneath the surface of long-term therapy: Therapist and client report of their own and each other's covert processes.

Therapists and clients reported on their own and their perceptions of each other's covert processes in long-term therapy. Therapists had a match rate of .45 for client reactions, with therapists rating match on therapeutic work reactions as helpful. Although 65% of clients left somethimg unsaid (primarily because of avoidance), only 27% of therapists were able to match what clients left unsaid. Of the clients, 46% had secrets (often sexual), primarily because of shame or insecurity. Clients had a match rate of .50 for therapist intentions, with therapists rating match on exploratory and restructuring intentions as helpful and both clients and therapists rating match on assessment intentions as not helpful. Thus, awareness of the other's covert processes had an effect on therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Maintaining the Safe and Effective Therapeutic Relationship in the Context of Distrust and Anger: Countertransference and Complex Trauma.

Prior research has shown that anger is a prominent feature in the psychopathology of trauma survivors. This hostile reactivity can be difficult for clinicians, who must balance instruction or interpretation designed to teach clients appropriate ways to handle anger and judicious withholding of response to maintain the therapeutic alliance for other purposes. Unlike studies that ask therapists to report their own mistakes, this research centers on advice given by 132 interview participants who had completed long-term trauma therapies. Clients generally reported greater satisfaction with trauma clinicians who were emotionally disclosing after angry episodes and who took partial responsibility for disagreements in therapy. Outcomes and satisfaction tended to be poor if therapists were "blank screens" in the face of anger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Emotion-focused therapy: Coaching clients to work through their feelings.

Reviews the book, Emotion-focused therapy: Coaching clients to work through their feelings by Leslie S. Greenberg (see record 2002-00066-000). This book was written for both novice therapists who have had little experience working with emotions in treatment, as well as for experienced therapists looking to systematize their understanding of how emotional change works. The book is divided into four parts. Part I examines the nature and function of emotions. Part II examines the first part of emotional coaching--arriving at emotion. Part III examines the second part of emotional coaching--leaving emotion. Finally, Part IV examines the application of emotion-focused therapy to the problems of living, in the context of individuals, couples therapy, and parenting. This book offers a wealth of therapeutic techniques and theoretical principles about the process of change. As such, it is an important and natural companion to seminal works in cognitive behaviour therapy and interpersonal therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing vicarious traumatization of mental health therapists: Identifying protective practices.

This qualitative study identified protective practices that mitigate risks of vicarious traumatization (VT) among mental health therapists. The sample included six peer-nominated master therapists, who responded to the question, “How do you manage to sustain your personal and professional well-being, given the challenges of your work with seriously traumatized clients?” Data analysis was based upon Lieblich, Tuval-Mashiach, and Zilber’s (1998) typology of narrative analysis. Findings included nine major themes salient across clinicians’ narratives of protective practices: countering isolation (in professional, personal and spiritual realms); developing mindful self-awareness; consciously expanding perspective to embrace complexity; active optimism; holistic self-care; maintaining clear boundaries; exquisite empathy; professional satisfaction; and creating meaning. Findings confirm and extend previous recommendations for ameliorating VT and underscore the ethical responsibility shared by employers, educators, professional bodies, and individual practitioners to address this serious problem. The novel finding that empathic engagement with traumatized clients appeared to be protective challenges previous conceptualizations of VT and points to exciting new directions for research, theory, training, and practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists' experiences treating Asian American women with eating disorders.

How do psychologists treat eating disorders (EDs) and subclinical issues in Asian American women in a culturally competent manner? Disordered eating and body dissatisfaction are so common in women that most therapists work with the issues to some degree, and it is increasingly likely they will see women of color. Asian American women are at significant risk and yet little treatment literature exists. Twelve therapists with experience in ED treatment were interviewed about their work with Asian American women. Grounded theory and consensual qualitative analysis methods were used to analyze the data, resulting in two central domains of conceptualization within the cultural context and treatment approach. Therapists reported that their clients were mostly first- and second-generation Americans who experienced acculturation stress and cultural conflict, particularly with elders. Other results suggested therapists perceived a strong connection between clients' desires to be thin and successful, and clients' efforts to conform to traditional Asian cultural values and fit in with U.S. mainstream culture. Therapists emphasized the cultural contextualization of family dynamics, developmental processes (e.g., individuation), and intergenerational conflicts. They viewed EDs as providing clients with culturally congruent coping strategies to affectively disconnect and to express distress. Treatment themes centered on psychoeducation and the importance of including parents in the treatment of their adult daughters. Helping clients navigate autonomy within the family and cultural context, and challenging clients and parents on the cultural (both Asian and mainstream U.S.) pressures regarding achievement and beauty were particularly important. Implications for therapy are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)