Stephanie is currently a doctoral candidate at the University of Wisconsin-Madison in the Department of Counseling Psychology. At present, she is a pre-doctoral intern at the University of Minnesota-Twin Cities counseling center (UCCS). In April, she successfully defended her dissertation regarding mental health outcomes for transsexual individuals throughout their transitioning process. As the recipient of the Charles Gelso Psychotherapy Research Grant, she will be conducing three separate meta-analyses regarding the efficacy of research trials for personality disorders. The first meta-analysis will be conducted regarding trials that compared evidence-based treatments to treatment-as-usual for personality disorders. The second meta-analysis will determine differences in efficacy for bona-fide treatments for personality disorders. Last, a cost-effectiveness analysis will be conducted on those trials that have compared treatments for personality disorders.

Please see the awards section of the Division 29 website for more information on the grant program and watch for upcoming details of the call for applications for the coming year’s grant awards. Eligibility for the Charles J. Gelso Psychotherapy Research Grant rotates biannually between graduate students/predoctoral interns and doctoral level psychologists/postdoctoral fellows. In 2011, doctoral level psychologists and postdoctoral fellows will be eligible.

Summary

Abbass et al. (2009) examined the preliminary efficacy of intensive short-term dynamic psychotherapy (ISTDP) in the treatment of patients with medically unexplained symptoms (i.e., somatization complaints) presenting to the emergency department (ED). ISTDP is a brief, although not time-restricted, approach that targets the unconscious emotional processes underlying patient’s manifest symptomatology (e.g., panic, back pain, headache). Using a pre-post intervention design, the researchers found that patients (n = 50) who received ISTDP following an ED visit evidenced a mean reduction of 3.2 (69%) ED visits in the following year compared to the year prior to the intervention. This reduction rate outperformed several benchmark comparison groups. Furthermore, patients evidenced significant favorable change in global symptom ratings following ISTDP. Although the study had limitations (e.g., lack of randomized control group), the findings provide preliminary evidence for the efficacy of a brief, dynamically oriented approach to somatization complaints.

Clinical Implications

The evidence, albeit preliminary, suggests that ED clinicians should consider helping patients to explore and to tolerate the emotional process connected to their manifest physical symptoms. Doing so might not only reduce ED subsequent visits, but also promote direct symptom reduction.

References

Abbass, A., Campbell, S., Magee, K., & Tarzwell, R. (2009). Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: Preliminary evidence from a pre-post intervention study. CJEM, 11, 529-534.

Summary

In an RCT study of 353 women assigned to either 12 sessions of trauma-focused or health education group treatment the researchers found that PTSD severity reductions were more likely associated with substance use improvement whereas minimal reduction in PTSD was found with substance use reduction (Hein et al., 2010). These findings have important implications because of the high rate of comorbidity between PTSD and substance abuse (Back, 2010). These findings also support earlier research. This research calls into question the commonly held assumption that abstinence from substances should be gained before undertaking exposure therapy. The previously held assumption that beginning trauma therapy before reduction or elimination of substance use will lead to an increase in substance use has not been borne out.

Clinical Implications

The evidence suggests that when treating comorbid PTSD and substance use the clinicians should actively initiate integrated treatment to address the PTSD actively while working on the substance abuse.

References

Hein, D. A., Jiang, H., Campbell, A. N., Hu, M-C et al. (2010). Do treatment improvements in PTSD severity affect substance use outcomes?  A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. American Journal of Psychiatry, 167(1), 95-101.

Back, S. E. (2010).  Toward an improved model of treating co-occurring PTSD and substance use disorders. American Journal of Psychiatry, 167(1), 11-13.

Linda Campbell

The APA Council In Action!  By Linda Campbell and Norine Johnson.

We are quite used to stalemates, filibusters, and partisanship these days, aren’t we? I wish you could all have attended this Council meeting to see actual decision-making, compromise, and respectful disagreement. There were items on this Council agenda that truly spoke to who we are, what our values are, and what is important to us. You would have been very proud to see how differing members conducted themselves and how the decisions were made.  We are going to plunge into the top items of importance to Div. 29 here and hope that if you want more detail or want to discuss any of these subjects that you will contact us at lcampbel@uga.edu or NorineJ@aol.com.

Recognition of Psychotherapy Effectiveness

Before your blood pressure goes up, yes, all of us who are members of Div. 29 know and have known for many years that psychotherapy is effective. What we recently realized, however, is that never has there been a resolution, declaration, or any official statement adopted by APA to acknowledge this fact. Melba Vasquez, Nadine Kaslow, and Linda Campbell authored a new business item to be presented in August for a vote of Council acknowledging this important fact. Linda Campbell or Nadine Kaslow can send you a copy of the statement if you would like to read it. Several of our Div. 29 members contributed to the supporting seminal references and citations. It’s a great read!

Amendment to The APA Ethics Code

For the first time ever, the APA Ethics Code has been amending between official revisions. You are aware of the concerns that many APA members have had regarding the potential use of the Standards 1.02 and 1.03 and the ambiguity of the meaning of the standards in serving as guidance for psychologists. A primary concern about the potential interpretation of the standards as they stood was the possibility that following the law could be used to coerce psychologists into inhuman treatment of others. The APA Ethics Committee drafted the proposed change that is meant to better define this uncertainty. The draft change went through without a hitch. The revised standards are written as follows. The underlining represents added text and the strike through represents deleted text:

Standard 1.02 Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority

If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologist clarify the nature of the conflict, make known their commitment to the Ethics Code and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. If the conflict is unresolvable via such means, psychologists may adhere to the requirements of the law, regulations, or other governing legal authority. Under no circumstances may this standard be used to justify or defined violating human rights.

Standard 1.03 Conflicts Between Ethics and Organizational Demands

If the demands of an organization with which psychologist are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and to the extent feasible, resolve the conflict in a way that permits adherences to the Ethics Code. Take reasonable steps to resolve the conflict consistent with the General Principles and Ethics Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.

These amendments represent hard work by many people and very difficult and challenging conversations. Those whose efforts were greatly invested in this matter rose to the occasion most admirably and respectfully.

The APA Model Licensure Act Has Been Approved!

The primary purpose of the Model Licensing Act is to provide a model to state, provincial, and territorial legislatures of language that would be consistent with APA’s policies in the event that legislatures enact a change in their law or regulations that affect the practice of psychology. Several areas were reviewed and updated; however, the major discussion centered around the use of the term “psychologist” in school settings and licensure requirements for I/O psychologists. The challenge for consensus came from the policy of APA enacted several years ago and the stance of professional psychology in that psychology is a doctoral level profession. Although, some state and provincial licensing boards have variations in masters level practices, the policy of APA is that psychology remains a doctoral level profession.

For many years, prior to licensure in some states, State Departments of Education have authorized and certified individuals who have masters and educational specialist degrees to practice in the schools and be termed “school psychologists.” Individuals who work in public school settings in these roles are typically not doctoral level. The question at hand was whether or not to extend the exemption that school psychologists have had for some years. In other words, could school psychologists be an exception to the requirement for doctoral level status of those calling themselves psychologists?

In hearing out all sides and all opinions on this very difficult matter, the Council voted to adopt the following: “The act recognizes the authority of appropriate state education bodies to issue titles to those who provide psychological services in schools as long as those titles incorporate the word “school.” The act continues to restrict the practice of such individuals and their use of their title to employment within school settings.” In other words, the adopted wording recognizes Departments of Education to be able to authorize professional positions under their aegis. The second amendment to the Model Act exempted I/O psychologists from the requirement of licensure (except as required in their jurisdictions) unless they provide mental health services to individuals.

Council Moves Out Of The Manchester

Contracts for APA Convention sites are made several years ahead of the event. After contracting with the Manchester Hyatt, it was discovered that the owner, Doug Manchester is a major contributor to the California Proposition 8, an effort to overturn the California Supreme Court ruling providing marriage equity for same-sex couples. This development resulted in much deliberation between values and money. On the one hand, many members felt that they could not in good conscience attend the Council meeting if held in the Manchester. The other meetings and where members’ hotel reservations are would, of course, be individual or divisional decisions. The Council meeting location represents a decision by APA that is logistical, financial, symbolic, and value-driven. The Treasurer, Paul Craig determined that a move would cost no more than $100,000. President Goodheart established a context for Council members’ remarks that was respectful, inclusive, and encouraging of all to speak. After the discourse, Council voted overwhelmingly to move the August Council meeting to another location. Dr. Goodheart summarized the discussion by saying, “Members of our Council will now not be faced with having to choose between their responsibilities as members of Council and their wish to express their opposition to Mr. Manchester’s action by not entering his hotel.”

Consensus and Endorsement of the APA Core Values

Our APA CEO Norm Anderson has initiated the development of our first ever Strategic Plan. Along with the plan was needed a mission statement, vision statement, and set of core values. As we have reported from earlier Council meetings, all had been decided except the core values. The task force charged with developing the core values for acceptance by Council was chaired most ably by Rodney Lowman and one of our representatives, Linda Campbell, was a member of this group. Over a period of months, the task force worked on finalizing the values with the sticking points being around (1) how to word the diversity value and (2) how to word the science value. Even on the floor of Council during the discussion, editing and compromise were still going on. Almost miraculously, we now have a set of core values overwhelmingly supported by Council and they are:

The American Psychological Association commits to its vision through a mission based upon the following values:

Continual Pursuit of Excellence

Knowledge and its Application Based Upon Methods of Science

Outstanding Service to its Members and to Society

Social Justices, Diversity and Inclusion

Ethical Action in All that We Do

Approval of APA 2010 Budget

Good news, sort of. As you know, APA like the rest of us was hard hit by the economic downturn of 2008 and 2009. Many cuts were made in meetings, personnel, and services, and benefits in order to right the ship. The cash flow from the buildings, however, yielded $3.5 million which contributed greatly. As a result, APA can report a forecast of $114,400. with expenditures of $113,500 resulting in a forecasted operating margin of $900.000.

Transparency In Advertising

APA has become aware that students and potential students who are reading APA materials see paid advertisements which sometimes appear to be endorsed by APA and therefore can be misleading for students who are looking for graduate programs and other educational services. As a result, the Council voted soundly to develop criteria and transparency for educational advertising:

1. Advertising of educational programs in APA publications and  web sites must be programs that are fully accredited by regional or other institutional accrediting associations recognized by the Department of Education.
2. Programs representing areas of professional psychology that are eligible for APA Accreditation (e.g., clinical, counseling, school, I/O, combined) must be accredited by APA to quality as advertisers.

To our loyal and faithful members, if you made it this far in the report, you not only get the t-shirt but a sweatshirt to boot!. It is our pleasure to serve as your Council representatives and we would very  much like to talk with you individually about your thoughts regarding Council and our Division 29.

Respectfully submitted,

Linda Campbell, Ph.D.

lcampbel@uga.edu
phone: 678-234-1444

Norine Johnson, Ph.D.

NorineJ@aol.com
phone: 617-471-2268

CHARLES J. GELSO, PH.D., PSYCHOTHERAPY RESEARCH GRANT

Division 29 created the annual Charles J. Gelso, Ph.D., Psychotherapy Research Grant to provide annual grants (up to $2000) supporting the advancement of research on psychotherapy process or psychotherapy outcome. Grant eligibility rotates biannually between graduate students/predoctoral interns and doctoral level psychologists/postdoctoral fellows.

The grant program was established in honor of Charles J. Gelso, Ph.D., who has made major contributions to theory and empirical research related to the psychotherapy relationship, including the working alliance, transference, countertransference, and the real relationship. In addition, his research has brought about important advances in our understanding of the research training environment in graduate education, as well as in the application of psychoanalytic concepts to short-term and long-term psychotherapy. He received his M.S. from Florida State University in 1964 and his Ph.D. from Ohio State University in 1970, and is a professor in the Department of Psychology at the University of Maryland, College Park. He has mentored many new investigators in the area of psychotherapy research.

University of Massachusetts Amherst

A voluminous and ever-expanding research literature points to the general effectiveness of psychotherapy (Lambert & Ogles, 2004). Through the use of controlled clinical trials, psychotherapy researchers have identified many empirically-supported treatments for specific clinical phenomena (Roth & Fonagy, 2005). The extant research also suggests that, with just a few exceptions, different therapy modalities yield comparable clinical effects (Lambert & Ogles, 2004). From a glass-half-full perspective, the field has made impressive strides in legitimizing the power of psychosocial interventions. Furthermore, as reflected in the long-standing “Dodo bird” interpretation of the comparative outcome literature, it can be asserted that everybody has indeed won and all should have prizes.

From a glass-half-empty perspective, psychotherapy’s general effectiveness is tempered by its clear limitations. For example, effective treatments for some psychological conditions have yet to be established, and the generalizability to everyday practice of treatments tested in controlled efficacy contexts remains tenuous. Furthermore, even when provided the “gold standard” treatment for a particular condition, some patients fail to respond, only partially respond, or respond but relapse; others drop out of treatment or even deteriorate (Lambert & Ogles, 2004). Thus, it seems that the Dodo verdict can be reconsidered to suggest that all therapies can be improved (Castonguay, Reid, Halperin, & Goldfried, 2003).

Although efforts toward improvement can come in many shapes and sizes, some scholars have argued that improvement may perhaps best be achieved through (a) theoretical humility and openness to the contributions of other (and perhaps historically incompatible or rival) orientations (e.g., Castonguay et al., 2003), and (b) treatment modifications based on process research (e.g., Grawe, 1997). Such approaches preserve the field’s advances in empirically supporting certain treatment packages, while inherently recognizing the complexity of change and the need to move forward creatively in refining treatments to both embrace and address such complexities.

Both of the aforementioned pathways to improvement reflect a specific model of psychotherapy integration (see Norcross & Goldfried, 2005). The former captures assimilative integration, or the attempt to improve an established system of psychotherapy by carefully considering the potential contributions of other systems. The latter captures common factors integration, which focuses on the conceptual and empirical contributions of pantheoretical and pandiagnostic therapeutic ingredients, and the inevitable influence of the momentary and dynamic context on the treatment process.

Among others, process research has persuasively implicated two common factors in the change process – the therapeutic alliance and patient expectations (see Castonguay, Constantino, & Holtforth, 2006; Greenberg, Constantino, & Bruce, 2006). To date, a facet of my research program has been directed at developing, systematizing, and experimentally testing alliance and expectancy-based treatment modules as a means to improve the efficacy of a particular empirically-established treatment (i.e., cognitive therapy; CT) for a specific condition (i.e., adult major depressive disorder; MDD). Although CT is an efficacious treatment for depression, recent estimates from controlled trials suggest that over half of MDD patients do not remit at posttreatment (De Matt, Dekker, Schoevers, & De Jonghe, 2006), while an even higher percentage fail to maintain lasting improvements (Hollon et al., 2005). Thus, there is room for significant improvement in CT for depression, and there remains a pressing need to refine treatments to increase response and decrease relapse. My collaborators and I have embarked on two such efforts. The alliance-based effort focuses on incorporating humanistic and interpersonal alliance-rupture repair strategies into standard CT and, thus, fits the assimilative and common factors models. The expectancy-based effort focuses on incorporating into CT systematic and responsive efforts to foster, manage, and change patients’ treatment expectations, which follows the common factors pathway. Below I describe each research line, including (a) a brief review of process findings that led to the treatment development, (b) a brief overview of the treatment module, and (c) a summary of our preliminary research to date.

Therapeutic Alliance Process Research and Integrative Cognitive Therapy

Pantheoretically defined, the therapeutic alliance reflects the quality of the patient-therapist working collaboration and affective bond (Bordin, 1979). As reflected in our own reviews and process-outcome studies (e.g., Constantino, Arnow, Blasey, & Agras, 2005; Constantino, Castonguay, & Schut, 2002), the alliance is a well-established predictor of treatment success across a variety of psychotherapies and presenting problems. The alliance not only predicts outcome, but it also provides a dynamic context for the implementation and utility of other interventions. For example, in a study of CT for depression, Castonguay, Goldfried, Wiser, Raue, and Hayes (1996) found that strict therapist adherence to prescribed CT techniques in the context of an alliance rupture was negatively related to outcome. Inspired by these findings, and guided by an assimilative integration model, Castonguay (1996) developed Integrative Cognitive Therapy (ICT), which is an approach to depression that remains grounded in CT but systematically incorporates humanistic and interpersonal strategies for identifying, addressing, and repairing emergent alliance ruptures.

Based on the contributions of Burns (1989) and Safran and Segal (1990), ICT presupposes that CT therapists can be more effective in dealing with alliance strains by exploring the source of the difficulty (including their own contributions) rather than increasing their adherence to core CT interventions. In this vein, the ICT manual outlines a 3-step rupture-repair sequence in which the therapist: (1) Invites the patient to discuss his negative reaction to the therapy or therapist; (2) Empathizes with the patient’s feelings and invites additional emotional disclosure in the service of understanding, respecting, and validating the patient’s subjective experience; and (3) Disarms the patient’s antagonism, anger, and/or other negative feelings by acknowledging his or her own contribution to the rupture. Such action promotes a restoration or enhancement of the collaborative working relationship, at which time the therapist then resumes standard CT techniques.

In an initial pilot investigation of ICT, Castonguay et al. (2004) found that ICT produced significantly superior outcomes than a wait-list control condition. As a follow-up, my research team conducted a pilot study (Constantino et al., 2008) to test further ICT’s efficacy and specificity by directly comparing it to standard CT. In this sense, the study employed an additive design, the strength of which resides in its high level of control across the independent treatment variable (e.g., Behar & Borkovec, 2003). With the exception of ICT’s additional rupture-repair strategies, the treatments were delivered according to the same CT protocol, thereby reducing the likelihood that outcome differences are a function of “nonspecific” factors and strengthening the causal inferences that can be made about the alliance manipulations. Furthermore, by using CT-as-usual as a control group, the additive design (a) transcends the specific versus common factors debate by assessing whether rupture-repair interventions work additively or synergistically to improve an already established treatment package, and (b) adds a cause-and-effect dimension to the alliance-outcome link. In our study, using clinicians-in-training, we found preliminary evidence that ICT could be distinguished from CT, and that ICT outperformed CT (small to medium effects) in terms of reducing depressive and global symptomatology. Furthermore, relative to CT, there were fewer dropouts, higher quality alliances, and higher perceived therapist empathy in ICT (medium to large effects). Thus, ICT may be considered a promising limited support treatment (Roth & Fonagy, 1996) worthy of future rigorous study.

Although preliminary, our emerging ICT findings suggest that psychotherapists should not only strive to foster good initial alliances with their patients, but also constantly assess for any deviations in the relationship climate. In the face of potential or actual alliance ruptures, clinicians should resist rigid adherence to the techniques they have been employing (e.g., standard CT interventions) and work through such relationship issues directly, openly, and nondefensively. The use of gentle probing, active listening, empathizing, and disarming may not only help to get the relationship back on track, but such metacommunication strategies may also promote a corrective relational experience (see also Safran & Muran, 2000).

Expectancy Process Research and the Expectancy Enhancement Treatment Module

Patients’ expectations have long been considered a common treatment factor (e.g., Frank, 1961). Outcome expectations refer to a prognostic belief that therapy will help, while process expectations reflect beliefs about what will transpire during therapy. As reflected in our own review and process-outcome studies (e.g., Constantino et al., 2007; Greenberg et al., 2006), expectations have been shown to be important contributors to adaptive during- and post-treatment outcomes. However, the expectation construct has been remarkably undervalued (Weinberger & Eig, 1999). Although many therapies include elements that address patient expectations in some manner, expectancy strategies are often neither explicit nor systematic. Moreover, in experimental treatment studies, expectations have been traditionally viewed as artifacts to be controlled – a perspective that now seems outdated. Thus, we have developed a treatment manual that outlines an explicit and systematic approach to enhancing patient expectations about therapeutic change and the treatment course.

The expectancy enhancement (EE) manual (Constantino, Klein, & Greenberg, 2006) addresses pre- and during-treatment expectations. Specifically, it comprises (a) an initial session EE interview to enhance patients’ outcome expectations and their expectations about the length and nature of treatment, (b) ongoing standard and reactive EE strategies, (c) general relationship strategies to be considered in light of patients’ expectations, and (d) a termination component that aims to enhance patients’ posttreatment expectations for maintaining their treatment gains. The present version of EE was designed as a companion manual to CT for depression. However, we suspect that such strategies can eventually be adapted for a wide range of clinical conditions and for other treatment modalities. We are currently conducting another pilot study, again utilizing an additive design, to foster the development of the EE manual and to test preliminarily its causative enhancement of standard CT. Although the outcome data are still forthcoming, we have been able to successfully train graduate trainees on the protocol, and they have been able to implement the treatment with good fidelity and competence.

Despite not yet having data on the specific efficacy of our EE manual, psychotherapy process research points consistently to the clinical importance of patients’ process and outcome expectations. Moreover, most psychotherapies involve some level of manipulation, exploration, challenge, and/or revision of patient expectations (Greenberg et al., 2006). Thus, clinicians should carefully assess patients’ expectations at the beginning of treatment in order to inform prognosis, case formulation, and treatment-planning. Regarding process expectations, clinicians may need to spend time socializing patients to the treatment process (e.g., typical role behaviors; duration), as well as checking in on patients’ met and unmet expectations as the therapy work unfolds. Regarding outcome expectations, clinicians should make a concerted effort to offer personalized hope-inspiring statements (e.g., “Your problems are exactly the type for which this therapy can be of assistance”) at the treatment’s outset, and to respond appropriately to hope-diminishing moments with both alliance-based sensitivity and expectation-enhancing strategies (e.g., reminding patients of depression’s recurrent nature; drawing on past successes) (Constantino et al., 2006).

Conclusions

The lines of research discussed above are representative of my overarching research program that focuses on understanding patient, therapist, and relational processes that influence the course and outcome of psychosocial treatments, and on the development and systematization of therapeutic interventions that address pantheoretical principles of clinical change. The overarching aim of the program is the development of empirically-grounded skills on which therapists can be trained to negotiate effective therapeutic relationships and to enhance patients’ treatment expectations. This focus on two key common factors adds a much-needed complement to the testing and training of theory-specific treatment techniques that have, to date, received much more empirical attention. Of course, the efficacy findings discussed above should be interpreted within their preliminary spirit. However, our hope is that when the jury returns, we will have uncovered two promising common factor treatment modalities that can be assimilated into CT to augment its effectiveness. If so, our work will have helped substantiate a glass-not-yet-full-but-still-full-of-promise perspective on psychotherapy outcome research.

References

Behar, E. S., & Borkovec, T. D. (2003). Psychotherapy outcome research. In J. A. Schinka & W.

F. Velicer (Eds.), Handbook of psychology: Research methods in psychology, Vol. 2. (p. 213-240). New York: John Wiley & Sons, Inc.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.

Burns, D. D. (1989). The feeling good handbook. New York: William Morrow & Co.

Castonguay, L. G. (1996). Integrative cognitive therapy for depression treatment manual.  Unpublished manuscript, The Pennsylvania State University.

Castonguay, L. G., Constantino, M. J., & Holtforth, M.G. (2006). The working alliance: Where are we and where should we go? Psychotherapy, 43, 271-279.

Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).  Predicting outcome in cognitive therapy for depression: A comparison of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497-504.

Castonguay, L. G., Reid, J. J., Jr., Halperin, G. S., & Goldfried, M. R. (2003). Psychotherapy integration. In G. Stricker & T. A. Widiger (Eds.), Handbook of Psychology, Vol. 8 (Clinical Psychology; pp. 327-345). New York: Wiley.

Castonguay, L. G., Schut, A. J., Aikins, D., Constantino, M. J., Laurenceau, J. P., Bologh, L., & Burns, D. D. (2004). Repairing alliance ruptures in cognitive therapy: A preliminary investigation of an integrative therapy for depression. Journal of Psychotherapy Integration, 14, 4-20.

Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S., (2005). The association between patient characteristics and the therapeutic alliance in cognitive behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203-211

Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the “scientist-practitioner” model in psychotherapy. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 81-131). Boston: Allyn & Bacon.

Constantino, M. J., Klein, R., Greenberg, R. P. (2006). Guidelines for Enhancing Patient Expectations: A Companion Manual to Cognitive Therapy for Depression. Unpublished manuscript.

Constantino, M. J., Manber, R., Ong, J., Kuo, T. F., Huang, J., & Arnow, B.A. (2007).

Patient expectations and the therapeutic alliance as predictors of outcome in group CBT for insomnia. Behavioral Sleep Medicine, 5, 210-228.

Constantino, M. J., Marnell, M., Haile, A. J., Kanther-Sista, S. N., Wolman, K., Zappert, L., et al. (2008). Integrative cognitive therapy for depression: A randomized pilot comparison. Manuscript submitted for publication.

De Maat, S., Dekker, J., Schoevers, R., & De Jonghe, F. (2006) Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: A meta-analysis. Psychotherapy Research, 16, 562-572.

Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: The Johns Hopkins Press.

Grawe, K. (1997). Research-Informed psychotherapy. Psychotherapy Research, 7, 1-19.

Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 26, 657-678.

Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D., Salomon, R. M., O’Reardon, J.P., et al. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression.  Archives of General Psychiatry, 62, 417-422.

Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In. M.J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5^th ed., pp. 139-193). New York: Wiley.

Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of Psychotherapy Integration (2nd ed.). New York: Oxford University Press.

Roth, A., & Fonagy, P. (2005). What works for whom: A critical review of psychotherapy research (2^nd edition). London: Guilford Press.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford.

Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.

Weinberger, J., & Eig, A. (1999). Expectancies: The ignored common factor in psychotherapy. In I. Kirsch (Ed.), How expectancies shape experience (pp. 357-382). Washington, DC:  American Psychological Association.

Garrison Keillor observes of the residents of Lake Wobegon, “All the women are strong, all the men are good-looking, and all the children are above average.” As psychotherapists, it is likely that we similarly believe we are above average, but as Keillor’s folksy humor reminds us, it ain’t so—half of us are below average, as a statistical necessity! Moreover, the variability in outcomes due to psychotherapists is greater than what is expected by chance (Wampold, 2001) and the differences are meaningful. In practice settings, some psychotherapists consistently attain better outcomes than others and this seems to be true regardless of patient diagnoses, age, developmental stage, medication status, severity, and so forth—good psychotherapists get consistently better outcomes across a range of patients (Wampold & Brown, 2005). The Wobegon flip side, is that some psychotherapists consistently have poorer outcomes.

What characterizes the psychotherapy provided by psychotherapists who consistently get better outcomes and how can we all adopt such practices to improve our effectiveness?

Unfortunately, definitive answers to this question have eluded us for decades and distressingly, as Beutler (2004) suggests, interest in psychotherapist variables is waning.  Nevertheless, there are some emerging trends that we should consider. But first, we should be clear about what does not appear to make a difference. The particular treatment delivered by psychotherapists does not appear to make a difference, in clinical trials (see Wampold, 2001) or in practice (e.g., Stiles et al., 2006). Indeed, and this is very good news for clinicians; it appears that services delivered in private practice, using a variety of treatments, produces benefits equivalent to those obtained by empirically supported treatments (ESTs) in clinical trials (Minami et al., in press). So, don’t give up your preferred treatment model in favor of an EST.

There are three areas where we should focus our attention with regard to increasing benefits to our patients. First, to attain benefits of psychotherapy, patients must be engaged in the therapeutic process. We know that many patients in clinical trials drop out of treatment and those who do have poorer outcomes than those who remain in treatment (Westen & Morrison, 2001). Patients engage in psychotherapy when, it appears, that they received a treatment that is consistent with their expectations, have positive expectations for success, and feel understood by the psychotherapist (Wampold, in press). Rather than administer OUR preferred treatment to all patients, we must be exquisitely sensitive to how patients wish to heal—they have expectations for the nature of treatment and we cannot think that “one size fits all.” CBT for PTSD (prolonged exposure, relaxation, and cognitive restructuring) is an effective treatment (although not more effective than some very different alternatives), but in clinical trials nearly half of patients prematurely terminate (McDonagh et al., 2005). This does not mean that we should rapidly change our approach, but rather we should be attuned to patients’ attitudes, values, context (including culture), and expectations and to be convincing in our presentation of treatment rationales, whether we do this implicitly or explicitly. We should be aware of each client’s motivation for change, their coping styles, and their tendency to resist, and select or adapt treatments accordingly (see Norcross, 2002). Our power to create positive expectations is great—but that task is accomplished in large part by employing treatment procedures that patients find acceptable.

A second critical component of effective therapy is a positive working alliance, as noted previously in News You Can Use. It is important to keep in mind that alliance is more than the relationship formed by being empathic and caring—it is also an agreement about the goals and tasks of psychotherapy. Again, the acceptance of the treatment provided is critical—the working alliance will be weak if the patient does not find the treatment convincing. The literature points to a few critical aspects of the alliance. Psychotherapy involves considerable risk to patients—we ask them to change core aspects about their beliefs in themselves and others. Patients naturally are willing to undergo this change only if they believe the psychotherapist understands them and that the treatment offered will benefit them (Wampold, in press). Moreover, alliance research points to the importance of collaborative work between the psychotherapist and the patient (Hatcher & Barends, 2006). Finally, we must recognize that some patients, perhaps due to poor attachment history, will have difficulty forming an alliance, but we should not be deterred, as it is the psychotherapist’s contribution, not the patient’s contribution, to the alliance that makes a difference (Baldwin, Wampold, & Imel, in press).

A final way to increase effectiveness is to monitor the outcomes we produce.  Michael Lambert’s groundbreaking research on providing feedback to psychotherapists demonstrably has shown that such feedback systematically leads to increased benefits to patients (Lambert et al., 2005). Without such feedback, we really are blind to whether we belong to the Lake Wobegon “false” above average folks or not. Reliable benchmarks exist for disorders (Minami et al., 2007) and we need to understand how effective we arewith our patients relative to benchmarks and to use that feedback to improve the quality of our services. There are a number of outcomes systems available and more on coming on line, including

• Miller and Duncan’s ORS ASIST (http://www.talkingcure.com/bookstore.asp)

• Lambert’s OQ Analyst (http://www.oqmeasures.com/)

• Grissom’s Polaris Mental Health Measures (http://www.polarishealth.com/index.html)

• Brown’s ACORN project (http://www.clinical-informatics.com/), among others. 1

Typically, the measures asses psychological functioning generically by assessing general symptoms, well-being, and social and role functioning, Although the use of outcomes in practice is not without significant issues for clinicians, the benefit of receiving feedback about the quality of our services seems to be great enough that we should pursue outcome-informed practice (Miller, Duncan, & Hubble, 2005).

In summary, our efforts to improve the effectiveness of our psychotherapy could profitably focus on ensuring engagement in the psychotherapy process, attending to the working alliance by focusing on the collaborative nature of our work, and receiving feedback about our effectiveness by measuring outcomes.

Footnotes

1Please note that I am not endorsing these particular measures and systems or recommending these over others. Psychotherapists will need to determine which set of measures and systems is cost effective for their particular practice, should they decide to use outcomes to inform their delivery of service.

References

Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (in press). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology.

Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 227-306). New York: Wiley.

Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165-174.

McDonagh, A., Friedman, M., McHugo, G., Ford, J., Sengupta, A., Mueser, K., et al. (2005). Randomized trial of cognitive–behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73, 515-524.

Miller, S. D., Duncan, B. L., & Hubble, M. A. (2005). Outcome-informed clinical work. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.). (pp. 84-102). New York: Oxford University Press.

Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E., Brown, G. S., & Kircher, J. (in press). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study. Journal of Consulting and Clinical Psychology.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.

Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centered and psychodynamic

therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555-566.

Wampold, B. E. (2001). The great psychotherapy debate: Model, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates.

Wampold, B. E. (in press). Psychotherapy: The humanistic (and effective) treatment. American Psychologist.

Wampold, B. E., & Brown, G. S. (2005). Estimating therapist variability: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73, 914-923.

Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorders: An examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875-899.