Psychotherapy change process research: Realizing the promise

Abstract

Change process research (CPR) is the study of the processes by which change occurs in psychotherapy and is a necessary complement to randomized clinical trials and other forms of efficacy research. In this article the author describes and evaluates four types of CPR. The first three are basic designs and include quantitative process–outcome, qualitative helpful factors, and microanalytic sequential process; the fourth, the significant events approach, refers to methods such as task analysis and comprehensive process analysis that integrate the first three. The strengths and weaknesses of each design are described and summarized using both causal and practical criteria as part of an overall argument for systematic methodological pluralism.     

Cross-National Research in Family Therapy: One Encouraging Collaborative Approach

In this article we share the structure and process of an ongoing cross-national family therapy research study that involves samples from 7 countries (Colombia, India, Iran, Indonesia, the Philippines, the United States, and 2 regions of China, mainland China and Taiwan). Various features of the study may serve as useful templates for others interested in collaborative cross-national research. Each of the 6 authors of this article at Virginia Tech have contributed 10 questions related to an area of their own particular family therapy research interest, and they will be the first authors on any brief research reports written on the topics of those 10 questions. Because all 6 Virginia Tech researchers have been part of the conceptualization, planning, and implementation of this study, all 6 also will be co-authors on each other's research reports. The authors include Filipino and Indonesian collaborators in the publication process, as well. This article reports on the structure and process of ongoing research and the lessons learned thus far.     

Looking back,looking forward: A historical reflection on psychotherapy process research

Abstract

In 1983, a group of 14 prominent psychotherapy process researchers attended a workshop sponsored by the US National Institute of Mental Health. Although the previous decade had seen a marked emphasis on psychotherapy outcome research, there had also been several major advances in the field of process research. The goals of the workshop were to review the current state of the field, address methodological and conceptual issues, and provide recommendations to advance scholarship in this area. In this paper, we summarize the major themes of the workshop and consider the degree to which its recommendations have come to fruition via subsequent developments in the field. Although 30 years have passed since the workshop was held, its insights remain highly relevant to psychotherapy process research today.     

Youth self-efficacy domains as predictors of change in routine community mental health services

Abstract

Objective: This study examined how youth self-efficacy in four domains—Social, Academic Diligence, Academic Proficiency, and Behavioral Regulation—was associated with youth symptoms and psychotherapy outcomes. Method: Participants were 104 youth (aged 12–17, mean age 14.6) and their parents/guardians. Youth completed a measure of perceived self-efficacy and the Youth Outcome Questionnaire–Self-Report (YOQ-SR) regularly over the course of treatment; parents/guardians also completed the Youth Outcome Questionnaire. Results: Although none of the self-efficacy domains significantly predicted changes in parent reports of symptoms, individual growth curve models indicated that increases in three of the four self-efficacy domains (Social, Academic Diligence, and Behavioral Regulation) over the course of treatment were associated with concurrent improvements in youth-reported symptoms. Conclusions: Results suggest that youth self-efficacy warrants further study in relation to change processes in youth mental health services.     

Therapist effectiveness: Implications for accountability and patient care

Abstract

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of “effective” and “harmful” therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d=?0.91 to ?1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.     

The narrative reconstruction of psychotherapy and psychological health

Abstract

When people complete psychotherapy, they carry the story of the experience with them. This retrospective reconstruction serves several psychological purposes, including contributing to narrative identity and influencing the maintenance of therapeutic gains after termination. Based on a prior qualitative investigation of therapy narratives (Adler & McAdams, 2007a), a new sample of 104 former clients wrote about their psychotherapy after treatment end. Quantitative analyses indicated that the retrospective narratives of participants high in subjective well-being focused on the protagonist's agency in struggling with a discrete problem. In addition, the narratives of participants high in ego development described a coherent story of growth. These findings suggest that the stories clients construct about psychotherapy reliably vary depending on their psychological health.     

Client experiences of helpful factors in a day treatment program: A qualitative approach

Abstract

The goal of the present study is to provide more information about which specific aspects of a day treatment program are experienced as most helpful by the patients. A semistructured interview was conducted. The narrated episodes were analyzed using a combination of grounded theory (Strauss & Corbin, 1997) and qualitative content analysis (Mayring, 2000). The authors collected 69 interviews of 26 patients over a 12-month period. The results show eight groups of helpful factors (the transfer factors being the most specific day clinical group) that are embedded in a conceptual frame of other categories. The discussion shows how they can be linked to other theoretical and empirical concepts, including the Assimilation of Problematic Experiences Scale (Stiles et al., 1990).     

‘You need to let your voice be heard’: research participants' views on research

Background Persons with intellectual and developmental disabilities have had regrettably few opportunities to voice their opinions on aspects of research with which they have had direct experience. Understanding and responding to these views can contribute to policies and practices that increasingly treat people as they desire to be treated. Methods We conducted individual interviews and focus groups with 16 adults with intellectual and developmental disabilities to examine their perspectives on participating in research. Results Our analysis indicates that adults with intellectual and developmental disabilities want to engage in research to improve their quality of life and to have greater access to a worthwhile activity through more active participation. Our results also highlight trust as a critical ingredient in the success of research with this group. Conclusions Our findings suggest that despite ethical challenges, researchers can and should pursue research that has the potential to improve the lives of persons with intellectual and developmental disabilities. Such research is more likely to be both ethical and successful if researchers pay attention to enhancing autonomy and person‐centredness, while at the same time engendering participant trust.     

An investigation of students’ with mild learning disabilities reactions to participating in sexuality research

This study investigates 35 students’ with mild learning disabilities reactions to participating in a research project exploring their sexual knowledge, attitudes and behaviour. Students completed an informed consent procedure prior to their participation in the sexuality research and all were interviewed using a confidential interview procedure. During the research interviews, each student's reaction to participation was observed and recorded by their interviewer. Following the interviews, each student's reaction to participation was observed and recorded by their college tutor. Researchers observed that although some students were embarrassed discussing certain sexual topics, none chose to stop their interviews when invited. Ten students requested additional information from their interviewers about the issues discussed. Tutors reported that no students appeared anxious or distressed following their interviews and that no inappropriate sexualized behaviour, or talk, were observed. Tutors also reported that several students appeared to have been positively affected by their participation. No tutors expressed concern about their students participating in similar research in the future. It is concluded that a number of methodological and participant factors may have accounted for the positive outcomes reported. The implications of these findings and recommendations for future research are discussed.     

Inclusive learning disability research: the (nondisabled) researcher's role

In this paper, the role of the nondisabled researcher who supports inclusive research in learning disability is explored. The author argues for more transparency about the role in order to highlight the challenges of working inclusively on research projects, the real contribution of people with learning difficulties to research, and the training/support implications of working inclusively.     

Willingness of subjects with thought disorder to participate in research

Greater attention is being focused on the willingness and motivations of potential subjects who are recruited for research protocols. Given the importance of subjects' abilities to choose freely and reason through their decisions about entering psychiatric research, empirical researchers have been developing assessment and education tools that address the potential vulnerabilities of research subjects. In this study subjects' responses and reasons for or against participation were elicited as part of an assessment of their research decision making. Fifty-two persons diagnosed with a thought disorder were asked to consider a hypothetical research study using the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). Their responses were documented, coded for content, and correlated with demographic characteristics and scores on scales rating psychosis, cognition, and health-related quality of life. Subjects expressed common considerations that have been identified by other psychiatric investigators, as well as by those studying nonpsychiatric protocols. In general, reasons were both appropriate to the study being considered and appropriately linked to common considerations that flowed logically from the study. However, elements of the therapeutic misconception were evident as well. Willingness to participate was correlated with higher MacCAT-CR scores on certain scales, better education, and lower levels of psychosis and cognitive impairment. These findings highlight both the strengths and weaknesses of the decision making of research subjects with thought disorder. Research protections and assessments may consequently be appropriately targeted to specific vulnerabilities. Because of differences in severity of illness, cognition, and reasoning among subjects who decline to participate in research, greater attention to this population appears warranted.     

Revisiting Practice-Based Research Networks as a Platform for Mental Health Services Research

Practice-based research networks (PBRNs)—collaborations of practice settings that work together to generate research knowledge—are underused in mental health services research. This article proposes an agenda for mental health services research that uses a variety of PBRN structures and that focuses on what really happens in practice, the effectiveness of practice innovations in real world care, the challenges of implementing evidence supported interventions, modification of clinician behavior, and assessment of the effect of mental health policy changes on practice. The challenges of conducting research within PBRNs are substantial, including difficulties in maintaining positive member relations, securing ongoing funding, sustaining productivity, overcoming IRB entanglements and achieving both scientific excellence in recruitment and measurement validity and utility for practitioner members. However, the awareness of these challenges allows researchers and practitioners to build networks that creatively overcome them and that infuse mental health services research with heavy doses of the realities of everyday clinical practice.     

The Patient's Experience of Attunement and Responsiveness Scale

Objective: This study sought to test the correlation between the patient's experience of attunement and responsiveness, and treatment outcome. Method: Utilizing a new measure—the Patient's Experience of Attunement and Responsiveness (PEAR) Scale—we asked both patients and therapists to rate their experience of a therapy session immediately after that session. Scores on the PEAR Scale were then correlated with two measures of treatment outcome. We obtained 405 total PEAR Scale administrations from 38 patient–therapist dyads across multiple sessions. Results: Exploratory factor analyses revealed a three-factor structure for the patient version of the scale and a two-factor structure for the therapist version. Patient ratings on the PEAR Scale were significantly correlated with OQ-45 and a 1-item measure of global outcome measured for the concurrent session. Conclusion: These findings suggest attunement during a therapy session may be an important predictor of concurrent session outcome.     

Client attachment orientations,working alliances,and responses to therapy: A psychology training clinic study

Abstract

The authors examined the associations between client attachment orientations, working alliance, and progress in therapy. Ninety-five clients at two university-based training clinics completed measures of adult attachment, attachment to therapist, and working alliance immediately preceding the third counseling session with therapists-in-training. A standardized measure of progress in therapy was administered at intake, third counseling session, and termination. Hierarchical linear modeling findings indicated that stronger working alliances and secure attachment to therapist were significantly associated with greater reductions in client distress over time. Higher levels of adult attachment anxiety were significantly associated with greater distress ratings at the outset of treatment. Directions for future research and suggestions for developing therapeutic relationships in the context of specific client attachment orientations are discussed.     

Correlates of the real relationship in psychotherapy: A study of dyads

Abstract

This study examined several theoretical propositions regarding the role of the real relationship using a sample of 59 psychotherapy dyads. As hypothesized, positive associations were evident between therapist ratings of the real relationship and their ratings of the working alliance and client progress; negative associations were found between therapist ratings of the real relationship and attachment avoidance. For clients, significant and hypothesized associations were found between ratings of the real relationship and secure attachment to therapists as well as their perceptions of therapist empathy. Regression analyses showed that client ratings of the real relationship were significantly associated with their ratings of progress in treatment above and beyond their ratings of the working alliance, therapist empathy, and attachment.     

Are Children with Anxiety Disorders Privately Referred to a University Clinic Like Those Referred from the Public Mental Health System?

Compared two groups of children with anxiety disorders served at a single mental health clinic whose referral source differed: private referrals (i.e., parent/legal guardian initiated) and public referrals (e.g., via state contracts—Departments of Health and Education, juvenile justice system). Comparisons were made across three domains of variables: (a) symptoms/diagnoses, (b) functioning, and (c) environments. Few symptom differences emerged. However, large differences were evident for contextual variables like family income and life stressors. Overall, the pattern of differences point to possible directions for adaptation of treatments for use with children with anxiety disorders served in public mental health systems.     

Clients' perspectives on therapy termination

Abstract

We used consensual qualitative research to analyze interviews with 12 clients about their termination from psychotherapy. Those who had positive termination experiences reported a strong therapeutic relationship and positive outcomes of therapy. They terminated primarily for logistical or financial reasons; their termination, post-termination plans, and feelings about termination were discussed in advance with their therapist, as was their growth in therapy, leading to mostly positive effects of the termination. In contrast, those who had problematic terminations reported a mixed therapeutic relationship and mixed outcomes of therapy. They usually terminated abruptly because of a therapeutic rupture, and thus termination was rarely planned and discussed in advance, rendering it a negative experience. Implications of these findings are addressed.