The relation between specific and general dimensions of the psychotherapy process in interpersonal psychotherapy of depression.

This article examines the relation between general dimensions of the psychotherapy process, rated with the Vanderbilt Psychotherapy Process Scale (VPPS), and a type of manual-guided psychotherapy, Short-Term Interpersonal Psychotherapy of Depression (IPT). With the use of data from a training program in IPT, two types of analyses were performed. First, VPPS factors were correlated with IPT therapist competence ratings. This analysis showed that all VPPS-rated dimensions of patient and therapist behaviors were significantly correlated with IPT competence ratings. Especially strong correlations occurred between IPT competence ratings and the VPPS therapist factors of (a) Exploration and (b) Warmth and Friendliness. Second, to evaluate whether the general process features that influenced IPT competence ratings were also related to the therapy's effectiveness, correlations between VPPS process dimensions and patient outcome were performed. This analysis indicated that VPPS-rated therapist behaviors were significantly predictive of patient outcome, whereas patient behaviors were generally not significantly related to outcome. Taken together, the findings indicate the importance of general aspects of the psychotherapy process in therapist evaluation and efficacy of manual-guided psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence.

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An open trial of brief supportive-expressive psychotherapy in the treatment of generalized anxiety disorder.

Conducted a treatment development study applying brief supportive-expressive psychodynamic psychotherapy (P. Crits-Christoph et al; see record 95-195001-002) to the treatment of generalized anxiety disorder (GAD). Background and rationale for the development of this therapy are presented, along with the project's methods and results. Project goals were to develop a treatment manual, train therapists, and assess the treatment's integrity and efficacy. Outcome data on 26 patients (aged 22–64 yrs) with a Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnosis of GAD indicate that the treatment is promising. Patients revealed significant change in anxiety, depression, worry, and interpersonal problems. Ratings of therapist adherence and competence indicate that the treatment manual can be implemented with fidelity and can be discriminated from other treatments. Methodological issues in the planning of treatment research on GAD, particularly the problem of comorbidity, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Observations on the training of therapists in time-limited dynamic psychotherapy.

Suggests that "manualized training" is most effective at increasing adherence to the technical procedures characterizing the treatment under scrutiny. There is minimal evidence that other skills associated with therapeutic competence are acquired or enhanced to the extent found with technical adherence. Drawing on findings from a study of manual-guided training of therapists in the techniques of brief therapy (H. H. Strupp and J. L. Binder, 1984), the author offers recommendations for improving therapy training. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting patient change from therapist competence and patient-therapist complementarity in short-term anxiety-provoking psychotherapy: A pilot study.

Examined therapist competence and patient–therapist complementarity, measured by the Structural Analysis of Social Behavior system (L. S. Benjamin, 1974), as to their interrelation and their unique, collective, and interactive contributions to patient change in 20 sessions of short-term anxiety-provoking psychotherapy (STAPP; P. E. Sifneos, 1979). Patients were 15 highly educated outpatients (mean age 30 yrs) with mainly anxiety diagnoses. Therapists were in postgraduate manual-guided STAPP training. Results show that competence in an early session did not relate to patient change. In contrast, patient–therapist complementarity ratings predicted patient change both alone and over and above competence. Predictions were strongest for changes in general distress and dysfunctional attitudes and for shorter term change rather than for longer term change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The T1/35kDa family of poxvirus-secreted proteins bind chemokines and modulate leukocyte influx into virus-infected tissues

This article presents the development of a new 82-item rating scale of therapist adherence and competence for supportive-expressive (SE) dynamic psychotherapy for the treatment of cocaine dependence. Sixty-four items are rated for adherence, appropriateness, and quality of prescribed interventions. As part of the pilot/training phase of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, two independent expert judges rated 32 audiotapes of SE therapy sessions with cocaine-dependent patients, 10 tapes of cognitive therapy (CT) sessions, and 10 tapes of individual drug counseling (IDC) sessions. Reliability was acceptable for adherence but poor for quality and appropriateness. SE therapists used more expressive (interpretative) techniques than did either CT therapists or IDC counselors, and they used more supportive techniques than did IDC counselors.     

Do treatment manuals undermine youth–therapist alliance in community clinical practice?

Objective: Some critics of treatment manuals have argued that their use may undermine the quality of the client–therapist alliance. This notion was tested in the context of youth psychotherapy delivered by therapists in community clinics. Method: Seventy-six clinically referred youths (57% female, age 8–15 years, 34% Caucasian) were randomly assigned to receive nonmanualized usual care or manual-guided treatment to address anxiety or depressive disorders. Treatment was provided in community clinics by clinic therapists randomly assigned to treatment condition. Youth–therapist alliance was measured with the Therapy Process Observational Coding System—Alliance (TPOCS–A) scale at 4 points throughout treatment and with the youth report Therapeutic Alliance Scale for Children (TASC) at the end of treatment. Results: Youths who received manual-guided treatment had significantly higher observer-rated alliance than usual care youths early in treatment; the 2 groups converged over time, and mean observer-rated alliance did not differ by condition. Similarly, the manual-guided and usual care groups did not differ on youth report of alliance. Conclusions: Our findings did not support the contention that using manuals to guide treatment harms the youth–therapist alliance. In fact, use of manuals was related to a stronger alliance in the early phase of treatment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Therapist competence and patient outcome in interpersonal psychotherapy of depression.

This article examines whether the therapist's level of competence in conducting interpersonal psychotherapy of depression (IPT) is associated with patient improvement. Data from 35 depressed outpatients treated for up to 16 sessions as part of the IPT training program for the National Institute of Mental Health Treatment of Depression Collaborative Research Program were used. Multiple regression analyses were performed to predict outcome from 4th-session ratings of therapist skill while controlling for important pretreatment patient characteristics including level of depression, social adjustment, and expectations of treatment outcome. The results showed that measures of therapist performance contributed significantly to the prediction of patient-rated change and change in the apathy associated with depression but not to measures of social adjustment at 16 weeks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Distinctiveness of behavioral versus insight-oriented marital therapy: An empirical analysis.

The present study determined whether behavioral and insight-oriented marital therapy could be rendered in a distinct and uncontaminated fashion in manual-guided outcome research in which therapists were crossed with treatment condition. Results indicated that therapist interventions could be reliably coded into techniques specific to the respective approaches and into additional interventions not specific to either treatment modality. When provided with explicit treatment manuals and ongoing case supervision, therapists were able to administer both treatment conditions faithfully without contamination from techniques that were inconsistent with that theoretical approach. Behavioral marital therapy (BMT) was shown to be highly structured, with 93% of therapist interventions reflecting techniques specific to that approach. In contrast, insight-oriented marital therapy (IOMT) comprised a large percentage of nonspecific interventions (62%) compatible with but not unique to a psychodynamic orientation. Implications for the two treatment approaches and for future marital therapy outcome research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior.

16 therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant–observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Testing the integrity of a psychotherapy protocol: assessment of adherence and competence

Manipulation checks should be used in psychotherapy trials to confirm that therapists followed the treatment manuals and performed the therapy competently. This article is a review of some strategies that have been used to document treatment integrity; also, their limitations are discussed here. Recommendations for improving these checks are presented. Specific guidelines are offered regarding when and how to assess both therapist adherence to treatment protocols and competence.     

A qualitative analysis of client perceptions of the effects of helpful therapist self-disclosure in long-term therapy.

Thirteen adult psychotherapy clients currently in long-term therapy were interviewed twice, with semistructured protocols, about their experiences with helpful instances of therapist self-disclosure. Data were analyzed with a qualitative methodology. Results indicated that helpful therapist self-disclosures (a) occurred when these clients were discussing important personal issues, (b) were perceived as being intended by therapists to normalize or reassure the clients, and (c) consisted of a disclosure of personal nonimmediate information about the therapists. The therapist self-disclosures resulted in positive consequences for these clients that included insight or a new perspective from which to make changes, an improved or more equalized therapeutic relationship, normalization, and reassurance. Implications for psychotherapy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapists, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder.

The relationship between therapists and treatment outcome was examined in 14 highly trained therapists who participated in the Multicenter Collaborative Study for the Treatment of Panic Disorder. Overall, therapists yielded positive outcomes in their caseloads; yet, therapists significantly differed in the magnitude of change among caseloads. Effect sizes for therapist impact on outcome measures varied from 0% to 18%. Overall experience in conducting psychotherapy was related to outcome on some measures, whereas age, gender, gender match, and experience with cognitive-behavioral therapy (CBT) were not. Therapists with above- and below-average outcomes were rated similarly on measures of adherence and competency. The results suggest that therapists make a contribution to outcome in CBT for panic disorder, even when patients are relatively uniform, treatment is structured, and outcome is positive. Implications for future clinical outcome studies and for training clinicians are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance.

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Differences in the effectiveness of psychodynamic therapists: A process-outcome study.

Using data from a study (e.g., H. H. Strupp; see record 1993-38424-001) on the effect of therapist training on psychotherapy outcome, 16 therapists were identified as either more effective or less effective based on patients' outcome scores and length of stay (LOS) in treatment. Measures were completed by patients, therapists, independent observers, and therapists' supervisors. In-session behaviors were assessed at Sessions 3, 8, 16, and 22. More effective therapists displayed more positive behaviors (e.g., warmth), fewer negative behaviors (e.g., attacking), and more self-criticism than did less effective therapists. All therapists, however, showed some negative behavior. Significant results were almost entirely relationship-oriented. LOS was related to therapist behavior more often than were outcome scores. Only supervisors were largely unable to make the distinction between more or less effective therapists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Racial/ethnic disparities in therapist effectiveness: A conceptualization and initial study of cultural competence.

As a result of mental health disparities between White and racial/ethnic minority clients, researchers have argued that some therapists may be generally competent to provide effective services but lack cultural competence. This distinction assumes that client racial/ethnic background is a source of variability in therapist effectiveness. However, there have been no direct tests of the therapist as a source of health disparities. We provided an initial test of the distinction between general and cultural competence by examining client racial/ethnic background as a source of variability in therapist effectiveness. We analyzed cannabis use outcomes from a psychotherapy trial (N = 582) for adolescent cannabis abuse and dependence using Bayesian multilevel models for count outcomes. We first tested whether therapists differed in their effectiveness and then tested whether disparities in treatment outcomes varied across therapist caseloads. Results suggested that therapists differed in their effectiveness in general and that effectiveness varied according to client racial/ethnic background. Therapist effectiveness may depend partially on client racial/ethnic minority background, providing evidence that it is valid to distinguish between general and cultural competence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression.

This study reports on the relationship of therapist competence to the outcome of cognitive-behavioral treatment in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Outpatients suffering from major depressive disorder were treated by cognitive-behavioral therapists at each of 3 U.S. sites using a format of 20 sessions in 16 weeks. Findings provide some support for the relationship of therapist competence (as measured by the Cognitive Therapy Scale) to reduction of depressive symptomatology when controlling for therapist adherence and facilitative conditions. The results are, however, not as strong or consistent as expected. The component of competence that was most highly related to outcome is a factor that reflects the therapist's ability to structure the treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of therapist and patient mood on the therapeutic functioning of high- and low-facilitative therapists.

Determined the effects of presession moods of 12 therapists and their patients on level of therapist empathy, warmth, and genuineness. Results of an intensively designed study indicate that high- and low-facilitative therapists were differentially affected by therapist moods. High-facilitative therapists functioned more facilitatively under dysphoric moods than under positive, while the opposite was true of low-facilitative. There were no differences in tape-rated therapist facilitativeness under different patient moods for either group, yet patients of low-facilitative therapists did perceive such a difference. It is concluded that the therapist feelings preceding the facilitative therapy hour were not the same for high- and low-facilitative therapists. The use of the intensive design in psychotherapy process research is discussed. (44 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Graduate training in psychotherapy: Are therapy outcomes enhanced?

Several sources of indirect evidence supporting the value of graduate training in psychotherapy are reviewed here. Training protocols that are known to enhance trainees' skills are briefly discussed, as are conclusions of meta-analytic reviews examining relationships between therapist experience and training, and therapy outcome. An updated meta-analysis of therapy outcome studies involving within-study comparisons of psychotherapists of different levels of training and experience is summarized. It is concluded that a variety of outcome sources are associated with modest effect sizes favoring more trained therapists. In many outpatient settings, therapists with more training tend to suffer fewer therapy dropouts than less trained therapists. Shortcomings of available research and speculations about possible variables influencing outcomes are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)