Assessing Interpersonal Relationships in Medical Education: the Connection Index

OBJECTIVE

The relationship between a resident physician and his/her supervising attending is foundational to graduate medical education and may impact the clinical learning environment and resident well-being. This paper focuses on how to measure connection between a resident and their clinical supervisor. Connection includes the subdomains of psychological safety, empathy, educational alliance, and feedback.

METHODS

After reviewing the literature, the authors designed the 12-item, 7-point Connection Index (CI₁₂) to quantitatively measure connections between a resident and his/her supervisor during a 6-month period (supervision dyad), and based on educational alliance, empathy, psychological safety, and effective feedback. A 9-criteria evaluation framework was applied to assess its reliability and validity on a sample of psychiatry residents at a residency program, July 2016 through June 2018.

RESULTS

Out of a total possible number of 50 residents, 100% participated to rate 41 supervisors over 201 supervision dyads; the CI₁₂ satisfied all eight of the eight testable criteria, including high scalability (H = 0.78), consistency (alpha = 0.98), test-retest validity (ICC = 0.95), and construct validity where CI₁₂ was found to have statistically significant correlations with outcomes measures (greater connection was associated with less negative emotional experiences, less mistreatment or bias, less burnout, and higher attendance to supervision sessions).

CONCLUSION

The authors showed the CI₁₂ can be a valid and reliable instrument to quantify whether a resident and his/her supervisor connects during a 6-month supervision with respect to empathy, psychological safety, educational alliance, and feedback. We recommend assessing connections as part of the overall evaluation of a resident's experience with the clinical learning environment.

The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals

Supervision is an essential part of the training and work environment of health professionals, especially of psychotherapists and clinical/health psychologists. However, although the supervisory process is always a relational one and may therefore be influenced by attachment dynamics, the importance of the supervisory relationship for the professional's performance and the well‐being of the supervisee has yet to be fully examined.

In this cross‐sectional observational study, the Experiences in Close Relationships‐Revised (ECR‐RD; avoidant and anxious attachment), the Supervisory Relationship Questionnaire (SRQ), the Maslach Burnout Inventory (MBI) and the Sense of Coherence Scale (SOC‐13) were analysed for 346 (81.8% female) health professionals.

Considering professional experience and number of supervision sessions as control variables, a better supervisory relationship negatively predicted burnout symptoms (β = −.31) but positively predicted sense of coherence (β = .31, both p < .01). The final model, including avoidant and anxious attachment as additional predictors, explained 30% of the variance in burnout symptoms and 41% of the variance in sense of coherence.

The results underline the importance of the supervisory relationship for the well‐being and the professional performance of health professionals. Interactions between the supervisory relationship and underlying attachment parameters should be further explored in future studies.

Why did she leave? Development of working alliance in a case of psychotherapy for depression

The present case study aims to explore the unfolding of the working alliance in a case that ended with the client dropping out of psychotherapy, unilaterally cutting off her contact with the therapist. However, both quantitative and qualitative outcome assessments strongly suggested that. An analysis of session transcripts, the Client Change Interview, and the Interpersonal Process Recall interviews for three selected sessions was used to analyze the development of the working alliance and its contribution to the dropout. This case study illustrates how the working alliance is constructed differently during the different phases of the therapeutic process. Specifically, the fruitful problem-solving in the first part of psychotherapy helped the client to improve her functioning. Yet this intervention seemed to exhaust its potential over time, and later the dyad had trouble finding another useful mode of interaction due to the interpersonal context, leading to more serious ruptures and, eventually, to the dropout. The findings are discussed in terms of therapist responsiveness and of its role in the continuous negotiation of the working alliance.

Experiences of breast cancer patients and helpful aspects of supportive-expressive group therapy: A qualitative study

OBJECTIVE

This study explored the experiences and perceived changes of breast cancer (BC) patients after participating in 16-weekly sessions of Supportive-Expressive Group Therapy (SEGT).

METHODS

A semi-structured interview adapted from Elliott's Client Change Interview was carried out with 12 women (aged 33-60 years) with BC, about 6 months after completing the treatment.

RESULTS

Content analysis identified four main themes: expectations and motivations to participate in SEGT, group processes and experiences, perceived changes enhanced by SEGT and perceptions about the therapeutic relationship. The most helpful aspects of SEGT mentioned by participants were as follows: the expression/normalisation of feelings, thoughts and reactions; the improvement of social support; and the learning opportunities obtained through sharing of experiences among participants. Additionally, participants mentioned that SEGT contributed to improve personal and social skills, such as the capacity to express emotions and the ability to establish satisfactory interpersonal relationships.

CONCLUSIONS

Based on the participants' experiences, SEGT seems to be an effective intervention to support women facing BC during the initial phase of cancer. The use of SEGT by health care professionals is encouraged, but the specific needs/problems of each group member should be carefully attended.

"It was hard work every session": Therapists' view of successful psychoanalytic treatments

OBJECTIVE

To explore therapists' experiences of the therapeutic process in successful cases of psychoanalytic psychotherapy.

METHOD

A two-stage, mixed-method design was used. Sixteen successful cases were drawn from a sample of 92 young adults in psychoanalytic psychotherapy according to Jacobson's criteria for reliable and clinically significant improvement. Therapist interviews at baseline and termination were analyzed applying Inductive Thematic Analysis.

RESULTS

Three core themes emerged: Being Particularly Motivated to be This Patient's Therapist, Maintaining a Safe and Attentive Therapeutic Position, and Assiduous Work Every Session. The therapists experienced positive feelings towards the patient from the outset of treatment and described active, relational work that included paying attention to incongruities in the patient's self-presentation and being mindful of patient's avoidant behavior. The therapist's motivation and attentive position made it possible to balance support and challenge in the therapeutic relationship.

CONCLUSIONS

Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads. Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

The professionalization and training of psychologists: The place of clinical wisdom

OBJECTIVE

The current study examines how clinical wisdom develops and how it both is and can be influenced by professional training processes. In this way, the project is studying the intersection of developmental and systemic processes related to clinical wisdom.

METHOD

Researchers analyzed the interviews of psychologists practicing in the USA and Canada who were nominated for their clinical wisdom by their peers. These interviews explored how graduate training and professionalization were thought to influence the development of clinical wisdom and were subjected to an adapted grounded theory analysis.

RESULTS

The findings described both professional and personal disincentives toward developing wisdom, including the dangers of isolation. Therapists reported concerns about educational systems that rewarded quick answers instead of thoughtful questioning in processes of admittance, training, and accreditation. Findings emphasized the importance of teaching multiple psychotherapy orientations, critical self- and professional-reflection skills, and openly supporting graduate students' curiosities and continued professional engagement.

CONCLUSIONS

Recommended principles for training are put forward for the development and evaluation of psychotherapy training programs that aim to foster clinical wisdom. These principles complement training models focused upon clinical competence by helping trainees to develop a foundation for clinical wisdom.

Self-criticism in therapist training: A grounded theory analysis

OBJECTIVE

The primary objective of this study is to engender an understanding of how therapists-in-training experience and cope with self-criticism in the context of their clinical training and therapy experiences.

METHOD

In this study, trainees were interviewed about their experience of self-criticism related to psychotherapy practice and these interviews were subjected to a grounded theory analysis generating a core self-critical process.

RESULTS

The analysis highlighted the vulnerability of self-criticism in therapists' training experiences, especially when they related to balancing the "expert" role while maintaining authentic interactions with their clients. The results also described ways in which self-criticism is mitigated by a sense of interpersonal safety and the provision of clinical freedom and flexibility in therapists' training.

CONCLUSIONS

The implications for future psychotherapy research and clinical training within clinical training environments are discussed.

Effects of parent management training programs on disruptive behavior for children with a developmental disability: a meta-analysis

This meta-analysis determined the effects of parent management training (PMT) on disruptive behaviors in children with a developmental disability. Parent management training programs, based on behavioral theories of psychology, are commonly used in addressing disruptive behavior in children. Eleven studies met inclusion criteria with a total of 540 participants, with 275 in experimental groups and 265 in control groups. The effect of PMT on the disruptive behavior in children with a developmental disability was significant (g=0.39). The moderator effects of type of PMT, delivery type and setting, and administrator level of education were also significant. The moderator effects of child age, and session number and duration were not significant in this meta-analysis.

Kompetenzbereiche in der psychotherapeutischen Ausbildung

Theoretischer Hintergrund: Die Kompetenzbasierung der Psychotherapieausbildung wird immer intensiver diskutiert. Ein Konsens über Komponenten psychotherapeutischer Kompetenz und deren Wichtigkeit in der Ausbildung besteht bisher jedoch nicht. Fragestellung: In diesem Beitrag wird der Frage nachgegangen, welche Kompetenzen Ausbildungsteilnehmer am Ende der Ausbildung erreicht haben sollten und für wie wichtig welche Kompetenzen angesehen werden. Methode: Die offenen Antworten von Leitern psychotherapeutischer Ausbildungsinstitute (N = 129) aus dem Forschungsgutachten zur Psychotherapieausbildung wurden mit qualitativer Methodik ausgewertet. Ergebnisse: Vor allem fachlich-konzeptuelle Kompetenzen (57,2 %) wurden häufig genannt, aber auch personale (21,0 %) und interpersonale (21,9 %). Schlussfolgerungen: Die Aussagen der Ausbildungsleiter stimmen im Wesentlichen mit bestehenden Kompetenzdefinitionen überein, wenngleich die Betonung von Theoriewissen bzw. Fachkompetenzen zulasten von Beziehungsgestaltungs- und personalen Kompetenzen sich nicht ganz mit den Befunden und Kompetenzkonzepten der Psychotherapieforschung deckt.

Schlüsselwörter: Psychotherapie, Ausbildung, Kompetenz, Qualitative Analyse

General practitioners' and psychiatrists' responses to emotional disclosures in patients with depression

OBJECTIVE

To investigate general practitioners' (GPs') and psychiatrists' responses to emotional disclosures in consultations with patients with depression.

METHODS

Thirteen patient consultations with GPs and 17 with psychiatrists were video-recorded and then analyzed using conversation analysis (CA).

RESULTS

Psychiatrists responded to patients' emotional disclosures by attempting to clarify symptoms, by rational argumentation, or by offering an interpretation of the emotions from their own perspectives. GPs responded by claiming to understand the emotions or by formulating the patients' statements, but without further exploring the emotions.

CONCLUSION

GPs displayed a greater engagement with patients' emotions than psychiatrists. Their approach could be described as empathic, corresponding to a mentalizing stance. The different approaches taken by psychiatrists could represent conceptual differences and might affect fruitful interdisciplinary work. Psychiatric nurses' responses to patients' emotions must also be studied to complete our knowledge from psychiatry.

PRACTICE IMPLICATIONS

Experiences from training in mentalization could be used to develop physicians' empathic or mentalizing approach. As most patients with depression are treated in primary care, developing GPs' mentalizing capacity instead of offering didactic training could have a substantial effect in the population.

Do prostate cancer patients suffer more from depressed mood or anhedonia?

OBJECTIVE

This study aimed to compare the prevalence of depressed mood and anhedonia in a sample of men with prostate cancer (PCa) and to determine which of these key symptoms contributed most to the overall depressive status of that sample.

METHOD

From Zung Self-rating Depression Scale (SDS) responses collected on 526 PCa patients, direct comparisons were made between the prevalence of the first two DSM-IV-TR symptoms of Major Depressive Episode. These symptoms were then tested for their predictive power on depression total score and Zung's criteria for 'clinically significant' depression.

RESULTS

Mean scores for anhedonia were significantly higher than for depressed mood, and nearly 25 times as many patients had a high score for anhedonia as for depressed mood. The same pattern of results was apparent for those patients who had clinically significant levels of depression. Anhedonia was a more powerful predictor of total SDS depression score for the entire sample as well as for those patients with more severe depression.

CONCLUSION

Because the biological basis for anhedonia is different to that for depressed mood, treatment options also differ for patients who show a preponderance of anhedonia in their depressive symptomatology. Suggestions are made for treatment choices for these PCa patients.

“Listening With the Third Ear”

This qualitative investigation sought parallels between empathy as experienced in musical performance relationships and empathy as described in therapeutic encounters. Nine professional musicians were invited to offer their reflections on the ways in which relational connections influenced their overall performance experience. Three themes emerged as illustrative of parallels between empathic connections in musical performance and those in therapy: striking a chord, likened to forming an empathic connection; staying in tune, likened to the working relationship; and making music, likened to therapeutic process. Participants emphasized the importance of felt-level mutuality and highlighted its complexity. This study confirms the centrality of the relational bond in forging effective communication and purposeful interaction. Examination of nontherapeutic relational models offers a promising and innovative direction for future study with potential for yielding perhaps deeper understanding of therapeutic constructs. Exploration of empathy in nonclinical relationships may also enhance the accessibility of this ephemeral construct for students and researchers dedicated to capturing its impact in therapeutic process.

Therapist empathy and client anxiety reduction in motivational interviewing: "She carries with me, the experience"

In this article, we examine the use of motivational interviewing (MI) to treat generalized anxiety disorder (GAD) by means of case illustration that focuses on four categories drawn from the client's experience of the key ingredients in MI therapy. The case illustration, drawn from the York study on combining MI and cognitive behavior therapy in the treatment of GAD (uses the client's pre- and post-therapy narrative interviews) to arrive at categories representative of the client's experience of MI therapy. The results of the qualitative analysis highlight the key contributions to positive client outcomes and readiness for change in brief MI therapy for GAD.

The Abiding Nature of Empathic Connections: A 10-Year Follow-up Study

This qualitative study explores the enduring impact of the therapeutic encounter. Participants, who had engaged in therapeutic relationships 10 years previously and endorsed empathy as a catalyst for personal growth, were invited to reflect on their experiences and to articulate ways in which the relationships have continued to shape their ongoing development. Two predominant themes emerged: therapeutic relationship as a foundation for change, and affirmation/enhancement of personal agency, which was characterized by inter- and intrapersonal self-efficacy and by emotional regulation. This study confirms the abiding nature of personal growth well beyond the therapeutic encounter. Ten years later, participants continue to credit the therapeutic relationship as the basis for their personal growth.