Psychotherapy Theory, Research, Practice, Training

Introduction to the special section on ethical issues in clinical writing.
This introduction provides an overview of the special section on ethical issues in clinical writing. A summary of the complex issues presented by the author of the lead article (Barbara Sieck), and the four authors who were invited to respond to the paper (Jeffrey Barnett, Mark Blechner, Constance Fischer, and Susan Woodhouse), is followed by a critique of instructions to authors about ethical standards included in Psychotherapy and other journals. It is recommended that journal editorial boards regularly review policies regarding ethical standards about published case material. The introduction concludes with Psychotherapy's newly revised instructions to authors submitting clinical manuscripts, which now require more specific information about how ethical guidelines were applied. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Obtaining clinical writing informed consent versus using client disguise and recommendations for practice.
Clinical writing about psychotherapy clients has long been a part of didactic texts and research articles because it allows new treatments and interventions to be presented in an effective and memorable way. The main ways that clinicians write about their clients include obtaining informed consent, using client disguise, or creating case composites. Although many clinicians use a combination of all three approaches, this article specifically addresses the implications of using clinical writing informed consent. The present article begins with a brief history of clinical writing and an examination of the relevant standards in the current APA Ethics Code and the Health Insurance Portability and Accountability Act; this is followed by a discussion of the benefits of engaging in the clinical writing informed consent process. Subsequently, the limitations of using clinical writing informed consent are explored, including the potentially negative impact on the therapeutic alliance and the client's progress. The article concludes that clinicians should be cautious when deciding to engage in clinical writing informed consent. Recommendations in the form of a checklist are provided to help clinicians identify when it is most appropriate to use client disguise or case composites, and how to do so, as well as when it is appropriate to engage in clinical writing informed consent. Future directions are considered. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Clinical writing about clients: Is informed consent sufficient?
The use of client information in clinical writings or presentations may be very helpful in advancing the knowledge base of the profession. Yet, the very act of asking a client for permission to use their treatment information in this way may be detrimental to the therapeutic alliance and treatment process. As such, great care must be taken in how such issues are considered and acted upon. Sieck's article (2011, Obtaining clinical writing informed consent versus using client disguise and recommendations for practice. Psychotherapy, 49, pp. 3–11.) on the use of informed consent for obtaining permission to use a client's treatment information for professional writing and presentations is examined and discussed. The nature and role of the informed consent process is accentuated; psychotherapist needs and goals and client vulnerabilities are each addressed in the context of the relevant sections of the APA Ethics Code and each psychotherapist's obligation to act only in ways consistent with each client's best interests. Recommendations for a thoughtful consideration of these issues are presented, consistent with Sieck's proposed decision-making process for use in these situations. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Confidentiality: Against disguise, for consent.
I am in favor of asking patients for permission to publish clinical material about them, but am against disguising clinical material. Altering facts to disguise a patient's identity is like publishing false scientific data. Instead, details should be omitted unless they are crucial. While there are quite a few reports of patients who were offended by publications with their clinical material, some patients may be offended if the clinician does not use their material. Whatever the procedure for requesting consent, the tone and mindset of the therapist are critical. There must be clarity, in the clinician's mind and communications, that the patient can refuse consent with no adverse consequences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Comments on protecting clients about whom we write (and speak).
This comment lauds Barbara Sieck's article (“Obtaining clinical writing informed consent versus using client disguise and recommendations for practice”, Psychotherapy, 49, pp. 3–11.) as a solid review not only for therapists but for all clinicians and researchers. Her review also is relevant for assorted spoken presentations and for presentation of psychological assessment excerpts/reports, film clips, and qualitative research data and findings. Procedures that promote adequate disguise are listed, with an emphasis on the importance of authentically engaging the person-to-be-presented in discussion of the intended audience/readers and of what is being illustrated. The latter step serves not only the integrity of the participant but also their sense of contributing and of being respected. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Clinical writing: Additional ethical and practical issues.
The recommendations by Sieck (2011, Obtaining clinical writing informed consent versus using client disguise and recommendations for practice, Psychotherapy, 49, pp. 3–11.) are a helpful starting point for considering the ethical issues involved in the decision to seek or not to seek informed consent from clients before writing about them. Sieck makes a compelling case for the idea that there are circumstances in which the most ethical choice would be to engage in clinical writing about a client without seeking informed consent, but instead disguising the client's identity. The present response raises a number of questions not considered in the article by Sieck. First, how should one disguise a case? Moreover, how should one assess whether the disguise is sufficient to preserve confidentiality while not distorting the clinical material to the point that the material is no longer useful to the field? Second, how can we estimate the likelihood of clients reading clinical writing, particularly in the age of the Internet? Given that psychologist-authored blogs that include reference to clinical material are beginning to emerge, it is crucial that we engage in a much deeper dialogue about the ethics of clinical writing. Third, how does the presentation of clinical material influence public perceptions of psychotherapy and confidentiality? If these public perceptions, in turn, could influence the likelihood of seeking psychotherapy, might these attitudes be important to consider in ethical thinking about clinical writing? Finally, where do we draw the line between clinical writing and single case study research (which requires informed consent)? (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Alliance rupture and repair in conjoint family therapy: An exploratory study.
In this article, we introduce a methodology for studying alliance rupture and repair in conjoint family therapy. Using the System for Observing Family Therapy Alliances (Friedlander, Escudero, & Heatherington, 2006), we identified rupture markers and repair interventions in a session with a single mother and her 16-year-old “rebellious” daughter. The session was selected for analysis because a severe rupture was clinically evident; however, by the end of the session, there was an emotional turnaround, which was sustained in the following session and continued until the successful, mutually agreed upon termination. The first rupture occurred when the psychotherapist suggested that the mother explore, in an individual session, how her “personal stress” may be affecting her daughter. The observational analysis showed repeated rupture markers, that is, confrontation and withdrawal behavior, hostile within-family interactions, and a seriously “split” alliance in family members' expressed feelings toward the psychotherapist. The time-stamped behavioral stream showed that the psychotherapist focused first on safety, then on enhancing his emotional connection with each client, and finally on helping mother and daughter understand each other's behavior and recognize their shared isolation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
“Co-constructing” stigma and the therapist–parent alliance.
Just as many relationships are susceptible to the distorting and distancing effects of stigmatization, so are therapist–parent relationships, particularly in instances where children/youth present with significant mental illness. Therapist awareness and attunement to the dynamics of stigma are critical to the development of engaged therapist–parent alliances, and therapist–parent alliances are key to successful child/youth psychotherapy. Intersubjectivity theory offers a useful lens by which to understand stigma dynamics as mutually reinforced, “co-constructed” experiences between therapists and parents. Applying this perspective provides direction for therapists to work in ways that recognize and reduce the negative impact of stigma dynamics on this important alliance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa.
This pilot study examines the role of therapeutic alliance in relation to weight gain and change in psychological measures during family-based treatment for adolescent anorexia nervosa (AN). Our sample consisted of 14 adolescents with AN and their families. Therapeutic alliance was measured using the System for Observing Family Therapy Alliances Scale. Those adolescents who attained at least 85% of their ideal body weight at the end of treatment had parents who showed a stronger therapeutic alliance with the therapist during the second session of treatment, while adolescents who were remitted on psychological measures showed a higher therapeutic alliance between themselves and the therapist early in treatment. It appears that therapeutic alliance plays an important role in outcome in family-based treatment for AN. Further study is needed in this area to explore the role of the therapist in creating and maintaining a strong therapeutic alliance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Examining therapist comfort in delivering family therapy in home and community settings: Development and evaluation of the Therapist Comfort Scale.
This study reports on the development and psychometric properties of a new measure assessing therapist comfort in the home treatment context and the relationship between therapist comfort, related process variables, and therapist characteristics. Data were drawn from a longitudinal evaluation of 185 families treated by 51 therapists using Multisystemic Therapy (MST). Therapist comfort was measured at four time points. Psychometric evaluation indicated that the measure was internally and temporally consistent. Examination of the measure's validity indicated that therapists' feelings of safety and comfort during the provision of home-based treatment were associated with family neighborhood characteristics and family socioeconomic factors. Furthermore, the therapist's reported level of alliance (as measured by the Emotional Bonding subscale of the Working Alliance Inventory) was related to her/his feeling of comfort. Analyses also indicated that therapists with greater belief in the clinical utility of the MST model felt more comfortable when delivering MST. Together the results suggest that economically disadvantaged families treated in home and community settings may be most at risk for erosions in the therapeutic relationship over time as a function of lower therapist comfort. Because therapist comfort was associated with therapeutic alliance—a factor found to be associated with clinical outcomes across studies and treatment models—findings imply that psychotherapists should regularly examine their own level of comfort, especially when providing services in nontraditional settings, and that therapist comfort should be routinely assessed as part of clinical supervision and training. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Attachment-based family therapy for suicidal lesbian, gay, and bisexual adolescents: A treatment development study and open trial with preliminary findings.
The objective of this paper is to adapt attachment-based family therapy (ABFT) for use with suicidal lesbian, gay, and bisexual (LGB) adolescents and to obtain preliminary data on the feasibility and efficacy of the treatment with this population. In Phase I, a treatment development team modified ABFT to meet the unique needs of LGB suicidal youth. In Phase II, 10 suicidal LGB youth were offered 12 weeks of LGB sensitive ABFT. Adolescents' report of suicidal ideation, depressive symptoms, and maternal attachment–related anxiety and avoidance were gathered at pretreatment, 6 weeks, and 12 weeks (posttreatment). In Phase I, the treatment was adapted to: (a) include more individual time working with parents in order to process their disappointments, pain, anger, and fears related to their adolescent's minority sexual orientation; (b) address the meaning, implications, and process of acceptance; and (c) heighten parents' awareness of subtle yet potent invalidating responses to their adolescents' sexual orientation. Results of Phase II suggest this population can be recruited and successfully treated with a family based therapy, evidenced by high levels of treatment retention and significant decreases in suicidal ideation, depressive symptoms, and maternal attachment–related anxiety and avoidance. This is the first family-based treatment adapted and tested specifically for suicidal LGB adolescents. Though promising, the results are preliminary and more research on larger samples is warranted. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Collaborative Assessment and Management of Suicidality in an inpatient setting: Results of a pilot study.
Patients hospitalized for psychiatric reasons exhibit significantly elevated risk of suicide, yet the research literature contains very few outcome studies of interventions designed for suicidal inpatients. This pilot study examined the inpatient feasibility and effectiveness of The Collaborative Assessment and Management of Suicidality (CAMS), a structured evidence-based method for risk assessment and treatment planning (Jobes, 2006). The study used an open-trial, case-focused design to assess an inpatient adaptation of CAMS, spread over a period averaging 51 days. The intervention was provided via individual therapy to a convenience sample of 20 patients (16 females and four males, average age 36.9) who were hospitalized with recent histories of suicidal ideation and behavior. Results showed statistically and clinically significant reductions in depression, hopelessness, suicide cognitions, and suicidal ideation, as well as improvement on factors considered “drivers” of suicidality. Treatment effect sizes were in the large range (Cohen's d > .80) across several outcome measures, including suicidal ideation. Although these findings must be considered preliminary due to the lack of a randomized control group, they merit attention from clinicians working with patients at risk for suicide. This study also supports the feasibility of implementing a structured, suicide-specific intervention for at-risk patients in inpatient settings. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments.
This practice review focuses on the challenges of conducting sensitive and accurate assessments of the relative risk for suicide attempts and completed suicides. Suicide and suicide attempts are a frequently encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of the most stressful tasks for clinicians. An array of risk factors, warning signs, and protective factors associated with suicide risk are reviewed; however, we are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions. Given the current limitations of assessment strategies, clinicians are advised to keep in mind that patients contemplating suicide are under enormous psychological distress, requiring sensitive and thoughtful engagement during the assessment process. An overarching goal of these assessments should be conducted within the therapeutic frame, in which efforts are made to enhance the therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. Within this treatment heuristic, the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a pragmatic multidimensional assessment protocol incorporating the best known risk and protective factors. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Review of Inside the session: What really happens in psychotherapy.
Reviews the book, Inside the Session: What Really Happens in Psychotherapy by Paul L. Wachtel (2011). In this volume, the author illustrates his theory and techniques of psychotherapy using annotated presentations of three sessions, two with one patient and the third with another. The first quarter of the book is devoted to a description and discussion of the author’s theoretical perspective that he calls “cyclical psychodynamic theory” or “integrated relational psychotherapy.” His approach is grounded in a two-person psychoanalytic perspective and contains elements of cognitive–behavioral, systemic, and experiential approaches. His theory is well articulated, scholarly, and even elegant; and the rationales for his approach are well thought out and compelling. The reviewer believes this book is a model for how all psychotherapy texts should be written and represents the most effective and accurate way to teach in a written format theory and its application. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Review of Heal your brain: How the new neuropsychiatry can help you go from better to well.
Reviews the book, Heal Your Brain: How the New Neuropsychiatry Can Help You Go From Better to Well by David Hellerstein (see record 2011-16360-000). This book articulates and helps create a new watershed moment in psychiatric worldview. To understand this watershed, and to understand its impact on psychotherapy, we need a little historical background. Psychiatric worldviews, as is commonly known, have been in rapid transition—moving over the last few decades from a discourse of psychoanalytic psychiatry to one of biopsychiatry. The 1980 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM)–III and the concomitant push toward more scientific standards is the usual internal marker for this change in psychiatry. A key external factor in the emergence of biopsychiatry is the ascent of neoliberalism (also around 1980), which resulted in more aggressive pharmaceutical and insurance industry influence on the field (Rose, 2003; Moncrieff, 2008; Pitts-Taylor, 2010; Lewis, 2011). Together, these internal and external forces combined to create a new way of perceiving and understanding in psychiatry. In the past, psychoanalytic research, education, and practice in psychiatry were organized around metaphors of unconscious psychic conflicts. In contrast, today’s biopsychiatric research, education, and practice are organized around metaphors of neurochemical imbalances. The change has transformed psychiatry, and it is rapidly affecting the larger culture. As a result, our cultural understandings of human suffering, difference, and healing are all in dramatic transition. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Psychotherapy - Vol 49, Iss 1