Principles of Change : Client Perspectives on Corrective Experiences

CASPR 2009 (Montreal, Canada)

10.24.09

1

CollaboratorsCollaborators Lynne Angus, York University

Michael Constantino, University of Massachusetts Amherst

Micki Friedlander, University at Albany/SUNY

Laurie Heatherington, Williams College

Stanley Messer, Rutgers University

2

Purpose of the Study What are the core features of

clients’ accounts of corrective experiences?

Are these accounts similar across different types of therapy or are they unique to each therapy?

What is the role of self-awareness in corrective experiences?

Do different understandings of corrective experiences emerge as time passes, i.e., a “sleeper effect?”

3

CE Questionnaire CE Questionnaire (every 4(every 4thth

session)session):: Have there been any times since you

started the present therapy that you have become aware of an important or meaningful change (or changes) in your thinking, feeling, behavior or relationships? This change may have occurred in the past four weeks or any time during the present therapy.

Please describe such change (or changes) as fully and vividly as possible.

If yes, what do you believe took place during or between your therapy sessions that led to such change (or changes)?

4

Emerging Major Categories: Question 1 (what?)

Stronger, positive sense of self

New awareness (more emotional than cognitive)

Recognition of hope, or reason to hope

New perspectives (more cognitive than emotional)

Changes in behavior

Acquisition/use of specific new skills

5

Question 2 (How ?)Therapist : helped client uncover/revisit past

problematic feelings or events

therapist directive to pay attention

therapist observations of client’s patterns

encourages client to own and express feelings

acceptance, positive regard, nonjudgmental, warm

teaches specific techniques (e.g., breathing, mindfulness)

gives advice, suggestions that client uses

provided new understanding of the basis of the clients’ problems

6

Question 2, (How ?) Client:

implemented techniques outside therapy

implemented something learned outside therapy

self-reflection

self-realization or insight

reviewed therapy experiences between sessions

disclosed disturbing events took responsibility for own behavior

tried to be honest, cooperative

paid attention to others who were successful

7

Question 2, (HOW ?) Client and Therapist

Something client and therapist did together

Role playing

Overcoming faulty logic

Focusing on the past

8

Question 2, (HOW?) External

changes in external demands

changes in daily routine

specific event prompted reflection

medication

unsure

9

Albany Medical Center Outpatient Clinic

Clients: 3 men, 10 women

Therapist: 1 man (highly experienced psychiatrist)

CE Questionnaires: 45

Theoretical Orientation: Short-term dynamic therapy

10

Brien Center for Mental Health & Substance Abuse Services(Pittsfield, MA)

Clients: 23

Therapists: 3 women

CE Questionnaires: 24

Theoretical Orientation: Cognitive-Behavioral Therapy

11

Examples (Question 1, what?) Psychodynamic:

“I am more aware of my feelings and needs. I am becoming closer to my family, mother and brothers. I do not feel like such an outcast.”

Cognitive-behavioral:

“I have learned better how to deal with my depression and anxiety. I’ve learned many skills that help me get through times I feel like giving up and when it feels hopeless.”

12

Examples (Question 2, something client did):

Psychodynamic:

“I pay more attention to what I say and how I say things to my children, and husband. I am more aware of how words, looks, and body language can change the tone of the conversation. I also see myself projecting my insecurities of being left, ignored and forgotten to my job and how I feel I am viewed outside of the home.”

Cognitive-behavioral:

“Part of it is mindfulness. Slowing down and making choices rather than just reacting. Making it be okay to have feelings like fear, sadness, and anxiety.”

13

Examples (Question 2, therapist behavior):

Psychodynamic:

“ I believe it’s the ‘gentle shove’ of questions that make me see what I have been trying to ignore since childhood.”

Cognitive-behavioral:

“My therapist explains to me things that I trust and understand. And knowing more about my mental problems really helps me deal with them.”

14

Rutgers University The Psychological Clinic – Training

Clinic

Clients: 6 female, 4 male

Therapists: 9 female, 1 male

Graduate Psychology Trainees

CE Questionnaires: 44

Theoretical Orientation: Psychodynamic & CBT

15

SA. 12th Session Question 1: Today I had a very powerful therapy

session. With the help of my therapist, I realized that I have internalized a judgmental voice. I often criticize myself and assume others are doing the same. In response, I either lash out by being critical of others, or become dependent and rely on others to discover answers for me.

Question 2: My therapist has spent the last 3 sessions focusing on my relationship with her. When I told her about new developments in my life, she asked me how I felt telling her. We realized how much I was projecting my own negative self-image onto her, using my self-critical voice to speak for her. Using our relationship as a mirror really helped us get closer to having an effective therapist/patient relationship as well as helping me see the boundaries I had to work on for myself.

16

C. 12th Session Question 1: My feelings toward emotions has

changed today. I'm less confrontational toward them and acknowledge (at least to some degree) that they still affect me, even when I ignore them, push them aside, or try to rationalize myself out of them.

Question 2: My therapist and I were talking today about a recent event with my friend and how I was angry, but didn't express it at the time. My therapist reminded me that babies express constantly without thought and said emotions are perfectly fine; It's what you do with them that counts for or against the situation. It's ironic, because writing this just now reminded me that I gave this advice to my boyfriend a little while ago but I was never comfortable with it for me.

17

SE. 24th Session

Question 1: I am more aware of how I am responding in situations we have discussed - times when I am overcome with shame, when I get embarrassed and shut down, when I am too uptight to enjoy myself. This allows me to try to make little changes. Therapy is also getting harder - more emotionally challenging. I am more nervous to come in thinking about the feelings I have to confront.

Question 2: In sessions we have been noticing more walls within me and I have been struggling to figure out what I am blocking from my therapist and even from myself. It feels like even in discovering this we are getting somewhere but it is difficult.

18

H. 12th SessionQuestion 1: I never really knew how much

being angry scares me and reminds me of people who have hurt me in the past. That is probably why I just clam up when I’m angry. I’d rather make excuses for other people’s bad behavior than let myself get angry. I also realized how my tendency to blame myself and assume I’m at fault led me to unintentionally “lock people out” of my life.

Question 2:I knew these feelings became more clear to me during and after therapy. My therapist helped me verbalize and understand my feelings regarding my poor sense of self worth, and the results of those feelings.

19

R. 4th Session

Question 1: Since the challenges from my therapist to change my ways, I’ve had better days, without my ruminating over regrets or the future, or being present in more of my actions and settings.

Question 2: Yes, the last several sessions have been very impactful. My therapist made me aware of how I have difficulty relating to people and confronting them by showing me how my relationship with her is a prime epitome of my issues with others.

20

University of Massachusetts Amherst Psychological Services Center -

Training Clinic

Clients: 1 man, 2 women

Therapists: 3 female graduate trainees (1-2 years of experience)

CE Questionnaires: 5

Theoretical orientation: Eclectic

21

Training Clinic Research: Training Clinic Research: BenefitsBenefits

Largely untapped resource for science-practice integration, yet favorably situated

Significant administrative control

Equipped with video recording equipment & computer terminals

Infrastructure can promote and accommodate various research designs

22

Training Clinic Research: Training Clinic Research: ChallengesChallenges

Significant administrative oversight – a good thing, but...

Many issues on which to reflect and take action before beginning data collection

Passive recruitment subject to referral “downtimes”

23

Patient 2Patient 2

Session 4; Question 1 (What?)

“I have become less upset when friends were unavailable.”

Session 4; Question 2 (How?)

“I learned to counter automatic thoughts that said they must not want to hang out with me because they don't like me. They were probably just busy.” [client & therapist]

24

Patient 2Patient 2

Session 8; Question 1 (What?)

“When something goes wrong, I am having more success in not blowing things out of proportion so that it escalates into either a panic attack or a particularly bad bout of depression.”

Session 8; Question 2 (How?)

“In therapy, I learned to come up with a list of alternative explanations for the automatic thoughts that I have when something goes wrong.” [client & therapist]

25

Patient 3Patient 3Session 4; Question 1 (What?)

“Back in April during the one year anniversary of the divorce. I wasn't sleeping or eating and thinking about the ex a lot more and wondering how someone who could say they loved me could cheat on me with another guy. Now I realized that I feel used.”

Session 4; Question 2 (How?)

“Getting me to think about whether it was my fault or more if it was her way of being secretive or dating other men. At one time I thought I was the one who made the thing fall apart.” [client & therapist]

26

Still to come…

More data!

Post-therapy interviews with clients!

27