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)     

Introduction to the special section on multivariate psychotherapy process research: Structure and change in the talking cure.

In response to the search for novel investigative strategies to apply in the study of psychotherapy processes, several investigators have turned to the use of factor-analytic methods of investigation. Four studies are presented that use such methods to investigate the structure of, and change in, aspects of the client and therapist discourse and symptoms over the course of treatments. The corpora of process data, culled from investigations taking place on three different continents, represent some of the largest samples of in-therapy behavior that have been analyzed in microanalytic detail. Providing both methodological advances and important substantive findings, the studies included were conducted to stimulate further use and development of factor-analytic methods to identify and track key processes over the course of psychotherapeutic treatment. (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)     

The outcome of psychotherapy: A selected analysis of research findings.

A selective review of outcome studies of psychotherapy with emphasis on the major methodological issues of spontaneous recovery and methods of experimental control. The results of 9 studies which used experimental controls were assessed in terms of their limitations and merits in demonstrating the effectiveness of psychotherapy. It is concluded that outcome research with available techniques could be fruitful even though conclusions based on present research must be carefully qualified. (30 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrating writing into psychotherapy practice: A matrix of change processes and structural dimensions.

Research on therapeutic writing indicates that it can offer a range of physical and psychological benefits. There is no consensus, however, concerning how writing achieves these benefits. To address this question, the authors propose a matrix framework with emotional-cognitive change processes (what can be activated) along its horizontal dimension and abstract-concrete structure (how the processes are activated) along its vertical dimension. On the horizontal dimension, writing can encourage clients who are distant from their emotional world to approach or to modulate emotional intensity, and to create meaning and coherence. Along the vertical dimension, these processes can be activated through tasks that vary in structure, including programmed writing, diaries, journaling, autobiography, storytelling, and poetry. Finally, the authors consider constraints on writing that apply to particular client groups. The matrix framework is meant to encourage clinicians to use therapeutic writing and to assist researchers in framing questions to advance our knowledge of writing as a therapeutic practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of manual-based training on treatment fidelity and outcome: A review of the literature on adult individual psychotherapy.

The authors examine training issues related to the use of treatment manuals in psychotherapy outcome research. In particular, they examine methodological considerations such as the operationalization of manual-based training, trainer effects, therapist variables that mediate training, issues related to experimental design, and the choice and definition of appropriate dependent variables. The research literature indicates that manual-based training can produce technical adherence. Improvements in treatment competence were seen within, as opposed to across, cases. Researchers have been unable to draw strong links between treatment fidelity and patient outcomes. The review concludes that the limited focus on training studies in the manual-based treatment field compromises conclusions drawn from psychotherapy outcome research that relies on manuals to ensure a uniform delivery of the experimental variable. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of psychodynamic psychotherapy.

Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of psychotherapy supervision on client outcome: A critical examination of 2 decades of research.

The supervision of counselors-in-training has become an important area of psychotherapy research. Through supervision, one expects that trainees will gain the knowledge and clinical skills needed to work effectively with clients. Much research has been dedicated to understanding trainee skill development through supervision, but relatively few studies in the literature have addressed whether clinical supervision leads to improved client outcome. The current article presents a review of 2 decades of research into the question of whether clinical supervision improves client outcome. Ten studies conducted between 1981 and 1997 are reviewed in detail. Caveats and criticisms, as well as suggested directions for future research, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The reliability of self-image change scores in psychotherapy research: An application of generalizability theory.

The aim of this study was to estimate the reliability of the pre- to posttreatment change scores for 3 different self-image aspects, Attack, Love, and Control. To measure self-image, we used the Norwegian version of the introject surface of Benjamin's (1974) structural analysis of social behavior. The article introduces Generalizability (G-) theory, combined with the recent concept of tolerance for error, as a framework for estimating the reliability and precision of change scores in 1- and 2-facet designs. Data were obtained from the Norwegian Multi-Site Study of Process and Outcome in Psychotherapy, including 291 outpatients. The mean number of treatment sessions was 47. The results show that change scores may be highly reliable. Generalizability coefficients resting on the relative and absolute score interpretations, respectively, for both the Love and Attack change scores reached acceptable levels. The reliability of the Control change score was, however, poor. G-theory combined with the error-tolerance concept proved to be a helpful framework for assessing the dependability of change scores in a psychotherapy research setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy.

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy’s comparable efficacy to other empirically supported approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Negative outcome in psychotherapy and what to do about it.

Reviews the book, Negative outcome in psychotherapy and what to do about it edited by Daniel T. Mays and Cyril M. Franks (1985). Negative outcome in psychotherapy is a topic of great importance to the field. The treatment of this topic by Mays and Franks is a comprehensive and ambitious one. Their goals, as outlined in the Introduction, are to 1) generate a definition of negative outcome, 2) bring some preliminary closure to the negative outcome debate, 3) identify contributing variables and 4) offer suggestions for research and treatment application. They proceed to do this through an edited volume, consisting of 14 chapters, which fall into six sections and an Appendix. Of the goals that the editors set for themselves in the Introduction, the most important one, to this reviewer's mind, was not even mentioned--that is, the development of a theoretical framework from which future research can develop. It is this synthesis that makes the book particularly valuable. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient's and therapist's views of early alliance building in dynamic psychotherapy: Patterns and relation to outcome.

Patients and therapists have somewhat divergent perspectives of alliance. Usually in psychotherapy research, the focus is on the patient's view of alliance, predicting parts of outcome. This study questions this hypothesis by applying the shape-of-change procedure to patient's and therapist's view of alliance-building processes in dynamic psychotherapy. The results of this naturalistic study indicate that none of the 3 patient patterns is related to outcome at the end of psychotherapy, but a specific therapist's pattern--out of 2--is linked to positive symptom change. These results are discussed in the context of present research on therapeutic alliance, especially in terms of level and process, its measurement, and potential in predicting outcome in dynamic psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rates of change in naturalistic psychotherapy: Contrasting dose–effect and good-enough level models of change.

Most research on the dose–effect model of change has combined data across patients who vary in their total dose of treatment and has implicitly assumed that the rate of change during therapy is constant across doses. In contrast, the good-enough level model predicts that rate of change will be related to total dose of therapy. In this study, the authors evaluated these competing predictions by examining the relationship between rate of change and total dose in 4,676 psychotherapy patients who received individual psychotherapy. Patients attended 6.46 sessions on average (SD = 4.14, range = 3–29, Mdn = 5). The results indicated that although patients improved during treatment, patients' rate of change varied as a function of total dose of treatment. Small doses of treatment were related to relatively fast rates of change, whereas large doses of treatment were related to slower rates of change. Total dose had a nonlinear relationship with the likelihood of clinically significant change. Given the variability in rates of change, it appears that time limits for treatment uniform to all patients would not adequately serve patients' needs. (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)     

An approach to psychotherapy change process research: Introduction to the special section.

This special section has a dual focus. One is on psychotherapy change research. The other is to explicate an approach to develop a program of research that builds on 2 aspects of scientific discovery: decomposition of observed phenomena and localization of specific elements that may combine to produce a complex whole. These aspects are considered within an ordered framework of 8 steps in the development and testing of a model, moving from discovery to model construction, validation, and prediction of complex outcomes. Studies on psychotherapy change processes were selected, after a masked review, to represent different levels in developing a program of research. Although it is argued that the early steps of decomposition and localization are important when developing a program of research, current editorial practices in first-tier journals, including the Journal of Consulting and Clinical Psychology, typically consider this type of study to be too preliminary for a scientific archival journal. Should this practice be revisited? (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Leading researchers' consensus on psychotherapy research findings: Implications for the teaching and conduct of psychotherapy.

We examined leading international psychotherapy researchers' views on psychotherapy outcome research. Participants completed a questionnaire on which they rated level of research evidence for or against various assertions about psychotherapy processes and outcomes. Participants rated how confident they were that the assertions were supported by psychotherapy research. Strong, or relatively strong, consensus was achieved on several of the questionnaire items. Areas for which relative uniformity of opinion does or does not exist have potential implications for the teaching and conduct of psychotherapy and for the science-practice interface in psychotherapy. Additionally, consensus about psychotherapy findings can be used as a yardstick by which to measure practicing clinicians' knowledge of the research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A self-determination theory approach to psychotherapy: The motivational basis for effective change.

The application of self-determination theory (SDT) to psychotherapy is particularly relevant because a central task of therapy is to support the client to autonomously explore, identify, initiate, and sustain a process of change. In this article, the authors discuss the experimental work, field studies, and clinical trials representing the application of SDT to the domain of psychotherapy. Evidence supports the importance of client autonomy for the attainment and maintenance of treatment outcomes. In addition, intervention studies suggest that therapist autonomy support enhances the likelihood that treatment gains will be achieved and maintained. The authors discuss some of the processes involved in enhancing autonomy, including the role of awareness, the importance of exploring and challenging introjects and external regulations, attention to need-related goal contents, and therapist attitudes required for a therapy approach that is process- rather than outcome-focused. (PsycINFO Database Record (c) 2010 APA, all rights reserved)