Using culture and the intersubjective perspective as a resource: A case study of an African-American couple

In this article a White Jewish-American therapist shares what she learned from her work with an African-American couple using a semi-structured protocol for planned short-term marital therapy. Twenty-eight months after the original treatment, the author met again with the couple for an audiotaped follow-up interview. Marital satisfaction for both partners was tracked with an Index of Marital Satisfaction over the course of the treatment and the follow-up process. The empirical findings augment the story of the couple and the therapist. During the middle phase, the therapy reached an impasse. With the goal of creating a cognitive shift, the therapist used the couple's culture as a resource for therapeutic change. The cultural metaphor is considered as the vital step in overcoming the treatment impasse. The major finding is that cultural responsiveness does not end with the engagement and assessment of clients. The culture of the clients and the culture of the therapist provide powerful metaphors and rich resources to introduce change possibilities. With this couple, when culture was combined with an appreciation of the intersubjective meanings for both clients and therapist, culturally responsive and effective therapy became possible.     

Engagement: Who's Engaging Whom?

A definition of ‘engagement’ in therapy is developed, based upon the proposition “the client engages the therapist”. Engagement is then distinguished from ‘joining’, and a consideration of the relational power between client and therapist, implied by this definition, shows it to be consistent with systemic theory for therapy.     

EXPLORING A FOURTH DIMENSION: SPIRITUALITY AS A RESOURCE FOR THE COUPLE THERAPIST

This article explores ways in which the therapist's own spirituality can serve as a resource in couple therapy. Spirituality is defined as subjective engagement with a fourth, transcendent dimension of human experience. This engagement enhances human life and evokes corresponding behavior. Spiritually based therapy may be influenced by three assumptions: that God or a Divine Being exists, that human-kind yearns innately for connection with this Being, and that this Being is interested in humans and acts upon and within their relationships to promote beneficial change. In therapy these assumptions affect how the therapist listens and responds throughout sessions. The authors incorporate a case example illustrating the application of this fourth dimension in couple therapy.     

Cultural Attunement in Therapy With Mexican‐Heritage Couples: A Grounded Theory Analysis of Client and Therapist Experience

There is a need for culturally attuned approaches for couple therapy with Mexican/Mexican‐Americans. This qualitative grounded theory study utilized interviews with 11 client couples of Mexican heritage and 14 marital and family therapists to shed light on how Latino and non‐Latino therapists co‐construct positive experiences of cultural attunement with Mexican and Mexican‐American couple clients. Analysis identified a model of cultural connection through personal engagement with four interrelated phases: (a) mutual invitation, (b) shared engagement, (c) expanding personal connection, and (d) creating cultural connections. Clients in this study valued professionalism and expertise of the therapist, but felt attuned to and respected when therapists demonstrated humility, shared personal stories and emotion, and engaged in a collaborative process.     

On Learning and Teaching Family Therapy

This paper explores some ideas about the process of learning to be a family therapist. It considers the questions: how does one learn to think like a family therapist? How is family therapy best taught? How is it learned? The author's experiences in learning and teaching are described. It is argued that family therapy differs from other approaches to therapy in some fundamental respects, and that learning to ‘be’ a family therapist is a different kind of task than learning to be a practitioner of other therapeutic approaches. The paper examines some key theoretical constructs, especially the idea of ‘levels’ of thinking, which are seen as central to both the learning and practice of family therapy.     

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.     

Thinking About the Emotional Interaction of Therapist and Family

The emotional interaction of therapist and family has been difficult to explore within the field of systemic family therapy. This paper looks at ways of thinking about this process. As a starting point, I take some feelings I had with three families in the course of therapy. These are used to illustrate some concepts from analytic therapy which address the emotional interaction of therapist and family. The kind of theoretical space and guidance offered within systemic family therapy is then explored, and it seems that the Milan frame gives some space for thinking about the process but offers little guidance as to exactly how this might be done. This is a paper about practice, though it's primarily a theoretical discussion. There is no aim of establishing a ‘correct’ way of understanding the emotional interaction of therapist and family.     

A Longitudinal View of the Association Between Therapist Warmth and Couples' In‐Session Process: An Observational Pilot Study of Emotionally Focused Couples Therapy

This longitudinal dyadic clinical process study used coded data from eleven couples to determine the influence of therapist warmth behaviors on couples' warmth behaviors over time in therapy. A mixed effects model was used to examine within‐ and between‐individual variability. Men and women were modeled separately. A series of two‐level multilevel models of change were examined, where Time is Level 1 and Individual is Level 2. Findings were mixed. There was no significant relationship between therapist warmth toward wife and wife warmth toward husband; however, there was a significant relationship between therapist warmth toward husband and husband warmth toward wife. Findings demonstrated that 62.9% of the variance in husband warmth toward wife was accounted for by therapist warmth to husband across time in therapy. Specifically, therapist warmth toward husband was significantly and positively related to husband warmth toward wife over time in therapy. Clinical implications and directions for future research are discussed.     

Responsive Persistence Part I: Therapist Influence in Postmodern Practice

Feminist and social constructionist developments in family therapy highlighted the importance of attending to therapist–client power relations and incorporating clients' understandings and preferences as a part of therapy. Significantly, less attention has been given to how postmodern therapists do use their power and influence. This is an important topic because it is therapists who have the major responsibility for guiding the interaction with clients and persisting in this so that change is facilitated. Therapist persistence in various forms and across dimensions of therapy process is examined to expand understanding of therapist influence in postmodern and collaborative work. An analysis of responsive persistence in a session with Karl Tomm as the therapist is presented to illustrate this conceptual framing.     

Therapist effects on dropout in couple therapy

Marriage and family therapy scholars have argued that therapists play a crucial role in successful couple therapy, yet little research has empirically documented that the therapist in couple therapy has a significant impact on outcomes. Known as the study of therapist effects, this study sought to assess the amount of variance attributed to the therapist in couple therapy outcomes. Using dropout as the outcome variable, this study analyzed data from 1,192 couples treated by 90 masters and doctoral student therapists at a university‐based training clinic. Results from multilevel analysis indicated that therapists in the sample accounted for 9.4% of the variance in couple dropout while controlling for initial couple impairment. Therapist gender and therapist experience did not significantly predict variability in therapist effects. These findings give promise to future research on therapist effects in couple therapy and encourage exploration into which therapist characteristics and behaviors contribute to successful clinical outcome.     

Woman Abuse and Conjoint Therapy: Therapists' Experiences of Engagement

ABSTRACT

Treatment approaches with couples in which woman abuse is a factor have been the subject of much attention and concern in the therapeutic community. We used focus groups to examine therapists' experiences of what they see as impeding or facilitating their ability to engage therapeutically with heterosexual couples when a man has used violence. Results were coded along four categories: contextual issues, the person of the therapist, client characteristics, and strategies for enhancing engagement. Results point to the difficulties therapist participants experienced engaging with males who have been violent with their partner. Strategies which therapists used to enhance engagement are illuminated. We discuss differences between the experiences of male and female therapists, and implications for clinical work and future research.     

Structuring Home-Based Therapy: Four Phases to Effective Treatment

ABSTRACT

Home-based services are gaining more popularity than in years past. Therapists going into the home are exposed to various treatment issues that differ from those in a clinic or office setting. One of these issues is that of structuring the therapeutic process. Much has been written about the structure and stages of clinic-based therapy; however, little is known about the process of home-based therapy. This paper will delineate four phases of home-based therapy which the in-home therapist can use as a guide to provide faster and more effective services.     

Common pitfalls of beginning therapists utilizing enactments

Empirical data, clinical observation, and theoretical rationales support use of enactments as a fundamental mechanism of change in relationship therapies. Yet beginning therapists may lack an adequate conceptual framework and operational training essential to effectively utilize enactments. Inadequate training may contribute to ineffective execution, and in turn to negative results, which could lead to abandonment of enactments. This study sought to identify proficiencies and nonproficiencies of beginning therapists in conducting enactments. Twenty beginning therapists from three Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE)-accredited programs were briefly trained in an indirect therapy style that incorporates enactments. Twenty-six therapist enactments were coded using a comprehensive observational measure designed to assess proficiencies and nonproficiencies in executing enactment phases, component tasks, and subcomponent operations. Results suggest that beginning therapists struggle with numerous clinical operations conceptually linked to the successful engagement of relationships in marriage and family therapy. In light of these findings, specific recommendations for additional enactment training in COAMFTE-accredited programs are offered.     

Vicarious resilience from attachment trauma: reflections of long-term therapy with marginalized young people

The concept of vicarious resilience captures the therapist's emotional growth occurring as a direct result of therapeutic engagement with traumatized clients. Three chronological case scenarios are presented for exploration of vicarious resilience in relation to attachment trauma. The purpose is to increase awareness and appreciation of the positive functions it serves for client mentalization, therapist skill and resilience factors for both parties. The reflective methodology considers the intrapsychic worlds of the client and the therapist and details how the therapist comes to experience the client's distressing projections. The potential for vicarious resilience begins from the outset of the therapist's actions of containment upon these projections. Advancing early ideas, it is advocated that vicarious resilience requires the therapist to have both the capacity and willingness to maintain a constant reflective stance.     

DO WE REALLY UNDERSTAND? AN EXPERIENTIAL EXERCISE FOR TRAINING FAMILY THERAPISTS

This paper presents an experiential exercise for training beginning marriage and family therapists, as well as several adaptations of the format. The basic exercise consists of role playing a therapy session in which the people playing the clients speak a language that is not understood by the therapist-in-training. Although the therapist cannot understand the clients, the clients can understand the therapist. This exercise assists students to become more cognizant of the need to be cautious and curious in the cocreation of meaning in therapy. In addition, this exercise builds confidence and clinical skills, such as learning about nonverbal communication while observing process.     

Beginning Struggles with Families*

Beginning treatment with families is marked by a sense of struggle between the family and the therapist. The family is seen as testing the therapist and as asking through their behavior questions about the therapeutic process. The therapist is advised to focus intently on the beginning interviews, working toward the point where the family relaxes and decides on an intuitive level to enter therapy. The major hurdle is in dealing with the family's anxiety as the therapist attempts to shift the focus from the individual patient to the family as a whole. Strategy in establishing this shift is outlined     

Phenomenology and intersubjectivity: considerations for webcam-facilitated psychotherapy

ABSTRACT

The clearest distinction between webcam-facilitated versus face-to-face psychotherapy is the available sensorial information. The following questions guide this discussion: 1. How do our senses inform the psychotherapeutic process? 2. What are the implications for the therapeutic process when sensory information is different than during face-to-face therapy? This examination of the role of the senses in the creation of knowledge is grounded in phenomenology. Individual unity of consciousness and reciprocal understanding are applied to literature on webcam-facilitated therapy. An amalgam clinical example illustrates these phenomenological concepts and role of intersubjectivity. The core issues are involvement of sensory processes in the process of psychotherapy and co-construction of knowledge. By accepting the limitations of therapist knowledge, the client is encouraged to articulate and develop their own knowledge, and make conscious their unconscious. It is not necessary for therapist and client to share a physical space for co-creation of knowledge necessary for client transformation.     

Single-Session One-At-A-Time Therapy: A Personal Approach

The terms ‘Single-Session Therapy’ (SST) and ‘One-At-A-Time’ (OAAT) therapy are both used to indicate a situation where the therapist and client set out with the expressed intention of helping the client in one session while acknowledging that additional sessions are available to the client. Both terms have their advantages and disadvantages and thus the author uses the blended term ‘Single-Session One-At-A-Time’ (SST/OAAT) therapy to highlight the advantages of both. It is a core feature of SST/OAAT therapy that it is client-centred especially where the session’s focus and goal are concerned. However, in an attempt to avoid SST/OAAT therapy being highjacked by therapists who operate from the ‘expert’ source of influence, the field has downplayed the contribution of the therapist’s expertise. In this paper, I make clear that the expertise of the therapist when allied to the expertise of the client can be a potent force for good in SST/OAAT therapy. My main task, however, is to outline my own approach to SST/OAAT therapy which is a blend of general principles that are likely to be held by the majority of SST/OAAT therapist and specific ideas that are derived from working alliance theory, pluralism and Rational Emotive Behaviour Therapy.