Client engagement in psychotherapy has been identified as a significant component of the therapeutic process, and research has found compelling links to psychotherapy outcomes. Attachment theory has been used to explore the various domains of client engagement in therapy. Specifically, the development of the therapy relationship and the client’s engagement in therapy can be understood as reflecting how a client forms new relationships in general. The primary aim of this dissertation is to explore how the attachment styles of adult clients and beginning therapists (still in training) influence clients’ engagement in individual psychotherapy, in terms of regularity of attendance, self-disclosure of important/relevant topics to the therapist, and the client’s perception of the working alliance. More specifically, this study explores the roles of client and therapist attachment style in client attendance and client self-disclosure, over and above what is explained by the alliance’s relationship with these other engagement measures. Data used in this dissertation were collected as part of an ongoing longitudinal study conducted at the Dean Hope Center for Educational and Psychological Services, a community-based outpatient training clinic at Teachers College. Participants were 181 adult individual psychotherapy clients and their masters and doctoral level student-therapists (n = 118). In this study, client and therapist attachment style (attachment avoidance and attachment anxiety) was measured using the Experiences in Close Relationships Scale- Short Form. The client engagement variables were measured using the client-rated Disclosure to Therapists Inventory-IV (client self-disclosure and self-disclosure discrepancy), the client-rated Working Alliance Inventory- Short Form (client-rated alliance), and objective measures of client attendance at scheduled sessions collected from a review of clinic attendance records (session attendance). Results showed no significant relationship between client or therapist attachment styles, or their interaction, and the client-rated alliance in this sample. Results also indicated no significant relationship between client or therapist attachment styles, or their interaction, and attendance during the initial sessions of therapy, after accounting for any effects of the alliance. However, results did show significant relationships between client and therapist attachment style and attendance in therapy after the initial sessions and self-disclosure discrepancy (extent of self-disclosure based on importance and relevance of topics to the client), after controlling for any effects of the alliance. Specifically, results showed that clients with a more secure attachment style had a higher percentage of attendance after the initial therapy sessions than clients with a more insecure attachment style. In addition, clients whose therapists were higher on attachment anxiety had a lower percentage of attendance after the initial therapy sessions, whereas clients whose therapists were higher in attachment avoidance had a higher percentage of attendance after the initial therapy sessions. Results also showed that clients with higher attachment anxiety showed greater self-disclosure discrepancy, in that they disclosed less to their therapists than was expected based on the salience of topics to clients. There was also a trending interaction between therapist attachment avoidance and client attachment anxiety on self-disclosure discrepancy. Study findings are compared to findings in the literature, and results are discussed in terms of attachment theory. Specific limitations and strengths of the study are then discussed. Implications of the study findings in terms of the development and training of beginning therapists are outlined. Findings in the current study indicating that client and therapist attachment style play a role in client attendance at therapy sessions and client self-disclosure in sessions, point to the need for more research in this area and additional consideration of the relationship between these variables and how they impact the therapeutic process, and ultimately therapy outcome.

The thesis is an exploration of a patient’s use of her body in intensive psychoanalytic psychotherapy. The therapeutic encounter studied is between myself, a child and adolescent psychotherapist working in an NHS Child and Adolescent Mental Health Team,and a fifteen-year-old female diagnosed with depression. Pivotal sessions were examined: where significant shifts in the therapy were identified. These consisted of sessions where there was a transformation in anxiety; and the patient was able to verbalise what was otherwise being communicated in a bodily way. The analysis of the data using grounded theory highlighted the importance of visual communication in the therapeutic encounter. The analysis indicated that vision is the receptive point for the beginning of the containment process. The analysis of the data also highlighted that when the patient is communicating intense primitive anxieties, the therapist needs to receive and process the anxieties at a bodily level, when the patient is, perhaps for the first time, coming into contact with the feelings from which they have dissociated. The analysis of the data indicated that mirroring back emotional states that are congruent with those projected by the patient, makes thepatient aware of themselves in terms of the effect they have on others. This suggests the importance of the therapist’s non-verbal responses, which can be observed and introjected by the patient. The study contributes to the understanding of bodily communication in the therapeutic exchange. It raises interesting technical issues about when the therapist should receive and hold the patient’s projective identification at a bodily level and reflect back non- verbally that their communication has been received, and when to make a verbal interpretation. It also highligh ts the use of observation to gauge if the patient has been able to receive the therapist’s communication at a bodily level.

Purpose: Honest disclosure about salient information is at the heart of the therapy process but sexual material has been found to be among the most frequently concealed types of content. Understanding why clients choose to be avoidant or explicitly dishonest about sexual topics may attune therapists to the types of concerns clients have when deciding whether or not to disclose this material, how non-disclosure or dishonesty about sex impacts therapy, and what would help clients be more honest about such material. This study directly queried clients who had been dishonest about four types of sexual content in order to learn how therapists can better promote honest disclosure about different domains of sex and sexuality. Method: As part of a comprehensive study of client “secrets and lies,” a sample of 798 outpatient therapy clients rated their dishonesty or honesty about four sexually related topics (“details of my sex life,” “my sexual desires or fantasies,” “my sexual orientation,” and “times I have cheated on a partner”) and completed measures about attitudes toward disclosure along with ratings of the therapeutic alliance. Follow-up samples of clients who stated that a sexual topic had been hardest to talk about in therapy answered multiple-choice and open-text questions about their motivations for being dishonest with the therapist, how it impacted them in terms of therapy progress and feelings about the decision, and what they believed the therapist could do to help them be more honest about this topic. Results: Two types of sexual content – “details of my sex life” and “my sexual desires and fantasies” – were the most common topics of dishonesty across the whole sample. Dishonesty about sex tended to manifest in total avoidance of the topic in therapy. Approximately 80% of clients indicated that their motivation for dishonesty was to avoid shame or embarrassment, while smaller numbers reported concerns about how the therapist would react to the disclosure. These clients cited worries about being stigmatized or judged, or felt unsure that the therapist would understand or be able to help; some referred to their belief that the therapy relationship could be jeopardized if they were more disclosing, a particularly salient theme for those who had been dishonest about sexual orientation and sexual fantasies. Based on a multiple choice format, a majority stated that their dishonesty about sexual issues had “no effect” but in an open-text format, a majority described more negative impacts, mainly the inability to address a relevant topic. A significant number of clients felt conflicted, guilty, or regretful about being dishonest, though some felt largely neutral; very few had positive feelings. When asked what would help facilitate honesty, about 80% of clients stated their wish for the therapist to “ask directly.” Some differences occurred in terms of specific facilitators based on topic. For instance, clients who had concealed a more overtly sexual topic (e.g., “details of my sex life” and “my sexual desires or fantasies”) wanted the therapist to normalize or provide a rationale for why it would be helpful to disclose; clients who concealed their sexual orientation wished for the therapist to display cultural competence and to ensure the safety of the relationship; and clients concealing infidelity were unsure if there was anything the therapist could do. Limitations: The findings of this study may be limited in its generalizability due to a few key factors. First, the sample contained a majority of highly educated Caucasian female clients, which mirrors the therapy-seeking population but may not accurately reflect the concerns of male or minority clients. Second, it was comprised solely of individuals who were willing to speak more about their experience in therapy, while the follow-up samples contained respondents who identified that a sexual topic had been hardest to talk about in therapy. Finally, self-report data is by its very nature limited by the willingness of clients to answer accurately. As such, it is unclear how these data extend to the general or clinical population more broadly. Conclusions: The concerns expressed by clients suggest that shame and the anticipation of a negative therapist reaction primarily motivate sexual dishonesty, and that direct inquiry by the therapist can help alleviate both of these interconnected worries by signaling that sex is a welcomed topic of disclosure. These findings also indicate the high prevalence of dishonesty about a spectrum of sexual topics and highlight the way that clients tend to avoid these discussions, which further supports the need for more active therapist intervention to frame the rationale and normalize honest discussion about clinically relevant sexual material.

Research regarding the experience of the psychotherapist in the therapeutic interaction is uncommon in scientific literature and rarer still in the literature of the U.S. When Freud recognized the therapist’s emotional experience in response to the client, he termed it countertransference and identified it as counterproductive to the analytic process. Later it was recognized as containing potentially useful information about the client. Despite a shift in academic concern away from the clinician’s experience, outcome studies have demonstrated the importance of the therapeutic relationship. If the therapist’s experience can help or hinder the relationship and, therefore, the process of therapy, it must continue to be explored. Some researchers have suggested that the field may be disproportionately populated by individuals who had excessive emotional demands placed on them as children (Miller, 1979/1990). Jurkovic (1997) proposed that, along with strengths endowed by this childhood responsibility, parentified therapists may find themselves more vulnerable to a sense of duty that they must help clients. Similarly, these therapists might feel compelled by their empathic concern to go above and beyond. The experience of a therapist in such a situation might be to “feel in too deep with a client” – the phenomenon of concern for this study. Ten practicing, doctoral level psychologists were asked to describe a specific experience in which they felt in too deep with a client. Selection analysis and situational descriptions were reviewed with each participant. Four core themes emerged. They revealed the participants’ experience of feeling in too deep as involving a variety of distressful thoughts and feelings. A specific cluster of feeling insecure, confused, or not in control was universal. The other three core themes were challenge in connection, altering personal style of therapy, and balancing the wants and needs of the different people in the therapy relationship. The unique experiences of participants relative to the core themes are discussed. Recent research on therapist-identified difficult situations provides a context for understanding these themes. Feeling in too deep is considered as a response to an ethical challenge.

Thesis (M.S.)--University of North Texas, Aug., 2009. / Title from title page display. Includes bibliographical references.

Thesis (Ph. D.)--West Virginia University, 2002. / Title from document title page. Document formatted into pages; contains viii, 170 p. Includes abstract. Includes bibliographical references (p. 108-157).

Thesis PlanB (M.S.)--University of Wisconsin--Stout, 2009. / Includes bibliographical references.

In the past decade the healing potential of mindfulness and its practice has gained widespread recognition across various health disciplines and institutions, especially mental health. Past and current research on mindfulness interventions have focused almost exclusively on the beneficial effects for clients. However, there is a serious shortage of research on how mindfulness practice influences therapists and their work. The current study looked specifically at how the influence of mindfulness meditation (MM) was experienced by therapists in the context of their work. An interpretive description methodology was used to guide the research process. Semi-structured in-depth interviews were conducted with six therapists who practiced MM regularly. A thematic analysis of interview transcripts highlighted commonalities and differences among participants’ perceptions of the influence of MM on their work. Eleven themes emerged from the data analysis. Thematic findings were considered in relation to key issues in psychotherapy, master therapist traits and other contemporary qualitative research addressing the influence of MM on practitioners. The results are discussed with an emphasis on the practical implications for future research, therapist training and clinical practice.

Therapist self-disclosure is an important topic and the literature explains that how a therapist responds to their client can greatly impact the treatment process and therapeutic alliance. One of the ways that therapists respond to their clients is through crying. Although there have been studies that conclude that the majority of therapists do in fact cry in therapy, no studies have tried to understand how this response is perceived by clients. This qualitative study aims to understand the client’s perspective and how therapists’ crying affects the treatment process and therapeutic alliance. The informants in this study were adolescent females who attended a particular therapeutic treatment center. Data was collected through a series of semi-structured interviews. Data was analyzed through a grounded theory approach in which open, axial, and selective coding was used. The results from this study indicate that therapists crying in therapy can be perceived as both beneficial and detrimental in regards to the treatment process and therapeutic alliance.

In the past decade the healing potential of mindfulness and its practice has gained widespread recognition across various health disciplines and institutions, especially mental health. Past and current research on mindfulness interventions have focused almost exclusively on the beneficial effects for clients. However, there is a serious shortage of research on how mindfulness practice influences therapists and their work. The current study looked specifically at how the influence of mindfulness meditation (MM) was experienced by therapists in the context of their work. An interpretive description methodology was used to guide the research process. Semi-structured in-depth interviews were conducted with six therapists who practiced MM regularly. A thematic analysis of interview transcripts highlighted commonalities and differences among participants’ perceptions of the influence of MM on their work. Eleven themes emerged from the data analysis. Thematic findings were considered in relation to key issues in psychotherapy, master therapist traits and other contemporary qualitative research addressing the influence of MM on practitioners. The results are discussed with an emphasis on the practical implications for future research, therapist training and clinical practice.