The Journal of psychotherapy practice and research

Publications
Although behavior therapy is designed to modify observable behaviors, it also brings about cognitive change. To achieve the best results with behavior therapy, it is sometimes necessary to combine it with cognitive procedures. The author gives examples of the uses of behavior therapy on its own and as combined cognitive-behavior therapy. These treatments have been tested extensively in clinical trials, and they are brief and highly suitable for use in managed care. Future developments are likely to include closer integration with pharmacotherapy and further extension into the field of behavioral medicine.
 
This study examined the extent to which improvement from baseline to weeks 2, 3, and 4 on the Beck Depression Inventory and Beck Anxiety Inventory predict week 16 clinical remission for patients with major depressive disorder, generalized anxiety disorder, and/or obsessive-compulsive or avoidant personality disorders who were receiving manual-based psychotherapies. Logistic regression and receiver-operator characteristic analyses revealed relatively accurate identification of remitters and nonremitters based on improvement from baseline to sessions 2 to 4 in both original and cross-validation samples. Predictive success did not vary as a function of diagnosis, treatment type (cognitive or dynamic), or treatment status (short-term or long-term). The clinical implications of the results are discussed.
 
The author discusses the state of the art of psychotherapy at the brink of the new decade. The theme of the 1990s is rapprochement, the bridging of divisive aspects of the field. Four major manifestations of increased detente are explored: convergence of mind and brain, collaboration of research and public policy, coordination of economic constraints and ethical standards, and connection between psychopathology and therapeutic practice. Factors of major importance for the future of psychotherapy are the impact of the neurosciences on psychological phenomena, the role of the computer in human simulation, the socioeconomic influence of government and third-party payers on the direction of treatment, and the utilization of clinical practice in devising new diagnostic dimensions.
 
As a professional and educational service, psychotherapy supervision looms large in importance. Yet if psychotherapy supervision is to most viably advance in the century ahead, a number of pressing measurement, research, and training/practice needs cry out to be better addressed. Ten such needs are identified by drawing on recent major research reviews and other substantive supervision publications. The author concludes that better addressing these needs would expand and fortify the empirical base of psychotherapy supervision and also enhance its training and practice base.
 
The predictive validity of instruments commonly used to measure the therapeutic alliance was evaluated, using 46 sessions drawn from a clinical trial comparing manual-guided therapies for substance use. The California Psychotherapy Alliance Scale, Penn Helping Alliance Rating Scale, Vanderbilt Therapeutic Alliance Scale, and Working Alliance Inventory (Observer, Therapist, and Client versions) were rated for participants receiving either cognitive-behavioral therapy or twelve-step facilitation. All observer-rated instruments were significantly correlated with outcome; however, therapist-rated and client-rated instruments did not predict outcome. Findings suggest that the different observer-rated instruments are minimally different with respect to predictive validity, whereas patient- and therapist-rated measures may have a weaker relationship to outcome when highly objective outcome measures are used.
 
Survivors of severe childhood abuse often encounter profound difficulties. In addition to posttraumatic and dissociative symptomatology, abuse survivors frequently have characterologic problems, particularly regarding self-care and maintaining relationships. Backgrounds of abuse, abandonment, and betrayal are often recapitulated and reenacted in therapy, making the therapeutic experience arduous and confusing for therapists and patients. Efforts must be directed at building an adequate psychotherapeutic foundation before undertaking exploration and abreaction of past traumatic experiences. This discussion sets out a model for treatment of childhood abuse survivors, describing stages of treatment and suggesting interventions. Common treatment dilemmas or "traps" are discussed, with recommendations for their resolution.
 
Both clinical experience and recent research statistics support the observation that childhood abuse survivors are vulnerable to revictimization as adults. The responsibility for revictimization, such as physical or sexual assault, belongs to the perpetrators. However, the factors that make abuse survivors more vulnerable to exploitation need to be examined and understood in order to provide adequate treatment and protection. This discussion integrates an understanding of three powerful forces-the repetition compulsion, post-traumatic syndromes, and profound relational disturbances-that permit the process of revictimization to occur.
 
This preliminary clinical report describes the usefulness of brief individual psychotherapy as a technique to engage relapse-prone substance abusers in addiction treatment. The authors propose that Mann's model of brief psychotherapy in the context of Brown's developmental model of recovery can be used during the early stages of recovery to improve retention in treatment. The use of Mann's model involves the identification of a central issue that is related to the substance abuse. Six commonly seen central issues are discussed: negative affective states, traumatic events, character pathology, unresolved grief, developmental arrest, and persistent denial. It is around one of these issues that a brief psychotherapeutic intervention is structured.
 
In this task force report, the authors define the field of child and adolescent psychotherapy; review the state of the field with respect to advocacy, training, research, and clinical practice; and recommend steps to ensure that psychotherapy remains a core competence of child and adolescent psychiatrists.
 
The authors examine the process of taking an initial history of childhood abuse and trauma in psychodynamic psychotherapy. In exploring the advantages, complexities, and potential complications of this practice, they hope to heighten the sensitivities of clinicians taking trauma histories. Emphasis on the need to be active in eliciting important historical material is balanced with discussion of concepts that can help therapists avoid interpersonal dynamics that reenact and perpetuate the traumas the therapy seeks to treat. Ensuring optimal psychotherapeutic treatment for patients who have experienced childhood trauma requires attention to the following concepts: a safe holding environment, destabilization, compliance, the repetition compulsion, and projective identification.
 
Projective identification is examined as an intrapsychic and interpersonal phenomenon that draws the analyst into various forms of acting out. The therapist struggles to use understanding and interpretation as the method of working through the mutual desire to act out the patient's core fantasies and feelings. Clinical material is used to illustrate the ways in which projective identification affects the analytic relationship. The focus is on methods of using interpretation to shift from mutual acting out to mutual understanding.
 
Although active involvement of patient and therapist predicts psychotherapy outcome, little is known about the mechanisms of action involved in the process. The authors investigated the relationships between variables that describe the participants' actions intrinsic to their active involvement and treatment outcome. A successful and an unsuccessful case were selected for 15 therapists, and an early and a late session for each case were coded using a newly developed instrument. Patients of a successful treatment compared with patients of an unsuccessful treatment made significant changes along variables that indicate the degree and quality of their involvement in treatment. This link between the participants' actions and treatment outcome may have practical utility in future investigations of the active components of different treatment modalities.
 
Interpersonal psychotherapy (IPT) has demonstrated efficacy in the individual treatment of antepartum and postpartum depression. The current investigation extends prior work by examining the efficacy of a group IPT approach for the treatment of postpartum depression. Depression scores of 17 women diagnosed with postpartum depressive disorder (DSM-IV criteria) decreased significantly from pre- to post-treatment. Follow-up assessments at 6 months revealed continuation of the treatment effect. Results indicate that IPT adapted for a group model has positive implications for the treatment of postpartum depression, demonstrating both short-term and longer-term effects in the reduction of depressive symptomatology. Study limitations include the small sample size, absence of control group, possible bias in therapist's assessments, and lack of monitoring adherence, which may have jeopardized the accuracy of the results.
 
Patients with dysthymia have been shown to respond to treatment with antidepressant medications, and to some degree to psychotherapy. Even patients successfully treated with medication often have residual symptoms and impaired psychosocial functioning. The authors describe a prospective randomized 36-week study of dysthymic patients, comparing continued treatment with antidepressant medication (fluoxetine) alone and medication with the addition of group therapy treatment. After an 8-week trial of fluoxetine, medication-responsive subjects were randomly assigned to receive either continued medication only or medication plus 16 sessions of manualized group psychotherapy. Results provide preliminary evidence that group therapy may provide additional benefit to medication-responding dysthymic patients, particularly in interpersonal and psychosocial functioning.
 
Adherence monitoring, a technology to specify research psychotherapies, was used in the NIMH Treatment of Depression Collaborative Research Program (TDCRP). The authors present adherence data from a similar randomized treatment trial of 56 depressed HIV-positive patients, comparing 16-week interventions with cognitive-behavioral therapy, interpersonal psychotherapy, and supportive psychotherapy alone or with imipramine. Therapists were certified in manualized treatments. Blind independent raters rated randomly selected taped sessions on an adaptation of the NIMH scale, yielding adherence scores for interventions and for therapist "facilitative conditions" (FC). All therapists were rated adherent. Interrater reliability was 0.89-0.99. The scale discriminated among the four treatments (P<0.0001), with each scoring highest on its own scale. FC, which might measure therapist competence independent of treatment technique, varied by intervention but did not predict treatment outcome. This study demonstrates the ability to reliably train adherence monitors and therapists able to deliver specified treatments. Its adherence findings provide the first replication of those from the landmark NIMH TDCRP study.
 
This article presents the development of a new 82-item rating scale of therapist adherence and competence for supportive-expressive (SE) dynamic psychotherapy for the treatment of cocaine dependence. Sixty-four items are rated for adherence, appropriateness, and quality of prescribed interventions. As part of the pilot/training phase of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, two independent expert judges rated 32 audiotapes of SE therapy sessions with cocaine-dependent patients, 10 tapes of cognitive therapy (CT) sessions, and 10 tapes of individual drug counseling (IDC) sessions. Reliability was acceptable for adherence but poor for quality and appropriateness. SE therapists used more expressive (interpretative) techniques than did either CT therapists or IDC counselors, and they used more supportive techniques than did IDC counselors.
 
Evidence continues to emerge that childhood symptoms of attention-deficit hyperactivity disorder (ADHD) persist into adulthood. These symptoms include motoric hyperactivity, restlessness, attention deficits, poor organizational skills, impulsivity, and memory impairment. Poor academic and work performance, frustration, humiliation, and shame are also components of adult ADHD. Psychotherapists are challenged to understand the meaning of the disorder and its ramifications in all aspects of life. An active multimodal approach, including somatic treatment and psychotherapy, is needed. In addition, cognitive remediation strategies to enhance attention, organization, memory, and problem-solving skills are an important adjunct to treatment. These strategies serve as psychological tools to circumvent deficits.
 
Demographic and clinical variables 
The authors have reported that adolescents with major depressive disorder had a higher remission rate with cognitive-behavioral therapy (CBT) than with systemic behavioral family therapy (SBFT) or nondirective supportive therapy (NST). Parent-rated treatment credibility deteriorated from baseline to end of treatment if patients were treated with SBFT or NST, compared with CBT. The present study evaluated the following variables as predictors of change in parent- rated credibility over time across the three treatment cells: severity of child's and parents' depression at baseline; parent-rated family climate at baseline; clinician age, gender, and years of clinical experience; and change in severity of child's depression and in family climate. The greater the baseline depression of children treated with CBT and NST, but not SBFT, the more favorable the change in parent-rated credibility at the end of treatment. Findings suggest that any improvement (for CBT) or a supportive therapeutic contact (for NST) may appeal to parents of severely depressed children.
 
Survivors of life-threatening pediatric illness and their families present a number of psychotherapeutic challenges. The authors present pilot data evaluating the long-term psychiatric impact of pediatric bone marrow transplantation on 10 adolescent transplantation survivors compared with a matched control group. On a quantitative assessment of posttraumatic stress symptoms, the survivors reported a consistent but low level of symptoms. Their narratives about the experience suggest the need for ongoing mental health assessment in addition to specific interventions with families early in the treatment.
 
In a 12-session open trial of cognitive therapy, depressed adolescent outpatients showed significant decreases in depressive symptomatology, although there was less improvement in a subgroup with comorbid attention-deficit hyperactivity or schizoid personality disorder. Decreases on measures of depressive symptoms and depressotypic cognition were maintained up to 5 months after acute-phase treatment. Outcome was not associated with age, gender, other comorbid diagnoses, concurrent use of antidepressants, duration of acute-phase therapy, or participation in subsequent booster sessions. Data suggest that cognitive therapy is a promising intervention for depressed adolescents and provide a rationale for pursuit of controlled cognitive therapy trials with this population.
 
Humor can provide useful information during the psychiatric evaluation of children and adolescents and can also facilitate the therapeutic process. Clinical examples demonstrate how humor is useful as a diagnostic tool; how it can be used to shape the therapeutic relationship; and the role of humor as a therapeutic technique. Humor may help the child and adolescent patient explore feelings and may help the therapist deal with resistance. In some circumstances, the humor itself can become an agent of change. Humor has been used in the treatment of depression, aggression, social ineptitude, and conduct problems. Both the benefits and the risks of using humor are discussed.
 
Short-term dynamic therapies, characterized by abbreviated lengths (10-40 sessions) and, in many cases, preset termination dates, have become more widespread in the past three decades. Short-term therapies are based on rapid psychodynamic diagnosis, a therapeutic focus, a rapidly formed therapeutic alliance, awareness of termination and separation processes, and the directive stance of the therapist. The emotional storm of adolescence, stemming from both developmental and psychopathological sources, leaves many adolescents in need of psychotherapy. Many adolescents in need of therapy resist long-term attachment and involvement in an ambiguous relationship, which they experience as a threat to their emerging sense of independence and separateness. Short-term dynamic therapy can be the treatment of choice for many adolescents because it minimizes these threats and is more responsive to their developmental needs. The article presents treatment and follow-up of a 17-year-old youth, using James Mann's time-limited psychotherapy method.
 
The authors review the literature on psychotherapy for the treatment of depression in children and adolescents, describing outcome studies in psychodynamic therapy, family therapy, group therapy, interpersonal therapy, and behavior therapy. The review revealed many limitations in study design; suggestions are made about the design of psychotherapy studies for the treatment of childhood depression. The current trend in the treatment of childhood depression is to modify treatments shown to be effective in depressed adults. Further systematic investigations are necessary before recommendations can be made regarding any particular psychotherapy for the treatment of depressed children and adolescents.
 
The multimodal treatment of adults with attention-deficit disorder (ADD) is described as consisting of a sequence of overlapping therapeutic measures. The initial objective is symptom amelioration through adequate pharmacotherapy. Once this has been accomplished, a period of psychoeducational therapy is recommended to teach the individual to live successfully with a chronic disorder. These two aspects of treatment may suffice for some ADD adults, but many others may require an additional course of psychotherapy to deal with dysfunctional personality characteristics resulting from having grown up with ADD. Among these are modes of defenses against painful affects, resistances to treatment, and inaccurate estimations and expectations of the self and others.
 
Psychotherapy for comorbid attention-deficit/ hyperactivity disorder (ADHD) and psychoactive substance use disorder (PSUD) is described. The authors suggest that relapse prevention is an appropriate initial treatment because it is well suited to manage both substance abuse and comorbid symptomatology such as impulsivity, distractibility, and avoidance associated with ADHD. Clinical vignettes describe typical interactions between patients and their therapists, highlighting opportunities for therapists to focus on overlapping symptoms. ADHD is one of the most common comorbid diagnoses with PSUD, and it is important that efficacious psychotherapies be developed to complement psychopharmacological approaches. Clinicians should consider psychotherapy as part of a multimodal treatment approach that includes medication and perhaps family therapy. Additional contributions from clinicians who have experience conducting psychotherapy with this population are needed in order to develop effective treatments.
 
Group forms of therapy have been growing at a rapid rate, in part because of their documented effectiveness and economic considerations such as managed care. It is therefore becoming increasingly important to assess the psychological risks of these interventions. The author provides an overview of the published literature and conference presentations on negative effects in adult outpatient groups. Although much of the literature on adverse outcomes in group therapy focuses on single risk factors (e.g., negative leader, group process, or patient characteristics), the author argues that an interactional model should be encouraged. Means of reducing casualties are also discussed, as well as methodological issues and research directions.
 
This study examined psychotherapists' experiences in conducting treatment with fellow mental health professionals. 349 psychologists (35% response) rated the extent to which their therapeutic approach with psychotherapists differed from their approach with laypersons of comparable intelligence, socioeconomic status, and diagnosis. Respondents also provided recommendations for conducting effective treatment with this elite clientele. Psychologists indicated that their practices with fellow psychotherapists were in most respects similar to those used with laypersons; 55 of the 78 items were rated of equivalent frequency. Practitioners' self-characterization as "a therapists' therapist" was related to the manner in which they treated mental health professionals. Broadly speaking, two types of advice were offered: to cultivate a warm and collaborative therapeutic relationship and to maintain proper boundaries. Recommendations for clinical work and future research on psychotherapists' psychotherapy are advanced.
 
A dynamic group treatment model for chronically ill persons allowing them to determine the frequency of attendance empowers the members and potentiates group development. This format respects patients' needs for space as represented by missed meetings. In this context, absences are formulated as self-protective and self-stabilizing acts rather than as resistance. In an accepting, supportive environment, members can be helped to explore affects and gain insight into their behaviors. A clinical example illustrates patients' examination of the meaning of missing and attending sessions, with particular focus on intensity of involvement, autonomy, and control. In the process of testing the therapist and group, members show capacity to gain insight into recent in-group and extra-group behaviors.
 
Affect consciousness (AC) was operationalized as degrees of awareness, tolerance, nonverbal expression, and conceptual expression of nine specific affects. A semistructured interview (ACI) and separate scales were developed to assess these aspects of affect integration. Their psychometric properties were preliminarily explored by having 20 former psychiatric outpatients complete the interview. Concurrent validity was assessed by using DSM-III-R Axis I and II diagnoses, the Health-Sickness Rating Scale, SCL-90-R, and several indexes from the Minnesota Multiphasic Personality Inventory. Satisfactory interrater reliability and high levels of internal consistency supported the construct validity of the measure. Results suggest the most meaningful use of this instrument is in measuring specific affect and overall AC. Clinically, the ACI has provided highly specific and relevant qualitative data for use in planning psychotherapeutic interventions.
 
There has been much outcome research on interpersonal psychotherapy (IPT) but little investigation of its components. This study assessed interrater reliability of IPT therapists in identifying interpersonal problem areas and treatment foci from audiotapes of initial treatment sessions. Three IPT research psychotherapists assessed up to 18 audiotapes of dysthymic patients, using the Interpersonal Problem Area Rating Scale. Cohen's kappa was used to examine concordance between raters. Kappas for presence or absence of each of the four IPT problem areas were 0.87 (grief), 0.58 (role dispute), 1.0 (role transition), and 0.48 (interpersonal deficits). Kappa for agreement on a clinical focus was 0.82. IPT therapists agreed closely in rating problem areas and potential treatment foci, providing empirical support for potential therapist consistency in this treatment approach.
 
There are few empirical studies of the subjective experience of separation from living parents in children who are removed from their families following abuse or neglect. The author presents the case of a child who spent most of his childhood in foster homes and treatment residences, including 7 years in which he had no contact with his natural family. The fate of his primary attachments and its influence on his capacity to form new ones are discussed, using material drawn from 6 years of individual therapy while he was "in care" and during the time that contact with his mother was renewed. Separation, loss, and attachment in a child welfare context and relevant clinical interventions are discussed.
 
Recent announcements about the discovery of a biological/genetic basis for homosexuality compel psychodynamically oriented therapists to reassess once again their understanding of mind/body relations. By comparing the claims made in regard to homosexuality, where a biological basis is pronounced evidence that this orientation is natural, with the claims of alcoholism researchers, where biological differences are cited as evidence of an underlying disease, we begin to see how the metaphorical use of biology often determines the use to which research findings are put. Recent anti-diet approaches to obesity and binge eating further illustrate the limits of the dominant disease/addiction metaphors that have hitherto been used to treat these problems.
 
High patient drop-out rates have traditionally interfered with both treatment and study of patients with borderline personality disorder (BPD). The authors tested hypotheses that an adequate treatment contract, a positive therapeutic alliance, and the severity of illness would all correlate with continuation of treatment versus drop-out in a BPD cohort receiving psychodynamic psychotherapy. Therapists' contributions to the contract and to the alliance correlated with the length of treatment. Patients' impulsivity was negatively related to length of treatment. This study supports the view that the therapist's technique plays a role in engaging the borderline patient to remain in treatment.
 
Alliance during short psychotherapeutic interventions (N12). Significant group effects: a Scheffé's F28.71, df2, P0.0001, with no difference between Profiles II and III. b F11.52, df2, P0.003. c Scheffé's F16.51, df2, P0.001, with no difference between Profiles I and II. d Scheffé's F17.03, df2, P0.001, with no difference between Profiles I and II. Profile I : High and stable alliance (n=4) Profile II : Improving alliance (n=4) Profile III : Low and stable alliance (n=4)  
Scores at the initial session for three cases and subsequent alliance pattern and change in SCL-90 scores
This preliminary study examined how patients' defense mechanisms and psychotherapists' techniques influence early alliance formation. The authors assessed the relationships among defense mechanisms, therapist interventions, and the development of alliance in a sample of 12 patients undergoing Brief Psychodynamic Investigation (4 sessions). Alliance development occurred rapidly and was clearly established by the third session. Neither defensive functioning nor supportive or exploratory interventions alone differentiated early alliance development. However, the degree of adjustment of therapists' interventions to patients' level of defensive functioning discriminated a low alliance from both improving and high alliances. The adjustment of therapeutic interventions to patients' level of defensive functioning is a promising predictor of alliance development and should be examined further, alongside other predictors of outcome.
 
Homework assignments can enhance therapeutic impact and increase therapy effectiveness by encouraging patients to focus on therapy-related issues between sessions. Computer technology provides a new avenue for reporting, monitoring, and feedback of patient homework assignments through electronic mail (e-mail). In two case examples, e-mail was used as an extension of therapy to enhance patient involvement in treatment. In both cases, patient reports suggest that therapeutic alliance and therapeutic impact improved with the use of e-mail homework reporting. The costs and benefits of the use of e-mail as an adjunct to therapy are discussed.
 
Top-cited authors
Jacques P. Barber
  • Adelphi University
Lynne Siqueland
  • University of Pennsylvania
Arlene Frank
Denis Daley
  • University of Pittsburgh
Per Høglend
  • University of Oslo