The dodo bird revisited: A qualitative study of psychotherapy efficacy research

This article is a qualitative study of psychotherapy efficacy research spanning more than four decades. The findings are organized into five temporal categories characterizing the evolution of psychotherapy research. All five categories are integrated in the central phenomenon of two views of human behavior, a reactive or a proactive view. The categories are (1) psychotherapy is no more effective than no psychotherapy (1950s and 1960s), (2) the “core conditions” (empathic understanding, unconditional positive regard, and congruency) are necessary and sufficient conditions for therapeutic personality change (1960s and 1970s), (3) psychotherapy is for better or for worse (early 1960s), (4) the core conditions are necessary but not sufficient for therapeutic personality change (late 1970s and mid-1980s), and (5) specific techniques are uniquely effective in treating particular disorders (late 1980s and early 1990s). The findings concerned with Categories 4 and 5 are (a) that the conclusion that Rogers's attitudinal conditions are necessary but not sufficient has virtually no direct research support, and (b) that the research concerning specificity of treatment, dysfunction, therapist variables, and client variables is characterized by fragmentation, few replications, and lack of generalizability. Implications of the study indicate that specificity research, driven by the unfounded assertion that Rogers' attitudinal conditions are not sufficient, have yielded inconclusive and misleading findings. The pattern of research is one that culminates in the picture of a self-fulfilling model driven and directed by the “scientificating” deterministic view of human behavior, the movement toward narrow and specific application. Over four decades, the major thread in psychotherapy efficacy research is the presence of the therapist attitudes hypothesized by Rogers.     

To switch or not to switch: Inviting bilingual clients to switch languages in psychotherapy

In the present study, we used an audio-analog design to test whether exposing bilingual participants to a therapist who invited a bilingual client to switch languages in a psychotherapy session would have a positive effect on participants’ perceptions of the therapist. We also explored whether participants’ sense of belonging to their ethnic group and to the larger US culture would enhance or attenuate this effect. Sixty-three bilingual Latino/a university students listened to one of two recordings of a simulated psychotherapy session with a bilingual Latina therapist and client. In one recording, the therapist invited the client to switch from English to Spanish when the client had trouble expressing complicated feelings; in the other, the therapist did not invite the client to switch. When listening, participants were asked to imagine themselves in the role of client and to rate the credibility and multicultural competence of the therapist, and the emotional bond they would anticipate with her. Contrary to expectation, only participants who expressed a greater sense of belonging to US culture rated the therapist who invited the client to switch as being more multiculturally competent. We discuss how these findings contribute to the literature on language switching and bilingualism in psychotherapy.     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

Patientensicht zur Qualität in der Psychotherapie

Concerning the discussion about the quality of psychotherapy, the different perspectives in the definition of quality are rarely considered. Especially the patients’ perspective is barely respected although quality assurance of psychotherapy should be for their benefit. Patients were interviewed (n=8) to answer the question which criteria of quality are relevant in their view. Using the grounded theory a variety of quality criteria was found. The interviewees emphasized the relationship between therapist and patient, the empathy of the therapist, the scheduling of appointments and the progress in therapy. The results suggest that when judging the quality of psychotherapy clients do not only focus on the outcome of psychotherapy, as presumed by some experts, but also on the dimensions structure and process. Professionals have to consider this fact when designing and applying methods of quality assurance.     

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.     

Passt oder passt nicht?

Differential indication in psychotherapy should be a process of decision making, that takes multiple factors into account, and not just the assignment of a particular disorder to the adequate therapeutic method. Unspecific characteristics of the patient, instead of disorder-specific features, as well as personality characteristics of the therapist having therapeutic relevance are important factors either. In this way decisions for an indication then turn into the crucial question of matching between patient and therapist. The receptivity of the patient is a central component. As a result of successful maching, the therapeutic relationship will improve which has a positive influence on the outcome of psychotherapy. According to the generic model of psychotherapy 4 levels of the decision-making process are defined. They serve as orientation for a differential indication taking into account both persons and methods. The realization of this indication model in in-patient treatment has some preconditions. Obligatory is the availability of a variety of therapists differing in therapeutic methods and personal characteristics. The mostly applied principles of matching decisions are listed in tabular form and illustrated by a case report.     

Therapiewechsler

At least 30% of the patients, currently in psychotherapy, have been in one or more psychotherapeutic treatments before the beginnig of the actual treatment. A great number of these patients decided as a consequence of their experiences with the former therapeutic treatments to change not only the therapist but also the form of the psychotherapy. The task was to find out the reasons for this. 25 patients who had changed from one of the Guideline Therapies into a client-centred therapy (CCT) were interviewed about their reasons for this change. It was assumed, that the failing of earlier therapies was caused by a lack of matching between patient and therapist, treatment and disorder in the sense of the Generic Model of Psychotherapy (GMP) conceptualized by Orlinsky and Howard. The results support this hypotheses: For most of these patients CCT turned out to be a necessary and successful alternative to the previous treatments. Most of the patients reported that they responded better to the therapeutic offer of CCT. The reasons mentioned for choosing another form of psychotherapy support the necessity of a differential indication for psychotherapy on the basis of the GMP.     

From Interpretation to Commentary: Truth and Meaning in Psychotherapy

Some of the epistemological consequences of adopting the narrative point of view in psychotherapy are explored. Attempts to apply principles and norms from the philosophy of science to psychotherapy are criticized, since psychotherapy is not a science, but a technique. In addition, those models, related to the acquisition of knowledge, that consider that knowledge could increase by apposition without transforming the subject who is knowing are discussed. Natural science and hermeneutic metaphors are not suitable for understanding the practice of psychotherapy. Traditionally, the interpretation of symptoms or problems to solve has been the main instrument in therapy. In other words, the therapist tries to look for the truth hidden under the symptom, which then becomes a sign. Our proposition is to substitute these metaphors for the paradigm of text commentary. Text commentary, instead of providing a unique truth, provides a set of meanings suggested by a commentary. Characteristics that allow one to distinguish a good and a bad commentary, and implications of the paradigm described for the training of psychotherapists, are discussed.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.     

Toward engaging the difficult patient

The difficult patient is here described as the one who does not readily accept the usual definitions of the treatment relationship and who tends to get the therapist to be overly-engaged in the therapeutic process. The therapist must be clear not only about his own characterological issues and counter-transference predispositions, but also about the unique propensity of these patients for the enactment of conflicts. While empathy is the sine qua non of our therapeutic work, the need to set limits and to address hostility should not be underestimated if these patients are to be engaged in any meaningful psychotherapy. To maintain an empathic perspective, the therapist must appreciate the purposefulness of the patient's defensive characterological behavior and that it cannot simply be dismissed as mere pathology. Such a perspective may help the therapist to better respond to the patient's behavior as a communication about his sense of self and his concerns about relatedness. This will facilitate the engagement process.     

An Indicator of Suicidal Ideation on the Rorschach Test

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn &; Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher &; Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.     

The development of therapeutic alliance during psychological assessment: patient and therapist perspectives across treatment

We examined the impact of patient- and therapist-rated alliance developed during psychological assessment on the subsequent alliance measured early and late in formal psychotherapy. We hypothesized that a working alliance developed during psychological assessment conducted from a collaborative therapeutic model of assessment (TMA; Finn & Tonsager, 1992, 1997; Fischer, 1994) between the patient and therapist would carry into formal psychotherapy. We also hypothesized that alliance for those patients receiving a TMA would be significantly greater than patients receiving psychological testing as usual. To test this hypothesis, we administered the Combined Alliance Short Form-Patient Version (Hatcher & Barends, 1996) and the Combined Alliance Short Form-Therapist Version (Hatcher, 1999) to a sample of outpatients and their therapists at the end of the assessment feedback session, early, and late in psychotherapy. The hypotheses were supported as alliance scales rated at the assessment feedback session demonstrated positive and significant relationships with alliance throughout formal psychotherapy and in relation to a control group. The clinical utility and research implications of these findings are discussed.     

The use of augmentative alternative communication in psychotherapy

The use of augmentative alternative communication (AAC) in psychotherapy is particularly important for psychotherapists who may have a disability related to speech-language production. The aim of our study was to examine the perceptions of using AAC in psychotherapy. We recruited 186 participants and randomly assigned them to either watch a video of a therapist using AAC or employing traditional talk psychotherapy. Subsequently, we asked participants to complete the Counsellor Rating Form-Short (CRF-S), respond to a question about behavioural intention to seek psychotherapy and complete the Working Alliance Inventory-Observer form (WAI-O). Most participants perceived the use of AAC to be related to the therapist having a disability. The use of AAC had higher ratings on the CRF-S and higher scores on the WAI-O. There were no significant differences in behavioural intention between the therapist using AAC or traditional talk psychotherapy. The use of AAC is a viable option for psychotherapy and is beneficial. Psychotherapists with a disability affecting speech-language production may opt to use AAC as others perceive the therapist positively, the alliance is rated higher and therapists do not need to be concerned with patients not wanting to seek out their services.     

New approaches in counselling: Healthy diversity or anti-therapeutic?

Concern is expressed about the proliferation of new or 'innovative' approaches in counselling or psychotherapy. Most of these approaches appear to be regressive in that they ignore what we have learned about the importance of certain conditions for the therapeutic relationship. They place the counsellor or therapist in the position of a charismatic expert controlling and directing the lives of his clients. The potential dangers of these methods are noted. Yet there seems to be no good way to protect clients either from well-intentioned but misguided professionals or from the untrained non-professional. If professionals are not successful in policing the field, injured consumers and an aroused public may succeed in imposing unnecessarily rigid restrictions on all practice of counselling and psychotherapy.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Counsellor interpretations and the occurrence of in-session client change moments in non-dynamic psychotherapies

This study explored the relationship between therapist interpretations and optimal in-session client processes in 20 sessions conducted by exemplary psychotherapists of three different theoretical orientations: Client-Centred Therapy (CCT), Rational-Emotive Behaviour Therapy (REBT), and Gestalt/Existential Therapy (GT). The results indicated that interpretations were used with similar frequency across therapeutic approaches, but they were neither superior nor inferior to other interventions in relation to the occurrence of optimal in-session client processes. The results support the notion that interpretation is a commonly used therapist intervention and that different therapies accentuate different aspects of interpretation. Implications for psychotherapy integration are offered and the findings are discussed with reference to theory and clinical practice.     

Two models,one mind: Integrating the biological and psychological

The investigation of psychopathology and the development of personality have traditionally been carried out by two different methods. Psychoanalytic theory has largely relied on the hermeneutic approach, that is the explication of meanings. This has yielded rich and clinically relevant insights into individual functioning, but has the danger of conflating meaning with causes. The empirical approach, the dominant method of science, has in recent years begun to establish aetiological factors for mental ill-health. In the clinical situation, these findings have to be applied with caution as one can only rarely determine with a particular individual how important they are. At the same time, these findings establish important parameters in understanding and treating patients. This paper argues that, for the effective practice of psychoanalytic psychotherapy, the therapist should both be conversant with these two models and be able to integrate them.     

Dropping Out of Marriage and Family Therapy: A Critical Review of Research

The lack of attention given to research on the premature termination by clients in marriage and family therapy is evident in research reviews of the dropout phenomenon in psychotherapy. This article is an attempt to fill that void. The research literature on dropping out of family therapy is reviewed and organized. Studies in this area tend to focus on four kinds of variables: client characteristics, therapist characteristics, therapy process variables, and interventions. Stable findings in each of these areas are pointed out. Both limitations and recommendations for future research are discussed.