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.

The power of the IAT is that it doesn't merely score how the words or words and images match—after all, many people try to conceal unflattering answers, from both researchers and themselves—it measures reaction times as well. (You can take a sample IAT at

Researchers, led by Matthew Nock of Harvard University, developed a version of the IAT that searched for associations of a person's sense of self in relationship to death, forcing people to rapidly associate "death" words, like lifeless and suicide; "life" words, like survive and thrive; "me" words, like I and self; and "not me" words, like them and others. They administered the IAT to 157 people who'd shown up at a hospital ER with psychiatric emergencies, 43 of whom were there for suicide attempts. The IAT found that the suicidal patients showed a much stronger association between thoughts of "self" and of "death" than the other psychiatric ER admissions did.

That's merely a descriptive finding, but Nock also followed everyone for six months, and the outcome of the follow-up suggests the IAT may have predictive value. Of the initial group that had attempted suicide, 14 made another attempt, and their IAT scores were significantly more accurate at predicting the suicide attempt than were the at-risk ratings by clinicians who'd interviewed them upon admission to the ER. The IAT also was more predictive than patients' own assessments of whether they'd attempt suicide, although the patients assessed their chances of trying again more accurately than the clinicians did.

It's Not Always PTSD

We've been hearing so much about PTSD for so long that we may forget it's only one possible emotional disorder that can develop after a physically traumatic incident. In fact, as a study in the March issue of American Journal of Psychiatry shows, it's not even the most common outcome.

The study, led by Australian psychologist Richard Bryant of Sydney's University of New South Wales, looked at 1,084 people who'd been admitted to hospitals for traumatic injuries, psychologically assessing them at admission and then 3 and 12 months later. About 33 percent of the people developed disorders subsequently. The most common was depression at 16 percent, followed by generalized anxiety disorder (11 percent), substance abuse (9.9 percent), and then PTSD and agoraphobia (9.7 percent each). Less frequent diagnoses were social phobia, panic disorder, and obsessive-compulsive disorder. This outcome is a reminder to clinicians not to assume that depression, anxiety, or other symptoms are secondary to PTSD; rather they need to be a separate, often primary focus of effective trauma treatment.

Bryant's findings are consistent with earlier, smaller studies of trauma victims, and may even provide an answer to the perpetual question of why some people develop PTSD following physical trauma, while others develop depression, anxiety, and other disorders. "Some research suggests that the appraisal of the event and the immediate, or shortly following, emotion may increase the likelihood of one type of disorder over another," says Yale PTSD researcher Joan Cook. For example, fear or horror may be likelier to lead to an anxiety disorder and sadness or guilt to a depressive disorder. Other researchers have noted that people who dissociate, especially shortly before or after the trauma, are likelier to develop PTSD.

However, Bryant's study found a strong connection between mild traumatic brain injury (TBI) and PTSD. Those who suffered mild TBI were more than twice as likely to develop PTSD as those who didn't. This raises the possibility that PTSD could result from a combination of actual brain injury and hyperactivated neural fear circuitries, rather than from strictly neurological and emotional reactions.

Meeting Clients' Needs

A frequently replicated finding in psychotherapy research is that therapists and clients often have different notions about how therapy is progressing. They frequently disagree when asked separately to rate the quality of the therapeutic alliance, whether therapy is working, or what the turning points in treatment were.

"When you're a therapist, you think you know the most important things about your client and therapy," says alliance researcher Robinder Bedi of Bellingham's Western Washington University, "but it's the client's perceptions about how things are going that have the greatest predictive value of the outcome of therapy." Therapists who pay more attention to their own intuitions and conceptions may be more "right" than their clients by some objective measure, but if their clients have other ideas, such therapists are likely to end up with a handful of notes and no clients.

In the March issue of Counselling Psychology Quarterly, lead author Carlton Duff, a doctoral candidate at the University of Alberta, and Bedi argue that therapists may do better therapy by paying more attention to the behaviors that are most appreciated by clients. They asked 79 clients who'd recently been in therapy to rate their therapists on 15 variables thought to affect the alliance. Then they assessed the alliance's strength using the short form of the Working Alliance Inventory. The results: the most powerful alliance-building behaviors turn out to be basic human courtesies and fundamental relationship skills, which have nothing to do with therapists' techniques or diagnostic abilities. Greeting clients with a smile, making eye contact, sitting still without fidgeting, identifying and reflecting back feelings, making encouraging and positive comments, truthfully sharing negative information, normalizing feelings and experiences, and remembering details from previous sessions turned out to be extremely important factors, accounting for 62 percent of the variance in the strength of the alliances.

Bedi worries that today's psychology education isn't emphasizing relationship-building skills enough. "We tend to get seduced by techniques and strategies," he says. "We need to focus more on empirically supported therapists, rather than empirically supported treatments." Duff concurs, "Simply making clients feel like they're important and that their experience is valid may be among the most important things we can focus on in therapy."

As Time Goes By

Time isn't just money: it's the essence of our existence, and how we experience time affects how we experience our lives. When we're deep in meditation, or even in a state of flow and completely absorbed in what we're doing, we come as close to transcending the ticking clock as mortal beings can. Research seems to indicate that we do better work when we're in a state of flow or after meditating. But increasingly, we find ourselves harried and cut off from any possibility of flow.

A sense of accelerated time has been shown to breed anxiety, depression, disconnection from others and ourselves, and even a sense of meaninglessness. In a classic 1977 experiment, seminary students were asked to prepare a lecture on the Good Samaritan. Then the researchers instructed some of the students to hurry over to another building to present a lecture on the subject and told others that they had plenty of time, but that they might as well get there early. Along the way to the lecture hall, they all passed someone who appeared to be gagging and fainting. Only the students who thought they had plenty of time before they delivered their lecture on the Good Samaritan stopped to help. The connection between heartlessness and time pressure is explored further by psychologist Robert Levine in his 1997 book, A Geography of Time. He writes that, generally, in cities with the fastest pace of living, people are the least likely to do such simple acts of kindness as give change for a dollar or help a blind person across a street.

Reviewing the research on the subjective sense of time and adding their own studies, psychologists William Friedman and Steve Janssen report in the June issue of Acta Psychologica that, these days, young adults and older people alike feel that time is moving unexpectedly quickly. They add that as far back as the 1970s, people of different age groups have reported a sense that time is speeding up.

"We are hertz machines in a megahertz world," write psychologists Philip Zimbardo and John Boyd in their 2008 book, The Time Paradox, pointing out that human brains have a processing speed of about 4 hertz compared to desktop computers with more than 3 gigahertz—75 million times faster. In the 1950s, futurists predicted that the biggest problem facing human beings at the end of the millennium would be what to do with all the leisure time that machines would create, but we've since learned that the more "time-saving" devices we have, the more things we feel compelled to do—and the more quickly. Many of today's efficiencies appear to be robbing us of both quality of life and time.

Psych Textbooks: What's New?

Introductory psychology textbooks don't merely present information: they're conceptual gatekeepers, influencing how the field is defined and redefined over time. In the April edition of the Observer, published by the Association for Psychological Science, eight authors of classic introduction to psychology textbooks talk about the trends and research that are noteworthy enough to merit inclusion in their latest editions—as well as the difficulties of incorporating the new material.

The article illustrates how the axis of psychology has shifted as a result of the developments in biological psychiatry. Today, says Susan Nolen-Hoeksema, a coauthor of Atkinson and Hilgard's Introduction to Psychology, "Instructors have to fight against students' assumptions that mental disorders are only due to biological factors, and that biological treatments are always better than psychological ones."

Another development is that multiculturalism has grown from a whisper to a roar. Charles Morris, whose Psychology: An Introduction was first published in 1973, says that, in 1970, a search of the PsycINFO database using the keywords diversity, gender or cross-cultural yielded 48 articles. In 2008, it resulted in 4,210. "Twenty-five years ago," write Carole Wade and Carol Tavris, whose Psychology is now in its 10th edition, "proposals to make women 'normal' in psychology and to include the study of cultural influences on behavior were . . . ideological goals rather than scientific ones." Now, in his 2010 edition of Psychology, Peter Gray discusses different sociocultural perspectives on disorders such as anorexia, schizophrenia, AD/HD, and taijin kyofusho (a Japanese-specific social anxiety disorder).

More and more textbook writers face the challenge of sifting through mountains of new knowledge and making decisions about what to include. At the same time, they're being pressed to reduce the number of pages by publishers responding to increasing production costs, protests about the price of textbooks, and the more limited timeframe available to digest the material brought on by shorter school semesters. Compromises are inevitable—never a good alternative where knowledge is concerned. For example, Nolen-Hoeksema feels pressured to include more about ESTs and less historical review, but can psychology and other social sciences be fully understood without their history?

Perhaps the greatest intellectual challenge to writers is the growing movement toward integration in science. The trend to link the discrete branches of science has been gathering momentum for some time, and was brought to public attention by such thinkers as sociobiologist Edward O. Wilson in his 1998 book, Consilience: The Unity of Knowledge. "Many of the best and brightest researchers today in psychology identify with hyphenated areas, such as social-affective-developmental-neuroscience," says James Kalat, whose Introduction to Psychology has just gone into its ninth edition.

But the growing emphasis on integrative approaches doesn't easily fit into what have become standardized ways to organize textbooks. Basically, says Carol Tavris, coauthor of Psychology, textbook writers are expected to provide a historical introduction and include chapters on research methods, personality, the brain, sensation and perception, thinking, memory, development, social psychology, abnormal psychology, therapy, learning, motivation, and emotion. Thus the desire to create a taxonomy of knowledge may end up fostering an inadequate model of psychological understanding and current research.

On top of all these pressures, textbook authors confront another problem. According to Tavris, counterbalancing all the efforts to transform the paradigm for teaching psychology is a simple fact: many instructors don't like to completely revamp their syllabi.


Therapeutic Connection: Psychotherapy Research 20, no. 3 (May 2010): 309-20; Psychotherapy Theory, Research, Practice, Training 47, no. 2 (June 2010 ): 260-67. Suicide: Psychological Science 21, no. 4 (April 2010): 511-17. PTSD: American Journal of Psychiatry 167, no. 3 (March 2010): 312-20. Clients' Needs: Counselling Psychology Quarterly 23, no. 1 (March 2010): 91-110. Time: Acta Psychologica 34, no. 2 (June 2010): 130-41. Textbooks: Observer 23, no. 4 (April 2010).

Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.


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