Introduction: perspectives on therapy with gay, lesbian, and bisexual clients.

The approach that mental health professionals have taken in working with gay, lesbian, and bisexual (GLB) clients has changed dramatically over the past 25 years. Once viewed as being pathological in nature-either a sociopathic personality disorder or a sexual deviation-homosexuality is no long conceptualized as a "disorder" and instead is viewed within the broader context of human diversity. Even with such changes, many mental health professionals nonetheless retain subtle biases against working with gay, lesbian, and bisexual clients, and often lack the necessary information for working with them effectively. This issue of In Session provides a series of articles designed to help practicing therapists to become better aware of those clinical issues if they are to work with GLB individuals-which they are likely to do.

The importance of parental support in the lives of gay, lesbian, and bisexual individuals.

This article underscores the very important role that parental acceptance and support plays in furthering the psychological well-being of gay, lesbian, and bisexual individuals. Parents, Families, and Friends of Lesbians and Gays (PFLAG), an organization dedicated to this goal, has as its mission the support for family members, education of the public, and advocacy for equal rights for lesbians, gay men, and bisexuals. By "coming out" themselves, straight parents and relatives-including those in the mental health field-not only can extend the support they offer to their gay/lesbian/bisexual children and relatives but also play a significant role in reducing the stigma of being gay, lesbian, or bisexual and in mainstreaming gay, lesbian, and bisexual issues.

Integrating gay, lesbian, and bisexual issues into mainstream psychology.

Despite the growing clinical and research literature dealing with gay, lesbian, and bisexual (GLB) issues, mainstream psychology has tended to ignore much of the work that has been done in this area. This article illustrates how clinical and research writings on GLB issues continue to remain invisible to mainstream psychology in such areas as life span development and aging, teenage suicide, substance abuse, victimization and abuse, and family and couple relationships. It also deals with some of the determinants of well-being among GLB individuals, such as family support, and notes the benefits accruing to mainstream psychology from studying GLB issues. A network of family members within psychology having GLB relatives has been formed--AFFIRM: Psychologist Affirming Their Gay, Lesbian, and Bisexual Family--and is dedicated to supporting its own family members, encouraging other family members to do likewise, supporting research and clinical work on GLB issues, and closing the gap between GLB clinical and research work and mainstream psychology.

Coding system of therapeutic focus on action and insight.

This study (a) used an established comprehensive process measure to uncover a latent pattern of therapeutic focus in cognitive-behavioral and psychodynamic-interpersonal sessions; (b) used these results to develop the coding system of Therapeutic Focus on Action and Insight, which makes it possible to evaluate therapists' relative emphasis on the Constructing Meaning and Facilitating Action domains of in-session focus; and (c) evaluated its reliability and validity.

Training the scientist-practitioner for the 21st century: putting the bloom back on the rose.

The field of clinical psychology has been characterized over the past five decades as shaped by social, economic, and political forces outside of it. Even before the Boulder Conference, meetings and writings evidenced the underpinnings of the scientist-practitioner model that was to be developed in a welcoming climate (Dosier, 1947; Kubie, 1949; Luchins, 1949). Difficulties in implementation, however, produced a schism between the scientist and practitioner aspects. Our thesis is that the current environment dictated by managed care necessitates a reaffirmation of the scientist-practitioner model. We believe that clinical psychologists are in an unparalleled position to intercede among forces in the current climate because of their sensitivity to clinical and research issues, and we offer suggestions for how clinicians, researchers, and training programs can close the gap between research and practice.

Role of theoretical bias in therapeutic interventions: to see or not to see?

Considering the role of theory in child psychosocial treatment, it is important to acknowledge some of its associated problems. Among the shortcomings of theory discussed in this article are its potential for biasing what we see and do clinically, the arbitrary nature of some theoretical explanations, and the way that theory-based jargon can interfere with communication. A bottom-up approach to the development of clinical principles is advocated instead, especially when these principles are derived from the convergence of clinical observation and research findings.

Toward the development of a clinically useful approach to psychotherapy research.

The controversial move toward the development of a consensus on evidence-based or empirically supported therapies may be seen as an international crisis facing psychotherapists. Researchers long have complained that practicing therapists all too often continue to guide what they do therapeutically on the basis of their clinical experience and not the available research findings. Practicing therapists long have complained that therapy research bears only a remote resemblance to what goes on in actual clinical practice and that research reports are written for other researchers, not for clinicians. In the hope of turning our current crisis into an opportunity, this panel involved a dialogue that was designed to bridge this clinical-research gap.

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.

Therapist interventions and client emotional experiencing in expert psychodynamic-interpersonal and cognitive-behavioral therapies.

Eighteen sessions of cognitive-behavioral (CB) and 13 sessions of psychodynamic-interpersonal therapy obtained from experienced clinicians in a naturalistic setting were investigated to determine the various therapeutic interventions associated with high and low emotional experiencing (EXP). Clients receiving reflections and acknowledgments, affiliative and noncontrolling interventions, or interventions highlighting nonspecific client content were associated with maintained high EXP. Lengthier interventions and interventions rated as affiliative but moderately controlling were associated with shifts to low EXP. For clients of CB therapists, questions, interventions rated affiliative but controlling, and highlighting minimal emotional content were also associated with shifts to low EXP. Male therapists were associated with clients who maintained high EXP and female therapists were associated with clients who shifted to low EXP.

A comment on psychotherapy integration in the treatment of children.

Interest in psychotherapy integration, which has developed into an ongoing movement in the past decade or two, now appears to be capturing the interest among therapists and researchers in the clinical child area. The articles in this section deal specifically with the integration of basic research on language and cognition into the clinical arena, and the complementary use of concepts and interventions from different schools of thought. In commenting on these contributions, I have underscored the importance of using a broader historical and conceptual perspective, so that we can advance, rather than rediscover, what we already know.

Toward a more clinically valid approach to therapy research.

Despite the advances in psychotherapy outcome research, findings are limited because they do not fully generalize to the way therapy is conducted in the real world. Research's clinical validity has been compromised by the medicalization of outcome research, use of random assignment of clients without regard to appropriateness of treatment, fixed number of therapy sessions, nature of the therapy manuals, and use of theoretically pure therapies. The field needs to foster a more productive collaboration between clinician and researcher; study theoretically integrated interventions; use process research findings to improve therapy manuals; make greater use of replicated clinical case studies; focus on less heterogeneous, dimensionalized clinical problems; and find a better way of disseminating research findings to the practicing clinician.

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 therapeutic alliance in psychodynamic-interpersonal and cognitive-behavioral therapy.

The quality of the therapeutic alliance was compared in sessions of psychodynamic-interpersonal and cognitive-behavioral therapy, and the alliance's relationship to various session impacts was investigated. As part of the Sheffield Psychotherapy Project 2 (D. A. Shapiro, M. Barkham, A. Rees, G. E. Hardy, S. Reynolds, & M. Startup, 1994), 57 clients diagnosed with major depression received 16 sessions of either psychodynamic-interpersonal or cognitive-behavioral therapy. Coders used the Working Alliance Inventory to rate 1 high-impact and 1 low-impact session from each client. Results indicated significantly greater alliance scores for cognitive-behavioral therapy sessions on the whole. Also, for the samples as a whole, high-impact sessions were characterized by higher alliance scores than those for low-impact sessions, and alliance was positively related to therapists' ratings of session depth and smoothness and to clients' ratings of mood.

Psychotherapy practice and research. Repairing a strained alliance.

Although the gap between psychotherapy practice and research has been present for some time, recent pressures for accountability from outside the system-managed health care and biological psychiatry-necessitate that we take steps to close this gap. One such step has been for psychotherapy researchers to specify a list of empirically validated therapies. However, as researchers who also have a strong allegiance to clinical practice, we are concerned that the conceptual and methodological constraints associated with outcome research may become clinical constraints for the practicing therapist. We firmly believe that, more than ever before, the time is ripe for us to develop a new outcome research paradigm that involves an active collaboration between researcher and practicing clinician.

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.

Comparative study of emotional experiencing in psychodynamic-interpersonal and cognitive-behavioral therapies.

Despite increased interest in the role of emotion in the process of psychotherapy, we currently lack a valid gauge of its importance in the change process. Significant sessions obtained from 13 experienced psychodynamic-interpersonal and 17 experienced cognitive-behavior therapists were examined to determine the extent of affective exploration and therapists' views of these client states. Results indicate that affective experiencing is present in equivalent amounts in the change sessions of these two orientations. However, therapists' clinical views were dissimilar. Psychodynamic-interpersonal therapists viewed portions containing higher affective experiencing as more critical to the change process, whereas cognitive-behavior therapists viewed lower levels of experiencing as being therapeutically more significant. These findings suggest that, with regard to emotional experiencing, psychodynamic-interpersonal therapists may share common ground with experiential therapists, whereas cognitive-behavior therapists appear to have a unique perspective.

On the movement toward psychotherapy integration : the case of panic disorder.

The prospect of using psychotherapy integration to enhance therapeutic efficacy increases as clinical discussion and empirical inquiry mount. The authors review briefly the historical origins of integrative thought, discuss the new receptivity with which it is being met, and examine the clinical use of an integrative framework, using progress in the treatment of panic disorder as an example of the potential of integrative treatment strategies.