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Clinician's Digest

Clinician's Digest

By Garry Cooper

The Therapeutic Connection

From the time of Sigmund Freud, a core belief in the therapy profession has been that clinicians should be trained rigorously in a specific technique and orientation to keep treatment on track. But two recent studies conducted half a world apart suggest that, irrespective of their specific training, most therapists pay more attention to making and maintaining a connection with their clients, especially when treatment doesn't seem to be working.

A study led by Christian Moltu of Helse Forde, a governmentally-run Norwegian psychiatric clinic, reported in the May Psychotherapy Research, finds that, when the going gets rough, clinicians focus far more on repairing the therapeutic bond than on diagnosis and technique. Moltu's team asked 12 highly experienced therapists from different orientations to select one extraordinarily difficult therapy impasse they'd encountered, and then had in-depth discussions with them about what they'd felt during the impasse and how they'd dealt with it. Every therapist in the study—cognitive-behavioral, psychodynamic, psychoanalytic, and body-oriented—reported they felt negative feelings toward their clients during impasses. But rather than thinking diagnostically about them or relying on specific treatment interventions, they'd worked through these difficulties by striving to find their way back into a supportive, empathic connection with their clients.

"If you have only technique to fall back on," a psychoanalytic therapist reported in the study, "you can really isolate that from what's human. . . . It's being mechanical." A psychodynamic therapist said, "I feel I have a special responsibility for carrying hope, for believing that we can come through." A cognitive-behavioral therapist found it helpful to remind herself that, as a therapist, she'd made a choice. "I said to myself that I'm her therapist. I don't ask her if she wants me to be her therapist. . . . The challenge is being able to tolerate the human feelings . . . being there [with the patient] in it."

In the June 2010 Psychotherapy Theory, Research, Practice, Training, Yale psychologist Joan Cook reports on her survey of more than 2,000 Psychotherapy Networker readers. She found that although most identify themselves primarily as eclectic or cognitive-behavioral, most also incorporate a client-centered humanistic perspective. When asked about their actual therapeutic process, as opposed to their orientation, a whopping 97 percent said warmth, caring, and respect were crucial to their work. Almost as many said they empathized with their clients' feelings and struggles, and focused on cultivating the therapeutic relationship. Among the least frequent approaches cited were processes irrelevant to relationship-building—the empty-chair technique or role playing, analyzing dreams or referring to outside resources.

It might be argued that Networker subscribers, a relationship-oriented group, aren't representative of therapists as a whole. However, Cook points to similar findings in other surveys of therapists and speculates that the magazine's subscribers are probably a more representative sample of clinicians than surveys based on membership in specific associations.

Predicting Suicide

Suicides are notoriously difficult to predict, for several reasons. Some clients who've decided to kill themselves will purposely conceal it from their therapists, family, and friends. Others may not realize they're perilously close to taking action because suicide is frequently an impulsive act. One study finds that 78 percent of people who killed themselves denied feeling suicidal in their last verbal communication. Yet, trying to determine who potentially might commit suicide through diagnosis casts too broad a net. Now a study in the April Psychological Science finds that a simple diagnostic test that can be completed in five minutes may predict suicide attempts with a greater degree of accuracy than clinicians' assessments.

The Implicit Association Test (IAT) purports to determine unconscious mental associations, but unlike such classic instruments as the much-maligned Rorschach test, it does so without relying on the subject's or the researcher's interpretations. People sitting at a computer make rapid, forced-choice decisions that associate words or words and images. For example, a picture of a young girl might appear on half the screen and the words good and bad on the other half. Subjects must instantly choose the word they feel matches the image by striking either the right or left key on the keyboard. These and other word choices appear and reappear with other images—a white man, a black man, a church. The amount of time in which people take to pair images with "good" or "bad" is believed to provide a measure of the implicit associations that the subject holds.

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