‘Bad Therapy’ as a Training Technique: An Empirical Analysis

The purpose of the present study was to gather empirical data to examine the usefulness of an intriguing training technique called “bad therapy”. The technique, developed by Lang (1980, 1982), is utilized in a role-play setting for experienced therapists who are having difficulty with specific clients showing little improvement. The therapist is instructed to disregard his or her usual style of treatment, and instead, within a role-play format with a colleague who plays the part of a client, to try an alternative style of treatment. This new treatment, termed “bad therapy”, instructs the therapist to try to make the client worse rather than better. Interestingly, reports from both the role-play therapist and client indicate that the “bad therapy” session was considered more beneficial than the therapist's usual mode of treatment. As well as empirically investigating Lang's assertion, the present study also attempted to look at different perspectives of bad therapy. Is “bad therapy” a directive to be harmful and destructive, or is it a suggestion to be more daring and to take more risks? Subjects were 56 therapists who formed twenty eight pairs of therapist-client dyads. First, each pair conducted a “session” where the therapist performed his or her typical therapy. Then, therapists in one group (N= 11) were given directives to try to make their clients worse rather than better (“destructive” set), while therapists in another group (N=11) were told to say and do things that they wished to, but never dared (“daring” set). Finally, six therapists were told to simply repeat their usual type of therapy (“control” set). Results indicated that clients perceived the destructive and daring groups differently with the daring group being perceived more favourably, yet more authoritarian. Similarly, therapists perceived the daring and control groups more positively than the destructive group. The results are discussed in terms of training techniques and current trends in psychotherapy.     

Therapists’ Assessment and Treatment of Internet Infidelity Cases

In this study, we investigated through an Internet survey of 508 practicing marriage and family therapists which treatment decisions varied by gender of the client and background variables of therapists. The subjects responded to several typical Internet infidelity scenarios. We varied the gender of the person initiating the infidelity for half of one sample. We also asked the family therapy participants to respond to how they might assess and treat each presenting problem. They also evaluated problem severity, prognosis of the case, number of sessions necessary for treatment, and the extent to which a therapist would focus individually or relationally. Results indicate that there were differences in how therapists assessed and treated clients based on client gender, therapists’ age, therapists’ gender, how religious therapists reported they were, and the extent of therapists’ personal experience with infidelity.     

Health Care Providers' Experiences with Problem Gamblers

The purpose of this study was to document health care providers' awareness of problem gambling and frequency of recognition and treatment. An exploratory survey was designed to collect data on awareness and knowledge of problem gambling. A structured questionnaire was completed anonymously by 180 health care providers (nurses, physicians, social workers, and other allied health professionals). Almost all respondents (96%) reported knowledge of problem gambling, and 30% reported asking clients about gambling problems when they presented with stress related symptoms. A third of the respondents reported identifying and treating clients for a gambling problem. The most frequently reported intervention was referral to counseling and other gambling resources. Respondents were generally interested in learning more about gambling problems, particularly those providers who have had a client discuss gambling related concerns. There were no significant differences in findings between provider groups.     

“If I Can Grapple With This I Can Truly Be Of Use In The Therapy Room”: Using The Therapist's Own Emotional Struggles To Facilitate Effective Therapy

This study premises that self‐of‐the‐therapist work is pivotal in the development of effective therapists. However, therapy models vary in their goals for this work and the means of accomplishing them. This study presents the perspective of the person‐of‐the‐therapist Training (POTT) model that prioritizes the ability to consciously and purposefully use the self‐as‐is at the moment of contact with the client over the traditional goal of therapists working to resolve their issues. A key underlying assumption of the model proposes that therapists' core issues (referred to as “signature themes”) are potent resources that can be tapped into to connect, assess and intervene effectively with clients. The study presents the model and illustrates the use of signature themes in clinical work.     

Correlates of Clients’ emotional and Behavioral Responses to Treatment Termination

This study investigates the associations between clients’ emotional and behavioral responses to treatment termination and eight sets of indepentent variables, covering the source of termination (client, therapist, external source); the termination process (speed, centrality, control, choice, and desire), and the perceived outcome (failure, goal achievement) of the therapy. Subjects were 92 student therapists and 40 professional therapists, who reported on their clients’ perceptions, experiences, and responses. All the variables examined were associated with one or another client response. The findings support the view of treatment termination not only as a loss experience but also as a transition. They highlight the need for therapists to pay careful attention to both the source and the process of treatment termination.     

Partners in the Spiritual Dance: Learning Clients’ Steps While Minding All Our Toes

We present four case illustrations highlighting the complex interplay of therapists’ and clients’ spirituality in therapy. Complexity, in these cases, results from (a) degrees of similarity and difference, both real and perceived, between clients’ and therapists’ spiritual beliefs and practices; (b) degrees of spiritual disclosure; (c) characteristics of the therapeutic relationship; and (d) geographic and cultural influences. Practicing therapists and therapist training programs can benefit from addressing how therapist and client spirituality intersect and influence therapy, how both similarity and difference present obstacles and opportunities, and how ambiguity and assumptions can contribute to misunderstandings. We believe that both the therapist’s and the client’s spiritualities are key influences in therapy that can contribute to the frustration, and the growth, of clients and therapists alike.     

The Pregnant Therapist: A Qualitative Examination of the Client Experience

This article reports on the findings of a qualitative study that was designed to capture the clinical dynamics that emerge when a therapist becomes pregnant during treatment. While there have been some empirical studies that have captured the pregnant therapist’s perspective, it is a sparse amount in comparison to the vast number of women therapists who become pregnant, and there have been no studies that have actually interviewed clients of pregnant therapists. This study seeks to begin to redress that crucial missing perspective by interviewing the clients of pregnant therapists, as well as first-time, formerly pregnant therapists. This article will look at the coded results of this qualitative study and the emergent themes from the client perspective, as well as discuss their implications for clinical social work practice.     

AN EXPLORATION OF THE THERAPEUTIC RELATIONSHIP AND COUNSELLING OUTCOMES IN A PROBLEM GAMBLING COUNSELLING SERVICE

This study examined the relationship between a number of counselling process variables thought to influence counselling outcomes in a sample of 150 clients undertaking short‐term counselling in the state‐wide government funded Gambler's Help problem gambling counselling services in Victoria, Australia. Factors measured included psychosocial well‐being of clients prior to and after counselling, client readiness to change, self‐reported gambling activity levels before and after counselling, self‐assessment of current gambling behaviour, strength of therapeutic alliance, self‐reported counselling outcomes achieved in the area of symptoms, life matters, and related problems and a measure of client satisfaction with the service. The therapeutic alliance was found to have the strongest predictive power with respect to the level of problem resolution achieved by clients across all but one of the problem areas. The implications of these findings for clinical social work practice and education of practitioners are noted.     

Client Evaluations of Therapeutic Processes and Outcomes in a University Mental Health Center

Abstract

Evaluations of therapeutic processes and outcomes by clients, therapists, and independent third parties are all important dimensions in an overall system of accountability for a college mental health facility. This study focused on client evaluation. All clients (N = 287) who used mental health services in a large midwestern university during a two-week period completed an evaluative questionnaire. In contrast to previous satisfaction studies that focused on overall satisfaction, this study examined specific therapist and client tasks and their relationship to outcomes. The findings indicate that different types of client evaluation items yield somewhat different results. Those specific evaluation items have varying relationships with overall measures of client satisfaction and problem improvement. The study also pointed to the importance of looking at sex differences in client evaluations of therapy and at differences among therapists in their relative success in working with clients with differing problems.

“The Diagnosis of Testicular Torsion,” Bruce E. Haynes, Howard A. Bessen, and Vital E. Haynes. Prompt diagnosis of testicular torsion remains difficult. Since warning symptoms occur in one third of patients and salvage rates correspond to the interval between symptom onset and operation, higher salvage rates should be achievable. Separating torsion from epididymitis is complicated by overlapping ages of peak incidence, shared symptoms, and the need for rapid distinction of the two. Doppler studies (88% accuracy) and nuclear scans (95% accuracy) help confirm the diagnosis, but correct technique is essential, and their use should not delay prompt operation. The diagnosis of epididymitis should be made cautiously in persons younger than the age of 35 years. (Journal of the American Medical Association 1983;249:2522–2527.)

“Hepatitis and Jaundice Associated with Measles in Young Adults: An Analysis of 65 Cases,” Dov Gavish, Yosef Kleinman, Abraham Morag, Tova Chajek-Shaul. We analyzed the clinical course of 65 adult patients hospitalized because of measles during the years 1975 and 1981–1982. Liver involvement was found in 80% (52/65) of the patients, five patients had clinical jaundice. The disturbances of liver function tests reached their peak values between days 5 and 10 of the disease. In this study of measles in adulthood we have three observations of unusual interest: (1) hepatitis occurs commonly in the more severely ill patients and it may manifest clinically as jaundice; (2) long-term follow-up (up to seven years) shows a clear tendency to complete resolution of the liver damage; (3) there is a clear correlation between the severity of hepatic involvement and the occurrence of secondary bacterial infections. (Archives of Internal Medicine 1983;143:674–677)     

The impact of therapist pregnancy on the treatment process

Therapist pregnancy is a powerful emotional stimulus and a real-life event that affects clients and the treatment process. In the present paper, previous literature is reviewed and clinical experiences of the author in a university counseling center are reported to address how therapist pregnancy influences clinical treatment. Although therapists often hesitate in emphasizing their pregnancy, evidence suggests that it is easy to underestimate the importance of the pregnancy for clients. Case examples are presented which demonstrate client responses and the significance of the pregnancy for four female clients. Gender differences in client reactions are not fully understood, and it may be particularly difficult to facilitate male clients in dealing with issues stimulated by the pregnancy. These clinical findings suggest that in a variety of settings, understanding and working with clients' reactions to the therapist's pregnancy can enhance treatment.     

A study of live supervisory phone-ins in collaborative family therapy: correlates of client cooperation

The behavior of five supervisors, 19 trainee family therapists, and 20 clients before, during, and after 88 live supervisory phone-in events was examined in this study to determine the correlates of client cooperation. Following supervisory phone-in conversations, client cooperation was associated exclusively with the presence and quality of the collaborative behavior shown by the therapist. Isomorphism between the behavior of the supervisor and therapist was not associated with subsequent client cooperation, nor was any particular category of supervisor behavior. Surprisingly, isomorphism between the quality of supervisor and therapist behavior preceded those events where client resistance occurred.     

A method for diagnosing and planning the treatment of adolescent drug abusers (the Adolescent Drug Abuse Diagnosis [ADAD] instrument)

There is a need for a diagnostic method and an instrument appropriate for adolescent drug abuse clients, that permits the assignment of clients to the most appropriate treatment setting, provides the basis for individualized treatment planning, and facilitates comparability across research studies. The development of the Adolescent Drug Abuse Diagnosis (ADAD), a 150-item instrument with a structured interview format, modeled after the Addiction Severity Index (ASI) (which is for adults), is described. The ADAD produces a broad-spectrum comprehensive evaluation of the client, the interviewer's ten-point severity ratings, and composite scores for each of nine life problem areas that are often relevant to the treatment needs of adolescent drug abuse clients. A series of validity and reliability tests are described. The characteristics of the standardization sample (N = 1,042), and the comparison of the characteristics of the three subsamples (outpatient, residential or non-hospital, and inpatient) are also presented.     

WHERE RELATIONAL THEORY AND ATTACHMENT THEORY INTERSECT: A REAL RELATIONSHIP AND A REAL ATTACHMENT

This paper demonstrates the importance of understanding the client’s early attachment patterns and of promoting a real attachment in the therapeutic dyad. A review of relational theory reinforces current acceptance of therapist self-disclosure as a tool for engaging difficult clients. Additionally, therapists can identify clients’ early attachment experiences and promote growth in fragile clients by allowing them judicious access to their inner world, thereby encouraging the formation of a real attachment. Case examples illustrate how to identify early attachment patterns and one therapist’s creative use of self in developing real, therapeutic attachments with her clients.     

Abstinence-Only: Are You Not Working the Program or Is the Program Not Working for You?

Low retention rates are common in substance use treatment programs. The dominant model of service delivery in the United States is abstinence-only, a high-threshold service delivery model requiring abstinence. What “doesn’t work” for the client—from the client point of view—is an overlooked source of insight about client engagement and disengagement. We report client counter-narratives about the choice to disengage from abstinence-based services, shifting from a story of “dropouts” to one of self-respect. Understanding why clients choose to disengage from treatment can help us as practitioners to “meet clients where they are” and enhance engagement in substance abuse treatment.     

Clients’ perceptions of marriage and family therapists’ way‐of‐being: a phenomenological analysis

Previous research highlights the influence of therapist factors on treatment outcomes. One therapist factor proposed as fundamental to the process of therapy is the therapist's way‐of‐being, a relational concept that refers to how the therapist regards a client—either as a person or object (Fife et al., [2014] Journal of Marital and Family Therapy, 40, 20–33). Although this case has been made conceptually, there is little empirical research on therapists’ way‐of‐being with clients. The primary purpose of this research is to investigate clients’ perceptions of their therapists’ way‐of‐being. Utilizing a common factors perspective, the study seeks to explore: (a) how clients experience their therapists’ way‐of‐being and (b) the influence therapists’ way‐of‐being has on clients’ engagement. Phenomenological methods were used to gain a nuanced understanding of the phenomenon. Qualitative data were collected through semi‐structured face‐to‐face interviews with clients (N = 10) who received individual therapy from a marriage and family therapist. Results were organized into two main themes: core tenets (attunement, congruency, and aligning with clients) and operational tenets (providing affirmation and validation, balancing flexibility and structure, and accomplishing goals). Findings are used to make a case for adding the concept of way‐of‐being as an overarching construct for several well‐established therapist factors. Clinical and training implications are discussed.     

Collaborative Influence

Collaborative therapists acknowledge their role in influencing clients and the outcomes of therapy. But the word ‘influence’, for many new to the collaborative therapies, can be mistakenly connoted as an undue exercise of therapist power. From a dialogic and social constructionist perspective, this article reflects on how therapists can be influential in collaborative ways. Negotiating ‘shared intentionalities’ with clients, while privileging their preferences in meaning‐making and change—as part of respecting their primary authorship over their lives—assists therapists to employ their influence in ways that stay collaborative. Furthermore, by regarding client ‘resistance’ and misunderstanding as instructive, therapists can enhance their efforts to stay collaborative.     

Lesbian Therapists and Lesbian Clients

Abstract

The authors, on the basis of their own experience, explore issues specific to therapists working openly as lesbians with lesbian clients. Their discussion covers the structure of a private practice, the therapeutic relationship between lesbian therapist and lesbian client, and personal challenges for the lesbian therapist. Questions are raised and direction given with the aim of facilitating congruence among the therapist's personal capacities, the therapeutic setting, and the psychological intention of the therapeutic work. The authors note the therapist's need to tolerate the exposure of her personal life and the pressure toward fusion that are both entailed in work with lesbian clients, and they suggest that these special challenges, when the lesbian therapist's engagement with them is conscious, offer rich material that can deepen the therapeutic relationship and the therapeutic work.     

Experiences and Perceptions of Problem Gamblers on Cognitive and Exposure Therapies When Taking Part in a Randomised Controlled Trial: A Qualitative Study

In South Australia (SA) problem gambling is mainly a result of the widespread availability of electronic gaming machines. A key treatment provider in SA offers free cognitive and behavioural therapy (CBT) to help-seeking problem gamblers. The CBT program focuses on the treatment of clients’ urge to gamble using exposure therapy (ET) and cognitive therapy (CT) to restructure erroneous gambling beliefs. The aim of this study was to explore treatment specific and non-specific effects for CT alone and ET alone using qualitative interviews. Interviewees were a sub-sample of participants from a randomised trial that investigated the relative efficacy of CT versus ET. Findings revealed that all interviewees gained benefit from their respective therapies and their comments did not appear to favour one therapy over another. Both treatment specific and treatment non-specific effects were well supported as playing a therapeutic role to recovery. Participants’ comments in both therapy groups suggested that symptom reduction was experienced on a gambling related urge–cognition continuum. In addition to symptom improvement from therapy-specific mechanisms, ET participants described a general acquisition of “rational thought” from their program of therapy and CT participants had “taken-over” their gambling urges. The findings also highlighted areas for further improvement including therapy drop-out.     

Clinical and Supervisory Considerations for Transgender Therapists: Implications for Working with Clients

Transgender therapists have unique and valuable perspectives into how gender organizes the therapeutic process. Currently, in the MFT field, there is discussion of the cisgender therapist's experience in the therapy room, but no known articles on the transgender therapist's experience. This article provides insight into the experiences of transgender therapists around issues of self‐disclosure, social locations of both therapist and client, and clinical supervision. Drawing from our clinical experiences as transmen, we highlight special considerations for working with cisgender, queer, and transgender clients. Implications for supervision of transgender therapists are also discussed. As more gender diverse students seek MFT training, there is an urgent need to acknowledge their perspectives. This article is a call for beginning conversations in this direction.     

Sympathetic Nervous System Synchrony in Couple Therapy

The aim of this study was to test whether there is statistically significant sympathetic nervous system (SNS) synchrony between participants in couple therapy. To our knowledge, this is the first study to measure psychophysiological synchrony during therapy in a multiactor setting. The study focuses on electrodermal activity (EDA) in the second couple therapy session from 10 different cases (20 clients, 10 therapists working in pairs). The EDA concordance index was used as a measure of SNS synchrony between dyads, and synchrony was found in 85% of all the dyads. Surprisingly, co‐therapists exhibited the highest levels of synchrony, whereas couples exhibited the lowest synchrony. The client–therapist synchrony was lower than that of the co‐therapists, but higher than that of the couples. A Video Abstract is available next to the online version of this article on the JMFT web site .