Psychotherapy relationships that work II.

This article introduces the special issue of Psychotherapy devoted to evidence-based therapy relationship elements and traces the work of the interdivisional task force that supported it. The dual aims of the task force are to identify elements of effective therapy relationships (what works in general) and to identify effective methods of adapting or tailoring treatment to the individual patient (what works in particular). The authors review the structure of the subsequent articles in the issue and the multiple meta-analyses examining the association of a particular relationship element to psychotherapy outcome. The centrality of the therapy relationship, its interdependence with treatment methods, and potential limitations of the task force work are all highlighted. The immediate purpose of the journal issue is to summarize the best available research and clinical practices on numerous elements of the therapy relationship, but the underlying purpose is to repair some of the damage incurred by the culture wars in psychotherapy and to promote rapprochement between the science and practice communities. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Alliance in individual psychotherapy.

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as “alliance,” “therapeutic alliance,” “helping alliance,” or “working alliance” were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25–.30. The statistical probability associated with the aggregated relation between alliance and outcome is p     

Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care.

The long-standing divide between research and practice in clinical psychology has received increased attention in view of the development of evidence-based interventions and practice and public interest, oversight, and management of psychological services. The gap has been reflected in concerns from those in practice about the applicability of findings from psychotherapy research as a guide to clinical work and concerns from those in research about how clinical work is conducted. Research and practice are united in their commitment to providing the best of psychological knowledge and methods to improve the quality of patient care. This article highlights issues in the research- practice debate as a backdrop for rapprochement. Suggestions are made for changes and shifts in emphases in psychotherapy research and clinical practice. The changes are designed to ensure that both research and practice contribute to our knowledge base and provide information that can be used more readily to improve patient care and, in the process, reduce the perceived and real hiatus between research and practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Repairing alliance ruptures.

In this article, we review the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the relation between rupture-repair episodes and treatment outcome (r = .24, z = 3.06, 95% CI [.09, .39], p = .002, k = 3, N = 148). The second meta-analysis reviewed the research examining the impact on treatment outcome of training therapists in the use of alliance rupture intervention principles (prepost r = .65, z = 5.56, 95% CI [.46, .78], p k = 8, N = 376). Both meta-analyses provided promising evidence regarding the relevance of alliance rupture-repair processes to therapeutic outcome. The limitations of the research reviewed are discussed as well as practice implications for repairing the inevitable alliance ruptures in psychotherapy. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evidence-based practices addressed in community-based children's mental health clinical supervision.

Clinical supervision is the principal method of training for psychotherapeutic practice, however there is virtually no research on supervision practice in community settings. Of particular interest is the role supervision might play in facilitating implementation of evidence-based (EB) care in routine care settings. This study examines the format and functions of clinical supervision sessions in routine care, as well as the extent to which supervision addresses psychotherapeutic practice elements common to EB care for children with disruptive behavior problems, who represent the majority of patients served in publicly funded routine care settings. Supervisors (n = 7) and supervisees (n = 12) from four publicly funded community-based child mental health clinics reported on 130 supervision sessions. Supervision sessions were primarily individual in-person meetings lasting one hour. The most common functions included case conceptualization and therapy interventions. Coverage of practice elements common to EB treatments was brief. Despite the fact that most children presenting to public mental health services are referred for disruptive behavior problems, supervision sessions are infrequently focused on practice elements consistent with EB treatments for this population. Supervision is a promising avenue through which training in EB practices could be supported to improve the quality of care for children in community-based “usual care” clinics. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The future of psychotherapy integration: Closing the gap between research and practice.

Over the past several decades, the field of psychotherapy has become more receptive to the idea of integration. For the most part, efforts have been made to find commonalities and complementarities across different theoretical orientations. When the Society for the Exploration of Psychotherapy Integration (SEPI) was formed in 1983, its stated goals were for the integration of different approaches to therapy, but also for the integration of research and practice. This article comments on the long-standing gap between practice and research, and offers ways in which this gap may be closed. Moreover, in light of increasing demands for accountability, it is maintained that empirical pragmatism needs to be the integrative theme of the 21st century. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Evidence-based Psychotherapy: Where Theory and Practice Meet.

Reviews the book, Evidence-based Psychotherapy: Where Theory and Practice Meet edited by Carol D. Goodheart, Alan E. Kazdin, and Robert J. Sternberg (see record 2006-02969-000). The distinguished editors and authors of Evidence-Based Psychotherapy: Where Theory and Practice Meet have created an intellectual atmosphere in the book that paves the way for generative development of evidence-based practice (EBP) in psychotherapy in the future. The book is organized into three sections: 1) "The Practice Perspective," 2) "The Research Perspective," and 3) "Training, Policy, and Cautions." This book is an important addition to the debate on EBP in psychotherapy and highlights issues that extend well beyond the role of psychotherapy in EBP. It is highly recommended for practitioners and researchers alike and is likely to invite thoughtful questioning and reflection on core assumptions at both ends of the spectrum. Moreover, the book would serve as a useful primer on the issues germane to EBP in psychotherapy training for graduate students and psychiatric residents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Introduction to special issue.

Recent years have witnessed the emergence of two powerful, and seemingly contradictory, visions of what most fundamentally causes change in psychotherapy. One of these visions emphasizes the primacy of therapist technique. According to this viewpoint, it is the specific methods used by the psychotherapist that account for, by far, most of the variance in treatment outcome. This viewpoint is seen most notably in what have been termed the empirically supported treatments (EST) and evidence-based practices (EBP) movements. The second vision instead focuses on the patient-therapist relationship and so-called therapist-offered relationship qualities as the sine qua non of therapeutic effectiveness. Advocates of this viewpoint underscore research on the importance of relational qualities such as the therapeutic working alliance (or cohesion in groups) and therapist-offered conditions. While acknowledging the value of both visions noted above, this special issue of Psychotherapy is based on the notion that what matters most in psychotherapeutic treatments is the interplay of the two, of techniques and the therapeutic relationship. Technical factors and relational factors are indelible elements in each and every psychotherapy encounter, and the articles in this special issue explore and seek to uncover why this is so. The articles, in addition, seek to describe the complex ways in which technique and relationship interact with one another in different treatments, at different points in treatment, and in conjunction with still other variables. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Foundations of counseling and psychotherapy: Evidence-based practices in a diverse society.

Reviews the book, Foundations of counseling and psychotherapy: Evidence-based practices in a diverse society by David Sue and Diane M. Sue (2007). This book delivers a broad overview of major theories of mental health practise that is provocative and up to date. Cutting-edge research and a passionate plea for multicultural considerations make this is a unique resource for students, educators, and mental health workers. In addition, the text is clear, well written, and understandable to both novice and advanced students or practitioners. It uses a language that is both reasonable and persuasive. Commencing with a fervent rationale for evidence-based practise and empirically supported theories, the authors show the detailed progression of the discipline of psychotherapy within the context of multiculturalism and diversity. The reader is led on a journey that emphasises employing a scientist–practitioner model “with a solid sense of how the various therapeutic approaches differ—and how each can be applied in clinical practice” (p. 2). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy in long-term care: II. Evidence-based psychological treatments and other outcome research.

This article is the 2nd of 2 that together examine 3 domains important to providing high-quality, evidence-based services to long-term care (LTC) facility residents: policy and advocacy, practical considerations, and outcome research. Older adults who reside in LTC facilities have a very high rate of mental health difficulties. Psychologists have been able to provide services to this population through Medicare since the late 1980s, and empirical findings on treatment approaches are important in guiding psychotherapists to more helpful intervention. The focus of this article is outcome research in LTC settings. This article emphasizes evidence-based psychological treatments (EBTs) but also examines other scientifically supported approaches and discusses the strengths and limitations of focusing on EBTs, as well as general issues in the relation between science and practice in the provision of psychotherapy in LTC settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrating outcome research and clinical reasoning in psychotherapy planning.

This article reviews the strengths and weaknesses of outcome research and clinical reasoning as bases of treatment planning and presents a synthesis in which these two types of information complement each other. The author proposes that therapy planning should begin with a review of the relevant outcome literature and also that divergence from research-based guidelines might be warranted under several conditions, including (a) when the client is demographically or culturally dissimilar to the study samples, (b) when assessment suggests a mismatch between the etiologies of the client's disturbance and the processes addressed by empirically supported treatments, and (c) when use of such treatments is followed by a lack of progress that signals the advisability of midcourse correction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Research summary on the therapeutic relationship and psychotherapy outcome.

Factors that influence client outcome can be divided into four areas: extratherapeutic factors, expectancy effects, specific therapy techniques, and common factors. Common factors such as empathy, warmth, and the therapeutic relationship have been shown to correlate more highly with client outcome than specialized treatment interventions. The common factors most frequently studied have been the person-centered facilitative conditions (empathy, warmth, congruence) and the therapeutic alliance. Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others. The improvement of psychotherapy may best be accomplished by learning to improve one's ability to relate to clients and tailoring that relationship to individual clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Goal consensus and collaboration.

This article updates our previous article in this journal (Tryon & Winograd, 2001) by examining via meta-analyses results of recent studies, published from 2000 through 2009, that relate goal consensus and collaboration to treatment outcome. Specifically, 15 studies with a total sample size of 1,302 yielded a goal consensus-psychotherapy outcome effect size of .34 (SD = .19, p SD = .17, p     

What Works in Psychotherapy and How Do We Know?: What Evidence-Based Practice Has to Offer.

Evidence-based practice may be insufficiently understood by dynamically oriented therapists and analysts. It includes the integration of the best available research evidence, clinical expertise, and considered attention to a patient's personal attributes, sociocultural characteristics, and unique dynamics. These 3 streams of knowledge inform clinical practice. Advocates of a manual approach to treatment have challenged clinicians to rethink the importance of what they consider salient in their therapeutic endeavors. This article demonstrates the relevance of an evidence-based practice perspective for dynamically oriented clinicians. An American Psychological Association task force has been established to develop and elaborate the view of current clinical practice so that it can be disseminated to clinicians and to the public as a policy statement that governs clinicians' thinking and work. The goal is to provide knowledgeable, reasonable, and responsible high-quality health care to those who need it based on these developed practice principles. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attending to the Omissions: A Historical Examination of Evidence-Based Practice Movements.

Evidence-based practice and empirically supported treatment movements are potent forces that affect the practice of psychology today and have the potential to mandate the types of treatments psychologists conduct. The histories of these movements reveal that certain aspects of therapy valued by psychologists have been ignored. It is shown that the evidence-based movements (a) overemphasize treatments and treatment differences and (b) ignore aspects of psychotherapy that have been shown to be related to outcome, such as variation among psychologists, the relationship, and other common factors. It is important that psychologists understand the development of these movements so that they can be critical consumers of research and can effectively influence the future course of events. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based psychological treatments for late-life anxiety.

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cultural influences on the process of conducting psychotherapy: Personal reflections of an ethnic minority psychologist.

I was asked to reflect how being a member of an ethnically diverse minority group, that is, Japanese American, may have influenced my clinical practice as a psychologist and psychotherapist. I first define the various facets of my “diversity status,” followed by an offering of reflections on how being a member of this group impacted both myself as a therapist and my clients. I conclude with several general recommendations geared to enhance a positive therapeutic alliance and client outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical practices with African Americans: Juxtaposition of standard clinical practices and Africentricism.

Rapidly changing demographics necessitate increased awareness of the impact of race, ethnicity, and levels of acculturation on treatment efficacy and differential diagnosis of ethnic minorities. Increasingly, psychologists are in a position of providing treatment for clients whose cultural background differs from their own. Because African Americans have historically underutilized mental health services, sensitivity to the cultural variables represented by this group is a growing concern. An integrated approach to conceptualizing, evaluating, and diagnosing African Americans from a culturally sensitive, Africentric perspective is provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving the relationship between the randomized clinical trial and real-world clinical practice.

I comment on the article by Krause (see record 2011-19228-002), which discusses a number of ways for clinical psychotherapy outcome researchers to make the results of randomized controlled trials (RCT) more useful to practicing psychotherapists primarily by making the distributions of raw data from those studies available to the public. In this way, it would be possible for psychotherapists to determine which treatment of an RCT (experimental or control) would be best for a specific patient. Problems with this proposal are discussed and an alternative model that integrates psychotherapy outcome data from group means and clinical case studies is offered. (PsycINFO Database Record (c) 2011 APA, all rights reserved)