On the Need for a New Psychotherapy Research Paradigm: Comment on Westen, Novotny, and Thompson-Brenner (2004).

Basic, process, and outcome research have the potential to inform clinical practice. However, as D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) observed in their timely analysis, the current dominant paradigm for psychotherapy outcome research--the randomized clinical trial--is not fulfilling this potential. The field's reliance on the medical model and manual-based interventions has contributed to the gap between research and clinical practice. Greater collaboration between practitioners and researchers, a focus on therapeutic principles rather than treatment packages, and systemic changes in how scholarly efforts are reinforced are needed to shift the current research paradigm. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A sociological perspective on the therapeutic alliance: Ethnomethodology and conversation analysis.

Traditional perspectives consider the therapeutic alliance as tied to specific goals of positive patient change. Psychometric studies suggest that the therapeutic alliance is better conceptualized as linked to aspects of the patient–therapist dyad independent from therapeutic goals. A framework to capture the relational identity of the alliance, proposed by E. Bordin (see record 94-105022-001), centers on patient–therapist collaboration. Ethnomethodology, a sociological research paradigm, suggests that "collaboration" in psychotherapy consists of methods that establish an impression of common sense between patient and therapist. These methods involve verbal and para-verbal cues, often subtle and implicit, that compose a subtext to the more explicit dialogue about therapeutic goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endangered by interpretations: Treatment by attitude of the narcissistically vulnerable patient.

Some narcissistically impaired patients present a particularly difficult therapeutic challenge. They often cannot tolerate interpretations because they view interpretations as humiliating evidence that they are shamefully defective. For these patients, "treatment by attitude" and without significant interpretation may be the only way they can feel safe enough to allow the therapeutic process to unfold. Two cases are discussed. In the 1st case, the usual therapeutic attitude of nonjudgmental acceptance was sufficient. The 2nd case was counterintuitive because the patient needed the therapist to demonstrate a complete lack of worry about the patient for her to make progress. Although the therapist's attitude is part of every treatment, it may be particularly important in the treatment of more severely disordered patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reunion at last--But with whom? A reply to Drs. Carter and Binder.

In their commentaries on The Reunion Process: A New Focus in Short-Term Dynamic Psychotherapy (see records 2007-09422-003 and 2007-09422-003), Drs. Binder and Carter have both suggested that the progress reported in the case history was due to the relationship between patient and therapist, rather than the intrapsychic work of reunion with the patient's parents. In my rejoinder, I will argue that the therapeutic relationship is absolutely necessary to a successful treatment, but not always sufficient to help the patient resolve his difficulties. Although current research demonstrates that the relationship in the office has a greater effect on outcome than technique, this research is based on existing technique; it is always possible that a new technique could be more effective than preceding ones. I note that there may be other reasons for skepticism about the reunion process. For example, the therapist may feel so empathic with the patient's anger that forgiveness and a sense of reunion are not considered possible. I conclude that using this method will give the patient a deep sense of reunion, both with the therapist and with his early attachment figures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression.

This study attempted to replicate an earlier study (R. J. DeRubeis & M. Feeley, 1990) of the prediction of symptom change from process variables in cognitive therapy for depressed outpatients. Measures of in-session therapist behavior and therapist–patient interactions were correlated with prior and subsequent symptom change. One of the positive findings was confirmed, but the other received only marginal support. A "concrete" subset of theory-specified therapist actions, measured early in treatment, predicted subsequent change in depression. The therapeutic alliance was predicted by prior symptom change in 1 of the 2 later assessments, but only at a trend level. Several negative findings were similar to those obtained in the earlier study. Specifically, the alliance, an "abstract" subset of theory-specified therapist actions, and facilitative conditions did not predict subsequent change. Implications for causal inferences in psychotherapy process research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the use of symbolic labels in psychotherapy outcome research: Comment on Wills, Faitler, and Snyder.

Wills, Faitler, and Snyder (1987) identified distinctive therapist behaviors, trained therapists to implement these techniques, and demonstrated that trained raters could reliably categorize different behaviors. The criteria used to operationalize certain behaviors as behavioral marital therapy and others as insight-oriented marital therapy were arbitrary and are not consistent with either theoretical conceptualizations or the applied utilization of these therapeutic approaches. Future comparative psychotherapy research should avoid such labels and focus on empirical validation of the most effective therapy behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists' emotional reactions to substance abusers: A new questionnaire and initial findings.

Developed and tested the Ratings of Emotional Attitudes to Clients by Treaters (REACT) scale. The REACT was administered to 52 therapists and 140 cocaine-dependent outpatients, at sessions 2, 5, and 24 of psychotherapy. It was found to have high internal consistency at each time point, moderately high convergent validity with therapists' (but not patients') therapeutic alliance ratings, and a factor structure that appeared to meaningfully derive 4 factors: "therapist in conflict with self," "therapist focused on own needs," "positive connection," and "therapist in conflict with the patient." Therapists' emotional responses were found to become more negative over the course of treatment, and, when compared by theoretical orientation, were found more positive for 12-step drug counselors than for cognitive or supportive-expressive therapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Termination in brief psychotherapy: The case for an eclectic approach.

Outlines theoretical perspectives on the termination phase of brief psychotherapy (i.e., termination as either a minimal or central focus in brief therapy). From both case studies and empirical investigations, a flexible approach is advocated in which termination work is in keeping with the goals of treatment and the quality of the therapist–patient relationship. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chance encounters: Unintentional therapist disclosure.

Explores how chance encounters influence the interpersonal relationship for both patient and therapist. Both patient and therapist experiences of the therapist's subjectivity may become accessible and available for analysis. Such encounters may reveal aspects of the interpersonal matrix that were previously defended against. In the chance meeting, the patient has the opportunity to experience the therapist as a separate person or as an extension of the self, as an object available for idealization or devaluation, or as a subject in his or her own right. Likewise, the therapist has the opportunity to experience him- or herself in ways that may be either concordant or discordant with the interpersonal relationship in the consulting room, bringing into focus new aspects of the interpersonal matrix. Case material highlights the challenges created by unintentional disclosure, by exploring the therapist's anxiety about such experiences. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

"Play therapy and psychopharmacology: What the play therapist needs to know": Correction.

Reports an error in "Play therapy and psychopharmacology: What the play therapist needs to know" by Daniel S. Sweeney and Ross J. Tatum (International Journal of Play Therapy, 1995, Vol 4[2], 41-57). The table "Childhood DSM-IV Diagnoses and Psychotropic Medications That May Be Indicated" on pages 46-47 contained three (3) errors. A corrected copy of the table is included with the erratum. (The following abstract of the original article appeared in record 1997-05134-004.) Provides a basic overview of pediatric psychopharmacology and examines specific related considerations for the play therapist. The article also addresses some medication considerations specific to the treatment modality of play therapy. It is argued that possession of even a cursory knowledge about child psychopharmacology places the play therapist in a better position to provide quality treatment. A list of childhood Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnoses and psychotropic medications that may be indicated is provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the Merits of Clinical Judgment: Comment.

Comments on the article by D. Westen and J. Weinberger (see record 2004-19091-002), which criticized academic clinical psychologists for being cynical about clinical judgment and clinical practice. In our view, it seems unlikely that more than a few academic clinical psychologists believe that they have little to learn from clinical practice or experience. In this comment, we examine the arguments about clinical judgment made by Westen and Weinberger (2004). Westen and Weinberger (2004) conflate the effect of training with the effect of experience. Westen and Weinberger (2004) do not mention that the value of training in psychology has been well-supported by research. While Westen and Weinberger (2004) make positive comments about the types of feedback that clinicians receive, for a number of reasons, including the Barnum effect, psychologists can be misled by feedback. Westen and Weinberger (2004) also argue that "psychotherapists tend to have much more direct and immediate feedback than most other medical practitioners, who may prescribe a medication or perform a procedure and not see the patient again for a year" (p. 603). But when psychologists make a diagnosis or describe a personality trait, they frequently do not receive "direct and immediate feedback" on whether they are right or wrong. In contrast, physicians often receive highly valid feedback. Finally, in discussing the value of ratings made by clinicians, Westen and Weinberger (2004) observe that "empirically, we have found surprisingly little evidence of theory-driven observational bias in using clinician-report methods" (p. 601). The issue is important because Westen and Weinberger argue in favor of using clinician ratings to construct diagnostic criteria. If clinicians' ratings are biased, then the criteria will be biased. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What has psychotherapy inherited from Carl Rogers?

Rogers' classic article (see record 2007-14639-002) on the necessary and sufficient conditions for therapeutic change--now 50 years old--has made an indelible impact on the field. In his brief article, Rogers broke with the past, making a compelling case for the importance of subjecting our hypotheses about how therapy works to empirical test. Moreover, his emphasis on the importance of the therapy relationship is now routinely accepted as necessary, even if not sufficient for change to occur. Having moved beyond Rogers' necessary and sufficient conditions, the field of therapy now recognizes that as important as the therapy relationship might be, there are certain clinical problems that require the use of specific techniques to bring about change. Still, it is currently recognized that therapist acceptance is essential, that nondirective methods can be effective in improving client motivation, and perhaps most important, that the therapist needs to work toward the development of evidence-based interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The beginning sessions of child therapy: Of messages and metaphors.

Contends that a number of important messages require communication from therapist to patient during the first few sessions of child therapy. These messages serve to foster the development of the therapeutic alliance and educate the patient about the therapeutic process. Several of these messages are described that concern defining a problem area, emphasizing the helping role of the therapist, reinforcing the belief that problems can be confronted and mastered, describing the therapeutic problem-solving process, and empathizing with the difficulties inherent in this process. The significant use of metaphors by both patient and therapist is discussed. (38 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Heart-pothesis" is a two-edged sword.

Challenges the notion of a "heart-pothesis," the act of bestowing scientific status on a personal conviction, presented in S. I. Abramowitz's (1978) article on Black patient–White therapist relationships. Some individuals may overestimate or refuse to see discrimination, while exclusive focus on equality and nondiscrimination fails to address larger issues of accessibility and outcome of treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On receiving the patient's transference: the symbolizing and desymbolizing countertransference

This is an empirical study of the therapist's experience of the patient delineating the boundaries between empathy and constructive and destructive forms of countertransference. The unique step was taken of focusing a video camera on the therapist in order to trace the therapist's nonverbal behavior during listening. The same therapist was observed first in a "not-so-difficult" and then a "difficult" session; the sessions could then be distinguished along dimensions of rhythmicity or arrhythmicity of nonverbal behavior. These observations suggested three modes of experiencing the patient: empathy marked by rhythmicity, a symbolizing countertransference marked by a transitory arrhythmicity, and a desymbolizing countertransference marked by continuous arrhythmicity. The congruence of these formulations based on direct observation of therapist behavior and ones derived from retrospective reconstructions of analysts in sessions (Schwaber, Jacobs, and Laskey) was explored and was found to enhance the validity of the proposed formulations.     

Understanding concerns about interventions to promote forgiveness: A review of the literature.

A new area in psychotherapy practice and research has arisen addressing therapeutic interventions to explicitly promote forgiveness. There is wide variation in the response to this new area including enthusiastic acceptance, wary openness, and vigorous opposition. Unfortunately, these reactions are not often based on a thorough understanding of the empirical literature and result in concerns about using forgiveness interventions in therapy that may or may not be warranted. The authors identify these potential concerns, framing them as concerns about the impact on clients, concerns related to therapist skill or knowledge, and concerns about the effect on the therapy process. The authors address these concerns with a review of the relevant research on forgiveness in therapy. Based on this review, the authors conclude that some skepticism of the new "forgiveness interventions" is warranted, although serious consideration needs to be given to these interventions at appropriate times. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client–therapist value similarity and psychotherapy outcome: A microscopic analysis.

Examined the association between patient–therapist pretreatment value similarity and subsequent improvement in 45 nonpsychotic psychiatric outpatients (aged 19–54 yrs) who were randomly assigned to 22 therapists. Pre-assignment assessment of similarity in 36 value dimensions on the Rokeach Value Survey was investigated to determine how the dimensions influenced symptomatic and global changes in the therapy process. Treatment outcome was assessed both by patient and therapist reports, and the SCL-90 was used to evaluate pre- to posttreatment symptom change on 9 symptom dimensions. In addition, therapists were asked to complete a subjective rating of improvement at the end of treatment. The results indicate that a complex pattern of similarity and differences in specific values promoted maximal improvement. Moreover, specific improvement measures were influenced differently by various patient–therapist value patterns. Generally, therapist ratings of outcome were enhanced by pretreatment dissimilarities in value placed on social ascendance and achievement and similar value emphasis being placed on humanistic and philosophical concerns. Patient ratings of outcome were also enhanced if patient and therapist shared philosophical and humanistic concerns, but were further facilitated if values relating to social attachment and independence were ranked differently for patient and therapist. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A paradigm for single-case research: The time series study of a long-term psychotherapy for depression.

Articulates a paradigm for single-case research in psychotherapy. A patient diagnosed as having major depressive disorder was seen in an intensive, twice-weekly psychodynamic psychotherapy for 2.5 years. Each session was videotaped, and assessments of patient change were obtained at regular intervals. A time-series analysis was used to model fluctuations in the therapy process to take into account time and the effect of previous events on subsequent changes, thereby preserving the context-determined meaning for therapist and patient actions. A bidirectional analysis of causal effects shows that the influence processes between therapist and patient are mutual and reciprocal and suggests that the effect of the patient on the therapist and on the process has not been made sufficiently explicit in previous models of process and change. The potential of intensive single-case designs for uncovering causal effects in psychotherapy is demonstrated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Discussion of "The Challenge of the Strong Adaptive Approach": Comment on Langs (2005).

According to the strong adaptive hypotheses of R. Langs (see record 2005-01622-004), unconscious processes within a patient pick up the precise interactional significance or core emotional impact of each act by the therapist, of which neither the therapist nor the patient is consciously aware. This initiates a search among millions of affect-image units within the mind of the patient until it finds and selects those that assemble around this core emotion to become a narrative that is analogous to the therapist's act. This matching narrative enters the patient's free associations. However, it is now a story about some other persons or interactional events in some other place, while at the same time it is about the meaning and implications of the specific action by the therapist that set this process in motion, of which the therapist and the patient were not consciously aware. An illustrative clinical example is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)