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.     

Common Factors Exist in Reality But Not in Our Theories

Weinberger's article on common factors (this issue) highlights crucial aspects of the psychotherapy process. Toward the aim of building a theory of psychotherapy change, I further suggest that theoretical eclecticism would fuel our conceptual creativity, by encouraging therapists to openly learn all major theoretical systems and avoid identifying themselves with a predominant one. I also propose that the development of an inte-grative model of personality represents a necessary building block toward the overall goal of understanding change. Finally, we need to work toward greater clarification of the common factors we have already identified. Throughout my commentary, I provide examples in an attempt to clarify those points.     

Pain Self-Management in the Process and Outcome of Multidisciplinary Treatment of Chronic Pain: Evaluation of a Stage of Change Model

For chronic pain patients, acceptance of a self-management approach for pain may influence success in treatment, and adopting such a perspective may be conceptualized as a stage of change model. For 65 chronic pain patients in multidisciplinary treatment programs, we examined whether pretreatment self-management stage, assessed with Pain Stage of Change Questionnaire subscales, affected improvements in outcomes, and whether changes in stage represented a therapeutic process factor. Results showed (a) low precontemplation, high contemplation, and high action attitudes at pretreatment predicted greater improvements in outcomes than the opposite pattern of attitudes; (b) pre- to midtreatment changes in precontemplation and contemplation attitudes predicted mid- to posttreatment changes in pain severity and interference, but not vice versa. Results support the usefulness of a stage model in conceptualizing patients' acquisition of a self-management approach to pain, and suggest that early-treatment progression across stages may lead to reductions in pain severity and lifestyle interference.     

Intrepid Pursuit of the Essential Ingredients of Psychotherapy

This article elaborates on Doss's (this issue) call for a programmatic psychotherapy change research that unveils the specific mechanisms inherent in the in-session and extratherapy client changes occurring over the course of a therapy. To accomplish this new agenda, both "process" and "outcome" investigators must formulate some clear conceptualization of the dependent variables of psychotherapy—both in and outside therapy, both proximate and remote—and their theoretical interrelationships. Dismantling the essential ingredients of any of the field's available psychotherapy "packages" requires explanation of each client change that results from a particular "miniature" intervention, and how that change is related to subsequent changes from other miniature interventions, across the entire course of therapy. For each miniature intervention researchers need to demonstrate also the level of expertise and the specific patient-therapist relationship context required for its successful execution. The field can profit from a new kind of "process diagnosis" for psychotherapy research, one that specifies and measures "process signs" (observable cues, markers, indicators) of a patient's distinctive set of in-session maladaptive behaviors, behaviors that can be ameliorated with an optimum sequence of tailored miniature interventions.     

Common Factors or Processes of Change in Psychotherapy?

To better identify and understand the role of common factors in psychotherapy, I argue that we should begin with what therapists actually do in psychotherapy, rather than what they say they do. Further, in contrast to Weinberger's position, I argue that there is not yet any convincing evidence regarding the causal role of any common factors in psychotherapy outcome, although research to determine the possible causal role of these and other potential change factors is sorely needed. Finally, I suggest that common factors are not isolated entities that should be taken out of context, but may more fruitfully be considered as complex, multidimensional and interactive processes that are affected by context and change over time. I believe that an important challenge for future work in common factors is the development of theories of the processes of change that include a variety of factors (common and specific) and their interactions.     

The Centrality of Emotion to Psychological Change

Despite ongoing discussion over how best to define and operationalize emotions, therapists increasingly agree on emotions' centrality to psychological health and change. Research suggests that accurately recognizing emotions is critical to psychological health, and most major therapeutic approaches aim to address deficits in emotional awareness. Interventions also strive to regulate emotions, with cognitive-behavior therapy typically working to reduce negative emotions such as anxiety and depression, and experiential and psychodynamic therapists to augment emotional experiencing. Increasingly, however, these approaches are converging toward using emotional experience within therapy to ultimately reduce negative emotions. This application of emotions' role in meaning change and human behavior points to the way in which drawing on basic emotion research can enable us to create assessments and treatments grounded in an empirically supported understanding of mechanisms of change, and in so doing foster greater psychotherapy integration.     

Clinical Versus Reliable and Significant Change

Sheldrick, Kendall, and Heimberg have illustrated and compared the use of the reliable change index (RCI) and normative comparisons procedures for assessing the clinical meaningfulness of research findings. Their presentation illustrates how the method of normative comparisons, combined with a reliability of change index such as that offered by Jacobson and colleagues can be used to assess the clinical meaningfulness of treatments. Their comparisons of treatments that have been previously identified as empirically supported reveal that a definition of worth, based on statistical significance, fails to identify the power (or lack thereof) of the intervention. Reliable change and clinical meaningful change estimates add substantially to the interpretation of statistical significance. However, they are complementary, not equivalent methods. The RCI can only indicate whether the change noted exceeds what can be expected because of the unreliability of the instrument used. Although estimates of clinical utility should be routine in research reports of treatment effects wherever possible, there are still situations in which procedures for estimating clinical significance are lacking, and new methods are needed in these instances.     

Change in Psychotherapy: A Plea for No More "Nonspecific" and False Dichotomies

What factors are responsible for change in psychotherapy? We welcome those who question the primacy frequently given to relationship variables in explaining client improvement, as well as the delineation of cognitive‐behavioral oriented treatments found to be effective for several disorders. However, we are also concerned about the terminology used (i.e., “nonspecific variables”), as well as with the dichotomy of variables (techniques vs. relationship) that was emphasized. Although such ways of defining and categorizing process variables are predominant in the field, we argue that they may fail to do justice to the complexity of the process of change.     

Progression of Therapy Research and Clinical Application of Treatment Require Better Understanding of the Change Process

The stage model of therapy research focuses on the development of treatment from pilot work, through randomized controlled clinical trials, to tests in clinic settings. A goal of the model is to develop effective treatments that can be used clinically. The present comments begin with a similar goal but emphasize the importance of a broader agenda designed to understand therapy. A central thesis is that developing effective treatments depends heavily on investigations that address critical scientific questions; particularly, what are the mechanisms through which therapy operates and under what conditions is therapy likely to be effective and why? The comments argue for a portfolio of research that addresses a broader range of questions and encompasses more diverse methods of evaluating treatment. Breadth and diversity are not ends in themselves but will be essential to obtain the requisite knowledge to effect optimal changes in clinical applications of treatment.     

"Negative Process": A Recurrently Discovered and Underestimated Facet of Therapeutic Process and Outcome in the Individual Psychotherapy of Adults

A good therapeutic alliance has proven to be an important contributor to positive outcome in the individual psychotherapies of adults. Treatment models that have been studied include psychodynamic, cognitive, cognitive-behavioral, interpersonal, experiential, and some eclectic approaches. However, the ability of therapists to establish and maintain a good alliance has been greatly overestimated. The reason for this is the enormous difficulty that human beings have in dealing with Interpersonal conflict in which they are participants. Evidence for the ways in which therapists struggle with negative therapeutic process—hostile interchanges between patients and therapists—is traced throughout the psychotherapy research literature. It appears that negative process is a major obstacle to successful treatment, and that its pervasiveness has been underestimated. A therapeutic technical strategy that uses metacommunication is recommended for effectively managing negative process. Training therapists to use this technical strategy is discussed, as are recommendations for future research on the topic of negative process.     

The Role of Process Research in Manual Development

In contemporary psychosocial treatment research, the test of the efficacy of standardized treatment manuals predominates in respectability relative to naturalistic research on the process components of flexible treatments, though the latter strategy is necessary for the empirical identification of effective process components. Standardizing a treatment constrains the variance of process variables and, thereby, attenuates the manifestation of potential correlations. Research is reviewed, providing evidence for several unexpected deleterious or moderating effects of utilizing standardized treatment manuals. We conclude that naturalistic research using flexible treatments is necessary for making the development of treatment manuals, and their modification, a truly scientific process.     

Distinctive Features of Short-Term Psychodynamic-Interpersonal Psychotherapy: A Review of the Comparative Psychotherapy Process Literature

The present article is a review of the comparative psychotherapy process literature. It is an effort to delineate techniques and processes that distinguish two prominent forms of treatment. Seven interventions stood out as distinguishing psychodynamic-interpersonal therapy from cognitive-behavioral treatment: (1) a focus on affect and the expression of patients' emotions; (2) an exploration of patients' attempts to avoid topics or engage in activities that hinder the progress of therapy; (3) the identification of patterns in patients' actions, thoughts, feelings, experiences, and relationships; (4) an emphasis on past experiences; (5) a focus on a patients' interpersonal experiences; (6) an emphasis on the therapeutic relationship; and (7) an exploration of patients' wishes, dreams, or fantasies. A better understanding of the specific techniques and processes that distinguish psychodynamic-interpersonal from cognitive-behavioral therapy can facilitate process-outcome research, aid in the training and teaching of psychodynamic-interpersonal psychotherapy, and provide psychodynamic-interpersonal therapists with a guide for session activity.     

Using Treatment Integrity Methods to Study the Implementation Process

[Clin Psychol Sci Prac 18: 36–40, 2011] The last decade has witnessed increased interest in the implementation and dissemination of evidence‐based treatments (EBTs) for youth. Nakamura et al. (2011) detail lessons learned over the past decade from the large‐scale implementation of EBTs for children in Hawaii. This commentary discusses how lessons from Hawaii’s initiative can help inform the next generation of implementation research. Specifically, we focus on how treatment integrity models and methods designed to characterize core aspects of treatment delivery can be used to study the implementation process. Using the new interactive online reporting systems developed by Nakamura et al. to collect treatment integrity data offers researchers a way to determine how best to implement EBTs in community‐based service settings with integrity and skill.     

On Entering and Remaining in Psychotherapy

Schauman and Mansell (2012) propose the use of perceptual control theory to help us understand why individuals may be reluctant to enter into therapy and, if they do, why they may terminate prematurely. Although there exists an extensive theoretical and research literature that documents the benefits of having control over oneself and situations, I maintain this does not totally explain why people either avoid entering therapy or drop out prematurely. Without denying the importance of perceived control, I suggest that certain principles of change also play a most important role, namely one's expectations about treatment, one's motivation to change, and the nature of the therapy alliance.     

Change in self-protect ion and symptoms after dynamic psychotherapy: the influence of pretreatment motivation

The First Experimental Study of Transference-interpretations (FEST) is a dismantling, randomized clinical trial of the long-term effects of transference interpretation. This article looks at the influence of motivation on the ability to self-protect and symptoms. Patients were randomized to receive a moderate level of transference interpretations or no transference interpretation. Assessments were made at pretreatment, midtreatment, posttreatment, and at two follow-ups. The outcome measure, change in ability to self-protect, was cluster 4 of the Structural Analysis of Social Behavior (SASB) Long Form Intrex Introject Questionnaire, a measure close to the SASB-coded treatment process. Symptom change (SCL-90) was also analyzed. Pretreatment motivation was a significant moderator of change in the ability to self-protect and in symptom distress. Those with low motivation had a significant, positive, and long-term treatment effect of transference interpretation. Patients with low motivation showed a significant, negative effect of transference interpretation.     

It Isn't the Size, but the Fit

The very structure and control that formed the reason for developing treatment manuals have now become their most frequently criticized characteristic. Carroll and Nuro (this issue) continue this critique and rightly call for ways to increase the flexibility in the processes used to develop treatment manuals. But it is insufficient to be flexible during the process of developing the manual. It is also necessary to find ways to increase the flexibility of selecting and applying the treatment procedures themselves. Offering therapists options in the selection and use of techniques can be accomplished by focusing more on the principles of therapeutic change than on theories of psychotherapy or the applications of techniques. This paper announces a Presidential Initiative from the Society for Clinical Psychology (Division 1 2) of the American Psychological Association (APA), which is designed to identify integrative and crosscutting principles of therapeutic change. It is hoped that this initiative will further foster the development of flexibility without sacrificing the basis of sound empirical support.