Researching psychotherapy integration: A heuristic approach

Moustakas argues that questions and methodology in heuristic research flow out of inner awareness, meaning and inspiration. The approach might arguably embrace a combination of qualitative research methods, and constitute a kind of bricolage. This paper describes a heuristic enquiry into psychotherapy integration that used such a combination of methods – an interpretative phenomenological approach, case studies, reflexive action, and writing. It demonstrates how each of these methods contributed to the six phases of heuristic enquiry, from the initial engagement with psychotherapy as a trainee to the creative synthesis of published works and a PhD thesis, together with some reflection on the enquiry's limitations and rigour. Published texts, training, clinical practice and reflexivity constituted the material from which a new organizing framework for understanding psychotherapy integration was formulated. The author reflects on how the research design allowed deep engagement with this material, and changed his perspective of psychotherapy integration. In conclusion, this paper suggests that both psychotherapy integration and heuristic enquiry can only be conducted on an individual and personal basis, and that it is the quality of the relationship, with the client, or the research material, that produces results.     

An advanced specialist-level training programme in psychodynamic individual psychotherapy of psychotic and borderline patients: the Finnish approach

Most training programmes in individual psychotherapy, including psychoanalytic training are, in practice, restricted to the treatmentof lessdisturbed patients than those who have succumbed to psychotic or severely borderline-level disorders. This has had a delaying effect on the development of psychotherapy with such patients. Psychotherapy of severely disturbed patients is usually regarded as a difficult domain and is often practised only by psychoanalysts or other psychotherapists specially dedicated to working with patients of this kind. Between 1994 and 1997, an advanced multi-professional training programme in psychodynamic individual therapy with an emphasis on borderline and psychotic-level disorders was organized through the Centre for Extension Studies of the University of Turku, Finland, to close the gap in systematic training for the treatment of the most serious psychic disorders, and also to integrate some of the special requirements of public and private psychiatric health care. Here we briefly describe the main elements of our training programme as well as some of our training experiences. It is important to emphasize that the training was not meant to replace psychoanalytic training. It is a question of a separate multi-professional programme based on psychoanalytic premises but with particular objectives of its own.     

Culturally educated questioning: Toward a skills-based approach in multicultural counselor training

Increased resources are being committed to the multicultural training of counselors. Despite these gains, training continues to focus almost exclusively on the acquisition of cultural awareness and culture-specific knowledge. Valuable though they are, awareness and knowledge, the authors argue, do not necessarily result in effective multicultural counseling skill. Therefore, it is recommended that current training models be modified to include techniques through which cultural knowledge can be synthesized into effective counseling interventions. Specifically, it is suggested that programs stress the need to conduct cultural assessments of clients using what the authors term “culturally educated questioning”: empirically rooted inquiry designed to elicit from clients clinically relevant cultural data. The benefits of culturally educated questioning, including its safeguards against cultural stereotyping, are discussed.     

Emotion-regulation skills as a treatment target in psychotherapy

Background

Deficits in emotion-regulation skills have been shown to be integral to the development and maintenance of a wide range of mental disorders.

Aim

To evaluate the importance of these skills as a treatment target in psychotherapeutic interventions.

Method

Nine specific emotion-regulation skills were assessed in a sample of 289 inpatients before and after cognitive-behavioural treatment. Self-reports of success in pretreatment skills application were first compared to those of 246 non-clinical controls. Pretreatment skills application and change in skills application during therapy were then related to a variety of outcome measures. Finally, the effects of integrating a brief training of general emotion-regulation skills into the CBT-based treatment were evaluated in a controlled trial.

Results

Uni- and multivariate analyses identified the skills of acceptance, tolerance, and active modification of negative emotions as particularly important for current mental health and treatment outcome. Replacing parts of the standard CBT treatment with the emotion-regulation training enhanced the effects of the CBT treatment on skills application and on other measures of mental health.

Conclusion

Incorporating interventions that directly target general emotion-regulation skills may improve the effectiveness of psychotherapeutic interventions.     

Interpersonal process in psychotherapy through the lens of the structural analysis of social behavior

As psychotherapy research focuses more and more on mechanisms of therapeutic change, increased attention has naturally been directed at therapy process. Over the past several decades, a variety of researchers have successfully applied Benjamin's 1974 Structural Analysis of Social Behavior (SASB) to the study of in-session psychotherapy events. This system for conceptualizing and analyzing interpersonal and intrapsychic processes has been shown to provide theoretically rigorous and empirically tractable instantiations of both helpful and hindering therapeutic exchanges. In this article the therapeutic alliance is conceived in terms of interpersonal processes as demarcated according to the SASB. This article also provides a review of SASB's wide-ranging applications to observing and studying the therapeutic relationship, therapy process, and client outcome. Also discussed are several data analytic and methodological considerations related to the SASB model and several new ancillary measures based on the SASB. Finally, the applied and clinical utility of the SASB system is discussed in light of a variety of contemporary empirical findings.     

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.     

Utilization analysis of a pedestrian safety training program

A previously developed and analyzed pedestrian safety training program was used to teach appropriate street-crossing behaviors to kindergarteners and first graders. Adult crossing guards were trained to provide pedestrian safety instruction. Trained observers monitored the quality of instructions given by crossing guards and the pedestrian behavior of young children as they crossed the street. A multiple-baseline analysis of the effects of two training programs indicated that guards were able to deliver the pedestrian safety program to several groups of children with a high degree of competence after receiving a single videotape and role playing training session. Furthermore, children's level of appropriate street crossing increased contemporaneous to the change in guard behavior both on the street where training was delivered and on a second street where no training was previously delivered. Utilization analysis of the guard training program indicated that one cannot expect to produce consistently high levels of street-crossing behavior by implementing only the "show and tell" portions of the training package. Similarly, results suggested that one is unlikely to produce consistently high quality guard training behavior by only giving written instructions describing how pedestrian training should be administered.     

Recollection training and transfer effects in Alzheimer's disease: effectiveness of the repetition-lag procedure

Objective

This study was designed to extend the use of a memory training technique, known as the repetition-lag procedure, to Alzheimer patients. The specificity of this procedure is to target the process of recollection for improvement.

Method

A group of 12 patients were trained individually for 6 h. The training procedure consisted of a series of yes/no recognition tasks in which some words were repeated throughout the test list across gradually increasing delays. Their performance was evaluated on pre-and-post tests and compared with a recognition practice group and a no contact control group.

Results

Initially, recollection training patients only performed accurately when the delay between repetitions consisted of one intervening word, but by the end of training their performance increased up to four-word intervals. Interestingly, these benefits generalized to other measures of memory, such as working memory, visual memory and source recognition.

Conclusions

Effectiveness of the repetition-lag procedure in Alzheimer’s disease is discussed.     

Preinternship Preparation of Clinical and Counseling Students in Psychological Testing, Psychotherapy, and Supervision: Their Readiness for Medical School and Nonmedical School Internships

Internship directors have been critical of students' preinternship preparation in test-based assessment and psychotherapy but have not, until recently, expressed their quantitative expectations for this training. Using data from the Association of Psychology Postdoctoral and Internship Centers application form, this study investigated the quantitative statements of 96 counseling and 238 clinical students regarding their preinternship testing, psychotherapy, and supervision training, comparing findings to medical school and nonmedical school directors' quantitative expectations. Results generally demonstrated adequate psychotherapy training but suggested deficiencies in testing training, particularly as related to medical school directors' expectations. Counseling students received more training in individual therapy with adults but not in other forms of therapy. Clinical students produced more integrated test-based reports. Both groups received similar amounts of supervision.     

Moving from efficacy to effectiveness trials in prevention research

Efficacy trials test whether interventions work under optimal, highly controlled conditions whereas effectiveness trials test whether interventions work with typical clients and providers in real-world settings. Researchers, providers, and funding bodies have called for more effectiveness trials to understand whether interventions produce effects under ecologically valid conditions, which factors predict program effectiveness, and what strategies are needed to successfully implement programs in practice settings. The transition from efficacy to effectiveness with preventive interventions involves unique considerations, some of which are not shared by treatment research. The purpose of this article is to discuss conceptual and methodological issues that arise when making the transition from efficacy to effectiveness research in primary, secondary, and tertiary prevention, drawing on the experiences of two complimentary research groups as well as the existing literature. We address (a) program of research, (b) intervention design and conceptualization, (c) participant selection and characteristics, (d) providers, (e) context, (f) measurement and methodology, (g) outcomes, (h) cost, and (i) sustainability. We present examples of research in eating disorder prevention that demonstrate the progression from efficacy to effectiveness trials.     

The Teaching Alliance Inventory: Evaluating the student-instructor relationship in clinical and counselling psychology training

The Teaching Alliance Inventory (TAI) was developed to measure the quality of the student-instructor relationship in graduate clinical and counselling psychology classrooms. Based on Bordin's (1983) original concept of the alliance as fundamental to the change process in psychotherapy, we developed the TAI to measure aspects of the classroom relationship that may be fundamental to learning essential skills of counselling and clinical psychology. Factor analysis revealed six subscales, four representing interpersonal variables not evaluated in traditional teaching effectiveness measures. We demonstrated internal consistency and split-half reliability with a large sample of graduate students and described evidence for the scale's face validity and content validity. Construct validity was supported by significant correlations between the TAI and its subscales with an established measure of teaching effectives and its logically related subscales (SEEQ; Marsh, 1987 Marsh, HW. 1987. Students’ evaluations of university teaching: Research findings, methodological issues, and directions for future research. International Journal of Educational Research, 11(Whole Issue 3): 253–288.  [Google Scholar]). The TAI may supplement traditional assessments of instructor quality by providing feedback regarding interpersonal impact in the classroom.     

A virtual training institute in Eastern Europe

This is a short outline of the development of psychoanalysis and of analytic training in Eastern Europe after the fall of the Iron Curtain. The Han Groen Prakken Psychoanalytic Institute for Eastern Europe was founded by the IPA and the EPF in 2002 to organize and coordinate this. The activity of such an unusual training institute, virtual and time-limited up to the birth of new IPA study groups, is described with the problems it has had to face, from shuttle analysis to research of this unusual training, from initial outreach activity to formation of new analytic groups, from unavoidable plurality of analytic approaches of an international staff to the need for systematic teaching, from criteria for selection of candidates in such a large area with many languages, cultures and histories, to the integration of new analysts and groups in the international analytic community. These problems are part of the challenge implicit in the globalization, with its unavoidable push to enlarge to the whole humanity the psychoanalytic theory and praxis. Such an experience is now used in Latin America, but may also soon have its application in other continents. Freedom of mind is a basic need of all humans and psychoanalysis still has much to say about this.     

Conducting clinical research in Polish conditions

This paper comments on Polish legal guarantees for diseased persons with reference to the hazards that accompany experimental treatment. While acknowledging that participation in a clinical research program provides patients with additional opportunities for advanced treatment, the paper also points out that systems for monitoring patients participating in experimental treatment require improvement. This paper was presented at the 6th International Bioethics Conference on the subject of ‘The Responsible Conduct of Basic and Clinical Research’, held in Warsaw, Poland, 3–4 June 2005.     

An evaluation of the effectiveness of Diploma-level training in cognitive behaviour therapy

Background

As part of the UK government’s initiative to Increase Access to Psychological Therapies (see http://www.iapt.nhs.uk/for full details of the IAPT programme) there has been an expansion in the provision of post-graduate Diploma training in cognitive behaviour therapy (CBT). Previous evaluations of such training programmes have yielded mixed results but have been limited by small sample sizes and/or limited assessment measures.

Aims

To evaluate the impact of a long-standing Diploma in CBT training programme on a variety of measures of CBT competence.

Method

Trainees’ levels of CBT skill are compared at the beginning and end of CBT training. The effect of therapist factors such as age, professional background and gender on the development of CBT competence is also examined.

Results

Results show that trainees demonstrate higher levels of CBT skills after completing the training than they did before, with the majority achieving pre-determined criteria for competence. Trainees’ gender was not related to their performance but trainees’ age showed a negative association with CBT skill (older trainees performed worse). Trainees’ professional background also had an impact on their level of CBT competence, with trainees who were clinical psychologists demonstrating the highest levels of competence across a range of measures.

Conclusions

CBT Diploma training leads to increases in the level of trainees’ CBT competence, with the majority achieving the levels demonstrated in research trials by the end of training. Thus, this training is likely to lead to improved outcomes for patients. Further research is needed to determine the most efficient ways of enhancing CBT skills.     

Creating a research agenda in career counselling: the place of action theory

After identifying historical and current problems in career counselling research, we propose a research agenda based on contextual action theory. This theory has been used as a framework for research in the career field and for general counselling practice. It is advantageous for several reasons including its conceptual basis, its detailed qualitative and quantitative research method, and the significant link it provides between research and practice. It is supported by the action-project method, an integrated set of procedures developed for conducting research. Contextual action theory and the action-project method can address major emerging issues in career counselling, for example the place of emotion and the use of narrative, and advance the research agenda in this field.     

Adolescent Health Care Training in Predoctoral Psychology Internship Programs: A Model of Interdisciplinary Training Needs in Health Care

This needs assessment of predoctoral psychology programs in a large southeastern state reveals that although many programs include adolescent health issues and often involve the psychiatry discipline in their curricula, many trainees do not have exposure to medicine, nutrition, or nursing disciplines. Opportunities for greater interdisciplinary adolescent health care training exist in psychology training programs in this southeastern state. Integrating such training into psychology programs may enhance psychology's ability to function as a vital component of adolescent health care teams within academic medical centers across the country.     

Social evaluation research: the evaluation of two police patrolling strategies

In most social evaluation research it is difficult to achieve the degree of experimental rigor possible in an applied behavioral study. This study illustrates how the evaluation researcher can increase experimental rigor in the analysis of social interventions. In the first evaluation, a variation of the time-series design that offered maximum experimental control given the limitations of the situation, was employed to evaluate the effects of a specialized home-burglary police patrol. This design revealed that no effects could be attributed to the patrol. In the second evaluation, a multiple baseline-like design was possible in determining the effects of a police walking patrol. This design revealed that the patrol produced an increase in crime reporting but not in arrests. Social interventions often occur in a manner that allows varying degrees of experimental analysis. The evaluation researcher must attain optimal experimental analysis given the limitations of each social intervention.