Therapists' and patients' experiences of using patients' self-reported data in ongoing psychotherapy processes-A systematic review and meta-analysis of qualitative studies.

OBJECTIVE: Using patient-generated quantitative data in psychotherapy (feedback) appears to enhance treatment outcome, but there is variability in its effect. Different ways and reasons to implement routine outcome measurement might explain such variability. The goal of this review is to address the insufficient knowledge on how these data are used by therapists and patients. METHODS: The present study is a systematic review and meta-analysis of qualitative reports of therapists' and patients' experiences using patient-generated quantitative data during ongoing psychotherapy. RESULTS: Four main categories of use were identified: (1) uses of patients' self-reported data as nomothetic/objective markers for assessment, process monitoring, and treatment planning; (2) intrapersonal uses that enhance self-awareness, initiate reflection, and influence patients' mood or responses; (3) uses that prompt interactional processes by facilitating communication, supporting exploration, creating ownership in patients, changing treatment focus, enhancing therapeutic alliance, or disturbing the psychotherapy process; and (4) patients responding for specific purposes due to uncertainty and interpersonal motives, or strategic responding to achieve a desired result. CONCLUSION: These results demonstrate that patient-reported data, when used in active psychotherapy, is very clearly not just an objective measurement of client functioning: the inclusion of patient-data has the potential to influence psychotherapy in numerous ways.

Controlling is not enough: the importance of measuring the process and specific effectiveness of psychotherapy treatment and control conditions.

The major argument of this article is that failing to measure what is taking place in treatment and control conditions can lead to scientifically invalid conclusions. It is argued that researchers are ethically responsible for being aware that variables related to the therapist, client, and the therapeutic relationship (as well as their interaction) might play a confounding role when treatment and control conditions are compared. As a consequence, they should either measure those variables or be tentative in their interpretation of their findings.

Compulsive checking behaviors in generalized anxiety disorder.

Recent evidence suggests that a relationship exists between worry, the central feature of generalized anxiety disorder (GAD), and compulsive behaviors, particularly compulsive checking. In this article we report the results from two studies. The first study assessed the frequency of obsessions and compulsions in 107 principally diagnosed GAD clients. The second study examined levels of alexithymia in analogue samples of GAD checkers (n = 31), GAD noncheckers (n = 30), and non-GAD nonchecking controls (n = 27) using the Toronto Alexithymia Scale-20 (Bagby, Parker, & Taylor, 1994). The results from these studies suggest that compulsive behaviors in the form of compulsive checking is more common in GAD than previously expected and that such behaviors in GAD may act as an additional mechanism by which affective experiences are avoided.

Psychotherapy for depression: current and future directions in research, theory, practice and public policy.

This article is based on a symposium held at the 1998 Annual Meeting of Society for Psychotherapy Research (Snow Bird, Utah). Recognized experts addressed current and future directions in psychotherapy for depression from the perspectives of process and outcome research, basic research, theoretical models, clinical practice and training, and public policy. The specific issues discussed at the symposium included the strengths and limitations of major forms of psychotherapy; the therapeutic factors common and unique to different approaches; the future viability of current theories of depression; the role of treatment manuals in clinical practice and training; the development of new interventions based on basic research; and the priorities that should guide federal funding.

The therapeutic focus in significant sessions of master therapists: a comparison of cognitive-behavioral and psychodynamic-interpersonal interventions.

Using the Coding System of Therapeutic Focus, this exploratory study was a comparative process analysis of clinically significant sessions obtained from 22 master cognitive-behavior and 14 master psychodynamic-interpersonal therapists. Therapists were nominated by experts in each of these orientations, and clients were seen in a naturalistic setting for problems with anxiety, depression, or both. Relatively few between-groups differences emerged with this master therapist sample. However, regardless of theoretical orientation, several differences were found between those portions of the session labeled by therapists as being clinically significant and those viewed as less significant. As these findings are different from those obtained in a previous study of the therapeutic focus in interventions carried out within the context of a controlled clinical trial, some of the possible factors contributing to these differences are noted.

What is the scientific meaning of empirically supported therapy?

It is important to define precisely what is and is not meant by "empirically supported treatments," rigorously based on what is actually known about the nature of experimental therapy research. The criteria for empirically supported treatments merely allow conclusions about whether treatments cause any change beyond the causative effect of such factors as placebo or the passage of time. Applied implications are limited, due to external validity and to the fact that applied decisions are influenced by cost-benefit analyses. Creating increasingly effective therapies through between-group designs is best done by controlled trials specifically aimed at basic questions about the nature of psychological problems and the nature of therapeutic change mechanisms. Naturalistic research is important for external validity but is valuable only if it uses scientifically valid methods to address basic knowledge questions.

A comparative analysis of the therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions.

This study compared therapeutic foci in a sampling of 30 cognitive-behavioral and 27 psychodynamic-interpersonal manual-driven treatments for depression. High- and low-impact sessions were coded for each client, with the Coding System of Therapeutic Focus. Results indicated that psychodynamic-interpersonal sessions focused more on such variables as emotion, patterns, incongruities, the impact that others made on clients, clients' expected reaction of others, the tendency to avoid therapeutic progress, therapists themselves, clients' parents, and links between people and time periods in clients' lives. Cognitive-behavioral sessions placed greater emphasis on external circumstances and clients' ability to make decisions, gave more support and information and encouraged between-session experiences, and focused more on the future. Relatively few differences emerged as a function of session impact. Results are discussed in terms of the different and similar theoretical conceptions of the change process.

The study of change in psychotherapy: a reexamination of the process-outcome correlation paradigm. Comment on Stiles and Shapiro (1994)

W.B. Stiles and D.A. Shapiro (1994) present a provocative argument that the yield of process research has been minimal because of researchers' overreliance on the drug metaphor and its corollary, the correlational design. Although Stiles and Shapiro raise excellent points regarding the possible misinterpretations of correlational research, their conclusion that the process-outcome correlation paradigm is flawed and has outlived its usefulness is questioned. The basic thesis is that Stiles and Shapiro did not provide a fair test of the correlation paradigm. The process variables used to test the paradigm do not have the strong theoretical and empirical grounding necessary to support the assumption that they should be related to outcome. In this article, examples are described, of programmatic process research that has used the correlation paradigm, along with other methods of inquiry, to advance the understanding of how change occurs and to improve treatment efficacy. It is contended that the correlational method is one useful tool of discovery and that it has contributed significantly to the advancement of the field when the process variables studied are grounded in solid theory and research.

Predicting the effect of cognitive therapy for depression: a study of unique and common factors.

The ability of several process variables to predict therapy outcome was tested with 30 depressed clients who received cognitive therapy with or without medication. Two types of process variables were studied: 1 variable that is unique to cognitive therapy and 2 variables that this approach is assumed to share with other forms of treatment. The client's improvement was found to be predicted by the 2 common factors measured: the therapeutic alliance and the client's emotional involvement (experiencing). The results also indicated, however, that a unique aspect of cognitive therapy (i.e., therapist's focus on the impact of distorted cognitions on depressive symptoms) correlated negatively with outcome at the end of treatment. Descriptive analyses that were conducted to understand this negative correlation suggest that therapists sometimes increased their adherence to cognitive rationales and techniques to correct problems in the therapeutic alliance. Such increased focus, however, seems to worsen alliance strains, thereby interfering with therapeutic change.

Effectiveness of targeting the vulnerability factors of depression in cognitive therapy.

I. H. Gotlib and C.L. Hammen's (1992) psychopathology model of depression was used as a conceptual framework for studying the process of change in an effective course of cognitive therapy (CT) for depression. Archived CT transcripts from 30 depressed outpatients in the Cognitive-Pharmaco-therapy Treatment project (S. D. Hollon et al., 1992) were studied. An observational coding system was used to assess whether therapists focused on the cognitive, interpersonal, and developmental vulnerabilities of depression and whether these interventions were associated with symptom reduction. Therapists maintained a primarily cognitive focus, but it was interventions that addressed the interpersonal and developmental domains that were associated with improvement. A developmental focus also predicted a longer time of recovery and better global functioning over the 24-month followup period. These findings are consistent with recent theoretical developments in cognitive therapy and with the psychopathology research on depression.

Sexual preference assessment of sexual aggressors: predictors of penile response magnitude.

A current method used to assess the sexual preference of sexual aggressors is the recording of their penile responses during the presentation of erotic stimuli. This method is ineffective in subjects who do not obtain sufficient penile responses. Whether variables related either to the subjects or their crimes would correlate with the magnitude of penile responses during sexual preference assessment was studied. The penile responses of 92 subjects were recorded. Older and pre-sentencing subjects showed a lower maximum penile response magnitude than younger and sentenced subjects. Results are discussed as they relate to the validity of physiological assessment of sexual preference.

Muscular response to the therapist and symptomatic improvement during biofeedback for tension headache.

The relationship between muscular response to the therapist's presence and symptomatic improvement was studied during biofeedback. Thirty-two patients suffering from tension headaches received muscular biofeedback training of six sessions plus a follow-up session two months later. Patients' electro-myographic frontal response was measured prior to treatment both with and without the therapist present. A relationship was found between symptomatic improvement at follow-up and muscular response to the therapist's presence before treatment: patients showing a decrease of at least 10% in muscular tension response to the presence of their future therapist improved more regarding headache intensity than the patients showing increase or smaller variation of their EMG. A significant correlation of .59 was found between the frontal EMG response to therapist presence during the evaluation session and headache improvement at follow-up. The results suggest that the decrease of muscular tension during the first contact with the therapist could be an indicator of good prognosis, possibly because of an immediate positive therapeutic relationship and/or favorable expectancies concerning future benefit of treatment.

Training psychiatrists and family doctors in evaluating interpersonal skills.

Ten psychiatrists and 15 family doctors were asked to score videotapes of patient-doctor encounters before and after each of two training periods. One period focused on the theory of assessment of doctors' interpersonal skills, while the other was purely practical. Results indicate that after one training session in either theory or practice, both groups of doctors achieved a significantly higher interrater reliability. The second session, which crossed over theory and practice of assessment, did not increase the improvement in interrater agreement achieved by the first training period. Although both groups of doctors showed a significant increase in interrater agreement, psychiatrists exhibited greater reliability scores than family doctors before the experiment as well as after the second training session. These results were discussed in terms of their implicatioins for future research on the doctor-patient relationship.

A comparison of three methods of scoring penile circumference changes.

There are presently three widely used methods of scoring penile circumference data. The present experiment attempted to determine the ability of each method to explain the variance within a data set. A total of 19 subjects were presented with 20 photographic slides assigned to five categories: neutral, female adult, female adolescent, male adult, and male adolescent. Erectile responses to each slide were recorded and the data analyzed in terms of the raw scores, percentage of full erection, and a z-score transformation. Results indicated that the z scores captured the highest proportion of the variance (52.7%), followed by the percentage scores (32.5%), and the raw scores (30.1%). Findings are discussed in terms of their research and clinical implications.