Change process research (CPR) is the study of the processes by which change occurs in psychotherapy and is a necessary complement to randomized clinical trials and other forms of efficacy research. In this article the author describes and evaluates four types of CPR. The first three are basic designs and include quantitative process–outcome, qualitative helpful factors, and microanalytic sequential process; the fourth, the significant events approach, refers to methods such as task analysis and comprehensive process analysis that integrate the first three. The strengths and weaknesses of each design are described and summarized using both causal and practical criteria as part of an overall argument for systematic methodological pluralism.

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Psychotherapy change process research: realizing the promise.

Evidence based assessment.

This article addresses the long-standing divide between researchers and practitioners in the field of psychotherapy, regarding what really works in treatment and the extent to which interventions should be governed by outcomes generated in a "laboratory atmosphere." This alienation has its roots in a positivist paradigm, which is epistemologically incomplete because it fails to provide for context-based practical knowledge. In other fields of evaluation research, it has been superseded by a mixed methods paradigm, which embraces pragmatism and multiplicity. On the basis of this paradigm, we propose and illustrate new scientific standards for research on the evaluation of psychotherapeutic treatments. These include the requirement that projects should comprise several parallel studies that involve randomized controlled trials, qualitative examinations of the implementation of treatment programs, and systematic case studies. The uniqueness of this article is that it contributes a guideline for involving a set of complementary publications, including a review that offers an overall synthesis of the findings from different methodological approaches.

Case studies within a mixed methods paradigm: toward a resolution of the alienation between researcher and practitioner in psychotherapy research.

The role of the individual in the coming era of process-based therapy

Numerous trials demonstrate that monitoring client progress and using feedback for clinical decision-making enhances treatment outcomes, but available data suggest these practices are rare in clinical settings and no psychometrically validated measures exist for assessing attitudinal barriers to these practices. This national survey of 504 clinicians collected data on attitudes toward and use of monitoring and feedback. Two new measures were developed and subjected to factor analysis: The monitoring and feedback attitudes scale (MFA), measuring general attitudes toward monitoring and feedback, and the attitudes toward standardized assessment scales-monitoring and feedback (ASA-MF), measuring attitudes toward standardized progress tools. Both measures showed good fit to their final factor solutions, with excellent internal consistency for all subscales. Scores on the MFA subscales (Benefit, Harm) indicated that clinicians hold generally positive attitudes toward monitoring and feedback, but scores on the ASA-MF subscales (Clinical Utility, Treatment Planning, Practicality) were relatively neutral. Providers with cognitive-behavioral theoretical orientations held more positive attitudes. Only 13.9 % of clinicians reported using standardized progress measures at least monthly and 61.5 % never used them. Providers with more positive attitudes reported higher use, providing initial support for the predictive validity of the ASA-MF and MFA. Thus, while clinicians report generally positive attitudes toward monitoring and feedback, routine collection of standardized progress measures remains uncommon. Implications for the dissemination and implementation of monitoring and feedback systems are discussed.

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Monitoring Treatment Progress and Providing Feedback is Viewed Favorably but Rarely Used in Practice

This article illustrates the application of an adjudicated form of hermeneutic single-case efficacy design, a critical-reflective method for inferring change and therapeutic influence in single therapy cases. The client was a 61-year-old European-American male diagnosed with panic and bridge phobia. He was seen for 23 sessions of individual process-experiential/emotion-focused therapy. In this study, affirmative and skeptic teams of researchers developed opposing arguments regarding whether the client changed over therapy and whether therapy was responsible for these changes. Three judges representing different theoretical orientations then assessed data and arguments, rendering judgments in favor of the affirmative side. The authors discuss clinical implications and recommendations for future interpretive case study research.

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An adjudicated hermeneutic single-case efficacy design study of experiential therapy for panic/phobia.

We present a range of evidence for the reliability and validity of data generated by the Personal Questionnaire (PQ), a client-generated individualized outcome measure, using 5 data sets from 3 countries. Overall pretherapy mean internal consistency (alpha) across clients was .80, and within-client alphas averaged .77; clients typically had 1 or 2 items that did not vary with the other items. Analyses of temporal structure indicated high levels of between-clients variance (58%), moderate pretherapy test-retest correlation (r = .57), and high session-to-session Lag-1 autocorrelation (.82). Scores on the PQ provided clear evidence of convergence with a range of outcome measures (within-client r = .41). Mean pre-post effects were large (d = 1.25). The results support a revised caseness cutoff of 3.25 and a reliable change index interval of 1.67. We conclude that PQ data meet criteria for evidence-based, norm-referenced measurement of client psychological distress for supporting psychotherapy practice and research.

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John Wagner

Papers

An adjudicated hermeneutic single-case efficacy design study of experiential therapy for panic/phobia.

Psychometrics of the personal questionnaire : a client-generated outcome measure