The Clinician's Cultural Countertransference: The Psychodynamics of Culturally Competent Practice

The purpose of this paper is to define the presence of the clinician's cultural countertransference in the cross-cultural therapeutic dyad, and describe its impact on the delivery of culturally competent services. The recognition of the contributing role of the therapist's own subjectivity in psychodynamically oriented practice cannot be more vital than in the treatment of patients whose culture, race, or class markedly differ from that of the therapist. The cultural countertransference is viewed as a matrix of intersecting cognitive and affect-laden beliefs/experiences that exist within the therapist at varying levels of consciousness. Within this matrix lie: the clinician's American life value system; theoretical beliefs and practice orientation; subjective biases about ethnic groups; and subjective biases about their own ethnicity. The author proposes that these countertransference attitudes are often: disavowed by the clinician; exert a powerful influence on the course of treatment; and though unspoken, are frequently perceived by the client.     

An Integrated Human Behavior Theory

Abstract

In this article, the behavioral exchange model as derived from the work of Emerson, is presented to help the practitioner more adequately conceptualize the interaction between the clinician and the client. This model can help the clinician develop and further his/her understanding of how power differentials between the clinician and the client affect the therapeutic relationship. This model describes how clients use a cost-benefit framework to determine if treatment is worthwhile-meaning that if the client perceives the rewards of an interaction as not outweighing the costs, then the client may terminate treatment. Finally, this model can assist the clinician in constructing an integrative framework for the diverse variables reviewed in the text, and with this framework will be better equipped to influence them.     

Clinical clues in the breathing behaviors of patient and therapist

Verbal communications have dominated treatment theories and will remain a privileged source of communication. This paper directs the therapist's attention to some of the possible breathing behaviors in treatment which may, like verbal language, convey an unconscious or conscious message that is possibly interpretable. Breathing has meaning in the transference—countertransference intersubjective world. Behavior symbolized by breathing may be included in the earliest somatic, dyadic interaction and may therefore go with one through life and reappear in every new relationship. This paper directs the clinician's attention to some of the possible meanings and interpretations of breathing behavior during treatment. It calls attention to techniques for exploring the rich connection between breathing, body, object and somatization.     

The Impact of Sexual Abuse Treatment on the Social Work Clinician

A growing body of literature exists on the prevalence and psychological sequelae of sexual abuse and its treatment. However, less attention has been focused on the experience of clinicians who treat these clients. This article uses the concept of vicarious traumatization (McCann and Pearlman, 1990a) to describe the impact this work may have on the social work clinician. The issues addressed include the impact of the work on the clinician's world-view and the possibility that there is a grief process as clinicians come to terms with their exposure to traumatic material. Implications of this reaction and suggestions to alleviate the detrimental effects arc addressed.     

A general moodel of crisis intervention

This article presents a general model of crisis intervention designed to be used in most practice settings. The model is a synthesis of what has previously been written about crisis intervention theory and practice along with the author's own contributions. The various definitions of what constitutes a crisis and the stages of a crisis reaction are discussed. In the beginning phases of crisis treatment it is suggested that the clinician should complete six tasks, one of which is identifying with the client and precipitating event that led to the crisis. As the treatment process continues it is suggested that the clinician should complete six tasks, one of which is designing psychological and behavioral tasks that will reduce stress and help the client resolve the crisis. Finally, the termination process is reviewed.     

Clients' unconscious communications as the basis for establishing the framework of treatment: A response to articles by Schamess and Saari

Robert Langs' conclusions regarding clients' needs for a specific type of framework are based on listening to unconscious communication. His critics argue that certain severely disturbed clients need modifications in this frame. But these critics are arguing from a different set of data—data derived primarily from manifest content listening. Clients' unconscious communications reveal that—in spite of apparent need or conscious demand for modifications in the framework—clients actually need the therapist to maintain the frame. Langs' concept of unconscious communication is explained. A clinical vignette demonstrates how a client communicates an unconscious need for a therapist to maintain an aspect of the frame.     

Autobiographical interviewing and narrative analysis: An approach to psychosocial assessment

Use of an autobiographical interviewing approach in the psychosocial assessment process allows the clinician efficient access to rich diagnostic material in a way that is comfortable for the client. This approach invites rather than discourages storytelling and is consistent with recent interest in narrative perspectives on assessment and treatment. This article describes the use of the autobiographical interview with a chemically dependent woman and details three analytical approaches for understanding the self-narratives which result.     

Resilience,mental health and Assertive Community Treatment

Clinicians try to promote resilience by building an effective therapeutic relationship with their clients. Assertive Community Treatment (ACT) is an established approach for providing services to individuals with severe mental illness who have not fared well in the regular mental health system. This work underscores the importance of a resilient therapeutic relationship in preventing relapse and assuring adherence to therapeutic outcomes. Persistent psychiatric illness takes a toll on the resilience of the client, while the relationship work takes a toll on the resilience of the clinician. This article explores the concept of relational resilience between clinician and client as a dynamic process of shared success and failure, progress and regression through cycles of crisis, stabilization, relapse, and partial recovery. This is a qualitative study exploring how ACT clinicians promote and sustain resilience and is based on interviews with social workers, nurses, occupational and recreational therapists, coordinators, and psychiatrists.     

Issues in Psychotherapy with Clients Affiliated with the Opposing Side in a Violent Political Conflict

The therapeutic dyad of clinician and client affiliated with rival groups in a violent conflict shares many features that complicate psychotherapy with persons of different ethnic, racial, and cultural groups, including lack of knowledge, negative stereotyping, differences in fundamental values and world views, and power differentials. Although a great deal has been written about these matters, very little has been written about the therapeutic dynamic where therapist and client are affiliated with different sides of a violent political conflict. Based on the sparse literature on the subject and on the clinical experiences of the author and her colleagues, this paper discusses three features that characterize this dynamic, which do not appear in the same way in therapy involving dyads of different races, ethnic groups, or cultures. These are the presence of the “enemy” in the consulting room, the therapist’s feelings of mistrust towards the client as a representative of the opposing group, and the client’s feelings of guilt towards the therapist as a representative of the injured group. The impacts of each feature on the therapist, client, and the therapeutic encounter are explored and suggestions are made for dealing with them. The hope is that professionals’ awareness of these issues will help improve the quality of psychotherapy with persons on the rival side of a violent political conflict.     

Arousal change and cognitive labeling: Pursuing the mediators of intimacy exchange

In recent years a considerable amount of research on nonverbal behavior has focused on identifying patterns of exchange in the component behaviors of interpersonal intimacy. The rapidly developing empirical research, occasionally giving hope for some convergence in the results, has precipitated efforts at explaining the processes underlying the exchange of intimacy. This paper attempts to analyze issues surrounding two of the more promising mediators of intimacy exchange—arousal change and cognitive labeling. This speculative discussion is offered as a means of stimulating several specific and empirically testable questions which may promote our understanding of the intimacy exchange process.This article is a revision of a paper presented as part of a symposium on Nonverbal Intimacy and arousal: Theoretical approaches and issues at the American Psychological Association Convention, San Francisco August 1977. The author would like to express thanks to the other panel members—Jack Aiello, James Dabbs, Jr., Phoebe Ellsworth, Eric Knowles, and Steve Worchel—for their symposium participation which facilitated the evolution of this paper.     

Therapy of the Conscience: Technical Recommendations for Working on the Harsh Superego of the Patient

An indispensable goal of intensive psychotherapy is to modify areas of the superego which are unreasonably harsh and punitive—yet, surprisingly little is written on this topic. In this paper, after discussing various aspects of the superego, I recommend an active treatment technique which involves educating the patient, over time, about how pervasive and punitive is—for lack of a better word—the conscience—of his or her mind. During this process, one can expect a softening and lessening of the patient's punitive superego and an expansion of the patient's benign or benevolent superego, as the patient begins to identify with and introject more of the compassionate attitudes which have been imparted and experienced in the intimate relationship of psychotherapy.     

The role of empathy in supervision

Empathy plays an important role in clinical supervision. It is the link between the client whose treatment is being supervised, the clinician/supervisee, and the supervisor. The supervisor uses an empathic capacity as well as theoretical knowledge to understand the clinical work and build the supervisory relationship. Often the progress of a case can be traced through the development of empathic understanding in the supervision. The transmission of empathy requires creativity and openness and is one of the major challenges in supervision. By analyzing the different uses of empathy in clinical supervision we can increase our understanding of the supervisory process.     

The Effects on Clinician Identification when Clinician and Client Share a Common Ethnic Minority Background

ABSTRACT

A quasi-experimental study addressed the question of whether clinician identification with the client differs in therapeutic dyads in which clinician and client are from the same ethnic minority background than in therapeutic dyads in which clinician and client are from a different ethnic background. An availability sampling plan was used to obtain a sample of sixty Japanese American and sixty White social workers. Subjects watched one of two videotaped vignettes of either a Japanese American or White client. An identification inventory was used to measure range and intensity of identification. Findings demonstrated that match of ethnic minority background heightened range and intensity of identification. Additionally, match of generation, place of origin, and assimilation level also increased the respondent's identification with the client. Furthermore, feelings of vulnerability, a concern of overidentifying, and an added sense of investment occurred more frequently when the respondent and vignette client were from the same ethnic minority background.     

In-depth learning in field education: evaluating the effectiveness of process recording

Process recording is the anamnestic recollection of narratives and behaviours of the participants in client interviews. Through critical incidents of teaching, this study explores how the process recording teaching and learning activity was operationalised in a field education seminar for postgraduate social work students, at an Australian University. Further, the study evaluates the student satisfaction aspect of the effectiveness of the activity. Assuming the practitioner/lecturer-researcher role, the author adopted a psychodynamic theoretical framework to identify relational roots in client problems, support students to carry out holistic bio-psychosocial assessments, correct practice mistakes and separate facts from thoughts—conceptualised as theories of practice—and emotions. An anonymous mixed-method questionnaire evaluated the satisfaction of students with the activity. The clear majority evaluated process recording as very beneficial for their learning and rated the reflections of the lecturer on the process recorded material as highly satisfactory.     

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.     

Unpacking the terms of engagement with local food at the Farmers’ Market: Insights from Ontario

Amidst much discussion of the values and venues of local food, the Farmers’ Market (FM) has emerged as an important, but somewhat uncertain, site of engagement for producers, consumers and local food ‘champions’. Despite the evident certainty of various operational rules, the FM should be seen as a complex and ambiguous space where (contingent) notions of local, quality, authenticity and legitimacy find expression in communications and transactions around food. This paper seeks to extend current reflections on the nature of the contemporary FM and its relationship to the tenets of local food. An empirical analysis involving sellers, shoppers and managers at 15 markets in the Province of Ontario, Canada sought to understand how participants ‘read’ the market as an operating space and subsequently construct the terms of (their) engagement. Findings suggest that Ontario FM customers wish to support farmers and farming via their food-related spending and express attachments to a wide range of alleged benefits pertaining to local food. Yet these values are also malleable in their meaning and amenable to trade-off against other considerations—particularly where social capital is concerned. The notion of ‘local’ emerges as being widely valued but also highly interpretive in its meaning and variable in its absolute importance. The paper concludes with some reflection on the degree to which the findings support, challenge or modify current normative beliefs about local food at the FM.     

A Philosophic Stance,Ethics and Therapy An Interview with Harlene Anderson

Harlene Anderson is director of the Houston Galveston Institute. With her late colleague Harry Goolishian she challenged family therapy theory, proposing that as therapists we consider theoretical metaphors based on language and social constructionism, and in effect has moved family therapy in a new direction. The physical and conversational context of interview was the Lofoten Islands, 300 km inside the Arctic circle, Far Northern Norway on the night after Mid Summer's Night, 24th June 1993. Tom Andersen was the host for several days to a gathering called Constructed Realities; Therapy Theory and Research. The aim of the gathering was to explore the concept of Knowledge in the fields of psychiatry, psychology, teaching and social work. The focus was to provide a bridge between the ‘practical’ and the ‘theoretical’ discourses around knowledge and the creation of the knowledge. There were eight main issues around which the conversations revolved — 1) Knowledge: One or Many? 2) Multiple Realities and the Therapeutic Process 3) Human Understanding 4) Language and the Construction of Self 5) Research Alternatives 6) Qualitative Research in Clinical Work 7) Feminist Issues in Theory and Research 8) Power, Ethics and Practice. Harlene Andersen has written extensively on many of these subjects taking a constructivist position and was central to the numerous conversations. She was also one of the prime movers in putting together such a challenging and multi-disciplinary conversation. In conjunction with Harry Goolishian, Harlene Andersen has proposed that what we call ‘problems' are created in language and are dissolved in language. Her interests are in the multiple realities that come to an intersection in a therapeutic conversation and how a therapist can engage with a client to open the possibility for the client to create and find some changes in his/her life. She takes the position that in order for a therapist to be helpful to his/her client, conversational space needs to be created that makes room for the exploration of the client's beliefs and realities. An essential element in this process of creating conversational space is the therapist taking a position of not knowing, of uncertainty, of exploring and making room for the client to talk about what is important for him/her to talk about and not for the therapist to lead from a position of knowing what is best for the client. Harlene Andersen is regarded as a leading theorist and clinician in the therapeutic community who is exploring the broad concept of therapy as a collaborative process at many levels. She is one of the major presenters at the forthcoming New Voices in Human Systems conference hosted by Lynn Hoffman in Northampton, Massachusetts in October 1994.     

Assessing outcomes for sufferers of severe mental disorder: A conceptual framework and review

A conceptual framework is presented for classifying the outcomes of services for sufferers of severe mental disorders. The proposed classification framework contains three dimensions: (a) the respondent type; (b) the social context; and (c) the domain of treatment outcomes. Respondent types include the client, the family, the extended social network, the clinician and the scientist. Social contexts include the individual, the family, work/school and the broader community. Domains of treatment outcome include “clinical status,” “functional status,” “life satisfaction and fulfillment,” and “safety and welfare.” This multidimensional framework is used to organize an illustrative review of existing outcome measures. It is concluded that: (a) measures of safety and welfare raise important social and policy questions and these measures require considerable development in order for utility to be realized; (b) although a good beginning has been made, more attention needs to be focused on defining and measuring “life satisfaction and fulfillment” and combining this domain with others to produce “well being” or “quality of life” scales; (c) the functional status area requires additional research and development especially when measurement is conducted in contexts other than work/school; and (d) although measures of clinical status are relatively well developed, the family perspective and context must be integrated into these measures.     

Treatment of violent offenders

In treatment of criminal offenders, especially those with a history of violence, it is essential that the clinician pay close attention to the criminal act itself. This area is often overlooked or avoided by practitioners who focus entirely on history, antecedents, current functioning, and problems of daily life. Important as these areas are, this paper suggests that a first step should be a detailed history of the criminal act, in a process requiring the client to walk the therapist through the crime. This procedure provides invaluable information both for assessing treatability and for evaluating change. The history and walk-through can be used as an adjunct to the therapist's primary clinical model, whatever it may be. Material presented is drawn from the author's experience at Atascadero State Hospital, California, the state's primary institution for sex offenders and the criminally insane.Originally prepared for presentation at the 10th Annual Scientific Conference of the Society for Clinical Social Work, Los Angeles, California, October 19–21, 1979.     

The mental health clinician in the affluent public school setting

This article explores problems and pitfalls confronting the mental health clinician working within a highly affluent public school setting. The special resources which affluent families bring to the assessment and treatment process are noted. Coping styles specific to very affluent and educated families are discussed which are brought into play in response to school dysfunction in a member and which can prove problematic for alliance building and effective intervention. Countertransference responses are discussed that relate to the particular status of the mental health clinician working as a member of the school staff with a wealthy client population. Bases for enhancing effectiveness are discussed, including recognition and management of countertransferance issues.