The assessment and conceptualization (formulation) processes are closely linked. When we have gathered sufficient information from a patient about their presenting problems, we can link this information to psychological theory, generate hypothesis, and subsequently implement appropriate intervention strategies.
Case conceptualization is the way in which we link theory to practice. By using an explanatory model to view and understand our patient's symptoms, we can help patients understand why problems have occurred, how they were initiated, how they are maintained, and the possible strategies that may be used to ameliorate them and/or prevent future occurrences.
Our text and supplemental readings discuss the importance of a patient-therapist "agreement" when it comes to case conceptualization. What are your own thoughts and opinions regarding this view? What are some of the factors that you feel would help you facilitate a case conceptualization negotiation (as defined in Sperry, p. 131) when working with chronically ill patients?
Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 16, 228–236 (2009) Published online 13 April 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.617
Copyright © 2009 John Wiley & Sons, Ltd.
Early Psychotherapy Processes: An Examination of Client and Trainee Clinician Perspective Convergence Joshua Swift1 and Jennifer Callahan2* 1 Department of Psychology, Oklahoma State University, Stillwater, OK, USA 2 Department of Psychology, University of North Texas, Denton, TX, USA
Convergence in the therapist–client dyad has been hypothesized to play an important role in the development of the therapeutic rela- tionship and in successful therapy outcomes. Further, understanding the client’s views and opinions of treatment has been identifi ed as a critical skill for therapists in training to learn in order to reach profes- sional competency in conducting psychotherapy. This study assessed convergence for 151 trainee therapist–client dyads on the identifi ca- tion of goals and tasks of treatment and on ratings of the therapeutic relationship, effectiveness of therapy and the client’s current coping ability with life stressors. Results indicated that trainee therapists’ and clients’ ratings were signifi cantly correlated; however, trainee therapists were more negative in their ratings of the relationship and progress of treatment and matched their clients’ goals for treat- ment only 31.1% of the time. Training and practice implications are discussed. Copyright © 2009 John Wiley & Sons, Ltd.
* Correspondence to: Jennifer Callahan, Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton, TX 76203-5017, USA. E-mail: [email protected]
as the 1960s, the phenomenon of perspective con- vergence between therapists and clients has been hypothesized as an important factor in psychother- apy. At that time, Pepinsky and Karst postulated that the level of convergence may be a dependent event that serves as a precursor to other therapeu- tic consequences, such as therapy ‘success’ or client ‘improvement’.
The importance of client–therapist agreement or perspective convergence in therapy has also been hypothesized to play a role in other thera- peutic variables that have been linked to positive therapy outcomes, viz. the therapeutic alliance. Gaston, Goldfried, Greenberg, Horvath, Raue, and Watson (1995), in a comprehensive review of the topic, indicated that convergence between
INTRODUCTION Convergence, defi ned as a two-way event where discrepancies in judgements, perspectives, beliefs and even behaviours are lessened (Pepinsky & Karst, 1964), is a phenomenon that has been found to occur in a number of different relation- ships between persons (or groups of persons), ranging from conformity in social groups (Asch, 1952; Sherif, 1936) to synchrony between parents and children (Wahler & Dumas, 1989). As early
Examination of Client and Trainee Convergence 229
Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 16, 228–236 (2009) DOI: 10.1002/cpp
the client and therapist is one of the key compo- nents of alliance. In a more recent review of the construct of alliance, Hovarth and Bedi (2002) indicated that although there is no universally accepted defi nition of the concept, most concep- tualizations include an emphasis on collaboration and consensus. Especially pertinent to the topic of convergence, Bordin (1976, 1994) defi ned the thera- peutic working alliance as including an agreement between the client and therapist on both the goals and tasks of therapy.
Findings on Client–Therapist Convergence
Although convergence between the client and therapist has been hypothesized as an important factor in the development of the therapeutic alli- ance and in successful therapy outcomes, empirical studies have indicated that convergence does not always occur. One area that has received atten- tion in relation to the topic of client–therapist convergence is in the causal explanations of the client’s presenting problems. For example, Long (2001) had 24 client–therapist dyads complete a measure assessing causal attributions (situational or personal), after the third session of therapy. The results of this study indicated that there was a sig- nifi cant disagreement between clients and thera- pists in their perceptions of the personal control that clients had over their problems. Long further found that the level of agreement in this area was signifi cantly related to early therapy change, with greater client–therapist convergence being associated with more effective perceived therapy outcomes. Similar results have been reported by other studies examining convergence in this area (Claiborn, Ward, & Strong, 1981; Tracey, 1988).
Another area that has received attention in relation to the topic of client–therapist convergence is in the recall and interpretation of session events. Examin- ing convergence in interpretations, Fuller and Hill (1985) compared therapist and helpee perceptions of the therapist’s actions. In this study, therapists and helpees observed a video recording of a pre- vious session and separately identifi ed what they perceived the therapist’s intentions to have been during that session. Results from this study indi- cated that the therapist–helpee dyads only matched interpretations 37% of the time. In a more recent study examining convergence for recall of impor- tant session events, Cummings, Martin, Hallberg, and Slemon (1992) asked both clients and therapists from 10 dyads to identify the most important event after the conclusion of each session. Of the 81 ses-
sions in which ratings took place, the client and therapist reported events matched only 34% of the time. Similarly low levels of convergence between clients and therapists have consistently been found in other studies also examining the recall and inter- pretation of session events (Cummings, Hallberg, Slemon, & Martin, 1992; Dill-Standiford, Stiles, & Rorer, 1988; Kivlighan & Arthur, 2000; Martin & Stelmaczonek, 1988).
The therapeutic alliance has received the most attention in the literature with regards to the issue of convergence between the client and therapist. For example, Fitzpatrick, Iwakabe and Stalikas (2005) recently had 48 client–therapist dyads sepa- rately complete the Working Alliance Inventory (Horvath & Greenberg, 1986) after every second or third session. Results from this study indicated that client and therapist ratings of the alliance were signifi cantly divergent, that the divergence was greater for ratings of goal and task agreement and that the level of divergence did not change over the course of therapy. Numerous other studies examining client–therapist convergence for ratings of the alliance have reported comparable results (see Bachelor & Salame, 2000; Clemence, Hilsenroth, Ackerman, Strassle, & Handler, 2005; Hilsenroth, Peters, & Ackerman, 2004; Ogrodnic- zuk, Piper, Joyce, & McCallum, 2000).
In summarizing the alliance convergence litera- ture, Tryon, Blackwell, and Hammel (2007) con- ducted a meta-analysis of 53 studies comparing client and therapist ratings of the therapeutic alli- ance. Averaging across variables such as the client’s level of disturbance, the length of therapy, the type of measures used, the therapists’ experience and the type of therapy, it was found that client and therapist alliance ratings were only moderately cor- related (r = 0.36). Tryon et al. further found that on average, client ratings were seen to be signifi cantly higher than therapist ratings on this factor (d = 0.63). Tryon et al. concluded that more research is needed in order to better understand why convergence/ divergence between clients and therapists occurs, and suggested that both quantitative and qualita- tive methods should be used (p. 639).
Aim of the Current Study
Although the topic of client–therapist convergence has received much attention since the time Pepinsky and Karst (1964) hypothesized its role in producing successful outcomes in psychotherapy, there are still a number of gaps or shortcomings in the avail- able literature. For example, studies examining
230 J. Swift and J. Callahan
Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 16, 228–236 (2009) DOI: 10.1002/cpp
convergence on ratings of the therapeutic alliance have compared alignment for both the goals and tasks of therapy. However, these comparisons have only been made by looking at subjective ratings of goal and task agreement or by comparing check- lists of goals to determine agreement. It would also be useful to know if clients and therapists were able to qualitatively identify the same target goals for therapy or the same tasks that have been most helpful in therapy. If clients and therapists were working towards qualitatively different things or if the therapist was using tasks that the client did not perceive to be helpful, then the therapeutic alliance would likely suffer and the client may be at greater risk to drop out prematurely from treatment (Reis & Brown, 1999).
Another gap in the convergence literature relates to the factors that have yet to be studied. Conver- gence for variables yet to be studied, such as how effective therapy is perceived to be or how the client is coping in life, may also affect the course and outcome of therapy. For example, if a therapist underestimates the effectiveness of therapy or the client’s coping ability, that therapist may continue to work on issues that have already been resolved, not yet perceiving that the client feels it is time to move on to new things. The reverse could also be true: if a therapist feels that the client is doing great and that therapy has been extremely effective, the therapist may move on, or suggest termination before the client is ready.
A fi nal gap in the literature relates to the atten- tion that has been given to convergence in a train- ing setting. Recently, understanding the client’s opinions and views of what is occurring in therapy has been emphasized as an important skill for trainee therapists to learn in order to achieve an entry level of competency for professional practice (Kaslow, 2004; Spruill, Rozensky, Stigall, Vasquez, Bingham, & Olvey, 2004). Although Tryon et al. (2007) included a handful of studies using trainee therapists, further exploration of understanding the strengths and weaknesses of trainees in the area of perspective convergence is needed, given the recent competency movement. For example, trainees may show to be convergent with their clients when it comes to one aspect of treatment, but not when it comes to another. Such knowledge would be helpful to supervisors in knowing what areas need further attention in helping develop competency in trainees.
Given the previous research examining client– therapist convergence, this study aimed to expand the current fi ndings by (1) examining convergence
for the therapeutic alliance by studying whether a qualitative match occurs for stated therapeu- tic goals and tasks; (2) examining convergence for perspectives of therapy variables that have yet to be studied (i.e., the effectiveness of treat- ment and the client’s current coping ability); and (3) examine convergence in a training setting to further identify areas of convergence strengths and weaknesses for trainee therapists. Given the fi ndings generally indicating greater divergence between client and therapist ratings on previously studied factors (see Tryon et al., 2007), it was hypothesized that this study would fi nd similar discrepancies.
Archival data from 151 clients seen for therapy at a Midwestern University-based training clinic were used in this study. The average age of this client population was 28.63 (standard deviation [SD] = 9.59), ranging from 18 to 62 years. These clients were largely female (62.3%) and of Cauca- sian ethnicity (90.4%). Other ethnicities included in this sample were Native American (4.4%), African American (2.2%) and other (3%). The mean of the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996) scores for this sample at intake was 21.73 (SD = 12.29) and the mean of the Beck Anxiety Inventory (Beck & Steer, 1993) scores at intake was 15.37 (SD = 11.75). The majority of these clients were given a diagnosis of a mood- or an anxiety- based disorder at intake. The average number of sessions attended by this group was 18.13 (SD = 17.83), ranging from 3 to 88 sessions. As routine practice in this clinic, all clients were treated in accordance with the American Psychological Association’s (APA) ‘Ethical principles of psychol- ogists and code of conduct’ (APA, 2002), and the archival study was conducted in compliance with the University’s Institutional Review Board.
The therapists in this study were 64 trainees working with the described clients and were all doctoral students enrolled in a clinical psychol- ogy scientist–practitioner Ph.D. programme at the same Midwestern University. The average number of clients seen by each therapist was 2.36, ranging from 1 to 8 clients. Demographic characteristics of enrolled students in this programme reveal an average age of 26.57 years (SD = 5.53), with the
Examination of Client and Trainee Convergence 231
Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 16, 228–236 (2009) DOI: 10.1002/cpp
majority of students being female (63%), Cauca- sian (70.4%) and having entered the programme with a bachelors’ degree (87.5%). Other ethnici- ties included in this sample were Native Ameri- can (11.1%), Hispanic (11.1%) and other (7.4%). In general, this specifi c doctorate programme empha- sizes the development of knowledge and skills in clinical theory, assessment and treatment proce- dures, and offers specialized tracks in the areas of clinical child, clinical health and adult clinical psy- chology. The programme’s theoretical orientation can be described as cognitive–behavioural, and all of the trainee therapists were highly encour- aged by supervisors to use cognitive–behavioural principles when working with clients. Further, as part of the programme’s emphasis on an evidence- based model to clinical care, trainee therapists were also strongly encouraged to understand and work towards client-identifi ed goals throughout treatment. To that end, clinic policy required that goals be documented in all client fi les prior to the third session of psychotherapy. Students in this programme typically begin their practicum train- ing at the University-based training clinic by con- ducting semi-structured intake interviews during their fi rst year and initiating intervention services following coursework in psychopathology, assess- ment and psychotherapy (usually at the end of this
fi rst year). All students seeing clients at the clinic received weekly supervision by a member of the clinical faculty.
Clients’ Ratings of Treatment This questionnaire was created by the pro-
gramme’s Clinical Training Committee as a face valid feedback survey. Three domains of inter- est were included in the creation of this measure: the therapeutic relationship, the client’s current coping ability and the effectiveness of treatment. Items pertaining to the therapeutic relationship included one item of the overall relationship rated on a 9-point Likert-type scale, one item instruct- ing clients to qualitatively report two target goals for treatment and one item instructing clients to qualitatively report the tasks that have thus far been most helpful in treatment. Five items rated on a 9-point Likert-type scale were included pertain- ing to the client’s current coping ability (with life, work, school, romantic relationships and family relationships) yielding an average coping ability score. One fi nal item was also included, asking clients to provide a subjective rating of how effec- tive therapy has been. The measure can be viewed in Table 1. Using this study’s sample of clients, the
Table 1. Client evaluation of treatment questionnaire
How do you feel about your relationship with your therapist right now? Very negative 1 2 3 4 5 6 7 8 9 Very positive
Overall, how well are you coping with life right now? Not at all 1 2 3 4 5 6 7 8 9 Very well
How well are you coping with your work or employment status right now? Not at all 1 2 3 4 5 6 7 8 9 Very well
How well are you coping with your educational status right now? Not at all 1 2 3 4 5 6 7 8 9 Very well
If you are married or in a continuous romantic relationship, how well are you coping with the relationship right now?
Not at all 1 2 3 4 5 6 7 8 9 Very well
How well are you coping with your family relationships right now? Not at all 1 2 3 4 5 6 7 8 9 Very well
Identify the two most important problems you are working on right now in therapy: Most important problem: __________________________________________________________________ Second most important problem: ____________________________________________________________
Overall, how helpful do you feel therapy has been for you so far?: Not at all 1 2 3 4 5 6 7 8 9 Very well
Please describe what you feel has been most helpful to you in therapy: _______________________________________
The therapist measure was identical except that where the client measure asks about ‘you’, the therapist measure asks about ‘your client’.
232 J. Swift and J. Callahan
measure is shown to have an overall high internal consistency (Cronbach’s alpha = 0.84), as well as high internal consistency for the fi ve items com- posing the overall coping ability score (Cronbach’s alpha = 0.85).
Therapists’ rating of treatment Trainee therapists were separately asked to com-
plete a parallel measure, differing from the client form only in that it directed the therapist to com- plete the measure for their client. Using this study’s sample of trainee therapists, the therapist measure is shown to also have an overall high internal consistency (Cronbach’s alpha = 0.88) and a high internal consistency for items compos- ing the coping ability average score (Cronbach’s alpha = 0.88).
Clients and therapists were asked to complete their respective measures during or directly after the third session. The third session was selected as the assessment time in order to (1) include as many clients as possible prior to termination and (2) to allow an adequate number of sessions for therapists to set treatment goals and identify a treatment plan with their clients (at the clinic used in this study, it was policy to have goals set and a treatment plan identifi ed by no later than the completion of the third session). Additionally, the selection of the third session matches other previously conducted studies of convergence (see Long, 2001).
Two trained graduate students independently coded the target complaints and the most helpful part of therapy questions to determine therapist– client match. These two students had been previ- ously trained in coding procedures on a separate data set with review of their work by the second author. In this study, the coders were asked to look at the responses separately for each dyad to see whether the responses were qualitatively the same or different. The coders were asked to pay atten- tion to both the words used and the meaning of the response. For example, the coders were instructed that a response by the client that a target of treatment was ‘issues with stepmom and dad’ would qualita- tively be the same as a response by the therapist that a target goal of treatment was ‘family discord’. The targets were coded as to whether neither of the therapist’s responses matched the client’s responses (coded 0), at least one of the therapist’s responses matched at least one of the client’s responses (coded 1) or both of the therapist’s responses matched
both of the client’s responses (coded 2). Order of the target responses was not taken into account. The coders showed a high level of agreement on this variable, as indicated by a signifi cant intraclass correlation coeffi cient of 0.94 (p < 0.001). The most helpful part of therapy was coded as to whether or not the therapist’s response and client’s response were the same (1 = same and 0 = not the same). Again, there was a high level of agreement in the coding of this variable, as indicated by a signifi cant kappa value (k = 0.91, p < 0.001). For items in which there was a discrepancy, the coders met and dis- cussed those items and came to a consensus.
RESULTS The fi rst research question was to examine con- vergence for the therapeutic alliance by examining whether a qualitative match occurred within the therapist–client dyads in terms of stated goals and tasks. For the goals of treatment, the therapist– client dyads matched on both target goals 31.1% (n = 47) of the time, matched on only one of the target goals 56.3% (n = 85) of the time and did not match on either of the target goals 12.6% (n = 19) of the time. For the tasks of treatment, the thera- pist–client dyads matched for the most helpful task thus far used in treatment in only 46.4% of the cases. Also pertaining to convergence for the therapeutic alliance, the therapist–client dyads were compared for the general rating of the thera- peutic relationship. Client and therapist ratings of the general therapeutic relationship were observed to be signifi cantly correlated (r = 0.33, p < 0.01). A paired samples t-test found that therapists’ ratings were signifi cantly lower than clients’ ratings (see Table 2 for results), showing a ‘small’ effect by con- ventional standards (Cohen, 1988). As indicated in Table 3, therapists rated the relationship lower than their clients in 48.9% of the cases, occurring greater than what would be expected by chance alone (χ2 [2, n = 139] = 21.95, p < 0.001).
The second research question pertained to exam- ining convergence in the therapist–client dyad for ratings of therapy factors that have yet to be studied; specifi cally, ratings of the effectiveness of treatment and ratings of the client’s current coping ability with life stressors. Signifi cant cor- relations were again observed between therapist and client ratings of the treatment’s effectiveness (r = 0.31, p < 0.01) and the client’s current ability to cope with life stressors (r = 0.69, p < 0.001). Paired samples t-tests indicated that therapists’ ratings
Examination of Client and Trainee Convergence 233
Table 2. Paired samples t-test comparisons of therapist ratings and client ratings
n Therapist rating Client rating t statistic Effect size d
Mean SD Mean SD
Relationship 139 7.53 1.13 8.01 1.16 4.34* 0.42 Client coping 151 6.07 1.59 6.17 1.72 0.91 Effectiveness 141 6.13 1.49 7.09 1.65 6.09* 0.61
* p < 0.001. Unequal values of n are due to some therapists or clients failing to complete the full measure. SD = standard deviation.
were signifi cantly lower than clients’ ratings on the effectiveness of treatment (a ‘medium’ effect was observed), but not on the client’s current coping ability (see Table 2 for results). As indicated in Table 3, therapists rated the effectiveness of treat- ment lower than their clients in 61% of cases (χ2 [2, n = 141) = 49.12, p < 0.001), but only rated their clients’ coping ability lower in 29.8% of cases (χ2 [2, n = 151] = 2.27, p > 0.05).
The third research question was to compare levels of convergence across variables for the therapist– client dyads in order to determine convergence strengths and weakness for these trainee therapists. This question was addressed by comparing the observed therapist–client correlations for the three continuous variables according to the methods described by Howell (2002) for comparing correla- tions. Results of these comparisons indicated that the therapist–client dyads showed a signifi cantly higher correlation in ratings of the client’s coping ability than ratings of the relationship (z = 4.24, p < 0.001) or ratings of the effectiveness of treatment (z = 4.47, p < 0.001). Observed correlations in the
therapist–client dyads did not differ signifi cantly between ratings of the relationship and effective- ness of treatment (z = 0.18, p > 0.05).
DISCUSSION The purpose of this study was to examine the convergence between trainee therapists and their clients regarding the ongoing course of treat- ment. First, convergence for factors related to the therapeutic alliance was examined. In terms of therapist–client match for the goals and tasks of treatment, this study found that in only 31.1% of the cases did the therapist and client match both goals, and in 12.6% of the cases, the therapist and client did not match on either of the identifi ed goals for treatment. Additionally, therapists and clients matched in terms of the helpful tasks for treatment in less than half of the cases. In terms of a general rating of the relationship, it was observed that the therapists’ ratings were moderately correlated with their clients’ rating; however, the therapists’ ratings were observed to be signifi cantly lower.
Table 3. Direction of therapist/client dyad ratings of the relationship, effec- tiveness and coping
Variable Frequency (%) χ2 value
Relationship (n = 139) Therapist rated higher 23 (14.5%) 21.95* Ratings agreed 48 (34.5%) Client rated higher 68 (48.9%)
Effectiveness (n = 141) Therapist rated higher 24 (17.0%) 49.12* Ratings agreed 31 (22.0%) Client rated higher 86 (61.0%)
Client coping ability (n = 151) Therapist rated higher 47 (31.1%) 2.27 Ratings agreed 59 (39.1%) Client rated higher 45 (29.8%)
* p < 0.001. Unequal values of n are due to some therapists or clients failing to complete the full measure.
234 J. Swift and J. Callahan
The observed low levels of convergence found in this study match the results from previous studies examining levels of convergence for ratings of the therapeutic alliance (Clemence et al., 2005; Fitzpatrick et al., 2005; Tryon et al., 2007).
Consensus, collaboration and agreement, espe- cially when it comes to the goals and tasks of therapy, have repeatedly been emphasized as key aspects of the therapeutic alliance (Bordin, 1976, 1994; Gaston et al., 1995; Hovarth & Bedi, 2002; Lambert & Ogles, 2004; Tryon & Winograd, 2002). This study found that for trainee therapists and their clients, consensus on the goals and tasks of treatment does not always occur. For example, one client indicated that her goal for treatment was to learn to cope with her recent divorce and loss of contact with her son because of restricted visita- tion rights. On the other hand, that client’s trainee therapist reported that the goal for treatment was to help the client overcome symptoms of post- traumatic stress disorder related to a car accident. As a second example, one client reported that the most helpful task for therapy was just ‘unloading on my therapist’. In contrast, the trainee therapist felt that ‘planning daily schedules’ was the most helpful task for that client. Therapists and clients who are working towards qualitatively different things or who are expecting different tasks to be used in therapy are both likely to experience frus- tration with the relationship, and if convergence does not occur, clients from such dyads may be at greater risk to prematurely terminate from treat- ment (Reis & Brown, 1999).
A mixed pattern was observed for convergence on the ratings of the effectiveness of treatment and ratings of the client’s current coping ability with life stressors. A moderate correlation was found between this study’s trainee therapists and their clients for ratings of the effectiveness of treatment; however, therapists again, on average, rated the effectiveness of treatment lower than their clients. In this sample, a signifi cantly stronger correlation was found between trainee therapists’ and their clients’ ratings for the current coping ability of the client. Given the sig- nifi cant difference, this area of convergence may be a relative strength for therapists in training.
In view of the growing interest in a competency- based approach for the training of future clinicians (Kaslow, 2004; Kaslow et al., 2007; Rubin et al., 2007) and …
George Engel’s contribution to clinical psychiatry
Graeme C. Smith, James J. Strain
The work of George Engel permeates the practice of medicine in the Western world to an extraordinary degree. Engel’s thesis was that a physician’s need to know and understand must be complemented by an ability to make the patient feel known and understood. That thesis has come to be regarded as common sense, and that which is expected of a doctor. It has helped medicine to remain human in the face of enormous pressures to remain biological. Engel’s exposition of the biopsychosocial model  epitomized his drive to have all doctors, not just psychiatrists, attend to the patient’s culture, psychological being, behaviour and, most importantly, the patient’s inner life in a systematic manner. It reflected his years of teaching medical stu- dents and residents in all disciplines. It reflected his unique qualifications as an internal medicine physician and a psychoanalyst. It reflected his intense case studies, the most famous of which was that of Monica, an infant with a gastric fistula whom he followed for 40 years, observing the links between her affective states and gastric functioning, and her relationships. It reflected his personal commitment to the entire context of the patient including the emotional needs and development of all with whom he worked.
Many leaders in the field of psychiatry in Australia, including a number who were subsequently appointed to chairs (e.g. Wallace Ironside and Bruce Singh), worked with and were trained by Engel in Rochester, New York. A number of Australian non-psychiatric physicians were similarly trained. Psychoanalysis was well enough
developed in Australia for these professionals to find a fertile field for t
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