Digests - March 2014

  1. Beauty and the Beast explored to provide insight into a past therapeutic relationship and to enhance reflection in supervision.
  2. Linguistic diversity needs attention in counsellor education.
  3. Case study shows how therapist interventions can facilitate clients’ assimilation of problems.
  4. Coping style influences how clients respond to cognitive therapy.
  5. Study makes a strong case for more gay-affirmative counsellor training.
  6. Patients that re-refer may be more likely to engage and complete treatments that offer regular, structured and one-to-one interventions.
  7. Personal growth possible, alongside the process of loss, possible for carers of people with dementia who have engaged in therapy.
  8. The core conditions perceived as effective for clients at risk of suicide.

1. Beauty and the Beast explored to provide insight into a past therapeutic relationship and to enhance reflection in supervision.

Two researchers participated in this study, one as supervisor/participant and the other as supervisee/participant. Drawing on an historic case study, the supervisee selected from a range of references, Beauty and the Beast, as the fairy tale that best represented a client’s therapeutic experience. Three sessions of supervision were then recorded, in which the therapy was explored using the fairy tale and using objects. Transcripts of the recordings were then analysed by both researcher/participants using a grounded theory methodology. Two main themes emerged concerning therapeutic process: using archetypal themes in fairy tales to enhance the clarity of the therapeutic landscape and the facilitation of the sense system through the use of small objects to reconceptualise the therapeutic dynamic.

This kind of practice – within a collaborative supervision relationship – can, the authors claim ‘enhance a therapist’s ability to work with clients’. Using fairy tales, metaphor and cognitive landscapes can allow therapists to develop a bigger picture or ‘meta view of complicated retrospective therapeutic work’. Using fairy tales and objects can stimulate the sense system, say the authors, which in turn can uncover processes of transference and countertransference. The authors hope that this kind of process could ‘enhance reflection within current supervision relationships.’

Fairy tales, landscapes and metaphor in supervision: An exploratory study

Margaret E. Smith & Drew Bird

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2. Linguistic diversity needs attention in counsellor education.

Practical language difficulties may impact on confidence and perception of competence; there are related emotional struggles faced by trainees, and using a second language in practice is a significant source of anxiety. These are the main conclusions of this study, exploring clinical counselling practice from the perspective of international, non-native language speaking trainees.

Using an interpretative phenomenological analysis study design, four female trainees (two Asian and two European) participated in semi-structured interviews. Participants had moved to the UK for training purposes and had between four and ten months’ clinical experience. The interviews were then transcribed and emergent themes identified and organised. The themes presented in this paper focus on the struggles related to language difference. The theme ‘practical struggles’ includes ‘expressing oneself’ and ‘understanding clients’ speech’. The theme ‘emotional impact upon trainees’ includes ‘anxiety’ and ‘low self-confidence’.

This paper sheds light on the detail of trainee counsellors’ experiences when they practice in a non-native language. The author recommends that counselling training programmes provide support for the ‘the additional challenges international trainees may encounter in practice in relation to linguistic competence’. She also notes that as clients may increasingly be non-native speakers, training programmes should recognise language as an aspect of diversity, and the author calls for further research into the area.

‘My language thing … is like a big shadow always behind me’: International counselling trainees' challenges in beginning clinical practice

Lorena Georgiadou

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3. Case study shows how therapist interventions can facilitate clients’ assimilation of problems.

The Assimilation of Problematic Experiences Scale (APES) describes eight levels that a problematic experience passes through before becoming part of a person’s self. Therapists help clients move their problem along the levels by using interventions appropriate for the problem’s current level. According to this theory, therapists help problems move from their current level to the next.

The aim of this study was to investigate the links between therapist interventions and the clients’ progress through therapy so the researchers used a theory-building case study design to put forward hypotheses about which interventions are best at each level and to test the hypotheses. Thirty-four sessions of therapy between a psychodynamic therapist and a client ‘Claire’ were analysed using the Comprehensive Psychotherapeutic Interventions Rating Scale - a list of 81 therapeutic interventions classified by the main therapeutic approaches or as common factors - and assimilation level, measured by APES.

The analyses enabled the researchers to adjust their hypotheses concerning appropriate interventions for each level. The researchers found more kinds of interventions used in practice than were hypothesised, so proposed new categories for the model. They also found interventions that were used to ‘encourage, facilitate or clarify communication’ and interventions about the therapeutic relationship that were appropriate for many assimilation levels. This study enabled the authors to revise the Assimilation Model theory in line with their findings and they aim to test this revised model in further psychodynamic case studies, acknowledging the importance of testing their hypotheses in therapy from other orientations.

How psychotherapeutic exchanges become responsive: A theory-building case study in the framework of the Assimilation Model.

Claudia Meystre , Ueli Kramer , Yves De Roten , Jean-Nicolas Despland & William B. Stiles

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4. Coping style influences how clients respond to cognitive therapy.

Cognitive therapy, claim the authors of this study, is considered a highly effective treatment for depression by changing negative thinking over time. However, a landmark study in 1999 found that there was no difference in effectiveness between cognitive therapy and a behavioural activation control intervention. The authors of this study suggest that an individual’s capacity to cope, plays a role in determining the benefits of a specific therapeutic intervention, and it is this that they investigate in this study.

Participants came from a previous larger study: the authors selected 30 participants who had completed a full cognitive therapy treatment condition (20 sessions of cognitive therapy according to the study protocol) within the study, and for whom there was also data on coping and cognitive errors. The third session of each participant’s therapy was transcribed and then coded for cognitive errors using the Cognitive Error Rating Scale and for coping using the Coping Patterns Rating Scale. Depression was measured using the Beck Depression Inventory pre- and post-treatment. The interrelation between cognitive errors and coping was analysed for significance and the pre- and post-treatment scores analysed.

Results showed that cognitive therapy works best for individuals who present with cognitive errors such as ‘jumping to conclusions’ or ‘personalisation’ if they also demonstrate ‘self-reliance’ or avoid the use of escape strategies. While the authors of this paper call for more research into coping strategies in response to their findings, they also point to the need for therapist to specifically address coping abilities in therapy.

Cognitive therapy for depression: Coping style matters.

Jesse Renaud , Keith S. Dobson & Martin Drapeau

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5. Study makes a strong case for more gay-affirmative counsellor training.

Individuals who identify as LGBT are more likely to seek therapy than their heterosexual counterparts, they have an increased risk of suffering from depression and other symptoms of psychological distress, and of engaging in self-injurious behaviour, including attempted and actual suicide claim the author of this paper. However, there is a consensus among writers that counselling and psychotherapy students are not being provided with enough basic competencies to work with LGBT clients in their core training.

To explore the clinical experiences of novice counsellors further and clarify the extent to which formal training had prepared them for working with this client group, the authors designed a qualitative study, collecting data from both face-to-face and email interviews. Sixteen novice (five years or less post-qualification) counsellors with experience of working with LGBT clients participated, and transcribed interviews were analysed using grounded theory methods.

Three higher order categories emerged from this analysis: ‘Engaging with learning’, Finding strategies that work’, and ‘Entering the client’s world’, under an overarching core category ‘Confronting homophobia and heterosexism’. Despite limitations of small sample size, the risk of ‘researcher effect’ on the data, and the homogenous nature of the self-selecting sample, the authors conclude that ‘our sample of novice therapists portrayed themselves as looking to, but failing to find, support in past training. They had to fall back on personal resources to develop therapeutic confidence and effectiveness, and admitted that they found it challenging to acknowledge the oppressive world in which their clients live.’

Exploring the clinical experiences of novice counsellors working with LGBT clients: Implications for training

Valerie Owen-Pugh & Laura Baines

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6. Patients that re-refer may be more likely to engage and complete treatments that offer regular, structured and one-to-one interventions.

Patients who re-refer to the service explored in this study represent only 6% of all referrals in one year, but they draw on a disproportionate allocation of administrative and therapist resources through DNAs and dropping out of therapy. The aim of this study was to explore re-referral patterns and examine the level of complexity of patients who accessed a service two or more times.

Using a retrospective observational study design, the data of 50 participants, collected routinely on the clinical database IAPTus between June 2009 and June 2011, was analysed, constituting 129 referral episodes. In her analysis, Cairns considered service outcome, compared types of therapy that resulted in planned and unplanned endings, and assessed the complexity of presentations.

A high proportion of multiple referrals resulted in no or minimal contact with the service and conversely a low proportion resulted in a planned end to treatment. An analysis of patient contact records, referral letters and other documentation, showed that a high proportion of the referrals presented with ‘caseness’ for depression and anxiety; they reported other difficulties as well as depression and anxiety, and also experienced environmental problems. The author concludes that ‘the evidence presented in this study indicates patients who re-refer exhibit complex environmental, historical and psychological problems’ and she makes a range of recommendations for practice which include a thorough, face-to-face assessment, examining a previous contact record with a service, and offering regular, structured one-to-one interventions to such patients.

Patients who come back: Clinical characteristics and service outcome for patients re-referred to an IAPT service

Margaret Cairns

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7. Personal growth possible, alongside the process of loss, possible for carers of people with dementia who have engaged in therapy.

In England, there are currently around 500,000 family members who care for a person with dementia and they experience varying degrees of stress. The National Dementia Strategy states that carers have a right to interventions that support their caring role, however, there is a lack of research into the client perspectives on what works or is helpful in therapy. This study seeks to explore the meaning of counselling/psychotherapy from the perspective of carers of people with dementia and examine the processes of change in their therapies.

Six carers of people with dementia, who had or were still engaged in various approaches of therapy, participated in semi-structured interviews. The interviews were transcribed and analysed using ‘holistic content’ analysis. Three main themes emerged: ‘Still doing the best I can’, ‘Feeling connected and being understood’, and ‘Wanting to share information’. The findings, the authors claim, highlight the ‘importance of the role and characterstics of the therapeutic relationship including the consideration of self-disclosure’. For example, carers placed emphasis on the age of the therapist and the amount of therapist self-disclosure. Participants also demonstrated that growth and positive adjustment could occur, alongside the process of loss.

This study, the authors tentatively conclude, provides insight into how therapy addresses the needs of carers of people with dementia and highlights similarities with other client groups.

The experiences of therapy from the perspectives of carers of people with dementia: An exploratory study

Ruth Elvish, Rosanne Cawley & John Keady

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8. The core conditions perceived as effective for clients at risk of suicide.

Thirteen qualitative studies exploring counselling and psychotherapy with people at risk of suicide were selected, according to the study criteria, for this research. Reported between 1997 and 2006, seven studies were conducted in the UK, four in the USA, one in Canada and one in Sweden. The meta-synthesis was a thematic analysis, with all studies being read and coded by two raters; codings then being reviewed to look for themes. The kinds of therapy considered within the studies were dialectical behaviour therapy (DBT) (4), counselling (5), psychodynamic interpersonal therapy (PIT) (1), and psychoanalytic therapy (1).

There was a consensus that therapists effective in working with suicidal clients were understanding, empathic and non-judgemental. The synthesis of the papers demonstrated a perceived effectiveness of psychological therapy for clients at risk of suicide. Barriers to therapy described by the clients included ‘secrecy concerning self-harm, and a consequent reluctance to bring significant material to therapy for fear of rejection, disapproval and criticism’.

The authors recommend that counselling and psychotherapy should be available to people at risk of suicide and that practitioners should note the importance of the therapeutic relationship. They call for more and specific training for counsellors working with suicidal clients. In light of the limited range of therapies and clients represented in the studies examined, and of the poor quality of some studies, they call for further qualitative research in this area.

A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 2. Qualitative studies

David Winter, Siobhan Bradshaw , Frances Bunn & David Wellsted

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