Showing papers in "Psychotherapy Research in 2007"

Presidential address: What we have learned from a decade of research aimed at improving psychotherapy outcome in routine care

Abstract: The findings of a decade-long program of research aimed at tracking patient treatment response are summarized. Outcome measures were developed and applied on a weekly basis with patients undergoing therapy in routine practice. Treatment response was defined as reliable and clinically significant change, and longitudinal statistical models for identifying poor progress were applied. The author was able to estimate the amount of therapy necessary for recovery, study early dramatic improvers, and assess the consequences of providing practitioners with alarm signals when patients were off track for a positive outcome. Results indicate that integrating treatment response research into routine mental health care reliably improved positive outcomes and reduced negative outcomes. Future directions for this line of action research are suggested.

Enhancing outcome for potential treatment failures: Therapist–client feedback and clinical support tools

Abstract: Enhancing treatment outcomes for clients who are predicted to deteriorate before leaving treatment has important implications for quality of client care. The effects of three interventions aimed at reducing client deterioration were examined in a sample of 1,374 clients whose outcome was contrasted across experimental groups and with a no-feedback/archival control group consisting of data from 1,445 clients. Results indicated that feedback to therapists reduced deterioration rates and improved outcome across clients, especially those predicted to be treatment failures. Therapist feedback effects were enhanced by the use of prompts to action based on a clinical support tools manual but not by the provision of direct feedback to clients.

A meta-analytic examination of client-therapist perspectives of the working alliance.

Abstract: Using 53 studies, comprising 52 separate data sets, published in refereed journals from 1985 through 2006, the authors conducted meta-analyses of the correlation and mean difference between client–therapist alliance ratings. Client and therapist alliance ratings were moderately correlated ( =.36, SD=.00); clients’ ratings were higher than ratings by their therapists ( =.63, SD=.42). Client disturbance was a significant moderator of client–therapist alliance rating discrepancies; clients with milder disturbances or with substance abuse problems tended to have larger rating discrepancies with their therapists than clients with more severe disturbances or moderate disturbance without substance abuse.

Autonomous motivation for therapy: A new common factor in brief treatments for depression

Abstract: The authors propose a new common treatment factor, autonomous motivation (Deci & Ryan, 2000), defined as the extent to which patients experience participation in treatment as a freely made choice emanating from themselves. Ninety-five depressed outpatients were randomly assigned to receive 16 sessions of manualized interpersonal therapy, cognitive–behavior therapy, or pharmacotherapy with clinical management. Self-report and interviewer-based measures of depressive severity were collected at pretreatment and posttreatment. Autonomous motivation, therapeutic alliance, and perceived therapist autonomy support were assessed at Session 3. Autonomous motivation was a stronger predictor of outcome than therapeutic alliance, predicting higher probability of achieving remission and lower posttreatment depression severity across all three treatments. Patients who perceived their therapists as more autonomy supportive reported higher autonomous motivation.

Outcomes of religious and spiritual adaptations to psychotherapy: A meta-analytic review

Abstract: The use of spiritually oriented psychotherapies has increased dramatically during the past decade. This article reports a meta-analysis of 31 outcome studies of spiritual therapies conducted from 1984 to 2005 with clients suffering from a variety of psychological problems. Across the 31 studies, the random-effects weighted average effect size was 0.56. This finding provides some empirical evidence that spiritually oriented psychotherapy approaches may be beneficial to individuals with certain psychological problems (e.g., depression, anxiety, stress, eating disorders). Recommendations for future research in this domain are offered.

Identifying core categories of client-identified impact of helpful events in psychotherapy: A qualitative meta-analysis.

Abstract: A growing number of psychotherapy studies using qualitative approaches to research call for the cumulative assessment of findings Although summaries of qualitative research studies have been published in psychotherapy research literature, the cumulative assessment of findings emerging from qualitative psychotherapy studies investigating the same research topic has not yet been attempted using empirical analysis This study explores, through an application of meta-analytical procedures that result in a rigorous secondary analysis of primary qualitative findings, the kinds of impacts that clients identify as helpful Findings from qualitative studies focusing on client-identified impacts of helpful significant events are analyzed The qualitative descriptive–interpretative analysis is conducted in an exploratory manner for selected studies The preliminary results of the qualitative meta-analysis are presented, together with the assessment of utility, possibilities, and shortcomings of the explore

A guide to conducting a task analysis of psychotherapeutic change

Abstract: The epistemological and methodological underpinnings of task analysis are discussed and the steps and concrete procedures for its implementation are described and exemplified in a task analysis of the resolution of unfinished business. Task analysis, a method for studying the process of change, consists of two main phases: a discovery-oriented phase based on rational–empirical model building and a validation phase based on hypothesis testing. The goals of the approach are to (a) build an observationally based model of how therapeutic change occurs for a particular type of affective–cognitive problem, (b) validate the model of change, and (c) relate the process of change to outcome. Benefits and strengths of the approach are presented and factors that have impeded the use of this approach in the study of change processes are discussed.

Understanding minds: Different functions and different disorders? The contribution of psychotherapy research

Abstract: Disorders in the ability to understand mental states (metacognition) have an important role in psychopathology. Some clinicians talk of a generalised impairment of metacognition and others of malfunctioning of specific aspects. We compare two contrasting hypotheses. We call the first one ‘fast running’ hypothesis according to which metacognition is a single function, like speed in running. The second one is the ‘tennis playing’ hypothesis according to which metacognition is composed, like the ability to play tennis, of various, relatively independent skills, which can get impaired selectively. We reviewed the main theories and researches on metacognition and, therefore, we outlined a research programme based on them, describing the contribution made by the research on the psychotherapeutic process to this programme.

Patients’ experiences of change in cognitive–behavioral therapy and psychodynamic therapy: a qualitative comparative study

Abstract: Research suggests that different therapeutic approaches produce roughly equivalent outcomes despite their theoretical and technical differences. This study explores whether the quantitative equivalence may conceal differences in patients’ experiences of the quality of change. Thirty-two patients who had terminated cognitive–behavioral therapy or psychodynamic therapy were interviewed about their experiences in psychotherapy. The cases were clustered in four groups depending on type of therapy and whether outcome was judged as satisfactory or not. An outcome narrative was reconstructed for each type. Even though the ratio of satisfactory to unsatisfactory cases was roughly equal in the two types of treatments, there were obvious differences in the kinds or quality of outcome that were reported as well as some experiences common to the two groups of patients. The narratives of the dissatisfied patients underscored the importance of matching the approach to the patient.

The recovery of metacognitive capacity in schizophrenia across 32 months of individual psychotherapy: A case study

Abstract: It has been asserted that psychotherapy might help persons with schizophrenia to improve their capacity for metacognition, that is, their ability to think about their own thinking and the thinking ...

The evolution of therapeutic change studied through generic change indicators

Abstract: Ongoing change and therapeutic outcome were studied in five psychotherapeutic processes: three brief psychodynamic therapies, one social constructionist family therapy, and one group therapy of a comprehensive nature for drug abuse patients. Using qualitative methodology, in-session and extrasession change moments were identified and classified in a hierarchy of generic change indicators. Additionally, all patients were administered Lambert's Outcome Questionnaire. Results show that (a) extrasession change moments are more frequent toward the end of therapy, (b) therapy types differ in the frequency of some change indicators but not others, and (c) change indicators observed at the beginning of therapy are of lower level than those occurring at the end.

Cognitive–behavioral group treatment for pathological gambling: analysis of effectiveness and predictors of therapy outcome

Abstract: The authors sought to examine short- and mid-term effectiveness of a group cognitive–behavioral therapy (CBT) in pathological gambling (PG) and to analyze predictors of therapy outcome. Two hundred ninety PG patients participated in the current study, all diagnosed on the basis of Diagnostic and Statistical Manual of Mental Disorders (4th edition) criteria, and were given manualized outpatient group CBT (16 weekly sessions). Specific assessment before and after the therapy and at 1, 3, and 6months follow-up was conducted. Logistic regression and survival analyses were applied. Outpatient group CBT was found to be effective, with abstinence rates of 76.1% by the end of therapy and 81.5% at 6months follow-up. The dropout rate during treatment decreased significantly after the fifth treatment session. Psychopathological distress (p=.040) and obsessive–compulsive symptoms were identified as factors predicting relapse and dropout, respectively. These findings suggest that group CBT is effective for tr...

Correlates of the real relationship in psychotherapy: A study of dyads

Abstract: This study examined several theoretical propositions regarding the role of the real relationship using a sample of 59 psychotherapy dyads. As hypothesized, positive associations were evident between therapist ratings of the real relationship and their ratings of the working alliance and client progress; negative associations were found between therapist ratings of the real relationship and attachment avoidance. For clients, significant and hypothesized associations were found between ratings of the real relationship and secure attachment to therapists as well as their perceptions of therapist empathy. Regression analyses showed that client ratings of the real relationship were significantly associated with their ratings of progress in treatment above and beyond their ratings of the working alliance, therapist empathy, and attachment.

Effectiveness of religiously tailored interventions in Christian therapy

Abstract: Christian therapy is sought by many clients, yet the existing research examining its effectiveness is sparse. Clients (n=220) and their therapists (n=51) in 6 Christian agencies and 1 secular agency across the United States participated in a study of Christian therapy. Clients and therapists in Christian therapy generally believed that religiously tailored interventions were appropriate. Clients in Christian therapy and secular therapy reported feeling equally close to their therapists and equal (and appreciable) improvements in their presenting problems over time. Compared with therapists in the secular agency, those in Christian agencies used secular interventions as frequently and religious interventions more frequently. Across all agencies, clients with high religious commitment reported greater closeness with their therapists and greater improvement in their presenting concerns when receiving religious interventions than did clients with low religious commitment.

A programmatic study of short-term psychodynamic psychotherapy: Assessment, process, outcome, and training

Abstract: The author reviews findings from his research program on short-term psychodynamic psychotherapy. A hybrid model of psychotherapy research is outlined that integrates efficacy and effectiveness methodology to examine interrelated issues regarding (a) psychological assessment, (b) psychotherapy process, (c) treatment outcome, and (d) training of graduate clinicians. The integration of applied clinical research initiatives into a doctoral training program, clinical implications, and directions for future research are also presented.

The relationship among emotional productivity, emotional arousal and outcome in experiential therapy of depression

Abstract: This study involved an intensive analysis of the productivity and degree of arousal of in-session emotional expression of four better outcome clients and four poorer outcome clients in brief experiential treatments of depression. The relationship between the productivity and arousal of expressed emotion and outcome was explored in these cases. No significant differences between better and poorer outcome groups were found on degree of expressed emotional arousal. Better outcome clients, however, expressed significantly more productive emotions in general as well as significantly more productive highly aroused emotions than did poorer outcome clients. Results indicate that it is the productivity of expressed emotions in general, as well as the productivity of more highly aroused expressed emotion, rather than the frequency of highly aroused expressed emotion that is important in facilitating therapeutic change.

Principles for facilitating agency in psychotherapy

Abstract: The idea of enhancing clients’ agency in psychotherapy is a key concept across psychotherapy traditions. However, there is little research on how therapists conceptualize agency within the process of change. To fill this empirical void, fourteen eminent psychotherapists from four major psychotherapy traditions were interviewed about their understanding of the role of agency in psychotherapy. The interviews were analyzed using grounded theory and resulted in an integrative conceptual model of expert therapists; conceptualization of agency in the change process, and of the place of psychopharmacological interventions within the process of enhancing agency. The analysis resulted in several principles across orientations designed to guide therapists moment-to-moment decision making process on enhancing clients agency and to further psychotherapy research.

The Inventory of Interpersonal Problems (IIP): Sensitivity to change

Abstract: Although the Inventory of Interpersonal Problems (IIP) is a standard instrument in both, psychotherapy research and quality control of psychotherapy, it's sensitivity to change has yet to be firmly established. The authors investigated the sensitivity to change of the IIP using a study design based on the assumption that psychoanalytic psychotherapy leads to significant improvement in interpersonal problems. To assess whether this type of change can be measured with the IIP, they did a pre/post comparison of IIP scores in 63 patients with depression. The authors evaluated therapeutic change by comparing means (t-test) and also by calculating standardized effect size (ES), the reliable change index and a measure of clinical significance (internal sensitivity to change). They also compared the IIP results with those of construct-near tests (external sensitivity to change). The IIP showed a satisfactory sensitivity to change, with highly significant differences on the t-test on all scales, an ES of ...

Therapist attitudes and patient outcomes: II. Therapist attitudes influence change during treatment

Abstract: Psychotherapists’ beliefs and attitudes in therapeutic matters, according to the Therapist Attitudes Scales (TASC-2) (Sandell et al., 2004), were related to symptom distress, as measured by the Symptom Checklist-90, in 2 groups of patients: one in ongoing psychoanalytical psychotherapy and the other posttreatment. In the posttreatment group, the zero-order correlations with symptom distress were significant for the therapist's attitudes toward kindness and insight as curative factors and supportiveness as a therapeutic style and his or her views on the nature of psychotherapy as a form of artistry; however, they were all near zero and nonsignificant in the in-treatment group. To account for correlations among the attitude variables, multiple regression analyses were compared between the groups. The multiple correlation was essentially zero in the latter group, whereas there was a significant multiple correlation of .51 in the former group. Thus Posttreatment outcome was significantly related to t...

Influences of patients’ and therapists’ interpersonal problems and therapeutic alliance on outcome in psychotherapy

Abstract: The aim of this study was to investigate the importance of therapists’ and patients’ interpersonal problems as well as the impact of the therapeutic alliance on symptomatic outcome in psychotherapy. Of interest were direct effects of interpersonal problems, represented through the dimensions of affiliation and control, as well as possible interaction effects between patient and therapist variables on outcome. Further hypotheses referred to therapist differences in the predictive impact of the therapeutic alliance for outcome. Outcome ratings of 1,513 psychotherapy inpatients treated by 31 psychodynamically oriented individual psychotherapists were studied. Therapists’ and patients’ interpersonal dispositions were assessed with the Inventory of Interpersonal Problems, and patients answered standardized outcome measures before and after therapy and retrospectively evaluated the therapeutic alliance at discharge. The results indicate that dominant patients profited better from their therapy and that...

Therapeutic collaboration: How does it work?

Abstract: Research on the role of the therapeutic bond has shown to be central to the psychotherapeutic process and to good outcomes. Exactly what happens at the interactional level remains understudied. This study uses conversation analysis, observing the turn-by-turn analysis of the talk, in combination with a computerized text analysis following the therapeutic cycles model locating clinically significant events. Transcripts from all eight sessions of a successful brief psychodynamic psychotherapy are analyzed. In the transcripts, the authors identify topics and then compute topic density, topic sequence, and participation structure as markers for topic coherence. These are compared with segments that fall into a therapeutic cycle. These findings support the correlation of topic coherence to periods of high therapeutic productivity.

The role of personality in psychotherapists’ careers: Relationships between personality traits, therapeutic schools, and job satisfaction

Abstract: This study explored the relationship between psychotherapists' personality traits (i.e., intuition, openness for experience, and need for cognition) and their therapeutic orientation (i.e., insight versus behavior oriented). Results of N = 184 psychotherapists indicate a higher relationship between personality and therapeutic orientation (TO) for the later stages of their careers. Although the TO of therapists? initial psychotherapy training was only explained by their discipline (psychology, medicine) and the TO of their graduate school, their current work as well as the TO of subsequent trainings were predominantly explained by personality traits. Insight orientation was positively correlated with intuition, openess for experience, and need for cognition. The data also reveal that self-employed, open, and psychoanalytically oriented therapists indicated higher job satisfaction. Finally, the congruence between personality and current TO affected job satisfaction.

Predictors of outcome and completion status in cognitive therapy for depression

Abstract: The aim of this study was to investigate the relationship among therapy outcome, premature termination, and client interpersonal style and therapeutic alliance. Of the 94 clients who began cognitive therapy for the treatment of depression, 24 did not complete their agreed-on number of therapy sessions, had poorer outcomes and alliance scores, and were more likely to have an ambivalent interpersonal style. However, mediation of this relationship between interpersonal style and completion status by alliance was not significant. Therapy outcomes for all clients were better for clients with a secure interpersonal style than for those with an insecure interpersonal style, particularly avoidant. The association between interpersonal style and outcome was mediated by the therapeutic alliance.

Use of dialectical behavior therapy skills training for borderline personality disorder in a naturalistic setting

Abstract: This nonrandomized, naturalistic study describes a modified outpatient dialectical behavior therapy (DBT) program for borderline personality disorder (BPD) in which some patients receive the comprehensive, empirically supported DBT package and others receive DBT skills group therapy with non-DBT individual therapy. Patients who completed one skills group cycle showed significant improvements in BPD, depression, and suicidal ideation as measured by the Personality Assessment Inventory. Fifty-one percent of patients dropped out of skills group, but patients with in-system individual therapy were significantly more likely to complete group therapy. Although causal conclusions cannot be drawn, this report demonstrates that a modified DBT program can be implemented successfully in settings in which a full DBT package for all patients may not be feasible and suggests that BPD patients receiving non-DBT individual therapy may benefit from DBT skills group.

Process and outcome of therapy in ethnically similar and dissimilar therapeutic dyads

Abstract: This study examined the effects of ethnic matching on two process variables —working alliance and perceived therapist credibility—and therapy outcome in 100 ethnic minority clients evenly split between matched and nonmatched therapeutic dyads. All clients and therapists belonged to ethnic minorities in London (South Asian, Black African, Black Caribbean, and Middle Eastern). Clients in the matched dyads had expressed a preference for matching. Outcome and process variables were all significantly better in matched than in nonmatched dyads, and the process variables mediated the relationship between ethnic matching and outcome. Age, gender, and length of therapy did not predict outcome or process. The validity of these results is discussed, and implications for further research, practice, and training are briefly considered.

The effects of borderline pathology on short-term psychodynamic psychotherapy for depression

Abstract: This study examines the impact of borderline pathology (BP) on the effectiveness of short-term psychodynamic psychotherapy for depression in a naturalistic setting. Two groups were examined: 18 depressed patients with no Axis II diagnoses and 15 depressed patients with comorbid BP. Both groups demonstrated significant changes in depressive symptomatology. Likewise, many patients exhibited clinically significant reductions in depressive symptoms. Secondary analyses demonstrated significant changes for interpersonal functioning; no significant differences for therapeutic alliance were found between the two groups; and five therapist interventions were found to be more prevalent in the psychotherapy of the depressed patients with comorbid BP. The clinical utility and implications of these findings are discussed.

Brazilian–Portuguese version of defensive style questionnaire-40 for the assessment of defense mechanisms: construct validity study

Abstract: The aim of this study is to analyze the reliability and validity of the Brazilian–Portuguese version of the Defensive Style Questionnaire (DSQ). Participants were evaluated by clinical interview and the Mini-International Neuropsychiatric Interview. Reliability was assessed by factor analysis and Cronbach's alpha. The 3-factor model's replication was tested using confirmatory factor analysis (CFA). Controls were reevaluated after 4 months to assess test–retest reliability. Subsamples were also evaluated using the Minnesota Multiphasic Personality Inventory and Defensive Functioning Scale (DFS). Factor analysis of the various defense mechanisms produced a distribution of mechanisms among the factors that was largely similar to previous analyses based on the original instrument. The 3-factor model was supported by CFA. The test–retest evaluation showed sufficient intraclass correlation for all factors. Patients used more immature and neurotic defenses than controls. There was a correlation between ...

Moderators of the effects of transference interpretations in brief dynamic psychotherapy

Abstract: The primary aim of this study is to measure effects of transference interpretations in brief dynamic psychotherapy using an experimental design. One hundred patients were randomized to dynamic psychotherapy over 1 year either with a moderate level of transference interpretations or without transference interpretations. The outcome measures were the Psychodynamic Functioning Scales, Inventory of Interpersonal Problems, Global Assessment of Functioning, and Symptom Checklist-90-Revised. No main effect of treatment was found. Several pretreatment patient characteristics related to interpersonal functioning and symptom severity were selected for exploratory analyses of moderator effects. Contrary to our hypotheses and mainstream clinical thinking, we found that patients with more interpersonal problems, more severe symptoms, or poorer quality of life responded better to therapy with transference interpretations than to therapy without such interpretations. Conversely, we found that more resourceful a...

Culture and the therapeutic relationship: perspectives from Chinese clients

Abstract: Chinese people in the UK and USA underutilise mental health services and, when they do seek help, may find that therapy does not meet their needs. In response to calls in the literature for naturalistic studies of therapy with people of Chinese background, this study used a qualitative, multiple case approach to examine clients’ individual experiences in depth and detail. Semi-structured interviews were conducted with eight Chinese clients. The aim was to investigate how culture might play a role in the therapeutic relationship. Qualitative analysis yielded four key themes concerning clients’ and therapists’ awareness of culture and how this impacted on their working relationship: “cultural encapsulation�, “cultural formulation�, “cultural liberation� and “culture is not important�. Although participants’ perceptions of therapy showed similarities to those reported by clients of European-American descent, culture entered into the therapeutic relationship in complex and diverse ways. The findings have implications for delivering culturally sensitive therapies.

The supervisory attachment relationship as a predictor of the professional development of the supervisee

Abstract: Attachment theory was used to conceptualize the supervisory relationship. The type of attachment that supervisees reported in their close relationships was used to determine whether or not their feelings toward their supervisor revealed a relationship of attachment. The sample consisted of 90 distinct supervisor–supervisee dyads from diverse professional backgrounds. Supervisees classified as secure, preoccupied, fearful, or dismissive in their close relationships were similarly attached in relationship to their clinical supervisor. Further, supervisees with an insecure attachment to their supervisor demonstrated low levels of professional development when professional development was based on self-report but not when it was based on supervisor report. Results are discussed in light of the role that attachment plays in the training of supervisees.