Causality in psychotherapy research: Towards evidential pluralism.

Identifying causal relationships is at the heart of all scientific inquiry, and a means to evidence base practices and to guide policymaking. However, being aware of the complexities of interactions and relationships, scientists and academics are cautious about claiming causality. Researchers applying methods that deviate from the experimental design generally abstain from causal claims, reserving them for designs that adhere to the evidential ideals of empiricism (e.g., RCTs), motivated by the Humean conceptions of causality. Accordingly, results from other designs are ascribed lower explanatory power and scientific status. We discuss the relevance of also other perspectives of causality, such as dispositionalism and the power perspectives of various realist approaches, which emphasize intrinsic properties and contextual variations, as well as an inferentialist/epistemic approach that advocates causal explanations in terms of inferences and linguistic interaction. The discussion will be illustrated by the current situation within psychotherapy research and the APA Policy Statement on Evidence-Based Practice. The distinction between difference-making and causal production will be proposed as a possible means to evaluate the relevance of designs. We conclude that clarifying causal relationships is an ongoing process that requires the use of various designs and methods and advocate a stance of evidential pluralism.

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study.

METHOD: To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28-59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements. RESULTS: Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient-therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses. CONCLUSION: Informants were preoccupied with calibrating the emotional-relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences.

A patient perspective on individual ED treatment processes is scarce for difficult-to-treat eating disorders (EDs) with childhood trauma (CT). We therefore interviewed six poor long-term outcome inpatients through video-assisted recall about a self-selected therapy session. Patients' covert in-session strategies included self-effacing behaviours in relation to their therapist, their respective preferences for closeness or distance to their therapist to be able to open up in session, and being more prone to engage in therapists' reflective interventions rather than experiential. In sum, patients were preoccupied with calibrating the emotional­relational landscape between patient and therapist in session, which were strategies that went undetected. We hypothesized that a lack of psychological security and affective tolerance limit patients freedom to explore own experiences from the perspective of traumatic attachment and self-differentiation theory.

Future orientation in successful therapies: Expanding the concept of goal in the working alliance.

OBJECTIVE: To better understand how therapists facilitate client goal attainment in therapy, we analyzed therapists' future-oriented actions in good outcome cases in which clients recorded high ratings on goal items in the Working Alliance Inventory-Short Revised. METHOD: We selected clients who were within the clinical range (OQ-45.2) at pretreatment, demonstrated reliable change at the end of treatment, and recorded high WAI client goals scores early in treatment. Qualitative analyses of transcripts of the initial three sessions and client posttreatment interviews were integrated into a combined analysis to identify themes across the two separate sets of findings. RESULTS: Therapist future-oriented activity included: (1) Picking up explicit and implicit intentions; (2) using linguistic devices, such as meta-communication, action language, and hedging; (3) using evocative interventions; and (4) nudging the client into practicing change. Core finding: Therapists aligned with clients' directionality in a forward-driven, gradually evolving process. CONCLUSION: Conceptual and clinical implications are discussed.

Change processes related to long-term outcomes in eating disorders with childhood trauma: An explorative qualitative study.

To date, eating disorder (ED) treatments are lacking for ED patients with psychiatric sequelae of childhood trauma, and successful outcomes are scarce. Therefore, the aim of this study was to explore therapeutic change processes from a patient perspective in relation to good versus poor long-term ED outcome at 1-year follow-up. Outcome categories were based on clinician assessment of ED behavior and diagnoses, body mass index, and Eating Disorder Examination Questionnaire scores. Eleven White, cisgendered female ED patients with childhood trauma were interviewed after a 3-month inpatient treatment: data was analyzed with elements from grounded theory and interpretative phenomenological analysis. The qualitative analysis rendered change-related descriptions (9 subcategories) and obstacles to change (6 subcategories), and 3 process-related domains differentiated good from poor long-term outcome: trauma exposure (4 subcategories), patient agency (6 subcategories), and patient-therapist dynamics (3 subcategories). First, sensory and emotional trauma exposure in good outcome informants was contrasted with avoiding or not addressing trauma and body in poor outcome informants. Second, promotion of patient agency while receiving support in the good outcome group was contrasted to an orientation toward others' needs, distrust in own abilities, and difficulties showing vulnerability in the poor outcome group. Third, poor outcome informants described either a distanced or immersed/idealizing relationship to their therapist, as opposed to more balanced between self-assertion and vulnerability in good outcome informants. Our findings raise new hypotheses that trauma work, fostering patient agency, and focusing on relational dynamics in patient-therapist dyad may be important in producing enduring ED outcomes for these patients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

From intention to action: A mixed methods study of clients' experiences of goal-oriented practices.

OBJECTIVES: Goal-oriented practices are central to many contemporary psychotherapies. The aim of this study was to explore clients' experiences of this work. DESIGN: Mixed methods, with a main qualitative part and a smaller quantitative component. Participants were 22 clients in integrative psychotherapy (15 females, 6 males, 1 "other"). Semistructured interviews after session 4 and at endpoint were analyzed thematically. On the basis of the identified themes, "goal attitude" scores were developed and their correlations with outcomes investigated. RESULTS: Goal-oriented practices could help clients move from intention to action through increased awareness and focus, setting manageable tasks, and progress monitoring. However, they had the potential to hinder clients' awareness of their intentions, feel irrelevant, disorientating, or demotivating. Effectiveness hinged on client's management of their expectations, flexible working, and time. Positive attitudes toward goal-oriented practices were associated with improvement. CONCLUSIONS: Goal-oriented practices can enhance psychotherapeutic work but need to be individually tailored and implemented collaboratively.