Changing the Way We Study Change in Psychotherapy

Despite a recent surge of interest in the mechanisms and processes of change during psychotherapy, investigations to date have yielded lamentably few interpretable results. The present article highlights previous barriers to the study of change in psychotherapy and offers a conceptual and methodological framework to increase the interpretability of future studies. A frequently overlooked distinction between change mechanisms, or intermediate changes in the client over the course of treatment, and change processes, or the active ingredients of the therapeutic process, is presented and developed into a multiphase model of programmatic change research. It is argued that investigators should first develop an understanding of change mechanisms and only subsequently conduct targeted process research to identify important change processes.     

Progress Review of the Psychosocial Treatment of Child Conduct Problems

I assess current methods for reviewing advances in psychotherapy research and describe a new method for evaluating such work—the progress review. The need for progress reviews is highlighted and the usefulness of this technique is demonstrated via an evaluation of the extant literature on the psychosocial treatment of child conduct problems. Overall, an impressive body of research has amassed in support of the efficacy of several different treatment approaches for child conduct problems. However, information about which treatment components are responsible for therapeutic change, which mechanisms are involved, and which factors influence therapeutic change is lacking for each of the treatment approaches discussed. A theoretically based plan for future research is outlined for each treatment approach, in accordance with the results of this review. The continued use of progress reviews in all areas of psychotherapy research will help ensure that all of the goals of such research are attended to and will increase our ability to develop more effective and efficient psychotherapeutic interventions.     

Psychotherapy for depression: current and future directions in research, theory, practice and public policy

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.     

A cognitive-interpersonal case study of a self

This article presents an integrated conception of the self based on cognitive and interpersonal theories. Implications for clinical practice are outlined, which include understanding the therapeutic relationship as a laboratory and change as involving self-expansion. Implications for clinical research are also presented and exemplified by two strategies, which are demonstrated in a single case study of a patient who successfully underwent a brief-term treatment. The first involves the use of Interpersonal Scenarios, which are structured idiographic vignettes scaled on several parameters, to measure change between psychotherapy sessions. The second involves the use of the Structural Analysis of Social Behavior, a measure of interpersonal process, and the Experiencing Scale, a measure of emotional involvement, to measure change within a session.     

The Therapeutic Alliance and Suicide: When Words Are Not Enough

Much has been written about the therapeutic alliance, and the concept has a long history in the psychoanalytic and psychotherapy literature. This paper endeavors to clarify certain aspects of the therapeutic alliance, and to highlight ways in which the concept is particularly important in the psychotherapy of suicidal patients. The realm of implicit relational knowing is emphasized as critical to understanding the therapeutic alliance and also as a major arena for psychotherapeutic change. A clinical example is presented of an intensive psychoanalytically oriented psychotherapy with a suicidal patient. The example demonstrates the importance of implicit relational knowing as essential to the therapeutic alliance as well as to psychotherapeutic change.     

Identifying mechanisms of change in psychotherapy: Mediators of treatment outcome

We know that psychotherapy works, but the processes and mechanisms underlying therapeutic change are still largely unknown. The study of mediators and moderators of change in psychotherapy is one way to improve our understanding of mechanisms operating in psychotherapy. Consensus is slowly building on how to define both mediators and moderators of change, while there is still a controversy on strategic issues, e.g., criteria for demonstrating causality. The rationales for mediator research are discussed, as well as some of the major obstacles inherent in this research area. Finally, we present some strategic considerations for future research. Copyright © 2007 John Wiley & Sons, Ltd.     

Attachment, psychotherapy, and assessment: a commentary

This article, a commentary, discusses questions and issues generated by 7 articles on the relationship between attachment theory and research, and psychotherapy and clinical assessment. The issues include the following: attachment-based therapeutic interventions for adults and child-caregiver dyads, change in attachment status as an outcome goal of therapeutic intervention, attachment pattern as a moderator of treatment outcome and therapeutic approach, clinical use of attachment measures, narrative/discourse and self-report measures of attachment patterns, and application of attachment theory to new areas. In the discussion of each of these issues, suggestions are made for future research.     

Reconsidering "between-group psychotherapy outcome research and basic science:" applications to child and adolescent psychotherapy outcome research

Borkovec and Miranda (1996) proposed that the purpose of controlled outcome studies is to increase our understanding of the change mechanisms associated with psychotherapy, and they suggested several ways that between-group outcome research establishes cause-and-effect relationships. Child psychotherapy outcome research presents special challenges for the issues raised by Borkovec and Miranda and four of these are discussed herein: (a) the multitude of influences on children and adolescents that affect their functioning and therapy outcomes, (b) accurately defining the referral problem, (c) identifying appropriate outcome measures and reliable informants of change in child and adolescent treatment, and (d) considering developmental processes that influence therapeutic effectiveness. It is suggested that transporting clinical trials methods to natural settings is of limited value in identifying cause-and-effect relationships, and an alternative methodology is proposed for advancing child therapy outcome research. This approach advocates developing a profile of the underlying causes that predict psychopathology and therapy outcome for individual children in real clinical settings and then aggregating the data for youth with similar profiles and outcomes. These data can then be used to generate hypotheses about what interventions work for specific children, and investigators can employ prospective studies of therapy outcome for youth with similar profiles.     

The role of stigma during the course of inpatient psychotherapeutic treatment in a German sample

The current study intends to investigate whether the therapeutic process is impeded by stigma and how stigma develops over the course of cognitive behavioural psychotherapy treatment. Sixty German psychotherapy inpatients were asked on a weekly basis about two facets of stigma: self‐stigma and perceived public stigma. That information was linked to additional process as well as outcome variables (therapeutic engagement, working alliance, depressive, and general psychological symptoms). Both facets of stigma decreased over the course of psychotherapy, but only the decrease in self‐stigma was significant. In a weekly interval, low (high) self‐stigma predicted high (low) levels of working alliance and therapeutic engagement and vice versa. The current study shows that self‐stigma is especially subject to change during the course of an inpatient psychotherapeutic treatment. In addition, our results point to the interrelation between self‐stigma and other process variables contributing to the effectiveness and success of psychotherapy.     

A review of empirical research supporting four conceptual uses of dreams in psychotherapy

The present review consists of a re-conceptualization of the existing empirical literature regarding the use of dreams in psychotherapy into four potential contributions. These four contributions of dreams to psychotherapy are discussed as being particularly relevant for clinicians in applied practice to (I) facilitate the therapeutic process, (II) facilitate patient insight and self-awareness, (III) provide clinically relevant and valuable information to therapists and (IV) provide a measure of therapeutic change. The present review is distinctive in that it emphasizes the pertinence of research regarding dream use to applied clinical practice and it includes previously unreviewed research regarding dreams in psychotherapy on these four specific ways dreams can be useful within the therapeutic process. In addition, this review includes a section discussing the under-researched and largely neglected potential for dreams to provide accurate and efficient information to therapists. Limitations of the research as well as future directions are presented. The generally positive findings of this research suggest that dreams can be considered an alternative type of clinical material that can be useful in psychotherapy. Copyright © 2005 John Wiley & Sons, Ltd.     

Ripley's Game: Projective identification,emotional engagement,and the counselling psychologist

Counselling psychology's dual emphasis on the use of the self as both vehicle of therapeutic change and legitimate focus of inquiry and research is one of the features by which the profession may be distinguished from related fields such as clinical psychology or psychotherapy. This paper discusses the relevance of the psychoanalytic concept of projective identification in understanding the extent, nature and subtlety of the ways in which the therapist's ‘self’ and emotions may be deployed within the therapeutic relationship. Illustrated with reference to the film ‘Ripley's Game’ and a clinical case vignette, Searles's (1978) advocacy of ‘a richness of emotional participation’ within clinical work is discussed in relation to the pluralist philosophy of counselling psychology; implications for the training and personal development of counselling psychologists are also briefly explored.     

Treatment Manuals for the Real World: Where Do We Build Them?

Carroll and Nuro (this issue) outline a model for development of psychotherapy manuals that parallels the recently articulated stage model of psychotherapy research. The authors outline excellent considerations for treatment manuals in early, middle, and late stages of development. As manual testing moves from pilot studies and efficacy tests in university settings to transportability studies in clinical settings, the complexity of the manuals increases. These considerations also raise the broader question, however, of whether the stages of psychotherapy research as commonly implemented are best suited for developing treatments appropriate for "real-world" clinical settings. I suggest that all stages of research are perhaps better conducted in clinical as opposed to university settings. A change in research infrastructure would be challenging at first but could ultimately accelerate development of psychotherapy technologies.     

Report on the European Association of Body Psychotherapy: Bodies of Knowledge: Resources for a World in Crisis

The heterogeneous field of body oriented psychotherapy (BOP) provides a range of unique contributions for the treatment of mental disorders. Practice based clinical evidence and a few empirical studies point towards good efficacy of these non-verbal intervention strategies. This is particularly relevant for those disorders with body image aberration and other body-related psychopathology, but also for mental disorders with limited treatment response to traditional talking therapies, e.g. somatoform disorders/medically unexplained syndromes, PTSD, anorexia nervosa or chronic schizophrenia. However, the evidence base is not yet sufficiently developed in order to get BOP recognised as suitable mainstream treatment by national health services and their commissioning bodies. Strong academic links are urgently required in order to support practitioners in their efforts to evaluate the clinical work in systematic research. The field would greatly benefit from the development of international higher education training in integrated clinical body psychotherapy, enabling practitioners to obtain a master's degree. From a scientific perspective, projects on the interface between neuroscience and psychotherapy research should be conducted in order to understand more fully the therapeutic processes in BOP, particularly with regard to emotional processing, movement behaviour and body/self perception. Qualitative research is needed to further investigate the specific interactive therapeutic relationship, the dynamics of touch in psychotherapy and the additional self-helping potential of creative/arts therapy components. Provided that these requirements will be fulfilled, BOP could be established as one of the main psychotherapeutic modalities in clinical care, alongside other mainstream schools such as psychodynamic, cognitive-behavioural and systemic.     

New approaches to diversity in clinical work

The inclusion of diversity issues in clinical work has risen in the last years. With APA's multicultural guidelines and diversity courses becoming a requirement in doctoral programs, we see a concerted effort to increase awareness, knowledge, and understanding of diversity issues in clinical work. Yet, there is still much to do. In this issue of Journal of Clinical Psychology: In Session, seven authors conceptualize diversity from various therapeutic approaches, including relational cognitive behavior therapy, couples therapy, multicultural counseling, and psychodynamic psychotherapy. We learn how diversity and clinical work are not mutually exclusive regardless of the therapeutic approach used as long as the therapist is culturally sensitive and competent, and motivated to pursue such integration. We also learn that regardless of their commitment to social justice, and their understanding of the consequences of inequality and oppression on individuals’ mental health, clinicians vary considerably in the extent to which they actively integrate diversity considerations in the treatment room. The authors in this issue present clinical vignettes describing how they have integrated diversity into their therapeutic work. Furthermore, they discuss how the process of addressing issues of diversity has impacted their work. Lastly, the authors offer recommendations from their experiences as clinicians.     

The interaction of drug- and psychotherapy in the long-term treatment of depression

Recent advances in our understanding of both short- and long-term therapeutic interventions for depressive disorders have necessitated greater precision in defining appropriate therapeutic interventions. While these remarkable changes in treatment have been based on the introduction of newer antidepressant agents, the advances have occurred because of more systematic clinical trials and a greater sophistication in defining diagnostic and treatment response criteria. This paper reviews key findings in recurrent depression with respect to long-term treatment. Particular attention is paid to the combination treatment of psychotherapy and antidepressant drugs.     

Factors associated to outcome in psychotherapy: An effectiveness study in Puerto Rico

Psychotherapy research has not received much attention among Latinos in the U.S. or in Latin America including Puerto Rico. The present study explores factors associated with the effectiveness of psychotherapy with a sample of Puerto Ricans. Seventy-nine persons who received psychotherapy participated in a study aimed at evaluating the process and outcome of psychotherapy. Participants completed a questionnaire on the effects of treatment on the presenting problem. Information from the questionnaire and other information from the clinical records included the BDI and the Symptom Check List-36 scores, the number of sessions received, etc. constituted the data set. The results show that symptomatic severity, age, the number of sessions, and the therapeutic alliance were associated with effectiveness. Also, the alliance explained 45% of the variance in effectiveness. The results suggest that the therapeutic alliance merits further study in psychotherapy research and in clinical training. © 1998 John Wiley & Sons, Inc. J Clin Psychol 54: 329–342, 1998.     

Normative data on cognitive measures of depression

The assessment of cognition and cognitive change is important for case conceptualization, monitoring the efficacy of specific interventions, and evaluating treatment outcome in cognitive-behavioral therapy. Unfortunately, a paucity of normative data exists on cognitive measures used for psychotherapy outcome research in depression, and little information is available to guide a practitioner's understanding of the magnitude and clinical significance of a patient's cognitive change. This article presents normative data on 6 self-report instruments that assess negative and positive automatic thoughts, hopelessness, cognitive biases and errors, and dysfunctional attitudes. Normative data were derived from studies published from the date of inception of a given cognitive index to the year 2000. Recommendations for the use of these normative data are provided.     

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.     

PSYCHOTHERAPY AND RESEARCH: A RELATION THAT NEEDS TO BE REINVENTED

abstract    In this paper I question whether the randomized controlled trial (RCT) and the evidence-based medicine model are well suited for psychotherapy research. First I discuss general characteristics of the randomized controlled trial and argue that, given a number of incompatibilities with the discipline of psychotherapy, these trials tend to provide us with data that have limited validity. The methodological objections I raise are important as the treatment protocols produced within the context of randomized controlled trials tend to be forced upon clinical practice in uncritical ways. On the other hand, I argue that systematic research is relevant for psychotherapy. If research is designed to address concerns arising from clinical practice – in particular, the far-reaching complexity of the therapeutic encounter – it can be a powerful tool for further developing our discipline.