The Health Maintenance Organization: II. Implications for psychotherapy.

Suggests that in an effort to make psychotherapeutic practice compatible with the benefit structure of the health maintenance organization (HMO), clinicians have modified various therapeutic practices, including goal setting, crisis management, the nature of the therapist–patient relationship, the timing and frequency of sessions, continuity and comprehensiveness of treatment, medical and nonmedical collaboration, the integration of pharmacology and psychotherapy, and termination. As a result, an "HMO" therapeutic orientation is emerging. A prototype of HMO therapy that combines features of the primary care model and the biodevelopmental model is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rights of clients, responsibilities of therapists.

Discusses ways in which ethical principles can be put into practice in the client–therapist relationship. Historically, ethical codes for therapists were drawn up to protect the professions from regulation by external agencies. Implicit in the ethical codes, however, is a model for the client–therapist relationship that fosters the goals of mental health. It is suggested that just as ethical codes have been given specific content in standards for providers of psychological services in human service facilities, ethical codes can be given specific content in the client–therapist relationship. It is recommended that therapists take responsibility for incorporating ethical standards into their practices so that clients' rights will be an integral part of therapy. Four illustrative situations are presented: providing clients with information to make informed decisions about therapy, using contracts in therapy, responding to clients' challenges to therapists' competence, and handling clients' complaints. (63 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Metatheoretical assumptions and psychotherapy orientation: Clinician attributions of patients' problem causality and responsibility for treatment outcome.

Investigated (1) the role of metatheoretical assumptions regarding clinicians' attributions of patient responsibility for problem cause and therapeutic change in contributing to similarities and dissimilarities in theoretical orientation and (2) the implications of these assumptions for clinical practice. 43 experienced clinicians with either psychodynamic, cognitive-behavioral, family-systems, or eclectic orientations participated. Two case vignettes served as stimuli in assessing Ss' conceptualization focus in clinical material, intervention strategies, treatment recommendations, and attributions of patient responsibility for problem cause and therapeutic change. Psychodynamic Ss diverged most from the other groups by attributing lower levels of patient responsibility for both problem cause and role in change. The other 3 orientations clustered together. In terms of clinical implications of the attribution of responsibility to patients, significant relations were observed with estimated costs of treatments recommended, areas of conceptual focus on case material, and types of interventions proposed. The assessment of attributions of responsibility for problem cause and treatment outcome is discussed as a meaningful area of research in the psychotherapeutic process. (8 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the basic ingredients of psychotherapy.

Presents a parsimonious statement of essential conditions for psychotherapeutic change: (a) a helping relationship patterned after the parent-child relationship, (b) the creation of a power base from which the therapist influences the client through common psychological techniques, and (c) a client who has the capacity to profit from the experience. It is asserted that the full range of common influencing techniques is inevitably brought to bear on any psychotherapeutic relationship, and this constitutes one of its defining characteristics. These conditions are equally applicable to psychoanalytic psychotherapy and behavior therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An integrative conceptual and organizational framework for treating suicidal behavior.

The current article provides an integrative conceptual and organizational framework for addressing suicidal behavior in clinical practice with 3 identifiable goals. The first goal is to provide a clinically accessible summary of treatment and assessment tasks (i.e., the content of therapy and assessment) consistent with existing standards of care and supported by empirical findings but not dependent on psychotherapeutic orientation. The 2nd goal is to summarize and discuss the uniformity and clinical implications of relevant process variables, as well as the complicating role of time and chronicity in assessment and treatment. The 3rd goal is to emphasize the varied roles, tasks, demands, and limitations of psychotherapy with suicidal patients. In general, the current article provides a flexible, yet comprehensive and thorough, template for treatment planning, risk assessment, patient management, and ongoing monitoring that is applicable regardless of the psychotherapeutic model employed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Differential treatment selection: The role of diagnosis in psychotherapy.

Outlines a 4-step model of disposition-based diagnosis in psychotherapy in which the role of diagnosis is only one of many patient, context, relationship, and technique variables that can be applied sequentially to select specific treatments. Certain nondiagnostic dimensions may allow clinicians to apply the best parts of different psychotherapeutic models and formats to maximize prediction from clinical assignments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapists' perceptions of stressful patient behavior.

Administered a 25-item Likert-type rating scale to a heterogeneous sample of 60 psychotherapists (mean age 38 yrs). Results indicate that Ss considered suicidal statements to be the most stressful form of patient behavior encountered in their practice. Factor analysis of the data revealed 2 general dimensions of stressful patient behavior: Psychopathological Symptoms and Resistances. The stress associated with each of these factors also varied significantly as a function of certain S background variables. A relatively high degree of stress engendered by premature termination of therapy was also found. This suggests that therapists are not simply detached observers of the psychotherapeutic process and are not likely to consider their patients as replaceable parts. Ss appeared to be personally as well as professionally invested in the emotional growth and welfare of individual patients. It is concluded that therapists must be sensitive to those particular sources of stress that affect them and the nature of the therapeutic relationship. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The psychotherapeutic relationship.

This paper attempts an exhaustive review of the literature on the psychotherapeutic relationship. The nature of the ideal psychotherapeutic relationship is defined and approximations of this ideal are shown to correlate positively with various measures of patient progress in the therapeutic enterprise. Other correlates of good therapeutic relationships are then explored: patient variables, therapist variables, therapist-patient similarity, and technique variables. In all these areas, significant correlations are found, though not as often as one might expect. The research on therapist variables is especially disappointing, while patient variables seem to be quite good predictors of the quality of the ensuring patient-therapist relationship. Methodological issues are considered throughout the paper. (72 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empathy and the working alliance: The mistranslation of Freud's Einfühlung.

Suggests that the working alliance has emerged as an important theoretical construct in both psychotherapeutic practice and research. A great deal of attention has been paid to the therapist's contributions to the working alliance, with empathy posited as a necessary condition for a strong attachment between patient and therapist. Although Freud has been recognized for laying the theoretical groundwork for what is called the working alliance, he has generally not been credited with making an association between empathy and the therapeutic relationship. It is demonstrated that in 1913, Freud did posit empathy (Einfühlung) as a necessary condition for the therapeutic relationship, and that this has been overlooked by English-speaking readers due to a translation error. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Responsibility and the elderly: Applications to psychotherapy.

Based on the analysis of P. Brickman et al (see record 1982-30315-001), 4 models of psychotherapy are proposed. It is argued that a key element in clinical interventions with the elderly is the extent to which the intervention affects the elderly clients' perceived responsibility for the cause of and solution to their presenting complaints. The dangers of a medical model psychotherapeutic orientation that strips clients' feelings of control are discussed. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The residential therapeutic caring community.

The residential therapeutic caring community (RTCC) for adolescents combines psychotherapeutic principles of the professional model and self-help concept of the therapeutic community by using the collective resources of members to mobilize peer pressure. The RTCC is a safe, structured, supportive treatment environment that employs a confrontation, teaching, interpretative, and reasoning approach and uses the psychotherapeutic principles of reality therapy and existential thought. In the RTCC, the staff serve as mentors and role models, and they demonstrate their concern by maintaining high expectations for immediate improved behavior. The personal qualities necessary for a psychotherapist working in an RTCC are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Approaches to informed consent

Informed consent (IC) is an indicator, or a pivotal point, in broader and more fundamental questions dealing with the way clinical experimentation and, more specifically, randomized controlled trials (RCTs) relate to routine clinical practice; the rules that characterize the doctor-patient relationship; the self-perception of medicine with respect to its capacity, duty, and autonomy in the production of new knowledge; and the role of medicine in society. The asymmetry of knowledge and power that characterizes the usual relationship between care providers and patients does not resolve when something experimental enters the relationship. The real world of clinical investigation is not uniformly distinct from clinical practice. Experimentation is more appropriately considered a continuum with respect to appropriate or recommended care. Fundamental patient rights come first and are more binding than compliance with procedures and regulations. The view that IC is the most important component of the "ethical" aspects of experimentation is highly misleading. The responsibility to foster well-informed decisions shapes the contents, the timing, the validity, and the credibility of IC. Documented, evaluable decisions are the natural substitute for individual IC when the patient is not able to handle information autonomously. Positive examples of IC practices and approaches suggest that IC may be important in improving the way medicine responds to its responsibilities and communicates with society.     

Catharsis in psychotherapy: A new perspective.

Reviews contemporary thinking about catharsis in psychotherapy, which is still dominated by J. Breuer and Freud's work with the cathartic method. Psychoanalysts view the fact that Freud abandoned catharsis as evidence of its ineffectiveness, while the emotive therapies developed in the 1960's returned to Freud's earliest view that neurosis results from repressed affect and can be cured by cathartic uncovering. Emotional memories continue to be thought of as foreign bodies lodged in the human psyche and requiring purgation. It is argued that this view divorces people from responsibility for their conduct and encourages a fractionation of human experience into feeling, thought, and action. It is proposed that catharsis is, instead, a label for completing a previously restrained or interrupted sequence of self-expression. It is accompanied by recovery manifestations of some sort, for example, tears or angry shouting. Implications of this view for psychotherapeutic practice are proposed, using examples of patients going through catharsis. It is concluded that therapists should allow catharsis as a means of helping patients discover their predilections, but should recognize this as a preliminary step. After blocked aspects of self have been discovered, then the patient must begin to claim responsibility for choosing more congruent actions and appropriate social expressions, thereby defining a richer, more satisfying existence. (60 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attribution of responsibility for onset of spinal cord injury and psychosocial outcomes in the first year post-injury.

Attribution questionnaires were administered to spinal cord injury patients during rehabilitation and at 1-yr (postinjury) follow-up in a prospective study of the relationship between attributions and psychosocial outcomes. Ss were also asked to complete life and family satisfaction scales prior to discharge and at 1-yr follow-up. A staff member reviewed chart data and rated the patient as an innocent victim or risk denier. Sample sizes for analysis varied (because of dropouts and missing data) from 80 to 104 primarily male patients. Results show that self-attribution of responsibility was associated with lower life satisfaction during rehabilitation, but this difference dissipated by 1-yr postinjury. Self-attribution of responsibility was not predictive of patient assessed family adjustment. It is concluded that staff assessment of patient responsibility for onset of injury is not predictive of outcomes even when congruence/incongruence between patient and staff attributions is examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A new role for psychology students in a medical setting.

Describes a 3-wk project in which psychology practicum students assumed primary responsibility for patient care on the psychiatric unit of a large medical center hospital. The project had interesting implications for issues related to clinical training and professional relationships. The pace was intense and demanding and students became totally involved in treating the patients and learning about themselves. Each student worked with about 7 patients primarily through group therapy and family counseling. It is felt that this training model was more likely to test the student's commitment to psychology and to solidify a professional identity than more traditional programs. The project was unique in that the only doctor-patient relationship that the patients had was with the psychology student. 2 physicians were available for medical consultation. Informal observations and analysis of rating scales filled out by the patients indicate that they valued highly the contribution of the students. It is concluded that current trends in medicine toward comprehensive care and family practice necessitate the physician's relinquishment of his exclusive relationship with the patient and to bring in nonmedical specialists on a peer basis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The place of informed consent in ethical dilemmas

Considers ethical questions raised by the psychotherapeutic treatment of a highly religious person to be specific instances of general issues in the conduct of psychotherapy. It is stressed that the therapist has a responsibility to insure that the consent of the client is obtained under conditions of full information. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the "folkloric" psychotherapy to schizophrenic patients--based on phenomenological study

Psychotherapeutic treatment of schizophrenia is generally considered difficult. One reason for this is that the doctor and patient can easily fall into a relationship of conflict with each other concerning the propriety of "judgments which are morbidly and mistakenly made (K. Jaspers)", referred to as delusions. We carried out close phenomenological structure-analyses of the delusions and of patients' fundamental experiences, based on the premise that a patient with delusions probably has some actual grounding for these in the patient's own concepts, considering the fact that the patient firmly believes these delusions. As a result, we have clarified the following matters from the primary experience of delusions. 1) We found that patients are in a conflicted mental condition which can be considered a collapse of adaptability to "Seken". 2) In this condition of conflict, patients feel guilt relative to "Seken" or feel that they are indebted and should be punished. When patients complained of their primary experience, we were able to persuade them to reserve their judgment of their primary experience, by 3) having each patient listen to the folktale "Torikuyou" in which the "logic of stealing" and the "logic of being stolen", appear in a reciprocal relationship relative to the constitution of crime and punishment, by 4) explaining to each patient about the ambiguity and reciprocity of reality experienced, 5) instead of disputing the propriety of patient's judgment about primary experience, doctor and patient worked together to enable the patient to form a positive understanding of the primary experience. 6) We reduced the patient's psychological conflict relative to primary experience, and were able to defuse and distance the patient's delusions caused by erroneous judgment of primary experience. 7) Regarding the area in which this type of psychotherapeutic approach shows efficacy, we analyzed the concept of "Seken" as a world which can cause conflicts relative to primary experiences. 8) We also analyzed "Giri" as a norm of "Seken" from which patients misconceive that they have deviated, in addition, 9) from the viewpoints of anthropology and cultural anthropology, we analyzed the bases for "Kotowaza (proverbs)" and "Monogatari (folktale)" such as "Torikuyou", which themselves can show psychotherapeutic efficacy. We consider that the psychotherapeutic approach has previously been developed around the concepts of the "individual" and "society", but we made our psychotherapeutic approach from the concept of "Seken" (yononaka = hito: person) that is a structure with deep strata of tradition and culture in Japan, and have reported its concrete development through the presentation of 3 typical cases of schizophrenia with difficulty in adapting to society due to showing the delusion of persecution in their foreground.     

Hope-focused practices during early psychotherapy sessions: Part I: Implicit approaches.

Hope is recognized as one of four key factors contributing to psychotherapeutic change across a variety theoretical approaches (Hubble, Duncan, & Miller, 1999), especially early in the psychotherapeutic sequence. To date little research has looked at how hope is translated into specific practices by psychotherapists during psychotherapy sessions. This case study employed basic interpretive inquiry (Merriam, 1998) to explore the hope-focused practices of five hope-educated psychotherapists with 11 clients early in the therapy sequence. Two categories characterize the overall findings, that is, implicit and explicit hope-focused practices. This first paper in a two-part research report focuses on implicit hope-focused interventions. Implicit hope-focused interventions were those practices identified by therapists as addressing client hope without employing the word hope explicitly. Implicit hope practices addressed two key aspects of therapy, (a) attending to therapeutic relationship, and (b) fostering client perspective change. The second paper in this series examines findings regarding explicit hope-focused interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapeutic outcome and reduction in medical utilization: A cautionary tale.

Studied the relationship between the offset effect and psychotherapeutic intervention. 22 psychotherapy groups studied were found to be finally composed of 32 therapy dropouts, 10 low changers, and 41 high changers. The total of visits to the health center and the cost of these visits were computed for each S. The data imply that dropouts—patients who might be considered as having the worst psychotherapeutic outcomes—also have the best medical offset outcomes. It is suggested that a single session or a limited number of sessions may have been enough to allow the dropout Ss to at least begin recovery. (23 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapeutic interventions with traumatically brain-injured patients.

Reviews personality disturbances that can occur after traumatic brain injury (TBI), including neuropsychologically based personality changes, emotional reactions to injury, and preexisting characterological styles. Denial, based in either psychological defensiveness or organic lack of awareness, presents a special rehabilitation problem that may be amenable to therapy. Psychotherapy following TBI is described, focusing on the use of the psychotherapeutic relationship, setting, rationale, and procedures. Psychotherapeutic techniques appropriate for working with TBI patients are noted, including cognitive-behavioral interventions, self-instructional training, dynamically oriented psychotherapies, and group psychotherapy. A comment by M. Rosenthal follows. (PsycINFO Database Record (c) 2010 APA, all rights reserved)