Do patients internalize the positive regard they are offered? A dyadic test of a Rogerian condition.

OBJECTIVE: Positive regard (PR) reflects a therapist's unconditional prizing of their patient, which meta-analytically correlates positively with patient improvement. However, most research has been limited to single-participant ratings of PR at a specific time, which neglects the dyadic and dynamic nature of PR (i.e., fundamental to benefitting from therapist-offered PR is that a patient internalizes it). Testing this premise, we hypothesized that therapist-offered PR at one session would predict patient-felt PR at a subsequent session (two sessions later), which would in turn predict the patient's next-session outcome (within-patient mediation). METHOD: Eighty-four patients with generalized anxiety disorder received cognitive-behavioral therapy with or without motivational interviewing. Therapists and patients provided postsession ratings of their offered and felt PR, respectively, at odd-numbered sessions throughout treatment. Patients rated their worry following each even-numbered session. We used multilevel structural equation modeling to test our hypothesis. We explored whether treatment condition moderated the mediational path. RESULTS: As predicted, when a therapist regarded their patient more than usual following one session, the patient felt more regarded than usual. In turn, this internalized regard was negatively associated with worry. Treatment condition did not moderate this path. DISCUSSION: Results support internalized positive regard as a treatment-common, ameliorative relationship process.

The nature and effects of psychotherapy clients' nondisclosure of eating and body image concerns.

Client nondisclosure about their eating disorders may result in significant delays in receiving treatment and subsequent poorer long-term outcomes. Despite these consequences and the high mortality rate among eating-disordered clients, there is a dearth of research on the concealment of or lying about symptomatology among this population. The present, qualitative study examined a sample of respondents (n = 45) who reported dishonesty in therapy about eating issues and body image concerns and provided information about their motives for, and perceived consequences of, being dishonest about these issues. Thematic analysis of responses to two open-ended questions was conducted by a six-member coding team. Shame was found to be the most commonly offered reason for nondisclosure, specifically, shame about the body, shame about the pathological behavior, and shame from anticipated therapist judgment. A second commonly reported motive was clients' sense that they wanted to avoid unwanted therapeutic interventions into their behavior. Most respondents did not perceive their nondisclosure to negatively affect their therapy. Therapists, we conclude, should generally be more active in their pursuit of accurate information when they suspect clients are engaged in eating disordered behaviors, doing so in a manner that mitigates feelings of shame.

Disclosure in psychotherapy versus in anonymous and non-anonymous online spaces.

OBJECTIVE: The primary aim of this study was to investigate the factors affecting individuals' decisions to discuss specific personal issues in psychotherapy vs on social media, either non-anonymously or pseudonymously/anonymously. METHOD: A heterogeneous sample of participants (N = 443) completed an online survey that included assessments of their therapy experience, attachment style, attitudes towards seeking mental healthcare, and the extent of their disclosures about personally distressing topics in therapy and online under different conditions. RESULTS: Results suggest that attachment style plays a significant role in determining individuals' likelihood of discussing personally distressing topics online and in determining the extent to which they find disclosures in therapy and in anonymous and non-anonymous online spaces to be helpful. CONCLUSION: Clinicians may find it helpful to monitor the extent to which patients disclose personal issues online, checking as to whether patients, especially younger patients and those with avoidant and ambivalent attachment styles, view psychotherapy as an appropriate domain to disclose specific personally distressful issues.

Clients' Perceptions of Changes in Their Therapists' Positive Regard in Transitioning from In-Person Therapy to Teletherapy.

OBJECTIVE: To investigate clients' perceptions of changes in their therapists' provision of positive regard (PR) following their transition from in-person therapy to teletherapy.Method A total of 2,118 clients, predominantly White, female, heterosexual, and in their mid-20s, who had been working with their therapist for an average of 20 months in-person and five months in teletherapy completed a Perceptions of Psychotherapy Process Scale (POPPS). This 42-item measure investigated, at a single time-point, the extent to which participants believed that specific therapist-related behaviors, statements, or attitudes changed since shifting to teletherapy. RESULTS: An exploratory factor analysis revealed, among other factors, a factor comprised of six items related to therapist-provided PR (e.g., "my therapist makes me feel cared about"). Clients' scores on this factor indicated a marginal but significant increase in therapists' provision of PR over teletherapy; these scores also significantly predicted scores on a factor reflecting clients' engagement in teletherapy. CONCLUSIONS: Despite the challenges of an abrupt shift to teletherapy, clients perceive their therapists as communicating PR to the same or even slightly higher degrees as compared to in-person therapy pre-pandemic; therapists and clients have seemingly adapted to the new demands of technology to preserve important elements of the therapeutic relationship.

The nature, motives, and perceived consequences of therapist dishonesty.

Honest communication between therapists and clients is an essential part of the process and values of psychotherapy, but the topic of therapist dishonesty has remained virtually unexplored. This study examined the prevalence, motivations, and perceived consequences of therapist dishonesty. Data were compiled from a Qualtrics survey, including several open-ended questions, of 401 practicing psychotherapists. Findings revealed that virtually all respondents acknowledged having been dishonest with their clients at least once, most often about their own emotional health and their attentiveness in session, and that they were significantly more likely to engage in covert than overt dishonesty. Most felt their dishonesty was in the service of their clients' therapy or wellbeing and perceived no negative consequences of such actions. Novice therapists reported being dishonest with their clients more frequently than therapists with more experience. Directions for future research, as well as the need for training programs to introduce students to this issue, are noted.

Trajectories of depression in psychotherapy: How client characteristics predict clinical improvement.

OBJECTIVE: The current study aims to ascertain the trajectories of psychotherapy clients' symptom change and identify client factors that predict treatment outcome. METHOD: We conducted a latent growth mixture model (LGMM) to identify the change trajectories of 44 clients' depression scores during psychotherapy. Client characteristics were then explored to determine whether any were associated with change trajectories. We examined whether the number of physician visits and/or client self-concealment scores predict 63 clients' improvement after controlling for initial symptom severity. RESULTS: Two trajectories of clients' symptom change were identified: nonimprovers (52.3%) and improvers (47.7%). Nonimprovers had higher levels of self-concealment and baseline depression than improvers. The number of physician visits was associated with higher depression scores at baseline and greater clinical improvement during psychotherapy. CONCLUSION: Clients showed distinct trajectories of symptom change in psychotherapy. Early identification of clients at risk for treatment failure may increase the probability of therapeutic success.

Disclosure, concealment, and dishonesty in psychotherapy: A clinically focused review.

This issue of Journal of Clinical Psychology: In Session focuses on the nature and consequences of psychotherapy clients' disclosures, secrets, and dishonesty, with a particular emphasis on the ways in which therapists can best facilitate greater and more honest disclosure. This introduction to this issue reviews the growing theoretical and empirical literature on the frequency, types, motives, and consequences of client and therapist dishonesty (broadly defined); it also reviews the contributions within this issue, noting the welcome focus of the majority of these papers on the nature of client dishonesty in specific disorders (e.g., eating disorders; substance abuse) and/or specific clinical settings (e.g., prisons). Taken together, these papers speak to the ways that therapists may tailor their clinical interventions to match the specific ways that dishonesty manifests in different clinical populations.

Client deception about substance use: Research findings and a case study.

Findings from a large sample of therapy clients indicate that substance use is among the most widely reported topics of dishonesty; that the primary motives for this dishonesty are shame, fear of being judged by one's therapist, and concern about real-world consequences of disclosure (e.g., being sent to a rehabilitation facility); and that the most widely held client beliefs about what might facilitate greater honesty about substance use include feeling reassured that a therapist would not overreact nor be judgmental. The case report here reflects many of these themes. Discussion focuses on the ways in which therapists might deal with clients who struggle to be consistently forthcoming about their substance use issues, for example, by asking direct questions and by discussing the parameters and consequences of client disclosure on this topic.

Ready when you are: Answering your questions about psychotherapy.

Psychotherapeutic treatment tends to have a high attrition rate ("premature termination") and there have been multiple efforts to help new patients, including those considering treatment, better understand the nature and expectations inherent to this process as a means to improve retention and outcome. These efforts are often grouped under the term "role induction." This script, from a DVD produced in 2010, was written to help prepare new psychotherapy clients for this new role in their lives-specifically, to educate prospective patients about the unique and sometimes surprising features of psychotherapy and to empower them to ask questions of their therapist about the process. This script presents a conversation that takes place among three patients in the waiting room of a psychotherapy clinic who speak about common fears, misconceptions, and uncertainties surrounding psychotherapy.

Psychotherapists' preferences for television and movies during the early stages of the COVID-19 pandemic.

This study investigated psychotherapists' media use since the onset of the COVID-19 pandemic. A total of 186 psychotherapists completed a 15-item self-report survey on the movies and TV shows they had watched, and the reasons for their choices, since the outbreak of the COVID-19 pandemic. Results indicated therapists primarily watched material they described as comedic, distracting, thought-provoking, and psychologically engaging. In addition, they reported choosing media that appealed to their spouses and/or children. It is theorized that therapists' media selections are reinforcing their regulatory flexibility, allowing them to grapple with the harsh reality of the pandemic while simultaneously providing themselves emotional safety and relief in the form of distancing and distraction.

"It is never okay to talk about suicide": Patients' reasons for concealing suicidal ideation in psychotherapy.

Objective: To identify psychotherapy clients' motives for concealing suicidal ideation from their therapist, and their perceptions of how their therapists could better elicit honest disclosure. Method: A sample of 66 psychotherapy clients who reported concealing suicidal ideation from their therapist provided short essay responses explaining their motives for doing so and what their therapist could do to help them be more honest. Content analysis was used to identify major motives and themes in these responses. Results: Seventy percent of suicidal ideation concealers cited fear of unwanted practical impacts outside therapy as the reason they did not disclose. Chief among these unwanted impacts was involuntary hospitalization, a perceived outcome of disclosing even mild suicidal thoughts. Less concrete motives for concealment, such as shame or embarrassment, were significant but secondary concerns. Nearly half of suicide-concealing clients said they would be more honest only if the threat of hospitalization was somehow reduced or controlled. Conclusion: Fostering disclosure of suicidal ideation in therapy may require renewed attention to providing transparent, comprehensive, and easy-to-understand psychoeducation about the triggers for hospitalization and other interventions. Clients make risk-benefit calculations about whether to disclose suicidal ideation, but may operate with exaggerated or inaccurate ideas about the consequences of disclosure.

Campus diversity, Jewishness, and antisemitism.

To explore current attitudes among Jewish students, faculty, and leaders of Jewish campus organizations regarding the putative exclusion of Jewish concerns from campus dialogs around diversity, we recruited 40 such individuals to engage in a semi-structured interview. The consensus among our interviewees was that there is a significant, ongoing, and too-often overlooked problem with virulent anti-Israel activity on many campuses that often seeps into antisemitism; that many, though not all, Jewish students are disturbed by this phenomena; that the consequences of anti-Israel hostility on some campuses are felt most significantly by self-identified progressive Jewish students who feel emotionally attacked for pro-Israel sentiments and ostracized in their attempts to join with seemingly progressive and/or intersectional campus movements; that college diversity officers and courses have, for the most part, failed to include issues of concern to Jewish students; and that psychotherapists, especially those on college campuses, maybe unprepared to deal with concerns specific to Jewish students. We believe that the failure to recognize and deal with campus antisemitism is both dangerous and morally disingenuous.

Patterns of utilization and a case illustration of an interactive text-based psychotherapy delivery system.

This paper provides data on the experiences of 267 patients, all with self-reported symptoms of depression or anxiety, engaged in an interactive text-based delivery system for psychotherapy. The paper also offers a case study that illustrates the use of this treatment, indicating ways in which such systems can be useful for patients who may not access or benefit from more traditional therapeutic models.

Honesty in psychotherapy: Results of an online survey comparing high vs. low self-concealers.

Objectives: This study sought to investigate client dishonesty in psychotherapy through the trait of self-concealment. We hypothesized that comparing low and high self-concealers would yield clinically significant differences in the nature, motives, and perceived consequences of client dishonesty. Method: A total of 572 respondents, self-reported as psychotherapy clients, reported about their experience of being dishonest in therapy via a multi-part online survey. Concealment status was assessed using the Self-Concealment to Therapist Scale, an adaptation of the Self-Concealment Scale. Results: Eighty-four percent of respondents reported having been dishonest about one or more topics in therapy, most often "details of my sex life" and "suicidal thoughts." High self-concealers reported more relationally oriented motives for dishonesty and acknowledged more negative effects on therapy than low self-concealers. In contrast, low self-concealers were more likely to report that non-disclosure was based on motives of practicality (e.g., managing therapy time), and that they would be willing to disclose if the therapist asked directly. Conclusions: Low and high self-concealers showed distinct patterns of motives, perceived consequences, and attitudes about facilitating disclosure in therapy. This suggests that self-concealment may be an important variable in tailoring treatment to foster greater and more honest disclosure. Clinical or Methodological Significance of this article: This article adds to the burgeoning literature on dishonesty in psychotherapy and presents a novel exploration of how self-concealment can be used to individually tailor treatment to facilitate increased levels of honest disclosure. High levels of self-concealment, or the trait-like tendency to conceal negative or distressing personal information from others, have been associated with deleterious long-term health and interpersonal effects. By exploring clients' motives for being dishonest, as well as their perception of how it impacted therapy and their self-identified techniques for how therapists can foster more honest, we provide specific clinical recommendations to increase disclosure in psychotherapy.

A qualitative investigation of the nature of "informal supervision" among therapists in training.

Objective: This study investigated how, when, why, and with whom therapists in training utilize "informal supervision"-that is, engage individuals who are not their formally assigned supervisors in significant conversations about their clinical work. Method: Participants were 16 doctoral trainees in clinical and counseling psychology programs. Semi-structured interviews were conducted and analyzed using the Consensual Qualitative Research (CQR) method. Results: Seven domains emerged from the analysis, indicating that, in general, participants believe that informal and formal supervision offer many of the same benefits, including validation, support, and reassurance; freedom and safety to discuss doubts, anxieties, strong personal reactions to patients, clinical mistakes and challenges; and alternative approaches to clinical interventions. However, several differences also emerged between these modes of learning-for example, formal supervision is seen as more focused on didactics per se ("what to do"), whereas informal supervision is seen as providing more of a "holding environment." Conclusions: Overall, the findings of this study suggest that informal supervision is an important and valuable adjunctive practice by which clinical trainees augment their professional competencies. Recommendations are proposed for clinical practice and training, including the need to further specify the ethical boundaries of this unique and essentially unregulated type of supervision. Clinical or Methodological Significance of this article: This is the first study to detail the wide-ranging uses and impact of "informal supervision," with significant clinical implications for psychotherapy training, education, and development, including a proposal for legitimizing and integrating informal supervisory practice into doctoral training programs, and an important discussion of ethics. Thus, this paper highlights the diverse range of important ways that trainees use "informal supervision" throughout their training to enhance their clinical and professional development. Results of our study show that "informal supervision" is a ubiquitous and often secretive practice that is a valuable complement to, rather than replacement for, formal supervision. Several important differences between these modes of learning (formal versus informal supervision) are also discussed.

Facets of Object Representation: Process and Outcome Over the Course of Psychodynamic Psychotherapy.

This study explores the effectiveness of psychodynamic psychotherapy in improving facets of object relations (OR) functioning over the course of treatment. The sample consisted of 75 outpatients engaged in short-term dynamic psychotherapy at a university-based psychological services clinic. Facets of OR functioning were assessed at pre- and posttreatment by independent raters using the Social Cognition and Object Relations Scale-Global rating method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, 1995 ) from in-session patient relational narratives. The Comparative Psychotherapy Process Scale (CPPS; Hilsenroth, Blagys, Ackerman, Bonge, & Blais, 2005 ) was used to assess therapist activity and psychotherapy techniques early in treatment. Independent clinical ratings of OR functioning and psychotherapy technique were conducted and all were found to be in the good to excellent range of reliability. Specific facets of OR functioning improved with medium to large effect changes posttreatment. These adaptive changes were significantly related to the incidence of psychodynamic-interpersonal (PI) techniques. Also, this study identified the role specific psychodynamic techniques had in facilitating change in a number of underlying dimensions of OR. Patient self-reported reliable change in symptomatology and reliable change in facets of OR were significantly related as well. This study highlights the utility of incorporating psychological assessment into psychotherapy practice to assess change at the explicit (symptoms) and implicit (OR) level. Limitations of this study, future research directions, and implications for clinical practice are discussed.

"Clowns to the left of me, jokers to the right": Politics and psychotherapy, 2018.

The election and postelection policies of Donald Trump have seeped into the psychotherapy sessions of many clients, in ways that are somewhat unique but also somewhat reminiscent of the ways that other dramatic social-political events, including 9/11 and the social divisions that were characteristic of the 1960s, were brought into the treatment room. The nine articles within this issue-seven papers from practicing psychotherapists, one from an executive coach, and one empirical paper-suggest strongly that the political events surrounding the election of 2016 have become a significant part of psychotherapeutic discourse for many clients, that many therapists have been willing participants in such discussions, and that a focus on political issues (broadly speaking) can have important clinical benefits, facilitating the therapeutic alliance and leading to greater understanding of long-standing client problems and interpersonal functioning. Taken together, these papers lead to the conclusion that, at a minimum, clinicians need to be sensitive to the very real possibility that their clients are acutely aware of and affected by the political events surrounding the 2016 presidential election and may welcome open discussion of these events and their consequences.

Let's not talk about sex.

This article uses both a case illustration and data from a large-scale survey of outpatient clients (N = 798) to understand the client's perspective about avoiding or being dishonest with his or her therapist about sexual topics. The case study, of a gay young man working with a heterosexual female therapist, explores this client's experience of what happens when it feels impossible to be forthcoming about sex and sexuality. Based on the findings of our study, we note clients' motives for avoiding these intimate yet important areas (e.g., shame), their perception of how this impacts the therapy process (e.g., impedes clinical progress), and their sense of therapist responses and attitudes that could increase their ability to be more honest ("just ask"). We discuss ways in which therapists can facilitate a more open dialogue about sexual material while attending to clients' concerns about doing so.

Introduction: Reflections of Senior Therapists.

This introduction to this issue of JCLP: In Session ("Reflections of Senior Therapists") focuses on the multifaceted ways in which adult development influences what it means to be a psychotherapist and to do the work of psychotherapy. This issue brings together first person narratives written by a group of eminent psychotherapists as well as an empirical report, based on a major international survey, on the challenges, demands, and rewards experienced by senior therapists. Taken together, these essays provide a compelling case that not only can practicing psychotherapy during the later years of one's life continue to be fulfilling and meaningful, but also the lessons learned along the journey can make one an even wiser and more effective therapist than previously. Learning to do psychotherapy, like adult development itself, is not a process that at some point comes to an end, but one that is resumed again and again in every decade. These essays provide a rich array of information, insight, and guidance regarding the personal and professional experience of practicing therapy during every era of adulthood, including one's senior years.

Attachment style, representations of psychotherapy, and clinical interventions with insecurely attached clients.

The primary aim of this article was to demonstrate the clinical utility of an empirically grounded perspective on the complex interplay between patients' attachment style and their ability to create, remember, and use benignly influential representations of their experiences with their therapists. We focused on 2 interrelated questions: Are there significant attachment-related differences in the thematic content of the remembrances and fantasies that patients have about therapy? And, if so, what are the implications for practice? Results of a study of individuals currently in therapy (N = 176) indicated that although all the patients with different insecure attachment styles struggled to evoke positively valenced therapist representations, the specific nature of their representational patterns varied as a function of specific attachment styles. We offer several clinical strategies that may increase insecure patients' abilities to form adaptive representations of their therapist and therapy. We illustrate our recommendations by presenting case material from the psychotherapy of a compulsively self-reliant man.